DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Underground Coal Mine
Fatal Hoisting Accident
November 8, 2001
Nelms Mine - Cadiz Portal
AEP Ohio Coal, L.L.C.
Cadiz, Harrison County, Ohio
I.D. No. 33-03349
Gregory W. Fetty
Daniel L. Stout
Mine Safety and Health Administration
5012 Mountaineer Mall
Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager
Release Date: April 9, 2002
On November 8, 2001, at approximately 11:30 p.m., Albert William Wright III, a 29 year-old General Laborer at AEP Ohio Coal, LLC, Nelms Mine - Cadiz Portal Mine, I.D. 33-03349, received fatal injuries when he was struck by a trip of three runaway loaded supply cars on the bottom of the slope while he was preparing to fill a rail mounted rock dusting pod.
Prior to the accident, Albert Wright, Victim, and Chad Spano, Beltman, had been assigned to fill the pod duster and rock dust belt conveyors in various locations. Rock dust is supplied to the underground mine from the surface through a 4 inch borehole. The rock dust supply hose from the surface borehole was about to be attached to the rock dusting pod when Spano heard the supply cars coming down the slope. Spano, located approximately 1 foot from Wright, attempted to grab Wright and pull him out of the way, but was unsuccessful. Wright was struck by the runaway supply cars.
Spano then attempted to locate Wright, but could not see anything due to the atmosphere being filled with rock dust. Spano attempted to make verbal contact with Wright, but received no response. Spano found his way to a mine phone where he called outside, and contacted Mike Sheehan, Electrician.
Gene Roberts, Mechanic, was working on a nearby pump in the elevator pit when the mine power was lost. Roberts phoned outside and spoke to Dan Panepucci, Mechanic, who informed him that the three loaded supply cars had become uncoupled. Roberts traveled approximately 500 feet across the portal bottom where he located Spano. Shortly after locating Spano, he and Spano attempted to call outside but could not reach anyone. Sheehan arrived shortly after Roberts. Wright was located and an attempt was made to recover him. The roof in the area showed signs of working and instability. After miners from the midnight shift arrived and additional roof support posts were installed, Wright was recovered.
Wright was taken by the Hopedale EMS to the Harrison Community hospital where he was pronounced dead on arrival.
Spano was transported by the Cadiz Emergency Squad to the Harrison Community Hospital where he was examined and released.
The accident occurred when three loaded supply cars came uncoupled from the brake car. The connecting safety chain failed, allowing the three loaded supply cars to roll down the 16.6o slope track and into the underground mine. Traveling at a high rate of speed through the mine on a straight track, the cars ran through a track derail before crashing into the parked pod duster car where two miners were in the process of attaching the rock dust supply hose. The surviving victim reportedly did not hear the audible warning device and did not see the visible warning device due to obstructions along the roofline.
AEP Ohio Coal L.L.C.=s Nelms Mine - Cadiz Portal underground mine is located near East Cadiz, Harrison County, Ohio. The mine employs 185 persons, 160 underground miners and 25 surface employees. An average of 5,000 tons of clean coal is produced daily from the Ohio 6A Lower Freeport coal seam by three advancing MMU=s on separate sections. Coal is mined two shifts per day, six or seven days per week.
Coal is transported from the active sections by a belt conveyor system to an underground storage bin. From there, it is transported by belt conveyor to a surface preparation plant where the coal is cleaned, sized, and crushed depending upon the quality.
Two exhausting mine fans, located on the surface, ventilate the mine. The mine liberates 250,000 cubic feet of methane per day.
The principal officials for the AEP Ohio Coal, L.L.C., at the time of the accident were:
Charles A. Ebetino, Jr. President
Lance Sogan Vice President, AEP Coal, Inc.
Dave Zatezalo . . . . . . . . . . Director of Operations, AEP Coal, Inc.
Mark McIntyre . . . . . . . . . . General Manager Underground
Donald Atkins . . . . . . . . . . Operations Superintendent
Anthony Bumbico . . . . . . . . . . Director, Human Resources, AEP Mining and Transportation
The last MSHA regular Health and Safety Inspection (AAA) was completed on September 28, 2001, and another was ongoing at the time of the accident. The Nonfatal Days Lost (NFDL) incident rate during the previous quarter for the nation was 7.86 and 3.13 for this mine.
