DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
UNDERGROUND COAL MINE
FATAL POWERED HAULAGE ACCIDENT
June 20, 2002
at
Buchanan Mine #1
Consolidation Coal Company
Mavisdale, Buchanan County, Virginia
I.D. No. 44-04856
Accident Investigator
Charles E. Upchurch
Coal Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
District 5
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Edward R. Morgan, Acting District Manager
RELEASE DATE: August 27, 2002
OVERVIEW
On June 20, 2002, Jerry A. Wilson, a 55 year old utility man with 14 years experience as a coal bunker operator, and 31 years total mining experience, was found entrapped between the frame of the number 12 bunker car and a stationary upright beam. The upright beam was attached to the handrail and catwalk that provided access to the bunker area, and had been installed to support two bunker car overtravel switches. A hand-operated grease gun was found on the catwalk below the victim's location. Several of the bearing grease fittings on the rollers in the victim's location appeared to have been recently lubricated. Wilson's assigned duties were to operate the bunker car system and lubricate the rollers in this area daily. The victim received fatal crushing chest injuries and mechanical asphyxia as a result of the entrapment.
The accident occurred when the bunker cars moved as Wilson placed himself in a pinch point while leaving the area where lubrication had been performed.
GENERAL INFORMATION
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 that averages 84 inches in thickness. Four fans exhausting 2,345,000 cubic feet of air per minute provide ventilation. Laboratory analysis of return air samples showed a methane liberation rate of 10,774,960 cubic feet per day. The face areas are ventilated using a double split system of ventilation and exhausting line curtains.
Employment is provided for 424 persons. A total of 358 underground and 66 surface employees work on three production shifts per day, seven days per week. The mine produced an average of 18,726 raw tons of coal daily from eight continuous mining machine units and one longwall unit. Coal is transported from the faces by shuttle cars and conveyor belts to two bunker surge areas, then out of the mine by way of hoist powered coal skip cars. A diesel-powered track haulage system is used to transport both men and materials.
Consol Energy, located in Pittsburgh, Pennsylvania, is the parent company of Consolidation Coal Company. The principal management personnel in charge of the mine at the time of the accident were:
Mine Superintendent . . . . . . . . . . . . . . . . . . . . . .Terry L. SuderThe 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 . . . . . . . . Terry L. Suder
The last regular safety and health inspection (AAA) was completed on March 29, 2002; however, a regular safety and health inspection was commenced on April 1, 2002, and was ongoing at the time of the accident.
The latest national NFDL (non-fatal days lost) injury incident rate for underground coal mines was 6.33. The rate for this mine was 1.72.
DESCRIPTION OF THE ACCIDENT
The night shift work crews began work at the mine at 11:30 p.m. under the supervision of James Mullins, Acting Shift Foreman and First Responder. Mullins issued the necessary work orders and the workers proceeded underground via the Page Portal shaft hoist. At the shaft bottom, Jerry Allen Wilson, Utility Man and victim, and Roy Hall, Acting Utility Man, traveled together to their respective workstations in a diesel-powered mantrip. Wilson exited the mantrip at his normal work area in 1 East Mains, the Stamler 1000-Ton surge car bunker, known as the old bunker. Hall traveled to A Shaft, the production shaft, and arrived at approximately 11:45 p.m. Wilson walked to the production shaft area and met with Hall between 1:30 a.m. and 2:00 a.m. to discuss the easiest way to change out a conveyor belt roller that had developed hot roller bearings. Wilson left to return to the bunker area.
Hall contacted Steve Ball, Page Portal Foreman, and informed him that there was a belt roller to change and that Wilson would assist. Ball arrived at the bunker at approximately 2:30 a.m. along with Bonnie Steele, Construction Foreman, and two other workers to take Wilson and some tools to change the belt roller. Ball noticed at this time that the bunker feed belt was not operating. He and Steele separately searched for Wilson in several locations but were unable to find him. When Ball arrived near the location of a stationary water pump, he performed a necessary check and returned to continue the search for Wilson at the bunker system power center, noting that the bunker feed belt was still off. Steele went to look for a lifting jack to take with them to change the roller. She returned and again searched for Wilson on the North side of the bunker cars. Steele observed that Wilson was entrapped in an upright position between a vertical support of one of the bunker cars and a vertical beam that was attached to the catwalk handrails near the bottom of the access stairway. Steele called to Wilson and got no response. Ball returned to the bunker area and was met by Steele. She informed him that Wilson was entrapped and they returned to the scene.
