RUDNY & SALLMANN FORENSICS OF ILLINOIS, LLC

Exhibit "A"
RUDNY & SALLMANN FORENSICS OF ILLINOIS, LLC
1/eliicte (Jfl(f!MObite !Equip/nellt Specialists
3575 Grand Avenue, Suite A
Gurnee, Illinois 60031-3774
Tel. (847) 244-8868
Fax (847) 244-9020
dsallmann @rseng.com
December 30, 2013
REPORT OF INVESTIGATION and ANALYSES
for the Accident that Occurred on September 1 1, 2008
at the Sterling Materials Mine in Gallatin County, Kentucky
The following are my findings regarding the subject incident. All of my findings,
conclusions and opinions set forth below are stated to a reasonable degree of scientific
certainty.
Accident Description
The subject incident occurred on Thursday, September 11, 2008 at approximately
7: 13 A.M. on the ramp between the second and third levels at the underground
dolomite limestone mine in Gallatin County, Kentucky. The incident involved a Komatsu
WASOO-3LK wheel loader operated by Scott Talbert and a fuel truck driven by Herschel
Moore. The subject loader rolled backward down the ramp and struck the left side of
the fuel truck on the crosscut below the ramp. Mr. Moore was in the cab of the truck
and consequently injured by the impact.
Prior to the collision, Mr. Talbert, the mine surveyor and Safety Director, was told by
his supervisor Mr. Moore, to move the subject Komatsu wheel loader to from one level
to another. As Mr. Talbert drove the loader up the ramp the engine stalled, reportedly
due to low fuel level in the tank. Mr. Talbert stated in his deposition that the machine
started rolling backward, and he stopped it with the foot brake. He held the brake
pedal down until he was able to communicate with Mr. Moore on the radio, at which
time Mr. Moore told him to turn the key off to apply the parking brake. Mr. Talbert
then turned the key off and released the foot brake. The machine did not roll.
Mr. Talbert stated that he did not check fuel level when he first started the machine
and first looked at the fuel gauge as he was going up the slope. At that time he saw
the fuel gauge low-level light flashing. After the loader was stopped on the ramp, Mr.
Moore drove the fuel truck up the ramp and parked it behind the loader. Sterling
mechanic Charlie Beckham approached the loader from the top of the ramp. Mr.
Beckham stated that he placed rocks behind two of the loader tires. Someone filled
the loader with fuel while Mr. Beckham filled the fuel filters. Mr. Moore told Mr. Talbert
not to start the loader until another loader could be parked behind the WASOO. Mr.
Moore then backed the fuel truck down the slope and around a concrete pillar out of
the line of sight of the loader. Mr. Beckham told Mr. Talbert to start the loader. After
Mr. Beckham told him several times, Mr. Talbert turned the key to the start position.
The engine did not start and the loader began rolling backward. Mr. Talbert stated that
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Moore v Sterling Enterprises
he hit the brake and tried the key at least three times but the loader never stopped
until it struck the fuel truck. Mr. Beckham testified that the loader rolled twenty feet
after Mr. Talbert turned the key, and then it came to a sudden stop for two or three
seconds. It then started rolling again and hit the fuel truck. Mr. Moore stated that he
was moving the fuel truck forward on the crosscut and into the path of the loader at
approximately 3-4 mph when the WAsOO struck the truck.
Fuel Truck Post Collision
Description of the Komatsu WAsOO-3LK Wheel Loader
The subject machine, PIN A71137, is a rubber tired front loader with articulated
steering. The loader is equipped with a 6.5 cubic yard capacity bucket. The operating
weight of the machine is 62,000 Ibs. The loader is powered by a 31 6 HP Komatsu
diesel engine. The machine has a lifting capacity of approximately 45,000 Ibs. The
machine is approximately 11 feet wide, 30 feet long and 12 feet 6 inches high to the
top of the operator's cab. It has a top speed of 20.5 mph in 4th speed forward and
22.4 mph in 4th speed reverse.
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Moore v Sterling Enterprises
WASOO-3LK SIN A7l 137 Post Collision
The service brake system has multi-disc hydraulically applied and lubricated brakes
mounted within the axle housings at each wheel. The service brakes can be actuated
by the right pedal that applies the brakes while transmission is engaged or by the left
pedal that simultaneously applies the service brakes and neutralizes the transmission.
