DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface Coal Mine
Fatal Machinery Accident
December 28, 2002
T & M Welding (XKH)
K-3 Surface Mine
Appalachian Fuels, LLC
Inez, Pike County, Kentucky
ID No. 15-17718
Robert J. Newberry
Coal Mine Safety and Health Surface Inspector
Mine Safety and Health Administration
100 Fae Ramsey Lane
Pikeville, KY 41501
Franklin M. Strunk, District Manager
Release Date: February 21, 2003
At approximately 10:45 a.m. on Saturday, December 28, 2002, a 23-year-old welder was fatally injured when he was pinned between the inside wall of the truck bed and the bucket of a hydraulic excavator. The victim was inside the truck bed preparing to weld a steel plate liner to the front of the bed. The accident occurred at the maintenance area of the K-3 Surface Mine of Appalachian Fuels, LLC
The mechanical condition of the excavator was investigated as a possible cause of the accident, but no defects were found. The procedure being used to attach the steel plate liner and the lack of training of both the victim and the operator of the excavator endangered the victim and other persons present in the truck bed.
Appalachian Fuels, LLC, K-3 Surface Mine, is located on Kentucky Route 40 approximately one mile southwest of the intersection of Kentucky Route 645 and Kentucky Route 40 near Inez, Martin County, Kentucky. The main office is located at 1500 North Big Run Road, Ashland, Kentucky. David Maynard is the general superintendent and Keith Smith is the safety director.
Mining Machinery, Inc. is an independent contractor (I.D. XDN) specializing in leasing, maintaining, and repairing heavy equipment. The main office is located at 1512 North Big Run Road, Ashland, Kentucky. Jeff Suttle is the vice-president of sales and Grover Benjamin Sargent is the foreman. Although Sargent is not certified in the state of Kentucky as a foreman, he was directing the workers at the time of the accident.
T & M Welding is an independent contractor (I.D. XKH) specializing in welding repairs of heavy equipment. The main office is in Verdunville, WestVirginia and the employees work out of a shop building located near Naugatuck, West Virginia. Mark Bryant is the owner of T & M Welding.
Appalachian Fuels, LLC, K-3 Surface Mine, began production on June 3, 2002, using mountaintop removal and contour methods of mining. The spoil from the mountaintop and contour mining processes is deposited in hollow fills located on Porter Branch and Lower Wolf Branch of Rockhouse Creek. Coal is produced from one active pit using highwall drills, a 992 Caterpillar Loader and Caterpillar Rock Trucks and produces about 1200 tons per shift. The accident occurred in the maintenance area of the mine.
This mine employs 27 persons and operates two ten-hour shifts, five days a week. Maintenance is conducted between shifts and on-shift as needed or scheduled. The last regular safety and health inspection of the mine was completed on September 25, 2002.
On December 20, 2002, production had ceased at the mine in observance of a holiday vacation period. Production was scheduled to resume on December 30, 2002. Consequently, at the time of the accident no production employees were present on mine property.
The principal company officers and officials as shown on the Legal Identity Report for Appalachian Fuels, LLC are:
John C. Smith . . . . . . . . . President
Bernie Mason . . . . . . . . . Vice-President
David Maynard . . . . . . . . . General Superintendent
Keith Smith . . . . . . . . . Safety Director
On the day of the accident, welders Clarence Matthew Copley (victim) and Henry Hundley met Mark Bryant, owner of T & M Welding, at 6:00 a.m. at the T&M shop, located at Triad Mining near Naugatuck, West Virginia. Bryant transported Copley and Hundley to Appalachian Fuels, LLC, K-3 Surface Mine, arriving at 7:00 a.m. Grover Benjamin Sargent, foreman and Jerry Runyon, welder, employees of Mining Machinery, Inc., were already at the mine. Sargent, Runyon, Copley and Bryant began preparations to install a 1-inch thick steel plate liner to the front of the bed of a Caterpillar 777C Rock Truck. They began by using an oxygen-acetylene torch to cut a piece of the steel plate to fit the area to be re-lined. This steel plate was 182 �-inches by 54-71-inches. Bryant received a phone call and left the mine to go to another job site off mine property.
