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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH


District 10


Report of Investigation
(Surface Coal Preparation Plant)


Fatal Powered Haulage

Island #1 Prep Plant (I.D. No. 15-18077)
LST, Inc.
Island, McLean County, Kentucky


February 14, 2000

by

Curtis W. Haile
Coal Mine Safety and Health Specialist


Originating Office
Mine Safety and Health Administration
100 YMCA Drive, Madisonville, Kentucky 42431-9019
Rexford Music, District Manager


Release Date: March 30, 2000



OVERVIEW

At 7:40 p.m., on February 14, Harry Milan, preparation plant operator, was fatally injured after being accidently struck by a Clark 275 rubber-tired front-end loader. Milan was in the area of the raw coal stockpile after dark when the loader returned to load a bucket of coal and haul it to the nearby rotary breaker.

Unaware that Milan had been struck and scooped into the bucket, the loader operator backed the machine away from the stockpile and transported the material, with Milan, to the hopper located above the rotary breaker. After seeing Milan fall from the bucket into the hopper, the loader operator exited the machine and de-energized the rotary breaker before Milan contacted the moving parts of the breaker. Milan died at the scene as a result of the trauma and excessive loss of blood which resulted from the amputation of his left leg and eighty percent of his right leg by the bucket of the loader.

GENERAL INFORMATION

The LST, Inc. Island #1 Prep Plant (ID 15-18077) is located two miles east of Island, Kentucky alongside Highway 85. This coal preparation facility began operating under the ownership of Knight Construction on June 29, 1998. On September 29, 1999, LST, Inc. became the official operator of the plant.

Island #1 Prep Plant is small operation providing employment for five persons who are not represented by an organized labor union. This facility operates two shifts a day, with two laborers on each shift. The foreman, James Todd supervises and conducts the on-shift examinations for both day and second shifts. Coal is trucked into the Island #1 Prep Plant from at least three separate mining operations. The daily operation of the Island #1 Prep Plant consists of transferring coal from one of the three stockpiles into the hopper located above the rotary crusher for sizing. Conveyor belts transferred some of the coal into the washer plant while the remainder was stockpiled and later transported to the D. B. Wilson and Paradise TVA power generating facilities located in western Kentucky. Island #1 Prep Plant processes approximately 2500 tons of coal daily on two production shifts.

A Regular Safety and Health Inspection (AAA) was started October 22, 1999, and was ongoing at the time of the accident.

DESCRIPTION OF ACCIDENT

The following information was obtained through testimony and the investigation of the accident scene:

On February 14, the second shift at the Island #1 Prep Plant began at 2:00 p.m., as scheduled. Foreman James Todd was loading coal trucks with the No. 9 Clark 275 rubber-tired front-end loader. Shane Knight, operator, began loading coal into the rotary breaker hopper with the No. 10 Clark 275 loader. When Harry Milan, victim and prep plant operator, arrived for work at 2:10 p.m., Foreman Todd instructed him to operate the washer plant and keep an eye on the No. 1 conveyor because they had been having problems with it during the day shift.

Around 3:15 p.m., the plant experienced a power outage which stopped production until contractor Jim Southard, owner of Power Electric, arrived and replaced two blown fuses on the 750 KVA bank of three-phase transformers supplying 480 volts to the plant. After the power had been restored around 6:00 p.m., Milan entered the control room and started the plant back into production. Knight resumed loading coal into the rotary breaker hopper while Foreman Todd fueled and serviced the No. 9 loader.

At approximately 6:30 p.m., Foreman Todd contacted Milan and Knight over his CB radio to tell them he was going to fuel his pick-up truck before going home. Todd radioed Knight and Milan again as he was leaving the plant around 6:50 p.m. and asked them to call him at home if they needed anything. Knight and Milan continued to feed and operate the washer plant for the next forty minutes without any problems. At 7:30 p.m., Knight used his CB radio to contact Milan, who was inside the plant's control room. Knight asked Milan to re-align the conveyor belt which extends from the rotary breaker to the washer because it was running off center of the tail-roller and belt framing. Knight told Milan that he had a key in his pocket to the tool building in case he needed tools to adjust the tail-roller. Milan informed Knight he had enough tools in his truck to align the belt. A CB radio was in Milan's truck that was parked near the control room. This was the last conversation Knight and Milan had prior to the accident.

