DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE PREPARATION PLANT)
FATAL SLIP OR FALL OF PERSON
PERRY COUNTY COAL CORPORATION (ID NO. 15-05485)
HAZARD, PERRY COUNTY, KENTUCKY
NOVEMBER 27, 2001
WILLIAM H. SHARP, JR.
COAL MINE SAFETY AND HEALTH INSPECTOR
ORIGINATING OFFICE-MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
3837 S. HWY. 25E, BARBOURVILLE, KENTUCKY 40906
JOSEPH W. PAVLOVICH, DISTRICT MANAGER
REPORT RELEASE DATE: July 02, 2002
On Tuesday, November 27, 2001, at approximately 8:15 p.m., a fatal slip or fall of person accident occurred at the Perry County Coal Corporation Preparation Plant near Hazard, Perry County, Kentucky. Mart Wicker, a 41 year old plant operator with 21 years of mining experience, suffered fatal injuries when he fell over 100 feet through the open doorway of the 6th floor of the preparation plant and struck the ground.
On the evening of the accident, the victim and others were working to install new equipment into the plant. A crane, located on the ground, was being utilized to hoist the new equipment up to the 6th floor, where it would be pulled in through a service doorway designed for that purpose. While attempting to engage the hook of a one ton chain hoist into the clevis of an overhead trolley located in the plant doorway, the victim accidentally dislodged the single safety rail placed across the doorway, lost his balance, and fell to his death.
Perry County Coal Corporation, Preparation Plant, is located near Hazard, Perry County, Kentucky. Teco Energy is the Parent Corporation of Perry County Coal Corporation.
The Preparation Plant currently provides employment for 25 miners and 3 supervisory employees. During normal operations, the plant operates two shifts per day, five days per week. Additional workdays are occasionally scheduled, as required by market demand.
The primary source of raw coal is from the HZ4-1 underground mine and is delivered to the plant by way of overland conveyor belt. Additional coal is transported to the plant by trucks hauling from various underground and surface mine sources. Approximately 14,000 tons of raw coal is processed daily.
Prior to the accident, the last Mine Safety and Health Administration (MSHA) regular inspection (AAA) was completed on June 26, 2001.
The afternoon shift began as scheduled, at 4:00 p.m. on Tuesday, November 27, 2001. Ted Ambrose, plant foreman, issued work assignments at the beginning of the shift. Mart Wicker, victim, was assigned his regular job duties as plant operator. Bobby Walker and Bobby Campbell, plant mechanics, were assigned to continue removal and replacement of a magnetic separator on the 6th floor of the plant. The plant was to continue operating as this work was performed.
Wicker received additional instructions from Ambrose at approximately 5:00 p.m., directing him to shut the plant down and to assist the two mechanics with the work on the magnetic separator. The old magnetic separator had already been removed from its installation and was awaiting final removal through a service door located on the 6th floor. As there was no landing or elevator, a Link Belt, model HTC 10-60, crane had been contracted from A&T Manufacturing to lower the old magnetic separator to the ground and to subsequently raise the new separator to the 6th floor. In order to provide clearance for the separator's removal from the plant, the trolley- mounted Harrington 1-ton chain hoist was removed from its location above the doorway. At this juncture, for the same reason, both safety rails were removed from the doorway.
The lifting straps provided by the crane operator, by which the separator was to be hoisted, proved to be too long. Discovering this, via radio communications with the workers, Ambrose provided shorter straps in order to complete the job. The longer straps were left lying on the floor. Finally, the old magnetic separator was removed and lowered to the ground.
