DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 7
ACCIDENT INVESTIGATION REPORT
(Underground Coal Mine)
FATAL FALL OF ROOF ACCIDENT
Leeco Inc.
Maces Creek Mine
I.D. No. 15-17911
Viper, Perry County, Kentucky
March 2, 1998
by
Billy A. Parrott
and
William R. Johnson
Coal Mine Safety and Health Inspectors
Originating Office-Mine Safety and Health Administration
HC 66 Box 1762, Barbourville, Ky 40906
Joseph W. Pavlovich, District Manager
Date of Release: June 12, 1998
OVERVIEW
On Monday, March 2, 1998, at 10:30 p.m. a roof fall accident occurred in the No. 3 entry of the 001 section. Michael D. Baker, a 29 year old roof bolting machine operator with nine (9) years and twenty-five (25) weeks total experience, was fatally injured when a section of the mine roof fell resulting in crushing injuries. The fallen rock measured eleven (11) feet by seven (7) feet and ranged from one (1) to twelve (12) inches in thickness.
Baker and Eddie Noble Jr., both roof bolting machine operators, were in the process of installing a temporary roof support inby permanent supports. The mine roof had been cut to a height of ten (10) feet in this area to allow for the future installation of an overcast and belthead. As a result of the additional height created, the Automated Temporary Roof Support (ATRS) system on the roof bolting machine would not contact the mine roof, necessitating the use of temporary supports.
The investigation revealed that multiple factors contributed to the accident. The No. 3 entry had been advanced to a depth of forty (40) feet despite a plan provision which stated that the maximum cut depth "when conditions or circumstances exist that the ATRS cannot be used," will be twenty (20) feet. The depth of the cut taken effectively doubled the amount of unsupported roof specified as maximum in the plan (20 feet). Also, contributing to the accident was the practice of installing temporary roof supports in a manner not consistent with the provisions of the approved roof control plan. The center post was being installed first, which subjected Baker and Noble to the greatest possible span of mine roof, near the middle of the entry.
The Leeco, Inc., Maces Creek Mine is located at Viper, Perry County, Kentucky. The mine is operated in the Hazard No. 4 seam through drift openings. The company employees forty-two miners on three shifts, forty underground and two on the surface. The mine produces two thousand, one hundred (2100) tons of coal per shift. Coal is transported to the surface on conveyor belts. The mine operates two production shifts and one maintenance shift per day, five days per week, eight hours per shift.
Coal reserves mined are owned by Ray Coal, Inc., Kentucky River Coal Co., and John Chris Cornett.
The maximum overburden is approximately seven hundred and fifty (750) feet. The mine roof is supported with roofbolts, resin rods, or tension rebars, depending upon roof conditions. The minimum length for overhead roof support is forty-eight (48) inches. Entries are advanced on forty-five (45) foot centers and crosscuts are mined on fifty (50) foot centers.
Mitchell Mosley is the miner's representative at this mine. The miners are not otherwise represented by a bargaining unit.
The last regular (AAA) Mine Safety and Health Administration (MSHA) inspection was completed February 25, 1998.
The principal officers of the operation are as follows:
Amon Tracy, General Superintendent;
Arnold Lowe, Mine Superintendent;
Fred Shannon, Safety Director
DESCRIPTION OF THE ACCIDENT
On Monday, March 2, 1998 at approximately 2:30 p.m. the second shift crew of the 001 section began their normal work duties. The crew, under the supervision of Wayne Brock, section foreman, traveled to the 001 section to prepare for the evenings production. After arriving at the working section, Michael D. Baker, Jr., victim, and Eddie Noble, Jr. were each assigned to their regular job task of roof bolting machine operators. Together they operate a twin head Fletcher roof bolting machine.
The second shift continued normally throughout the evening. At 10:10 p.m. Brock phoned the results of the pre-shift examination for the third shift to the surface. It was received by Andrew Sumner. The recorded results of the preshift examination showed that the No. 3 heading was not bolted and was dangered off.
At approximately 10:15 p.m. Baker and Noble trammed the roof bolting machine into the No. 3 heading to begin installing roof bolts. The continuous mining machine had just mined a cut of coal in this heading. Baker reportedly cleaned the dust collector box on the roof bolting machine and the two miners spot-bolted additional roof bolts along the ribs. They repaired some loose straps outby the cut and also drilled a test hole into the mine roof.
