DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE COAL MINE)
FATAL MACHINERY ACCIDENT
Samples Mine (I.D. No. 46-07178)
Catenary Coal Company
Leewood, Kanawha County, West Virginia
December 26, 2002
Sherman L. Slaughter
Mine Safety and Health Specialist
Originating Office-Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: March 31, 2003
On Thursday, December 26, 2002, a 48-year-old dragline oiler with 26 years mining experience, received fatal crushing injuries when the right walking shoe of the dragline struck him. After completing his work shift and leaving the dragline, the victim returned and attempted to board the machine while it was in operation. The dragline crew was not aware the victim had been struck and continued normal production activities for several hours. When the machine operator paused at the end of a dump cycle to let dust clear, he saw the victim lying on the ground to the right of the machine near the digging face.
The Samples Mine is a surface coal mine located near Leewood, Kanawha County, West Virginia. The mine began operations May 26, 1987. It is operated by Catenary Coal Company whose parent company is Arch Coal, Inc. of St. Louis, Missouri.
The 7-Block, 6-Block, 5-Block, Stockton, and Coalburg bituminous coal seams are mined at this location. Total seam thickness is approximately 19.5 feet. The maximum overburden removed is approximately 340 feet. The methods of mining utilized are mountain-top, contour, and highwall mining. A 53-cubic yard Bucyrus-Erie 495B electric shovel, a 23-cubic yard DeMag hydraulic shovel, three Letourneau L-1400 loader spreads, and a 110-cubic yard Bucyrus-Erie 2570-W dragline are used to remove overburden. A Superior highwall mining system is used by a contractor to mine in the Coalburg coal seam.
Coal is loaded into trucks by front-end loaders and transported to an on-site preparation plant. Overland conveyor belts transport the clean coal to a unit train loadout facility.
The mine works two 12-hour shifts per day, seven days per week. Production shifts start at 6:00 a.m., and 6:00 p.m. The mine has 380 employees and approximately 150 independent contractor personnel that produced 5.4 million tons of coal in 2002.
The last Mine Safety and Health Administration regular safety and health (AAA) inspection was completed September 5, 2002. The Non-Fatal Days Lost (NFDL) incidence rate during the previous quarter was 6.54 for surface mines nationwide and 1.27 for this mine.
The principal officers of Catenary Coal Company at the time of the accident were Peter Lawson, President; Eddie Turner, Mine Manager; and Terry Tolley, Manager of Safety.
DESCRIPTION OF THE ACCIDENT
On Thursday, December 26, 2002, at approximately 5:50 p.m., Keith Smith, 2nd shift dragline operator, and Franklin Bauer, 2nd shift dragline oiler, boarded the dragline to begin their shift. Before leaving, Bruce Ude, day shift dragline operator, discussed digging procedures with Smith. The crew normally consisted of an operator, oiler, and ground man. During this shift, Smith would operate the dragline and Bauer would perform both the oiler and ground man duties.
At approximately 6:45 p.m., Dan Gray (victim), 1st shift dragline oiler, was ready to leave the dragline after completing his shift. At approximately 6:45 p.m., Gray told the operator, Smith, to stop on the next pass to let him off the machine. Smith swung the machine around, set the swing brakes and let Gray off as requested. Frank Bauer, observed Gray descend the steps onto the shoe before closing the access door to the machine house. (Later, during the investigation, Bauer said that he had noticed that Gray had cleaned up (taken a shower) before leaving.) Smith waited until he saw Gray in the mirror and figured he was past the fantail swing radius, before continuing operations. A short time later, unknown to the crew, Gray returned to the dragline. He had left his cell phone in the dragline Programmable Controller Room. Physical evidence suggests that Gray drove his vehicle to the dragline, left the engine and heater running, lights on, and approached the machine with intentions of boarding to retrieve his cell phone. The dragline crew could not see the truck and did not know he had approached the machine. He did not notify anyone to make them aware he was going to board the machine. Time line reconstruction and physical evidence indicate that this is when the accident occurred.
At 7:10 p.m., Bauer answered the dragline cell phone. He reported to Smith, the operator, that it was Gray's wife calling looking for Gray. Smith swung the dragline around approximately 90 degrees clockwise to see if Gray's pickup truck was still at the mine. They saw the truck and Bauer told the caller that Gray's truck was still there. The crew was apparently not concerned because it was not unusual for Gray to leave his truck running near the dragline after his normal shift while he remained on the machine. Bauer said he "did not think anything of it" because Gray usually "stays later to take a shower." Production continued.
