Accident Report: Fatality Reference
PDF Version
FAI-2019-21
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface Metal Mine
(Iron Ore)
Fatal Powered Haulage Accident
November 5, 2019
ArcelorMittal Minorca Mine Inc.
Virginia, St. Louis County, Minnesota
ID No. 21-02449
Investigators
Duane L. Hongisto
Mine Safety and Health Inspector
Daniel J. Goyen
Mine Safety and Health Specialist
Gary Rethage
Mechanical Engineer
Mark Kvitkovich
Mechanical Engineer
Originating Office
Mine Safety and Health Administration
North Central District
515 W. 1st Street, Suite 323
Duluth, Minnesota 55802-1302
Christopher A. Hensler, District Manager
OVERVIEW
Kenny L. Mattson, a 51-year-old mobile mechanic with 15 years of mining experience, died on November 5, 2019. While operating his service truck, it veered off the road, struck a berm, and ejected him as it overturned.
GENERAL INFORMATION
ArcelorMittal Minorca Mine Inc. owns and operates the ArcelorMittal Minorca Mine Inc. (Minorca) in Virginia, St. Louis County, Minnesota. Minorca employs 353 miners and operates twenty-four hours per day with multiple shifts. Minorca mines iron ore from a multiple bench open pit. Haul trucks transport the ore to the crusher. The ore is milled in a multi-step process and formed into heat-hardened pellets used for steel manufacturing.
The Mine Safety and Health Administration (MSHA) completed the last regular inspection on June 3, 2019. The non-fatal days lost (NFDL) incident rate for Minorca Mine for 2018 was 2.34, compared to the national average of 1.20.
The principal official for the ArcelorMittal Minorca Mine Inc. at the time of the accident was:
John Brett..........................................................................................................Chief Executive Officer
DESCRIPTION OF ACCIDENT
On November 5, 2019, Kenny L. Mattson started work at 4:55 a.m. Mattson worked alone, performing maintenance at various working places.
At approximately 9:35 a.m., David J. Woods, Truck Driver, observed Mattson traveling east on the East Pits haul road toward the Laurentian and Lynx pits. Woods saw Mattson momentarily stop on the haul road, then resume traveling around a roadway curve and out of sight. As Woods rounded the same curve a short time later, he discovered Mattson’s service truck overturned on the driver’s side in the roadway. Woods radioed for emergency assistance.
Mine emergency response team members and plant security responded to the scene followed by local police and fire departments. Justin Root, Paramedic, City of Virginia Fire Department pronounced Mattson dead at the scene, at approximately 10:06 a.m. Root documented the victim’s primary cause of death as “Traumatic Injury” and “Cardiac Arrest” as secondary cause of death. According to the medical examiner, since the victim had obvious multiple blunt force traumas, he performed an external exam only.
INVESTIGATION OF THE ACCIDENT
On November 5, 2019, at 9:50 a.m., Mark Anderson, Safety Manager, contacted the Department of Labor National Contact Center (DOLNCC). The DOLNCC contacted Daniel J. Goyen, Mine Safety and Health Specialist. Richard V. Boeckerman, Supervisory Mine Safety and Health Inspector responded to the accident. Upon arrival, Boeckerman issued an order under the provision of Section 103(k) of the Mine Act to ensure the safety of the miners and began the investigation.
On November 6, 2019 at 8:00 a.m., Duane L. Hongisto, Mine Safety and Health Inspector arrived on the scene to continue the fatal accident investigation. On November 8, 2019, Gary Rethage and Mark Kvitkovich, Mechanical Engineers, with MSHA’s Approval & Certification Center, assisted with the investigation. On November 12, 2019, Amy A. Sandelin, Mine Safety and Health Specialist, with MSHA’s Educational Field and Small Mine Services, assisted in the review of training plans and documentation. MSHA’s accident investigation team conducted a physical examination of the accident scene, and interviewed mine management, mine employees, the union representative, local law enforcement and rescue agencies. See Appendix A for a list of persons who participated in the investigation and those interviewed.
DISCUSSION
Location of Accident
The accident occurred on the “East Pits” haul road leading to the Laurentian and Lynx pits. The haul road was hard-packed dirt, wide and relatively level with an approximate one percent grade (see Appendix B). Berms, approximately ten feet high, alongside the roadway were made of hard-packed spoil material. Cold dry weather conditions created a frozen, but not icy, roadway.
Weather
The weather at the time of the accident was 17° F with clear skies. Investigators did not consider the weather to be a factor at the time of the accident.
Equipment Involved
The service truck involved in the accident was a 2012 Freightliner M2 Business Class, VIN 1FVACXDTODHFE6526, equipped with a Model 7500 IMT crane. Examination of the service truck did not reveal mechanical deficiencies or defects that would have caused the accident.
Tires on the service truck exhibited adequate tread depth and did not show any signs of mechanical damage.
The investigators examined the driver’s seat belt and found the buckle to be functional. However, the seat belt retractor mechanism did not function properly. Investigators were unable to determine if this condition existed before the accident or if the accident damaged the seat belt retractor. Since Mattson was ejected from the vehicle and the seat belt was found to be unfastened, investigators concluded that the victim was not wearing his seat belt at the time of the accident.
Training and Experience
Kenny L. Mattson had 15 years of mining experience with Minorca and met all Part 48 training requirements.
Root Cause
Root Cause: Minorca’s policy required drivers and passengers of all vehicles to wear seat belts at all times. A seat belt was not in use at the time of the accident, allowing ejection from the cab of the vehicle.
Corrective action: The company retrained all employees on seat belt usage and modified their policy to include performing a proper seat belt examination to ensure its functionality.
Conclusion
Kenny L. Mattson, died while operating his service truck; it veered off the road, struck a berm, and ejected him as it overturned.
Approved By:
______________________________ ____________________
Christopher A. Hensler Date
North Central District Manager
Appendix A
Persons Participating in the Investigation
(Persons interviewed are indicated by a * next to their name)
ArecelorMittal Minorca Mine
John Kramer*........................................................................................................ Shift Supervisor
David J. Woods*........................................................................................................ Truck Driver
Justin Klakoski*............................................................................................. Truck Shop Laborer
Thomas Beton*.................................................................................................................. Laborer
Joseph Scinto*................................................................................................................... Laborer
Thomas Kingsley*............................................................................................................. Laborer
Lee Omdahl*...................................................................................................................... Laborer
David Illies*....................................................................................................................... Laborer
Michael Hoard*................................................................................................................. Laborer
Jerimiah Reing*................................................................................................................. Laborer
Anthony House*................................................................................................................ Laborer
Todd Olson*.................................................................................................................. Millwright
Thomas French*............................................................................... Safety/Union Representative
Mine Safety and Health Administration
Duane L. Hongisto .................................................................. Mine Safety and Health Inspector
Daniel J. Goyen ........................................................... Mine Safety and Health Safety Specialist
Richard V. Boeckerman...................................... Supervisory Mine Safety and Health Inspector
Gary Rethage............................................................................................... Mechanical Engineer
Mark Kvitkovich ......................................................................................... Mechanical Engineer
Amy A. Sandelin........................................ Mine Safety and Health Safety Specialist (Training)