# Presentation: 878029

## This presentation is for illustrative and general educational purposes only and is not intended to substitute for the official MSHA Investigation Report analysis nor is it intended to provide the sole foundation, if any, for any related enforcement actions. 

## GENERAL INFORMATION

- Operator:		Wilson & Wilson
- Mine:		Barrackville Refuse Pile
- Accident Date:	September 24, 2004
- Classification: 	Machinery
- Location: 		District 3, Marion County, WV
- Mine Type: 	Refuse Pile
- Employment:	3

## ACCIDENT DESCRIPTION

- On Friday, September 24, 2004, at 11:00 a.m., a 63-year equipment operator was fatally injured while apparently attempting to dismount a bull dozer. Just prior to the accident, the victim was observed grubbing the area around a water treatment pond. He had a total of 8 years mining experience and more than 30 years experience operating various pieces of construction equipment.

## ACCIDENT DESCRIPTION

- There were no eye witnesses.  For unknown reasons, the victim trammed his bull dozer just off the grubbing area and stopped the bull dozer on a sloped berm area adjacent to a level graveled roadway.  It appears he then attempted to dismount the bull dozer with the blade elevated and the parking brake not engaged.  During this process the bull dozer apparently began to drift forward.  He slipped and fell to the ground in front of the moving bull dozer and was struck by grouser(s) on the left track and received fatal injuries.

## ROOT CAUSE ANALYSIS

_*Causal Factor:*_  The bull dozer was not secured from movement before the operator attempted to exit the machine. The parking brake was not set and the blade was not lowered the ground.
_*Corrective Actions:*_  Management must enforce all mandatory safety regulations and safe work practices.

## CONCLUSION

## ENFORCEMENT ACTIONS

- _104(a) Citation was issued for a violation of 30 CFR 77.1607(p)_ because dippers, buckets, scraper blades, and similar movable parts were not secured or lowered to the ground when not in use.  The operator of the model D4H Series II Caterpillar bull dozer failed to lower the front blade of the machine to the ground prior to attempting to dismount the stated equipment.  The operator subsequently slipped and fell in front of the drifting bull dozer and sustained fatal crushing injuries.  Note, the dismounting steps are part of the blade mechanism.

## ENFORCEMENT ACTIONS

- _104(a) Citation was issued for a violation of 30 CFR 77.1607(n)_ because mobile equipment shall not be left unattended unless the brakes are set. The operator of the model D4H Series II Caterpillar bull dozer failed to engage the parking brake prior to attempting to dismount the stated equipment. The operator subsequently slipped and fell in front of the drifting bull dozer and sustained fatal crushing injuries.

## BEST PRACTICES
Park mobile equipment on level ground if possible. 
Set the parking brake and lower the bull dozer blade to the ground before dismounting equipment. 
Wear footwear that provides good traction (e.g. rubber or neoprene soles) while climbing or descending. 
Clean foot wear and then maintain 3 points of contact to climb onto or descend from equipment. 
Ensure that equipment ladders, steps, and platforms are securely anchored, well maintained, and free of slipping and stumbling hazards. 
Never carry personal items or supplies when climbing or descending equipment. 

- Park mobile equipment on level ground if possible.
- Set the parking brake and lower the bull dozer blade to the ground before dismounting equipment.
- Wear footwear that provides good traction (e.g. rubber or neoprene soles) while climbing or descending.
- Clean foot wear and then maintain 3 points of contact to climb onto or descend from equipment.
- Ensure that equipment ladders, steps, and platforms are securely anchored, well maintained, and free of slipping and stumbling hazards.
- Never carry personal items or supplies when climbing or descending equipment.