On the evening of November 8, 2001, Mike Sheehan, Electrician, and Dan Panepucci, Mechanic, were assigned by Marion Albright, Master Mechanic, to change the high alarm system on the underground storage bins from limit switches to electrical probes. Sheehan and Panepucci traveled by pickup truck from the shop on the surface to the main portal. They went underground on the elevator, and walked across the bottom to the location of the storage bins to determine what tools and supplies would be necessary to complete the task. Sheehan and Panepucci decided to send the slope car to the surface so that the tools and supplies that were necessary to complete the conversion could be lowered in the mine, rather than being carried. Sheehan and Panepucci stated that the safety chains and the couplers were checked prior to sending the trip outside. Sheehan and Panepucci then traveled back to the bottom, and rode the elevator to the surface. On earlier shifts, Sheehan had been making modifications to a belt starter unit. Sheehan asked David Porter, midnight shift Crew Leader, Move Crew, if he wanted members of the midnight shift trained on the belt starter unit. Porter agreed and everyone traveled to the hoist house where Sheehan conducted a training class lasting approximately 45 minutes to an hour. Sheehan and Panepucci then gathered the tools and supplies that they needed to perform their assignment and loaded them onto the slope car. The couplers and safety chains were again checked, and the slope car was released to travel into the mine. Panepucci was conversing with Fred Kress, Loader Operator, when the annunciator alarm was activated on the hoist. Panepucci checked the slope and saw that the cars had came uncoupled. Sheehan went to the hoist house where he heard Chad Spano, Beltman, calling out on the mine phone, stating that he could not locate Albert Wright III, General Labor. Wright and Spano had been assigned to fill a pod duster with rock dust, and then apply rock dust to various beltlines throughout the mine. Spano and Wright were in the process of attaching the rock dust hose from the dust borehole to the pod duster when Spano heard the cars coming down the slope. Spano was located approximately 1 foot from Wright at that time. Spano, unsuccessfully, attempted to grab Wright and pull him out of the way of the runaway trips.
Sheehan and Panepucci drove from the hoist house to the main portal. Sheehan instructed Panepucci to go back to the slope mouth on the surface, and travel the slope from the surface to the underground slope bottom. Eugene Roberts, Mechanic, was already underground when he noticed that the mine had lost power. Roberts phoned outside on the elevator phone and spoke to Panepucci, who informed him that the supply cars came loose from the slope car. Since Roberts was already underground, he traveled across the bottom and was the first person that arrived at the accident scene. He located Spano, who informed him of what had transpired. Sheehan proceeded underground and walked across the bottom to the accident site where he found Roberts and Spano. Sheehan and Roberts attempted to recover Wright=s body, but determined that the roof needed additional support due to the top working. Because a shift change was in progress, numerous miners from both shifts responded to the accident. Posts were set and Wright=s body was recovered. He was taken by Cadiz EMS to Harrison Community Hospital where he was pronounced dead on arrival. The death certificate states the time of death as 12:30 a.m., November 9, 2001.
The investigation was conducted by MSHA in conjunction with the State of Ohio, Division of Mineral Resources Management. Other participants included miners and management from AEP Coal L.L.C. A list of those persons who participated in the investigation is contained in Appendix A of this report.
At 12:30 a.m. on November 9, 2001, Mark McIntyre, General Manager Underground, notified MSHA's St Clairsville Field Office that a hoisting accident had occurred at the bottom of the slope entry, resulting in the death of one miner and causing injury to another. A 103(k) Order was immediately issued to ensure the safety of all persons until an investigation was completed and the mine deemed safe. Gregory W. Fetty, Industrial Hygienist, and Daniel L. Stout, Electrical Engineer, arrived at the mine at 3:30 a.m., at which time a pre-investigation conference was conducted. Persons having knowledge of conditions and events relevant to the accident were interviewed at Cadiz Portal on November 9, 2001, and February 6, 2002. The underground investigation of the accident site was initiated during the morning of November 9, 2001, and was completed December 17, 2001. Photographs and measurements of the accident site were collected underground.
On November 9, 2001, personnel from MSHA's Approval and Certification Center - Gary L. Clark, Mechanical Engineer, Equipment Branch, and Benjamin Gandy, Mine Safety & Health Specialist, Accident Reduction Program - joined the investigation team and took additional photographs and measurements at the accident site. The investigation also included a review of training records by Educational Field Service Specialist Cindy Shumiloff.
