A steam truck operator with 16 years of experience was fatally injured when he fell 9 feet from a front-end loader’s deck while steam cleaning the machine. He wasn’t wearing fall PPE at the time.
U.S. Mine Safety and Health Administration (MSHA) investigators determined that the root cause of the incident was the employer’s failure to ensure use of fall PPE when a fall hazard was present.
He collapsed and fell through gap in machine’s deck
Jeffrey Hudnall worked for Marfork Environmental as a steam truck operator whose job duties involved cleaning mining equipment.
Marfork Environmental was owned and operated by Marfork Coal Company, a mine located in Whitesville, West Virginia. Marfork Environmental worked exclusively for Marfork Coal company, maintaining roadways, ditch lines and impoundments and performing other work as needed. Both companies were located on the same property.
On Aug. 4, 2021, Hudnall was assigned to steam clean a front-end loader. He performed a pre-operational examination of his steam truck and filled it with fuel and water before beginning this task.
After fueling his truck, Hudnall met with another employee at about 7:44 a.m. who had already started cleaning the front-end loader at the ground level. Ten minutes later, Hudnall took the steam cleaner wand from the other worker and continued cleaning the machine from the ground.
At 8:09 a.m., Hudnall climbed up a ladder to the right-side deck of the front-end loader and continued steam cleaning. A few minutes later, he collapsed and fell through an opening in the deck between a handrail and the closed cab. He fell more than 9 feet to the concrete pad below.
The co-worker, who had been close by, turned around and saw Hudnall lying on the ground. He called for help and several other employees responded. Someone called 9-1-1 and emergency responders arrived at 8:25 a.m.
Hudnall was transported to a local hospital. He was pronounced dead on Aug. 8, 2021.
Opening was designed by manufacturer for maintenance access
MSHA investigators examined the front-end loader after the incident and found no defects that would have contributed to Hudnall’s death.
The machine had an 18-inch opening between the handrails and the cab when the door was closed, which was designed by the manufacturer to provide maintenance access. This is the opening Hudnall had fallen through when he collapsed.
Failure to wear fall PPE contributed to his death
Investigators determined that Hudnall’s death was the result of his failure to wear fall PPE while working where a fall hazard was present.
Marfork’s fall protection policy at the time of the incident required fall PPE to be worn when there was a danger of falling. Fall PPE was provided and available, but Hudnall didn’t use it.
MSHA found that Marfork failed to ensure its employees wore fall protection when there was a danger of falling, which contributed to the fatal incident.
MSHA Review Committee had to review case
Investigators submitted the facts of Hudnall’s death to the MSHA Chargeability Review Committee following the investigation for a decision on whether the fatality should be charged to the mining industry. This was presumably because Hudnall collapsed for some reason before he fell, although MSHA doesn’t make this clear in the incident report.
The committee reviewed the autopsy report and MSHA’s investigation and concluded that Hudnall’s death was the result of injuries he sustained in the fall. That meant his death was chargeable to the mining industry.
Employer revised safety procedures, modified equipment
MSHA determined that the root cause of the incident was Marfork’s failure to ensure its workers wore fall protection when there was a danger of falling.
To prevent a similar incident, Marfork developed a new written procedure and modified its equipment.
The new procedure requires:
- fall protection consisting of a full-body harness or full-body vest-type harness with an anchored lanyard
- use of fall protection when working within 6 feet of a ledge or opening that lacks safety rail protection
- use of fall protection when working in precarious positions at any elevation, such as working while leaning or working inside an approved bucket, basket, man-lift, chute, bin, and all overhead hoist doorways or access points, and
- use of fall protection while performing work in an elevated position with exposure to falling 5 feet or more.
Marfork also installed an additional handrail closing the gap between the factory handrail and cab on all of its front-end loaders that had a gap similar to the one Hudnall fell through.