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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

REPORT OF INVESTIGATION

Surface Coal Mine

Fatal Machinery Accident
October 4, 2000

Job 17 West
17 West Mining Inc.
Lovely, Martin County, Kentucky
ID No. 15-07295

Accident Investigators

B. G. Cure
Coal Mine Safety and Health Surface Specialist

Robert J. Newberry
Mining Engineer

Ronald Medina
Mechanical Engineer


Originating Office
Mine Safety and Health Administration
District 6
4159 North Mayo Trail
Pikeville, KY 41501
Allen Dupree, Acting District Manager


Release Date: January 24, 2001


OVERVIEW

At approximately 6:05 p.m., on Wednesday, October 4, 2000, a fatal machinery accident occurred in the 3 South Area of 17 West Mining, Inc., Job 17 West surface mine. James Paul Sparks was operating a Caterpillar Model D-11N Bulldozer on the Stockton Coal Seam elevation when the machine fell 108 feet over a highwall into the coal pit at the Coalburg Seam elevation resulting in fatal injuries. The Stockton Seam is located at elevation 1110 and the Coalburg Seam is located at elevation 1005. Sparks was tramming the bulldozer in reverse in a westerly direction along the top of Dragline Panel No. 7 in the 3 South Area (see map in Appendix). Ira Cantrell, bulldozer operator, trammed a Caterpillar Model D-11R Bulldozer along the same path approximately 75 feet ahead of the victim's bulldozer. He stated that he observed the victim wiping the inside of the front windshield while the dozer was traveling in reverse.

The accident occurred due to the equipment operator not having full control of the Caterpillar Model D-11N Bulldozer while it was in motion. Evidence indicates the equipment operator was not wearing a seat belt.

GENERAL INFORMATION

17 West Mining Inc., Job 17 West is located on Kentucky Route 1724, approximately twelve miles from Lovely in Martin County, Kentucky. 17 West Mining Inc. is a wholly owned subsidiary of Coal Ventures Holding Company, Inc., located in Ashland, Kentucky.

This mine was placed in producing status on November 23, 1998. Coal is produced in three active pits using highwall drills, an electric shovel, an electric dragline, a 992 Caterpillar Loader and Caterpillar Rock Trucks. The company uses contour and mountain top removal with cross-valley fills, and produces 13,000 tons per day. The accident occurred in the area of Three South, Panel 7. This area was using the mountain top removal method of mining.

The mine operates two-ten hour shifts, seven days a week, employing 132 persons. Maintenance is conducted between shifts and during production shifts as needed and/or scheduled. The last regular safety and health inspection of the mine was completed on August 24, 2000.

The principal company officers of 17 West Mining Inc. are:
Stephen Addington .................................President
Scott Perkins ..........................................General Manager
David Maynard .......................................Area Manager
Keith Smith .............................................Safety Director
DESCRIPTION OF ACCIDENT

On the day of the accident, bulldozer operator James Paul Sparks (victim) arrived at the mine site to begin work at 6:00 p.m. on the evening shift. Sparks along with the rest of the employees met in the parking lot where they received their work assignments. James Sparks and Ira Cantrell, dozer operators, were transported to the Three South Area by Donald Wells, foreman. Two dozers had been parked in this area by the day shift crew. Routine maintenance and fueling of the dozers were performed between the day and evening shift. As work began, Cantrell trammed his dozer in reverse toward the work site approximately 100 feet ahead of Sparks. Cantrell observed Sparks cleaning the front windshield as the dozer was being trammed in reverse. Cantrell made a 90 degree turn onto Panel 10 in the Three East Area. He traveled over a mound of spoil material to the work area and waited for Sparks to enter. When Sparks failed to arrive, Cantrell trammed to the top of the mound of spoil to look for him. Cantrell exited his dozer, looked over the highwall and observed Spark's dozer at the bottom of the highwall. Cantrell summoned help via C.B. radio, trammed back to where the dozers were parked at the beginning of the shift and ran down to the accident scene. Donald Wells, foreman, was present at the scene when Cantrell arrived. Sparks apparently had been ejected from the dozer, receiving traumatic injuries. He was pronounced dead at the scene at 7:15 p.m. by the Martin County Coroner.

INVESTIGATION OF ACCIDENT

At 7:40 p.m. on October 4, 2000, Henry Collins, evening shift superintendent for Job 17-West, called John South, MSHA Supervisor for Special Investigations, to report the accident. Debra Howell, Coal Mine Inspector, and Kenneth Murray, Supervisory Coal Mine Inspector, were dispatched to the scene. Representatives from the Kentucky Department of Mines and Minerals (KDMM) and 17 West Mining, Inc. were present at the scene when they arrived at approximately 9:45 p.m.

