DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Fatal Machinery Accident
December 13, 2002
Lower Elkhorn Mine
American Mining & Manufacturing Corporation
Dorton, Pike County, Kentucky
ID No. 15-18008
Anthony L. Burke
Coal Mine Safety and Health Inspector
Mine Safety and Health Administration
100 Fae Ramsey Lane
Pikeville, Kentucky 41501
Franklin M. Strunk, District Manager
Release Date: February 10, 2003
On December 13, 2002, a 31 year-old roof bolting machine operator was fatally injured while operating a Fletcher, Model DDO-13, Dual Head Roof Bolting Machine. Apparently, the victim inadvertently contacted the fast-feed drill boom lever while he was positioned between the right side canopy cover frame and the drill boom of the machine. Contact with this lever caused the drill boom to rise rapidly. Elmer Hammonds, II, was fatally injured when he was caught between the drill boom and the canopy of the roof bolting machine.
The Lower Elkhorn Mine of American Mining & Manufacturing Corporation is located on Johns Fork Road, approximately � miles from U.S. Route 23 near Dorton in Pike County, Kentucky. The company is wholly owned by Timothy Smith of Buckner, Kentucky. The sole officer of the company is Timothy Smith, president. The mine superintendent is Silas Adkins.
The mine began production on December 08, 1997, as South Akers Mining #6 Mine, South Akers Mining, LLC, using continuous mining machines and shuttle car haulage. Since that time, the mine has operated under four other owners and company names prior to American Mining and Manufacturing Corporation. The previous companies were:
Garrett Mining, Inc. Mine No. 3American Mining & Manufacturing Corporation assumed control of the mine on August 27, 2002. Rehabilitation work was performed from that time until the mine began to produce coal on or about November 30, 2002. (At the time of the accident, the mine had been producing coal for approximately two weeks).
Ember Contracting, Inc. No. 8
Westenn Inc. Mine # 2
JLN Construction Company, JLN # 1A
The mine operated three shifts per day, five days per week and two Saturdays per month, and produced 200 tons of coal per day.
The last complete safety and health inspection of the mine by MSHA was started on October 13, 2002, and was ongoing at the time of the accident. There had been no lost-time accidents at this mine from the time American Mining & Manufacturing Corporation assumed control until December 13, 2002.
The second-shift crew entered the mine at 2:30 pm under the supervision of acting section foreman Marty King. Mr. King is the mine examiner, and this was the first night he had been assigned to be foreman of the production crew.
The crew entered the mine and traveled approximately 6,000 feet underground to the 002 working section via rubber-tired, battery-powered mantrips. Upon arriving on the section, the crew started coal production.
Although there were no major equipment breakdowns, approximately two hours prior to the accident the section electrician/mechanic, Eddie Dwayne Eversole, installed a new "pot insert" (drill chuck) on the right-side (victim's side) of the roof bolting machine. The pot insert is the part of the roof bolting machine's drill mechanism that connects to the drill steel. After this minor repair was made, an additional three places were bolted by the roof bolting crew.
After tramming the roof bolting machine to the No. 7 working place, the operator's side (left side) bolting machine operator, Sherd Caudill, Jr., stated that he observed Marty King conducting a preshift examination for the oncoming shift.
The roof bolting crew, consisting of Sherd Caudill, Jr. - left side roof bolter operator, and Elmer Hammonds, II - right side bolter operator (victim), had installed two rows of permanent roof support in the No. 7 working place. Caudill trammed the machine forward to set up for installation of the next row of roof bolts. Caudill drilled the first hole to a depth of approximately 18 inches when he noticed that Hammonds had not begun to drill. Caudill then looked under his drill boom in the direction of Hammonds and noticed what he believed to be evidence of an injury to Hammonds. Due to the seam height and the size of the roof bolting machine, Caudill's view was impeded and he could not see Hammonds from his location.
Caudill stated that he de-energized the roof bolting machine by using the panic bar (emergency de-energization device). This action de-energized the pump motors. Caudill then crawled around to the right side of the roof bolting machine and observed that Hammonds was caught between the drill boom and the canopy of the machine. Caudill also observed that Hammonds was facing outby (in the direction of the machine's controls) with his left hand positioned on the drill boom swing and fast-feed levers. Caudill informed Marty King that there had been a serious accident involving Hammonds.
King crawled from the No. 4 entry to the No. 7 entry, checked Hammonds for a pulse and found none. King also stated that, when he arrived at the roof bolting machine, the victim's left hand was positioned on the control levers and that his right hand was on the drill pot of the machine.