Function tests were conducted on the slope hoist's slack rope switch and the visual and audible alarms. Wear on the rail car couplers was evaluated with a certified template. The safety chain and its broken link were analyzed and evaluated by Touchstone Research Laboratory, Ltd.
The 103(k) Order was modified on November 13, 2001, to allow the company to lower supplies into the mine by using one rail car with a maximum gross weight of 20 tons.
The company has implemented procedures and has installed additional safety devices to improve the safety of hoisting rail cars on the surface, the slope and the slope bottom areas. These improvements were listed in the company's letter and depicted on a map, dated December 7, 2001. All provisions were completed on December 17, 2001, at which time the 103(k) Order was terminated.
The hoisting system, involved in the accident, consisted of a Nordberg single-drum mine hoist, S/N 7030-1189, equipped with a digital drive component. The system was designed by Frontier-Kemper Constructors Inc. of Evansville, Indiana. Since the controls could be operated automatically through an Allen Bradley program logic controller (PLC), an operator was not required to be at the hoist house control console.
The hoist utilized a 1-1/2", 6x25, extra improved plow steel (XIP), right lang lay, preformed, independent wire rope core (IWRC) wire rope for transporting trips on the 16.6o track slope, which was approximately 1,821 feet long (See Appendix B, Figure No. 1A).
The first rail car permanently attached to the hoist rope was the Frontier-Kemper brake car. Coupled to the other (inby) end of the brake car were three supply cars. The supply cars were used for transporting materials and equipment to and from the underground mine.
The Frontier-Kemper brake car had a passenger capacity of four. The hoist/brake car system was a designated emergency escape facility for the mine. Being a four-wheel unit, the brake car was equipped with two battery powered electro-magnetic track brakes, designed to prevent a runaway condition due to rope breakage or hoist failure. The braking system could be activated manually by pressing an emergency stop button within the passenger compartment or automatically when the car exceeded a certain speed, normally 115% of normal operating speed. A speed probe mounted on the brake car provided an input signal to its monitoring system. When the speed of the car exceeded a calibrated value, the monitoring system set the electro-magnetic track brakes. During the investigation, the overspeed monitoring system failed to operate when tested.
The braking capacity of the two magnetic track brakes was designed to stop only the brake car with four passengers. The manufacturer stated that it would be impossible for the magnetic brakes to stop the brake car with three attached supply cars which, with their loads, had a total estimated weight of 15 tons on the 16.6o track slope. Company procedure did not require the brake car's magnetic brakes to be armed when supply cars were attached.
Safety System Shutdowns
Tests and observations of the controls after the accident indicated that the hoist functioned correctly at the time of the accident.
While in the automatic mode of operation, the hoist speed was observed as making a smooth ramping transition from zero to 325 feet per minute, the normal operating speed.
After the accident, Mark McIntyre, General Manager Underground; Donald Atkins, Operations Superintendent; and Sheehan, stated that they saw the "slack rope alarm" on the hoist operator's annunciator panel. The investigation revealed that three wraps of the hoist rope were not in their normal wrap position on the hoist drum. This condition supports the possibility that a slack rope condition had occurred.
The slack rope protection system utilized a trip wire and a limit switch. The trip wire was suspended approximately 5 inches below the hoist rope and was located between the hoist drum and the outside wall of the hoist house. The system was designed such that when a slack rope condition occurred, while the brake car was located between the slope mouth and the bottom station, the weight of the hoist rope falling on the trip wire would actuate the limit switch. The activated slack rope protection system would stop the hoist drum from turning by deenergizing the hoist motor and setting the hoist brake. Testing verified that the slack rope protection system performed properly.
Warning devices were located on the surface near the slope mouth and underground near the bottom of the slope. When the warning devices were activated, miners were trained to leave the bottom danger zone and not to enter the area until the flashing light was off. Spano stated he did not hear or see the audible and visible warning devices, which were located approximately 150 feet from the borehole, prior to the accident.
Audible Warning Device
The audible warning devices were the buzzer type. When the hoist start button was actuated, the warning devices buzzed for approximately 10 seconds. After the buzzing sound stopped, the hoist motor was energized.
Approximately 1-1/2 hours prior to the accident, Sheehan and Panepucci, who were underground, heard the slope bottom buzzer activate when they sent the supply car trip from the bottom to the surface.
