DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE PREPARATION PLANT)
FATAL EXPLODING-VESSEL-UNDER-PRESSURE ACCIDENT
TUG VALLEY COAL PROCESSING (ID NO. 46-08590)
TUG VALLEY COAL PROCESSING
Naugatuck, Mingo County, West Virginia
December 27, 2000
Curtiss Vance, Jr.
Coal Mine Safety and Health Inspector
Phillip L. McCabe
Mechanical Engineer, Mechanical Safety Division
Approval and Certification Center
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mt. Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: March 19, 2001
On Wednesday, December 27, 2000, at 12:00 p.m., a fatal exploding vessel under pressure accident occurred on the first level below the crest of the slurry impoundment for the Tug Valley Coal Processing Preparation Plant, Tug Valley Coal Processing. The accident resulted in the fatal injuries to Ricky Ferris, a 46 year old preparation plant foreman for Tug Valley Coal Processing. Ferris had a total of 26 years experience including 17 years as foreman at this preparation plant. The accident occurred while Ferris was attempting to dislodge an ice clog from the "B" slurry pipeline. The slurry pipeline was frozen in a section of the pipeline laying in a swag on the face of the impoundment and had been cut apart to flush the ice clog out of the slurry pipeline. Ferris had the "B" slurry circuit pumps started, which pressurized the pipeline pushing the ice clog out the end of the pipeline which fouled against the hill side stopping the ice flow. Ferris took a wedge-shaped end loader bucket tooth and broke the fouled ice off the end of the pipe to allow the slurry material to continue flushing the ice clog out of the pipe. After Ferris broke the extruding ice clog off the pipeline end for the third time, the pressurized pipeline discharged the pressure rapidly, causing the pipeline to whip into the air. It is believed that Ferris was struck by the pipeline, causing fatal injuries. There were no eyewitnesses to confirm whether the pipe or ice hit the victim.
The Tug Valley Coal Processing Preparation Plant of Tug Valley Coal Processing is located at Naugatuck, Mingo County, West Virginia. A. T. Massey Coal Company developed the complex in 1974, and actual mining commenced in June 1976. Shell Mining attained full ownership in 1987. Zeigler Coal Holding Company purchased Marrowbone Development Company in 1992, and the company became signatory in 1993. Addington Resources purchased the company in 1998, and were the present owners.
Employment is provided for 48 hourly and 8 salaried persons on two production and one maintenance shift seven days a week. The coal preparation plant produces an average of 3,430,000 clean tons of coal annually. Raw coal is transported from underground and surface mine operations via conveyor belts and coal trucks to open stockpiles totaling 50,000 tons and 3 silos at the plant totaling 50,000 tons. Raw coal is processed through a total heavy-media preparation facility. The plant's current capacity of 10 million raw tons per year makes it one of the largest in the region. The plant features full-stream automatic sampling, both of coal entering clean coal silos and of coal loaded into railcars, as well as analysis of incoming coal.
The parent company of Tug Valley Coal Processing is Mountaineer Coal Development Co., doing business as Marrowbone Development Company. Principal officials for Mountaineer are as follows: Jim Campbell, President; William Haselhoff, Secretary and Treasurer. The principal official for Marrowbone Development Company is Paul Goad, President. Principal officials for Tug Valley Coal Processing are as follows: Dana Hellmondollar, Superintendent; and Roger Runyon, Safety Director.
DESCRIPTION OF THE ACCIDENT
On Wednesday, December 27, 2000, at 6:30 a.m., the day shift preparation plant foreman, Ricky Ferris, arrived at the plant to meet with the midnight shift foreman, James Price, and went over all the work that had been conducted during the midnight shift. At 7:00 a.m., Ferris began assigning jobs that had not been finished by the midnight shift and normal daily job duties in and around the preparation plant. Once Ferris had completed assigning work to all persons working his shift, Ferris traveled to the top of the impoundment to assess work which needed to be done to clear the "B" slurry pipeline that was frozen. The midnight crew had cleared the "A" slurry pipeline that had also been frozen but was unable to clear the frozen "B" slurry pipeline.
