DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 4
ACCIDENT INVESTIGATION REPORT
SURFACE FACILITY
FATAL FALL OF PERSON ACCIDENT
Fola Coal Company, Inc.
Peachorchard Preparation & Loading Facilities (ID No. 46-08376)
Long-Airdox Co. (ID No. MK3)
Bickmore, Clay County, West Virginia
January 9, 1995
by
Paul E. Hess, Jr.
Coal Mine Safety and Health Inspector
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Michael J. Lawless, District Manager
OVERVIEW
Abstract
On Monday, January 9, 1995, about 10:45 a.m., a fall of person accident occurred at the Peachorchard Preparation & Loading Facilities. Jerry Trump, connector, received multiple injuries when he fell 27 feet through an open refuse chute to a concrete floor. The victim died on January 15, 1995, at 2:45 p.m., as a result of the injuries.
The accident occurred as the victim was standing on a pipe on the refuse drain screen, located on the first full floor above ground level, using a set of come-alongs to hoist a distribution box up to a chainfall. He was going to further hoist the distribution box with the chainfall to the heavy media pressure vessel. When the distribution box was hoisted to less than an inch from the top of the refuse screen, the victim bent over to assist James Dix, connector, in lifting the distribution box over the top of the screen. As the distribution box was lifted over the top of the screen, it swung toward the victim, striking the pipe and his feet, causing him to fall through the open refuse chute.
The accident occurred because safety belts were not used when a danger of falling existed, the open refuse chute was not guarded, and workers did not stay clear of hoisted materials. Another contributing factor to the accident was that, had a second chainfall been used instead of a come-along, it probably would not have been necessary to have conducted the work from a hazardous location.
Jerry Trump, age 47, had approximately 20 years experience in construction, including about 3 years experience with Long-Airdox Co. and about 6 months experience at the Peachorchard Preparation & Loading Facilities.
Background
The Peachorchard Preparation & Loading Facilities of Fola Coal Company, Inc., is located at Bickmore, Clay County, West Virginia. Long-Airdox Co. was contracted by Fola Coal Company, Inc., to construct the preparation plant and the loading facilities. According to officials of both companies, Fola Coal Company, Inc., does not direct the work force nor participate in the construction, or conduct any required examinations required by 30 CFR. Fola Coal Company, Inc., only monitors the progress and adequacy of the construction. Long-Airdox Co. employs 37 persons on 1 shift, 6 days per week.
Fola Coal Company, Inc., is a subsidiary of Amvest Minerals Corporation of Kingsport, Tennessee. The principal officers of Fola Coal Company, Inc., are William S. Perkins, president/ treasurer; Joel K. Davis, vice president/secretary; and Timothy K. Lowe, resident agent.
Long-Airdox Co. is a subsidiary of Marmon Group of Chicago, Illinois. The principal officers of Long-Airdox Co. are William Meador, president; Anthony McKeon, controller; Larry Harding, vice-president engineering; and Larry Hall, construction manager.
The last Mine Safety and Health Administration (MSHA) regular (AAA) inspection at this major construction site was completed on August 29, 1994.
DESCRIPTION OF THE ACCIDENT
On Monday, January 9, 1995, the Long-Airdox construction crew began their shift at 7:30 a.m., under the supervision of Teddy Trump, construction superintendent. Teddy Trump relays job assignments through Ray Diegert, print man, to the construction crew. The crew was transported to the construction site via pickup truck. Jerry Trump and James Dix, both classified as connectors, were assigned to secure two motors on a refuse screen. After completing that assignment, they were assigned to hoist a distribution box from the first full floor above ground level up to the second full floor of the preparation plant. The distribution box was to be welded to the bottom of the heavy media pressure vessel.
The distribution box had earlier been lifted from the ground to the first full floor above with a crane. About 10:25 a.m., Jerry Trump climbed onto the pipe on the refuse drain screen to operate the come-along being used to hoist the distribution box up to a chainfall. The chainfall was to be used to hoist the distribution box up to the heavy media pressure vessel. When the distribution box was hoisted to less than an inch from the top of the refuse screen, the come-along ran out of slack cable. This made it necessary for the victim to bend over and assist Dix in lifting the distribution box over the top of the refuse screen. When the distribution box cleared the top of the refuse screen, it swung toward the victim, striking the pipe and the victim's feet, causing him to fall backward and through an open refuse chute to the concrete ground floor 27 feet below.
When Jerry Trump fell to the ground floor, Carlos Trump, pipefitter, and James Ramsey, a millwright and an EMT, who were both located near the refuse screen, ran to the victim on the ground floor. The victim was momentarily unconscious when they arrived. According to Carlos Trump and Ramsey, when the victim regained consciousness, he appeared to be alert. They stabilized the victim's neck and covered him to treat for shock. Carlos Trump stated that the victim's skin was clammy, his eyes were rolled back, and his left wrist appeared to have multiple fractures. It was decided by those present at the accident scene that an ambulance service and a Health Net helicopter should be notified.
Clay County Ambulance Service arrived at the guard shack at 11:08 a.m., arriving at the accident scene a few minutes later. A paramedic from the ambulance service confirmed the need for a Health Net helicopter. The helicopter arrived at the accident scene at 11:32 a.m., departed the scene at 11:41 a.m., and transported the victim to Charleston General Hospital. The victim was admitted to the intensive care unit where he died at 2:45 p.m. on January 15, 1995. According to Teddy Trump, also a brother of the victim, Jerry Trump suffered a broken pelvis, a fractured wrist, and back injuries.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration was notified of the accident at 8:30 a.m., January 10, 1995. MSHA personnel began to arrive at the site about 9:30 a.m. Discussions were held with construction personnel and officials at the site. Photographs and some measurements were taken at the accident scene. According to officials at the mine, the victim was in stable condition; therefore, an investigation was not started at that time.