Upon their arrival, a 103-K order was issued by MSHA to assure the safety of all persons until the accident investigation could be completed and the Job 17-West Mine determined safe.

Interviews were conducted on October 7, 2000, at 17 West Mining, Inc. office in Lovely, Martin County, Kentucky. Thirteen persons deemed to have relevant information concerning the accident were interviewed jointly by MSHA and KDMM. The sessions were recorded on audio tape with the consent of the interviewees, and a written transcript was later produced for the investigation file.

A survey of the Three East Area was performed on October 6, 2000, by Abbott Engineering, Inc. to determine the path both dozer operators had taken at the time of the accident. Copies of these surveys were forwarded to MSHA and KDMM.

Ronald Medina, mechanical engineer from MSHA Technical Support, examined the dozer on-site for mechanical defects that may have contributed to the accident. The examination was difficult due to the heavy damage sustained by the bulldozer.

John South and B.G. Cure visited the victim's son on October 12, 2000, to discuss preliminary information gathered during the accident investigation.

DISCUSSION

The investigation revealed the following factors relevant to the occurrence of the accident.
1. MACHINE INFORMATION: The track-type Caterpillar Model D11N tractor was equipped with a bulldozer blade and a ripper. The operating weight of the machine was approximately 215,000 pounds. It was equipped with an eight cylinder, Model 3508 Caterpillar diesel engine, rated at 817 gross horsepower. The machine was extensively damaged and the engine was inoperable.
2. ROPS AND SEAT BELT: The dozer was equipped with a Rollover Protective Structure (ROPS) and a seat belt. The ROPS was intact and no visual damage was observed. The seat belt was found in the unlatched condition. When visually examined, there did not appear to be any damage to the seat belt buckle or latch plate. When tested, the seat belt latched and unlatched satisfactorily. The victim was ejected from the dozer cab during the accident and the seat belt was found unlatched after the accident. No visual damage or deformations were observed during the examination of the seat belt assembly. The seat belt latch mechanism functioned when tested and the release button unlatched the buckle assembly with minimal finger pressure.
3. STEERING AND BRAKE CONTROL VALVE: The Steering and Brake Control Valve was installed on top of the main transmission housing case, as designed. This valve controlled all the steering and braking functions of the machine. The steering levers, the foot brake service pedal, and the parking brake lever were connected to the valve by mechanical linkage. This linkage was found to be operational and undamaged. The valve itself visually appeared undamaged.
4. SERVICE BRAKE AND PARKING BRAKE HYDRAULIC DESIGN DESCRIPTION: The service brakes were spring applied and hydraulically released. The braking force was controlled by varying the hydraulic release pressure. When the brake pedal was in the released position, pressurized oil was sent to the brake housings. This held the brakes in the released position and permitted the outer axle shafts to turn, allowing machine movement. When the foot brake was pushed, the release pressure decreased. The reduction in pressure allowed Belleville springs to push the brake piston against the disc and plates to stop the machine. The parking brake lever could also be used to apply the same Belleville spring applied brake system. When the parking brake lever was in the engaged position, the spring applied brake was fully applied. When the parking brake lever was in the released position, pressurized oil was sent to the brake housings to fully release the spring applied brakes. The steering levers also applied the same Belleville spring applied brake system if they were pulled all the way back. This action reduced the brake release pressure which allowed the Belleville springs to apply the brake.
5. CONTROL POSITIONS: The control positions were found to be as follows:
The machine had two Steering Clutch and Brake Control Levers, both on the operator's left side. The left lever controlled steering and braking for the left track and the right lever controlled steering and braking for the right track. The levers were located immediately beside each other. The machine was designed such that pulling a steering lever back a small distance caused a modulated reduction of the corresponding steering clutch pressure. As the steering lever was pulled back farther, the clutch pressure could be modulated to zero psi. This caused one track to receive more power than the other track and resulted in a gradual turn. Further movement of the steering lever started engaging the brake and caused a sharper turn. The turn is sharper because one track is powered and the other is braked. As the lever was pulled back farther, the braking force gradually increased until maximum steering is achieved. The Steering Clutch and Brake Control Levers were found to be bent. Physical evidence indicated the victim struck the steering levers due to the impact force of the accident. The steering levers were operated during the investigation. Despite the deflection of the steering levers, they spring returned to the neutral position upon release, as they were designed to do. A step-type increase in the spring return force could be felt when the levers were pulled approximately half way back through their range of motion. This was due to the compression of the brake spool return springs in the Steering and Brake Control Valve. Lesser movement of the steering lever only caused compression of the steering clutch spool return springs, which offered less resistance. According to the Operation and Maintenance Manual for the D11N tractor, this additional resistance was designed to let the operator know that the brake is beginning to engage. Other than the bent steering levers, no steering system defects were found.
