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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 3

ACCIDENT INVESTIGATION REPORT
(Underground Coal Mine)


Fatal Fall of Roof Accident

#3 Mine (I. D. No. 46-08633)
Fairfax Mining Co., Inc.
Clarksburg, Harrison County, West Virginia

July 22, 1999

by

Chris A. Weaver, Mining Engineer (Ventilation)

Randy Sharp
Coal Mine Safety & Health Inspector (Roof Control)

M. Terry Hoch, Chief, Roof Control Division
Pittsburgh Safety & Health Technology Center


Originating Office - Mine Safety and Health Administration
5012 Mountaineer Mall, Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager

GENERAL INFORMATION

The Fairfax Mining Co., Inc., #3 Mine, I. D. 46-08633, is located ten miles west of Clarksburg, in Harrison County, West Virginia. The mine is accessed by 5 drift openings into the Pittsburgh coal seam which averages 58 inches in thickness. Ventilation is provided by one main mine fan which supplies a total of 80,000 cubic feet of air per minute. Coal is produced by advancing entries with remote-controlled, scrubber-equipped continuous mining machines. Second mining is currently not practiced at this mine. The immediate mine roof consists of weak gray shales above a thin layer (typically less than one foot) of head coal and dark shale. Since these shales are extremely sensitive to moisture when exposed to air, head coal is maintained wherever possible.

Employment is provided for 64 underground and 8 surface employees. The mine is operated three shifts per day, five days per week, producing 2250 tons of raw coal per day from two continuous mining machine units. Coal production is primarily achieved on day and afternoon shifts. Maintenance crews are scheduled on midnight shifts and may also engage in limited coal production. Coal is transported to the surface via belt conveyor. Battery-powered track haulage and rubber tired equipment are utilized for transportation of materials and personnel at this mine.

The approved mine ventilation plan permits the use of either blowing or exhausting line curtain for ventilating working faces. Scrubbers must be operated when blowing face ventilation is used to cut coal, during which time the line curtain must be maintained within 40 feet of the point of deepest penetration of the face. Exhaust face ventilation must be used to cut coal when the scrubber is off, during which time the line curtain must be maintained within 20 feet of the point of deepest penetration of the face

The approved roof control plan specifies that roof bolts are to be installed on four-foot centers and permits mining cuts up to 25 feet deep. The plan also specifies that prior to mining cuts that would extend more than 20 feet from the last row of installed permanent roof support, additional roof bolts must be installed by one of the following methods: (a) two additional roof bolts must be installed within the last two rows of roof bolts; or (b) six roof bolts must be installed in the last row of roof bolts. Also, the plan requires examinations to be made to assure that the adjacent entry or crosscut is clear of persons or equipment before a place is mined through into the adjacent area during an extended cut. The plan permits the 25-foot extended cut to be made in two passes with the continuous mining machine, each to a depth of 25 feet. The first pass is called the "A" run and the second pass is called the "B" run. Where adverse roof conditions are encountered during penetration of the face, the depth of the mining runs must be limited to 12 feet from the last row of installed permanent supports. When adverse conditions are first encountered in the "B" run, mining must stop until the area is supported.

.The principal officers for the #3 Mine at the time of the accident were:

President..................................................... David Maynard
Superintendent............................................. Johnny Nickels

The last MSHA Safety and Health Inspection (AAA) was completed on May 12, 1999. The Non-Fatal Days Lost (NFDL) incident rate during the previous quarter was 7.52 for underground mines nationwide and 10.00 for this mine.


DESCRIPTION OF ACCIDENT

On July 21, 1999, the 1 Left Mains midnight shift crew (6 persons), supervised by Robert L. Carter, Jr., entered the mine at the regularly scheduled time of 10:30 p.m. The crew traveled from the surface to the 1 Left Mains section via a battery-powered track vehicle. The afternoon shift continuous mining machine operator, Ford Fink, had just completed a 25-foot deep "A" run on the right side of the crosscut being mined (6 right crosscut) toward the No. 7 entry from the No. 6 entry when the midnight shift crew arrived on the section at approximately 10:50 p.m. Mining in the "B" run of the 6 right crosscut had not been initiated prior to shift change. After the midnight shift crew arrived, the afternoon shift crew left the section.

