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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 4

ACCIDENT INVESTIGATION REPORT
UNDERGROUND COAL MINE
FATAL ROOF-FALL ACCIDENT

Clinton No. 8 (ID No. 46-08394)
Dale Coal, Inc.
Wharton, Boone County, West Virginia

May 26, 1995

By

Vaughan Gartin
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

GENERAL INFORMATION

The Clinton No. 8 mine, Dale Coal, Inc., is located at Wharton, Boone County, West Virginia. The mine is developed from the surface by four drift entries into the Buffalo Creek coalbed that averages 36 inches in height.

The mine began production during September 1994. Employment is provided for 27 employees on two production shifts and one maintenance shift. The mine produces an average of 600 tons of coal daily from one continuous-mining-machine section. Coal is transported from the section to the surface via belt conveyor. The immediate roof is comprised of shale and sandstone and is primarily supported with 36-inch conventional bolts. The roof supports are installed on 4-foot lengthwise and 4-foot to 5-foot crosswise spacing with 6- by 6-inch bearing plates. Ventilation is induced into the mine by a 5-foot blowing fan that produces about 80,000 cubic feet of air a minute. The mine does not liberate any substantial amounts of methane in a 24-hour period. The roof control plan in effect at the mine was approved by the Mine Safety and Health Administration (MSHA) on March 10, 1995.

The last MSHA Safety and Health inspection (AAA) was completed April 27, 1995.


DESCRIPTION OF THE ACCIDENT

The section foreman, Willie Johnson, arrived at the mine site and traveled underground to the 002-0 working section. At 7:00 a.m., he proceeded to examine the face areas for gas liberations and obtained an air reading in the last open crosscut. Johnson was crossing the section when Jerry Brinkley, third-shift foreman and preshift examiner, and Nathan Hayes, chief electrician, informed Johnson that the continuous-mining-machine cable was grounded. Brinkley and Hayes began tracing the ground on the continuous- mining-machine cable.

The second shift production crew had mined the crosscut between the No. 3 and No. 2 entries on May 25, 1995. When they mined this crosscut, the left side of the working face holed through into the No. 2 entry. The right side of the working face did not hole through into the No. 2 entry, which left a coal stump measuring approximately 2 feet wide and 8 feet long. The coal stump extended across the working face of the crosscut from the inby rib to the holed-through area on the left side of the crosscut.

The day-shift production crew arrived at the mine site and proceeded underground at 7:30 a.m. to the 002-0 section. The crew was informed by Chester Osborne, superintendent, that his brother, Charles Osborne, continuous-mining-machine helper, would be late for work. When the crew arrived on the section, Johnson informed Harry Bower, continuous-mining-machine operator, and Donald Hood, ram-car operator, that when repairs were made on the grounded continuous-mining-machine cable, the crosscut between the No. 3 and No. 2 entries needed additional cleaning before the roof-bolting machine could be taken into the crosscut and roof bolting started. Johnson also instructed James F. Cook, roof-bolting-machine operator, to begin installing permanent supports when the crosscut was cleaned. Johnson then left the section and traveled to the surface to get Charles Osborne.

Prior to going underground, Okie Tilley, scoop operator and roof- bolting-machine helper, was instructed by the superintendent to take the scoop and supplies to the section. When Tilley arrived on the section, the scoop lights went out. Tilley informed Hayes of the problem. While repairs were being made on the scoop, the belt conveyor system shut down. Tilley went to the belt conveyor to see what was wrong.

After repairs were completed on the continuous-mining machine, Bower trammed the machine from the No. 3 entry to the No. 2 entry and began mining the coal stump in the crosscut between the No. 2 and 3 entries. Bower mined and loaded 1 1/2 ram cars from the stump, including loose coal that had been pushed through when the crosscut was mined during the second shift.

As Bower mined the coal stump from the No. 2 entry, Cook trammed the Galis 300 roof-bolting machine into the crosscut from the No. 3 entry. The first cut mined from this crosscut had been previously supported with 48-inch conventional roof bolts. Cook then installed three 48-inch conventional roof bolts in the first row 4 feet inby the last row of permanent supports. Cook positioned the roof-bolting machine at an extreme angle and began drilling the hole for the fourth roof bolt in the first row. The installation of the fourth bolt in this row of bolts in this manner placed Cook under unsupported roof.