Noble then positioned the roofbolting machine to begin bolting the cut. Baker was on the left side of the roofbolting machine helping Noble to properly align the machine. The mining height in this area had been increased to allow for the future installation of an overcast and a conveyor belt head drive. As a result of the additional height of the mine roof, the Automated Temporary Roof Support (ATRS) system on the roof bolting machine would not contact the mine roof to give support and protection against falling material. Noble stated that at approximately 10:30 p.m., he and Baker were attempting to install a temporary support jack (jack) inby the A.T.R.S. system. Baker had helped him free the jack from the top of the roof bolting machine and had come around to the right side to assist him. The jack proved to be too long for that particular location. Noble was attempting to lay the jack down when Baker came up to assist him. As they were laying the jack down, Noble reportedly heard the roof crack and called for Baker to run. Noble ran to the left side of the machine and Baker was struck by the falling mine roof while attempting to run to the right side of the roof bolting machine.
When Noble realized that Baker had been struck by the falling roof he summoned help. Freddie Coleman, repairman and EMT, arrived at the scene to assist. Coleman had been repairing the front mobile bridge carrier in the No. 3 entry approximately one hundred feet outby when the accident occurred. Noble and Coleman moved Baker to the rear of the roof bolting machine. At this time Coleman began to administer CPR to Baker. When other miners arrived with first aid supplies and a three wheeled personal carrier Baker was placed on a stretcher, loaded on the personal carrier and transported to the track. He was then transferred to a track mounted mantrip and transported to the surface. After approximately ten minutes an ambulance arrived and Baker was transported to the hospital. CPR was continuously administered from the 001 section until the ambulance arrived. Baker was subsequently transported to the Hazard Appalachian Regional Hospital located in Hazard Kentucky. Baker was pronounced dead at 12:37 a.m. on March 3, 1998.
INVESTIGATION
At approximately 11:55 p.m. on March 2, 1998 Joe Burke, MSHA Supervisor in Hazard, KY, was notified by Pat Schoolcraft that a serious accident had occurred. Burke immediately dispatched Don Baker, Inspector, to the mine. A 103 (K) Order was issued by Baker at 1:15 a.m. March 3, 1998 to ensure the safety of the miners until an investigation could be conducted. Billy A. Parrott and William R. Johnson, MSHA Accident Investigators, were notified and arrived at the mine at approximately 9:00 a.m. March 3, 1998 to conduct the investigation. MSHA and the Kentucky Department of Mines and Minerals jointly conducted the investigation with assistance of mine management, miners, and representatives of the miners. Joseph Luckett, attorney, U.S. Department of Labor, Office of the Regional Solicitor, Nashville, Tennessee, also assisted in the accident interviews.
PHYSICAL FACTORS
The investigation revealed the following factors relevant to the
occurrence:
- The No. 3 entry had been cut to a height of approximately
ten (10) feet to allow for the future installation of an
overcast and belt drive in the area.
- The maximum extended height of the Fletcher roof bolting
machine's integrated ATRS was eight (8) feet and one (1) inch.
- The normal mining height in this area is approximately five
(5) feet.
- The immediate roof in the area of the accident is laminated
shale approximately seven (7) feet in thickness. The main
roof is sandy shale approximately five (5) feet in
thickness. Six (6) foot resin roof bolts were being
installed in the entry.
- The entries were being advanced on forty-five (45) foot
centers and crosscuts on fifty (50) foot centers.
- The No. 3 entry had been advanced to a depth of forty (40)
feet. The entry width at the location of the accident was
twenty-one and one half (21.5) feet.
- Inspection of the working section after the accident
revealed loose, cracked and broken roof along the right rib
in the unsupported cut of the No.3 entry. Material
continued to fall in the cut while the investigation was on
going.
- The roof bolting machine being used at the time of the
accident was a Fletcher DDD-15-E twin head, S/N 85009.
- The temporary roof support jack being installed was a mine-manufactured and was of a screw type. The length of the jack when measures after the accident was ten (10) feet and six (6) inches. The jack has an adjustable range of eighteen (18) inches.
