Accident Report: Fatality Reference
PDF Version
FAI-6932417-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Construction Sand and Gravel)
Fatal Machinery Accident
June 1, 2023
Hockley Plant
Alleyton Resource Company, LLC.
Hockley, Harris County, Texas
ID No. 41-03491
Accident Investigators
Homer Pricer Jr.
Supervisory Mine Safety and Health Inspector
Michael Tefertiller
Supervisory Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
Dallas District
1100 Commerce Street RM 462
Dallas, TX 75242
William O’Dell, District Manager
OVERVIEW
On June 1, 2023, at 1:49 p.m., Ricardo Martinez, a 61 year-old customer truck driver, died from injuries he suffered after being struck by the right rear passenger side suspension assembly. Martinez was attempting to repair the ride height adjustment that controlled the rear air bag assembly at the time of the accident.
The accident occurred because the mine operator did not ensure the machinery was blocked against hazardous motion before repair work began.
GENERAL INFORMATION
Alleyton Resource Company, LLC., a subsidiary of Summit Materials LLC., owns and operates the Hockley Plant. This is a surface construction sand and gravel mine located in Hockley, Harris County, Texas. The Hockley Plant employs three miners and three contractor miners, and operates one eight-hour shift per day, five days per week. The contractor miners mine sand from the pit and use haul trucks to transport it to the screening plant where it is screened and stockpiled. The finished product is loaded into customer trucks for delivery. Martinez worked for the customer trucking company, KK Trucking.
The principal management official at the Hockley Plant at the time of the accident was:
Santos Guerra Plant Manager
The Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection at this mine on December 13, 2022. The 2022 non-fatal days lost incident rate for the Hockley Plant was zero, compared to the national average of 1.34 for mines of this type.
DESCRIPTION OF THE ACCIDENT
On June 1, 2023, at 6:41 a.m., Martinez arrived at the Hockley Plant and obtained a load of sand for delivery to an off-site job location. At 11:06 a.m., Martinez arrived back at the Hockley Plant after completing a second delivery and parked his truck near the Hockley Plant’s breakroom building. The customer truck drivers use this building while waiting to be loaded.
According to interviews, Martinez entered the breakroom before 12:00 p.m. to retrieve a blue mat that customer truck drivers would often use to lay on the ground to perform maintenance or inspect their trucks. Due to the ride height adjustment valve becoming dislodged from its connection point on his truck, investigators believe Martinez was evaluating a rear air bag issue while waiting to be loaded. Based on the examination of the accident scene, investigators believe Martinez’s truck was running while he laid the mat between the rear dual tires at the rear of the truck in an attempt to loosen the worm gear hose clamp with a flathead screwdriver to position the valve rod back into the connection point. Investigators believe Martinez was pushing the valve rod in an upward motion inadvertently actuating the valve that allows air to inflate the air bag. The air bag rapidly inflated the right rear passenger side suspension assembly, causing a component of the system to slide off the mounting bracket, striking Martinez on the right side of the head and neck area.
Milton Celz and Osmar Salmgron, Customer Truck Drivers, arrived at the mine and parked their trucks near Martinez’s truck to use the breakroom facilities. Upon exiting his truck, Celz stated he observed Martinez under the truck. At 12:43 p.m., Celz rushed to Martinez while Salmgron called 911. Celz saw that Martinez was injured. At 12:47 p.m., Celz called Santos Guerra, Plant Manager, who also called 911.
At 1:02 p.m., Waller County Emergency Medical Services arrived and began patient care. Hermann Memorial Life Flight arrived and transported Martinez to Hermann Memorial Hospital where Bryan Cotton, MD, pronounced Martinez dead 1:49 p.m.
INVESTIGATION OF THE ACCIDENT
On June 1, 2023, at 2:04 p.m., Jacob Roberts, Safety Manager, called the Department of Labor National Contact Center (DOLNCC) to report the accident. At 2:27 p.m., the DOLNCC contacted Steven Oates, Staff Assistant. Oates contacted Nickolas Gutierrez, Assistant District Manager and informed him of the accident. Gutierrez contacted Michael Tefertiller and Homer Pricer Jr., Supervisory Mine Safety and Health Inspectors, and assigned Pricer as the lead accident investigator.
