Fatality #3 - April 12, 2018 - Final Report

Accident Report: Fatality Reference: 

MAI-2018-03

 

UNITED STATES
DEPARTMENT OF LABOR

MINE SAFETY AND HEALTH ADMINISTRATION

Metal and Nonmetal Mine Safety and Health

REPORT OF INVESTIGATION

Dredge Non Metal Mine
(Sand)

Fatal Powered Haulage
April 12, 2018

 Rye Dredge & Plant

Trinity Materials, Inc.
Cleveland, Texas
Mine ID No. 41-02547

Accident Investigators

Homer Allen Pricer Jr.

Mine Safety and Health Supervisor

Armando Moreno Jr.

Mine Safety and Health Inspector

Murray Jackson

 Mine Safety and Health Inspector

Originating Office

Mine Safety and Health Administration

South Central District

1100 Commerce Street RM 462

Dallas, TX 75242

Michael A. Davis, District Manager

 


OVERVIEW

Manuel G. Rodriguez, a 59 year old customer truck driver, received fatal injuries on April 12, 2018, when he fell from his truck and was run over by the truck’s rear wheels.   Mr. Rodriguez was attempting to scan a card that identifies customer trucks entering the facility to load material.  Investigators believe Mr. Rodriguez approached the Apex Express Radio Frequency Identification Card Reader (RFID) but positioned the vehicle too far away from the RFID to scan the card from inside the truck.  Investigators conclude Mr. Rodriquez removed his seatbelt, opened the driver’s side door, and leaned out of the cab with his right foot on the clutch pedal and the truck in gear. 

The truck moved forward, causing him to fall ouThe accident occurred because the victim did not properly secure the truck by setting the parking brake and putting the vehicle in park before opening the door and leaning out of the truck.
 

GENERAL INFORMATION

Trinity Materials, Inc. owns and operates the Rye Dredge & Plant (Rye), a sand dredge mine facility.  The facility is located in Cleveland, Liberty County, Texas.  Reid Essl, president, is the principal operations official.  The facility operates six days a week on one ten-hour shift and employs six miners.

The mine uses a large suction dredge to extract sand and gravel from below the deposit.  A pipeline transports material to a wet screening plant that separates the material into four stockpiles.  Heavy equipment loads the finished material into over-the-road trucks and transports it to off-site locations for use in construction.
 
The Mine Safety and Health Administration (MSHA) completed its last regular inspection of the operation on January 7, 2018.

 

DESCRIPTION OF ACCIDENT

On April 12, 2018, at 8:30 a.m., customer truck driver Manuel G. Rodriguez arrived at the Rye Dredge & Plant to pick up a load of sand.  Rodriguez traveled to the mine operator’s RFID and attempted to scan his card.  The RFID directs the driver where to go on the site to get material, or instructs the driver to go to the scales to obtain an empty truck weight.  The driver must place the card within two inches of the RFID. A green light on the RFID indicates the scanner read the card.  To avoid striking the driver’s side mirror against the scanner, it appears Rodriguez stopped his truck too far away to reach the RFID from inside of the cab.  Investigators believe Rodriguez unbuckled his seat belt and opened the driver’s side door while pressing the clutch pedal with his right foot.  Investigators believe Rodriguez leaned out of the truck with the truck in gear and his right foot slipped off the clutch, causing the truck to move forward.  The sudden forward motion threw Rodriguez from the truck, and the truck’s rear wheels ran over him.

Angela Worrell, scale house attendant, heard a loud noise, looked through the scale house window and saw a truck on the side of the road near the RFID.  Worrell went to the scale house door and saw someone under the belly dump portion of the truck.  Worrell called for help on a hand-held radio and then travelled to the accident scene.  Bryan Payne, customer truck driver, was sitting in his truck on the scales and saw Worrell running to Rodriquez’s truck.  Payne exited his truck and noticed the victim’s truck was still running and in gear with no one in the cab.  Payne put Rodriguez’s truck gear in the “park” position.  David Parks, loader operator, heard Worrell’s radio transmission and travelled to the scene.  According to Parks’s interview, Rodriguez had no pulse.  Parks began cardiopulmonary resuscitation, but Rodriquez did not respond.  Robert Jones, dredge operator, arrived to relieve Parks with chest compressions while Parks prepared the emergency defibrillator.  Liberty County Emergency Medical Services and the sheriff’s department arrived at the accident scene at 8:58 a.m., and county responders attended the victim.  Cody Parrish, Liberty County justice of the peace, pronounced Rodriguez dead at the scene.  The cause of death was later determined to be “blunt force injuries.”

