DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
DISTRICT 5
ACCIDENT INVESTIGATION REPORT
UNDERGROUND COAL MINE
FATAL FALL OF PERSON ACCIDENT
Buchanan Mine #1 (ID No. 44-04856)
Consolidation Coal Company
Mavisdale, Buchanan County, Virginia
December 5, 2000
By
Roy D. Davidson
Electrical Engineer
Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Ray McKinney, District Manager
RELEASE DATE: JANUARY 31, 2001
On Tuesday, December 5, 2000, at approximately 10:00 a.m., a 45 year old environmental monitoring technician was fatally injured as a result of a fall sustained while he was in the process of readying equipment to take air quantity measurements from the exhaust emission stack of a thermal dryer. The victim was preparing to lift sampling equipment with a rope onto a platform located 130 feet above ground level. As he was removing ice from the platform with his feet, a 24 inch x 28 inch section of steel grating on which he was standing collapsed, causing him to fall to the ground. The grating was severely corroded where it lay on a support beam near the exhaust emission stack, causing it to break at this location.
The accident occurred because the steel grating on which the victim was standing had not been maintained in good repair to prevent injuries to personnel. The grating had lost its structural integrity and collapsed because of severe corrosion.
Consolidation Coal Company's Buchanan Mine #1 is located two miles south of Route 460 on State Route 632 at Mavisdale, Buchanan County, Virginia. The mine is opened into the Pocahontas No. 3 Seam by eight shafts. Employment is provided for 425 persons. The preparation plant employs 44 hourly and six salary personnel on three production shifts per day, seven days per week. The surface area of the mine includes a large preparation plant which processes 19,000 tons of raw coal per day. Coal is cleaned, dried, stockpiled, and loaded into unit trains for transport, or when stockpiles are at or near capacity into trucks which deliver coal to the mine's impoundment area for storage. The plant area includes a coal preparation facility, raw and clean coal silos, stockpiles, draw off tunnels, a thermal dryer, and loadout facilities.
Consol Energy, located in Pittsburgh, Pennsylvania, is the parent company of Consolidation Coal Company and Consol Research and Development, as well as other subsidiaries. Consol Research and Development performs environmental and engineering work for Consol Energy and is located in South Park, Pennsylvania.
The principal management personnel in charge of the mine at the time of the accident were:
Mine Superintendent . . . . . . . . . . . . . . . . . . . . . J. Michael OniferThe mine address is P.O. Box 230, Mavisdale, VA 24627. The corporate address is 1800 Washington Road, Pittsburgh, PA 15241.
Principal Officer of Health and Safety . . . . . . . . .J. Michael Onifer
General Plant Foreman . . . . . . . . . . . . . . . . . . . Tom Burton
Plant Foreman . . . . . . . . . . . . . . . . . . . . . . . . . .Mike Case
The last regular Safety and Health Inspection(AAA) was completed on September 30, 2000; however, due to the size of the mine, a regular safety and health inspection is continuously ongoing.
The latest NFDL (non-fatal days lost) national injury frequency rate for underground mines (which includes the underground area and the surface work areas of underground mines) was 8.66 and the rate for this mine was 4.06. The latest national NFDL frequency rate for preparation plants was 3.10 and for this mine was 0.00.
On December 5, 2000, at approximately 8:00 a.m., three employees of Consol Research and Development arrived at the office of the mine's preparation plant. These employees were Matthew S. DeVito (victim), Research Group Leader, Jeffrey A. Withum, Senior Research Technician, and Denis Kowalski, Technician. On this day, they were to set up and prepare instrumentation to conduct annual mandatory environmental compliance testing on the exhaust gases at the stack of the thermal dryer. The actual testing was to be performed the next day with monitors from the Commonwealth of Virginia's Department of Environmental Quality. Tom Burton, General Plant Foreman, had been called one week earlier by DeVito to reserve this time for the set up and testing. Burton met with the group and explained that the preparation plant was not in operation because they had run out of water. Burton stated that he was in the process of obtaining water from a nearby location and hoped to have the plant running for the second shift. Burton left the group to solve the water problem. Michael Case, Plant Foreman, arrived to give DeVito, Withum, and Kowalski hazard training. Case gave each man a written list of potential hazards at the plant area. After they read the list, Case told the men to be cautious of ice on the walkways and advised them to take a hammer to remove any ice they may encounter. Case then left to perform other duties but said he would return later and connect their electrical extension cord for the sampling trailer.