On June 2, 2023, at 6:46 a.m., Tefertiller arrived at the mine to secure the accident scene and begin the investigation. Tefertiller issued an order under the provision of Section 103(k) of the Mine Act to ensure the safety of the miners and preservation of evidence. Pricer arrived at 10:00 a.m. and proceeded with the investigation.
The accident investigation team conducted an examination of the accident scene, interviewed management, miners, contractors and other pertinent personnel, and reviewed conditions and work practices 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 customer staging area and outside of the breakroom located in the mine site (see Appendix B).
Weather
The weather at the time of the accident was 90 degrees Fahrenheit and sunny. Investigators determined that weather did not contribute to the accident.
Equipment Involved
The over-the-road haul truck involved in the accident was a 2013 Kenworth T880 quad axle dump truck (see Appendix C). Investigators discovered the right rear passenger side suspension assembly had a missing mounting bolt that was never found after the accident. Investigators believe this bolt was improperly installed and became dislodged during travel at some point off the mine site. The mine operator did not ensure the machinery was blocked against hazardous motion before Martinez began repair work, which contributed to the accident. Investigators examined the rest of the truck and did not find any other mechanical deficiencies or defects that would have contributed to the accident.
Training and Experience
Martinez worked for KK Trucking for approximately one month and had over 20 years of experience driving an over-the-road commercial vehicle. The state of Texas issued a Class “A” Commercial Driver License to Martinez on July 11, 2020. The mine operator uses signs and posted warnings to provide Part 46 site-specific hazard awareness training.
ROOT CAUSE ANALYSIS
The accident investigation team conducted an analysis to identify the underlying causes of the accident. The investigator identified the following root cause, and the mine operator implemented the corresponding corrective action to prevent a recurrence.
Root Cause: The mine operator did not ensure the machinery was blocked against hazardous motion before repair work began.
Corrective Action: The mine operator established a new procedure preventing anyone that is not an employee or a designated contractor of Hockley Plant from performing maintenance or repairs while on their property. The mine operator has trained, and will continue to train, all customer truck drivers on their new procedure.
CONCLUSION
On June 1, 2023, at 1:49 p.m., Ricardo Martinez, a 61 year-old customer truck driver, died from injuries he suffered after being struck by the right rear passenger side suspension assembly. Martinez was attempting to repair the ride height adjustment that controlled the rear air bag assembly at the time of the accident.
The accident occurred because the mine operator did not ensure the machinery was blocked against hazardous motion before repair work began.
Approved By:
__________________________________ _____________
William O’Dell Date
District Manager
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to Alleyton Resource Company, LLC.
A fatal accident occurred on June 1, 2023, at approximately 1:40 p.m. This order is being issued under the authority of the Federal Mine Safety and Health Act of 1977, under Section 103(k) to insure the safety of all persons at the mine, and requires the operator to obtain the approval of an authorized representative of MSHA of any plan to recover any person in the mine or to recover the mine or affected area. This order prohibits any activity in the affected area. The operator is reminded of the obligation to preserve all evidence that would aid in investigating the cause or causes of the accident in accordance with 30 CFR 50.12.
2. A 104(a) citation was issued to Alleyton Resource Company, LLC. for a violation of 30 CFR 56.14105.
On June 1, 2023, a fatal accident occurred at this location when the driver of the Kenworth T880 quad axle dump truck was struck by the right rear passenger side suspension assembly while making repairs. The driver was attempting to repair the ride height adjustment rod when the air bag inflated and slid off the mounting bracket. The mine operator did not ensure the machinery was blocked against hazardous motion before repair work began.
APPENDIX A – Persons Participating in the Investigation
Alleyton Resource Company, LLC.
Santos Guerra Plant Manager
Jacob Roberts Safety Manager
KK Trucking
Juan Carlos Owner
Jose Espinosa Translator
Danko Trucking
Milton Celz Customer Truck Driver
J. Garcia Trucking
Osmar Salmgron Customer Truck Driver
Mine Safety and Health Administration
Homer Pricer Jr. Supervisory Mine Safety and Health Inspector
Michael Tefertiller Supervisory Mine Safety and Health Inspector
Jerry Anguiano Mine Safety and Health Training Specialist
Lilia Ruan Mine Safety and Health Inspector