King told Matthew Smith, scoop operator, to get the first aid supplies from the power center area. Smith and Eversole brought the supplies to the accident area. Jimmy Darrell Hall, shuttle car operator, notified the outside man of the accident and told him to call an ambulance. Third shift mine foreman, Can Bentley, who had arrived on site in preparation for the third shift, notified MSHA and the Kentucky Department of Mines and Minerals (KYDMM) of the accident and called the Neon Volunteer Fire Department in Neon, Kentucky. Delbert Anderson, Letcher County Coroner, arrived at the mine and pronounced the victim at 1:10 am on December 14, 2002.
Can Bentley, third shift mine foreman, reported the accident to MSHA's Whitesburg Field Office supervisor Sandra Barber at her residence at approximately 9:15 pm on December 13, 2002. Barber then telephoned Inspectors Eddie Taylor and Jeffrey Meade at their residences to inform them of the accident.
Anthony L. Burke, Coal Mine Safety and Health Inspector, was assigned the task of investigating the accident.
Barber, Taylor, and Meade proceeded immediately to the mine and began the initial phase of the investigation. A 103(k) Order issued to ensure the safety of all persons until an investigation could be made to determine the extent of hazards contributing to the accident.
On Sunday, December 15, 2002, lead accident investigator Anthony L. Burke went to the mine. Also present were Johnny Greene, Deputy Chief Investigator and Randy Campbell, electrical inspector from the KYDMM. The investigation team examined the scene, took measurements and photographs, and informally interviewed employees who were at the mine at the time of the accident.
Formal interviews were conducted on December 16, 2002, at the MSHA field office located at Whitesburg, Kentucky. Eight miners and three supervisors were interviewed during this session. The interviews were tape recorded and later transcribed.
William Gray and William Williams, mining engineers from the Roof Control Division of MSHA's Pittsburgh Safety and Health Technology Center, in Pittsburgh, Pennsylvania, traveled to the mine site on December 16, 2002. They examined the roof bolting machine in its entirety, including the controls. A description of the machine and the results of their examination is contained in the Appendix.
On December 31, 2002, Eugene Hennan, a mechanical engineer from MSHA's Approval and Certification Center in Triadelphia, West Virginia, traveled to the mine site. He examined the roof bolting machine and tested hydraulic pressures and machine function on both sides of the dual head machine. A description of the results of his examination is in the Appendix.
Conditions observed during the examination of the machine that were determined not to be contributing factors in the accident were cited under a separate inspection event. The non-contributory violations were corrected prior to returning the machine to service.
Training records for American Mining & Manufacturing Corporation were reviewed by the investigation team and personnel from MSHA's Educational Field Services Division. Although several deficiencies were cited, none were contributory factors to the accident.
1. There were no eyewitnesses to the accident.
2. The left side bolter operator could not see the victim due to the coal seam height and the size of the roof bolting machine.
3. The victim had apparently positioned himself in a pinch-point area of the machine while using the drill controls.
4. Post-accident employee statements revealed that the victim's left hand was positioned on the boom-swing and fast-feed control levers.
5. Tests conducted on the slow speed boom raise lever revealed the average time required for the boom to rise from floor level to the mine roof (43-inches) was approximately 5.7 seconds.
6. Tests conducted on the fast-feed boom raise lever revealed the time required for the boom to rise from floor level to the mine roof (43-inches) ranged from 1.6 seconds to 1.9 seconds.
7. The fast-feed boom raise lever had an extension (3/8 inch diameter "all-thread" bolt) taped to the lever handle. This extended the length of the lever on the right-side (victim's side) by 3 � inches. This extension resulted in the fast-feed lever being the lever nearest to any person reaching from the area of the drill pot.
8. The Letcher County Coroner's report listed the official cause of death as "�crushing blunt injury of the head by a coal mining roof bolting machine."
The investigation revealed the cause of the accident as extension of the fast-feed boom raise lever.
On site examinations of the roof bolting machine were conducted by MSHA's Technical Support Division on December 16, 2002, and by MSHA's Approval and Certification Center on December 31, 2002, and are included in the appendices of this report.
The primary cause of this accident appears to have been inadvertent contact with the fast-feed boom control lever. Contact with the fast-feed boom control lever caused a rapid upward movement of the drill pot and boom, resulting in the victim being caught between the drill boom and the canopy of the roof bolting machine.
The primary contributing factor in the accident was the extension of the fast-feed lever. The lever had been extended 3 � inches longer than normal and was longer than any of the other control levers on the victim's side of the machine. In addition, the fast-feed boom control levers on the roof bolting machine had not been disconnected or retrofitted with a two-hand system, which would have required the use of both hands to actuate the fast-feed control. This modification was specified in a safety notice, dated April 03, 1994, from J.H. Fletcher and Company.