At approximately 9:00 a.m., the group began to set up and prepare their instrumentation to ready themselves for the time when the preparation plant would begin operation. The sampling trailer was parked near the base of the thermal dryer stack and unhitched from their truck. Withum went inside the trailer to prepare the instrumentation for the emission testing. DeVito and Kowalski began unloading equipment from the back of their truck, including a ten foot sampling probe, stand for the probe, and two five-gallon buckets loaded with tools, rope and equipment. DeVito prepared to climb the stack and pull up equipment he would need to make air measurements on the stack during the environmental testing. DeVito began climbing the stack with one of the buckets as Kowalski waited on the ground. At approximately 10:00 a.m., DeVito reached a work platform located 130 feet up the stack, where he intended to pull equipment from the ground. He radioed to Kowalski that there was ice on the platform and to get out of the way because he was going to clear the ice. Kowalski, who was standing directly below, moved under some nearby structure and told DeVito he was in the clear. Kowalski saw DeVito try to kick some ice or move his foot which he believed was for the purpose of removing ice. Immediately thereafter, he saw a section of grating fall, followed by the victim.
Kowalski yelled for Withum, who was in the sampling trailer. Withum and Kowalski ran to the victim and tried to get a response, but were unsuccessful. Kowalski then ran to the mine office for help. Case, who was in the mine office, radioed Burton and told him to call an ambulance. Case and Kowalski returned to the victim and were followed shortly by Burton, who had arrived at the plant site. Withum and Case checked for a pulse, and having found none began cardiopulmonary resuscitation (CPR). CPR was continued until the Grundy Ambulance Service arrived approximately 20 minutes later and transported the victim to the Clinch Valley Medical Center in Richlands, Virginia, where he was pronounced dead by Dr. Stefanini at approximately 11:30 a.m.
At 10:20 a.m., on December 5, 2000, Luther Marrs, Supervisory Coal Mine Inspector in the Richlands, Virginia field office, was notified by J. Michael Onifer, Superintendent, of the accident. Marrs called Wayland Jessee, Assistant District Manager, and made him aware of the accident.
Roy Davidson, Electrical Engineer, was at the mine inspecting the hoists when the accident occurred. Davidson was informed of the accident at 10:45 a.m. by Sam Beavers, Chief Electrician. Davidson traveled to the accident site where he met Opie McKinney, Mine Inspector Supervisor for the Virginia Department of Mines, Minerals and Energy (VDMM&E) and Mike Onifer, Superintendent. Jessee called Davidson shortly after his arrival at the accident site and told him to begin the investigation. Preliminary information concerning the fatality was obtained and a Section 103(k) Order was issued to ensure the safety and health of any person at the mine. The accident scene was observed and company officials were told the investigation would continue at 10:00 a.m., on December 6, 2000.
Officials from the VDMM&E and MSHA met at the Richlands, Virginia, field office at 8:30 a. m., December 6, 2000, to discuss the accident investigation. The accident investigation teams arrived at the mine at 10:00 a.m., and met with company officials and J. B. Vandyke, Miners' Representative, concerning the investigation. The accident site was inspected and a scaled drawing, photographs and a video were made. Eight persons were interviewed at the mine's conference room. A meeting was then held with company officials and they submitted a written plan of action for the purpose of preventing similar accidents in the future.
On December 20, 2000, a Section 104 (a) Citation for failure to maintain the work platform in good repair was issued with a due date of January 16, 2001. On January 16, 2001, the Section 103 (k) Order and Section 104(a) Citation were terminated.
On January 26, 2001, two additional employees were interviewed at the mine office.
1. The thermal dryer for the mine's preparation plant is an E-N-I Coal Flow Model 10. The thermal dryer is a negative pressure type that uses natural gas to provide heat for drying the coal. Dual-gas burners are used to dry the wet, clean coal. The dry coal falls into hoppers and is discharged onto an outgoing belt. The gas emissions exit the dryer facility through the exhaust stack into the atmosphere.
2. Thermal dryer exhaust gas emission testing is conducted annually by personnel from Consol Research and Development and monitored by personnel from Virginia's Department of Environmental Quality. Testing is conducted for carbon monoxide, carbon dioxide, sulphur dioxide and volatile organic compounds in accordance with the operating permit. A series of three separate tests is performed which normally takes between one and two hours per test. These tests are conducted while the preparation plant operates in a normal processing mode.
3. The last environmental exhaust gas emission tests for the thermal dryer were conducted on February 17, 1999. Matthew DeVito participated in those tests as well as every other emission test conducted at this facility. The testing began in 1985.