A pile of refuse material separated during the crushing process was located below the ramp on the right side of the rotary crusher hopper. Knight backed the loader down the ramp away from the hopper, dipped up a bucket of refuse, and transported it to the northeast entrance of the plant where he deposited it along the ramp which was being built for the truck scales. Milan had apparently walked to the raw coal stockpile without notifying Knight. The area around the stockpile was not considered a normal work area for Milan, especially after dark. Knight returned via his normal route to the raw coal stockpile with the loader bucket raised approximately three feet from the ground. Milan was accidently struck and scooped into the loader bucket as Knight was gathering a load of coal from the stockpile. Unaware that Milan had been struck and was in the bucket, Knight backed the loader away from the stockpile and transported the material, including the victim, to the hopper located above the rotary breaker.

Because material flow is restricted through the grizzly, coal must be dumped slowly into the hopper. As Knight eased the bucket load of coal into the hopper, he saw what he thought was a man's leg fall out of the bucket, but dismissed it as only being a piece of brattice curtain cloth from the underground mine where the coal was purchased. After a pause, he eased more coal out of the bucket and saw Milan fall into the hopper. Knight immediately backed away from the hopper, exited the loader, and ran to activate the stop switch for the rotary breaker which was located approximately 25 feet to the right of the hopper. When Knight climbed to the top of the hopper and saw that Milan was seriously injured and in need of medical attention, he climbed down from the hopper, got in his truck and drove across the highway to the Sextet #1 Underground Mine office and asked the security guard to call 911. When Knight returned to the hopper Milan was still breathing, but stopped shortly thereafter prompting Knight to begin mouth to mouth resuscitation.

Representatives from the Island Fire Department, who are also emergency medical technicians (EMT), arrived at the accident site at 7:49 p.m. The Ohio County Advanced Life Support Unit and Air Evacuation Unit were dispatched but canceled at 8:05 p.m. McLean County's East District Fire Department, Central District Fire Department, South District Fire Department, rescue squads, and an ambulance responded to the 911 alert. McLean County Coroner Michael Muster and Sheriff Lester Stratton arrived at 8:40 p.m., and were later accompanied by Sheriff's Deputy Kenny Thompson. According to Muster, the cause of death resulted from excessive blood loss and body wide trauma due to the amputation of the upper portion of Milan's left leg, in addition to 80 percent of his right leg. Muster pronounced Harry Milan dead at 8:45 p.m.

INVESTIGATION OF THE ACCIDENT

At 9:00 p.m., on February 14, Allen Dupree, MSHA District 10 staff assistant, was notified of the accident by Joe McCoy, LST, Inc.'s business manager. Curtis Haile, Coal Mine Safety and Health Specialist, was appointed as lead investigator for MSHA and was accompanied to the Island #1 Preparation Plant by Darold Gamblin, Beaver Dam Field Office supervisor, Michael Moore, electrical inspector, and Robert Simms, mining engineer. Representatives from the McLean County fire departments, rescue squads, ambulance service, sheriff department, and the coroner's office had left the accident site prior to the arrival of the MSHA accident investigation team.

Upon arrival at 10:35 p.m., a pre-investigation conference was conducted by MSHA during which copies of the victim's training records were obtained. A 103(K) Order was written at 11:00 p.m., to ensure the safety of persons at the facility until an examination or investigation could be made to determine that the area was safe. The on-site investigation was also initiated that same night which included preliminary interviews with the witness. Photographs, electronic images, and video recordings were made of the accident site. The lighting system on the front-end loader in addition to the area lighting was also evaluated.

On February 15, Curtis Haile, Michael Moore, Robert Simms, and Troy Davis, mining engineer returned to the accident site to take additional photographs and make a drawing of the surface area including the route of travel taken by the front-end loader immediately prior to the accident. Knight operated the loader to assist MSHA in the filming and timing sequence of events which occurred prior to the accident. LST, Inc. contracted an engineering firm to provide a scaled drawing of the area and structures at the coal preparation facility to assist MSHA with it's accident investigation. Copies of the Daily OnShift Inspection Report which contained the pre-operational inspection of mobile equipment were also obtained.

On February 16, Curtis Haile, Ron Scaggs, Arlington Headquarters, Eugene Hennen, MSHA Technical Support, and Mary Beth Bernui, Solicitor, heard testimony from James D. Todd, plant foreman, and Michael Shane Knight, loader operator, regarding the events leading up to and after the accident occurred. The above personnel revisited the accident site and, based on the information obtained thus far, attempted to re-create the accident with as much accuracy as possible. Photographs were taken in addition to filming the sequence of travel by the Clark front-end loader prior to the accident and with the bucket in the approximate position. Michael Muster, McLean County coroner, assisted with the investigation by providing information related to the victim's injuries. Since the operator never saw the victim until he initially dumped the coal into the hopper, the accuracy of the locations and events occurring prior are somewhat inconclusive.