Runyon then lifted the cut piece of steel plate into the bed of the truck using a Caterpillar 330 BL Hydraulic Excavator. A chain was used to attach the steel plate to the excavator bucket. Sargent was directing the work of Runyon, Copley, and Hundley. As the steel plate was lowered into the bed of the truck, Sargent, Copley and Hundley guided it into place. The plate was too large to fit so it was hoisted back to the ground and Hundley used a torch to trim the piece on one side. The steel plate was placed back into the truck bed. Sargent, Copley and Hundley once again guided the steel plate into place by hand as the excavator lowered it into the truck bed. Upon obtaining a better fit this time the boom of the excavator was lowered into the truck bed and the chain released from the bucket.
As the bucket of the excavator was suspended near the front center of the truck bed, Sargent began to call out instructions to Runyon who was still in the operator's cab of the machine which was running at about half-throttle. Hundley left the bed of the truck to adjust the welding machine that was located on a GMC 600 truck parked beside the excavator. The welding truck contained two welders and a compressor, which were all running. Copley was positioned between the suspended bucket of the excavator and the inside wall of the truck bed.
Runyon was having difficulty hearing Sargent's instructions due the noise of the engine of the excavator, the welders and the compressor. Runyon's efforts to hear the instructions were further limited because the excavator door would not latch in the open position. Runyon raised out of the seat and leaned out of the door (which he was holding open with his left forearm) of the excavator, to hear Sargent's instructions. Sargent instructed Runyon to use the bucket of the excavator to press the steel plate against the bed of the truck so that Copley and Hundley could tack-weld the steel plate in place. As Runyon returned to the operator's seat he inadvertently contacted the left joystick control, which caused the boom and bucket of the excavator to swing to the right, pinning Copley between the bucket and the inside wall of the truck bed.
Upon seeing the excavator swing Sargent turned and saw Copley pinned against the truck. Sargent called to Runyon to swing the bucket away from Copley. Sargent went to aid Copley and helped him to the floor of the truck bed. Sargent told Runyon and Hundley to tend to Copley. Sargent attempted to call 911 on his mobile phone but was unsuccessful because of a lack of signal. He got in his pickup to go to a better location on mine property to obtain a stronger signal. Sargent met Roger Brown, mechanic and trained Mine Emergency Technician, and instructed him to go to the aid of Copley. After changing locations, Sargent was able to call 911 and an ambulance was dispatched to the scene, arriving approximately twenty minutes after the accident occurred. After the ambulance arrived, the excavator was moved to allow access to Copley. First aid efforts at the scene by the ambulance technicians were unsuccessful however, and Copley was pronounced by the Martin County Coroner at 11:28 a.m.
Thomas Meredith, Assistant District Manager (Technical Division), received a telephone call at 11:05 a.m. from Roger Brown, a mechanic at the mine, informing him of the fatal accident. Meredith called Anthony Webb, Accident Investigation Coordinator, who in turn called Robert Newberry and Debra Howell, accident investigators. Meredith and Newberry traveled to the mine and arrived at about 1:00 p.m. Howell arrived a short time later. Representatives of Mining Machinery, Inc., Appalachian Fuels, Inc., T & M Welding, the Kentucky Department of Mines and Minerals (KYDMM) and the Martin County Coroners Office were also present at the scene.
A 103-K order was issued by MSHA to assure the safety of all persons until the accident investigation could be completed and the K-3 Surface Mine determined to be safe.
Interviews were conducted on December 30, 2002 at the Martin District Office of the KYDMM in Martin, Kentucky. Eight persons, deemed to have relevant information concerning the accident, were interviewed jointly by MSHA and Kentucky Dept. of Mines and Minerals. The sessions were recorded on audio tape with the consent of the interviewees, and a written transcript was later produced for the investigation file. Grover Benjamin Sargent declined to be interviewed at that time.
Ronald Medina, mechanical engineer from MSHA Technical Support, examined the hydraulic excavator on-site for machine defects that may have contributed to the accident. No defects were found.
The 103-K order was terminated on January 6, 2003, after the operator developed and implemented a program to prevent a similar occurrence and had reviewed this program with the equipment operators.
Anthony Webb and Robert Newberry visited the victim's father and fiancee` on January 8, 2003, to discuss preliminary information gathered during the accident investigation.
The investigation revealed the following factors relevant to the occurrence of the accident .