4. The exhaust emission stack for the thermal dryer is 180 feet high with an inside diameter of 8 feet 6 inches.
5. At the time of the accident, the victim was standing on a work platform that surrounded the thermal dryer emission stack, preparing to lift air measuring equipment up the side of the stack with a rope. This platform was located approximately 130 feet above ground level.
6. The group decided to lift these items up the stack with a rope because some of the equipment to be lifted, such as the 10 foot long sampling probe and the support tripod, were too awkward to carry up the stairs.
7. The victim carried a five-gallon bucket that contained a rope, ball peen hammer, and other items up the stairs to this work platform.
8. The stairs led to a walkway that approached the platform from the back side of the thermal dryer stack. This work platform surrounded the stack so that the front side could be approached from either the left or right side. The victim traveled to the front side using the right approach because plywood air straightening vanes were stacked on the left side approach which blocked this access.
9. A ball peen hammer was laying on the right front side of the platform. On the left front side of the platform was a five-gallon bucket with a coiled rope in front of the bucket. The grating that collapsed was located near the middle of the front area of the platform. Therefore, the victim walked over the grating that collapsed at least once without incident. 10. The actual air measurements were to be made on the uppermost work platform for the stack, which was located 25 feet above the platform where the accident occurred. However, this platform did not have a front side where the equipment could be raised unimpeded from the rest of the structure. For this reason, the equipment was to be pulled up to this lower platform and then carried to the top platform.
11. The protocol for taking air quantity measurements in the stack during emission testing required that twelve air velocity measurements be conducted at different prescribed depths into the stack from one port, then twelve more similar measurements be taken from a different port located 90 degrees from the first port. These measurements are to be made with the ten foot sampling probe used to insert a Pitot tube into the stack. The velocity pressure is measured and then the velocity and quantity of air flowing through the stack calculated. These air quantity measurements are made at the same time the air quality measurements are made from another port near the bottom of the stack.
12. The work platform at the accident location was constructed of 1 1/8 inch x 1/8 inch steel bar grating. The steel grating slats were spaced on 1 1/4 inch centers on their edge and connected on the top side by 1/4 inch round rods spaced four inches apart.
13. The grating was supported on two structural steel beams which were part of the supporting structure for the stack and access ways. The grating was connected to these support beams by metal clips. The outer beam, type W10 x 33, was four inches wide and the inner beam, type C10 x 15.3, was 2.2 inches wide. The beams were spaced on 34 inch centers. The inner beam was located approximately 10 inches from the stack.
14. The section of grating the victim was standing on measured approximately 24 inches x 38 inches. A portion of this grating measuring 24 inches x 28 inches collapsed due to severe corrosion and fell to the ground at the time of the accident. A portion of the grating measuring approximately 14 inches x 10 inches was left hanging between the inner beam and the stack. This portion was also severely corroded. A section of the grating measuring approximately 10 inches x 10 inches, located between the inner beam and stack, had previously disintegrated due to corrosion and was probably missing before the accident. Several smaller pieces of corroded grating were still laying on the inner beam. The grating was structurally sound from its outer edge away from the stack, but had severely corroded where it lay on the inner beam and had corroded almost completely away close to the stack.
15. The platform constructed around the thermal dryer stack from where the victim fell, was used to provide a work area from which 3/4 inch x 4 feet x 8 feet plywood vanes could be temporarily installed into the stack to correct the cyclonic gas flow to axial flow and reduce air turbulence during emission testing. Six equally spaced gate-covered slots were installed at this level to provide access for the vanes to be inserted into the stack. The vanes were installed so that the plywood was inserted into the stack for approximately four feet with the eight foot length standing vertically. These vanes were installed into the stack only during emission testing and were removed after the testing was completed.
16. The gate-covered slots immediately over the platform at the accident location would not seal to prevent moisture and grit from escaping the emission stack and settling onto the platform. This action accelerated the corrosion of the grating near the stack.
17. Grating examined at other locations in and around the preparation plant indicated various degrees of deterioration. In some instances, the grating was covered by rusted material which adhered to the sound material and maintained the thickness of the original metal with little difference in color. The corroded areas of this grating were therefore difficult to detect visually, especially from a standing position. Without some form of pressure or shock applied to the corroded area, such as striking the grating with a hammer which loosened and dislodged the rust layers, the true structural integrity of the grating could not easily be determined. At the time of the accident, ice accumulations and possibly grit were also present on the grating that collapsed. These conditions may have obscured the deteriorated condition of the grating at the accident site.
