UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Western District
Accident Investigation Report
Surface Nonmetal Mine
Fatal Other Accident
DOM-EX, Incorporated
Contractor ID No. DVZ
at
Boron Operations
U.S. Borax Incorporated
Boron, Kern County, California
ID No. 04-00743
July 28, 1996
by
Edward E. Lopez
Mine Safety and Health Inspector
David A. Kerber
Mines Safety and Health Inspector
Western District Office
3333 Vaca Valley Parkway, Suite 600
Vacaville, Ca 95688
Fred M. Hansen
District Manager
GENERAL INFORMATION
Quinn Allen Richardson, field service mechanic, age 34, was
fatally injured and Peter Martin, lead field mechanic, age
37, was seriously injured at 12:03 p.m., on July 28, 1996,
when the wheel they were removing from a front-end loader
blew off the hub. Both men were contractor employees
performing work at the mine site. Richardson had four years
of mining experience, including one month with this company.
Martin had 16 years of mining experience, four years with
this company as a lead mechanic. Both men had received MSHA
approved Part 48 training for contractors through a technical
college. Neither man received required Part 48 hazard
training for this mine site, nor had they received task
training specific to this type loader. The mine's Part 48
Training plan was approved by MSHA July 10, 1979 and was last
revised January 24, 1994.
Terry W. Cleveland, safety manager for U.S. Borax Inc.,
notified MSHA at 2:30 p.m., on the day of the accident. An
investigation was begun the same day.
Richardson and Martin were employees of DOM-EX INC., a
company with 48 employees that dealt in new and used
equipment and spare parts. The two men had been dispatched
to dismantle purchased equipment, including the front-end
loader involved in the accident, and prepare the equipment
for shipment to company headquarters in Hibbing, Minnesota.
The principal officials for the DOM-EX INC. were Daniel
Motter, vice president, and Peter Martin, lead field
mechanic.
The Boron Operations was a multiple bench open pit borax mine
owned and operated by U.S. Borax Incorporated. The mine was
located near Boron, Kern County, California. Principal
officials were Preston S. Chiaro, vice president, and Terry
W. Cleveland, safety manager. The mine normally operated
three 8-hour shifts, seven days a week. A total of seven
hundred fifty employees worked at the mine site.
The last regular inspection, of this operation was completed
on April 27, 1995. A regular inspection following the
accident was completed on October 31, 1996.
PHYSICAL FACTORS
The equipment involved in the accident was a 1981 LeTourneau
L-800 front-end loader, serial number 1178. The loader had
been moved the day of the accident from the mine salvage yard
to the staging area for disassembly. Wooden blocks were
placed under the loader by the DOM-EX employees to facilitate
wheel removal.
At the time of the investigation, the 16-yard loader was
intact with the exception of the right front wheel. The
wheel, including the tire and split rim, was lying on the
ground, between the loader and the contractor's truck, a few
feet from the damaged right front hub. Damage to the hub
consisted of the cover plate's upper rear quarter being bent
outward, with a three and one-half inch gap between it and
the hub.
The Bridgestone series L5 tire measured seven and one half
feet in diameter and including the wheel weighed
approximately five thousand pounds. In normal use the tire
would have contained water and air and been inflated to 100
pounds per square inch. The tire was still on the split rim,
which had a two inch gap between its two sections. The rim
liner protruded through the gap and showed signs of damage.
The valve stem's air valve was still in place.
Prior to disassembly, the two piece rim was held together
with sixteen, 3/4" by 2" capscrews (rim bolts). The wheel
was secured to the loader hub with forty-eight 1" by 3"
capscrews (lug bolts). The investigation disclosed that all
of the rim bolts and 41 of the lug bolts had been removed.
The remaining seven lug bolts had been cut with a torch and
were protruding from the hub. Six bolts appeared to have
been completely cut in two while the seventh looked as if it
snapped while being cut. After the accident the torch was
found partially detached from its hoses with oxygen and
acetylene spewing.
The manufacturer's maintenance manual required that the tire
be deflated to zero psi and the air valve be removed from the
valve stem prior to removal of the rim bolts. The manual
further stated that, "Failure to follow standard safety
precautions could be devastating".
A DOM-EX INC., Ford LTL 9000 diesel boom truck was parked
parallel to the loader, approximately fifteen feet away. It
received no damage from the accident.
The weather on the day of the accident was clear and warm
with temperatures climbing over 100 degrees Fahrenheit.
DESCRIPTION OF ACCIDENT
Quinn Allen Richardson (victim) and Peter Martin arrived at
the mine at 7:11 a.m., on July 28, 1996. They were granted
access by the guard at the mine gate and proceeded to the
salvage yard where the LeTourneau L-800 front-end loader was
parked. They had intended to drive the loader to the staging
area but found that it was inoperable. The men then drove
their vehicle to the truck maintenance shop seeking
assistance. Michael Newling, U.S. Borax shop foreman, had
his employees tow the loader to the mine staging area. The
loader was delivered at approximately 10:00 a.m. and
Richardson and Martin began blocking the loader off the
ground. The U.S. Borax employees returned to their duties.
