Mine Safety and Health Administration
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U.S. Department of Labor Mine Safety and Health Administration Protecting Miners' Safety and Health Since 1978 |
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Jump to Overview MAI-2008- 01
DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION Metal and Nonmetal Mine Safety and Health REPORT OF INVESTIGATION Surface Nonmetal Mine (Cement) Fatal Fall of Person Accident January 21, 2008 Robertson's Transport Contractor I.D. No. T363 at Oro Grande Quarry Riverside Cement Company Oro Grande, San Bernardino County, California Mine I.D. No. 04-00011 Investigators Bart T. Wrobel Supervisory Mine Safety and Health Inspector Larry Larson Mine Safety and Health Inspector Isabel Williams Mine Safety and Health Specialist Robert S. Setren, PE Mechanical Engineer Originating Office Mine Safety and Health Administration Western District 2060 Peabody Road, Suite 610 Vacaville, California 95687 Arthur L. Ellis, District Manager OVERVIEW
Stanley Xavier, contract truck driver, age 58, was fatally injured when he fell from the top of a bulk cement trailer to the ground below. Xavier was on top of the trailer closing and securing the hatches after the trailer was loaded with cement. The accident occurred because management did not have policies and procedures in place to ensure that contract truck drivers could safely open and close trailer hatches before and after loading. The victim was working without fall protection where there was a danger of falling. GENERAL INFORMATION
Oro Grande Quarry, a surface quarry and cement plant owned and operated by Riverside Cement Company (Riverside), was located at 19409 National Trails Highway, Oro Grande, in San Bernardino County, California. The principal operating official was Gordon Johnson, plant manager. The mine normally operated three, 8-hour shifts per day, seven days a week. Total employment was 228 persons. Limestone was drilled and blasted from multiple benches. The broken rock was transported by haul trucks to a primary crusher. The material was conveyed to the plant where it was mixed with other materials to produce cement. Finished products were sold in bulk and bag for use in the construction industry. Robertson's Transport, located in Rialto, San Bernardino County, California, was contracted by Riverside to haul bulk cement, sand, and rock. The principal operating official was Daniel Crane, operations manager. Robertson's Transport employed 3 or 4 drivers at the Oro Grande Quarry. The last regular inspection at this operation was completed on December 5, 2007. DESCRIPTION OF THE ACCIDENT
On the day of the accident, Stanley Xavier (victim) reported to work at the Robertson's Transport yard at 11:48 a.m., his regularly scheduled time. Xavier contacted Gilbert Sanchez, dispatcher, who instructed Xavier to perform a pre-trip inspection of his truck and to call Kevin King, another dispatcher, for his first assignment. At 12:00 p.m., King instructed Xavier to go to the Oro Grande Quarry, have the trailer loaded, and call for delivery instructions. Xavier arrived at the mine at 12:34 p.m., used the south truck access structure (lid rack) to get the top of his truck, opened the hatches of his trailers, and drove to the loading area where the trailer was loaded with bulk cement. At 12:55 p.m., Xavier received a load ticket and left the loading area. He drove to the outbound north lid rack to close the hatches on the trailer. Riverside required all truck drivers to use these lid racks to get to the top of their trailers when opening and closing the trailer hatches. About 1:30 p.m., Richard Huidor, Robertson's Transport truck driver, arrived and drove by the north lid rack. Huidor saw Xavier on the ground behind the second axle of his truck. Huidor and Gil Andrade, a truck driver from another trucking company, went to Xavier but he was non-responsive. Andrade called for emergency medical personnel. Xavier was pronounced dead at the scene at 1:57 p.m. by the San Bernardino County coroner. The cause of death was attributed to blunt force trauma. INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) was notified of the accident at 1:44 p.m., on January 21, 2008, by telephone from Diane Fionda, Riverside's safety coordinator, to MSHA's emergency call center. Michael Franklin, assistant district manager, was notified and an investigation was started the same day. An order was issued under the provisions of 103(k) of the Mine Act to ensure the safety of the miners. MSHA's accident investigation team traveled to the mine, made a physical inspection of the accident scene, interviewed employees, and reviewed documents and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine and contractor management and their employees, miners' representative, and the California Occupational Safety and Health Administration's Mining and Tunneling Division. DISCUSSION
Location of the Accident The accident occurred in an area located on the northwest section of the mine where contractor and over-the-road trucks entered and exited. Two truck access structures, designated as the north lid rack and the south lid rack, were located in this area. The lid racks were built to provide access to the top of the trailers so truck drivers could open and close the hatches of their bulk cement trailer compartments. The accident occurred at the north lid rack. The road grade in this area was 7 percent. Weather The weather on the day of the accident was overcast and 42 degrees with wind gusts up to 24 mph. Weather was not considered to be a factor in the accident. Truck The truck involved in the accident was an over-the-road 2000 Mack model CH612 powered by a Mack model 400 engine. Two dry bulk transport trailers, models 550A and 550, manufactured in October, 1996, by Beal Trailers of Oregon, Inc. were attached to the truck. The front trailer contained 28,000 pounds of cement and the rear trailer contained 29,000 pounds of cement. Each trailer had one hatch on top that could be opened to fill the trailer. The hatches were 22 inches in