The workers then requested that Ambrose send them some sheets of plywood to be utilized to insulate the steel floor from the new magnetic separator before it's final placement. This material was provided, and without further problems, the new separator was lifted to the 6th floor and the installation process began. As the speed reducer was being installed onto the magnetic separator, a grease fitting was observed broken off in the bearing housing. Wicker informed Ambrose of this condition and requested that he send a new grease fitting to them. Wicker reportedly told Ambrose that he would send down the old grease fitting for comparison, in order to insure the selection of the correct sized fitting. Walker, one of the mechanics working with the victim, stated that he saw Wicker attempt to pick up the chain hoist for the purpose of mounting it back onto the trolley so that the fitting could be sent down to the ground. Walker reportedly asked Wicker to wait so that he could assist him in lifting the hoist. Walker stated that, although the lower rail had not been reinstalled, the top rail was in place at that time. Next, the two, working together, rested the chain hoist on the top rail in order to reposition themselves. As the two lifted the hoist near the trolley, Walker stated that he heard the safety rail fall and informed Wicker of the same. They continued to lift the hoist, in an attempt to place the hoist hook into the mounting bracket on the trolley. As they released the hoist, it fell through the open doorway, but remained hanging by its power cable. Walker stated that he observed Wicker stumbling toward the unprotected door opening.
Although he reportedly reached out to Wicker with his left hand, they failed to make contact and Wicker continued to fall through the unprotected doorway. Walker stated that Wicker momentarily grasped the chain on the trolley, but slipped, and fell to the ground.
Below, as Ambrose returned with the requested grease fitting, he stated that he heard someone call out from above. As he looked up, he reportedly saw the victim fall and strikes the ground approximately 20 feet from his location. He immediately rushed to the victim, rolled him over and assessed the extent of Wicker's injuries. Failing to detect any vital signs, Ambrose called for additional miners to come to his assistance and gave instructions to summon an ambulance. Perry County 911 reported receiving a call requesting an ambulance at 8:10 p.m., to which they immediately responded, arriving at the scene at 8:20 p.m. They subsequently transported the victim to the Hazard Appalachian Regional Hospital where Perry County Coroner, Jimmy Majored, Sr pronounced him dead at 9:30 p.m.
At approximately 9:30 p.m. on November 27, 2001, John Dishner, Coal Mine Safety and Health (CMS&H) Inspector of MSHA's Hazard, Kentucky Field Office, was notified by Ottis Mullins, Safety Coordinator of Perry County Coal Corporation, that a fatal accident had occurred at the preparation plant. An MSHA initial response team, comprised of Jim Fields, Supervisory CMS&H Inspector and Dishner immediately traveled to the mine sit, where Dishner issued a 103(k) order to ensure the safety of the miners and to preserve the accident scene until an investigation could be conducted.
John Pyles, District 7 Assistant District Manager for Enforcement, was notified of the accident and an Accident Investigation Team consisting of William H. Sharp, Jr., CMS&H Specialist, and William R. Johnson, Supervisory CMS&H Inspector was dispatched to the mine to begin the investigation. Foster Brock, CMS&H Specialist-Electrical and Arlie Massey, Electrical Engineer, of MSHA's Approval and Certification Center (A&CC), located in Triadelphia, West Virginia, assisted in the on-site investigation and testing of the Harrington, 1 ton, 480 volt chain hoist.
MSHA and the Kentucky Department of Mines and Minerals (KDMM) jointly conducted the investigation with the assistance of mine management and the miners. Initial interviews were conducted at Perry County Coal Corporation's office on the morning of November 28, 2001 with three miners who were present on the 6th floor of the plant at the time of the accident, and additionally with two miners that administered first aid at the accident site. Formal interviews were conducted in conjunction with KDMM at their office in Hazard, Kentucky, on November 29, 2001. A list of those persons who were present and/or participated in the investigation is included as Appendix A. None of those persons interviewed requested that their statements be kept confidential.
All records examined, showed that Wicker had received training in accordance with 30 CFR Part 48.
The examination record books indicated that daily examinations of surface areas and surface facilities were being conducted and recorded in accordance with 30 CFR Part 77.
Interviews were conducted with all persons known to be on the 6th floor of the preparation plant at the time of the accident. According to statements obtained in the interviews, the safety rails provided for the open doors had been removed to allow for removal of the old magnetic separator. After the new magnetic separator was placed inside the plant and prior to the hoist being lifted, the top safety rail was put back into place. Fall protection systems were reportedly available to miners, however none were located on the 6th floor at the time of the accident.
