UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Accident Investigation Report
Underground Metal Mine
Fatal Powered Haulage
Getchell Mine
Getchell Gold Corporation
Golconda, Humboldt County, Nevada
Mine ID No. 26-02233
January 15, 1997
by
Stephen A. Cain
Mine Safety and Health Inspector
Thomas E. Barrington
Mine Safety and Health Inspector
Mine Safety and Health Administration
Western District
3333 Vaca Valley Parkway, Suite 600
Vacaville, CA 95688
Fred M. Hansen
District Manager
GENERAL INFORMATION
Isabelle Marcelle Justus, age 36, an underground lube
technician/laborer, was fatally injured at approximately 4:20
p.m. on January 15, 1997, when the loader she was servicing
crushed her against the rib. Justus had one year and three
months of mining experience, all at this mine. She had held the
title of lube technician the past nine months. Justus originally
was hired as a surface warehouse worker and was given 24 hours of
surface new miner training. She was later transferred
underground but was not given the required underground new miner
training. There also were no records to indicate that she had
received task training upon being assigned lube technician
duties.
Timothy Kilbreath, Safety Engineer for Getchell Gold Corporation,
notified MSHA of the accident at 6:09 p.m. on January 15, 1997.
An investigation was started the same day.
The Getchell Mine was a multi-level, gold producing, underground
mine located 30 miles north of Goldconda, Humboldt County,
Nevada. The mine was owned and operated by Getchell Gold
Corporation. Principal officials were R. David Russell, vice-president and CEO, Tim Harter, general mine manager, Craig
Gimmel, mine superintendent, and Patrick S. Allen, loss control
manager. The mine worked two shifts per day, seven days per
week. A total of 241 employees worked on the surface and
underground.
The mining method was underhand cut-and-fill with conventional
drilling and blasting. Mucking was done with rubber tired LHD
mobile equipment. The ore was hauled to the surface to
processing points where it was sized and placed on cyanide leach
pads. Gold was recovered through a carbon collection/
electrowinning process.
The last regular inspection of this operation, prior to the
accident, was completed on March 21, 1996. A regular inspection
was completed February 25, 1997.
PHYSICAL FACTORS INVOLVED
The accident occurred at the 4850-162 drift, an access cross-cut
drift located between the 4850 haulage drift and the 4864
production drift. The 4850-162 drift was about 50 feet in length,
13 feet wide, and 14 feet high. It was developed on a 10 percent
grade.
The Tamrock/EJC, model 130, Load-Haul-Dump scoop tram(LHD) was a
3-1/2 yard, rubber tired, articulated, front-end loader. The LHD
was 27 feet, 9 inches in length and, at the operator's station, 7
feet, six inches in height. It weighed 17.5 tons. Approximately
one yard of muck was in the bucket at the time of the accident.
The loader articulated in the center with the operator's
compartment on the left side behind the articulation pivot point.
The LHD was powered by a Detroit, four cylinder, turbo charged,
diesel engine. Power was transferred through a Powershift three-speed transmission and a Clark C273 torque converter. Because of
the grades the LHD operated on, the third gear had been blocked
out as both a safety and maintenance measure. The overall gear
ratio was 22.39 to 1.
The brakes on the LHD operated on two separate systems. The
service brake was an enclosed, liquid cooled, multi-disc system.
Hydraulically actuated service brakes were provided on each wheel
unit and had an accumulator reserve. A dual, closed center,
control valve was actuated by a foot pedal at 1500 psi. The
accumulators were piston type, nitrogen charged at 800 psi pre-load. Cooling of the service brakes was attained through the use
of a one quart receiver located above the differential. This
system experienced a constant loss of coolant and required
regular refilling.
