DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
FATAL MACHINERY ACCIDENT
Chess Processing (I.D. No. 46-06188),
Elk Run Coal Co., Inc.
Sylvester, Boone County, West Virginia
April 11, 1999
William H. Uhl, Jr.
Coal Mine Safety and Health Inspector
John W. Fredland, Jr.
Supervisory Civil Engineer
Mine Waste and Geotechnical Engineering Division
Pittsburgh Safety and Health Technology Center
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: July 30, 1999
The Chess Processing Plant, a coal preparation plant located near Sylvester, Boone County, West Virginia, is operated by Elk Run Coal Co., Inc. The plant consists of one main cleaning facility and one stoker facility. Coal from mines located nearby is transported via conveyor belt to the
raw coal side of the plant and stockpiled utilizing 4 stackers, each having two vibratory feeders and one surge pile draw-off tunnel. Clean coal is stored by utilizing one stacker belt structure and three vertical stackers. The clean coal stackers and stockpiles are referred to as Nos. 1, 2, 3,
and 4 respectively. The clean coal transported from the stoker plant facility is stored utilizing three vertical stackers which are identified as stockpiles and/or stackers Nos. 5, 6, and 7. Chess Processing provides employment for sixty-three employees. Load-out and dozer operators work
two 12-hour shifts per day and main plant personnel work three 8-hour shifts per day. Personnel are on duty seven days per week. Two complete work crews are maintained and rotated at two to five day intervals. The plant produces approximately 15,000 clean tons of coal per day for an annual production of approximately 3 million tons. The plant entered operation status in
September 1981, having 8 stackers with underlying feeders. The stoker facility with 3 additional stackers and underlying feeders has been in service approximately one year. Coal is loaded directly into railcars from the clean coal stockpiles and the stoker facility stockpiles by three
separate reclamation tunnels using a 72-inch conveyor belt. The train load-out facility is provided with a 200-ton surge and/or batch bin. The entire load-out system is computer operated and can be synchronized with the speed of the train during load-out operations. The principal officials of Elk Run Coal Co. are:
Frank Foster.....................................Vice President
Woodrow Slone...............................Safety Director
Dana Ball.........................................General Plant Foreman
The last Mine Safety and Health Administration (MSHA) regular inspection (AAA) was completed November 25, 1998.
DESCRIPTION OF ACCIDENT
On Sunday, April 11, 1999, Dwain Bunch, day-shift plant foreman, reported to work at approximately 6:00 a.m., and began his shift reviewing reports and train load-out schedules. A train was being loaded by the night shift crew members and coal was being blended off of the No. 2 clean coal stockpile and the stoker facility, No. 6 stockpile. The load-out crews work 12-hour shifts which run from 7:00 a.m., to 7:00 p.m., night shift works from 7:00 p.m., to 7:00 a.m.
James Harris, Harold Clay, and Billy Starling were the day-shift load-out crew. All three were classified as dozer operators and each shift they rotated duties from dozer operator to clean coal load-out operator. Charlie Evans was the plant operator.
Dwain Bunch, plant foreman, had given instructions to the day-shift load-out crew to continue loading the train. Bunch assigned Larry Neff, dozer operator and victim, to operate the dozer on the No. 2 clean coal stockpile pushing coal to the feeders until Harris arrived. Neff normally worked 3:00 p.m. to 11:00 p.m., but on this day he was scheduled to work 7:00 a.m. to 3:00 p.m. Bunch instructed Billy Starling to operate the dozer on the No. 6 pile pushing coal to the feeders. Harold Clay was the designated load-out operator for the day shift and had reported to the load-out at 6:30 a.m., and continued loading the train.
James Harris arrived for work at 8:00 a.m., and reported to the No. 2 stockpile where he resumed his duties as dozer operator. Neff had received instructions from the plant foreman to go to the stoker plant and to clean up some areas. Harris stated that after the train was loaded at approximately 12:00 p.m., he went to Nos. 5 and 6 stockpiles and continued benching operations, where the coal is pushed and graded away from the stacker tube.
Harold Clay had been directed to go to the refuse site after the train was loaded, and continued to work there until approximately 1:00 p.m., when he was notified by radio that the next train had arrived and was placing empties. Bunch went to the refuse site and picked Clay up and took him back to the load-out facility. Bunch stated that the train was to be loaded from the No. 3 stockpile and he instructed Harris and Starling, dozer operators, to stop benching on Nos. 5 and 6 stockpiles and to report to the No. 3 stockpile. Clean coal from the stoker facility was going to be directed to the No. 7 pile and be benched. He would utilize Neff to operate the dozer on the No. 7 stockpile.
