Mining Incidents
Fatality · MSHA Record #220192110010

Mine Manager

July 17, 2019 at 11:55 AM
BOURBEAU AGGREGATE LLC · Surface · Metal/Non-Metal
Franklin County, VT
Classification MACHINERY
Type Struck by falling object
Investigator narrative
Workers removing a jaw crusher motor. As the hammer attachment was being positioned towards the crusher motor, the hydraulic hammer attachment fell from the excavator quick coupler. The hammer attachment struck the victim in the head pining them to the work platform.
Final MSHA investigation
Ryan I. Charbonneau, a 32-year-old general manager with over 14 years of mining experience, died on July 17, 2019, at 12:13 p.m., when a hydraulic hammer attachment (hammer) fell on him. Charbonneau was preparing to replace the motor on a crusher using an excavator with the hammer attached. Charbonneau stood below the hammer and signaled the excavator operator into position over the old drive motor. The hammer fell from the excavator, struck Charbonneau, and pinned him on the crusher work platform. The accident occurred because: 1) The operator did not remove the excavator from service to repair damaged hydraulic components; and 2) The installed carrier attachment was incompatible with the Fleco 325B C-linkage quick coupler (quick coupler), rendering the secondary means of latching inoperative when the primary means of latching failed.
Root causes
  1. The accident occurred because the operator did not repair the disconnected and damaged hydraulic cylinder assembly for the quick coupler or remove it from service after discovering a hydraulic oil leak.

    Corrective action: The quick coupler involved in the accident was removed from service. Mine management and miners have been reinstructed on the provisions of 30 CFR § 56.14100 including the removal of unsafe equipment that affects the safety of miners.

  2. The accident occurred because the operator used an incompatible carrier attachment. The mismatched equipment components circumvented the secondary latching system allowing the hammer to disengage from the quick coupler when the primary means of latching failed.

    Corrective action: Management removed the quick coupler from the excavator and adopted a policy eliminating the use of quick coupling devices at this operation. The operator will ensure that all equipment is used within the design capacity of the manufacturer.

Findings from MSHA's final investigation report, which supersedes the preliminary narrative above.

Record details
Activity at time of incident
Supervise
Subunit / location
STRIP, QUARY, OPEN PIT
Accident type
Struck by falling object
Source of injury
SURFACE MINING MACHINES
Nature of injury
CRUSHING
Body part affected
HEAD, MULTIPLE PARTS
Total mining experience
14 years
Experience at this mine
14 years
Experience in this job
14 years
Degree of injury
FATALITY
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Source: US Mine Safety and Health Administration (MSHA) · Document 220192110010 · Mine ID 4300585 Trainer view →