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UNITED STATES DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

Accident Investigation Report
(Underground Mine)

Fatal Electrical Accident

Mine No. 3 (I.d. No. 15-18008)
Garrett Mining, Inc.
Burdine, Letcher County, Kentucky

April 30, 2000

Accident Investigators

Stevie Justice
Coal Mine Safety and Health Inspector (Electrical)
Paul R. Fuller
Supervisory Mine Safety and Health Inspector (Electrical)

Release Date: July 05, 2000

Originating Office - Mine Safety and Health Administration
Coal Mine Safety and Health, District 6
4159 North Mayo Trail, Pikeville, Kentucky 41501
Carl E. Boone, Ii, District Manager





Overview


On the evening of April 30, 2000, Dewey Dwyane Niece, certified electrician, was fatally injured when he came in contact with high voltage while removing a cover from the right side 7,200 volt 001 section power center (super section). Larry Watson, pre-shift examiner, traveled underground at approximately 9:00 p.m. to conduct the pre-shift examination. He took Niece with him for the purpose of changing two low-voltage circuit breakers on the right-side section power center. Watson left Niece at the transformer to install the breakers while he conducted the pre-shift examinations on the 001-0 and 002-0 working sections. At approximately 10:00 p.m. Watson heard the power knock on the 002 transformer, located in the No. Three Entry. Watson, realizing the power should not have knocked, immediately traveled back to the 001-0 transformer located in the No. Five Entry. Niece was found lying unconscious at the back of the transformer, adjacent to the high voltage compartment. The top lid covering the high voltage compartment had been moved thirteen inches, exposing the energized termination connections of the 7,200-volt cable. Measurements revealed that 5 � inches of space was provided between the bottom of the lid and the energized connection at the top of a stand-off insulator. Burns observed on the victims hands suggested this was the contact point. There were no eye witnesses to the accident.

The accident occurred because the victim failed to de-energize, lock and tag the high voltage circuit at an outby location prior to conducting work on the high voltage compartment.


General Information


Garrett Mining, Inc

The No. 3 Mine of Garrett Mining, Inc., is located 2 miles south of Dorton, near Burdine in Letcher County, Kentucky.

Garrett Mining assumed responsibility of this previously abandoned mine and began production in October, 1999. Production is accomplished using two continuous mining machines operating in a common set of entries to develop the 001 and 002 working sections. This method of mining is commonly referred to as a super section. The mine is developed into the Lower Elkhorn Coal Seam which has an average mining height of 40 inches and is approximately 4,500 feet underground from the drift opening portals. Shuttle cars are used for coal haulage on the section. Coal is then transported to the surface by conveyor belts. Miners are transported to the working sections by rail and rubber-tired mantrips.

The principal company officers of Garrett Mining, Inc. are:
Rex Fought ...............................President
Roger Richardson.......................Mine Superintendent
James Newsome.........................Chief Electrician
Darrell Richardson.......................Safety Director
Garrett No. 3 Mine currently employs 34 persons on two production shifts and one maintenance shift. The mine normally operates five days-per-week and produces an average of 1200 tons per day.

The last health and safety inspection of the mine was completed on February 16, 2000, by the Mine Safety and Health Administration.

DESCRIPTION OF ACCIDENT


On Sunday, April 30, 2000, at approximately 8:15 p.m., Larry Watson, third shift foreman and pre-shift mine examiner, met with Dewey Niece, third shift electrician (victim) at the mine office. Watson begin his pre-shift examination on the surface while Niece checked the surface belt conveyor drive gear boxes for oil. Both men traveled underground by rail at approximately 9:00 p.m. Pre-shift examinations were conducted at each of the four belt drives while Niece checked the gear boxes for oil. After completing the work outby the men traveled to the end of the track. At this time they boarded a rubber-tired mantrip and traveled approximately five crosscuts to the 001-0 section (right side) power center located in the No. Five Entry.