Hydraulic apply pressure is supplied by an engine driven pump. Brake apply pressure is
supplied by gas charged accumulators when the engine is not running. Brakes on the
front and rear wheels are actuated independently to permit braking in the event of a
mechanical or hydraulic failure. The service brakes are also equipped with automatic
slack adjusters to compensate for brake lining wear.
The parking brake is multi-disc oil lubricated and spring actuated. The braking force is
applied to the output shaft of the transmission. The parking brake is released by oil
pressure from the transmission pump. When the steering column parking brake switch
is actuated, a solenoid valve allows the park brake pressure to drop to zero resulting in
spring force application of the parking brake. When the engine is shut off, transmission
pump pressure drops to zero and the parking brake applies regardless of the position
of the column switch. When the engine is started with the park brake control switch in
the off position, the parking brake remains engaged until that switch is moved to the
on then off positions.
In the event that the engine cannot be started and the machine must be towed, the
parking brake needs to be released. This can be accomplished by placing the parking
brake emergency release switch in the "release" position and turning the key switch to
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Moore v Sterling Enterprises
the "on" position. Then pressurized oil from a brake accumulator will release the
springs that apply the parking brake. The parking brake emergency release switch is
located in an enclosed fuse compartment behind the operator seat. Whenever the
parking brake emergency release switch is in the "release" position a warning buzzer
will sound continuously.
Fuse Box Containing Parking Brake Emergency Release Switch
Depicted on Exemplar WASOO-3LK
Parking Brake Emergency Release Switch on Subject WSOO
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Moore v Sterling Enterprises
Post Accident Inspection by Brandeis Mechanic Ed Burns
Ed Burns inspected the subject WA500-3LK loader on September 12, 2008, the day
after this accident. He found that the parking brake emergency release switch was in
the "release" position. He also found that the warning buzzer did not function. On
September 15, 2008 when he returned to replace the switch and buzzer, he found the
buzzer electrical wiring disconnected.
Description of the Roof Bolter Incident
On September 9, 2008, Ricky Williamson, the regular operator on the subject WA500
loader, parked it on a slight grade and shut the engine off. When he turned the key on
the loader rolled down the grade into a roof bolter machine. Only slight damage and no
injuries resulted. Herschel Moore observed the incident and tagged the loader for
inspection and repair.
Scott Talbert
Mr. Talbert worked at this Sterling Mine from April 2008 to the day of this accident on
September 11, 2008. He had worked as a land surveyor for most of his adult life
including three years prior to working at this mine. His only experience around
construction sites was as a land surveyor. He also worked as a truck driver for
approximately two years. His responsibility at the Sterling Mine was Safety Director
and surveyor; however, he stated that he was not responsible for the safe operation of
the heavy equipment at the mine. Mr. Talbert had operated a smaller Volvo wheel
loader at the Sterling Mine, but he stated that he never operated the Komatsu WA5003LK. Mr. Talbert stated that he was never certified to operate a loader at the Sterling
Mine.
Herschel Moore
Mr. Moore was the 1st shift, 3rd level Forman at the Sterling Mine at the time of the
accident. He was hired by Sterling Ventures in 2004. His first job was on the powder
crew, loading explosives to blast the rock underground. Prior to becoming foreman he
operated a roof bolter.
He also operated wheel loaders in the course of his
employment at the mine. He stated that he was an MSHA certified loader operator at
the time of the accident.