At approximately 8:10 p.m., Bauer got off the dragline to position the trailing cable for a move. The skidder, which is normally used to move the cable, would not start. A welder, Don Leach, was contacted to check the skidder. Leach determined that the skidder was out of fuel. A fuel truck came to the pit but they were still unable to get the skidder started. All of this activity was performed behind the dragline out of the swing radius. Unable to start the skidder, Bauer decided to use the dozer to handle the cable while they moved the dragline back.
Bauer used the dozer to skim mud from the area where the machine would be positioned for the next cut. He shoved the material forward to the fantail area behind the dragline. Continuing to the highwall side of the cable, where Gray's truck was parked, Bauer moved the truck out of the way and cleaned the pad on that side.
At 9:00 p.m., Smith began the dragline move on to the new set, about 18 steps straight back and 4 more steps angled toward the highwall. The foreman, Tom Bass, arrived in the pit at approximately 9:20 p.m., as the move was being completed. Seeing Gray's truck, Bass asked Bauer who it belonged to. Bauer told him that it was Gray's. Bauer informed Bass that he and Smith had looked for Gray but had not located him. The dragline crew had not alerted Bass or any other management personnel to questions regarding Gray's whereabouts.
After the move was completed at approximately 9:30 p.m., Bass and Bauer boarded the dragline and ate lunch. With Smith at the controls and the dragline back in production, Bass directed Bauer to conduct another search for Gray. During the investigation, Bass recalled that the crew was not overly concerned about not locating Gray at that point. At 11:06 p.m., Gray's wife called the dragline to locate him. Smith swung the machine around and saw that Gray's truck was still in the pit. He informed Mrs. Gray that the truck was still there, but he did not know where her husband was located. At approximately 12:00 a.m., Bass left the dragline en route to a call for EMT assistance at the warehouse, where a truck driver was ill.
At approximately 1:00 a.m., on 12/27/2002, Bauer got off the dragline to push in the roll. The roll is spoil material that accumulates at the top of the digging face as the dragline works. When it becomes high enough to be a problem to the machine the ground man will push it in. At first Bauer worked on the highwall side with the ground dozer dressing up the pad. Smith walked the machine back 3 or 4 steps to allow Bauer enough room to work in front of the dragline. He then stopped operations of the machine. Bauer worked around the front of the drag pushing the roll. Physical evidence indicates that the dozer Bauer was operating came within 5 feet of the victim during this ground work. While Bauer was doing the ground work, Smith went back in the dragline house and activated the lower cab lights on the front of the machine. While digging, these lower cab lights are usually kept off. They interfere with the visibility of the operator when dust and steam rises out of the digging face. After Bauer completed the ground work in front of the dragline, Smith walked the machine forward 3 or 4 steps to the digging face and resumed operations at approximately 1:10 a.m.
Bauer reboarded the machine and production continued. Bauer stated that he again looked for Gray before operating the machine while Smith ate lunch. After his lunch break, Smith also looked for Gray before returning to the controls. Bass, the foreman, called the dragline on his way to the 7B pit to see if Gray had been located, and was informed he had not. (Efforts to locate Gray had been confined to the various compartments on the machine. No one had made a ground search for Gray.)
At approximately 2:30 a.m., Bass left the 7B pit and called about Gray again. The call initiated another search. On Bauer's third search of the programmable control room, he found Gray's cell phone on a table connected to a charger that was plugged into the wall. He went back to the operator's cab and told Smith about the cell phone.
At approximately 3:15 a.m., Smith paused at the beginning of a dig cycle because of dust, and saw Gray lying on the ground to the right of the dragline, on the spoil side, near the digging face. He immediately stopped operations, set the bucket down, and radioed for help. Smith and Bauer got off the machine. Smith went to the victim but Bauer stated that he did not. Bass, an EMT, who had responded to the radio call for assistance, also joined them. Bass examined the victim and did not find any vital signs.
Rodney Cairns, Superintendent, also responded to the call for help by contacting the warehouse requesting that they call an ambulance and notify other mine managers. Work stopped on the dragline side of the mine and the miners were sent home. Cairns joined Smith, Bauer, Bass and Dave Butler, foreman, at the accident site.