After examining the conditions of the slurry pipeline on the impoundment, Ferris came back down off the impoundment to the plant. Ferris asked Dana Hellmondollar, preparation plant superintendent, to come with him to the top of the impoundment to look at the frozen slurry pipeline. Hellmondollar traveled in Ferris's truck to the top of the impoundment where Ferris showed him the slurry pipelines on the up stream face of the impoundment. The "A" slurry circuit was pumping, but the "B" slurry circuit line was not. Ferris told Hellmondollar he wanted him to see what it was doing, so Ferris called and had the "B" slurry circuit pumps started. The "B" slurry pipeline only put out a little clear water once the pumps were running. Hellmondollar and Ferris discussed what they would need to do to get the "B" slurry pipeline clear and pumping properly. Ferris was to go down over the down stream face of the impoundment to a swag in the slurry pipeline and cut the line. Ferris told Hellmondollar he would get Vadis Blackburn, mechanic, and bring him up to the impoundment and take care of the "B" slurry pipeline. Hellmondollar told Ferris he would get William Smith, welder, and work on another project they needed to get done on the belt line and the ones who finished first could get back in touch with the others.
Ferris drove Hellmondollar back off the impoundment and stopped to talk to Blackburn about fixing the slurry pipeline. Ferris then drove Hellmondollar to his truck and dropped him off. Ferris then drove back to the truck shop to get Blackburn where they discussed what Ferris wanted to do. Blackburn got a chain saw from the shop to cut the pipeline. Ferris and Blackburn then traveled up to the first level below the crest of the impoundment to where the swag was frozen in the "B" slurry pipeline. Blackburn cut the plastic 8-inch "B" slurry pipeline, exposing the frozen ice, in the middle of the swagged pipeline. Once the "B" slurry pipeline was cut, both Ferris and Blackburn went back to Ferris's truck setting about 30 feet down hill from where the slurry pipeline had been cut. Ferris called George Marcum, preparation plant control room operator, and told him to start the "B" slurry pumps. Once the pumps cycled and liquid began to be pumped through the pipeline, water started flowing from the end of the pipeline and then stopped. A big piece of ice came out and stuck against the hill side stopping the flow out of the pipe. Ferris ask Blackburn if he had a hammer. Blackburn stated no, but if we had something, we could break that ice off with it. Blackburn told Ferris he would go and break the ice off, but Ferris told him to stay in the truck and be ready to tell Marcum to shut the "B" slurry pumps down when he told him to. Ferris got a wedge-shaped end loader bucket tooth out of his truck and walked up to the cut end of the pipe and, using the tooth, broke the ice fouled against the hill. The ice flowed out and fouled against the hill side again, stopping the flow for the second time. Ferris broke the ice off again, and it flowed out of the pipe and fouled against the dirt bank stopping the flow for the third time. Blackburn watched Ferris break the ice off the pipe to free the ice flow, for the third time, just before turning away to spit out of the truck window when he heard a loud booming noise. Blackburn turned back toward Ferris and saw Ferris going through the air landing face down on the impoundment. Blackburn immediately called Marcum on the company radio and told him to shut the pumps off and get help, because Ferris was hurt.
Blackburn ran to Ferris and began first aid and shock prevention treatment on Ferris, who was conscious at this point. Ferris asked Blackburn what hit him. Blackburn told him he believed it was the pipeline. Ferris told Blackburn that he was as weak as he could be and that it was hard to breathe. Blackburn stated Ferris stopped breathing a short time later before help arrived. Hellmondollar and Smith arrived shortly on the crest of the impoundment, not aware of the exact location of Ferris. Smith got out of the truck and walked over the impoundment down to where Ferris was laying. Hellmondollar drove back to the main road to direct the EMT's to where Ferris was located. Smith was checking Ferris's vital signs when Roger Runyon arrived. No pulse was found by either Smith or Runyon. They began cardiopulmonary resuscitation on Ferris, with Smith giving mouth to mouth and Runyon preforming chest compressions. Both miners continued to administer cardiopulmonary resuscitation on the victim until emergency personnel arrived with the ambulance. The victim's condition was evaluated by emergency personnel as he was loaded onto a stretcher and carried to the ambulance. The victim was transported via Critical Link Ambulance Service to the Williamson Memorial Hospital, Williamson, West Virginia, where the victim was pronounced dead by a physician at 2:11 p.m.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration was notified at 12:40 p.m., on December 27, 2000, that a fatal exploding vessel under pressure accident had occurred. MSHA personnel at the preparation plant at the time of accident secured the site and issued a 103(k) order to ensure the safety of the miners. The MSHA investigation team arrived at 2:30 p.m. and, along with the West Virginia Office of Miners' Health, Safety and Training, jointly conducted the investigation with the assistance of mine management and representatives of the miners. A list of those who were present and/or participated in the investigation is included in the Appendix.
All parties were briefed by mine management personnel as to the circumstances surrounding the accident.
On December 27 and 28, 2000, representatives from all parties, including MSHA Technical Support, conducted the on-site portion of the investigation. Photographs were taken and relevant measurements and sketches were made of the accident site.
