Final Report - Fatality #29 - November 26, 2014

OVERVIEW

Daniel J. Pabian, Contract Maintenance Repairman, age 58, was fatally injured at Pabian Enterprises LLC’s Ottawa Plant on November 26, 2014. Pabian was assisting in the installation of an overhead electric hoist.  The accident occurred when the victim fell from a ladder, striking a steel guard to the water pump drive belts and sheave, and then continued to fall onto the cement floor below. The ladder being used was a 12-foot portable step ladder erected on a level cement floor. The victim fell from the lower rungs of the ladder.

On April 20, 2015, the Mine Safety and Health Administration (MSHA) referred the accident to the Chargeability Review Committee (CRC). On July 14, 2015, the CRC determined that this death should be charged to the mining industry. The death certificate and autopsy report both indicated that the manner of death was accidental and the cause of death was a cervical spinal fracture due to a fall from a ladder.

GENERAL INFORMATION

Ottawa Plant is a surface industrial sand mine owned and operated by U.S. Silica Company located in Ottawa, LaSalle County, Illinois. The principal operating official is Patrick Smelko, Plant Manager. The mine operates two 12 hour-shifts per day, 7 days a week with alternating shifts working the weekends. Total employment is 179 employees.

The sandstone formation is drilled and then blasted. After blasting the sand is then turned into a slurry and pumped to the finish plant for washing, drying, and sizing. Finished products are sold for use in glass or counter top manufacturing and to the oil and gas industry as a fracking product.

U.S. Silica Company contracted Pabian Enterprises, LLC to perform maintenance and installation of overhead electrically powered hoists at the mine. Pabian Enterprises, LLC, is based in Oglesby, Illinois. At the time of the accident, there were four Pabian Enterprises employees working at the mine site. The principal operating official is Steven Pabian, owner, Pabian Enterprises, LLC.

The Mine Safety and Health Administration (MSHA) completed the last regular inspection of this operation on November 17, 2014.

DESCRIPTION OF ACCIDENT

On the day of the accident, Daniel J. Pabian (victim) reported to the Pabian Enterprises, LLC shop in Oglesby, Illinois at 6:30 a.m., which was his normal starting time. After receiving the day’s instructions from his supervisor, the victim traveled to the Ottawa Plant mine site with Bruce Patterson and Jonathon Koniecky, both maintenance/repairmen.

These three men reached the mine at approximately 7:15 a.m. and met Steve Pabian, owner of Pabian Enterprises, LLC, who had driven separately. As they arrived, work began at the #7 Relay Pump Station installing an overhead electric hoist. Work progressed normally through the early morning.

At approximately 11:00 a.m., Steve Pabian left the #7 Pump House to check conditions on #8 Pump House.

At approximately 11:05 a.m., Koniecky was working on the overhead hoist from the top of a step ladder. Daniel Pabian bent over to retrieve a wrench on the pump house floor and then began climbing up the first couple of rungs of the same ladder to hand Koniecky the tool.  Patterson, who was standing nearby, watched Daniel Pabian climb the ladder rungs and then fall backwards unexpectedly, as if he made no attempt to catch himself or control the fall. During the fall, Pabian struck his head on a steel guard to the water pump drive belts and sheave. He landed on the concrete pump house floor.

At approximately 11:10 a.m., Patterson called Steve Pabian to inform him that Daniel Pabian had fallen. Patterson and Steve Pabian then both contacted 911 operators for emergency assistance.  After calling 911, Steve Pabian went to the mine gate so he could direct emergency responders to the scene. Patterson relayed 911 dispatcher instructions to Koniecky so cardiopulmonary resuscitation (CPR) could be administered.

Emergency medical services arrived, continued CPR, and transported the victim to a local hospital, where he was later pronounced dead. The cause of death was attributed to cervical spinal fracture, with a contributing factor being coronary atherosclerosis.

INVESTIGATION OF THE ACCIDENT

On November 26, 2014, at 12:41 p.m., MSHA was notified of the accident by a telephone call made by U.S. Silica’s Environmental Health and Safety Manager, Kent Purcell. The Department of Labor’s National Contact Center then notified Christopher Hensler, MSHA’s North Central District Manager, and an investigation was begun the same day.

MSHA’s accident investigation team conducted a physical inspection of the accident site, interviewed employees, and reviewed conditions and work procedures relevant to the accident.  MSHA conducted the investigation with the assistance of management and employees. 

DISCUSSION

Location of the Accident 

The accident occurred at U S Silica’s Ottawa Plant, at the # 7 Pump Relay Station. The floor was level, clear of debris, and no slip or trip hazards were revealed. The ladder was a 12-foot portable step ladder. The ladder was in good condition, free of any hazards which might have contributed to the accident. 

Weather

At the time of the accident the temperature outside was 26 degrees and was not deemed a contributing factor in the accident.

Medical Analysis and Findings

An autopsy was performed and the results indicated that the manner of death was an accidental fall from a ladder and that the cause of death was a cervical spinal fracture. The death certificate also listed coronary atherosclerosis as a significant condition contributing to death, but not an underlying cause of death.

Training and Experience

Daniel Pabian (victim) had a total of 25 years of experience as a maintenance/repairman.  He had been working for Pabian Enterprises LLC for 9 months and had received Part 46 New Miner Training.  He had also received site specific hazard awareness training given by U S Silica when work began at the Ottawa Plant.

TRAINING and EXPERIENCE

Robert A Fleenor, Jr. had 12 years, 27 weeks of mining experience operating trucks all at this mine.  The investigator conducted an in-depth review of the of the operator’s training records.  Fleenor’s training records, provided by the mine operator, were examined and found to be in compliance with MSHA training requirements. 

CONCLUSION

On April 20, 2015, the Mine Safety and Health Administration (MSHA) referred the accident to the Chargeability Review Committee. On July 14, 2015, the Chargeability Review Committee determined that this death should be charged to the mining industry. The death certificate and autopsy report both indicated that the manner of death was accidental and the cause of death was a cervical spinal fracture due to a fall from a ladder.

Approved by:                                                            Date:

_________________________                                  _____________________
Chris Hensler
District Manager
North Central District

APPENDIX A

Persons Participating in the Investigation 

U S Silica Company

Pat Smelko                             Plant Manager

Kent Purcell                            Environmental Health and Safety Manager

Daniel Smith                           Operations Manager

Zack Zmudka                          Environmental Health and Safety Coordinator

Brad Ruger                             Alternate Miners Representative

Trevor Clayton                        Shift Foreman

Lyle Piecha                             Shift Foreman

Pabian Enterprises LLC

Steve Pabian                          Owner

Bruce Patterson                      Maintenance/repairman

Jonathon Konieczki                 Maintenance/repairman

LaSalle County Coroner’s Office

Bill Wujek                                Chief Deputy Coroner

Mitra Kalelka, M.D.                  Forensic Pathologist

Mine Safety and Health Administration

James Hines                           Mine Safety and Health Inspector

Jeffery Washkowiak                Mine Safety and Health Inspector