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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

REPORT OF INVESTIGATION

Underground Coal Mine

Other (Drowning) Accident
March 23, 2000

SUFCO Mine
Canyon Fuel Company, LLC
Salina, Sevier County, Utah
I.D. 42-00089
Accident Investigators

Fred L. Marietti
Coal Mine Safety and Health Inspector, Electrical

John C. Hancock
Coal Mine Safety and Health Inspector, Electrical

Kendall C. Whitman
Coal Mine Safety and Health Inspector, Electrical

Cord D. Cristando
Coal Mine Safety and Health Inspector

Originating Office
Mine Safety and Health Administration
District 9
P.O. Box 25367
Denver, Colorado 80225-0367
John A. Kuzar, District Manager



OVERVIEW


On March 23, 2000, at approximately 6:00 a.m., Larry L. Christensen, a pumper/electrician, was found submerged in the water sump at crosscut 124 in the 13L4E entries. Christensen started work on the afternoon shift of March 22, 2000, at 2:30 p.m. and was assigned to move a pump in the 13L4E entries. He worked alone on this assignment.

At approximately 12:30 a.m., March 23, 2000, Glenn Lott, graveyard shift supervisor, noticed that Christensen had not checked out of the mine. Christensen's normal quitting time was 12:30 a.m. Lott inquired about Christensen and was told that his truck was parked in the 13L4E longwall set-up section. Attempts to reach Christensen by mine phone were unsuccessful. Christensen worked into the next shift on many occasions, and Lott thought he was still working on a pump in the 13L4E entries.

Christensen's wife called the mine at approximately 3:00, 4:00, and 5:00 a.m. inquiring about her husband. After the 5:00 a.m. call, management officials were notified and a search for Christensen was started. Searchers probed the sump in crosscut 124 with poles and discovered the body face down, submerged in the sump. The water was six feet deep where Christensen was found.

The autopsy determined the immediate cause of death to be "drowning due to occlusive coronary artery disease."

GENERAL INFORMATION


The SUFCO Mine is an underground coal mine located approximately 10 miles north of Interstate 70, exit 72, east of Salina, Sevier County, Utah. The mine, which was opened in 1941, is currently operated by Canyon Fuel Company, LLC, with LLC members Itochu Coal International, Inc. and Arch Western Resources, LLC. Arch replaced ARCO Uinta Coal Company as an LLC member on June 1, 1998. ARCO and Itochu purchased the mine from the Southern Utah Fuel Company, a subsidiary of Coastal Corporation, on December 20, 1996.

The mine has 11 drift openings and is ventilated with two fans exhausting 981,000 cfm of air. The mine liberates 67,651 cubic feet of methane daily and makes up to 3 million gallons of water daily. Two development sections and one longwall section are active and producing coal.

The 13L4E section, where the accident occurred, was started in January 1998. It was developed with 3 entries on 90-foot centers and crosscuts on 150-foot centers. The 13L4E entries were ventilated with intake air at the time of the accident. These entries will be the tailgate return and bleeder for the 14L4E longwall, which was in the process of being setup. Coal is conveyed on belt conveyors to surface crushing and loadout facilities and is transported from the mine by independent contract trucking companies. The coal is primarily used for electrical power generation.

There are 199 underground and 43 surface employees. The average daily production is 22,000 tons. The work schedule is a 10-hour shift, 4 days per week, with 2 production and 1 maintenance shifts per day. Maintenance and rehabilitation work is regularly scheduled for Friday and weekends.

The last Mine Safety and Health Administration Safety and Health Inspection (AAA) was completed on December 29, 1999. A Safety and Health Inspection (AAA) was started on January 5, 2000, and was ongoing at the time of the accident. The Non-Fatal Days Lost (NFDL) incidence rate, excluding office workers, for the mine is 1.55. The NFDL rate for the nation is 8.14.

The principal officers at the mine at the time of the accident were:
Kenneth E. May .......... General Manager
Chad L. Beach .......... Production Manager
Glenn D. Lott .......... Mine Shift Supervisor
Allen Robins .......... Mine Maintenance Manager
Gary L. Jensen .......... Safety Compliance Officer
DESCRIPTION OF THE ACCIDENT


On Wednesday, March 22, 2000, Larry L. Christensen, pumper/ electrician, started work on the afternoon shift at 2:30 p.m. David Blake, Christensen's supervisor, assigned him to move a pump in the 13L4E intake entries, at crosscut 94.