Spano stated that he had heard the buzzer during past occasions and the buzzer was loud. However, prior to the accident, Spano did not hear the warning device.
Sources of noise, which might have drowned out the buzzer warning sound, could not be determined. The Roots Blower, which loads the rock dust into the rock dust pods, was not running. The 10-ton locomotive, which was attached to the dust car, had a braking system that utilized an air compressor that could have cycled "on" and muffled the buzzer sound.
Visual Warning Device
The visible warning devices were red-flashing lights, one on the surface and one underground. The underground warning light was attached to the roof near the bottom of the slope. When the hoist start button was actuated, the warning light flashed continuously until the bottom approach limit switch deenergized the hoist motor. The bottom approach limit switch was activated when the trip arrived at its designated parking position.
The investigation revealed that the flashing lights were unexpectedly turned off, when the slack rope protection system was activated. Immediately prior to the accident, when the weight of the three supply cars was detached from the brake car, the stretch of hoist rope was removed. The sudden rebound of the hoist rope, while retracting to a slightly shorter length, caused a whipping action which activated the slack rope switch. During the time the three runaway cars traveled down the slope and through the mine to the accident site, the red flashing warning lights were turned off. However, due to obstructions along the roofline, the victims still would not have been able to see the underground flashing light while standing at the rock dust borehole. The distance between the flashing light and the rock dust borehole was approximately 150 feet.
Willison Automatic Couplers
The focus of this section is on the couplers and safety chain that connected the brake car to the first supply car, which had the unexplained parting.
Coupler Load Capacity Ratings
Willison heavy duty and Willison regular (industrial) automatic couplers were the two types being utilized at the mine. Both types are designed to inter-couple with each other. The maximum capacity rating for the heavy-duty couplers is 40 tons and the regular couplers, 20 tons. The estimated maximum gross weight of the three runaway loaded supply cars was reportedly 54 tons, which includes the weight of each car (5 tons) plus its load (13 tons). The weight of 54 tons on a 16.6o slope was 15 tons (54 tons x sine of 16.6o). Therefore, the maximum load capacity ratings for the couplers were not exceeded.
Couplers were interlocked
Prior to the accident and before the trip was sent down the slope, Sheehan and Panepucci had determined by visual examination that the brake car and supply cars were properly coupled and safety chained. Touchstone Research Laboratory, Ltd.'s analysis of the broken link from the safety chain determined that the dimpled rupture condition on the fractured surface appeared to be the result of a single event, such as a sudden overload. This analysis supports the statements that the supply car was coupled to the brake car.
The approximate 400 feet length of wire rope from the hoist drum to the brake car was stretched due to the 15-ton weight of the three supply cars. When the supply cars separated from the brake car, the rope's stretch suddenly recoiled to a slightly shorter length. The recoil's whipping action along the length of hoist rope activated the slack rope switch, located in the hoist house. The slack rope switch caused the hoist brake to set. While the hoist brake was stopping the brake car, the three supply cars continued to roll down the slope. The safety chain broke when the approximate 1 foot of slack was jerked taut with the impact of the 15-ton dynamic weight.
Vertical Displacement between Couplers
The face of each coupler was 9 inches in height. A vertical displacement of 9 inches between two interlocked couplers would result in an accidental parting.
The length of track, which the cars traveled before separating, had a constant slope angle of approximately 16.6o with no knuckles. The rails had no noticeable dips or humps. No other track conditions were found that would cause a vertical displacement of 9 inches (See Appendix B, Figure No. 1B).
Normally, while cars are being lowered down a 16.6o slope with a hoist rope, their interlocking couplers are in tension. However, if a problem existed, which created enough drag or resistance to car movement, the couplers could be in compression. A possible safety chain wedging between a car(s) wheel and rail was not likely, since all safety chains were properly fastened and there was no safety chain on the inby end of the third supply car. All safety chains were mounted on the supply cars' outby ends. Other possible problems, such as a flat spot on a wheel, bad wheel bearing or a dragging broken restraining strap that holds the axle in place were checked and none of these problems existed. The four cars had no protruding or dangling objects that could have presented a clearance problem from a car to the ground, rib or roof. A reason for a compressive force condition to create a 9 inch vertical displacement was not found.