After completing the mining of the stump, Bower was tramming the continuous-mining machine from the No. 2 entry when, at about 8:30 a.m., he heard the roof fall occur. Bower stopped the continuous- mining machine and crawled to the No. 3 entry and into the crosscut where he discovered Cook underneath the fall with his right hand on the controls of the roof-bolting machine. Bower examined Cook and no vital signs were detected. Bower crawled toward the tailpiece and notified Hood of the accident.

Johnson had just arrived back at the section with Charles Osborne and was informed by Bower and Hood of the accident. Johnson attempted to remove the rock from Cook by using a lifting jack and pry bars, but was unsuccessful. Johnson then called Chester Osborne and informed him of the accident.

Osborne traveled underground to the accident site where he attempted to remove the rock manually from Cook by using a lifting jack and pry bars, but was also unsuccessful. Osborne decided to back the roof-bolting machine out of the crosscut and instructed Tilley to use the scoop to lift the rock. The victim was successfully removed. Osborne administered first aid to the victim and also checked for vital signs, but none were detected. Cook was placed on a stretcher and transported to the surface at 9:38 a.m.

Before leaving the section, Bower trammed the continuous-mining machine to the No. 7 entry.

Attendants from the Boone County Ambulance Service were waiting on the surface. The victim was transported to the Boone Memorial Hospital where he was pronounced dead on arrival.


INVESTIGATION OF THE ACCIDENT

The Mine Safety and Health Administration was notified at 9:43 a.m. on May 26, 1995, that a fatal roof-fall accident had occurred. Mine Safety and Health Administration personnel arrived at the mine at 11:00 a.m. A 103(k) Order was issued to ensure the safety of the miners.

The Mine Safety and Health Administration and the West Virginia Office of Miners' Health, Safety and Training jointly conducted the investigation with the assistance of mine management personnel, the miners, and representatives of the miners.

All parties were briefed by mine management personnel as to the circumstances surrounding the accident. A discussion was held with two miners involved with the roof-bolting system to ascertain how the approved roof-control plan was being followed.

On May 26, 30, and 31, 1995, representatives from all parties traveled to the accident scene. Supplemental roof supports were installed in the area of the accident site. The on-site portion of the investigation was conducted. Photographs, sketches, and relevant measurements were taken at the accident site.

Interviews of individuals known to have direct knowledge of the facts surrounding the accident were conducted at the Mine Safety and Health Administration Office at Uneeda, West Virginia, on June 1 and 2 and August 14, 1995.

During the discussions at the on-site investigation and the interviews on June 1 and 2, the mine operator did not advise MSHA that the continuous-mining machine had been removed from No. 2 entry after the accident. The witnesses interviewed did not mention that fact, and initially MSHA was unaware that the accident scene had been changed in that way and that some information had not been disclosed. Subsequent to the initial interviews, MSHA learned that it had not discovered all the facts and conducted additional interviews on August 14.

The physical portion of the investigation was completed on June 8, 1995, and the 103(k) Order was terminated.


DISCUSSION

Training

Records indicate that training had been conducted in accordance with Part 48, 30 CFR.

An examination of Mr. Cook's training records revealed that he had received all required training.

Examinations

Records and the examiner's date, time, and initials indicated that the required examinations were being conducted at the mine.

Roof Control

The approved roof-control plan required the use of roof bolts of sufficient length to anchor the roof bolts in at least 12 inches of competent strata.

The mine roof in the crosscut where the accident occurred was being supported with 48-inch conventional roof bolts. The mine roof in the entries and crosscuts adjacent to the accident site was supported with 36-inch conventional roof bolts. A change in the thickness of the shale strata in the crosscut required longer bolts in order to anchor in 12 inches of competent strata.

The roof bolts were being installed on 4- to 5-foot crosswise and 4-foot lengthwise spacing as required by the approved roof-control plan.

Entries and crosscuts were developed to a width of 20 feet in accordance with the roof-control plan. No second mining had occurred in the area which may have affected the roof integrity or contributed to this accident.

The victim was not installing roof bolts in accordance with the approved roof-control plan when the accident occurred. The victim had installed three roof bolts in the first row and had drilled a fourth hole to a depth of 33 1/2 inches in the same row when the rock fell. The approved roof-control plan requires installation of the fourth, fifth, and sixth roof bolts in the second row before installing the last roof bolt in the first row. When the victim was drilling the fourth hole with the roof-bolting machine positioned at an extreme angle, he was beneath and with his back to the unsupported area. The approved roof-control plan stipulates a safe sequence for roof-bolt installation.

