August 18, 2020 Fatality - Final Report

Accident Report: Fatality Reference: 

FAI-6871921-1

UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

REPORT OF INVESTIGATION

Surface
(Construction Sand and Gravel)

Fatal Machinery

August 18, 2020

HJ Hove

Hi-Grade Materials Co.
Indio, Riverside County, California
I.D. No. 04-01854
 

Accident Investigators

Charles Snare

Mine Safety and Health Inspector

Gary Hebel

Assistant District Manager

Originating Office
Mine Safety and Health Administration
West Region

Vacaville District
991 Nut Tree Road

Vacaville, California, 95687
James M. Peck, District Manager


OVERVIEW

On August 18, 2020, at 6:15 a.m., Diego Resendiz, a 21-year-old Laborer/Equipment Operator with over one year of mining experience, entered the cone crusher and falling material entrapped him beneath the feed hopper.  Resendiz was rescued and died the next day.

The accident occurred because Hi-Grade Materials did not: 1) establish safe procedures to clear blockages in feed hoppers or bins, 2) provide access to areas from which blockages could be cleared safely, 3) provide mechanical devices or other effective means to prevent and/or safely clear blockages, and 4) adequately train miners in entry to bins, hoppers, tanks or similar areas.

GENERAL INFORMATION

Robar Enterprises Inc. owns Hi-Grade Materials Co. who operates the HJ Hove mine located in Indio, Riverside County, California.  Miners excavate, crush, and screen construction sand and gravel at this site.  The mining company sells the material to the public and supplies a cement ready mix plant adjacent to the mine site. 

The principal officers for Robar Enterprises at the time of the accident were:                                                      

Jonathan D Hove.......................................................................... President

Lori A Clifton.............................................................. Secretary/Treasurer

The Mine Safety and Health Administration (MSHA) last completed a regular mine inspection of this site on October 10, 2019.  The 2019 non-fatal days lost (NFDL) incident rate for HJ Hove was 0, compared to the national average of 0.69 for mines of this type.

DESCRIPTION OF THE ACCIDENT

On August 18, 2020, at 4:00 a.m., Resendiz started his shift by receiving the day’s work assignment during the morning line out.  Jacob DeRuiter, Foreman, issued work assignments to Andres Aguilar, Crusher Operator; Jose Flores, Laborer/Equipment Operator; and Resendiz to clear the cone crusher and the feed hopper because of a blockage that occurred the previous day.  At approximately 4:45 a.m., the three miners started to remove the blockage by removing rock by hand from the cone crusher (see Appendix C).  At approximately 6:00 a.m., the miners removed most of the rock outside of the hopper discharge loop.  Resendiz climbed down over the rock guard onto the crusher mantel, kicking small material down and handing large material out to the other two miners.  At 6:15 a.m., Aguilar noticed rock starting to trickle and attempted to warn Resendiz to get out.  Resendiz started to stand up but the material began to engulf him.  Aguilar and Flores attempted to prevent rocks from striking Resendiz and called out on the radio for help.  Aguilar’s and Flores’ attempts to stop the material flow did not work and the material further engulfed the victim.  At 6:38 a.m., Juan Avila, Laborer/Equipment Operator, called 911.

At 6:50 a.m., the first fire department unit arrived and began rescue efforts.  Several other fire rescue units arrived and continued the extraction efforts with cutting torches and an air arc unit.  The rescue team extricated Resendiz from the cone at 10:23 a.m., and medical personnel evaluated him on the site.  Resendiz had been entrapped for over 4 hours, and at times buried up to his neck in course material consisting of rocks measuring up to 12 inches wide, 14 inches long and six inches thick.  At 10:55 a.m. a helicopter air ambulance flew the victim to Desert Regional Medical Center and placed him in the Intensive Care Unit.  He died on August 19, 2020 12:32 p.m.  