1. 103(k) Order No. 7394330 was issued on December 13, 2002, to protect the safety of all persons until an investigation could be made to determine the extent of the hazards contributing to the accident.
2. 104(a) Citation No. 7394349 was issued on January 16, 2003, to American Mining & Manufacturing Corporation. The condition/practice cited was as follows:
"The Fletcher dual head roof bolting machine (Serial Number 84051) was not maintained in safe operating condition.
The fast-feed drill boom control levers (which are located under the driller canopy on both sides of the machine) were modified to extend the levers. The right-side (off-side) lever was extended 3 � inches, and the left-side lever was extended 3 inches. The extension of these levers increased the likelihood of inadvertent contact by the roof-bolting machine operator. Contact with the fast-feed drill boom control lever caused rapid movement of the drill pot boom. The extension of the right-side fast-feed drill boom lever was a contributing factor in an accident that resulted in the death of the right-side roof bolting machine operator.
On December 13, 2002, Elmer Hammonds, II was performing duties as the right-side (off-side) roof bolting machine operator on the 002-0 working section of this mine when he inadvertently contacted the fast-feed drill boom control lever, causing the drill pot boom to rise rapidly. Mr. Hammonds was fatally injured when he was caught between the drill boom and the canopy of the roof bolting machine.
Related Fatal Alert Bulletin:
Silas Adkins . . . . . . . . . Superintendent
Marty King . . . . . . . . . Foreman
Bobby Ashworth . . . . . . . . . Accident Investigator
Bob Banks . . . . . . . . . Roof Control Department
Johnny Greene . . . . . . . . . Deputy Chief Accident Investigator
Tony Oppegard . . . . . . . . . General Counsel
Tracy Stumbo . . . . . . . . . Chief Accident Investigator
Sandra Barber . . . . . . . . . Supervisory CMS&H Inspector
Anthony L. Burke . . . . . . . . . Coal Mine Safety & Health Inspector
William Gray . . . . . . . . . Mining Engineer
Eugene Hennan . . . . . . . . . Mechanical Engineer
Jeffrey Meade . . . . . . . . . Coal Mine Safety & Health Inspector
Eddie Taylor . . . . . . . . . Coal Mine Safety & Health Inspector
William Williams . . . . . . . . . Mining Engineer
LIST OF PERSONS INTERVIEWED
Silas Adkins . . . . . . . . . Superintendent
Darvin Levy Belcher . . . . . . . . . Foreman
Robert David Cable . . . . . . . . . Roof Bolter Operator
Sherd Caudill, Jr. . . . . . . . . . Roof Bolter Operator
Eddie Dwayne Eversole . . . . . . . . . Mechanic/Electrician
Jimmy Darrell Hall . . . . . . . . . Shuttle Car Operator
Marty King . . . . . . . . . Foreman
Brian Reynolds . . . . . . . . . Roof Bolter Operator
Robert Robinson . . . . . . . . . Surface Electrician
Timothy Smith . . . . . . . . . President
Rance Wendell Tackett . . . . . . . . . Repairman/Welder
(Pittsburgh Safety and Health Technology Center)
1. The machine was not equipped with a two-hand valve arrangement for fast feed. J.H. Fletcher and Company developed the two-hand fast feed arrangement following a 1994 fatal accident in which it was suspected that the fast feed function was inadvertently activated. The purpose of the two-hand arrangement is two-fold. First, by requiring the simultaneous actuation of two separate levers, the possibility of an inadvertent fast feed activation is virtually eliminated. Secondly, the two-hand requirement results in a known location for the machine operator, safely away from the boom arm/canopy pinch point.
2. Due to the nature of the accident circumstances, which suggest an inadvertent activation of the fast feed function, the Roof Control Division's (RCD) evaluation began with an analysis of this aspect. In addition, other machine areas with possible safety shortcomings were examined. These secondary areas evaluated included the ATRS system, drill station canopies, machine guarding aspects, and drill boom set pressures.
3. Prior to our December 16 observation of the subject Fletcher DDO bolter, we were informed by Anthony Burke, Lead Accident Investigator for MSHA, that a non-original equipment manufacturer (OEM) control lever extension had already been removed from the machine by personnel from the Kentucky Department of Mines and Minerals. The extension consisted of a piece of "all-thread" bar that had been splinted onto the original fast feed lever with electrical tape, reportedly increasing the overall length of the handle on the victim's side of the machine from 18 � inches to 22 inches.