To limit vertical displacement, Willison has designed a coupler with a hood. The hood is a casting that is an integral part of the coupler head. The supply car coupler, which was interlocked to the brake car coupler, had a hood (See Appendix B, Figure No. 3). Therefore, the unexpected parting was probably not due to a 9" vertical displacement between couplers.
Five checks were made for wear on the contour surfaces of the coupler heads. These checks were made with a template from Winchester Industries, certified by the Association of American Railroads for gages and calibration (See Appendix B, Figure No. 2). The brakeman car coupler exceeded the maximum allowable lock thickness wear limits. The inspection and maintenance guidelines for Willison Couplers states that this coupler should be removed from service and replaced.
The components that firmly interlocks two coupler heads together are their spring activated locks (See Appendix B, Figure No. 4). The coupler locks were examined. Each operated properly when the spring-activated lock was depressed until the lock was fully retracted into the coupler body and was lined up with the coupler contour surface. When released, the locks returned to their normal positions (See Appendix B, Figure No. 5).
During these tests the compression of the brake car's lock spring appeared to be weaker than the other lock springs. Touchstone Research Laboratory, Ltd.'s analysis determined that 43 lbs. for closure was required on the brake car lock spring as compared to 55-58 lbs. for three new springs. The brake car lock spring was also shorter in length when compared to the new springs.
While underground earlier in their shift, Sheehan and Panepucci's visual examinations determined that the rail cars were properly coupled to each other. With the hoist controls in the automatic mode, one of the electricians actuated the switch for the hoist to transport the trip to the surface. The trip traveled up the slope, stopped at the slope mouth, and remained parked for over an hour. Tools and materials were loaded in the brake car's passenger compartment. Before the trip was sent back down the slope, another visual examination by Sheehan and Panepucci determined that the couplers were still properly interlocked. Then the hoist began lowering the trip down the slope. After traveling approximately 46 feet from the mouth, the supply cars unexpectedly separated from the brake car.
Therefore, prior to the accident, visual examinations proved that the brake car and three loaded supply cars were able to remain coupled while traversing the slope to the surface and while parked for approximately one hour at the slope mouth. Measurements, testing and examinations could not determine conclusively why the three supply cars uncoupled from the brake car. Mine management was not aware of rail cars ever uncoupling on the slope prior to this accident.
The purpose of the safety chain is to retain connection between two coupled rail cars so that if an accidental uncoupling occurs, a runaway condition would be avoided. At this mine, the safety chains were installed on the outby end of each rail car.
Touchstone Research Laboratory, Ltd. evaluated a broken link and two lengths of the separated safety chain of which one end had been attached to the brake car and the other to the supply car. Conclusions based on analysis and examinations were as follows: the broken link had been a part of this safety chain; the broken link's fractured surface appeared to be the result of a single event, such as a sudden overload; the approximate link weight loss of 15% from the center section of the chain length was probably due to dragging on the ground; and the weight loss weakened those center links and allowed them to deform during the incident, while the remaining links on either end of the chain remained relatively unaffected.
The Proof Test Certification by Laclede Chain Mfg. has a caution statement which asserts in part, "All chains should be periodically inspected for wear, elongation, nicks, gouges, cracks, and suitability for the application. . . . Sudden applications of dynamic loads, which cause the load in the chain to exceed the working load limit, are to be avoided."
The estimated gross weight of the three runaway loaded supply cars was 54 tons, which includes the weight of each car (5 tons) plus its load (13 tons). The weight of three loaded supply cars on a 16.6o slope was 15 tons.
At the time of the accident, a 5/8", Grade 43, carbon steel chain was being utilized. The Proof Test Certification by Laclede Chain Mfg. for 5/8" chain states that the Working Load Limit is 13,000 lbs., which is the maximum load that shall be applied in direct tension to an undamaged straight length of chain. Therefore, the 5/8" chain's working load limit of 6.5 tons (13,000 lbs.) was undersized for a 15-ton dynamic load.
After the unexpected parting of the three supply cars, the brake car was found still attached to the hoist rope and was setting 46 feet inby the mouth of the slope. The three runaway cars traveled 1,775 feet down a 16.6o slope, 169 feet through the mine to a derail switch, and then 31feet beyond the derail, where they crashed into the outby end of the parked dust car. The impact of the crash knocked the 10-ton locomotive 195 feet inby from the rock dust borehole site. The closest wrecked supply car was 22 feet from the borehole (See Appendix B, Figure No. 1C and Plan View of Bottom). The 10-ton locomotive, Company Number 2, had been coupled to the dust car's inby end. William Tremblay, Assistant Mine Foreman, was involved in clean up of the accident site and found a broken track rail run through the bottom frame of the dust car. The rail probably limited the travel of the wrecked cars.