About noon, William Case, U.S. Borax heavy equipment
milwright, saw Martin walking down the road near the tire
barn, approximately three hundred feet from the staging area.
Martin was not wearing his hard hat and was holding his side
as if something was wrong. When Case approached, Martin told
him he needed to get help for his partner. He also said that
he had just regained consciousness and did not know what had
happened.
Case radioed for help and then proceeded with Martin to the
staging area. They found Richardson, lying face down,
halfway under the rear of the boom truck. A few moments
later they were joined by Newling and other employees,
including an Emergency Medical Technician (EMT) and a
paramedic. An assessment of the situation disclosed that
there was nothing that could be done for Richardson. Martin,
who had received lacerations and contusions, was administered
first aid prior to being air evacuated.
The county coroner/investigator pronounced Richardson dead at
the accident scene and listed the time of death as 12:03 p.m.
His death was attributed to "blunt force trauma".
Martin was unable to recall events relating to the accident
and there were no other witnesses to what occurred once the
men began removing the first of the loader's wheels. Based on
the facts observed at the accident scene and information
obtained during the investigation, it was determined the two
contractor employees were attempting to disassemble the wheel
and remove it without deflating the tire.
Evidence at the accident scene indicated the men had not
given consideration to the fact that the tire was inflated.
It appears they were having difficulty removing seven of the
bolts with their air wrench so they decided to cut them off
with a torch. As the last bolt was being cut, the rims
separated and air escaped with an explosive force. The wheel
was blown off the hub striking both men.
CONCLUSION
The direct cause of the accident was the failure to
completely deflate the tire and remove the valve core
assembly before working on the wheel assembly. Contributing
causes were the failure to follow manufacturer's written
recommendations and provide appropriate training for the
individuals assigned to disassemble the loader.
CITATIONS/ORDERS
Order No. 4144130
Issued on July 28, 1996 under
provisions of Section 103(k) of the Mine Act.
This order was issued to assure the safety of persons until
an investigation can determine that affected areas of the
mine are safe. The order was terminated on July 29, 1996.
Citation No. 7953601
Issued to U.S. Borax, Inc. On July
29, 1996 under provisions of Section 104(d)(1) for violation
of 30 CFR 48.31(a).
A field service mechanic was fatally injured on July 28, 1996
when he and his supervisor attempted to remove a tire and
wheel assembly from a Le Tourneau L-8000 front-end loader.
Required hazard training, including instructions regarding
health and safety standards, safety rules, and safe work
procedures, was not provided to the two men prior to the
commencement of their work duties at the Boron Operations.
This is an unwarrantable failure to comply with Part 48.
The citation was terminated July 29, 1996, as the two men
were no longer working at the mine site. The mine operator
has instructed appropriate personnel to prohibit entrance of
contractors prior to providing hazard training.
Citation No. 7953604
Issued to DOM-EX, Inc. On July 31,
1996 under provisions of Section 104(a) for violation of 30
CFR 56.14104(a).
A field service mechanic was fatally injured on July 28, 1996
when he and his supervisor were attempting to remove a tire
and wheel assembly from a Le Tourneau L-8000 front-end
loader. They had failed to deflate the tire and remove its
valve assembly prior to using a torch to cut rim bolts to aid
in removing the tire. This is an unwarrantable failure.
The citation was terminated August 12, 1996 after the company
instituted a tire and rim safety awareness program.
Citation No. 7953605
Issued to DOM-EX, Inc. On July 31,
1996 under the provisions of Section 104(d)(1) of the Mine
Act for violation of 30 CFR 48.31(a).
A field service mechanic was fatally injured on July 28, 1996
when he and his supervisor attempted to remove a tire and
wheel assembly from a Le Tourneau L-8000 front-end loader.
Required hazard training, including instructions regarding
health and safety standards, safety rules, and safe work
procedures, was not provided to the men prior to the
commencement of their work duties at the Boron Operations.
This is an unwarrantable failure to comply with Part 48.
This citation was terminated on August 12, 1996 after the
company initiated a comprehensive hazard training program to
be completed prior to employees entering mining properties.
They also instructed appropriate personnel to ensure their
employees receive hazard training prior to commencement of
work at mine sites.
/s/ Edward E. Lopez
Mine Safety and Health Inspector
/s/ David A. Kerber
Mine Safety and Health Inspector
Approved by: Fred M. Hansen, District Manager
Related Fatal Alert Bulletin: [FAB96M32]
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