Accident Report: Fatality Reference
PDF Version
FAI-6934008-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Limestone)
Fatal Powered Haulage Accident
March 9, 2023
Plant & Quarry
Texas Lime Company
Cleburne, Johnson County, Texas
ID No. 41-00072
Accident Investigators
Brody Haddock
Mine Safety and Health Specialist
Neal Davis
Supervisory Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
Dallas District
1100 Commerce Street, Room 462
Dallas, Texas 75242
William O’Dell, District Manager
OVERVIEW
On March 9, 2023, at 1:55 p.m., Don Reynolds, a 60 year-old delivery truck driver with over five years of delivery truck driving experience, died when a front-end loader struck his truck and trailer. Reynolds was underneath his truck; the impact caused his truck’s left rear dual wheels to roll onto him.
The accident occurred because the mine operator did not ensure that the front-end loader operator maintained control of the front-end loader.
GENERAL INFORMATION
Texas Lime Company owns and operates the Plant & Quarry mine. This is a surface limestone mine and plant facility located in Cleburne, Johnson County, Texas. The Plant & Quarry mine employs 79 miners and operates two twelve-hour shifts, seven days per week. The mine extracts limestone from an open pit and haul trucks transport the limestone to the mill for processing. The mine operator sells the final product to various industries.
The principal management officials at the Plant & Quarry mine at the time of the accident were:
Julius Harris Vice President/Plant Manager
Dennis Johnson Safety Compliance Manager
The Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection at this mine on May 26, 2022. The 2022 non-fatal days lost incident rate for the Plant & Quarry mine was 3.41, compared to the national average of 1.17 for mines of this type.
DESCRIPTION OF THE ACCIDENT
On March 9, 2023, Reynolds began his shift at the AMS Co., Inc. truck yard at 4:40 a.m. An AMS Co., Inc. dispatcher assigned him to haul coke (solid material derived from oil refining) from the AMS Rail Transloading Facility in Cleburne, Texas to the Plant & Quarry mine. Reynolds hauled coke to the Pit & Quarry mine throughout his shift, delivering the first load at 5:51 a.m. At approximately 9:00 a.m., James Turner, Front-End Loader Operator, traveled to the coal unloading area (see Appendix A) to begin pushing up the coke that Reynolds delivered. Efrain Ramirez, Production Supervisor, called Turner at 1:50 p.m. and instructed him to return to the plant to help clean up at the plant’s clinker pit. Turner then left the coal unloading area to return to the plant via the exit road.
Investigators were unable to interview Turner, but according to interviews with Ramon Ledbetter, Maintenance Planner, and Clint Miller, Floating/Relief Supervisor, Turner told them that he was leaving the coal unloading area and he elevated the bucket of his front-end loader to clean out any remaining coke. Turner said that he felt the front-end loader abruptly stop and saw that he had contacted the rear of Reynolds’ trailer (see Appendix B). Turner then exited the cab of the front-end loader and found Reynolds under the truck’s left rear dual wheels. Turner called Ramirez on the company radio to come to his location.
According to interviews, Ledbetter, James Ringo, Maintenance Supervisor, and Clifton Rotenberry, Production Manager, heard the call from the office. Ledbetter and Ringo traveled to the accident location. Ledbetter assessed the scene, determined that Reynolds had died, and called 911 at 2:00 p.m. American Medical Response emergency medical services pronounced Reynolds dead at 2:01 p.m.
INVESTIGATION OF THE ACCIDENT
On March 9, 2023, at 2:03 p.m., Harris called the Department of Labor National Contact Center (DOLNCC). The DOLNCC contacted Brett Barrick, Assistant District Manager. Barrick contacted Neal Davis, Supervisory Mine Safety and Health Inspector, and Brody Haddock, Mine Safety and Health Specialist, and assigned Haddock to be the lead investigator. At 3:50 p.m., Davis arrived at the accident site and issued an order under the provisions of Section 103(k) of the Mine Act to ensure the safety of the miners and preservation of evidence.
On March 10, 2023, at 9:15 a.m., Haddock arrived at the mine to continue the investigation. MSHA’s accident investigation team conducted an examination of the accident scene, interviewed miners and mine management, and reviewed conditions and work practices relevant to the accident. See Appendix C for a list of persons who participated in the investigation.
DISCUSSION
Location of the Accident
The accident occurred on the exit road of the coal unloading area from the lime plant.
Weather
The weather at the time of the accident was 63 degrees Fahrenheit with overcast skies. Investigators determined that weather did not contribute to the accident.