The day shift fireboss reported that a pump was not running at crosscut 124 in the 13L4E entries, and the area was flooding. At approximately 4:00 p.m., Mel Yardley, the afternoon shift maintenance foreman, told Christensen, who was in the surface shop, to correct the problem. Christensen proceeded underground alone to work on the pump.

Scott Stewart, belt foreman, saw and spoke to Christensen at 7:50 p.m. in the Main North Entries at crosscut 179. He observed him proceed inby, alone, in an electrician's truck. This was the last known time that anyone saw or spoke to Christensen.

Jerry Deaton, afternoon shift fireboss, moved Christensen's parked truck at approximately 8:40 p.m. to allow his truck to pass in the 14L4E longwall setup room on the tailgate side. He did not see Christensen. The afternoon shift ended at 12:30 a.m. on March 23, 2000.

At approximately 12:30 a.m., Glenn Lott, graveyard shift supervisor, saw that Cristensen had not checked out of the mine. Sam Brown, an afternoon shift electrician, was standing near the check-in, check-out board, and Lott asked him if he knew of Christensen's location. Brown said that he had been trying to call Christensen on the mine phone since 11:30 p.m., but Christensen had not answered.

Paul Brotherson, who was checking out of the mine, told Lott and Brown that he saw Christensen's truck parked in the 14L4E longwall setup tailgate. Brown said that he would change back into his mine clothes and go look for Christensen. Lott told him to catch his ride home, that he would find Christensen. Lott said that it was normal for Christensen to remain after his shift, and there were water problems underground at the time. He assumed Christensen was working on the problems.

Christensen's wife called the mine inquiring about Christensen at approximately 3:00, 4:00, and 5:00 a.m. Mrs. Christensen told MSHA investigators that Christensen never stayed more than an hour over his scheduled shift, and he was always home by 2:30 a.m. Mark Thomas, warehouseman and the responsible person on the surface, answered Mrs. Christensen's calls. At the 3:00 a.m. call, he told her that Christensen must still be underground, and he heard him being paged. He then tried to page Christensen or anyone in the mine and got no response. At the 4:00 a.m. call, he told her the same thing and tried to call underground and got no one. At the 5:00 a.m. call, he heard Randy Young, maintenance foreman, in the shop, and he referred the call to him.

Chad Beach, production manager, arrived at the mine at this time. He heard the pages, picked up the phone and asked Young what was going on. Young started to tell him about the mine status and breakdowns, but Beach asked him about Christensen. Young told him Christensen was unaccounted for and his wife was calling the mine about him. Beach told Young to find Christensen. Beach then paged Lott, who had arrived at the Main North Belt, and told him to find Christensen.

Lott organized a search party to begin in the 14L4E tailgate area where Christensen's truck was parked. Donald Ervine and Kenney Poulsen, an EMT, probed the water sump at 13L4E, crosscut 124. While probing, Poulsen tried to get closer and fell into the sump. He was able to touch the bottom, keep on his feet, and walk up the slope out of the sump. After this, Ervine probed and found Christensen, who was submerged in the water. They pulled him out at approximately 6:00 a.m. Christensen had been in the water for awhile and was obviously deceased. They contacted Lott, who called outside and informed Beach about Christensen.

Christensen's body was taken to the Office of the Medical Examiner in Salt Lake City, Utah for an autopsy.

INVESTIGATION OF THE ACCIDENT


At approximately 6:30 a.m. on March 23, 2000, MSHA personnel at the Castle Dale, Utah field office were notified of Christensen's death. John Hancock, Coal Mine Safety and Health Inspector (Electrical); Kendall Whitman, Coal Mine Safety and Health Inspector (Electrical); and Cord Cristando, Coal Mine Safety and Health Inspector, were dispatched to the mine to obtain preliminary information and to take pictures of and secure the accident scene. Fred L. Marietti, Coal Mine Safety and Health Inspector (Electrical) and Accident Investigator from the Price, Utah office, was assigned as Team Leader for the investigation.