The track derail switch was designed to be manually operated. Located near the derail was its visual warning device, which was a red light mounted on a 4 foot or 5 foot metal pole. The red light had to be manually turned on or off when the derail position was changed. When the derail was in the straight position, the light was turned off. When in the derail position, a steady red light was switched on. This warning device was damaged during the wreck and was found lying on the ground.
The reason that the runaway cars traveled approximately 31 feet past the derail could not be established. Based on the following observations, the track switch derail should have diverted the cars off track. The switch was found in the derail position. The amount of debris found in the derail did not appear to be of sufficient quantity to have prevented the rail cars from being derailed. Gap measurements of 2-1/4 inches between adjacent rails of the derail, which were measured after the area was restored to normal, should have been adequate for a wheel flange measurement of 1 inch.
With a layer of rock dust varying between 3 to 6 inches and covering the cross ties and ground, fresh wheel marks to indicate a derailment could not be seen. The ability for this switch to derail supply cars weighing 54 tons and traveling at excessive speeds was not determined. However, the rail that was found run through the frame of the dust car may have been displaced from its normal position as a result of the high speed derail.
Training Records and Examinations
A review of the training records indicated that training had been conducted in accordance with 30 CFR Part 48. All records indicate that the required electrical and preshift examinations were conducted and recorded in accordance with 30 CFR Part 75.
The accident occurred when three loaded supply cars came uncoupled from the brake car. The connecting safety chain failed, allowing the three loaded supply cars to roll down the 16.6 degree slope track and into the underground mine. Traveling at a high speed through the mine on a straight track, the cars ran through a track derail before crashing into the parked pod duster car where two miners were in the process of attaching the rock dust supply hose. The surviving victim reportedly did not hear the audible warning device and did not see the visible warning device due to obstructions along the roofline.
1. A 103(k) Order was issued to ensure the safety of all persons in the mine during the investigation, until the affected area and equipment were returned to normal.
2. A 104 (a) Citation, No. 7143350, was issued for a violation of 30 CFR 75.1725(a). The brake car being utilized on the slope entry to the mine was not maintained in a safe operating condition. While being lowered down the slope by the hoist rope, three loaded supply cars uncoupled from the brake car at 11:30 p.m. on 11/8/2001. As a result, the three supply cars rolled down the 16.6 degree slope track and into the underground mine, which caused a fatal accident.
The two interlocking couplers between the brake car and the first supply car were checked for wear with a template from Winchester Industries, certified by the Association of American Railroads for gages and calibration.
Checks revealed that the maximum allowable wear on the lock of the brake car coupler met or exceeded 1/8". The inspection and maintenance guidelines for Willison Couplers states that this coupler should be repaired with a new lock when the lock wear equals or exceeds 1/8". Also, the brake car coupler's locking spring was found to be approximately 3/4" shorter than a new spring. Testing revealed that the brake car's locking spring had significantly less force than the force of a new spring to open the coupler lock.
3. Safeguard notices were issued pursuant to 30 CFR 75.1403. This standard states that: Other safeguards adequate, in the judgment of an authorized representative of the Secretary, to minimize hazards with respect to transportation of men and materials shall be provided.
"A fatal accident occurred at this mine on November 8, 2001, involving three runaway flat cars that were loaded with various supplies. The three flat cars became uncoupled and the single 5/8" safety chain that connected the brake car and the first flat car failed. This chain was expected to hold a weight of 15 tons on the 16.6 degree mine slope entry. The maximum working load rating for this chain was 6.5 tons. An undersized safety chain presents a hazard of the chain failing and allowing runaway flat cars, which would easily strike an unsuspecting miner working along the track haulage, should the cars become uncoupled."
"This is a notice to provide safeguard requiring the operator provide safety chains, ropes, or other devices between all cars on the mine slope. Such device must be of such a working load rating sufficient to hold the maximum load carried in order to prevent runaway if the couplers between cars fail. Safety chain or rope length shall be minimized to prevent dragging."
