DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 7
ACCIDENT INVESTIGATION REPORT
(Surface Mine)
Fatal Powered Haulage Accident
Star Fire Mining, Star Fire Mining Co.
ID No. 15-13936
John Chaney Trck. Co., Inc., ID No. (F10)
Talcum, Knott County, Kentucky
September 2, 1995
by
Elmer Hall and Roy Parker
Coal Mine Safety and Health Inspectors
and
Joseph Judeikis
Mechanical Engineer
Originating Office - Mine Safety and Health Administration
HC 66, Box 1762, Barbourville, Kentucky 40906
Joseph W. Pavlovich, District Manager
GENERAL INFORMATION AND BACKGROUND
Star Fire Mining Co., surface mine, is located at Ary, Perry County, Kentucky. The access road and area of the accident is located at Talcum, Knott County, Kentucky.
The mine entered operational status on March 31, 1994.
The mine produces approximately 6,500 tons of clean coal daily and employs 154 miners on two production shifts, seven (7) days per week. Coal is hauled in trucks operated by the independent contractor from the mine to one of two sites, both in Perry County: the Buckhorn Processing Co. Washer; and Buckhorn Processing #1 Preparation Plant.
Star Fire Mining, is a wholly-owned subsidiary of Cyprus Amax Minerals Co. of Englewood, Colorado.
The last MSHA regular safety and health inspection (AAA) at Star Fire Mining was completed February 28, 1995; however, a MSHA regular safety and health inspection was ongoing at the time of the accident.
John Chaney Trck. Co., Inc. is located at Ary, Perry County, Kentucky. John Chaney Trck. Co., Inc. employs 42 persons and is exclusively contracted for coal haulage at Star Fire Mining. John Chaney, Owner, is normally involved in the daily activities of his company.
DESCRIPTION OF ACCIDENT
On the morning of September 2, 1995, at about 6:00 a.m., Harold Godsey (victim), driver of the #26 truck accompanied by his brother, Terry, driver of the #6 truck, arrived at the garage and parking area of John Chaney Trck. Co., Inc. The two drivers obtained their respective trucks and traveled to the stockpile area of Star Fire Mining via the Talcum entrance arriving at about 6:30 a.m. Harold Godsey, being one of the first drivers to enter the stockpile area, had his truck loaded and then traveled a short distance away from the stockpile area. Soon thereafter, the truck he was operating began experiencing rear brake difficulties. Godsey then pulled the truck to the shoulder of the road and parked. Travelling behind, Terry Godsey, observed the #26 truck parked at the edge of the haulroad. Godsey stopped and asked his brother, Harold, if he was having problems. Harold replied that he had applied the hand control valve and the rear brakes were tightly engaged and would not release. Terry Godsey then climbed into the cab of the truck and attempted to release the brakes. Seeing that the brakes would not release, he then utilized his citizens-band radio and contacted Carlos Hall, driver of the #10 truck, and instructed him to contact the truck garage and inform them that the #26 truck was having brake problems. Hall, contacted Kenny Stacy and Greg Messer, mechanic helpers, and informed them of the problem. Before Terry Godsey left the mine site en route to the Washer Plant Facility, he instructed his brother to descend the hill with his transmission in "Lo-Lo" gear range. Harold acknowledged and replied that he would do so. The two also discussed air leaking from the No. 26 truck when the clutch pedal was depressed which was evident by the sound.
Stacy and Messer arrived at the location of the #26 truck at about 8:00 a.m. The two asked Harold what had happened to the truck and he reportedly stated that the hand brake had been applied, engaging the rear brakes, and would not release. Stacy immediately diagnosed the problem as being in the hand control valve, and according to his statement, performed work on the device in order to release the control air supply which had the brakes engaged. Upon releasing the air supply the brakes then disengaged. After the repairs were completed, the brakes were tested by moving the truck forward and backward while applying the service foot brake. According to the mechanic helpers, the brakes appeared to be operating properly.