INVESTIGATION OF THE ACCIDENT

On August 18, 2020, at 7:20 a.m., Lori Clifton, Robar Secretary/Treasurer, called the Department of Labor National Contact Center (DOLNCC).  The DOLNCC contacted Gary Hebel, Assistant District Manager.  Hebel contacted Miles Frandsen, Supervisory Mine Safety and Health Inspector, and Frandsen dispatched Chad Hilde, Mine Safety and Health Inspector to the mine.  Frandsen verbally issued an order to the mine operator under the provisions of 103(j) to ensure the safety of miners and rescue personnel prior to inspector Hilde’s arrival at the site at 10:00 a.m.  Curtis Roth, Assistant District Manager, contacted Patrick Barney, Supervisory Mine Safety and Health Inspector.  Barney dispatched Charles Snare, Mine Safety and Health Inspector to the mine.

On August 19, 2020, Snare and Hebel, arrived at the mine site at 8:30 a.m. to continue the investigation.  MSHA’s accident investigation team conducted a physical examination of the accident, interviewed miners, reviewed conditions and work procedures relevant to the accident.  See Appendix A for a list of persons who participated in the investigation.

DISCUSSION

Location of the Accident

The accident occurred at the primary cone crusher plant, located roughly in the center of the plant near the stockpiles (see Appendix B).

Equipment Involved

A feed conveyor transports un-sized rock to a two-deck Telsmith vibrating screen.  The screen separates the rock into specific sizes.  The top screen separates large rock, which travels through a feed hopper to the Telsmith D-style 66S gyroscopic cone crusher.  The bottom screen allows smaller sized rock to pass through and drop onto conveyors for stockpiling (see Appendix C).

Weather

On the day of the accident, the weather was clear and hot.  Due to recent elevated temperatures, the company was operating earlier hours for cooler working conditions with shift start tines at 4:00 a.m.  Investigators determined that weather was likely not a factor in the accident.

Training and Experience

Diego Resendiz had over one year of mining experience, all at this mine.  He received initial new miner training and annual refresher training in 2019 in accordance with Part 46.  Investigators determined that his annual refresher training was current, but identified contributory task training deficiencies.  Mine management did not train the victim or any other miners on how to safely clear blockages in the primary cone crusher and feed hopper.  Additionally, even though mine management knew of the blockages, they did not develop procedures, mechanical devices, access points, or other effective and safe means to prevent and clear blockages.  Due to numerous previous blockages, the mine operator had built an inspection door at the upper end of the chute.

Examinations

Management did not perform workplace examinations of the crusher for two consecutive days.  Management did not identify hazardous conditions and ensure miners initiated proper and safe corrective actions before work commenced, contributing to the accident.

ROOT CAUSE ANALYSIS

The accident investigation team conducted a root cause analysis to identify the underlying causes of the accident. The operator implemented the corresponding corrective actions to prevent a reoccurrence.

  1. Root Cause: Management did not adequately train miners in health and safety aspects of assigned tasks.

Corrective Action: Hi-Grade Materials Co. developed a written policy based upon a Job Task Analysis to determine and identify the hazards of specific tasks, PPE requirements, safe procedures and access that includes hands on training in the field.  The training plan was amended to include this policy.

  1. Root Cause: Management did not have adequate controls in place to prevent or safely access/remove material blockages in the hopper system.

Corrective Action: Hi-Grade Materials Co. reviewed and analyzed the material flow of the entire crusher system to allow material to flow smoothly through the plant and modified access to allow safe removal of blockages if needed.  The operator also has on site tools and PPE to address such hazards.  The mine operator has trained miner on the modified process, tools, and PPE.

  1. Root Cause: Management did not conduct and record work place examinations prior to any work commencing.

Corrective Action: Hi-Grade Materials Co. has conducted training with all employees to ensure understanding the importance of conducting, hazard recognition, and corrective action required to meet compliance with the standard.  The training plan was amended to include workplace examinations.  The company has instituted a policy that includes management audits of workplace examinations.

CONCLUSION

On August 18, 2020, at 6:15 a.m., Diego Resendiz, a 21-year-old Laborer/Equipment Operator with over a years mining experience, entered the cone crusher and falling material entrapped the miner beneath the feed hopper.  Resendiz was rescued and died the next day.