A work order prepared by Landis Slone, chief electrician on the second shift, instructed Niece to change two 225-ampere, 550-volt circuit breakers on this power center. One of the breakers was for the No. One Shuttle Car and the other breaker was a spare 225-amp breaker. Watson made a visual examination of the transformer before leaving Niece to change the breakers. Watson stated the transformer was energized at this time. Watson traveled to the No. Eight Working Place where he began his pre-shift examination. Each of the eight working places was examined as he traveled across the working sections. Watson made his last face examination at 9:57 p.m. in the No. One Working Place. Watson traveled back to his rubber tired man trip, parked outby the No. One Entry, at approximately 10:00 p.m. While preparing to take an air reading in the last open cross-cut he heard the 002 section transformer, located in the No. Three Entry, de-energize. Watson, realizing the power should not have knocked, immediately traveled back where he had left Niece at the 001 power center, located in the No. Five Entry. When Watson arrived he saw Niece lying on his back at the outby end of the power center, adjacent to the high voltage compartment. He called out for Niece, but received no response. Watson, realizing he needed help immediately, traveled to a mine phone approximately 100 feet away. He notified Larry Johnson, security guard, on the surface and instructed him to call an ambulance and send the first person that arrived underground to help. Johnson notified the 911 dispatcher in Pikeville, Ky and requested an ambulance.

Watson traveled back to the power center and determined Niece did not have a pulse. Watson, who is also a Mine Emergency Technician (MET), immediately began cardiopulmonary resuscitation (CPR).

Keith Stevens, maintenance foreman, and Larry Pease, electrician, arrived at the mine at approximately 10:15 and learned of the accident. Pease moved a scoop off the mine track while Stevens got his light and hat and immediately traveled by rail to the accident site. Stevens arrived at the accident scene and assisted Watson in performing CPR on the victim. Watson asked Stevens if he could continue CPR while he traveled to the surface to get help to transport the victim outside. Watson called outside and said Niece was not breathing and had no pulse. At this time Larry Pease, and Andre'(Andy) Smith, roof bolt operator, left the surface in route to the accident site by scoop. Pease arrived at the accident site and assisted Stevens in administering CPR (for a short time) before placing him in the scoop and transporting him to the end of the track. Niece was then placed in the outby end of the rail man trip and Pease, Smith and Stevens transported him to the surface. When Watson arrived on the surface, he learned that Pease and Smith were on their way under ground in the scoop. Watson traveled back under ground and met Peace on the track. Everyone then exited the mine. CPR was performed continuously while the victim was being transported.

The call was received at the 911 emergency service station in Pikeville, Ky at 10:15 p.m. on April 30, 2000. DHP Ambulance Service was dispatched and arrived at the mine at 11:02 p.m. Niece was placed in the care of DHP Ambulance Service at 11:03 p.m. He was then transported to the Jenkins Community Hospital were he was pronounced dead at 11:56 p.m.

INVESTIGATION OF THE ACCIDENT


Buster Stewart, an MSHA Special Investigator who lives near the mine, was notified of the accident and proceeded to the mine. Sandra Barber, Supervisory Coal Mine Inspector, and Jeffery Meade, Coal Mine Inspector, of the MSHA Whitesburg, Kentucky, field office were notified and joined Stewart at the mine. A 103(k) order was issued to protect the safety of the miners until the investigation determined no other hazards existed.

Barber and Meade, along with members of the Kentucky Department of Mines and Minerals (KDMM), began a joint investigation at approximately 12:00 a.m., May 1, 2000. Information and facts relative to the accident were gathered. The investigation team traveled underground to the accident site. Photographs and relevant measurements were taken and shared by both agencies.

The on-site portion of the investigation continued on May 1, 2000, with electrical personnel from MSHA and the (KDMM) present. They included, Robert Phillips, Mine Safety and Health Specialist, Division of Safety; Arlie Massey, Electrical Engineer, Approval and Certification Center; Paul Fuller, Electrical Supervisor; and Stevie Justice, Coal Mine Electrical Inspector. Members of the (KDMM) investigation team were Tracy Stumbo, Chief Accident Investigator; David Johnson, Chief Electrical Inspector; and, Brad Fuller, Electrical Inspector, were also assigned to the on site part of the investigation.

Joint interviews were held with persons having information of the accident at 10:00 a.m., May 2, 2000, at the (KDMM) office in Pikeville, Kentucky.

DISCUSSION


The investigation at the 001 power center revealed the following information. The disconnect switch (located at the back of the power center), which provides a positive means to de-energize the step-down transformer and low-voltage circuits inside the enclosure, was in the "open" position. This power center has two plexiglass windows provided on the side panel of the high voltage compartment for viewing the disconnecting switches. Although the two windows should have provided a visual means for determining each of the three phases were de-energized and that each switch was in the "open" position, one of the windows were dirty/cloudy and one disconnect was not clearly visible. Two of the disconnects could be seen, but the third was not visible. The emergency stop button provided in the high voltage ground check monitor circuit and located on the back of the enclosure was in the "out" position (circuit closed). This switch was functional and could have been used to de-energize the high voltage circuit breaker on the surface and disconnect all power coming under ground. There were four safety switches (lid switches) provided for the three enclosure panels that covered the high voltage compartment. These switches are designed to open the control circuit of the circuit breaker (i.e. trip) that provides incoming power to the power center. The lid switch nearest the victim's side on the high voltage side of the power center was bent over and secured under a wire. This placed the switch in a permanently closed position and rendered it inoperable.

