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Jump to Overview MAI-2008-13
DEPARTMENT OF LABOR MINE SAFETY & HEALTH ADMINISTRATION Metal and Nonmetal Mine Safety and Health REPORT OF INVESTIGATION Surface Metal Mine (Copper) Fatal Electrical Accident August 15, 2008 Ray Asarco LLC Ray, Gila County, Arizona Mine I.D. 02-00150 Investigators Steven H. Thoring Mine Safety and Health Inspector Dean F. Skorski Supervisory Electrical Engineer Originating Office Mine Safety and Health Administration Rocky Mountain District P.O. Box 25367, DFC Denver, CO 80225-0367 Richard Laufenberg, District Manager OVERVIEW
Peter Eudave, apprentice electrician, age 41, was fatally injured on August 15, 2008, when he contacted a 480-volt electrical conductor. He was replacing the ballast in a floodlight. The accident occurred because management policies and controls were inadequate and failed to ensure that the electrical circuit was deenergized, locked-out, tagged, and tested before work was performed. GENERAL INFORMATION
Ray, an open pit copper mine, owned and operated by Asarco LLC, was located in Ray, Gila County, Arizona. The principal operating official was Richard Rhoades, general manager. The mine operated multiple shifts, 24 hours a day, 7 days per week. Total employment was 790 persons. Copper ore was drilled and blasted in the open pit and transported to the primary crusher. Crushed ore was transported to the mill by conveyor belt. The ore was then milled, concentrated and smelted into copper plates. The last regular inspection of this operation was completed on April 29, 2008. DESCRIPTION OF ACCIDENT
On August 15, 2008, Peter Eudave (victim) started work at 7:00 a.m., his normal starting time. Eudave and Timothy Knight, journeyman electrician, met with Jeffrey Hall, supervisor. Hall assigned them to make various electrical repairs. At approximately 10 a.m., Eudave and Knight traveled to the tailings booster pump station to troubleshoot and repair defective flood lighting. They tested the lighting circuit and discovered a defective lighting ballast. Eudave and Knight traveled to the electrical shop, retrieved a new ballast, and returned to the booster station. They removed the light reflector and two, five ampere in-line fuses supplying the electrical power to the ballast, but did not deenergize the circuit by opening the circuit breaker. The circuit breaker was located a short distance away in the tailings booster pump station. The old ballast was removed and replaced. Knight turned around to retrieve the light reflector. When Knight turned back, he noticed Eudave was holding one of the energized wires, located on the line (energized) side of the in-line fuse. He unsuccessfully attempted to pull the wire free from Eudave's hand. He then picked up a section of hose and pulled the victim free from the energized conductor. Knight used a radio to call for emergency medical assistance. He administered cardiopulmonary resuscitation (CPR) until help arrived. Eudave was transported to a local hospital and pronounced dead by the attending physician. Death was attributed to electrocution. INVESTIGATION OF THE ACCIDENT
MSHA was notified of the accident on August 15, 2008, at 11:20 a.m., by a telephone call from Wes Cruea, senior safety engineer, to Jamie Eubanks, mine safety and health inspector. An investigation began the same day. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of the miners. MSHA's investigation team traveled to the mine, conducted a physical inspection of the accident site, interviewed employees, and reviewed conditions and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine management, employees, miners' representatives, and the State of Arizona mine inspectors office. DISCUSSION
Location of the Accident The accident occurred on the upper deck of the tailings booster pump station. The area was dry. Electrical Equipment and Analysis The equipment being worked on at the time of the accident was a Holophane (Predator series) high pressure sodium floodlight. The floodlight was rated at 480 volts and 400 watts. This floodlight was one of four on the upper deck of the booster pump station where the power circuits were being protected by a 20 ampere, 480 volt, Cutler Hammer circuit breaker. The circuit breaker was located in the nearby tailings booster pump station building. Two in-line fuses (5 amperes each) had been added to the existing circuitry inside the light fixture. During the investigation, power was restored to this light fixture and a phase to ground voltage of 268 volts was measured. The victim was exposed to this voltage level at the time of the accident. An energized conductor had been cut off on the line side exposing the inner conductive material. A pair of cutting pliers was found at the accident scene. Investigators could not determine why the conductor was cut. Weather Conditions The weather at the time of the accident was clear with a temperature of 103 degrees Fahrenheit and calm winds. Weather was not considered to be a factor in the accident. Training and Experience Peter Eudave, victim, had 14 years of mining experience that included 1 year and 20 weeks of electrical experience. Eudave had received training in accordance with 30 CFR, Part 48. Timothy Knight had 4 months of mining experience and 20 years of naval electrical experience with the Department of the Navy. Knight had received training in accordance with 30 CFR, Part 48. ROOT CAUSE ANALYSIS
A root cause analysis was conducted and the following root cause was identified: Root Cause: Management policies and controls were inadequate and failed to ensure that the electrical circuit was deenergized, locked-out, tagged, and tested before work was performed on the circuit. Corrective Action: Management should establish policies and controls to ensure that electrical circuits are deenergized, locked-out, and tagged when work is performed on electrical circuits and equipment. CONCLUSION
The accident occurred because management policies and controls were inadequate and failed to ensure that the electrical circuit was deenergized, locked-out, tagged, and tested before work was performed. ENFORCEMENT ACTIONS
Order No. 6451806 was issued on August 15, 2008, under provisions of Section 103(k) of the Mine Act:
Citation No. 6423348 was issued on September 3, 2008, under provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.12017:
Related Fatal Alert Bulletin: APPENDIX A
Persons Participating in the Investigation Asarco LLC
James Brown…….. ……..safety engineer James Coward, Jr……….attorney Wes Cruea……………….senior safety engineer
Greg Zaragoza…………...safety representative
Jack Speer…………..…….deputy mine inspector
Dean F. Skorski…………..supervisory electrical engineer |
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