The accident occurred because Hi-Grade Materials did not: 1) establish safe procedures to clear blockages in feed hoppers or bins, 2) provide access to areas from which blockages could be cleared safely, 3) provide mechanical devices or other effective means to prevent and/or safely clear blockages, and 4) adequately train miners in entry to bins, hoppers, tanks or similar areas.

Approved by:

 

__________________________                                                        __________________                       

James M. Peck                                                                                          Date
Vacaville District Manager

ENFORCEMENT ACTIONS

  1. A 103(j) Order No. 8592296 was issued to Lori Clifton/Hi-Grade Materials Co. on 8/18/2020.

An accident occurred at this operation on 8-l8-2020 at approximately 0630. As rescue and recovery work is necessary, this order is being issued, under Section 103(j) of the Federal Mine Safety and Health Act of l977, to assure the safety of all persons at this operation. This order is also being issued to prevent the destruction of any evidence, which would assist in investigating the cause or causes of the accident. It prevents all activity at the Telsmith 66S cone crusher, the screen above, the belts below and all the service trucks parked in the area, until MSHA has determined that it is safe to resume normal mining operations in this area. This order applies to all persons engaged in the rescue and recovery operation and any other persons on-site.  This order was initially issued orally to the mine operator at 08:l7 and has now been reduced to writing.

The 103(j) Order was modified to 103(k) Order when MSHA inspector arrived at on site.

  1. A 104(d)(1) Citation was issued to Hi-Grade Materials Co. for a violation of 30 CFR 56.16002(c)

A fatal accident occurred on August 18, 2020, when material from the cone crusher feed hopper slid and partially engulfed a laborer (victim).  The victim climbed over top of the hopper above the crusher mantle to dislodge built up material from the feed hopper that clogged the crusher.  The victim moved material, which caused the material above him to move, engulfing the victim.  The company did not empty the hopper, hopper, or install a means to prevent material from moving.  The mine foreman engaged in aggravated conduct constituting more than ordinary negligence because he knew the frequency of the blockages, but implemented no procedures, mechanical devices, access points, or other effective and safe means to prevent and clear blockages.  This violation is an unwarrantable failure to comply with a mandatory standard.

  1. A 104(d)(1) Order was issued to Hi-Grade Materials Co. for a violation of 30 CFR 56.18002(a)

A fatal accident occurred on August 18, 2020, when material from the cone crusher feed hopper slid and partially engulfed a laborer (victim).  The victim climbed over the top of the hopper above the crusher mantle to dislodge built up material from the feed hopper that clogged the crusher.  The victim moved material, which caused the material above him to move, engulfing the victim.  The mine foreman engaged in aggravated conduct constituting more than ordinary negligence because he knew the frequency of the blockages but did not perform workplace examinations of the crusher for two consecutive days.  This violation is an unwarrantable failure to comply with a mandatory standard.

  1. A 104(d)(1) Order  was issued to Hi-Grade Materials Co. for a violation of 30 CFR 46.7

A fatal accident occurred on August 18, 2020, when material from the cone crusher feed hopper slid and partially engulfed a laborer (victim).  The victim climbed over the top of the hopper above the crusher mantle to dislodge built up material from the feed hopper that clogged the crusher.  The victim moved material, which caused the material above him to move, engulfing the victim.  The mine operator did not provide task training to the victim prior to him performing this task.  The mine foreman engaged in aggravated conduct constituting more than ordinary negligence in that he assigned the victim to work on clearing this blockage and he knew the frequency of blockages. This violation is an unwarrantable failure to comply with a mandatory standard.


Appendix A

Persons Participating in the Investigation

Robar Enterprises Inc.

Rosa Rivera..................................................... Human Resources Manager

Hi-Grade Materials Co.

Bryon Forgey..................................................... Vice President Aggregate

TJ Lamb....................................................... Quarry Area Manager CVMB

Mine Safety and Health Administration

Charles Snare......................................... Mine Safety and Health Inspector

Gary Hebel........................................................ Assistant District Manager

Chad Hilde............................................. Mine Safety and Health Inspector

Ralph Chavez Educational Field and Small Mine Services