Accident Report: Fatality Reference
PDF Version
FAI-6927394-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Dimensional Stone)
Fatal Powered Haulage Accident
September 6, 2024
Bosket Mountain
Bosket Brothers Bluestone, LLC
Deposit, Broome County, New York
ID No. 30-04141
Accident Investigators
Jason Dibble
Mine Safety and Health Inspector
Mark Kvitkovich
Mechanical Engineer, Technical Support
Davin Sweeney
Mechanical Engineer, Technical Support
Originating Office
Mine Safety and Health Administration
Warrendale District
178 Thorn Hill Road, Suite 100
Warrendale, PA 15086
Peter Montali, District Manager
OVERVIEW
On September 6, 2024, at 3:24 p.m., Brandon Felter, a 29-year-old miner with one year and five months of mining experience, died after he lost control of the articulating haul truck (truck) he was operating down a steep roadway and crashed into a residence.
The accident occurred because the mine operator did not: 1) ensure the miner maintained control of equipment while it was in motion, and 2) task train the miner on the operation of the truck.
GENERAL INFORMATION
Bosket Brothers Bluestone, LLC owns and operates the Bosket Mountain mine, a surface dimensional stone mine located in Deposit, Broome County, New York. The mine employs three miners and operates the mine based on demand for the product. The mine drills and blasts stone into blocks. Haul trucks transport the blocks to the Saw Shop where they are cut to size and/or palletized. The cut blocks and some palletized blocks are placed into commerce. The rest of the palletized blocks are used for road projects.
The principal management official at the Bosket Mountain mine at the time of the accident was:
Andrew Bosket Owner
The mine operator had been operating illegally on this property since January 2023 and did not notify the Mine Safety and Health Administration (MSHA) before commencement of mining. Therefore, MSHA had not conducted a regular safety and health inspection, and since the mine operator was not reporting injuries and work hours, no non-fatal days lost injury rate could be calculated. The mine operator legally operated a mine at a different location that was placed on abandoned status approximately ten years ago and was aware of MSHA’s requirements.
DESCRIPTION OF THE ACCIDENT
On September 6, 2024, at approximately 7:00 a.m., Felter arrived for his shift. Andrew Bosket, Owner, assigned him his normal task of working at the Saw Shop. At approximately 11:30 a.m., A. Bosket and Felter traveled to the mine area where A. Bosket assigned Felter to operate an articulating haul truck (truck) and assist in the process of widening the roadway. At approximately 12:00 p.m., A. Bosket operated an excavator and loaded material into Felter’s truck. Felter hauled the material to designated areas along the mine entrance roadway. Richard Phillips, Equipment Operator, operated a track loader to push the material Felter delivered into areas of the roadway for road stabilization and widening.
At approximately 3:00 p.m., A. Bosket loaded Felter’s truck with the 12th load for delivery to Phillips. However, Felter traveled past Phillips, and continued south down the mine entrance roadway. After traveling approximately 570 feet past Phillips, Felter’s truck traveled off the mine entrance roadway and crashed into the residence of Joshua Bosket, Saw Shop Supervisor.
J. Bosket’s wife alerted him of the accident. At 3:11 p.m., J. Bosket, who was at the Saw Shop, called 911 and traveled to his residence. J. Bosket checked on Felter, but he was unresponsive. New York State Police responded and secured the scene until Emergency Medical Services arrived. John Prindle, Coroner, pronounced Felter dead at 3:24 p.m.
INVESTIGATION OF THE ACCIDENT
On September 6, 2024, at 5:56 p.m., Jeffrey Prebish, OSHA Area Director, called the Department of Labor National Contact Center (DOLNCC) to report the accident. The DOLNCC contacted Cody Sheldon, Supervisory Special Investigator, who sent Colin Keller, Mine Safety and Health Inspector, to the mine. Keller arrived at approximately 8:15 p.m. and issued an order under the provisions of 103(k) of the Mine Act to ensure the safety of miners and preservation of evidence. Thomas Rasmussen, Assistant District Manager, assigned Jason Dibble, Mine Safety and Health Inspector, as the lead accident investigator. Dibble arrived at the mine on
September 9, 2024, at 10:15 a.m. and continued the investigation.
MSHA’s accident investigation team conducted an examination of the accident scene, interviewed miners and mine management, and 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 on the mine entrance roadway (see Appendix B). The roadway had a turnaround that measured 48 feet wide and 52 to 36 feet long. The grade of the roadway at the turnaround was approximately 20 percent. From the turnaround, the truck traveled down a 24-percent grade for 288 feet, then turned into a small patch of woods. The truck traveled down an 8-foot-tall embankment and across a 39-foot-wide roadway. There were no tire tracks observed on the embankment wall or the roadway, indicating that the truck jumped the roadway due to the steep grade, the high rate of speed, and the weight. The truck then entered a thicker patch of woods, traveled 95 feet until it entered the backyard of the residence, and finally traveled 158 feet through the backyard and into the residence.
Weather
The weather at the time of the accident was 73 degrees Fahrenheit with fair skies. Investigators determined that the weather did not contribute to the accident.
