The MSHA has reported its investigation into a fatal fall of material accident at Lonestar Prospects’ Vista Sand open pit sand mine, Granbury, Texas.
The accident occurred due to management’s failure to have policies and controls in place to ensure that the truck load of pipe was unloaded in a manner that did not create a hazard to persons.
Elvin T Terrell, delivery truck driver, age 61, was fatally injured on February 26, 2016. Terrell was in the process of securing the tie down straps on the driver’s side of his flatbed trailer when a 50-foot section of pipe rolled off the top of the load and struck him. ??The accident occurred because management’s policies and controls were inadequate to ensure the unloading of the pipe from the truck was performed in a manner that did not create a hazard to persons, the MSHA report says.
Lonestar contracted Powell Transportation (Powell), located in Columbia, Mississippi, to deliver several hundred feet of high-density polyethylene (HDPE) pipe from Snyder, Texas to the mine. Lonestar planned to use the HDPE pipe to transport a waste stream, consisting of water, fine sand, clay, and silt, from the sand washing/recovery areas of the plant to the tailings area.
The Mine Safety and Health Administration’s last regular inspection at Vista Sand was completed on July 13, 2015 and a regular inspection was started on February 22, 2016 but was not completed at the time of the accident.
At approximately 7:50am, Terrell pulled his Volvo trailer truck into position at the unloading area. The trailer load of pipe consisted of nine pipe sections arranged in three rows of three sections each. Two pipe sections in each row were banded together by the manufacturer.
Five, four by four wooden timbers were placed between each row of pipe to provide stabilization. There were chock blocks for 3 out of 5 timbers that were used to prevent the sections of pipe from rolling. The load of pipe was secured to the trailer with sixteen, four-inch wide, nylon ratchet straps.
Jenkins centered the JCB Load-All (forklift) to the trailer and set the forks on the ground. Terrell began loosening the ratchet straps that secured the top row of pipes. Once the straps were loosened and out of the way, Jenkins observed Terrell standing at the front passenger side of the truck. Jenkins, using the forklift, began offloading the pipe. He lifted two banded sections of pipe leaving a 3rd unsecured on top of the other two rows of pipe. He lifted the banded pipe sections until they were clear of the load, put the forklift in reverse until he felt he was a good distance away from the trailer, and lowered the boom closer to the ground.
As Jenkins maneuvered the pipe to the staging area, he saw the 3rd unsecured pipe roll off the truck and hit the ground. Bolden, who was with the other drivers, heard a pipe hit the ground. He immediately looked at Jenkins and saw banded pipe on the lift. He then noticed that the 3rd pipe had fallen to the ground and saw a white hardhat. Bolden ran to the area and saw Terrell lying on his back with the pipe positioned on his chest. Bolden yelled at Jenkins to drop the pipe he was transporting and bring the forklift to lift the pipe off Terrell. Jenkins positioned the forks as close to Terrell as possible, picked the pipe up, placed the machine in reverse, and parked it away from the truck.??Bolden stated that Terrell had a pulse but was unresponsive. He then ran to his truck and called Austin via CB radio, and Austin contacted 911 from his cell phone at 8:37 am to report the accident. Billy Gomez, Safety Representative, and Brian Hecht, Safety Director, arrived at the scene at approximately 8:50 am. At that time, they determined that Terrell did not have a pulse. Gomez and Hecht began performing CPR on Terrell until Hood County EMS arrived to the scene and took over. Efforts to resuscitate Terrell were unsuccessful. Tarrant County Medical Examiner attributed cause of death as blunt force trauma of chest and abdomen due to strike by falling object.
Dana Glover-Smith, safety manager, called the Department of Labor’s National Contact Center (DOLNCC) to notify MSHA of the accident at 8:44 am on February 26, 2016. The DOLNCC notified William O’Dell, Assistant District Manager for MSHA’s South Central District, and an investigation was started the same day. In order to ensure the safety of all persons, MSHA issued a 103 (j) order and later modified it to a section 103(k) of the Mine Act when the first Authorized Representative arrived at the mine.
MSHA’s accident investigation team traveled to the mine, conducted 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 management, mine employees and Powell management.
The accident occurred at the unloading staging area, located on the east side of the primary sand plant. The victim’s truck was parked facing north on relatively dry and level ground.
The weather at the time of the accident was mostly clear with calm winds and a temperature approximately 40 degrees Fahrenheit. Weather was not considered to be a factor in the accident. ??High Density Polyethylene Pipe?The pipe was manufactured by WL Plastics. Each section was 1-inch thick with a 26-inch outside diameter. Each pipe section was 50 feet long and weighed 1,732 pounds. The pipe that struck the victim was positioned on the trailer in the top layer, 12 feet above the ground and was not secure. The ratchet straps used to secure the pipe in transit were rated by the manufacturer for 5400 pounds of weight. Two of the ratchet straps closest to the cab of the truck were rolled up on the side of the trailer. The third strap located closest to the victim was not secured and the tool was positioned next to the strap on the flatbed trailer.
Loading and Unloading Procedures??
There was a manufacturer’s warning label attached to one section of pipe on the passenger side bottom, opposite of where the victim was found, specifying instructions for the proper handling and transportation of the pipe. Investigators also found a detailed manufacturer’s procedure safety document in a briefcase in the cab of the truck. Vista Sand had no unloading policies or procedures that designated safe areas for drivers. At the time of the accident, Jenkins was operating the Load-All, transporting the pipe to the pipe staging area, and Terrell was unaccompanied.
Training and Experience
Terrell had 12 years of over-the-road truck driving experience. The day of the accident was Mr. Terrell’s first day at this site. Terrell did not receive training in accordance with 30 CFR, Part 46, Site Specific Hazard Awareness training. MSHA issued a non-contributory citation for the lack of training.
Root cause analysis
A root cause analysis was conducted and the following root cause was identified:
Root Cause: Management’s policies and work procedures were inadequate and failed to ensure that a truck load of pipe was unloaded in a manner that did not create a hazard to persons.
Corrective Action: Management established the following mandatory policies and controls:
A completion of a Load Assessment Risk form
Freight Loading and Unloading Site Specific sign off form
Load Assessment form
Set pedestrian danger zones and safe zones to ensure that pipe can be unloaded from trucks in a manner that does not create a hazard to persons.