Interviews of individuals known to have knowledge of the facts before and after the accident were conducted in the Tug Valley Coal Processing Preparation Plant conference/training room in Naugatuck, Mingo County, West Virginia, on December 28, 2000.
The physical portion of the investigation was completed December 28, 2000, and the 103(k) order was terminated. The investigation included checking training records, surface examination records, specifications on the pipeline and pumps used, engineering drawings, and the operator's plan to prevent a reoccurrence of the accident.
All records provided showed training given to Ferris was in accordance with 30 CFR, Part 48.
The operators training plan was revised after the fatal to include the safety precautions that were implemented prior to miners returning to work after the fatal accident. Those precautions were to make sure pumps are turned off before any work begins on pipelines, securing the pipeline being worked on from movement, all persons shall move to a safe location from pipelines being flushed, no persons will be positioned in front of the pipeline opening being flushed and pipelines will be positioned so as to minimize swags to minimize freezing of material in pipelines.
The on shift examination record book indicated that an on-shift examination had been conducted of surface areas for the midnight shift but had not been recorded for the day shift at the time of the accident. Records of daily examinations of surface areas and surface facilities were being conducted in accordance with 30 CFR, Part 77.
1. Slurry Pump Information:
Slurry is a waste product in the water which is used to clean the coal prior to shipment. Slurry is a mixture of coal dust, other contaminants and water which is usually disposed of at the earthen slurry pond impoundment. The three slurry pumps used to transfer the liquid from the preparation plant to the slurry pond impoundment were located on the ground level of the plant building. The three centrifugal pumps were of metal construction, Size 4/3,Type HH, and were manufactured by the Warman International Incorporated company. Each pump was mounted on a base and driven by a 200 horsepower, three-phase AC motor, operating at 1780 rpm nominal. The pump was driven by the motor using V-belts and pulleys. Each pump had a number 5V18.7 X 6 groove pulley and each motor had a number 5V13.2 X 6 groove pulley. The numbers 18.7 and 13.2 represent the pulley diameters in inches and each pulley had 6 grooves. The pulley ratio yields a 1.42 speed reduction which turns the pumps at approximately 1256 rpm nominal.
The slurry was gravity fed to the intake of the first pump by steel piping connected to a slurry buffer tank. This slurry buffer tank was a large metal cylinder fabricated from steel plate. A manually operated gate valve was located in the steel pipe between the slurry buffer tank and the intake of the first pump. This gate valve could be opened and closed by turning the handwheel on to of the valve. This gate valve was used to isolate the slurry buffer tank and the slurry pumps when maintenance was performed on the pump system.
The pumps were connected in a series fashion in which the discharge from the first pump was connected with steel piping to the intake of the second pump, the discharge of the second pump was connected with steel piping to the intake of the third pump, and the discharge of the third pump went to the slurry pipeline. This arrangement made for a three-stage pump system which accumulated or added the pressure output from each pump. The maximum design pressure was 450 psi at the discharge of the third pump. The flow of the pumps was 800 g.p.m., and could produce a total dynamic head of 844 feet when using a specific gravity of slurry being 1.22. The specific gravity of a liquid is the density of the liquid when compared to the density of water. The density of the slurry is greater than the density of water.
The slurry was transferred to the slurry pond impoundment using two pumping systems, an "A" slurry pipeline and a "B" slurry pipeline. Both pipelines used the same pump arrangement as described above and were connected to the bottom of the slurry buffer tank. The "A" slurry pipeline had three pumps, a "B" slurry pipeline had three pumps, and the pipelines were not connected to each other. Each pipeline pumping system could be operated independently of the other pipeline.
2. Slurry Piping Information:
The slurry pipelines were used to transfer the slurry to the slurry pond impoundment. The pipelines traversed the mountain side up an elevation change of approximately 613 feet and a distance of approximately 6000 feet. An 8-inch steel pipe was connected to each of the third slurry pump discharges. These steel pipelines emerged from the preparation plant building and were anchored to the incline of the mountain which headed toward the slurry pond impoundment. The sections of steel pipe were welded together to provide a smooth and continuous pipeline. The steel piping was needed on the lower section of pipeline where the high pump discharge pressure could cause a rupture. Each steel pipeline was approximately 600 feet long and transferred the slurry up the major portion of the elevation change.