A Service Brake Foot Pedal was provided in the operator's compartment. It moved freely and no obstructions were found that interfered with pedal movement. The mechanical linkage between the foot pedal and the Steering and Brake Control Valve was found to be operational and undamaged.
The Parking Brake Lever was located on the operator's left side near the seat. It had two positions: lever up (released) and lever down (applied). The Parking Brake Lever was found in the down (applied) position. With the engine stopped, the lever could be placed in either position and when released it remained in position by a detent mechanism. This lever operated as designed. The Parking Brake Lever was visibly bent. The mechanical linkage between the Parking Brake Lever and the Steering and Brake Control Valve was operational and appeared undamaged.
The Transmission Direction and Speed Selector Lever was located on the left console. It could be shifted into neutral or any of the three forward or reverse speeds as designed and appeared undamaged. The tractor was designed such that when the parking brake handle was pushed down to apply the parking brake, a mechanical interlock automatically shifted the transmission lever into neutral. This feature was tested and operated as designed. The transmission lever was found to be in the neutral position during the investigation. However, a witness reported that the machine was traveling in reverse just prior to the time of the accident.
The Engine Speed Governor Control was found in the center position. This control consisted of a rocker switch, located on the right console, that allowed the operator to select a low or high idle engine speed. This switch was designed to increase and decrease the engine speed by momentarily holding down the switch until the desired rpm was achieved. It was also designed to automatically return to the center position upon release. The engine was inoperable and the speed increase/decrease functions could not be tested. When pressed, the rocker switch did return to the center position as designed.
A Decelerator Pedal was provided in the cab. The Decelerator Pedal was designed to override the governor and reduce engine speed. The decelerator pedal was found in the fully released (up) position. The pedal moved freely and returned to the up position when released, as designed. The decelerator pedal was connected to the engine control module electronically, rather than by mechanical linkage.
The Dozer Blade and Ripper Controls were both found in the neutral position. The dozer blade control, when moved to the float position by pushing it all the way forward, dented in this position as designed. When placed in any of the other control positions, it returned to neutral when released, as designed. The ripper control was operated and it returned to the neutral position when released, as designed.
6. HORN AND BACKUP ALARM: The horn and backup alarm were tested and found to provide audible sound.
7. MIRROR: The overhead rearview mirror was intact and generally clean.
8. DAMAGE: The dozer was extensively damaged as a result of the accident. Each of the blade lift cylinder rods was found to be broken such that most of the rod remained inside the cylinder. The overhead windshield wiper control was found to be torn loose from its anchor point and other components in the operators' compartment were damaged. Photographs were taken to document the damage to the machine.
9. Examination of the Caterpillar D11 dozer did not reveal any braking, steering, or travel control defects that would have contributed to the accident.
10. There were no known witnesses to this accident.
11. The coroner's report listed head and body trauma as the cause of death. An autopsy was not performed on the victim.
12. The area was generally dry, very sunny, and warm at the time of the accident. At the time of the accident, the sun was setting in the direct line of view of the victim.
CONCLUSION

The accident occurred because the victim was wiping the windshield of the dozer while tramming the machine in reverse, and was unaware of his location relevant to the edge of the highwall. The dozer backed over the edge and fell 108 feet landing in an upright position. The victim was ejected from the dozer. Apparently, the seat belt was not being worn. No defect in the dozer's operating control system was found that would have caused or contributed to the accident.

ENFORCEMENT ACTIONS

1. 103(k) Order No. 7373999: This mine has experienced a fatal haulage accident in the 3 East Area. This order is issued to assure the safety of any person at this mine until an investigation is made to determine that the area is safe. Only those persons selected from company officials, state officials, representatives of the miners and other persons deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area.

2. 104(a) Citation No. 7370474, a violation of 30 CFR 77.1607(b): A fatal accident occurred on October 4, 2000, when the Caterpillar D-11N Bulldozer, Co. No. M1053, was being trammed along a bench in the Three South Area while the operator did not have full control of the machine. Evidence obtained during an accident investigation revealed that the operator was cleaning the front windshield while the machine was traveling in the reverse direction when the bulldozer overtraveled the roadway and fell 108 feet resulting in fatal injuries to the operator.