4. As part of our evaluation, the drilling controls were examined for appropriate movement and any potential fouling of the controls. Although the "homemade" extension had been removed prior to our investigation, observation of the removed handle and tape, and information obtained from Mr. Burke appeared to indicate that the extension was not in a position to be inadvertently activated by an adjacent lever.
5. Similarly, examination of the other drilling control levers and the connections between the control handles and the valve bank sections did not reveal any interference. Although the machine was not equipped with control handle separator guides as designed by Fletcher, control handle lateral movement did not appear to be excessive. The subject handle/ valve section connection arrangement was via a clevis pin and "E"-clip.
6. This connection was the appropriate arrangement as per a 1994 clevis pin retrofit program implemented by the machine manufacturer, J. H. Fletcher and Company. (The E-clip replaced a cotter key that was suspected of a lever interference problem resulting in an inadvertent actuation of the fast feed lever in a 1994 accident).
7. As mentioned, the RCD evaluation of the Fletcher DDO included an examination of the ATRS system and drill station canopies. The ATRS was a scissors-style single-bar system, adjustable in length from 9-to-11 feet. Our observation revealed that the pads were improperly installed on the ATRS bar, with the wider side of the pad extending towards the face rather than in the outby direction. In addition to the improper pad installation, it appeared that the ATRS bar sump capability was being improperly used. Based on the observed position of the ATRS sump cylinder, it appeared that the bar was being positioned an excessive distance inby the row of bolts being installed. However, because the ATRS may have been repositioned during the recovery efforts prior to our observation, this position or use of the ATRS could not be determined conclusively.
8. The evaluation of the ATRS bar also found that the pins that attach the roof contact pads to the bar (as well as the keeper pins for these pins) appeared to be non-o.e.m. components. These modifications could affect the load capacity of the bar and would void the manufacturer's certification of the ATRS system. Also regarding the ATRS certification, the required tag on the bar reflected a different serial number (84046) than that of the machine (84051). These two serial numbers should correlate for the certification to be valid (or a separate certification letter should be produced for the bar with serial number 84051 specifically referenced).
9. In addition to the deficiencies with the ATRS system, there were also some shortcomings observed with the drill station canopies. First of all, only the right side canopy had the proper certification tag in place. Furthermore, even for this canopy, mine management was apparently not able to produce a certification letter. Contributing to the certification issue even further was the fact that both canopies had obviously been modified by welding. Instead of the o.e.m. design for attaching the canopy to the post using 12 bolts, both canopies were missing bolts and instead had been welded to the post.
10. One other bolter safety aspect that was examined was the drill boom foot jack set pressure. During our evaluation of control functions it was observed that the left side foot jack set pressure was significantly higher than normal. This was readily apparent from the undesirable lifting of the front end of the machine when the foot jack was lowered to the mine floor. According to statements in a Fletcher Information Bulletin discussing this problem, the properly set foot pressure "will prevent the operation of one boom from mechanically affecting the operation of the opposite boom." Although such a severe effect was not observed on the subject machine, the potential is nevertheless present for unwanted and sudden machine movements from the improper set pressure. (Several years ago the RCD investigated an accident where a bolter operator was injured from the sudden dropping of a canopy that resulted from the foot jack set pressure exceeding the manufacturers prescribed range of 500-700 psi).
11. Other observations of machine problems included a hydraulic problem with the right side drill boom feed circuit. The drill boom was observed drifting upward without activation of any controls. The extent of the boom travel appeared to depend on oil temperature, with the worst case on start-up of a "cold" machine resulting in approximately 20 inches of upward travel. (This problem has subsequently been investigated by personnel from the Mechanical safety Division of Technical Support, and will be reported on separately).
12. Finally, as part of our examination of the subject machine it was noted that it had not been equipped with a Fletcher recommended guard for arm feed machines. This guard is simply a length of rubber belting approximately 18 inches wide by 40 inches long, which is bolted onto the boom arm. The primary intent of the boom guard is to keep the operators hands off the boom arm and away from the identified pinchpoint.
(MSHA Approval and Certification Center)
1. The purpose of the examination was to determine if the components in the feed section in each of the control valves were the correct components for a Fletcher Roof Bolter Control Valve, and to determine if the valve had been assembled with new or remanufactured components.Machine Testing:
2. The examination revealed the valves had the correct components, including the heavier return springs in the control valves.
3. The examination did not reveal any evidence that the components in the valves were remanufactured before being placed in the valves.
4. The purpose of the tests was to determine the leak rate of the feed section of each control valve when these sections are in the neutral position, and to determine if the weight of the handle extension on the fast feed section would cause that valve section to be activated without the operator pushing the control.
5. The leak rate on the valve sections were in an acceptable range. The weight of the fast feed control handle extension did not cause that valve to open without operator activation.