According to persons interviewed during the accident investigation, the victim had always followed the proper sequence for roof-bolt installation prior to the accident. It could not specifically be determined why the victim had deviated from the installation sequence; however, the victim would have been in close proximity to where the coal stump was being mined if he had advanced the roof- bolting machine to the second row to install the fourth bolt.

The third left crosscut had been mined during the evening shift on May 25, 1995, and had been left unsupported during the 11:00 p.m. to 7:00 a.m. maintenance shift. All other working places on the 002-0 working section were permanently supported.

The first left section (002-0 MMU) utilized a Galis 300 single-head roof-bolting machine, Serial No. 300-304-5721, to install permanent supports. The roof-bolting machine was equipped with a "Safe- Shield" ATRS system. The investigation did not reveal any defects of the roof-bolting machine that may have contributed to the accident.

The first left section (002-0 MMU) utilized a Lee-Norse 245 continuous-mining machine. The machine is not equipped with a remote control system and is operated from the deck. Depths of cuts were limited to 20 feet.

The No. 2 heading had been mined slightly to the left of center. This caused the pillar between the No. 2 and No. 3 headings to be wider where the right side of the No. 3 left crosscut intersected with the No. 2 heading. The left side of the No. 3 left crosscut holed through into the No. 2 heading just as the controls of the continuous-mining machine were advanced to the last row of roof bolts installed in the No. 3 left crosscut. When the controls of the continuous-mining machine were advanced to the last row of bolts during the mining of the right lift, a coal stump measuring approximately 2 feet wide and 8 feet long remained. The stump extended from the right rib to where the left lift holed through. This occurred at the end of the evening shift.

The operator of the continuous-mining machine stated that he was not aware that the victim had begun roof-bolting operations in the No. 3 left crosscut when he mined the coal stump from the No. 2 entry. He further stated that the fall occurred shortly after the coal stump was removed.

The immediate roof strata consisted of shale ranging from 0 to 30 inches in thickness and is overlaid by sandstone strata 80-plus feet in thickness. The mine did not have a history of roof falls or adverse roof conditions.

Test holes were being drilled at 20-foot intervals in accordance with the approved roof-control plan. The longer roof bolts used in the No. 3 left crosscut were installed as a result of the test holes drilled during roof-bolting operations.

The fall at the accident site measured 16 feet wide, 20 feet in length, and 18 to 24 inches in thickness. The fall extended from the row of bolts being installed by the victim to the row of bolts which had been installed 4 feet from the right rib in the No. 2 heading.

The shale rock that fell from the immediate mine roof was unconsolidated but apparently fell in mass when the accident occurred. There were no eyewitnesses.


CONCLUSION

The fatal accident occurred because the safe and proper sequence for roof-bolt installation was not followed. The deviation from the method stipulated in the approved roof-control plan resulted in the roof-bolting-machine operator being positioned beneath the unsupported roof. The removal of the coal stump with the continuous-mining machine during roof-bolting operations in the same unsupported area also contributed to the accident. The coal stump provided some degree of roof support and, when removed, allowed the mine roof to sag and separate from the main roof. The 9 hours that it remained unsupported may have contributed to the sag. The accident occurred within a few minutes after the removal of the coal stump.


CONTRIBUTING VIOLATIONS

A 104(a) Citation No. 3569530 was issued, stating in part that roof supports were being installed out of sequence in the crosscut between the No. 3 and No. 2 entries, a violation of Section 75.220(a)(1), 30 CFR.

A 104(a) Citation No. 3569531 was issued, stating in part that a miner was working inby roof supports in the crosscut between No. 3 and No. 2 entries, a violation of Section 75.202(b), 30 CFR.

A 104(a) Citation No. 4193584 was issued, stating in part that the accident site was altered prior to the start of the investigation, a violation of Section 50.12, 30 CFR. The continuous-mining machine was moved from the accident site to the No. 7 entry. This information was revealed on August 14, 1995, during MSHA's follow- up interviews of witnesses.



Respectfully submitted by:

Vaughan Gartin
Coal Mine Safety and Health Inspector


Approved by:

Billy G. Foutch
Assistant District Manager

Michael J. Lawless
District Manager

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon [FAB95C17]