On March 23, 2000, Sergeant William Brewer, Sevier County Sheriff's Department, and Charles Ogden, Sevier County Medical Examiner, investigated the accident. Brewer and Ogden tape recorded interviews with the miners and management involved in the recovery of Christensen. Hancock, Whitman, and Christando were present and participated in the interviews, which were transcribed and made available to MSHA.

Hancock, Whitman, and Cristando went underground, secured the area, and tested for stray electrical current. No stray current was found. The electrical equipment in the area was examined and no problems were found. Pictures of the accident scene were taken. Air readings and air samples were taken at the accident area. Christensen's training records were checked and no deficiencies were observed. After Marietti arrived at the mine, the Section 103(k) Order was modified to allow the pump to run to keep the area from being inundated by water.

The company idled the mine from March 23 through March 27, 2000, due to the normal Friday and weekend schedules and for the funeral on Monday March 27. The investigation resumed on Tuesday, March 28, 2000.

On Monday, March 27, 2000, Marietti contacted Lieutenant Delbert Lloyd of the Seiver County Sheriff's Office to obtain information about the cause of death. Lieutenant Lloyd said it appeared that the death was due to drowning with possible coronary complications. The State of Utah Office of the Medical Examiner was also contacted and the cause of death was reported to be drowning with coronary complications immediately before or during the drowning. The autopsy results were also reviewed by the Department of Defense Armed Forces Institute of Pathology which concurred that death was due to accidental drowning.

Formal interviews were conducted on March 28 and 29, 2000, and the accident site was examined again on March 28, 2000. The Section 103(k) Order was modified to allow a substantial guard to be built around the sump hole. Additional interviews were conducted on Wednesday, April 5, 2000.

DISCUSSION


1. Christensen had a history of coronary artery disease. A metallic stint had been previously placed in the right coronary artery. Following this operation, he was given a full release to return to work, and he chose to return to his duties as a pumper/electrician.

2. An autopsy was conducted by the State of Utah Office of the Medical Examiner in Salt Lake City, Utah. The autopsy determined the death to be accidental with the immediate cause of death as "drowning due to occlusive coronary artery disease." The autopsy found the right coronary artery, near total occlusion, mid portion, with a metallic stint in place in the area of atherosclerotic plaque; and the first diagonal branch, left anterior descending coronary artery, 70-80% occluded.

3. The sump, where the accident occurred, was located in crosscut 124, between the Nos. 1 and 2 entries of the 13L4E section. The sump was 39 feet long and 10.5 feet wide. It was located against the rib such that a 9-foot wide section of the mine floor paralleled the sump, providing a walkway along the side of the sump. The sump was approximately 6 feet deep. The walkway beside the sump was flooded with water and the No. 1 entry behind the sump had water to a depth of approximately 40 inches. Danger tape was placed across both ends of the sump to warn of the drop-off into the sump. No physical barrier marked the edges of the sump or prevented an accidental fall into the sump.

4. Christensen wore hip or chest waders whenever he worked at the sumps. At the time of the accident, Christensen wore hip waders.

5. No stray electrical current was found at the sump and no defects were found with the electrical equipment at the sump.

6. Christensen normally worked alone as a pumper/electrician in remote areas of the mine, which were not normally traveled by other miners. The work included setting and removing heavy pumps in deep water, which could contain slip, trip, and fall hazards.

7. The miners interviewed said that there was no policy for miners working alone to call someone on a frequent basis as to their location.

8. An effort was not made to locate Christensen when he did not exit the mine at his scheduled quitting time of 12:30 a.m. Sam Brown, electrician, noticed as early as 11:30 p.m., on August 22, 2000, that Christensen's absence was abnormal. Brown said that Christensen always came outside to eat in the shop and would leave his lunch bucket at his place at the shop dinner table. Brown said Christensen's lunch bucket was not at the dinner table that night, so at approximately 11:30 p.m. he began to page Christensen on the mine phone. Christensen's lunch box was found in his truck underground and his lunch was not eaten.