 

INVESTIGATION OF ACCIDENT

John Worrell, plant manager, called the Department of Labor National Contact Center (DOLNCC) at 8:40 a.m. on April 12, 2018, and notified MSHA of the accident.  DOLNCC notified William O’dell, assistant district manager in MSHA’s South Central District.  MSHA issued an order under provisions of Section 103(k) of the Mine Act to ensure the safety of the miners, and the agency started the investigation. 

MSHA's accident investigation team travelled to the mine, conducted a physical examination of the accident, conducted eighteen interviews with mine employees and customer truck drivers, and reviewed documents and work procedures relevant to the accident.  MSHA conducted the investigation with the assistance of mine management, miners, customer truck drivers, and owners of the truck involved in the accident.

 

DISCUSSION

Location of the Accident

The accident occurred at the customer RFID, which is located on the road adjacent to the scale house, on the south side of the primary sand plant.  The victim stopped the truck as it faced north on relatively dry, level and stable sand.

Weather

The weather service reported the weather at the time of the accident as clear, with calm winds and a temperature of 52 degrees Fahrenheit. Investigators did not consider weather to be a factor in the accident.

Truck/Trailer Information

The accident involved a 2007 Freightliner tractor with a belly dump semi-trailer.  The tractor and trailer combination is commonly used on public highways in this region.

Training and Experience

Manuel G. Rodriguez had 20 years of experience driving an over-the-road tractor trailer truck combination.  For the last two years, Rodriguez picked up material at this mine site and transported it to end users.  Trinity Materials provided driving policy and procedure training to customer truck drivers, and the training included traffic controls at the mine site and personal safety.  Trinity Materials required customer truck drivers to report to the office/scale house or point of contact prior to starting work.

Apex Express RFID Card Reader

RFID cards are used to identify trucks when entering or leaving the site. The software allows the mine operator to track the sale of materials.

 

ROOT CAUSE ANALYSIS

Investigators conducted a root cause analysis and identified a root cause.

Root Cause:  The accident occurred because the victim did not properly secure the truck by setting the park brake and taking the vehicle out of gear before opening the door and leaning out of the cab.

 
Corrective Action:  The mine operator has discontinued the use of the RFID system and in the future will be using handheld and CB radios for communications with customer truck drivers. Site specific training now includes instructions to visitors advising them to set park brakes and place equipment in the park position prior to leaving the operator’s cab.

 

CONCLUSION

While attempting to scan a customer card on the operator’s RFID, Manuel G. Rodriguez fell from the cab of his truck and the rear wheels ran over him.  The accident occurred because the victim did not properly secure the truck from movement.

 

 

 

Approved: ______________________________   Date: _______________

                   Michael A. Davis

                   District Manager

 


Appendix A

Persons Participating in the Investigation

(Persons interviewed are indicated by a * next to their name)
 

Trinity Materials, INC.

Tye Parker                                Lead-man

*John Worrell                         Plant Manager

*Arturo Munoz                       Safety Director

*Angela Worrell                     Scale Operator/Office Assistant

Michael Stripe                        Vice President Safety

Justin Allen                            Associate General Counsel

*David Parks                          Loader operator

*Robert Jones                         Dredge operator
 

Customer Truck Drivers

*Corliss Matters

*Lvoian Harmon

*Robert Brittain

*Joe Fontenot

*Mark Hollerback

*David Odom

*Cavazos Gomez

*James Miller

*David Bickerton

*Evilo Hernandez

*Rene Gill

*Bo Potter

*Bryan Payne                        
 

Mine Safety and Health Administration

Homer Allen Pricer Jr.          Supervisory Mine Safety and Health Inspector

Armando Moreno Jr.             Mine Safety and Health Inspector

Murray Jackson                       Mine Safety and Health Inspector