A Kanawha County Ambulance Authority ambulance was logged in at the guard station at 4:00 a.m. Upon arrival at the accident site, ambulance personnel examined Gray and found no vital signs. Terry Keen, Inspector with the West Virginia Office of Miners' Health, Safety and Training arrived at the accident site at approximately 5:05 a.m., prior to removal of the body. The ambulance left the mine with the victim's body at approximately 5:51 a.m., en route to the Kanawha County Medical Examiner's Office in Charleston, West Virginia.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) was notified at 3:45 a.m., on Friday, December 27, 2002, that a serious accident had occurred. MSHA accident investigators were immediately dispatched to the mine. A 103(k) order was issued to ensure the safety of all persons at the mine. The investigation was conducted in cooperation with the West Virginia Office of Miners' Health, Safety and Training (WVMHST), with the assistance of the operator and mine employees. A list of those persons who participated, were interviewed, and/or were present during the investigation can be found in Appendix A of this report.
Representatives of MSHA and the WVMHST traveled to the accident scene to conduct an investigation of physical conditions. Photographs, video recordings, and relevant measurements were taken. Sketches and a survey were also conducted at the site. Persons who had knowledge of the accident were interviewed on December 30, 2002, and on January 6, 2003. The physical portion of the investigation was completed on January 6, 2003.
Records of training were reviewed and mine personnel were interviewed regarding training provided to Gray and other employees. The victim had received the required training.
The records of mandatory examinations and on-site evaluation of conditions indicated that the required examinations were being conducted and recorded in accordance with 30 CFR. Part 77.
1. The machinery fatality occurred on the pad where the Bucyrus-Erie 2570W dragline was working in the H Boxcut on the Stockton coal seam level between approximately 6:45 p.m., and 9:00 p.m., on December 26, 2002.
2. The dragline was digging on the spoil side of the cut and operating on a short swing. The right shoe was partially hanging over the edge of the pad during the swing. There was no room for a person to board when the dragline was in the dig cycle on this set. Only the back of the right shoe would be opened up for a person to board in the dump cycle. There was limited room beside the shoe and a short period of time to board during the dump cycle with the machine operating in this position.
3. The ground at the dragline was uneven and partially frozen.
4. Lighting was good on the ground at the pad where the dragline was working.
5. The dragline had settled during the period of time that it operated on the set where it was located at the time of the accident. It had settled to the spoil side (it was not level) causing the right shoe to be closer to the ground than the left shoe. The right shoe had actually been dragging the ground slightly during the day shift. The dragline remained in this position until the move at 9:00 p.m., on 12/26/2002.
6. Because the dragline was not level and was working close to the edge of the pad on the spoil side, the operator would have had to swing clockwise far enough to position the right shoe so a person could get to the boarding ladders and set the swing brakes for a person to safely board the machine.
7. The victim had worked on draglines for at least 17 years. His experience made it likely that he would have recognized the necessity of contacting the operator to have him swing the machine and set the swing brakes to allow a person to safely board.
8. There were three methods used by the workers at this mine to contact the dragline operator when the dragline was in operation. The first method was to use radios. When persons were on the ground doing ground work or helping to move the dragline they used the company FM, 2-way, hand-held radios. Two of these radios were kept on the dragline. CB radios were provided in the ground dozer (Caterpillar D10N - Co. No. 20504) and the skidder (Caterpillar 518 - Co. No.22103). The skidder also had a stationary mounted 2-way FM radio. Two CB radios were also provided on the dragline. The second method used by workers was to get the attention of the dragline operator by walking up to the right side of the machine on the ground where the operator could see the person. The third method was to walk up to the cable hoist controls located on the back of the dragline and actuate the top button on the controls to activate a buzzer in the operator's cab. This would let the operator know that a person wanted to board. There were two separate hoists with controls hanging down within reach of a person standing on the ground at the back of the dragline. A person could activate the buzzer with either set of controls.
9. When a person who did not have a hand-held radio would park out of the swing radius of the dragline and notify the operator with a stationary mounted radio in the vehicle that they needed to board the dragline, the machine would continue to operate while they walked up to the machine. When they got to the machine they would step up to one of the cable controls and "buzz" the operator while the machine was digging or dumping and step back until the operator would swing around to let them board. It would not be necessary to use the buzzer if the operator happened to see them approach.