1. The Caterpillar track-type, Model 330BL excavator was equipped with a 1.88 cubic yard bucket. The bucket was 50 inches wide and had five teeth. A Caterpillar Model 3306B, 222 horsepower, six cylinder, turbocharged diesel engine, Serial No. 6NC16878, powered the excavator. The operating weight of the excavator was 74,500 lbs.
2. The direction of travel and steering functions were controlled by two foot-operated treadles that were mechanically linked to two hand-operated levers located in front of the operator. When tested, these travel controls operated as described in the Operator's Manual. Pushing the handles forward or moving the treadles forward caused forward travel. Pulling the handles back or moving the treadles back caused reverse travel. When the handles or treadles were released, they returned to the neutral position and the machine stopped. Steering was accomplished using the same controls. A right turn was accomplished by moving the left handle/treadle forward while leaving the right handle/treadle in neutral position. Faster and sharper right turns were accomplished by moving the left handle/treadle forward while moving the right handle/treadle rearward. Left turns were accomplished using the controls in the same manner as used for right turns.
3. The Operator's manual refers to the three major components of the excavator arm as the boom, stick, and bucket. The right side work equipment control joystick controls the functions of the boom and bucket. When tested, the control functioned as described in the Operator's Manual. Pulling the control back, raised the boom. Pushing the control forward, lowered the boom. Moving the control to the left corresponded to the bucket curl position, and moving the control to the right corresponded to the bucket dump position. When the control lever was released, it returned to the neutral position and the boom and bucket remained in the position in which they stopped.
4. The left side work equipment control joystick controls the functions of the stick and cab/boom swing. When tested, the control functioned as described in the Operator's Manual. Pushing the control forward moved the stick away from the machine. Pulling the control back, moved the stick toward the machine. Moving the control to the left, caused the upper structure to swing to the left. Moving the control to the right, caused the upper structure to swing to the right. When the control lever was released, it returned to the neutral position and the stick and upper structure remained in the position in which they stopped.
5. The hydraulic activation control lever functioned as described in the Operator's Manual. This control lever was located on the left side of the left console beside the operator. The console was stationary. When the hydraulic activation control lever was pulled back into the "locked" position, the travel, swing, boom, stick, and bucket movement controls were deactivated. In tests conducted with the engine running and the controls locked out, the machine did not move when any of the travel or work equipment controls were operated. When the hydraulic activation control lever was pushed forward into the "unlocked" position, the travel, swing, boom, stick, and bucket controls were functional. When in the "unlocked" position, a flexible fiberglass rod flipped up to block the door of the operator's compartment. When in the "locked" position, the fiberglass rod flipped down to allow entry and exit from the operator's compartment. The door was located to the operator's left. It was reported that the hydraulic activation control lever was in the "unlocked" position when the accident occurred.
6. The excavator was provided with an electronic work mode selector that permitted the operator to choose from four working modes: boom priority mode, swing priority mode, fine control mode, and user mode. The Operator's Manual provided the following descriptions of each work mode and examples of applicable work in each mode. The boom priority mode increases the boom up speed and is used in short swing loading, deep trenching, and level finishing. The swing priority mode is used in truck loading or trenching with a large swing angle, and is recommended when greater swing force is needed. The fine control mode uses 70% of available engine power and is used in lifting work and precise finishing work. The user mode allows personalized machine characteristics to be programmed and recalled.
7. The boom was raised and lowered, the stick was moved outward and drawn back toward the machine, the bucket was tilted up and down, and the upper structure was swung left and right numerous times. All these movements were smooth with no abnormalities. These tests were conducted in all of the work modes.
8. The operator's compartment door was provided with a latch that was designed to hold the door in the fully open position. This latch feature did not function to hold the door open.
9. The steel plate being welded to the inside front wall of the truck body at the time of the accident was 182-� inches wide, 61 inches to 74 inches high, and one inch thick. It weighed 3,470 pounds.
10. The boom, stick, bucket, travel and swing functions were tested and no equipment defects were found.
11. Three co-workers were in the immediate area and observed the victim caught between the excavator bucket and the inside wall of the truck bed immediately after the accident occurred.