Documents Reviewed
• Accident Notice to Komatsu of America
• MSHA Mine Citation/Order Report with supporting documentation & field notes
• Deposition Transcript of Herschel Moore, Volume I & Volume II with exhibits
• Deposition Transcript of Scott Talbert with exhibits
• Deposition Transcript of Charlie Beckham with exhibits
• Deposition Transcript of Ed Burns, Volume I & Volume II with exhibits
• Deposition Transcript of Chris Pulliam with exhibits
• Deposition Transcript of Sam Van, Volume I with exhibits
• Deposition Transcript of Ricky Williamson, Volume I with exhibits
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Moore v Sterling Enterprises
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Deposition Transcript of Dwight Dunn with exhibits
Deposition Transcript of Kenneth Smallwood with exhibits
Deposition Transcript of Andy Carpenter with exhibits
Deposition Transcript of Johnny Watson with exhibits
Deposition Transcript of Jason Taylor with exhibits
Deposition Transcript of Mike Lucas with exhibits
Deposition Transcript of Dan Dyers with exhibits
Deposition Transcript of Jamie Barnes with exhibits
Affidavit of Charlie Beckham
Affidavit of Shannon Stamper
WASOO-3LK Operation & Maintenance Manual for SIN A71 001 and up
WASOO-3LK Shop Manual for SIN A71 001 and up
WASOO-3LK Parts Manual for SIN A71 001 and up
Complaint and Jury Demand
Komatsu of America's Answer to Plaintiff's Complaint
Komatsu of America's Answer to 1st Amended Complaint
Plaintiff's Motion for Leave to File Second Amended Complaint
Plaintiff's Second Amended Complaint
Plaintiff's Responses to Komatsu of America's 1st Discovery Request
Komatsu's Responses to Plaintiff's 1st Set of Interrogatories & Production Requests
Komatsu's Responses to Plaintiff's 2nd Set of Interrogatories & Production Requests
Plaintiff's 3rd Set of Interrogatories, Production Requests & Admission Requests to
Komatsu
Order Acknowledgement & Invoice for subject Loader
Bramco Brandeis Documents: Bates numbers 0001 - 0828
Bramco Brandeis Documents: Bates numbers 001871 - 002498
Sterling Ventures Pre-Operational check lists for subject loader
Sterling Ventures Mine Visitor Logs for January thru September 2008
Sterling Ventures File documents for WASOO loaders SIN A71 1 37 & A72070
Sterling Ventures Warranty Claims for WASOO SIN A71 137
Simovic photographs from 9/1 S/08 inspection
Scott Talbert Training Certificates
Task Training file for Charlie Beckham
Task Training file for Herschel Moore
Task Training file for Ricky Williamson
Report of Donald Kadunc dated November 13, 2013
Report of Ronald Spear dated November 7, 2013
Report of Thomas Huston dated November 14, 2013
Video recording of Plaintiff inspection of subject Loader
Komatsu Marketing brochure Number AESSSS7-01 for WASOO-3 "avance plus"
MSHA "Prevent Fatalities: Rules to Live By" pamphlet
SAE Surface Vehicle Standard, JIISO 34S0, Jan 98; Brake Systems for Rubber Tired
Loaders
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Moore v Sterling Enterprises
Inspections and Tests Conducted on the WA500-3LK. PIN A71 317
On January 15, 2011, I traveled to Clark Heavy Equipment Co. in Pleasureville,
Kentucky to inspect, measure, photograph and test the subject Komatsu wheel loader
(PIN A71 1 37). The loader had 13,602 meter hours at the time of my inspection.
Numerous deficiencies and unsafe conditions were observed on this machine during the
inspection. I observed that work lights, mirrors and handrails were missing. I observed
steps to be bent and broken. I found the fuel tank to have been deformed due to an
impact, and the fuel tank vent pipe closed. I also found hose clamps missing and
misplaced. The cover locking screw for the fuse box behind the operator seat was
missing. The warning label on the cover was worn off or torn off. The warning buzzer
was not functioning.
Fuse box Cover with Worn or Torn Off Warning Label on Subject WA500
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Moore v Sterling Enterprises
Fuel Tank Impact Damage Found on Subject WA500
I performed several functional tests during this inspection. I found the steering column
park brake switch to function as designed. The parking brake held the loader
stationary on a 25% grade. The parking brake emergency release switch functioned as
intended with the exception that no warning buzzer sounded when the switch was in
the "release" position. (The buzzer was found to be disconnected). When the parking
brake emergency release switch was placed in the "release" position, and the key
switch was turned on, with the engine not running, the machine rolled on a 7% grade;
but the loader stopped immediately with the application of either brake pedal.
On May 12, 2011 I traveled to the Sterling Mine in Gallatin County, Kentucky.
inspected and measured the accident site. Using a laser level, I measured a 25% grade
at the location where the loader stopped. The loader stopped approximately 200 feet
above the crosscut where the impact occurred. The maximum ramp grade that I
measured was 29% approximately 100 feet below where the loader initially stopped. I
measured the wall-to-wall distance along the ramp to be approximately 24 feet. The
ramp had a crowned surface and the travel portion of the ramp was approximately 15
feet wide.
On June 5 and June 6, 2013, I inspected and tested the subject Komatsu WA500-3LK
loader at the Roland Machinery Co. facility in Bolingbrook, Illinois. The loader had
13,604 meter hours at the time of this inspection. I observed the same deficiencies
that I previously found during my January 15, 2011 inspection. I also found that
several panels including the fuse box cover behind the operator seat had been
removed. The Park Brake Emergency Release Switch was removed from its original
location in the fuse box and suspended by the electrical wires attached to it. The
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Moore v Sterling Enterprises
warning buzzer was still disconnected and a 35 amp fuse was connected to electrical
wires outside the fuse box.