The midnight shift crew began work at their assigned duties. Dale See, Shuttle Car Operator, proceeded to the shuttle car located near the section loading point where he noticed that the conveyor belt was off. See was informed by mine phone that the belt was down to repair the scraper on the No. 3 head drive. The section belt was restarted a few minutes after See arrived at the loading point. See then proceeded to the 6 right crosscut where Carter was operating the continuous mining machine. Frank Bible, Mechanic, prepared to perform maintenance on the other shuttle car which was located outby the power center. Jack White (victim) and Charles Garrison, Roof Bolting Machine Operators, traveled toward the faces of Nos. 6 and 8 entries, respectively, to their roof bolting machines. Harry Adams, Scoop Operator, went directly to the scoop located behind the power center in the No. 5 entry. Adams normally operates the continuous mining machine; however, Carter had assigned Adams to scoop operator for the past week. Adams' assigned duties this shift included scooping the haul roads and supplying the roof bolting machines.

Carter started mining by advancing the "B" run of the 6 right crosscut for 10 to 15 feet (2 or 3 shuttle cars). Carter then backed the miner out of the place so that White could install two rows of bolts. See indicated that roof rock had fallen near the face prior to Carter backing out of the 6 right place. Carter mined a cut from the face of the No. 6 entry while White bolted in the 6 right crosscut.

The investigation could not determine the number of bolts installed by White in the 6 right crosscut prior to Carter resuming mining in this place. Carter stated that White installed two or three rows of bolts, while See indicated that White may have been chased out of the place by falling rock prior to completing the second row of bolts. Physical evidence indicated that the first two rows installed by White contained four bolts and that no additional bolts were installed between these rows. Therefore, when Carter returned to the 6 right crosscut after completing the cut in the No. 6 entry, he was faced with one of three conditions: either (1) two full rows of bolts were installed beyond that left by afternoon shift, which should have indicated to Carter that White had just installed bolts out of sequence; (2) only one full row of bolts was installed beyond that left by afternoon shift; or (3) two full rows and one partial row of bolts were installed between cuts with the partial row installed against roof rock, indicating that adverse conditions existed prior to further mining in the 6 right crosscut. Adams later stated that he last saw White installing the second bolt from the inby (left) rib after the final cut in the 6 right crosscut was completed. Therefore, the third possibility appears to have been unlikely.

After completing the cut in the face of the No. 6 entry, Carter hung the cable to White's bolting machine and trammed the miner back into the 6 right crosscut. At this point in time, White started bolting the face of the No. 6 entry. Garrison had completed bolting the face of the No. 8 entry and was bolting the face of the 7 right crosscut. Adams was scooping roadways and faces between the Nos. 6 and 8 entries; working in close proximity to Garrison. Bible was outby the section power center, replacing a wheel on the shuttle car that he was servicing. See was running the shuttle car as Carter resumed mining in the 6 right crosscut.

According to See, several loads of rock were then removed from the pre-existing unsupported portion of the 6 right crosscut prior to further advancement of the face. Carter was positioned along the inby (left) rib, approximately ten feet outby the last row of bolts, operating the continuous mining machine by remote control. Approximately 35 feet of coal remained to be mined along the left rib and approximately 15 feet of coal remained along the right rib.

As mining progressed in the 6 right crosscut, Adams and Garrison were located in the working places of the No. 7 entry and the 7 right crosscut. Garrison completed bolting the 7 right crosscut and started bolting the face of the No. 7 entry. Spillage in the face of the No. 7 entry needed moved before the last two rows of bolts could be installed. Adams then helped Garrison place the bolting machine cable along the left rib of the No. 7 entry before moving the spillage out of the face of the No. 7 entry into the face area of the 7 right crosscut. Neither Adams nor Garrison expected the miner to mine through into the No. 7 entry. Although Garrison had spent nearly the entire shift in the face areas of the Nos. 7 and 8 entries, he had not seen Carter make any examinations in these areas and had not been warned that the crosscut would be mined through. However, the sound of the miner grinding coal from the adjacent rib indicated to Adams and Garrison that the 6 right crosscut was about to be extended into the No. 7 entry. Standing on either side of the anticipated cut-through, Adams and Garrison picked up the energized bolting machine cable and threw it across the entry. They immediately grabbed the line curtain, also located along the left rib, ripping it down just as the cutting head of the continuous mining machine cut into the No. 7 entry. Carter then mined the remaining coal from the crosscut. The resulting cut was 38 or 42 feet beyond the last row of fully installed roof bolts, depending on the number of bolts installed by White between cuts. After the dust cleared, Adams could see Carter on the other side of the unsupported cut and a rock ledge was exposed two to three feet from the end of the cut. Carter asked Adams how the cut looked. Adams responded that the cut was high. A ledge of approximately two feet needed graded from the floor.