9. Glenn Lott, shift supervisor, knew that Christensen had not checked-out at the end of the afternoon shift. He went into the 14L4E tailgate area where Christensen's truck was last reported to be parked at approximately 2:30 a.m. He worked in that area until he was called at approximately 4:15 a.m. to go to a problem at the Main North Belt.

10. Action was not taken in response to Mrs. Christensen's three calls to the mine, starting at approximately 3:00 a.m. After each of the first two calls, the warehouseman paged for someone underground to answer the mine phone, but no one responded. He referred the third call to the maintenance foreman, whom he heard on the mine phone in the shop. An actual search was not ordered until the production manager arrived early for day shift and overheard the mine phone and intervened.

11. A Personal Emergency Device (PED) communication system is used at the mine to send text messages from the surface to miners underground. Christensen was wearing one of the PED receivers that day. When a message is received by a miner, the miner's cap lamp flashes. This is a signal to look at the text message on the receiver located on the top of the cap lamp battery. No PED messages were sent to Christensen in an attempt to locate him that night. Kenneth May, general mine manager, said that the PED system was not fully developed and that Christensen could not be contacted at his location in the mine.

CONCLUSION


The immediate cause of death, according to the State of Utah Office of the Medical Examiner, was "drowning due to occlusive coronary artery disease." Based on evidence available at the accident scene, it could not be determined whether Christensen accidentally fell into the sump from the adjacent walkway and was unable to extricate himself due to complications from his medical condition; or whether, in the course of his activities, complications from his medical condition may have caused him to loose balance or collapse into the water. Factors relating to the accident were: 1) the edges of the sump were not adequately marked or protected with a physical barrier to prevent accidental entry into the sump; and 2) Christensen worked alone.

ENFORCEMENT ACTIONS


1) A Section 103(k) Order No. 4704315 was issued to the operator on March 23, 2000, to ensure the safety of all persons until an investigation could be completed and the mine deemed safe.

2) A Section 314(b) Notice to Provide Safeguard No. 7611656 was issued on July 7, 2000, to require that a substantial physical barrier be constructed around all accesses to sumps in the mine where there is a danger of falling into the sump. This Safeguard was issued to prevent a person from accidentally falling into a sump where injury or death could occur.


Related Fatal Alert Bulletin:
 FAB00C08




APPENDIX A

List of persons participating in the investigation:

Canyon Fuel Company, LLC. Officials
Kenneth E. May ............... General Manager
Chad Beach ............... Production Manager
Allen Robins ............... Maintenance Manager
Gary Jensen ............... Safety Compliance Supervisor
Gary Leaming ............... Training Supervisor
Glenn Lott ............... Shift Supervisor
David Blake ............... Electrical Supervisor
Randy Young ............... Maintenance Supervisor
Scott Stewart ............... Belt Foreman
David Arnolds ............... Attorney
Michael Christensen ............... Victim's Son
Arch Western Resources, LLC Officials
Robert Shanks ............... Vice President
Charles Russell ............... Corporate Safety Director
Canyon Fuel Company, LLC., Employees
Donald Ervine ............... Beltman
Kenny Poulson ............... Welder (EMT)
Jerry Deaton ............... Fire Boss
Mark Thomas ............... Warehouseman
Sam Brown ............... Electrician
Sevier County Sheriff's Department
Sgt. Bill Brewer ............... Sevier County Sheriff
Lt. Delbert Lloyd ............... Sevier County Sheriff
Charles Ogden ............... Sevier County Medical Examiner
Mine Safety and Health Administration Kendall C. Whitman ............... Coal Mine Safety & Health Inspector (Electrical) John C. Hancock ...............Coal Mine Safety & Health Inspector (Electrical) Cord D. Christando ............... Coal Mine Safety & Health Inspector Fred L. Marietti ............... Coal Mine Safety & Health Inspector (Electrical) APPENDIX B

List of persons interviewed:

Canyon Fuel Company, LLC.
David Blake ............... Electrical Supervisor
Scott Stewart ............... Belt Foreman
Glenn Lott ............... Shift Supervisor
Donald Ervine ............... Beltman
Kenny Poulson ............... Welder (EMT)
Randy Young ............... Maintenance Foreman
Jerry Deaton ............... Fire Boss
Sam Brown ............... Electrician
Mark Thomas ............... Warehouseman