12. The coroner's report listed the cause of death as abdomen and lower chest trauma.
13. An autopsy was not performed on the victim.
14. Although the ground conditions were muddy in the area, the weather was clear.
The investigation and root cause analysis of the accident focused on three possible causal factors: equipment failure, safe job procedures, and training.
An examination and test of the excavator's mechanical and hydraulic systems revealed no evidence that either of these systems failed. The latch provided to hold the door of the operator's compartment open was not functioning and may have contributed to the operator's inability to hear verbal instructions from persons located in the truck bed.
The root cause of the accident was the lack of training for the victim and the excavator operator. This lack of training was deemed to have directly contributed to the occurrence of the accident. Task training would have familiarized the excavator operator with the need to disengage the Hydraulic Activation Control prior to leaving the operator's seat. Had the victim received hazard training he would have been aware of the need to "stay clear of moving equipment" as detailed in the operator's hazard training checklist.
The primary cause of the accident was the lack of an established safe job procedure for installing steel plate liners inside truck beds. The practice of persons being positioned inside the truck bed alongside the bucket and boom of the excavator was the major contributing factor in the accident.
1. 103(k) Order No. 7396400 was issued to protect persons from possible hazards until the investigation could be conducted
2. 104(d)(1) Citation No. 7397081 was issued to Mining Machinery, Inc. because the operator of the Caterpillar 330 BL Hydraulic Excavator placed the machine in motion without all persons being clear as required by 30 CFR 77.1607(g)
3. 104(d)(1) Order No. 7397082 was issued to Mining Machinery, Inc. because the Caterpillar 330BL Hydraulic Excavator being used to hoist, place, and press a steel plate liner inside the dump bed of a Caterpillar 777C Rock Truck was operated by a welder/mechanic who had not been trained to operate the excavator as required by 30 CFR 77.404(b).
4. 104(a) Citation No. 7397083 was issued to Appalachian Fuels, LLC. because the Caterpillar 330BL Hydraulic Excavator being used to hoist, place, and press a steel plate liner inside the dump bed of a Caterpillar 777C Rock Truck was operated by a welder/mechanic who had not been trained to operate the excavator as required by 30 CFR 77.404(b).
5. 104(d)(1) Order No. 7397084 was issued to Mining Machinery, Inc. because Jerry Runyon, welder, had not received Task Training in the safe operation of a Caterpillar Hydraulic Excavator as required by 30 CFR 48.27
6. 104(d)(1) Citation No. 7397085 was issued to Appalachian Fuels, LLC. because Jerry Runyon, welder for Mining Machinery, Inc., had not received Task Training in the safe operation of the Caterpillar Hydraulic Excavator as required by 30 CFR 48.27.
Related Fatal Alert Bulletin:
Bernie Mason . . . . . . . . . Vice-President
Everett Gibbs . . . . . . . . . Superintendent
Kenny Colvin . . . . . . . . . Foreman
Keith Smith . . . . . . . . . Safety Director
Tracy Stumbo . . . . . . . . . Chief Investigator
Randy Smith . . . . . . . . . District Supervisor
Bobby Sexton . . . . . . . . . Safety Inspector
Jerome Howard . . . . . . . . . Safety Analyst
Robert Newberry . . . . . . . . . Mining Engineer
Ronald Deaton . . . . . . . . . Training Specialist
Debra Howell . . . . . . . . . Coal Mine Inspector (surface)
Thomas Meredith . . . . . . . . . Assistant District Manager
Ronald Medina . . . . . . . . . Mechanical Engineer
List of Persons Interviewed
Keith Smith . . . . . . . . . Safety Director, Appalachian Fuels, LLC
Mark Bryant . . . . . . . . . Owner, T & M Welding
Henry Hundley . . . . . . . . . Welder, T&M Welding
Jerry Runyon . . . . . . . . . Welder/Mechanic, Mining Machinery, Inc.
Grover Benjamin Sargent . . . . . . . . . Foreman, Mining Machinery, Inc.
Everitt Gibbs . . . . . . . . . Superintendent, Appalachian Fuels, LLC
Kenny Colvin . . . . . . . . . Foreman, Appalachian Fuels, LLC
Clayburn Lewis . . . . . . . . . Excavator Operator, Appalachian Fuels, LLC
Roger Brown . . . . . . . . . Mechanic, Mining Machinery, Inc.