Ball checked Wilson for signs of life and found no response. He observed that the bunker car emergency-stop pull-cord device had been actuated on the East side of the two switches. Ball directed Steele to call for additional help and an Emergency Medical Technician (EMT). Steele notified James Mullins of the accident. Ball notified mine security personnel on the surface to call an ambulance, and notified Hall to come to the scene to help operate the bunker cars to extricate the victim. When Hall arrived he observed the bunker system operation control switch in the automatic position. Donald Ratliff, Electrician and EMT, traveled to the scene from the shaft portal with first aid material, checked Wilson for signs of life and found no response. Mullins arrived at the scene at approximately 3:05 a.m., checked Wilson for signs of life and got no response. Mullins placed the emergency-stop device back into the operating position. Ratliff started the bunker, and Steele moved the bunker cars in manual control to extricate the victim. Wilson was transported to the surface to the awaiting ambulance. The Dismal River Volunteer Rescue Squad, Inc. transported Wilson to the Clinch Valley Medical Center, arriving at 4:08 a.m., where he was pronounced dead on June 20, 2002, by Dr. Sheris Shoukry. The body was transported to the Virginia Medical Examiner's facility in Roanoke, VA for an autopsy. The autopsy revealed the cause of death as crushing chest injuries and mechanical asphyxia.
INVESTIGATION OF THE ACCIDENT
Lee Blackburn, Safety Inspector for Consolidation Coal Company, notified Luther E. Marrs, MSHA Coal Mine Inspection Supervisor, of the accident at 4:00 a.m. Marrs contacted Edward R. Morgan, Acting District Manager. Marrs and Randall Ball, Coal Mine Safety and Health Inspector, proceeded to the mine. They issued a closure order under Section 103(k) of the Mine Act for the Stamler 1000 ton surge bunker located in the A Shaft area of the mine to ensure the health and safety of persons at the mine until an investigation of the accident could be completed. They observed the accident scene, assured that the accident scene was secured, and gathered preliminary information related to the accident.
The accident team members were designated and the investigation continued on the morning of June 20, 2002. The accident scene was observed, measurements were taken for a scaled drawing, and photographs and a video were made. Joint interviews were conducted with Virginia Department of Mines, Minerals, and Energy (VDMME) officials of four supervisory and eight hourly employees on June 20 and 21, 2002, at the company's mine office facility. Preliminary findings indicated that conditions existed that might expose other miners to similar hazards. The company was required to develop an action plan to address methods for elimination of any such related hazards prior to returning the bunker system to operation.
DISCUSSION
1. The Buchanan Mine #1 is an underground coal mine accessed by shafts. Coal is transported from the mine through the production shaft by a skip car system. Each skip car transports approximately 18 tons of coal.
2. Surge bunker cars are used to regulate the volume of coal supplied to the skip cars by the production conveyor belt.
3. The victim, a utility man whose regular job duty was as a bunker operator, was operating the old bunker. The old bunker is one of two bunkers being used in the mine.
4. The old bunker is a Stamler 1000-Ton Surge Bunker, model MCB-1000-B511-21-C-V, serial no. 50003, comprised of 21 fifty-ton cars.
5. The flow of mine-produced coal stored or released from the bunker is controlled by a sensor system designed to keep coal moving at a proper rate for the skips to transport out the shaft. These sensors, through control circuits, automatically regulate the direction and amount of movement of the bunker cars. Manual control of the cars is also provided by a manual/automatic switch at the control station located on an upper level of the victim's workstation. Provisions are also in place through a gate system to allow the coal to be automatically deposited directly onto the production belt while the bunker cars are deenergized.
6. Rescuing personnel found the manual/automatic switch at the control station to be in the automatic mode. The power to the control circuit was found deenergized at the North side emergency-stop pull-cord switch at the victim's immediate location. The East pull cord switch had been actuated. Emergency-stop pull-cords are installed alongside the North and South walkways between the walkways and the bunker cars extending in the easterly and westerly direction from a switch provided for each of the pull cords.
7. The victim was found entrapped on the bunker car side of the emergency-stop device between a vertical four-inch I-beam of the bunker car structure and the East side of the vertical three-inch angle-iron beam attached to the catwalk to support two bunker car overtravel switches. The victim was standing on the outer horizontal I-beam of the bunker car structure. It was necessary to reset the emergency stop device, place the control circuit into an operational mode, and place the automatic/manual switch in the manual mode to move the cars easterly in order to extricate the victim.
8. There were no eyewitnesses to the accident.
9. The bunker cars move easterly when coal is being added and westerly when coal is being discharged to the production belt. The victim was entrapped on the easterly side of the angle-iron beam in the pinch point created as the bunker cars moved in the westerly direction. As the I-beam of a car moved by the angle-iron beam, a separation space of approximately 5 inches was present. The cars were constructed with the I-beams on 44-inch centers.
10. According to witness statements, the bunker cars would drift to the empty, or westerly, direction an estimated one half of one-inch increment each seven to ten minutes while deenergized. The cars were observed moving approximately one foot to the easterly direction while being loaded with coal. The cars were observed moving approximately three feet to the westerly direction at a rate of approximately one foot per three seconds when discharging coal.
11. The victim's normal assigned duties included the manual lubrication of the bearings of the bunker car system in the area where he was found entrapped. The grease observed on the bearing grease fittings appeared to have been freshly applied. According to witness statements, two hand operated grease guns with rigid piping extensions were used to lubricate the bearings. Some grease fittings could be accessed from the walkway, and some lubrication tasks could be performed while the bunker car system was energized. In some locations grease hoses extending to the catwalk hand railing were installed in the bearing grease fittings.
