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MNM Fatal 2005-02

This fatal accident occurred when a 33-year-old mechanic lost control of his tractor in an underground roadway. The accident was caused by inadequate policies, standards, and controls, as well as multiple defects in the tractor. Learn best practices to prevent similar accidents.

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MNM Fatal 2005-02

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  1. MNM Fatal 2005-02 • Powered Haulage • January 31, 2005 (Kentucky) • Crushed Stone Operation • Mechanic • 33 years old • 4 years experience

  2. Overview • The victim was fatally injured when he failed to maintain control of his tractor in an “S” curve on an underground roadway and the tractor overturned.

  3. Why Did Accident Occur? • The accident occurred because policies, standards, and controls were inadequate and failed to identify excessive free play in the steering wheel and improper air pressure in the tractor tires.

  4. Causal Factors • Management policies, standards, and controls were deficient and did not ensure that the agriculture tractor was operated safely in the underground environment. The tractor was operated at speeds that were not consistent with conditions of roadway, grades, clearance, visibility, and the type of equipment.

  5. Causal Factors • Management policies, standards, and controls were inadequate and failed to implement corrective actions in a timely manner. Multiple defects were found on the tractor including the steering system, defective throttle detent, low tire air pressures, and imbalanced air pressures across tire sets. The equipment manufacturer’s guidelines were not utilized to evaluate the need for maintenance or repairs.

  6. Causal Factors • Management’s task training failed to utilize the equipment manufacturer’s operation procedures for operating the tractor.

  7. Best Practices • Ensure adequate pre-operational checks are conducted on all self- propelled mobile equipment and that any defects found are promptly corrected. • Ensure that service brakes will stop and hold mobile equipment prior to operating mobile equipment. • Exercise caution when approaching grades and operate mobile equipment in the appropriate gear at speeds consistent with the grade being traveled.

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