The park brake system was a single caliper/rotor assembly. The
assembly was located on the front drive line at the union with
the front differential third member. The caliper was mounted
under the rotor on a 9 16 inch thick metal frame that extended
across the lower portion of the main frame. Application of the
caliper was spring applied when the hydraulic pressure in the
system was released, causing three pistons with pads on each side
of caliper to extend and make contact with the rotor. Release
pressure was set at 1400 psi with an accumulator reserve system
similar to the service brakes.
The company had adopted the manufacturer's recommendations for
pre-operational testing of the brakes. There were separate
procedures to follow in testing the service brakes and the park
brake. During the investigation it was found that loader
operators did not know the correct testing procedures.
A Tamrock service technician visited the mine in June of 1996 to
review brake problems the mine was experiencing. Brakes were
wearing out sooner than anticipated. The technician's follow-up
report listed major problems with the equipment operators'
knowledge of the park brake test procedures. The technician also
stated that improper maintenance was the reason for the short
brake life. Equipment operators reported park brake defects on
service logs, but records indicated that the mine operator failed
to initiate corrective action.
Both the service brakes and the park brake systems were
disassembled and inspected. The service brakes were found to be
in serviceable condition. The park brake had major deficiencies
including; extensively worn brake pads, missing brake pads,
missing dust covers, a scarred brake piston, a scarred and worn
brake rotor, leaking hydraulic piston covers, a missing brake
caliper guard, misaligned park brake caliper, and misaligned
caliper mounting frame. Deficiencies in the electrical and
hydraulic systems were also observed. An electrical
coil/solenoid necessary for testing the park brake was
inoperative because the coil was burned out. The park brake test
could not be performed prior to operating the LHD because a valve
was blocked and would not open. Foreign material in the valve
indicated contamination of the hydraulic system.
A misalignment was noted in the caliper mounting frame resulting
in an uneven wear pattern on the caliper and the rotor. By being
misaligned, the caliper components could not apply nor release as
designed. A circular pattern cut across the rear half of the
caliper body and caliper pistons indicated the inability to
properly release, completely wearing away the brake pads. The
application between the rear caliper and the rotor was metal on
metal at the time of the accident. The front portion of the
caliper was able to apply only an estimated 33 percent of the
pads to the rotor and were worn unevenly. The park brake caliper
mounting frame had two torch-burned holes in it, affecting the
integrity of the frame. It was concluded that the holes may have
been for the straightening of the mounting plate at some earlier
date. A metal plate, designed by the manufacturer to protect the
caliper and its mounting plate from damage, was not in place.
DESCRIPTION OF ACCIDENT
Justus (victim) reported for work at 7:30 a.m. At approximately
4:10 p.m., she was notified that Joshua Rugh, miner first class,
had called requesting fuel for the Tamrock 130 LHD he was
operating. Justus was told that Rugh could be found tramming
backfill in the 4850-184 area.
Justus arrived at the 4850-184 but Rugh was not there. She then
contacted Willie Brown, lead miner, who directed her to the 4850-162 area. While Justus was enroute, Brown went to Rugh and told
him to "rib" the loader. Rugh stopped the loader on a ten
percent grade with the bucket pointed uphill and the left rear
into the rib. He set the park brake, shut off the engine, and,
along with Brown, checked the loader's fluid levels. Rugh and
Brown waited approximately ten minutes, until about 4:15 p.m.,
for Justus to arrive with the service truck.
Upon arrival Justus backed the truck toward the LHD, parking
about four feet from the loader motor. She pulled the diesel
fill hose off the spool and passed it to Rugh who was between the
motor and the rib. Brown told Justus that the LHD also needed
brake fluid and hydraulic fluid. They pulled the hydraulic fluid
hose off its spool and Justus climbed over the motor compartment
into the area where Rugh was located. Rugh filled the diesel
tank approximately one-third full. As he was replacing the
diesel tank cap and passing the hose to Justus, the loader began
moving. It scraped along the rib as it traveled approximately
two feet. Justus was crushed and Rugh was caught between the rib
and the loader.