The plastic polyethylene piping was connected to the steel piping. The plastic polyethylene pipe was used to transfer the slurry along a shelf ledge on the side of the mountain and over the top of the slurry pond impoundment into the pond. The plastic piping was laid on the shelf ledge without any anchors which allowed the piping to slip off the shelf in several locations creating the low spots (swags), or liquid traps. This plastic pipe is a smooth material and very flexible even in cold weather. The plastic pipe was supplied by two different manufacturers. The pipe could be interchanged in any combination. The pipe provided by the Phillips Driscopipe, Inc., was 8-inch-nominal Driscopipe 1000, Type SAR 15.5, rated for 110 psi pressure. The outside diameter measured 8.625 inches with a .556-inch wall thickness and weighed 6 pounds per foot. The pipe provided by the Chevron Company, was 8-inch nominal Plexco PE 3408, Type DR 17.0, rated for 100 psi pressure. The outside diameter measured 8.625 inches with a .507-inch wall thickness and weighed 5.6 pounds per foot. This plastic pipe could be spliced in the field using a special apparatus which thermally welded the ends which made for a smooth and leak-free piping system.
3. Accident Scene:
At the time of the investigation, the cut pipe was left in place and several pieces of the broken ice clog were strewn around the end of the cut pipe. The end of the of the cut pipe, which was pressurized at the time of the accident, was laying approximately 89 feet up the hillside from the point of the original cut. The larger ice chunks were shaped like solid cylinders and varied in length. It was noted that some of the ice chunks had a hole in the center and were shaped like a tube. This indicated that the ice clog was not actually a solid ice mass but that it was hollow at the end.
The ground was covered with pea-size ice chips near the cut pipe which indicates that the pressurized pipe discharged the pressure very rapidly spraying the ice chips. After the pipe discharged, no slurry was present near the accident site which indicates the pressure was not a liquid pressure but an air pressure which discharged violently.
4. Situation Prior To Accident:
During the plant holiday shutdown, no slurry was being pumped but clear water was being intermittently pumped through the lines to keep them clean. The intermittent operation of the slurry pumps allowed the trapped water to become frozen causing the ice clogs. The "A" slurry pipeline was also clogged with ice but it was cleared by using the slurry pump pressure without incident. The "B" slurry pipeline had a low spot, or liquid trap, which froze and caused a pocket of air to be trapped between the cut pipe clog and the slurry buffer tank. When a sufficient amount of ice was removed at the point where the pipe was cut, the compressed air between the ice clog and the slurry buffer tank discharged rapidly and caused the pipeline to whip.
The examination of the equipment involved in the fatality revealed no defects in construction, but installation and operation was found to be improper. The low spot in the pipeline contributed to the accident by allowing water to be trapped and frozen during the shutdown in cold weather. The pipeline was not installed with the proper slope to allow all water or slurry to drain into the slurry buffer tank.
The accident and resulting injuries occurred when, without warning, an 8-inch unsecured, plastic slurry pipeline, whipped striking the victim causing fatal injuries. The pipeline had become pressurized from slurry material and air being pumped against an ice clog. Management failed to recognize the hazards associated with the pipeline being pressurized.
A 103 (k) Order, No.7195254, was issued to ensure the safety of all miners until and investigation was completed and all areas and equipment were deemed safe. All slurry pumps were shut down to prevent pipeline from pressurizing. A means was provided to secure pipelines from movement while being worked on and all persons were instructed of hazards of flushing slurry pipeline. The swags were removed as much as possible to minimize freezing of liquids in pipelines.
Related Fatal Alert Bulletin:
The Mine Safety and Health Administration conducted and investigation, and those present and/or participating were as follows: Marrowbone Development Company
Paul Goad ............... PresidentTug Valley Coal Processing
Dana Hellmondollar* ............... SuperintendentTug Valley Coal Processing Employees
Roger Runyon * ............... Safety Director
Harmon Harbin * ............... Floor WalkerRepresentatives of Miners
Vadim Blackburn * ............... Mechanic
William Smith, Jr. * ............... Welder
George Marcum * ............... Control Room Operator
Sam Diamond ............... Electrician
United Mine Workers of America
Harmon Harbin ............... Local 93 PresidentAttorney-at-Law
Dennis Block ............... Local 93 Vice-President
Steve Madding ............... Mine committee Safety Committee
Mark E. Heath ............... Heenan, Althen & Roles, LLC Tug Valley Coal ProcessingWest Virginia Office of Miner' Health, Safety and Training
Terry Farley ............... Health and Safety AdministratorMine Safety and Health Administration
Dennis Ballad ............... Inspector-at-Large
Billy E. Dobson ............... District Inspector
William A. Blevins ............... Supervisory Coal Mine Safety and Health Inspector* Persons interviewed during investigation of accident.
Dennis Holbrook ............... Coal Mine Safety and Health Inspector
Douglas M. Smith ............... Education Field Services
Phillip L. McCabe ............... Mechanical Engineer, Mechanical Safety Division, Approval and Certification Center
Curtiss Vance, Jr. ............... Coal Mine Safety and Health Inspector