Equipment Involved
The equipment involved in the accident was a Caterpillar D400D Articulating Haul Truck, Serial No. 8TF00798. The mine operator purchased the truck in used condition on July 1, 2024. Investigators determined that the mine operator did not ensure the miner maintained control of equipment while it was in motion, which contributed to the accident.
On September 13, 2024, the MSHA accident investigation team conducted an initial inspection of the truck’s braking system. Investigators found a potential air leak in the truck’s braking system but could not determine if the air leak was present at the time of the accident due to the damage resulting from the accident.
On September 26 and December 12, 2024, MSHA Technical Support and representatives from Milton Caterpillar conducted another limited inspection of the truck. MSHA Technical Support identified defects with the truck’s service brake system and various warning systems which were intended to alert the truck’s operator to hazardous conditions. Investigators were unable to determine the effect these defects had on the overall braking and steering system operation at the time of the accident due to the condition of the truck.
Examinations
Investigators could not confirm if Felter conducted an adequate pre-operational inspection of the truck, including a brake test, prior to operation. There were no known defects to the truck’s braking system prior to the truck being placed into operation.
The mine operator visually examined the mine entrance roadway daily. However, there were no records of workplace examinations. Investigators did not identify hazards on the mine entrance roadway that would have caused the accident. The lack of workplace examination records did not contribute to the accident.
Training and Experience
Felter had one year and five months of mining experience; all working for the mine operator. The mine operator hired Felter as an experienced drill operator on March 29, 2023. A review of training records showed Felter received Annual Refresher Training on January 29, 2024. Felter operated the truck intermittently since July 2024. Investigators determined the mine operator did not provide Felter task training on the operation of the truck, which contributed 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 causes, and the mine operator implemented the corresponding corrective actions to prevent a recurrence.
1. Root Cause: The mine operator did not ensure the miner maintained control of equipment while it was in motion.
Corrective Action: The mine operator implemented an updated Standard Operating Procedure (SOP) to their Surface Powered Haulage Program for maintaining control of mobile equipment while it is in motion. The SOP ensures miners operate equipment consistent with the conditions at the mine and the type of equipment. The mine operator trained all miners on the updated program.
2. Root Cause: The mine operator did not task train the miner on the operation of the truck.
Corrective Action: The mine operator implemented an updated SOP to their Surface Powered Haulage Program for training on mobile equipment used at the mine. The SOP ensures miners receive training on the safe operation of mobile equipment that they are assigned to operate. The mine operator added the SOP to their Part 46 training plan and trained all miners on the updated program.
CONCLUSION
On September 6, 2024, at 3:24 p.m., Brandon Felter, a 29-year-old miner with one year and five months of mining experience, died after he lost control of the articulating haul truck (truck) he was operating down a steep roadway and crashed into a residence.
The accident occurred because the mine operator did not: 1) ensure the miner maintained control of equipment while it was in motion, and 2) task train the miner on the operation of the truck.
Approved By:
__________________________________ _____________
Peter Montali Date
District Manager
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to Bosket Brothers Bluestone, LLC.
A fatal accident occurred on September 6, 2024, at 3:24 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 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 Bosket Brothers Bluestone, LLC for a violation of 30 CFR 56.9101.
On September 6, 2024, a fatal accident occurred when a miner lost control of the articulating haul truck he was operating down a steep roadway and crashed into a residence. The mine operator did not ensure the miner maintained control of the equipment while it was in motion.
3. A 104(d)(1) citation was issued to Bosket Brothers Bluestone, LLC for a violation of 30 CFR 46.7(a).
On September 6, 2024, a fatal accident occurred when a miner lost control of the articulating haul truck he was operating down a steep roadway and crashed into a residence. The mine operator did not task train the miner on the operation of the Caterpillar D400D Articulating Haul Truck. The mine operator engaged in aggravated conduct constituting more than ordinary negligence. The miner operated the truck intermittently since July 2024, and the mine operator did not provide any task training. This violation is an unwarrantable failure to comply with a mandatory standard.
APPENDIX A – Persons Participating in the Investigation
Bosket Brothers Bluestone, LLC
Andrew Bosket Owner
Joshua Bosket Saw Shop Supervisor
Richard Phillips Equipment Operator
Adele Abrams Counsel
New York State Police Department (Troop C)
Jessica Poole Investigator
William Baumgartner Senior Investigator
David Sly Collision Reconstruction Unit Senior Investigator
David Sersen Collision Reconstruction Unit Investigator
Brandon Conway Collision Reconstruction Unit Investigator
Milton Caterpillar (Binghamton, NY)
Scott Stewart Service Manager
Todd Fillinger Regional Technical Communicator
Bill Starr Chief Legal Officer
Caterpillar Inc.
Thomas Robertson Counsel, Tanenbaum Keale LLP
John Nelson Consultant, S-E-A Consulting
Mine Safety and Health Administration
Sean Murphy Supervisory Mine Safety and Health Inspector
Shawn Heim Mine Safety and Health Specialist
Jason Dibble Mine Safety and Health Inspector
Colin Keller Mine Safety and Health Inspector
Mark Kvitkovich Mechanical Engineer, Technical Support
Davin Sweeney Mechanical Engineer, Technical Support