DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 6
ACCIDENT INVESTIGATION REPORT
(Coal Refuse Facility)
FATAL MACHINERY ACCIDENT
Chapperal Preparation Plant (ID: 15-05406)
Lodestar Energy, Inc.
Pikeville, Pike County, Kentucky
February 20, 1998
by
Timothy R. Watkins
Mining Engineer
Robert H. Bellamy
Mining Engineer
Joseph F. Judeikis
Mechanic Engineer
Originating Office - Mine Safety and Health Administration
100 Ratliff Creek Road, Pikeville, Kentucky 41501
Carl E. Boone II, District Manager
GENERAL INFORMATION
The Lodestar Energy, Inc., Chapperal Preparation Plant, MSHA I.D.
No. 15-05406, coal preparation plant is located 1.2 miles off
Island Creek Road on Marion Branch Road near Pikeville, Pike
County, Kentucky. Lodestar Energy, Inc. is a subsidiary of
Rencoal, Inc. and the principal officers are as follows:
John W. Hughes...........................................President, Chief Operating Officer
Mike Francisco............................................Vice President, East Kentucky Operations
Marvin M. Koenig........................................Vice President
John R. Siegel, Jr..........................................Vice President
Roger L. Fay................................................Vice President
R. Eberley Davis...........................................Vice President, Assistant Secretary
Michael E. Donahue......................................Vice President, Treasurer
Eugene C. Holdaway.....................................Senior Vice President
Justin W. D'Atri.............................................Secretary
Dennis A. Sadlowski.....................................Assistant Secretary
Michael C. Ryan...........................................Assistant Secretary
The principal officers of the Chapperal Preparation Plant are:
Billy Joe Deel................................................Superintendent
Tom Runyon..................................................Foreman
Paris Charles.................................................Safety Services Director
The Chapperal Preparation Plant was placed in active status on April 5, 1974. The facility currently processes coal from six of the company's mining operations, using jigs and froth flotation recovery methods. A total of 27 people are employed at the plant, which normally operates one and one-half production shifts per day, five days a week. The remainder of the second shift is used for maintenance. The plant processes approximately 10,000 tons of raw coal daily which generates 4,500 tons of clean coal and 5,500 tons of refuse daily.
The refuse is disposed of at the coal refuse impoundment site. The Mine Safety and Health Administration (MSHA) approved the construction plan for the impoundment on March 8, 1984. The facility consists of two areas, the West Hollow and the East Hollow. The fine refuse (slurry) is now pumped from the preparation plant into the West Hollow pool area for disposal. The coarse refuse is transported from the preparation plant to the East Hollow via two R-85 Euclid haul trucks. The East Hollow is in the abandonment phase and is being capped with coarse refuse. The cap is formed as the coarse refuse is pushed, by a bulldozer, into the slurry pool to form a consolidated layer over the slurry, capable of supporting the weight of the equipment.
The last regular Health and Safety Inspection was completed at this facility on June 3, 1997.
DESCRIPTION OF ACCIDENT
On February 20, 1998, at approximately 5:40 a.m. Nolan Auton, bulldozer operator, arrived for his shift which began at 6:00 a.m. Auton had a brief conversation at the preparation plant with Carlis Johnson, truck driver. Auton then drove his personal vehicle to the coal refuse facility (slurry impoundment), to begin his shift.
At approximately 6:40 a.m., Johnson arrived at the East Hollow area with the first load of coarse refuse, of the day. The area was still dark at this time of the morning. Johnson reported that he did not see Auton or any sign (i.e., lights) of the bulldozer. Johnson also did not see any sign of Auton on his second trip at approximately 7:10 a.m. At approximately 7:40 a.m. Johnson arrived with his third load of the day. Enough daylight was present at that time for him to visually scan the area. However, there was no sign of Auton. Johnson became worried and asked the other truck driver, Jackie Robertson, who was also hauling coarse refuse, if he had seen Auton. Robertson stated that he had not seen Auton all morning. Robertson thought that Auton may have gone to the West Hollow area of the impoundment. Johnson replied that there were no bulldozer tracks leading away from the East Hollow area. While Johnson returned to the preparation plant, Robertson drove around the East Hollow impoundment looking for Auton.
At approximately 8:00 a.m., Johnson returned to the plant and told Tom Runyon, plant foreman, that they could not find Auton. About that time, Bill Deel, Plant Superintendent, arrived. Runyon informed Deel that they could not find Auton. Deel and two mechanics, Ralph and Lowell Tackett, immediately went to the impoundment. Upon their arrival, they discovered a location where it appeared that a bulldozer had backed into the slurry with the blade down. Deel contacted Runyon and instructed him to notify emergency personnel along with state and federal authorities.
The accident was reported to Donnie Johnson, supervisor at the MSHA field office in Martin Kentucky, at 8:30 a.m. At 8:40 a.m. the MSHA district office was notified of the accident. At 9:20 a.m., personnel from the district office arrived on-site. Company and emergency personnel were already concentrated at the head of East Hollow, when MSHA personnel arrived. A 103(K) order of withdrawal was issued at 9:40 a.m., to ensure the safety of the other miners on mine property.
An examination of this area indicated that Auton had apparently made several pushes of coarse refuse toward the slurry pool at the head of East Hollow. The impressions left by the bulldozer blade indicated that he started to back-drag the haulroad on his way out. The bulldozer then made a half circle, with a radius of approximately 30 feet. The half circle started where the impoundment and the hillside met and continued around to the right until it disappeared into the slurry.