During the investigation electrical personnel conducted tests for compliance of the high-voltage system and the 001-0 section power center (S/N 10386) where the accident occurred. The investigation revealed the following factors relevant to the occurrence of the accident:

1. The mine receives power through a 34,500 VAC service drop. Power is transformed on the surface to 7,200 volts by three 2,000-KVA transformers at an enclosed surface substation for underground transmission. A one-line diagram of the distribution system is included in the appendix.

2. The mine has 2 mechanized mining units (super section).

3. Two high voltage power centers, (transformers) are being used to supply the super section. The 002 section is powered by a power center located in the No. 3 entry and the 001 section is powered by a power center located in the No. 5 entry. The 001 power center, (S/N 10385) was re-manufactured by High Tech Electric and has a 1,250 KVA rating. The transformer is configured delta-wye and the primary is supplied from the surface by a 7,200 volt feed. The secondary (line out) is 995 volts at 500 KVA and 480/600 volts at 750 KVA. This power center is considered to be a high voltage branch circuit and is required to have a visual disconnect.

4. The accident occurred at the high voltage end of the 001 section power center located in Entry No.

5. Evidence indicates that the victim had opened the lid, exposing the high voltage components, and came in contact with an energized connection.

6. The high-voltage circuit that supplies 7,200 volts, three phase, power to the 001 section power center was not de-energized, grounded, locked out, or suitably tagged before opening the lid to the high voltage compartment.

7. Only 5 � inches of space existed between the bottom of the lid and the energized connections. There were no handles on the lid to keep the victims hands external to the high voltage compartment. In removing the lid the victims hands would be under the lip of the lid, thereby placing the hands closer than the above measurement to the 7,200-volt energized connection.

8. The two plexiglass windows located on the side panel are designed to provide a visual means for determining that all three phases are de-energized and that the three blade switches are in the open position. One of the windows was stained (dirty/cloudy) by what appeared to have been a previous phase-to-phase fault. Although two of the disconnects were visible, the third was not.

9. One of the four safety switches (lid switch) was defeated. The top lid switch on the victim's side of the power center was bent over and secured under a wire. This placed the switch in a permanently closed position and rendered it inoperable. The switch is intended to open the control circuit on the circuit breaker (i.e. trip, at the surface sub-station) and de-energize the incoming power to the power center when the lid is removed.

10. Proper protective equipment, such as high-voltage gloves, or grounding devices, were not being used.

11. The high voltage 7,200 VAC visible disconnect on the section power center had been placed in the open position prior to beginning electrical work. The section power center was still energized at the out-by side of the switch.

12. The victim was found lying near the high voltage compartment of transformer.

13. The threaded bolts in lid cover had been removed and the lid shifted from it's normal location, creating a 13 by 34 inch opening. This opening exposed energized components.

14. Evidence indicates that the victim made contact with at least one phase of the 7,200 VAC circuit where the high voltage cable terminates at the top of the stand off insulators. This contact resulted in burn injuries to the victim's hands and chest.

15. Testimony of co-workers and management personnel indicated that no one had any knowledge why the victim performed work inside the energized high voltage compartment.

16. The victim was a certified electrician.

17. A volt-ohm meter was not found near the accident scene.

18. The emergency stop button provided on the back of the power center was in the out position (closed circuit). This switch could have been used to de-energize the power entering the transformer.

19. The height from the floor to the roof at the immediate scene of the accident was 55 inches.

20. Cables lying on the mine floor near the power center created a stumbling hazard.

21. Results from the Kentucky, Office of the Associate Chief Medical Examiner listed the immediate cause of death as electrocution.

CONCLUSION

Dewey D. Niece was electrocuted when he came in contact with the lugs of a stand off insulator (7,200 high-voltage circuit) while removing the cover from the 001 section power center. This accident occurred because the circuit had not been de-energized, grounded, locked out, or suitably tagged prior to electrical work being performed.

ENFORCEMENT ACTIONS


Garrett Mining, Inc.