Fuse Panel and Parking Brake Emergency Release Switch
as Found at 2nd Inspection of Subject WA500 Wheel Loader
The right front tire had zero air pressure. The front tires were inflated to 70 psi and
the rear tires to 40 psi prior to conducting the tests. The warning buzzer was
reconnected. Engine coolant was found to be 1.5 gallons low. Coolant was added to
the proper level. The fuel level was reduced until the low fuel level light began flashing
on a 6% grade. The loader was moved onto a 35% grade and the engine ran normally.
The machine was then operated for more than 5 minutes on a grade between 26% and
35%. The engine ran normally with no sign of fuel starvation.
Checker model MCl 910 chocks were placed behind each rear tire on the 27% slope.
With the engine running, the service brakes and the parking brake were released. The
chocks prevented the machine from rolling. This test was repeated with the chocks
placed behind each left tire. The brakes were released and the loader did not roll.
These chocks were 10" high, 14 ~" wide and 17 %" long.
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Moore v Sterling Enterprises
Subject Loader on 27% Grade
Prevented from Rolling with Wheel Chocks
The next test conducted was to
chocks. The engine was stopped
placed in the "release" position.
machine rolled down the grade.
machine immediately stopped.
place the loader on a 26% grade without wheel
and the Park Brake Emergency Release Switch was
The key was turned to the on position and the
The key was turned to the off position and the
The loader was again placed on the 26% grade without wheel chocks. With the engine
off and the Park Brake Emergency Release Switch in the "release" position, the key was
turned to the on position, and the loader rolled down the grade. The right service
brake pedal was applied and the loader immediately stopped.
The above test was repeated except the left service brake pedal was applied instead of
the right pedal. The machine stopped.
The final test involved placing the loader on a 26% grade with wheel chocks behind
each rear tire. The engine was shut off, the Park Brake Emergency Release Switch was
placed in the "release" position and the key was turned on. The chocks stopped the
loader from rolling down the grade.
Opjnjons
A. The primary cause for this accident was the improper actions of the
inexperienced and untrained operator when he encountered a parking brake
release situation. Mr. Talbert should not have been operating this loader on a
Page 1 1 of 1 1
Moore v Sterling Enterprises
B.
C.
D.
E.
F.
G.
H.
I.
J.
steep grade with an unresolved brake issue. After the loader was refueled, Mr.
Talbert turned the key on and the loader began to roll, but he applied service
brakes and machine stopped (per Beckham). He should not have released the
brake pedal without turning the key off or speaking to Moore as he did earlier
when he ran out of fuel. He should have turned the key off immediately when
machine started to roll. He also never should have attempted to ascend grade
after low fuel warning light came on.
A cause for the accident was failure to properly block the loader tires on the
steep grade after the engine quit.
A cause for the accident was the deliberate disconnection of the warning
buzzer.
A cause for the accident was failure of the mine to determine why this machine
rolled unintentionally 2 days prior to this incident (Roof Bolter Incident).
A cause for this accident was Mr. Moore's actions to move the fuel truck
forward into the path of the loader when Moore was aware that the loader
might roll unintentionally.
The WASOO-3LK loader parking brake emergency release switch is not
dangerous or defective because the operator has a reasonable means to
compensate for an unintentional release of the parking brake. If the operator
turns the key switch on and the machine rolls unintentionally, he need only turn
the switch off and the loader will stop. Also, if any vehicle rolls unexpectedly,
the immediate reaction of a trained and experienced operator should be to step
on the brake pedal. Application of the service brake would have stopped this
loader and would have prevented the accident.
Komatsu incorporated the feature described under patent number 4,660,696
in the design of the WASOO-3LK parking brake control system. This feature
requires the operator to turn the parking brake switch on and then off to
release the parking brake when it has been automatically applied.
A method for releasing the parking brake to tow the machine, if the engine
can't be started, is necessary. Placing the control for that system in the
operator compartment provides a safer alternative to releasing brake from
ground level or under machine.
The parking brake released at the time of this incident because the parking
brake emergency release switch had been put in the "release" position.
The fuel gauge and fuel supply system on the WASOO-3LK functioned properly
and was not defective, in spite of the damage and associated deformation to
the bottom of the fuel tank. The low fuel warning light would have been
illuminated on a level surface before starting to ascend the grade where this
incident occurred.
Respectfully Submitted,
,tJr:w;/ t:/ J<!~
David W. Sallmann