After mining was completed, Carter cleaned up material in the 6 right crosscut that had fallen from the mine roof. This material was pushed through into the No. 7 entry and contained both coal and gray shale, including rocks with bit marks. Carter then moved the miner to the 5 right crosscut to clean up rock which had fallen late in the afternoon shift from the unsupported area of a 25-foot cut. White then moved his bolting machine into the 6 right crosscut as Garrison completed bolting the face of the No. 7 entry. By this time, Donny Nickels, Mechanic, had arrived on the section and was helping Bible with maintenance duties on the shuttle car located outby the power center. Adams obtained a new line curtain for Garrison in the face of the No. 7 entry. At approximately 3:00 a.m., Adams left Garrison to perform rock dusting duties outby. As he passed the 6 right crosscut, Adams noticed Jack White (victim) installing the second roof bolt from the inby rib against exposed roof rock. Adams stated that the mine floor was clear of debris in the 6 right crosscut at this time.

At approximately 3:15 a.m., Carter and See finished loading rock from the 5 right crosscut. Carter trammed the miner back to the last open crosscut between the Nos. 5 and 6 entries. At this point, Carter and See realized that White's bolting machine was still near the beginning of the cut. Carter and See parked their machinery and proceeded into the 6 right crosscut to check on White. They found White pinned between a large rock and the roof bolting machine. White was located at the drill controls of the single-head Fletcher LTDO-13 roof bolting machine, with his chest pinned against the panic bar. White's back and legs were concealed by the rock which was part of a large fall that encompassed nearly the entire unsupported area. The bolting machine was angled toward the right rib with the drill steel extended into the hole for the fourth bolt in the row. See, a Certified Emergency Medical Technician (EMT), checked White for signs of life. No pulse was detected and resuscitation could not be attempted until White was extricated. The roof bolting machine could not be energized because the panic bar was being forced in the off position by White's chest.

See and Carter then assembled help. Carter found Garrison in the No. 7 entry and informed him of the accident. Carter returned with Garrison to the accident site. See went toward the power center to obtain the EMT first response box, where he met Bible and Nickels. See asked Nickels to call outside for an ambulance and sent Bible to obtain the medical box. Nickels contacted Robby Fitchett, Outside Man, who called 911 at 3:23 a.m. On his way to the emergency car, Bible met Adams at the rock dust storage pile and informed him of the accident. Adams trammed the scoop to the accident site, followed by Bible, who arrived at the 6 right crosscut with a chain to be used in conjunction with the shuttle car to pull the bolting machine away from White.

The crew members began working to free White. Carter and See held White from falling forward as the roof bolting machine was pulled back until it was a sufficient distance from White to be re-energized. Garrison then lowered the A.T.R.S. and moved the roof bolting machine into the No. 6 entry, outby the 6 right crosscut. At this point, White's legs were still trapped beneath the rock at the edge of the roof fall. Bible, Garrison, and See used jacks from the man trips to lift the rock off of White's legs; after which, Adams pulled White free of the roof fall. Approximately 30 minutes had transpired since See first checked White for signs of life.

The victim was then transported to the surface in a battery-powered track vehicle, along with Adams, Bible, Nickels, and See. Upon arrival to the surface, the victim was transported by the Harrison County Emergency Squad to the United Hospital Center in Clarksburg, West Virginia, where he was pronounced dead at 4:51 a.m., on July 22, 1999, by Dr. Steven A. Smith, attending physician. Bible drove the mantrip back to the section to get Carter and Garrison with whom he returned to the surface near the end of the shift.


PHYSICAL FACTORS

The investigation revealed the following factors relevant to the occurrence:
  1. The Fairfax Mining Co., Inc., #3 Mine (I.D. No. 46-08633) was developing a nine entry continuous mining machine section in the Pittsburgh coal seam. The section was designated as the 1 Left Mains. The nine entries were numbered from left to right, 0 through 8.

  2. The approved roof control plan allowed both entries and crosscuts to be driven on 50 to 105- foot centers. Typically, on the 1 Left Mains section, entries and crosscuts were mined on 60-foot centers. The crosscuts were driven 60 degrees off of the No. 4 belt entry, resulting in 69.3-foot centers as measured along the crosscut centerline. However, the centers between the Nos. 6 and 7 entries at the accident site were 73 feet apart, resulting in 84.3-foot centers as measured along crosscut centerline.

  3. The accident occurred in the crosscut between the No. 6 and No. 7 entries, approximately 45 feet from the centerline of No. 6 entry.