10. Workers arriving to begin their shift and some maintenance people would typically not have hand-held radios. Some of the workers did not have radios in their vehicles. The workers who did not have radios would have to contact the operator by using the buzzer or get in position near the machine on the ground so the operator could see them when the dragline would swing towards them.
11. The cable hoist controls where the buzzer is activated are located approximately 31 feet from the tub. The outside corner of the right shoe was approximately 34 feet and 10 inches from the tub. A person standing on the ground at the cable hoist controls was located within the swing radius of the dragline shoes.
12. At 6:45 p.m., on 12/26/2002, the dragline was working too close to the spoil side for a person to get in position beside the machine to get the operator's attention from the ground. It was dark, making it nearly impossible for the operator to see a person behind the dragline on the ground in the mirror located on the right side of the operator's cab.
13. When the victim came back to the dragline after 6:45 p.m., on 12/26/2002, the machine was operating too close to the spoil side of the pad for him to safely contact the operator from the ground beside the right side of the machine. The dragline operated in this position until approximately 9:00 p.m., when it moved to a new set.
14. The victim's shift ended at 6:00 p.m., on 12/26/2002. He stayed on the dragline after the end of the shift to take a shower and clean up. He cleaned up by using a makeshift shower every day at the end of his shift.
15. The 2nd shift oiler, Frank Bauer, noticed that the victim had cleaned up when he got off the machine at approximately 6:45 p.m., to leave the mine. Bauer watched the victim go down the steps to the shoe and get onto the shoe. Then Bauer shut the door to the dragline house. Keith Smith, the operator of the dragline, watched the victim get off the shoe and waited until he thought the victim had cleared the shoe before resuming operations.
16. When the day shift operator, Bruce Ude, left the dragline at approximately 6:02 p.m., he noticed that the victim's truck was parked with the vehicles of other workers. The truck was running and parked in the direction facing out of the pit, apparently being warmed up.
17. It was normal for the victim to work over after his normal shift ended. He would also come to work before his shift would begin. He had worked 72.5 hours in the five days preceding the beginning of his shift at 6:00 a.m., on 12/26/2002.
18. When the victim left the dragline at approximately 6:45 p.m., on 12/26/2002, he left his cell phone in the programmable control room on the dragline. It was on charge. The charger was plugged into an electrical outlet with the charger cord extending from a bench across part of the room. The phone and charger cord were readily visible to persons who entered the room. Two missed calls were shown on the phone. They were placed after 1:00 a.m., on 12/27/2002.
19. Blood stains were found on the outer side and bottom of the right dragline shoe between the back of the shoe and the rear ladder. The stains on the outer side of the shoe were approximately 12 feet and 3 inches from the center of the rear ladder of the shoe.
20. According to witnesses, the victim's body was found face down on the ground approximately 12 to 15 feet from the outer edge of the right dragline shoe when the shoe was parallel with the edge of the pad. These measurements were made from the approximate location of the dragline at the time of the accident through about 9:00 p.m., when the machine moved onto a new set.
21. The victim's body was lying approximately 25 to 35 feet from the rear ladder of the right shoe when the dragline swung around to let the oiler, Bauer, off at approximately 8:10 p.m., to move the cable. The machine was not positioned over the body when it set up for the oiler to get off. The area was well lighted.
22. The ground dozer pushed within approximately five feet of the victim's body when the oiler got off the dragline at approximately 1:00 a.m., to push the roll in using the dozer. The roll is material that accumulates at the top edge of the digging face as the dragline works.
23. The dragline moves by utilizing the walking shoes attached to the machine on an eccentric arm rotated by a geared mechanism. The dragline moves approximately nine feet each time it takes a step.
24. The CB radio in the victim's truck had a defective power wire. When it was moved the power would sometimes go off and the radio would not work. It could be moved again and the power would come back on and the radio could be used.
25. The two CB radios, the FM radio, and the company cell phone in the dragline all were in working order at the time of the accident. The CB radio in the Caterpillar D10N ground dozer (Co. No. 20504) and the CB radio and FM radio in the Caterpillar 518 skidder (Co. No. 22103) were in working order at the time of the accident.
26. The company policy required persons to notify the operator before boarding or leaving the dragline and required that persons not board or leave the machine while it was in motion. According to statements made during interviews, workers would often leave and board the dragline at this mine while the machine was in operation. It is unknown when the policy was last discussed with employees. There were no warning signs posted at the dragline to make persons aware of the policy. It was common knowledge among mine personnel that persons did not follow the policy.