Clay began loading coal from the No. 3 stockpile at approximately 1:25 p.m., and Harris and Starling were pushing coal to the feeders at the No. 3 stockpile while Bunch returned to the stoker plant to pick up Neff. Neff was taken to an area near the No. 6 stockpile, stoker plant facility, where he began making pre-operational checks to the dozer he would be operating. Neff was delayed for several minutes trying to start the D9L dozer and he called Bunch, plant foreman, and reported the problem. Bunch returned to the stoker facility and helped Neff start the dozer. Bunch stated that he watched from his vehicle as Neff completed his pre-operational checks, got in the dozer, and began benching operations on the No. 6 stockpile.
At approximately 2:00 p.m., Charles Evans, plant operator, notified Neff by radio that he would be sending approximately 7,000 tons of coal to the No. 7 stockpile. At approximately 2:10 p.m., Evans reported to Neff again that coal was now on its way. According to Evans, it would normally take about 30 minutes for the coal to be conveyed through the mountain and reach the No. 7 stockpile. Evans said that at approximately 2:40 p.m., he noticed coal was beginning to cone up at the No. 7 stacker and he attempted to contact Neff several times by radio and received no answer.
Bunch had returned to his office and stated that he had some concerns about the ventilation and escape tube located on No. 7 stockpile. He contacted the plant operator to have him caution Neff not to push coal over the escape tube. Evans, plant operator, reported back to Bunch that he was unable to make radio contact and that other personnel contacted in the area said they could not see Neff. Evans stated that he was not overly concerned at first because the dozer operators sometimes moved their equipment from sight of the camera to relieve themselves.
Bunch stated that he drove to the stoker facility and ran to the top of the No. 7 stacker, thinking that Neff had possibly backed over the back side of the stockpile and was unable to tram the dozer back onto the pile. Bunch then turned, and looking down in the direction of the No. 16 feeder, saw the tip of the dozer blade protruding out of the pile.
Bunch said that he ran to the top floor of stacker No. 7 and immediately pulled the emergency stop cord on the conveyor belt. He then contacted Evans by radio to cease loading operations and told Evans to have the dozer operators on the hill as soon as possible. Bunch reported to Evans that he had a dozer in the feeder and that it looked bad.
Evans, plant operator, contacted James Harris and Billy Starling, dozer operators, to have them report to the No. 7 stockpile. Evans then contacted the Whitesville Fire and Rescue Department and requested their assistance. Their records indicate that they were contacted at approximately 2:51 p.m., April 11, 1999. Evans then contacted Health Net to place them on standby. As instructed by Bunch, Evans was told to notify all authorities and to have the plant superintendent, Jeff Walkup, and other members of management notified of the accident.
The computer readout from the plant operator's control room indicated the emergency stop switch on the belt conveyor was activated at 2:51 p.m., and 566 tons of coal had been delivered to the No. 7 stockpile by the time the accident was discovered.
James Harris and Daniel Davidson, D10N dozer operators, began removing coal in the area of the No. 16 feeder at 3:00 p.m.
Jerry Tucker, electrician, removed all electrical service to the stoker facility. Gerald Ramsey, an EMT and mechanic, and Fred Griffith, mechanic, were instructed to gather all first-aid equipment, oxygen boxes, safety harnesses, and life lines, and bring them to the scene of the accident.
The Whitesville Fire and Rescue Department arrived and was standing by as the coal was being removed. Coal removal continued until the dozer was exposed and access to the dozer cab could be accomplished. Ramsey, while attached to a life line, entered the area first and began removing the coal from the dozer cab by shovel. Members of the fire rescue team were present and jointly working to recover Mr. Neff. Ramsey said that the doors to the cab were open and the cab was inundated with coal to within 2 to 3 inches of the cab roof. Mr. Neff was fastened in the operator's seat by the seat belt and his hands were positioned near his face, the radio microphone in his hand. Paramedics immediately checked for vital signs and found none. Recovery of the body occurred at 4:40 p.m.