  4. At the time of the accident, Jack White, victim, was drilling the hole for the fourth roof bolt in the same row (the bolt closest to the right rib). This row was the first and only row installed since the previous cut. No additional roof bolts had been installed inby the row being installed.

  5. The roof bolting machine being used was a Fletcher LTDO-13 with A.T.R.S. (Automated Temporary Roof Support) system and was equipped with a canopy at the drilling controls.

  6. The Pittsburgh Coal Seam in this area is relatively low, measuring 58 inches near the accident area.

  7. The approved roof control plan specifies the mined width of an opening shall not exceed 16 feet. The width of the opening in the caved portion of the 6 right crosscut measured 16.7 to 17.3 feet wide.

  8. The approved roof control plan permits mining cuts up to 25 feet deep. Prior to extending cuts beyond 20 feet from the last row of installed permanent roof support, additional roof bolts must be installed by one of the following methods: (a) two additional roof bolts must be installed within the last two rows of roof bolts; or (b) six roof bolts must be installed in the last row of roof bolts. However, no additional bolts were installed between the last two full rows of installed bolts prior to the extended cut in the 6 right crosscut. At the time of the accident, the 6 right crosscut had been mined at least 38 feet beyond the last full row of installed roof bolts.

  9. The bolts used in the accident area were #5 tensioned rebars, 60 inches long, anchored with four equivalent feet of resin. Donut embossed bearing plates, measuring 6 inches by 6 inches, were used when contact was made against coal roof. Larger plates, measuring 6 inches by 16 inches, were used when installed against roof rock.

  10. Observations of fallen material at the accident scene revealed that the roof in the area consisted of weak shales. The fall extended from rib to rib and domed out at approximately 44 inches above the coal seam. A one-inch thick coal rider seam was present at the 3 foot horizon. The pieces of fallen material were relatively large. The average size appeared to be 5 feet by 7 feet by 1 foot thick. The rock did not have well defined bedding planes or vertical jointing. Roof bolts close to the fall were unaffected as the roof fall was entirely contained to the unsupported area.

  11. The roof bolt operator was in the process of installing bolts when the fall occurred. The hole for the fourth bolt in the row was being drilled at the time of the accident. A portion of the drill steel (1 foot) was hanging from the hole and may have become jammed. This could indicate lateral shifting of the roof. It was later determined that the drill steel had been extended to the full depth of the hole for the last bolt.

  12. The proper sequence of roof bolt installation, as approved in the roof control plan, was not being followed. Three roof bolts had been installed in the first row of the unsupported area and a hole for the fourth roof bolt was being drilled in the same row when the roof fall occurred in the unsupported area. No bolts had been installed inby the row in which the hole was being drilled. Installing the right rib-line roof bolt in this manner while using a single-head roof bolting machine placed the victim inby the last row of installed roof bolts and inby the protection afforded by the A.T.R.S. system

  13. During the investigation, observations of the overall ground conditions were noted. There was no evidence of high stress on the pillars and where roof bolts were installed the roof appeared to be stable. Roof falls, and some sloughing roof was noted; however, this occurred infrequently. Roof falls were most likely to occur when mining would leave no head coal and nick the roof rock. Since the shales in the immediate roof are extremely sensitive to moisture when exposed to air, head coal has been maintained wherever possible. Miners interviewed during the investigation indicated that the standard practice at the #3 Mine is to stop the cut whenever roof rock is exposed while mining coal, even if the point of deepest penetration is less than 12 feet from the last row of installed permanent supports. However, ripper marks along the ribs below the caved area indicated that the continuous mining machine had penetrated into the roof rock in at least three locations within the first 14 feet of the "B" run. Two large roof falls were observed on the section: one at the accident scene and the other in the 5 right crosscut, just inby spad #1956. These falls were similar in nature and neither area had been roof bolted prior to falling. No wet conditions were observed on the section.

  14. The overburden on the section ranged between 240 to 350 feet. Information provided by the operator from a borehole located just inby the accident area revealed the following: (a) the distance from the surface to the coal seam was 342.70 feet; (b) the roof immediately above the coal seam consisted of 0.20 feet of Dark Shale, 1.20 feet of Gray Shale, 22.00 feet of Sandy Shale, and a 0.10 foot thick coal rider. The bore log does not mention the coal rider that was visible in the roof at the accident scene. The borehole was drilled and log information was charted by L J Hughes and Sons, Inc., Summersville, West Virginia. The drill hole number was BL-22-99.