3. 104(a) Citation No. 7370475, a violation of 30 CFR 77.1710(i): A fatal accident occurred October 4, 2000, when the victim, James Paul Sparks, was operating the Caterpillar D11N Bulldozer, Co. No. M1053, (manufactured in 1994 with rollover protection) along a bench at the Stockton seam elevation in the Three South Area when the bulldozer overtraveled the roadway and fell 108 feet to the Coalburg seam elevation in the Three East Area. The victim was not wearing a seatbelt and was ejected from the machine resulting in fatal injuries. A seatbelt was provided and was in good working condition.



Related Fatal Alert Bulletin:
FAB00C30


APPENDIX A


List of Persons Participating in the Investigation
17 West Mining, Inc. Officials
David Maynard . . . . . . . . . . . . . . . . . . . . . . . Area Manager
Frank Suttles . . . . . . . . . . . . . . . . . . . . . . . . . Day Shift Superintendent
Henry Collins . . . . . . . . . . . . . . . . . . . . . . . . .Night Shift Superintendent
Donald Wells . . . . . . . . . . . . . . . . . . . . . . . . .Night Shift Foreman
Keith Smith . . . . . . . . . . . . . . . . . . . . . . . . . . Safety Director
Kentucky Department of Mines and Minerals
Tracy Stumbo . . . . . . . . . . . . . . . . . . . . . . . . .Chief Investigator
Hershell Tackett . . . . . . . . . . . . . . . . . . . . . . . Supervisor
Bobby Sexton . . . . . . . . . . . . . . . . . . . . . . . . .Safety Inspector
Jerome Howard . . . . . . . . . . . . . . . . . . . . . . . Safety Analyst
Fred Moore . . . . . . . . . . . . . . . . . . . . . . . . . . Safety Analyst
Mine Safety and Health Administration
B. G. Cure . . . . . . . . . . . . . . . . . . . . . . . . . . . Coal Mine Surface Specialist
Robert Newberry . . . . . . . . . . . . . . . . . . . . . . Mining Engineer
Buster Stewart . . . . . . . . . . . . . . . . . . . . . . . . .Special Investigator
James R. Baker . . . . . . . . . . . . . . . . . . . . . . . .Training Specialist
Debra Howell . . . . . . . . . . . . . . . . . . . . . . . . . Coal Mine Inspector (surface)
Kenneth Murray . . . . . . . . . . . . . . . . . . . . . . . .Supervisory Coal Mine Inspector
Gerald W. McMasters . . . . . . . . . . . . . . . . . . .Conference Litigation Representative
Ronald Medina . . . . . . . . . . . . . . . . . . . . . . . . Mechanical Engineer
U.S. Department of Labor
Office of the Associate Solicitor
Phillip Giannikas . . . . . . . . . . . . . . . . . . . . . . . Attorney
APPENDIX B

List of Persons Interviewed
Frank Suttles . . . . . . . . . . . . . . . . . . . . . . . . . .Superintendent
Victor Dean Boyd . . . . . . . . . . . . . . . . . . . . . .Maintenance Foreman
Donald J. Wells . . . . . . . . . . . . . . . . . . . . . . . .Foreman
Timothy Lee Hall . . . . . . . . . . . . . . . . . . . . . . .Foreman
Ira Michael Cantrell . . . . . . . . . . . . . . . . . . . . .Bulldozer Operator
Clarence A. Clifton . . . . . . . . . . . . . . . . . . . . . Bulldozer Operator
David Wayne Wells . . . . . . . . . . . . . . . . . . . . .Bulldozer Operator
Buel Cantrell . . . . . . . . . . . . . . . . . . . . . . . . . . Bulldozer Operator
Larry Phillip Isaac . . . . . . . . . . . . . . . . . . . . . . Welder
Michael Lee Walters . . . . . . . . . . . . . . . . . . . . Greaser
Randy Allen . . . . . . . . . . . . . . . . . . . . . . . . . . .Greaser
Edgar D. Day . . . . . . . . . . . . . . . . . . . . . . . . . .Greaser
Paul D. McKenzie . . . . . . . . . . . . . . . . . . . . . . Greaser

Map Showing Accident Location

Fatal Machinery Accident
17 West Mining, Inc.
Job 17 West
ID No. 15-07295
Lovely, Martin County, Kentucky
October 4, 2000



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