18. Tom Burton, General Plant Foreman, initiated a systematic approach in January 2000, to replace grating and steps at all areas of the plant including the thermal dryer area after he noticed grating being replaced more frequently at the plant. As a result of this initiative, three sections of grating were replaced on January 24, 2000, by Steve Berry, Stationary Equipment Operator, and Mike Bradshaw, Mobile Equipment Operator, at the work platform where the accident occurred. Berry stated one section of grating was replaced on the front of the platform near the section that collapsed, another on the right side and one on the rear side of the platform. After the three sections were replaced, Berry stated the area looked good when he left, and Bradshaw stated he remembered no other bad places on the platform.
19. No evidence was obtained during the investigation to indicate that mine personnel had traveled to the accident site between January 24, 2000, when the three sections of grating were replaced, and December 5, 2000, when the victim entered the area. Jimmy Fuda, Mobile Equipment Operator, had traveled to this platform approximately one week earlier to check the condition of the plywood air straightening vanes, but did not travel to the front of the platform where the accident occurred.
20. An unwritten policy at this mine, as stated by company officials during the investigation, prohibited employee travel above the explosion relief doors for the thermal dryer while the dryer was in operation. The explosion relief doors are located approximately 25 feet above ground level. The thermal dryer is normally scheduled to operate 24 hours a day, seven days a week. However, due to operating permit constraints, operational constraints, and maintenance, the thermal dryer averaged operating approximately 70 percent of the available operating time or 16.5 hours per day during the last year. The thermal dryer's non-operational time was not scheduled on a regular time frame but occurred on a sporadic basis. Because of the aforementioned policy and the operational parameters of the thermal dryer, travel up the stairs and to the platforms surrounding the stack was infrequent.
21. The person who takes the air quantity measurements near the top of the thermal dryer stack during annual mandatory emission testing must do so when the thermal dryer is operating.
22. DeVito, Withum, and Kowalski decided among themselves to climb the thermal dryer stack and ready equipment for the environmental emission testing at the time of the accident.
23. Consolidation Coal Company officials have agreed to the following actions to prevent similar accidents from occurring in the future:
a. All existing grating will be removed at the platform level where the accident occurred.
b. Six inch channel will be bolted in place with galvanized bolts to reduce the span between the support beams for the grating.
c. Fifteen (15) square feet of 1 1/4-inch stainless steel bar grating will be installed at each inspection door for the stack.
d. Grating on the uppermost level will be inspected and replaced as necessary with heavy duty 1 1/4-inch galvanized bar grating.
e. All grating will be welded in place using 7018 all purpose welding rods.
f. Because these areas are seldom traveled with no requirement for periodic inspections by mine personnel, these areas will now be inspected quarterly by a Preparation Plant Foreman.
g. Require the wearing of a safety harness when personnel enter platforms on the stack to perform work.
The accident occurred because the grating the victim was standing on was not maintained in good repair to prevent injuries to personnel. The grating lost its structural integrity and collapsed because of severe corrosion.
1. A Section 103(k) Order (No.7309642) was issued to ensure the safety of all persons at the mine until an investigation was completed and all areas were deemed safe.
2. A Section 104(a) Citation (No.7296994) was issued citing 30 CFR 77.200. A metallic work platform on the thermal dryer exhaust emission stack, located approximately 130 feet above ground level, was not maintained in good repair to prevent accidents and injuries to employees. A section of metal grating measuring approximately 24 inches x 38 inches had deteriorated from corrosion, allowing a portion measuring approximately 24 inches x 28 inches to collapse. On December 5, 2000, an environmental technician, who was standing on this section of grating when it collapsed, fell through the platform to the ground below, resulting in fatal injuries. Two other sections of grating on this platform, one which was adjacent to the section that broke loose and fell, were not maintained in good repair and were severely corroded.