12. A hand operated grease gun with a rigid piping extension approximately 18 inches long was found on the catwalk at the victim's location. A second hand operated grease gun, which was not at the victim's location, was constructed with a rigid piping extension approximately 24 inches long.
13. The drive chain obstructed access from the catwalk to a grease fitting installed in the top of the gearing mechanism on the side opposite the catwalk. This grease fitting appeared to have been recently serviced.
14. A review of training records revealed no deficiencies in the victim's training.
ROOT CAUSE ANALYSIS
A root cause analysis was performed on the accident. The root cause of the accident was a failure to ensure that no manual lubrication work was performed on the coal bunker car system while it was in motion, unless extended fittings or cups were provided. A contributory causal factor was the positioning of the victim in a hazardous location at a pinch point while performing manual lubrication work on moving machinery.
CONCLUSION
The accident occurred when the victim became entrapped at a pinch point while performing manual lubrication work on the bunker cars while they were still in motion.
ENFORCEMENT ACTIONS
Section 103(k) Order number 7325768 was issued on June 20, 2002, and reads as follows: The mine has experienced a fatal haulage accident along the Stamler 1000 ton surge bunker located in the area of "A" Shaft. This Order is issued to assure the safety of any person in the coal mine until an examination or investigation is made to determine that the Stamler surge bunker is safe. Only those persons selected from company officials, the miner's representative, and other persons who deemed by MSHA to have information relevant to the investigation, may enter or remain in the affected area.
Section 104(a) Citation number 7323300 was issued citing 30 CFR 75.1725(d). Manual lubrication was being performed on the coal bunker car surge system, referred to as the old bunker, while the cars were moving. On June 20, 2002, at 2:51 a.m., Jerry A. Wilson was found pinned between a vertical support beam of the no. 12 car and the stationary vertical beam attached to the access catwalk and handrail. Evidence of freshly greased bearings, not provided with extended fittings, was present at this area. A hand-operated grease gun fitted with a rigid extension of approximately 18 inches was present on the catwalk immediately below the victim's location.
Related Fatal Alert Bulletin:
FAB02C14
APPENDIX A
List of persons providing information and/or present during the investigation:
CONSOLIDATION COAL COMPANY - MANAGEMENT
Danny Crutchfield ............... Mine ForemanCONSOL ENERGY
Bonnie Steele ............... Construction Foreman
Steve Ball ............... Foreman
James Mullins ............... Acting Shift Foreman and Emergency Medical Technician
Howard Sam Adams ............... Section Foreman
Sam Beavers ............... Chief Electrician
Walt Scheller ............... Vice President of Consol EnergyCONSOLIDATION COAL COMPANY - LABOR
Barry D. Dangerfield ............... Vice President of Operations
Elizabeth Chamberlin ............... Corporate Safety Director
Rick Marlowe ............... Corporate Safety Inspector
David R. Berry ............... Safety Manager
Lee Blackburn ............... Safety Inspector
Terry Mason ............... Supervisor of Human Resources
Terry Mitchell ............... Bunker OperatorVIRGINIA DEPARTMENT OF MINES, MINERALS, AND ENERGY
Charlie Asbury ............... Bunker Operator
Roy Hall ............... Acting Utility Man
Benny Patterson ............... Bunker Operator
Don Ratliff ............... Electrician
George Shelton, Jr. ............... Utility Man
Billy O'Quinn ............... Utility Man
Danny Damewood ............... Mine Examiner
Frank Linkous ............... Chief, Division of MinesMINE SAFETY AND HEALTH ADMINISTRATION
Opie McKinney ............... Mine Inspector Supervisor
Carroll Green ............... Mine Inspector Supervisor
Joeseph Altizer ............... Coal Mine Inspector
Danny Altizer ............... Coal Mine Inspector
Terry Ratliff ............... Coal Mine Inspector
Dwight Miller ............... Coal Mine Technical Specialist-Electrical
David Elswick ............... Coal Mine Technical Specialist-Roof Control
Ray McKinney ............... Administrator, Formerly District ManagerLIST OF PERSONS INTERVIEWED
Edward R. Morgan ............... Acting District Manager, Formerly Assistant District Manager, Technical Division
Benjamin Harding ............... Inspection Supervisor
Larry Coeburn ............... Inspection Supervisor
Charles E. Upchurch ............... Coal Mine Inspector
David Woodward ............... Mining Engineer
Russell Dresch ............... Electrical Engineer
James Hackworth ............... Educational Field Services Specialist
Kimra Collier ............... Program Analyst
Bonnie Steele ............... Construction Foreman
Terry Mitchell ............... Bunker Operator
Charlie Asbury ............... Utility Man
Steve Ball ............... Foreman
Roy Hall ............... Acting Utility Man
James Mullins ............... Acting Shift Foreman and Emergency Medical Technician
Benny Patterson ............... Bunker Operator
Howard S. Adams ............... Section Foreman
Don Ratliff ............... Electrician and Emergency Medical Technician
George Shelton, Jr. ............... Utility Man
Billy O'Quinn ............... Utility Man