Rugh yelled to Brown to get the LHD off them. Brown started the
loader and trammed to a level area above the accident scene where
he parked. Eddie Mendoza, miner third class, hearing and seeing
what had happened, ran to the pager phone in the 4850 and called
for help. Rugh and Odoms began first aid on Justus.
Sally Shipman, EMT, responded to the call and began emergency
aid. Justus was transported to the surface on Odom's haul truck
and transferred to a mine emergency vehicle. The Humboldt County
ambulance met the mine vehicle approximately 20 miles from the
mine and transported Justus to Humboldt General Hospital where
she was pronounced dead by the county coroner.
CONCLUSION
The cause of the accident was the failure of the park brake, a
result of poor maintenance practices. Inadequate employee
training also contributed to this occurrence.
CITATIONS/ORDERS
Order No. 4141013
Issued on January 15, 1997 under provisions
of Section 103(k) of the Mine Act:
On January 15, 1997 an underground miner was fatally injured when
she was pinned against the rib by a LHD. This order was issued
to insure the safety of persons until the affected areas of the
mine could be returned to normal operation. This order was
terminated on 01/18/97 after it was determined it was safe to
resume operations.
Citation No. 7951336
Issued January 15, 1997 under provisions
of Section 104(a)for violation of 30 CFR 48.5(a).
On January 15, 1997 an underground miner was fatally injured when
she was pinned against the rib by a LHD. The victim had not
received health and safety training required to be given a new
inexperienced underground miner.
The citation was terminated January 30, 1997 after the company
was instructed in the requirements of 48.5(a).
Citation No. 7951549
Issued January 15, 1997 under provisions
of Section 104(a)for violation of 30 CFR 48.9(a).
On January 15, 1997 an underground miner was fatally injured when
she was pinned against the rib by a LHD. The company failed to
provide task training records for the victim.
The citation was terminated March 18, 1997 after required records
were produced.
Citation No. 7951338
Issued January 15, 1997 under provisions
of Section 104(d)(1) for violation of 30 CFR 57.14101(a)(2).
On January 15, 1997 an underground miner was fatally injured when
she was pinned against the rib by a LHD. The parking brake was
not capable of holding the loader at the location it was parked.
The condition of the brake had been reported to company agents
with no corrective action taken. This is an unwarrantable
failure.
The citation was terminated January 30, 1997 after the vehicle
was taken out of service and shipped to the manufacturer.
Order No. 7951339
Issued January 15, 1997 under provisions of
Section 104(d)(1) for violation of 30 CFR 57.14101(a)(3).
On January 15, 1997 an underground miner was fatally injured when
pinned against the rib by a LHD. The park brake on the LHD was
not being maintained in a functioning condition. The condition
of the brakes had been reported to company officials with no
corrective action taken. This is an unwarrantable failure.
The order was terminated on January 30, 1997 after the LHD was
removed from service.
Order No. 7951340
Issued on Juy 15, 1997 under provisions of
Section 104(d)(1) for violation of 30 CFR 57.14100(b).
On January 15, 1997 an underground miner was fatally injured when
pinned against the rib by a LHD. Brake defects reported to
company officials were not corrected in a timely manner. This is
an unwarrantable failure.
The order was terminated on January 30, 1997 after company
officials were made aware of the requirements of 57.14100(b).
Citation No. 7951341
Issued January 15, 1997 under provisions
of Section 104(a) for violation of 30 CFR 50.12.
On January 15, 1997 an underground miner was fatally injured when
pinned against the rib by a LHD. Following the accident, the
scene was not protected in that the lube truck had been moved and
foot traffic was permitted through the area.
The citation was terminated on January 30, 1997 after company
officials were made aware of the requirements of 50.12.
/s/ Stephen A. Cain
Mine Safety and Health Inspector
/s/ Thomas E. Barrington
Mine Safety and Health Inspector
Approved by: Fred M. Hansen, District Manager
Related Fatal Alert Bulletin: [FAB97M03]
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