Kenneth Harvey, driver of the #33 truck, stated that after he had been loaded, he proceeded to leave the mine site. He further stated that he caught up with the #26 truck which was, at that time, moving slowly. According to Harvey, the victim then indicated for Harvey to pass. After the pass was completed, Harvey continued traveling toward the downhill section of the roadway where the accident later occurred. After Harvey had started his descent down the hill, he heard someone on the citizens-band radio remark that a truck was "running away". As he continued his descent, he looked into his rear-view mirror and saw Harold Godsey begin to pass. As Harold Godsey passed in the #26 Truck, Harvey stated that it appeared as though the truck was traveling at a high rate of speed, estimated at 40 M.P.H., and was out of control. After the victim completed his pass harvey alerted the other drivers using his citizens-band radio that a truck had "run away". Harvey further stated that the #26 truck was driven along the ditched side of the cut slope of the haulroad in an apparent attempt to slow the trucks momentum, however, the shallow ditch line had little or no effect.
Orbin Chaney, General Manager was located at the bottom of the roadway and heard the announcement on the CB radio. According to Chaney, he looked up the hill and saw the #26 truck turn over onto its side and slide down the haulroad coming to a rest over the edge of the embankment. After evaluating the accident Chaney then contacted Edward Abner, Coal Haul Boss of Star Fire Mining, and requested an ambulance. The Viper Rescue Squad was contacted and responded. Also called was the Knott County Coroner, Kenneth Gayheart. Upon his arrival, Gayheart found no vital signs and pronounced the victim dead. The victim was extracted from the wreckage at about 1:30 p.m., and transported to the Engle Funeral Home at Hazard, Kentucky. The victim was later transported to Louisville, Kentucky for further examination by the Kentucky Medical Examiner's Office.
INVESTIGATION
John Dishner, CMI of MSHA's Subdistrict Enforcement Group, was notified of the accident at approximately 11:36 a.m. by Roger Barnett, a Safety and Loss Control Representative of Lost Mountain Mining Company. Lost Mountain Mining Company, located adjacent to Starfire, is also a subsidiary of Cyprus Amax Minerals Co.
MSHA's investigation began immediately after notification of the accident. The investigation was conducted jointly with the following: Kentucky Department of Mines and Minerals, Kentucky State Police, and the Kentucky Department of Motor Vehicle Enforcement. Additionally, Joseph F. Judeikis, Mechanical Engineer of MSHA's Technical Support Approval and Certification Center, Triadelphia, West Virginia, conducted the technical evaluation of the 1989 Volvo/GM autocar coal truck #26.
PHYSICAL FACTORS INVOLVED
The following physical factors were determined to be relevant to the occurrence of the accident:
- The vehicle involved was a 1989 autocar (81,280 LB. Chassis)
utility truck, equipped with a dump bed. The vehicle
identification number was 4V2SCBJG6KU503449.
- The accident occurred on the victim's first day and first
shift of work at this operation. The victim replaced the
regular driver as a substitute.
- The roadway guardrail at the point of impact was constructed
of lengths of drill steel, 6 inches in diameter and was
determined to be adequate.
- The roadway was dry, and weather was not considered to be a
factor. However, the right lane of the roadway traveling up
hi3:21PM 5/20/96ll was paved and partially covered with gravel, creating a
dry, skid-prone condition.
- The subject haulage road is maintained by Star Fire Mining.
It's principal use is for coal haulage. Company security
personnel are stationed near the entrance to the haulroad at
its junction with Kentucky State Route 1087, outby the
location of the accident.
- After examining the accident scene and the wreckage, it
appeared that the truck was traveling at a high rate of
speed. There was no tire mark evidence to indicate that the
brakes had been applied.
- Immediately prior to the accident, repairs were made on the
truck's brake system. The repairs involved those to the
handbrake control valve made in order to release the air
pressure which had the rear brakes set.
- According to statements obtained through interviews, the
brakes on the right front tandem had been "backed off" or
released subsequent to the accident. Also the brakes on the
other three rear wheels were freed by cutting the slack
adjusters with a cutting torch.
