Accident Report: Fatality Reference
PDF Version
FAI-F005CB0-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Dimension Sandstone)
Fatal Drowning Accident
August 22, 2024
Vasquez Standup (C1484)
Montrose, Pennsylvania
at
Paguay Stone Quarries
Paguay Stone LLC
Hallstead, Susquehanna County, Pennsylvania
ID No. 36-08942
Accident Investigators
John Harvey
Mine Safety and Health Inspector
Vincent D’Angelo
Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
Warrendale District
178 Thorn Hill Road, Suite 100
Warrendale, PA 15086
Peter Montali, District Manager
OVERVIEW
On August 22, 2024, Wilson Vasquez, the 30 year-old owner of Vasquez Standup with 12 years of mining experience, drowned in a pool of water.
GENERAL INFORMATION
Paguay Stone LLC owns and operates the Paguay Stone Quarries mine, a dimension sandstone mine located in Hallstead, Susquehanna County, Pennsylvania. This mine employs 13 miners and operates one ten-hour shift per day, five days per week. The mine extracts dimension sandstone from the quarry by drilling and blasting. The mine cuts the stone at a saw shop on site and loads the cut stone onto trucks for commerce.
The mine operator contracted Vasquez Standup to pattern and cut the sandstone. Patterning sandstone is performed by making precision cuts and shaping the sandstone to create uniformity for visually appealing designs. The contractor operated one crew of eight miners at Paguay Stone Quarries.
The principal management official at Paguay Stone Quarries at the time of the accident was:
Luis Paguay Owner
The principal management official for Vasquez Standup at the time of the accident was:
Wilson Vasquez Owner
The Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection at this mine on May 8, 2024. The 2023 non-fatal days lost incident rate for the Paguay Stone Quarries was zero, compared to the national average of 1.12 for mines of this type.
DESCRIPTION OF THE ACCIDENT
On August 22, 2024, at approximately 10:30 a.m., Vasquez was working in the stone patterning area at the top of the quarry highwall. According to interviews, Vasquez was last seen operating a pressure washer in this area. The contracting crew from Vasquez Standup continued their normal work process throughout the rest of the day and left the mine at the end of their shift at approximately 4:20 p.m. At approximately 5:15 p.m., Mireya Nugra, Contract Miner, returned to the mine site to begin looking for Vasquez. Between 5:15 p.m. and 7:38 p.m., Nugra left and returned to the mine site three times to continue to look for Vasquez.
At approximately 7:50 p.m., Luis Paguay (L. Paguay), Owner, received a phone call from Roman Landi, Contract Miner, stating that Vasquez was missing. Paguay looked through still photos from the mine’s security camera for any evidence of Vasquez leaving the mine. At 8:28 p.m., Paguay returned to the mine site with Luis Alfredo Paguay, Miner, and began looking for Vasquez. At 8:49 p.m., L. Paguay found Vasquez submerged in a pool of water at the base of a highwall (see Appendix A). L. Paguay called his wife and requested she call the police.
At approximately 9:00 p.m., the Pennsylvania State Police and the Susquehanna County Coroner’s Office arrived at the accident scene. Jessica Chiaramonte, Susquehanna County Coroner, reported the time of death as 11:00 a.m. on August 22, 2024. The cause of death was determined to be drowning.
INVESTIGATION OF THE ACCIDENT
On August 23, 2024, at 9:36 a.m., Donnie Lunger, Pennsylvania Department of Environmental Protection, called Willam MacDonald, Supervisory Mine Safety and Health Inspector, to report a fatal accident at the mine. MacDonald sent Casey Dudeck, Mine Safety and Health Inspector, to the mine. At 2:30 p.m., Dudeck arrived at the mine 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 August 26, 2024, Peter Montali, District Manager, sent John Harvey and Vincent D’Angelo, Mine Safety and Health Inspectors, to the mine site to continue the investigation. MSHA’s accident investigation team conducted an examination of the accident scene; interviewed miners, mine management, and contractors; and reviewed conditions and work practices relevant to the accident. See Appendix B for a list of persons who participated in the investigation.
DISCUSSION
Location of the Accident
The accident occurred at a pool of water at the toe of the highwall below the stone patterning area (see Appendices A and C). The pool of water was approximately eight feet wide by 15 feet long, and approximately four feet deep. Investigators were not able to determine how or why Vasquez entered the water.
Weather
On the day of the accident, the weather was 67 degrees Fahrenheit and clear. Investigators determined weather did not contribute to the accident.
Examinations
L. Paguay conducted a workplace examination of the quarry working areas on the morning of the accident and did not note any hazards. Investigators reviewed workplace examination records for the previous three months and determined that no hazards in the quarry were documented. Investigators determined the examinations were adequate and did not contribute to the accident.
Training and Experience
Vasquez had over 12 years of mining experience and approximately one month of experience at this mine. Vasquez had over four years of experience working as a contractor and had recently become the owner of Vasquez Standup within the four weeks prior to the accident. Investigators determined that the mine operator did not provide Vazquez with site-specific hazard awareness training. No records were provided indicating any annual refresher training had been received in 2024. The last annual refresher training recorded was on March 7 and 8, 2023 for a total of three hours and 40 minutes. New miner training was also provided on March 8, 2023, for a total of 13 hours. Task training was documented on the following subjects, but no date, subject length, or competent person was provided: table saw, block saw, skid steer, excavator, and stone splitter. Although Vasquez did not receive all training in accordance with MSHA Part 46 training regulations, investigators determined that it did not contribute to the accident due to his previous experience.
Autopsy Findings
The autopsy examination revealed blunt head trauma injuries, a fractured rib, abrasions on Vazquez’s body, knuckles, and hands, as well as a large amount of watery liquid in his stomach. The autopsy report states the cause of death is “drowning,” the contributory condition is “blunt head trauma,” and the manner of death is “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 contractor drowned in a pool of water.
Corrective Action: The mine operator will retrain all miners on hazards of drowning, including the use of fall protection or a life jacket, when required.
CONCLUSION
On August 22, 2024, Wilson Vasquez, the 30 year-old owner of Vasquez Standup with 12 years of mining experience, drowned in a pool of water.
Approved By:
___________________________________ _______________
Peter Montali Date
District Manager
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to Paguay Stone LLC.
A fatal accident occurred on August 22, 2024. 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 activities 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.
APPENDIX B – Persons Participating in the Investigation
Paguay Stone LLC
Luis Paguay Owner
Luis Alejandro Paguay Foreman
Luis Enrique Mayllazhungo Miner
Luis Ricardo Mayllazhungo Miner
Luis Alfredo Paguay Miner
Vasquez Standup
Roman Landi Contract Miner
Mireya Nugra Contract Miner
Darwin Tapia Contract Miner
Pablo Vasquez Contract Miner
John Heeman Driller
Mine Safety and Health Administration
Ramiro Jimenez Supervisory Mine Safety and Health Inspector
William MacDonald Supervisory Mine Safety and Health Inspector
Vincent D’Angelo Mine Safety and Health Inspector
Casey Dudeck Mine Safety and Health Inspector
John Harvey Mine Safety and Health Inspector
Kathleen Hemmerlin Mine Safety and Health Training Specialist
Scott Chiccarello Mine Safety and Health Training Specialist