  15. The 911 call was received at 3:23 a.m., fixing the time that the accident was discovered at approximately 3:15 a.m.


CONCLUSION

The victim was struck in the back by rock which fell from the unsupported area of the 6 right crosscut, pinning him against the roof bolting machine and causing fatal injuries. The rock which struck the victim was part of a larger roof fall which was caused by mining an excessively wide and deep cut in adverse conditions. The victim was further exposed to hazards related to falls of roof from the unsupported area by installing roof bolts in a pattern which positioned him inby the last row of installed roof bolts and inby the protection afforded by the A.T.R.S. system.


ENFORCEMENT ACTIVITIES

The following orders/citations were issued due to conditions revealed during the investigation:

  1. A 103(k) Order (No. 7142381) was issued to ensure the safety of all persons in the mine until an investigation was completed and all areas and equipment were deemed safe.

  2. A 104(d)(1) Citation (No. 7142384) was issued citing 30 CFR 75.220(a). The approved roof control plan was not being followed on the 1 Left Mains section while mining in the 6 right crosscut inby survey station 1940 as follows:

    1. A miner cut had been driven to a depth of 38 feet by Robert Carter, Section Foreman, who was operating the Joy 14 CM-10 remote control continuous mining machine. Adverse roof conditions were encountered during the initial portion of the cut in that roof rock was exposed and fell prior to exceeding the first 15 feet of mining of the B run. The approved roof control plan states: "Where adverse roof conditions are encountered during penetration of the face, the depth of the mining runs shall be limited to 12 feet from the last row of installed permanent supports."

    2. Where conditions permit, the Approved Roof Control Plan allows for mining extended cuts of up to 25 feet from the last full row of undisturbed roof bolts. The approved roof control plan contain 16 provisions which must be followed when using remote control mining machines for extended cuts. Three of these provisions were not being complied with when mining the 6 right crosscut, as follows:

      1. The depth of cut was 38 feet from the last full row of bolts to the point of deepest penetration of the face at the rib line of the No. 7 entry. The Roof Control Plan also states that the maximum depth of the extended cut shall not exceed 25 feet.

      2. The last full row of undisturbed roof bolts contained four roof bolts and was located approximately 38 feet outby the point of deepest penetration. No additional roof bolts were installed between the last two rows of roof bolts. The Roof Control Plan states that when extended cut mining is being performed, additional support shall be installed by one of the following methods:

        1. Two additional roof bolts shall be installed within the last two rows of roof bolts; or

        2. Six roof bolts shall be installed in the last row of roof bolts.

      3. An examination of the adjacent No. 7 entry was not made before completing mining from the 6 right crosscut into the No. 7 entry where persons were performing roof bolting and scoop operations. The Roof Control Plan states that before an entry or crosscut is holed through, examinations shall be made to assure that the adjacent entry or crosscut is clear of persons or equipment.
      1. A 104(a) Citation (No. 7142385) was issued citing 30 CFR 75.202(b). The operator of a single-head roof bolting machine was working under unsupported roof while installing the right rib-line roof bolt in the 6 right crosscut of the 1 Left Mains section when a fall of roof in the unsupported area occurred, resulting in fatal injuries to the roof bolting machine operator. Installing the right rib-line roof bolt in this manner while using a single-head roof bolting machine places the operator inby the last row of installed roof bolts and inby the protection afforded by the A.T.R.S. system.

      2. A 104(a) Citation (No. 7142386) was issued citing 30 CFR 75.220(a). Roof bolts were being installed in the 6 right crosscut of the 1 Left Mains section in a manner that did not comply with the roof bolt installation sequences shown in the approved roof control plan. Three roof bolts had been installed in the first row of the unsupported area and a hole for the fourth roof bolt was being drilled in the same row when a fall of roof occurred in the unsupported area, resulting in fatal injuries to the roof bolting machine operator. Installing the right rib-line roof bolt in this manner while using a single-head roof bolting machine places the victim inby the last row of installed roof bolts and inby the protection afforded by the A.T.R.S. system (refer to Citation No.7142385). The roof bolting sequences in the approved roof control plan require that roof bolts be installed in the next inby row prior to positioning the roof bolting machine in an angled position toward the right rib-line.



      Submitted by:

      Chris A. Weaver
      Mining Engineer (Ventilation)

      Randy Sharp
      Coal Mine Safety & Health Inspector
      (Roof Control)

      M. Terry Hoch, Chief, Roof Control Division
      Pittsburgh Safety & Health Technology Center


      Approved by:
      Timothy J. Thompson
      District Manager

      Related Fatal Alert Bulletin:
      FAB99C19


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