- The following reflects the results of the examination of the
trucks braking system:
- The right front steering axle brake chamber (type 24)
pushrod travel exceeded the safe adjustment limits of 1
3/4 inch by 1/2 inch, the pushrod stroke was measured
at approximately 120 p.s.i. and the total measurement
was 2 1/4 inches. The brake assembly was out of
adjustment. The brake linings were also totally
saturated with wheel lube grease as observed during the
examination. The saturation occurred over an extended
period of time exceeding the previous shift.
- The left front steering axle top brake shoe lining was
of an incorrect width of 5 inches. The correct width
is 6 inches.
- The left front drive axle bottom brake shoe front
lining segment was found to be missing.
- The left rear drive axles bottom shoe forward lining
was found to have a 13/8 inch section of lining missing
across the entire 7 inch shoe width. The remaining
section was found to have 1 bolt missing and the
remaining bolts were found to be loose allowing the
lining to shift about on the shoe.
- The hand control valve was examined and found to be
defective in that the supply air check diaphragm and
seating spring were missing from the valve. This
allowed the free discharge of the rear braking system
air, resulting in a loss of supply air to all four (4)
drive wheel brakes. This defect is of particular note.
In the absence of the missing components, the brakes could not have failed to release as was reported immediately prior to the accident. As such, these components were present in the system at the time that the brakes failed to release and prior to repairs conducted the morning of the accident.
- The foot valve-mounted double check valve was found to be contaminated by dirt and grit to the extent that the shuttle plunger would not freely slide in its bore tube. This prohibits air pressure from being delivered to the relay valves for the service chambers of the four (4) rear drive wheel brakes and results in zero braking contribution by the four (4) rear wheel brakes.
- The right front steering axle brake chamber (type 24)
pushrod travel exceeded the safe adjustment limits of 1
3/4 inch by 1/2 inch, the pushrod stroke was measured
at approximately 120 p.s.i. and the total measurement
was 2 1/4 inches. The brake assembly was out of
adjustment. The brake linings were also totally
saturated with wheel lube grease as observed during the
examination. The saturation occurred over an extended
period of time exceeding the previous shift.
- The truck's engine brake system was examined and no apparent
defects were observed. During interviews a statement was
given by the truck's regular driver which indicated that the
clutch pedal, when depressed, would intermittently not
completely return to rest against the micro-switch which
engaged the engine brake. The clutch pedal was damaged
during the wreck to the extent that a positive determination
could not be made.
- The roadway on which the truck was traveling was on a 12.5%-
17.1% grade and averages approximately 36 feet in width.
- The victim held a class "A" Commercial Drivers License and
had approximately eight (8) years experience as a truck
driver prior to the accident.
- The independent contractor, nor the company, maintained any
training records for the victim, nor was any training
provided prior to the victim's assignment to work duties.
- Interviews and an examination of the unit subsequent to the accident revealed that the citizens-band radio installed in the victim's truck was not functioning prior to the accident.
CONCLUSION
The accident and resultant fatality occurred as a result of the failure of the independent contractor to maintain adequate brakes on the subject truck and to provide training to his newly-hired employee.
ENFORCEMENT ACTIONS
The following citations and orders were issued during the accident investigation:
- A 103 (k) Order, No. 3215376, was issued to ensure the
safety of all persons at the mine until the investigation
was conducted.
- A 104 (d)(1) Citation No. 4463985, was issued to the
independent contractor for failure to provide newly-employed
experienced miner training to the victim.
- A 104 (a) Citation No. 4463986, was issued to the
independent contractor for failure to adequately maintain
the braking system of the truck.
- A 104 (a) Citation No. 4463987, was issued to the
independent contractor for failure to immediately notify
MSHA of the occurrence of the accident.
- A 104 (a) Citation No. 4463988, was issued to the mine operator for failure to immediately notify MSHA of the occurrence of the accident.
Respectfully Submitted:
Elmer Hall and Roy Parker
Coal Mine Safety and Health Inspectors and Accident Investigators
Joseph Judeikis
Mechanical Engineer
Approved by:
Joseph W. Pavlovich
District Manager
District 7
Related Fatal Alert Bulletin:
[FAB95C28]