"A fatal accident occurred at this mine on November 8, 2001, involving three runaway flat cars that were loaded with various supplies. The two miners, who were working at the slope bottom at the time the flat cars ran away, could not see a flashing light that was installed due to differences in the elevation of the track. Additionally, the audible alarm that was provided stopped sounding after 10 seconds. Failure to provide continuous visual alarms to notify miners that the brakeman car and or supply cars are being transported on the slope entry for the mine presents a hazard to miners being struck with runaway haulage equipment should there be a failure with the couplers or the hoisting system."
"This is a notice to provide safeguard requiring that a visual alarm be installed and maintained at locations to visibly warn all persons walking or working on or near the slope bottom. The alarm shall operate continuously while cars are being hoisted, lowered or parked on the incline slope track. Miners, who might be struck by runaway cars, shall exit the slope entry and areas on the bottom when the alarm is active."
"A fatal accident occurred at this mine on November 8, 2001, involving three runaway flat cars that were loaded with various supplies. The three flat cars traveled 1,775 feet down a 16.6 degree slope and 169 feet through the mine to a derail, where they passed either through or over the derail device. There was no indication that the flat cars were ever effectively derailed. The existing derail device was located approximately 30 feet from the work area of two persons at the rock dust loading point. An ineffective derail device presents a hazard of persons being struck with runaway haulage equipment. The derail device should be placed far enough from the work area so that the noise of the derailing cars would give miners more time to get clear of the runaways."
"This is a notice to provide safeguard requiring a deflector type derail or no less effective means of a derail device to assure that runaway haulage equipment will be derailed in the event of a runaway. This derail device shall be installed and maintained at a location at or near the bottom of the slope at least 100 feet from the rock dust loading point (borehole). Other derail devices shall be installed and maintained at other locations in the mine where there are steep grades and the potential hazard of runaway haulage equipment exists."
Related Fatal Alert Bulletin:
Listed below are the persons furnishing information and/or present during the investigation:
Marion Albright .......... Master Mechanic
Donald Atkins .......... Operations Superintendent
Clifford Bolon .......... Afternoon Shift Foreman
Anthony Bumbico .......... Director, HR, AEP Mining & Transportation Operations
Kay Coen .......... Manager, HR, AEP Mining & Transportation Operations
Charles Crumbaker .......... Assistant Mine Foreman
Mike Doane* .......... Crew Leader, Move Crew
Robert Griffin .......... Senior Coordinator
Bruce Hann .......... AEP Human Resources
Fred Kress* .......... Surface Mobile Equipment Operator
Gary Jones .......... Mine Foreman
Nelson Kidder .......... Director of Engineering, AEP Coal, Inc.
Mark McIntyre .......... General Manager Underground
Dan Panepucci* .......... Mechanic
David Porter* .......... Crew Leader, Move Crew
Eugene Roberts* .......... Mechanic
Mike Rotilio .......... Assistant Master Mechanic
John Scopel .......... Safety Director
Mike Sheehan* .......... Electrician
Chad Spano* .......... Beltman
Lance Sogan .......... Vice President, AEP Coal, Inc.
William Tremblay* .......... Assistant Mine Foreman
Dave Zatezalo .......... Director of Operations, AEP Coal, Inc.
Thomas Carvoo* .......... Night Watchman
Shawn Collins .......... Engineer
H. L. Stauver .......... Director, Research & Development
Jerry Stewart .......... Manager/Mine Safety
Mel Byers Jr. .......... Mine Safety Inspector
Gary L. Clark .......... Mechanical Engineer, Equipment Branch, Approval and Certification Center
Benjamin Gandy .......... Mine Safety & Health Specialist, Accident Reduction Program,
Approval and Certification Center
Gregory W. Fetty .......... Industrial Hygienist
Cindy Shumiloff .......... Mine Safety and Health Specialist (Training)
Daniel L. Stout .......... Electrical Engineer
* Persons Interviewed
AEP Ohio Coal, LLC.
Nelms Mine - Cadiz Portal, I.D. No. 33-03349
Figure No. 1A
Figure No. 1B
Slope Mouth and Surface Profiles
Figure No. 1C
Slope Bottom and Underground Profile
Figure No. 2
Overview of Accident Site
Figure No. 3
Supply Car, Hooded Coupler
Figure No. 4
Willison Coupler with internal components parts
Figure No. 5
Brake Car's Willison Coupler with Lock
Top & Bottom of Slope
Plan View of Bottom