The Whitesville Ambulance Service transported Mr. Neff to the Boone County Memorial Hospital and then to the Charleston Area Medical Center. Upon arrival, Neff was pronounced dead by the Chief Medical Examiner at 5:50 p.m. The estimated time of death was approximately 2:45 p.m. The cause of death was established as suffocation.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) was notified of the accident by Woodrow Slone, safety director, at 3:30 p.m., Sunday, April 11, 1999. MSHA personnel arrived at the accident scene at 7:05 p.m. State representatives were also present at the scene during recovery operations. MSHA personnel and representatives of West Virginia Office of Miners' Health, Safety and Training jointly conducted the preliminary investigation. A 103(k) closure order was issued to ensure the safety of all persons until the investigation could be completed.
Photographs, sketches, audio/video recordings, and an engineering survey of the area of the accident were made. The recovery of the D9L dozer occurred on Monday, April 12, 1999. The 103(k) order was subsequently modified to allow the dozer to be moved to a safe location for further testing and evaluation.
On April 13, 1999, MSHA and West Virginia Office of Miners' Health, Safety and Training continued the investigation, assisted by officials and mine personnel of Elk Run Coal Company, Inc. Interviews were conducted in the training building conference room located at the Chess Processing Plant. Statements were taken from persons considered to have knowledge of the facts surrounding the accident. Those persons who took part in the investigation are listed in the Appendix. The on-site portion of the investigation was completed on April 16, 1999, and the 103(k) order was terminated.
The examination of records and interviews with the miners and management personnel indicated that all required training was provided in accordance with 30 CFR Part 48.
- The accident occurred at the No. 16 feeder located near the No. 7 stacker, which is part of the stoker facility surge pile. The pile consists of three stacker tubes which are referred to as stacker Nos. 5, 6, and 7. The piles associated with these stacker tubes are designated as pile Nos. 5, 6, and 7 respectively.
- A reclaim tunnel runs underneath the surge pile. Each stacker has two feeders located about 20 feet to each side of it. The stacker tubes and feeders are in a straight line. The feeders have hydraulically controlled slide gates with no vibrators. The opening when the gate is all the way open is 4 feet by 4 feet. When coal is being drawn from the pile, the gate opening is adjusted to obtain the desired discharge rate. The geeders discharge coal onto a 72-inch conveyor belt.
- The material in the pile is clean coal which has been crushed and sized in the stoker facility. At the time of the accident, the coal in pile 7 was 2 inch by zero size. When the train is loaded, multiple feeders may be opened to obtain a blend of coal from this pile and other piles at the Chess Processing Plant.
- The accident occurred when a bulldozer fell into a cavity which formed when the coal bridged over the No. 16 feeder in the No. 7 pile. The two feeders for the No. 7 pile are designated as No. 15 and No. 16. Feeder No. 16 is the last reclaim gate on the southern end of the pile.
- The height of the coal in pile No. 7 was about 40 feet at the time of the accident. The stacker tubes are approximately 68 feet high.
- The feeder locations on the stoker facility surge pile were marked with an object suspended above them. Either a small diameter plastic pipe or a larger cutout in the shape of an arrow was used.
- The bulldozer involved in the accident was a Caterpillar D9L. It had a fully-enclosed cab. The laminated glass windows were held in place by a rubber off-set type gasket. A sample of the glass measured 0.23 inches thick.
- The dozer was buried in the pile directly over the No. 16 feeder with the blade pointing upward. The dozer was setting at an angle of about 50 degrees from horizontal. It was covered with coal except for a few feet at the right end of the blade and one of the lights mounted at the top of the right side hydraulic cylinder that controls the blade height.
- When the dozer was dug out, the cab was nearly full of coal. The front and rear windows of the dozer cab were fractured and pushed into the cab. Both doors were found to be latched in the fully opened position. No one had reported seeing the victim operate with the doors open. The last time the victim was seen heading toward the pile, the doors were reportedly closed. The cab's air conditioner was found to be in operating order after the accident.
- Following the accident, the cab was out of alignment enough that neither door could be closed. The rear cab post over the driver's left shoulder had been bent forward toward the center of the cab by over 2.5 inches.
- When the dozer was recovered, the controls were found in a forward gear. The radio worked and was set to channel 2. The victim was wearing a seatbelt when recovered.
- The control rooms for sending coal (plant operator) to the stockpile and loading coal from the stockpile (load-out operator) were in two separate locations. The pile could be observed by a video camera monitor from the plant operator's control room. The load-out operator and dozer operators communicated by radio. The plant operator sending coal to the pile transmitted on channel 1. The load-out operator transmitted on channel 2.