The victim's condition deteriorated sometime late January 12, 1995. He had stopped breathing and was placed on a life-support system. On January 13, 1995, MSHA and the West Virginia Office of Miners' Health, Safety and Training began an investigation of the accident. The accident scene was videotaped, additional photographs and measurements were taken, and interviews were scheduled on January 13, 1995, at the MSHA Mount Carbon Field Office.
Interviews were conducted January 13, 1995, with a Fola Coal Company, Inc. representative and a Kanawha Valley Scale Serv. Inc. representative. Employees and officials of Long-Airdox Co. declined to be interviewed at that time because they wanted to be represented by an attorney. Interviews were rescheduled for January 19, 1995, at the Mount Carbon Field Office. When an attempt was made to begin the interviews, the Long-Airdox Co.'s attorney advised interviewees not to allow the interviews to be audio taped. A court recorder was retained, and the interviews were again rescheduled for January 27, 1995, at the West Virginia Office of Miners' Health, Safety and Training in Charleston, West Virginia. Three employees and two officials of Long-Airdox Co., known to have knowledge of facts surrounding the accident, were interviewed on January 27, 1995.
DISCUSSION
Examinations
The on-shift records and statements made during interviews indicated that on-shift examinations were conducted prior to the accident.
Training
The records indicated that Jerry L. Trump had received up-to-date annual refresher training.
Physical Factors
Long-Airdox Co. had negotiated a contract with Fola Coal Company, Inc., to construct the preparation and loading facilities. Any work, which Long-Airdox Co. was not equipped to do, was subcontracted to other companies.
Long-Airdox Co. began construction of the preparation and loading facilities in July 1994.
The pipe that Jerry Trump stood on while hoisting the distribution box was 50 inches from the floor. The pipe was about 5 inches in diameter.
The distribution box was being hoisted from the second full floor to the bottom of the heavy media pressure vessel, a distance of about 17 feet.
The come-along did not have enough cable to hoist the distribution box over the top of the refuse drain screen which is about 4 feet from floor level. This required Dix and Jerry Trump to lift the distribution box less than an inch to clear the top of the screen.
The pipe was located 22.5 inches from the two motors on the refuse drain screen. The distribution box had to clear the area between the motors and the pipe. This did not allow the victim anywhere, other than the pipe, to position himself to conduct his activities.
The distribution box was cone-shaped, measuring 27 inches long, 36 inches wide, and 21 inches high. The distribution box weighed approximately 225 pounds.
An I-Beam was located directly in line with the projected path of travel of the hoisted distribution box. The I-Beam was 67 inches above the pipe that Jerry Trump was standing on.
According to Carlos Trump, he offered to get another chainfall for Jerry Trump and Dix. Carlos Trump stated that an additional chainfall would have eliminated the need to use the come-along; therefore, Jerry Trump could have stayed on the floor in a safe location.
The refuse chute was to be enclosed upon completion of construction. The opening in the chute was about 4 feet above floor level; therefore, it would not normally present a hazard. The opening in the refuse chute was in a rectangular shape, measuring 105 inches by 18 inches.
Long-Airdox Co. requires all employees, as a condition of employment, to provide themselves with safety belts. On three occasions, one of the topics of weekly safety meetings at this site has been safety belt requirements.
According to company officials, if employees were observed not using a safety belt when a danger of falling existed, an oral policy was in effect which constituted a verbal reprimand on first offense, suspension on the second offense, and discharge on the third offense. It could not be determined that any disciplinary action, other than verbal reprimands, had ever been taken at this site.
On August 29, 1994, an MSHA inspector observed three workers, employed by S I McAllister Construction Co., a subcontractor for Long-Airdox Co., not using safety belts where a danger of falling existed. On October 24, 1994, an MSHA inspector observed three workers, employed by San-Con Inc., another subcontractor for Long-Airdox Co., not using safety belts where a danger of falling existed. On November 29, 1994, an MSHA inspector observed two workers, employed by Long-Airdox Co., not using safety belts where a danger of falling existed. These violations were all observed and cited at the Fola Coal Company, Inc., major construction site.
CONCLUSION
The accident occurred because a safety belt was not used when a danger of falling existed, the open refuse chute was not guarded, and workers did not stay clear of the hoisted distribution box. Another contributing factor to the accident was that, had a second chainfall been used instead of the come-along, it probably would not have been necessary for the victim to have been in the hazardous location. Also contributing was the failure to implement an aggressive program to ensure workers used safety belts.
CONTRIBUTING VIOLATIONS
A 107(a) Imminent Danger Order No. 4206103 was issued to Long-Airdox Co., stating in part that the victim did not use a safety belt where a danger of falling existed, and the victim did not stay clear of the hoisted distribution box.
A 104(a) Citation No. 3743459 was issued to Long-Airdox Co., stating in part that the victim did not use a safety belt where a danger of falling existed, a violation of 30 CFR, 77.1710(g). This was a contributing factor to the issuance of Imminent Danger Order No. 4206103.
A 104(a) Citation No. 4206101 was issued to Long-Airdox Co., stating in part that the victim did not stay clear of the hoisted distribution box, a violation of 30 CFR, 77.210(b). This was a contributing factor to the issuance of Imminent Danger Order No. 4206103.
RELATED VIOLATIONS
A 104(a) Citation No. 3743456 was issued to Long-Airdox Co., stating in part that an injury with reasonable potential to cause death occurred at this site, and MSHA was not immediately notified.
Respectfully submitted by:
Paul E. Hess, Jr.
Coal Mine Safety and Health Inspector
Approved by: Michael J. Lawless
District Manager
Related Fatal Alert Bulletin:
[FAB95C03]