A decision was made to use an excavator to locate the bulldozer. An excavator was brought up from the preparation plant area. While the excavator was in route, sketches, photographs and video tapes of the accident scene were made.
The excavator arrived on site and immediately began trying to locate the missing bulldozer. At approximately 10:00 a.m. the bulldozer was located 12 - 15 feet below the surface of slurry. The company then called for a long boomed excavator. An attempt was made to remove the slurry using the excavator. The slurry was too fluid to allow only the material from around the submerged bulldozer to be removed and the impoundment was too large to allow removal of all slurry down to the level of the bulldozer.
A decision was made by company officials along with state and MSHA representatives to construct a dike across the slurry impoundment to limit the amount of material requiring removal. A holding area for the slurry to be removed was also constructed. Because modifications were being made to the slurry impoundment MSHA Technical Support was asked to assist in the recovery operations. Stanley J. Michalek, civil engineer for the Mine Waste and Geotechnical Engineering Division, provided that assistance.
The material removed during the construction of the holding area was used in constructing the dike. The remainder of the material (coarse refuse) needed to finish the dike was trucked in. The dike was completed on February 21, 1998 at approximately 10:35 a.m. Two long-boom excavators immediately began removing the slurry. Once the slurry was removed it was placed in the holding area or into the impoundment, on the up-stream side of the dike.
The first visual contact with the bulldozer was made at 10:00 p.m. on February 21, 1998, when the top left corner of the blade was uncovered. On February 22, 1998 at approximately 5:40 a.m. an outside contractor, Donahue Brothers, attached winch lines to the bulldozer. Two retrievers (bladeless bulldozers with winches) and two track mounted front end loaders with winches were used to recover the bulldozer. At 7:55 a.m. the bulldozer was recovered from the impoundment with the victim's body located in the operator's compartment. Auton was pronounced dead by the Pike County, Kentucky coroner at 8:00 a.m.
EXAMINATION OF EQUIPMENT
The D-8K Caterpillar bulldozer, serial number 77V18055, involved in the accident was taken to Wayne Supply Company for examination. Whayne Supply Company is the authorized dealer for Caterpillar equipment in the area. Joseph F. Judeikis, mechanical engineer for MSHA Technical Support, oversaw the examination. The work performed during the examination was performed by a Certified Caterpillar mechanic from Whayne Supply. Jim Ashley, maintenance supervisor for Lodestar Energy, Inc., was present during the examination of the equipment. This examination revealed no mechanical problems which might have contributed to the accident.
PHYSICAL FACTORS INVOLVED
The investigation revealed the following factors relevant to the occurrence of the accident:
GENERAL:
- There were no eye witnesses to the accident.
- Auton was working approximately 300 yards from where
the trucks were dumping.
- The accident occurred before daylight.
- The weather conditions at the time of the accident
consisted of rain and fog.
- It is normal work practices at this site for the
bulldozer and the haul trucks to operate a couple of
hours before daylight. Although lighting is provided
on all equipment, no additional lighting was provided.
- The truck drivers delivered a total of six loads of
coarse refuse to East Hollow area between 6:40 a.m. and
7:50 a.m.. Auton was not seen during this period of
time.
VICTIM:
- Relevant work experience:
- Bulldozer operator for 25 years.
- Operated a bulldozer at this facility for
approximately 4 years.
- Operated a bulldozer on the impoundment for
approximately 2 years.
- Bulldozer operator for 25 years.
- A review of the victim's training records showed them
to be up-to-date.
- Interviews with the family members revealed:
- Auton was a diabetic.
- He did not take insulin shots.
- Current medication consisted of one pill per day.
- He had never blacked out.
- Auton was a diabetic.
- An autopsy was performed on the victim at the Kentucky
Medical Examiners Office located in Frankfort,
Kentucky. The report concluded the victim died of
asphyxia.
EQUIPMENT:
- The dozer involved in the accident was not provided
with communication
equipment.
- Steve Haynes operated the bulldozer the evenings of
February 18 and 19, 1998. Haynes reported that the
bulldozer operated correctly.
- Maintenance records for the bulldozer indicated:
- New undercarriage was installed in December of 1996.
- Transmission was rebuilt in March of 1997, by
Western Branch Diesel, Inc.
- Engine and torque convertor were rebuilt in
August of 1997, by Guyan Machinery Co.
- Guyan Machinery Co. replaced a broken crankshaft
and reinstalled the engine on February 11, 1998.
- Guyan Machinery Co. corrected a problem with
the exhaust manifold on February 19, 1998.
- New undercarriage was installed in December of 1996.
- No mechanical defects which might have contributed to
the accident were discovered during the examination of
the bulldozer.
- All lights on the bulldozer were found to be functional.
CONCLUSION
For undetermined reasons the bulldozer backed into the slurry impoundment asphyxiating the entrapped operator. There is no physical evidence to indicate why the bulldozer went into the slurry impoundment. However, insufficient illumination in the area may have contributed to the accident.
- 103(K) Order, Number 4496573, was issued to assure the
safety of any person at the impoundment until an examination
or investigation determines that the area is safe.
- 104(a)(S&S) Citation, Number 4496576, was issued under 30 CFR, Section 77.207, for insufficient illumination of the dumping site and work areas of the coal refuse storage facility.
Respectfully submitted,
Timothy R. Watkins
Mining Engineer
Robert H. Bellamy
Mining Engineer
Joseph F. Judeikis
Mechanical Engineer
Approved by:
Carl E. Boone, II
District Manager, CMS&H District 6
Related Fatal Alert Bulletin:
FAB98C05