- At the time of the accident, the feeder doors were closed and no coal was being loaded out from the stoker facility (stockpiles Nos. 5, 6, and 7). Coal had just started to be conveyed to the No. 7 stacker and the dozer operator had gone to "bench" the coal, or grade it away from the stacker tube. When the accident was discovered, coal was discharging from the stacker opening just above the dozer's location. The company estimated that 566 tons of coal had been conveyed to the No. 7 stacker before the conveyor was stopped when the accident was discovered. The coal discharging from the
No. 16 feeder side of the stacker would have been accumulating on the dozer.
- A train was being loaded at the time of the accident and coal was being drawn from the clean coal No. 3 stockpile only.
- No mechanical problems were found on the dozer.
- The feeder gates are opened and closed using a computerized system. The amount that the gate is opened is controlled by the load-out operator and indicated by a digital readout from an electronic signal. The No. 16 feeder gate was verified as being in the closed position following the accident.
- The company's practice was to keep track only of the tonnage loaded from a pile. Which of the two feeders was used to draw coal from the pile was not recorded. Company records indicated that coal was last loaded from the No. 7 pile on April 5, 1999, when about 10,000 tons of coal were blended from piles 6 and 7. However, according to the load-out and dozer operators, the No. 15 feeder was used at that time, not the No. 16 feeder where the accident occurred. According to company personnel, coal was last loaded from the No. 16 feeder on March 31, over 10 days prior to the accident.
- Company personnel indicated that the feeders for the No. 7 pile were particularly troublesome for "plugged" conditions. The combination of the size distribution of the coal, which included a high percentage of finer material, and the practice of operating equipment over the feeders, likely made the coal in the No. 7 pile prone to bridging over the feeder.
- Methods used to free a "plugged or suspected cavity" condition were pounding on the side of the feeder with a hammer, using water pressure from inside the reclaim tunnel, or excavating into the pile from off to the side. The water line was not available for use on the pile No. 7 feeders.
- It was common practice to operate the dozers over the feeders in pushing coal away from the stacker tubes. Two methods were relied on to detect the presence of a cavity. When a feeder was opened, the load-out operator checked by radio with the dozer operators to determine whether a drawhole developed over that feeder. The second method was to monitor the weight of the coal on the belt during the load-out process. Unless the feeder had run empty, a reduction in the weight of coal on the belt indicated a bridged condition and the dozer operators would be alerted.
- According to company personnel, the No. 16 feeder had been "plugged" or bridged over on March 30, 1999. This condition was noted on a bulletin board in the load-out control room. The condition had been eliminated on March 31, 1999. According to the statements from company personnel, this was the last time that the No. 16 feeder had been used and it was feeding properly at that time. Reportedly, March 31st was also the last time that coal had been conveyed to stacker No. 7 prior to the day of the accident.
- According to company statements and records, the cavity existed over the feeder which had not been opened in the ten days prior to the accident. The procedures used in operating the surge pile did not allow this condition to be detected and did not require that the feeder be verified before traveling over the feeder.
- There were no eyewitnesses to the accident.
The conditions observed during the accident are depicted in the plan view on Figure 1 and in the photographs taken at the scene of the accident.
Sometime between March 31, 1999, and the time of the accident, coal had to have been loaded out, either intentionally or inadvertently, from feeder No. 16. Sufficient coal was loaded to create a bridged-over cavity large enough for the D9L dozer to fall in. The minimum amount of coal that would have to be loaded to create such a void would be on the order of 100 to 200 tons. Coal is typically loaded at the rate of 3,200 tons per hour. At this rate 160 tons of coal would be drawn from the pile in only 3 minutes.
The accident occurred because the dozer was driven directly over a feeder that had a void and bridged condition above it. The weight and movement of the dozer and the coal being pushed caused the void to collapse. The dozer fell into the void and coal filled the cab suffocating the operator.
- A 103(k) order No. 4207902 was issued to ensure the safety of the miners until the investigation could be completed.
- A 104(a) citation No. 7157382, Section 77.209, Title 30 CFR, was issued, stating in part, that the dozer operator was positioned in a hazardous location over a void/bridged condition that was created by coal reclaiming operations beneath the storage pile and the exposure resulted in fatal injury to the victim.
- A 104(a) citation No. 7157383, Section 77.1713(a), Title 30 CFR, was issud, stating in part, that adequate on shift examinations were not being conducted during each working shift or more often when necessary for safety and hazardous conditions to be reported and corrected.
William H. Uhl, Jr.
Coal Mine Safety and Health Inspector
John W. Fredland, Jr.
Supervisory Civil Engineer
Richard J. Kline
Assistant District Manager
Edwin P. Brady
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