Equipment Involved
The truck involved in the accident was a 2021 Mack semi-truck and the trailer was a 2016 Travis aluminum trailer. The investigators examined the braking systems on both the truck and trailer and found the trailer brakes were set but the truck’s parking brake was not. The investigators also identified an air leak on the rear trailer reserve tank, although they could not determine when the leak occurred, as the rear of the trailer had received significant damage from the collision. Investigators tested the braking systems and determined that each system would set automatically as designed when the air decreased below 60 PSI. An audible and visual alarm also sounded. Investigators did not find any defects in the truck or trailer that contributed to the accident.
The front-end loader was a 2019 Komatsu WA480-8. Investigators examined the front-end loader and did not find any defects that contributed to the accident. According to interviews, Turner was operating the front-end loader with the bucket raised so that it restricted visibility while the front-end loader was in motion. The operator’s manual states, “When driving the machine or performing operations, always keep a safe distance from people, structures, or other machines to avoid coming into contact with them.” Additionally, it states to keep the bottom of the bucket 16 to 20 inches above the ground when traveling on level ground. A warning label on the front-end loader states, “Improper operation can cause serious injury or death. Read manual and labels before operation.” Turner could not maintain line of sight with the bucket raised to the height of the operator’s cab, which is greater than 20 inches above the ground. The mine operator did not ensure Turner maintained control of the front-end loader, which contributed to the accident.
Training and Experience
Reynolds worked as a truck driver for AMS Co, Inc. for over five years. He had a commercial driver’s license and had driven trucks with similar braking systems for five years. The mine operator provided Reynolds with site-specific hazard awareness training in accordance with MSHA Part 46 training regulations on June 6, 2022.
Turner worked at the Plant & Quarry mine as a front-end loader operator beginning January 4, 2023. The mine operator provided eight hours of new miner training at the start of his employment and 12 hours of task training on the Komatsu WA480-8 Front-End Loader on January 13, 2023. Turner received all training in accordance with MSHA Part 46 training regulations.
Examinations
Turner performed a pre-operational inspection of the front-end loader on the day of the accident. Turner noted in the inspection that the back top right light was defective. Investigators determined this did not contribute to the accident.
Reynolds conducted a pre-operational inspection of the truck and trailer at the AMS Co., Inc. truck yard prior to driving to the mine. Investigators determined the inspection was adequate and did not contribute to the accident.
The mine operator designated Turner to conduct workplace examinations in the coal unloading area. Investigators determined that the workplace examination was adequate and did not contribute to the accident.
ROOT CAUSE ANALYSIS
The accident investigation team conducted an analysis to identify the underlying causes of the accident. The team 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 that the front-end loader operator maintained control of the front-end loader.
Corrective Action: The mine operator retrained all mobile equipment operators on maintaining line of sight while operating equipment.
CONCLUSION
On March 9, 2023, at 1:55 p.m., Don Reynolds, a 60 year-old delivery truck driver with approximately five years of delivery truck driving experience, died when a front-end loader struck his truck and trailer. Reynolds was underneath his truck; the impact caused his truck’s left rear dual wheels to roll onto him.
The accident occurred because the mine operator did not ensure that the front-end loader operator maintained control of the front-end loader.
Approved By:
__________________________________ _____________
William O’Dell Date
District Manager
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to Texas Lime Company.
A fatal accident occurred on March 9, 2023, at 1:55 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 Texas Lime Company for a violation of 30 CFR 56.9101.
On March 9, 2023, at 1:55 p.m., a fatal accident occurred at this mine when a front-end loader struck a delivery truck driver’s tractor trailer. The delivery truck driver was underneath his truck; the impact caused his truck’s left rear dual wheels to roll onto him. The mine operator did not ensure that the front-end loader operator maintained control of the front-end loader.
APPENDIX C – Persons Participating in the Investigation
Texas Lime Company
Julius Harris Vice President/Plant Manager
Jason Nutzman Director of Legal and Compliance
Nathan O’Neill Vice President of Production
Dennis Johnson Safety Compliance Manager
Clifton Rotenberry Production Manager
Efrain Ramirez Production Supervisor
Clint Miller Floating/Relief Supervisor
James Ringo Maintenance Supervisor
Ramon Ledbetter Maintenance Planner
James Turner Front-End Loader Operator
Arley King Miners’ Representative
Robert Callahan Miners’ Representative
AMS Co., Inc.
Jackie Dooley Transportation Manager
Mine Safety and Health Administration
Neal Davis Supervisory Mine Safety and Health Inspector
Brody Haddock Mine Safety and Health Specialist