Related Fatal Alert Bulletin::
FAB00C35
APPENDIX A
List of persons providing information and/or present during the investigation:
J. Michael Onifer . . . . . . . . . . . . . . . . . .. . . . Mine Superintendent
Bill Hagy . . . . . . . . . . . . . . . . . .. . . . . . . . . . Assistant Mine Superintendent
Dennis Perry . . . . . . . . . . . . . . . . . .. . . . . . . Safety Inspector
Tom Burton . . . . . . . . . . . . . . . . . .. . . . . . . General Plant Foreman
Michael Case . . . . . . . . . . . . . . . . . .. . . . . . .Plant Foreman
Ed Davidson . . . . . . . . . . . . . . . . . .. . . . . . . Supervisor Human Resources
Steve Berry . . . . . . . . . . . . . . . . . .. . . . . . . Stationary Equipment Operator
Mike Bradshaw . . . . . . . . . . . . . . . . . .. . . . Mobile Equipment Operator
Alvin Brewster . . . . . . . . . . . . . . . . . .. . . . . Welder - Preparation Plant
Jimmy Fuda . . . . . . . . . . . . . . . . . .. . . . . . . Mobile Equipment Operator
Allen Osborne . . . . . . . . . . . . . . . . . .. . . . . .Utility - Preparation Plant
J. B. Vandyke . . . . . . . . . . . . . . . . . .. . . . . .Miners' Representative
Barry Dangerfield . . . . . . . . . . . . . . . . . .. . .Vice-President Group 3
Jack Holt . . . . . . . . . . . . . . . . . .. . . . . . . . .Vice-President Safety
Elizabeth Chamberlin . . . . . . . . . . . . . . . . . .Corporate Safety Director
Raymond Perr . . . . . . . . . . . . . . . . . .. . . . . Contract Administrator
Bill Fertall . . . . . . . . . . . . . . . . . .. . . . . . . . Manager Engineering Group 3
Jeffrey Withum . . . . . . . . . . . . . . . . . .. . . . .Senior Research Technician
Denis Kowalski . . . . . . . . . . . . . . . . . .. . . . Technician
Frank Linkous . . . . . . . . . . . . . . . . . .. . . . . .Chief
Carroll Green . . . . . . . . . . . . . . . . . .. . . . . . Mine Inspector Supervisor
Opie McKinney . . . . . . . . . . . . . . . . . .. . . . Mine Inspector Supervisor
David Elswick . . . . . . . . . . . . . . . . . .. . . . . .Coal Mine Technical Specialist
John Talbert . . . . . . . . . . . . . . . . . .. . . . . . . Coal Mine Technical Specialist
Danny Altizer . . . . . . . . . . . . . . . . . .. . . . . . Coal Mine Inspector
Joseph Altizer . . . . . . . . . . . . . . . . . .. . . . . .Coal Mine Inspector
John Brown . . . . . . . . . . . . . . . . . .. . . . . . . Coal Mine Inspector
Terry Ratliff . . . . . . . . . . . . . . . . . .. . . . . . . Coal Mine Inspector
Ray McKinney . . . . . . . . . . . . . . . . . .. . . . .District Manager, District 5
James W. Poynter . . . . . . . . . . . . . . . . . .. . Conference and Litigation Representative
James R. Baker . . . . . . . . . . . . . . . . . .. . . . Educational Field Services Specialist
Arnold D. Carico . . . . . . . . . . . . . . . . . .. . .Mining Engineer
Russell A. Dresch . . . . . . . . . . . . . . . . . .. . .Electrical Engineer
Roy D. Davidson . . . . . . . . . . . . . . . . . .. . . Electrical Engineer
Michael Shaughnessy . . . . . . . . . . . . . . . . . .Mechanical Engineer
Erik Scherer . . . . . . . . . . . . . . . . . .. . . . . . . Mine Safety and Health Specialist
J. Michael Onifer . . . . . . . . . . . . . . . . . .. . . .Mine Superintendent
Denis Kowalski . . . . . . . . . . . . . . . . . .. . . . .Technician
Jeffrey Withum . . . . . . . . . . . . . . . . . .. . . . . .Senior Research Technician
Alvin Brewster . . . . . . . . . . . . . . . . . .. . . . . .Welder - Preparation Plant
Jimmy Fuda . . . . . . . . . . . . . . . . . .. . . . . . . . Mobile Equipment Operator
Michael Case . . . . . . . . . . . . . . . . . .. . . . . . . Plant Foreman
Tom Burton . . . . . . . . . . . . . . . . . .. . . . . . . . General Plant Foreman
Allen Osborne . . . . . . . . . . . . . . . . . .. . . . . . Utility - Preparation Plant
Steve Berry . . . . . . . . . . . . . . . . . .. . . . . . . . Stationary Equipment Operator
Mike Bradshaw . . . . . . . . . . . . . . . . . .. . . . . Mobile Equipment Operator
Photos Accompanying Report
Thermal Dryer Emission Stack
Section of Grating That Collapsed
Platform Location