ROOT CAUSE ANALYSIS
A root cause analysis was performed using evidence obtained during the accident investigation. The following root causes were identified:
1. The company did not provide oversight to make sure persons followed the policy for boarding and leaving the dragline.
2. When persons who did not have hand-held radios parked out of the swing radius of the machine, the dragline would continue to work while they approached the machine. When the dragline was working close to the spoil side persons did not have room to get beside the machine to make eye contact with the operator. If the operator failed to stop to let them board because he was not aware they were in position to board, the person would often use the buzzer to contact him. Statements of witnesses indicated that they would use the buzzer, presumably because that was more convenient, even though radios were available in the ground dozer and skidder. The company did not establish alternatives to this procedure.
3. The boarding ladders on the dragline shoes were easily accessible and provided an opportunity for persons to board or leave the machine while it was operating without the operator being aware of what the person was doing. The location of the buzzer controls made them accessible to persons on the ground. Persons would use these controls on occasion while the machine was operating to make the operator aware that they wanted to board the dragline.
The investigation team concluded that the direct cause of the accident was that the victim received multiple crushing injuries when struck by the right walking shoe of the dragline while he was within the swing radius of the operating machine. Indirect causes of the accident were that the victim approached to board the dragline while it was operating and did not notify the operator to make him aware that he was going to board the machine. The root causes of the accident were the failure of management to enforce its policy governing boarding and leaving the dragline, management's failure to provide alternatives for communication for all persons approaching the dragline from the parking area, the opportunity for persons to board or leave the dragline without the knowledge of the operator, and the accessibility of the buzzer controls to persons standing on the ground within the swing radius of the machine.
A 103(k) Order, No. 7185876, was issued to Catenary Coal Company, to ensure the safety of all persons at the mine until all areas and equipment were deemed safe.
A 104(a) citation, No. 7185878 was issued to Catenary Coal Company, for a violation of 30 CFR, 77.409 (a) stating in part that the dragline was being operated in the presence of the oiler who was exposed to the hazard of being struck by the machine because he was located within the swing radius of the machine.
A 104(a) citation, No. 7185879 was issued to Catenary Coal Company, for a violation of 30 CFR, 77.1607 (f) stating in part that the victim did not notify the dragline operator before attempting to get on the machine.
Related Fatal Alert Bulletin:
Sketch of Site (PDF File) Photo of Site (PDF File)
Listed below are the persons furnishing information and/or present during the investigation.
Catenary Coal Company
Peter Lawson .......... PresidentARCH COAL, INC.
Eddie Turner .......... Mine Manager
Terry Tolley .......... Manager of Safety
Mark Heath .......... Attorney
Norris Dyer .......... Safety Technician
Bryant Fletcher .......... Miners' Representative
Mike Colgrove .......... Miners' Representative
Jeff Calwell .......... Engineer
Frank Ellison .......... Transit Man
Keith B. Smith .......... Dragline Operator
Frank Bauer .......... Dragline Oiler
Rodney Cairns .......... Superintendent
Thomas E. Bass .......... Foreman
Bruce Ude .......... Dragline Operator
Nick Pack .......... Foreman
Charles Russell III .......... Director of SafetyWEST VIRGINIA OFFICE OF MINERS' HEALTH, SAFETY, AND TRAINING
Gary S. Snyder .......... Inspector-at-LargeMINE SAFETY AND HEALTH ADMINISTRATION
Terry L. Keen .......... Surface Mine Inspector
Michael Rutledge .......... Safety Instructor
Sherman L. Slaughter .......... Surface Coal Mine Safety and Health Specialist/Accident InvestigatorThe following persons were interviewed during this investigation:
James Beha .......... Mine Safety and Health Specialist / Accident Investigation Coordinator
Aubrey T. Castanon .......... Supervisory Coal Mine Health and Safety Inspector
Terry Willis .......... Coal Mine Safety and Health Inspector (Electrical)
Mike Hess .......... Coal Mine Safety and Health Inspector
Gilbert Young .......... Coal Mine Safety and Health Inspector
CATENARY COAL COMPANY
Franklin Bauer .......... Dragline Oiler
Keith B. Smith .......... Dragline Operator
Thomas E. Bass .......... Foreman
Nick Pack .......... Foreman
Rodney Cairns .......... Superintendent