Curtis Haile, Ron Scaggs, Eugene Hennen, James Todd, and Russell Badgett, IV, returned to the accident site again at 7:00 p.m., in an effort to re-create the exact conditions at the time of the accident. The purpose was to evaluate the effectiveness of the illumination. Lighting was provided by overhead area lights and lights mounted on the front end loader.

DISCUSSION

Training


Island #1 Prep Plant's Training Plan was approved by the Mine Safety and Health Administration on October 8, 1999. Harry Milan (victim) was certified as a surface miner on May 7, 1997, by the Kentucky Department of Mines and Minerals located in Madisonville, Kentucky. His most recent 8 hours of Annual Refresher Training was conducted on June 16, 1999, at the Department of Mines and Minerals. On February 2, 2000, he received Hazard Training in addition to New Task Training on the safe operation of the Clark 275 loader, D-6 dozier, and the Mack water truck from Foreman James Todd. Todd is certified by the Kentucky Department of Mines and Minerals as a Surface Foreman, Certificate No. S-122-95. Testimonies and records indicate that Harry Milan had approximately 17 months experience working in and around coal preparation plants.

Environmental Conditions

According to measurements made by a local water treatment plant official, 1.05 inches of rain had fallen during the day of February 14. Because the work area around the preparation plant was wet from the rain and the darkness of the night, visibility was somewhat diminished.

Illumination of Working Area


The bucket end of the Clark 275 front-end loader was equipped with five working lights located on top of the operator's cab. The rear of the cab was equipped with two working lights in addition to the two factory installed lights mounted on the rear of the machine.

Pole mounted lights are used for area lighting at various locations in the preparation plant area. All the area lights were operating at the time the accident occurred. The lights were placed in such a manner that the loader would never totally block the lights to any one location.

Non-Reflective Clothing


According to Coroner Michael Muster, Milan was wearing dark colored paints and a dark colored coat the night of the accident. It was not a requirement for the employees to wear reflective clothing while working in and around the preparation plant after daylight hours.

Communication


During the daily operations at the Island #1 Prep Plant, the employees communicated by the use of citizen band (CB) radios. Radios were located inside the plant control room, each of the two front-end loaders, and the employees's personal vehicles.

Equipment Braking System


The operational status and the braking system of the No. 10 Clark front-end loader were not relative to the accident. However, this braking system of this machine was examined and found to be in safe operational condition.

CONCLUSION

The consensus of the investigative team is that Milan did not find sufficient tools to adjust the tail-roller and had walked to the vicinity of the stockpile to await Knight's return to get his assistance. Milan waited in the area in front of the coal stockpile assuming Knight would see him. The accident occurred when Harry Milan was accidently struck by the Clark 275 front-end loader and scooped into the bucket as it was gathering a load of coal from the raw coal stockpile.

ENFORCEMENT ACTIONS

1. 103(k) Order No. 7640599 was issued to insure the safety of any persons at the mine until an investigation was conducted.

2. There were no contributory violations observed or revealed during this investigation.


Approved by:

Rexford Music
District Manager


Related Fatal Alert Bulletin:
 FAB00C03




APPENDIX A

Listed below are the persons who furnished information and/or participated in the recovery and subsequent investigation:

LST, INC.
Kem Knight........................................................................Co-Owner
Russell Badgett, IV..............................................................Co-Owner
James D. Todd....................................................................Plant Foreman
Joe McCoy..........................................................................Business Manager
Michael Shane Knight...........................................................Loader Operator
911 EMERGENCY RESPONSE TEAMS
Kathy Abrams........................................................................Central Dispatch Officer
South East District Fire Department from Island, Kentucky
Central District Rescue and Fire Department from Calhoun, Kentucky
Rescue Squad from Island, Kentucky
East District Fire Department from Livermore, Kentucky
McLean County Ambulance Service
McLEAN COUNTY SHERIFF DEPARTMENT

Lester Stratton...............................................................................................................Sheriff
Kenny Thompson...............................................................................................Deputy Sheriff
McLEAN COUNTY CORONER
Michael Muster...........................................................................................................Coroner
MINE SAFETY AND HEALTH ADMINISTRATION
Curtis W. Haile..........................................................................Accident Investigator
Michael Moore.........................................................................Coal Mine Safety and Health Inspector (Electrical)
Robert A. Simms......................................................................Mining Engineer
Troy K. Davis..........................................................................Mining Engineer
Ron Scaggs..............................................................................Coal Mine Safety and Health Inspector
Mary Beth Bernui....................................................................MSHA Solicitor
Eugene D. Hennen .................................................................MSHA Technical Support
Ted Smith................................................................................Coal Mine Safety and Health Supervisor\Specialist
Darold Gamblin.....................................................................Beaver Dam Field Office Supervisor