DISCUSSION
Examination of records indicated that all required training had been conducted in accordance with Part 48, Title 30 CFR. Baker received Newly Employed, Experienced Miner training January 13, 1998 and Roof Bolting Machine Operator New Task training January 15, 1998. Baker received his Annual Refresher training on January 31, 1998.
The Maces Creek Mine was placed in producing status on August 4, 1997.
Prior to this fatal accident the mine had reported five falls of roof between September 16, 1997 and February 3, 1998. The Roof Control Plan, approved July 11, 1997 and revised January 9, 1998, includes several safety precautions to protect miners from fall of roof accidents. The following precautions are included;
"(1) In the event the ATRS will not reach the roof in fall areas, one (1) row of temporary supports will be installed on not more than five foot centers and advanced as clean-up progresses.
(2) When adverse roof conditions are encountered, the depth of cut shall be limited to a distancecompatible with the roof conditions."
(3) When conditions or circumstances exist that the ATRS cannot be used the approved plan dictates that the cut depth would be a maximum of twenty (20) feet.
(4) When conditions or circumstances exist that the ATRS cannot be used the approved plan dictates that the cut width would be a maximum of twenty (20) feet.
(5) Page 3 of the approved Roof Control Plan Supplement dated January 9, 1998, described the sequence of installation of temporary support jacks. The plan required that initial temporary support jacks be installed beginning adjacent the coal rib and progressing to the center of the entry to afford protection for roof bolt installation. Upon installation of a complete row of roof bolts, the sequence is repeated for roof bolts to be installed inby.
A subsequent inspection conducted in conjunction with the accident investigation, found three other locations on the working section where wide entries existed. Citations were issued for excessive entry widths at corner clips in the crosscuts between the Number One and Number Two entries and between the Number Four and Number Five entries. Also a citation was issued for a violation observed in the crosscut between the Number Two and Number Three entries stating, in part, that the entry width was from twenty (20) to twenty-three (23) feet wide. A citation was also issued for two resin roofbolts having exposed bolt lengths and for loose draw rock in the Number Four working face. Finally, a citation was issued in the Number One working face stating, in part, that the distance from the last row of permanent support to the face exceeded four (4) feet as required by the approved plan. These violations were not cited as being contributory to the accident.
SUMMARY AND CONCLUSION
The following factors contributed to the accident. The No.3 entry had been advanced to a depth of forty (40) feet despite a plan provision which stated that the maximum cut depth "when conditions or circumstances exist that the ATRS cannot be used," will be twenty (20) feet. The depth of the cut taken effectively doubled the amount of unsupported roof specified as maximum in the plan (20 feet). Also, contributing to the accident was the practice of installing temporary roof supports in a manner not consistent with the provisions of the approved roof control plan. The center jack was being installed first, which subjected Noble and Baker to the greatest possible span of mine roof, near the middle of the entry.
ENFORCEMENT ACTIONS
- 103-K Order, no. 4719710, was issued to assure the safety of
any person in the coal mine until the investigation could be completed.
- A 104-D-1 citation, No. 7450229, for violation of Title 30,
Part 75.220(a)(1) was issued stating in part that the
operator was not following the approved roof control plan in
that the cut depth in the No. 3 entry, forty (40) feet, was
not limited to twenty (20) feet as required by the roof
control plan when "conditions or circumstances exist that
the ATRS cannot be used". The entry width, twenty-one and
one half (21.5) feet, was not limited to twenty (20) feet as
required by the plan. Also the cut depth was not compatible
with the roof conditions as required by the plan.
- A 104-A citation, No. 7450230, for violation of Title 30, Part 75.209(c)(1) was issued stating in part that safety jacks were not being installed in the sequence approved in the roof control plan. Also the first jack was not being installed within five (5) feet of the rib on either side of the entry as required by the plan.
Submitted by:
Billy A. Parrott
Coal Mine Safety and Health Inspector
William R. Johnson
Coal Mine Safety and Health Inspector
Approved by:
John M. Pyles
Assistant District Manager
for Enforcement
CMS&H, District 7
Joseph W. Pavlovich
District Manager
CMS&H, District 7
Related Fatal Alert Bulletin:
FAB98C07