1. A 103 (K) Order (No. 7371429) was issued on April 30, 2000, to Garrett Mining, Inc. The order was issued to ensure the safety of the miners working in the area and to ensure that the area was not disturbed until an investigation could be conducted.

2. A 104 (a) Citation (No. 7368627) was issued on May 4, 2000, to Garrett Mining Inc., for a violation of 30 CFR, Part 75.511. The citation was issued for failure to lock out and suitably tag the electrical system before electrical work was performed on the 7,200 VAC electrical system.

3. A 104 (a) Citation (No. 7368628) was issued on May 4, 2000, to Garrett Mining Inc., for a violation of 30 CFR, Part 75.512. The citation was issued for not maintaining the HighTech Electric power center (as designed by the manufacturer) in a safe operating condition. The top lid switch on the victim's side of the power center was bent over and fixed under a wire. This fixed the switch in a permanently closed position and rendered it inoperable. This is a safety switch that is intended to open the control circuit on the circuit breaker (i.e.trip, at the surface sub-station) and de-energize the incoming power to the power center.

4. A 104 (a) Citation (No. 7368629) was issued on May 4, 2000, to Garrett Mining Inc., for a violation of 30 CFR, Part 75.808. The disconnecting device provided at the beginning of the 7,200-volt (phase-to-phase) branch circuit (HighTech Electric 001-0 section transformer) is not maintained or equipped in such a manner that it could be determined by visual observation that the circuit was de-energized and the three blade disconnect switches were in the open position. Visibility through the plexiglass windows (provided on the side panel of the hi-voltage compartment) was in such a poor condition, dirty/cloudy/stained, that the disconnects were not clearly visible. Two disconnects were visible, however the third was not visible.

5. A 104 (a) citation (No. 7368630) was issued on May 4, 2000, to Garrett Mining Inc., for a violation of 30 CFR, Part 75.509. The 7,200-three phase high voltage power circuit connected to the Hi-Tech Electric, 001-0 section power center was not de-energized before work began on the high voltage compartment. For an unknown reason the lid covering the high voltage compartment and prevents persons from coming in contact with energized connections was removed by the victim.


Related Fatal Alert Bulletin:
 FAB00C10




Sketch of Accident Scene

APPENDIX A

The following persons provided information and/or were present during the investigation:

GARRETT MINING, INC. OFFICIALS
Steve Cordial................................................................Maintenance Manager
Roger Richardson.........................................................Superintendent
James Newsome...........................................................Chief Electrician
Darrell Richardson........................................................Safety Director
Larry Watson ................................................................Foreman
Terry Keith Stevens.......................................................Maintenance Foreman
Mark Heath....................................................................Attorney
GARRETT MINING, INC. EMPLOYEES
Larry C. Pease..............................................................Electrician
Paris (Andy) Andri Smith...............................................Roof Bolt Operator
A AND A ENTERPRISES, INC.
(Security Services)
Larry Wayne Johnson...................................................Security Guard
LETCHER COUNTY, KENTUCKY OFFICIALS
Delbert Anderson.........................................................Letcher County Coroner
SHELBY CREEK VOLUNTEER RESCUE SQUAD
Anthony Newsome
Ralph Mullins
Donna Mullins
Karen Newsome
KENTUCKY DEPARTMENT OF MINES AND MINERALS
Tracy Stumbo...............................................................Chief Accident Investigator
David Johnson.............................................................Chief Electrical Inspector
James B. Fuller .....................................................Electrical Inspector
Raymond Slone .....................................................Accident Investigator
MINE SAFETY AND HEALTH ADMINISTRATION
Robert Phillips..............................................................Mine Safety and Health, Specialist, Division of Safety
Arlie Massey................................................................ Mine Safety and Health, Specialist, Electrical Engineer, Approval and Certification Center
Paul R. Fuller................................................................Coal Mine Safety and Health Specialist, Electrical Supervisor
Stevie Justice...............................................................Coal Mine Safety and Health Specialist
(Electrical)/Accident Investigator
Buster Stewart..............................................................Special Investigator
Sandra Barber...............................................................Supervisory Coal Mine Safety and Health Inspector
Jeffery Meade...............................................................Coal Mine Safety and Health Inspector


APPENDIX B

List of persons interviewed in the investigation:

Larry Johnson........................................................Security Guard
Paris (Andy) Andri Smith.......................................Roof Bolt Operator
Larry C. Pease.......................................................Electrician
Terry Keith Stevens...............................................Maintenance Foreman
James Newsome...................................................Chief Electrician
Larry Watson.........................................................Foreman