diameter and were equipped with hinged covers. When closed, the hatch covers were locked in place by six individual cam-type latches. Investigators found the trailer hatch covers closed on both trailers. All six of the cam-type latches were locked on the rear trailer hatch cover. Five of the latches on the front trailer hatch cover were closed and one was open. When tested, the five closed latches required approximately 10 to 20 pounds of force to close and latch. The latch that was not closed required approximately 100 pounds of force to close and latch. The truck and trailers had a total of five axles. Three of the axles were equipped with emergency brakes capable of holding the truck on the 7 percent grade where it was parked. The truck and both trailers were inspected and no defects were found. Truck Access Structure The north lid rack was a fabricated steel structure with a railed stairway consisting of 15 treads leading to a 4-foot wide steel grating walkway approximately 50 feet long. The stairway was on the north side of the access rack. Safety railings constructed of 1¾-inch round steel pipe, and consisting of top- and mid-rails and a 4-inch high toe board lined both sides of the walkway. Two pivoting gangways were fixed to the rack structure along the east side of the walkway and spaced to align with the hatches on top of each of the tandem bulk cement trailers they typically served. The gangways were 58-inch long, 24-inch wide pivoting steel ramps utilizing counterweights to keep them in a stored position when not in use. The stored position was angled upwards at approximately 45 degrees from the fixed walkway and allowed trailers to be positioned close enough to the structure to gain access to the trailer tops. The opening between the gangway and the trailer involved in the accident was 24 inches. Two fixed safety rails were spaced 30 inches apart on both sides of each gangway. When a driver stepped on a gangway, it lowered and came to rest on top of the trailer body. When a driver stepped off the gangway onto the trailer, the counterweight caused the gangway to pivot back to its raised, stored position. No locking mechanisms prevented the gangways from rising to the stored position after a driver had accessed the top of the trailer. To leave the top of the trailer the driver reached out and pulled the gangway back down into place using his/her hand or foot, then walked across to the fixed portion of the walkway. Each lid rack was provided with a rectangular enclosure constructed of two steel pipe handrails spaced 24 inches apart vertically, cantilevered in a fixed position over the trailer parking area, and enclosing an area 110 inches long by 62 inches wide. The bottom rail of the enclosure was 14 feet 9 inches from ground level. This height accommodated trailers ranging in height from 10 feet to 13 feet 6 inches. The enclosure had a 39-inch opening at the access ramp point. The distance between the bottom rail of the rectangular enclosure and the trailer parked beneath it varied from a minimum of 36 inches to a maximum of 53 inches. Due to the curvature of the trailer, the vertical gap increased as horizontal distance increased from the centerline of the trailer. No manufacturer's name or date could be found on the lid racks, but management estimated they were installed in the early 1970s. Fall Protection No policies or procedures were established requiring truck drivers to wear fall protection where there was a danger of falling at the truck access structures. No fall protection was provided and the victim was not wearing fall protection at the time of the accident. Training and Experience Stanley Xavier had been task trained on truck driving and route process by a Robertson's Transport trainer. As part of that training, he had been instructed to use mine-supplied truck access racks. Riverside used signage to provide site-specific training to Robertson's Transport employees. ROOT CAUSE ANALYSIS
A root cause analysis was conducted and the following causal factor was identified: Causal Factor: Management did not provide equipment or establish policies and procedures to ensure contract truck drivers could safely open and close the hatches on their bulk trailers. Corrective Action: Management should establish policies and procedures to ensure that truck drivers wear fall protection where there is a danger of falling. Persons should be monitored to ensure that the policies and procedures are followed. CONCLUSION
The accident occurred because management did not have policies and procedures in place to ensure that contract truck drivers could safely open and close trailer hatches before and after loading. The victim was working without fall protection where there was a danger of falling. ENFORCEMENT ACTIONS
Riverside Cement Company Order No. 6431605 was issued on January 21, 2008, under the provisions of Section 103(k) of the Mine Act:
Citation No. 6373637 (S&S - High Negligence) was issued on June 12, 2008, under the provisions of Section 104(a) for a violation of 56.15005:
Robertson's Transport Citation No. 6373639 (S&S - Low Negligence) was issued on June 19, 2008, under the provisions of Section 104(a) for a violation of 56.15005:
Related Fatal Alert Bulletin: 
FAB08M01
Fatality Overview: PowerPoint / PDF
APPENDIX A
Persons Participating in the Investigation Riverside Cement Company (TXI Oro Grande)
Larry Ratcliff ............... safety manager, TXI Mike Cardin ............... distribution supervisor Dave Morris ............... assistant plant manager Gordon Johnson ............... plant manager Terry Jacobs ............... maintenance manager Chuck McCollum ............... assistant maintenance manager Jason Jacobs ............... miners' safety representative
Roger Hortick ............... manager
Kevin Hirsch ............... supervisory mine safety and health inspector Larry Larson ............... mine safety and health inspector Isabella Williams ............... mine safety and health specialist Robert Setren ............... mechanical engineer, P.E. |
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