Arlie Massey, Electrical Engineer, of MSHA's Approval and Certification Center (A&CC), with the assistance of Foster Brock, MSHA Specialist-Electrical, conducted extensive testing on the 1 ton hoist and associated circuits. These tests included: 1. Continuity tests of the ground conductors and grounding of the hoist frame,
2. Voltage potentials on the frames of preparation plant and hoist,
3. Induced voltage potentials, and
4. Stray current tests.
The results of these tests were negative. There were no sources found such as to cause an electrical shock. Also, there were no operational defects revealed on the hoist.
The following factors were determined to be relevant to the occurrence of the accident. 1. The 6th floor of the preparation plant is located 101 feet 9 inches above the ground.
2. Adequate railings, barriers, or other protective devices were not maintained around the open doors on the 6th floor of the preparation plant. Only one of the two designed and installed railings had been replaced after removal.
3. Fall protection systems in the form of safety belts and lines were not readily available on the 6th floor of the preparation plant and were not in use by employees where a danger of falling existed.
4. Extraneous materials, including plywood and lifting straps were present in and around the unprotected open doorway on the 6th floor of the preparation plant.
5. The overhead trolley was located in the open doorway.
It is the consensus of the accident investigation team that the primary root cause of the accident and subsequent fatality was due to the operator failing to insure employees wear safety belts and lines despite an obvious falling hazard. The secondary root cause was the miners not wearing fall protection prior to the removal of the safety rails. This hazard was created when work from an elevated position continued after both the upper and lower safety rails were first removed from the doorway, and secondarily when the replaced upper safety rail was dislodged after coming in contact with the hoist.
Underlying the accident, statements obtained during the interviews revealed that although safety belts and lines were available at the shop location, they were not provided at the more convenient and useful location of the work area itself.
1. A 104(k) Order, No. 7473380, was issued to ensure the safety of the miners and to preserve the accident scene until an investigation could be conducted.FAB01C40
2. A 104(d)(1) Citation, No. 7534007, was issued for violation of 30 CFR, Part 77.1710(g), stating, "the operator failed to require employees to wear safety belts and lines where there is a hazard of falling."
List of persons furnishing information and/or present during the investigation.
D. Craig Mullins ......... Director of Operations
Dave Blankenship ......... Director of Safety and Environmental Affairs
Leonard Davis ......... Manager of Safety and Environmental Affairs
Ottis Mullins ......... Safety Coordinator-Underground
Paul Moore ......... Plant Superintendent
Ted Ambrose ......... Plant Foreman
J. L. Roark ......... Attorney
Sharon L. White ......... Paralegal
Herman Scott Harvey ......... Utility Man
Bobby Campbell ......... Plant Mechanic/Repairman
Roy Lee Hurt ......... Equipment Operator/Mechanic
Bobby R. Walker ......... Plant Mechanic/Repairman
Tracy Stumbo ......... Accident Investigator
David Mullins ......... Inspector/Accident Investigator
Johnny Greene ......... Inspector/Accident Investigator
Robert Ashworth ......... Inspector
William R. Johnson ......... Supervisory CMS&H Inspector
James D. Fields ......... Supervisory CMS&H Inspector
William H. Sharp, Jr. ......... CMS&H Inspector/Accident Investigator
John W. Dishner ......... CMS&H Inspector
Foster Brock ......... CMS&H Inspector/Electrical Specialist
Arlie Massey ......... A&CC/Electrical Engineer
Ronnie J. Deaton ......... EFS/Education and Training Specialist
Mary Sue Taylor ......... Office of the Solicitor/Attorney
Cecil Partin ......... CMS&H Inspector
Looking out 6th Floor (Arrow shows victim's approximate location)
PHOTOGRAPHS OF ACCIDENT SITE
Door Opening on 6th Floor