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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 5

ACCIDENT INVESTIGATION REPORT
(SURFACE AREA-UNDERGROUND COAL MINE)

FATAL MACHINERY


Buchanan Mine #1 (ID No. 44-04856)
Consolidation Coal Company
Mavisdale, Buchanan County, Virginia


November 22, 1998

by


Benjamin S. Harding
Mining Engineer


Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, VA 24273
Ray McKinney, District Manager

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 by eight shafts. Employment is provided for 345 persons. A total of 306 underground and 39 surface employees work on three production shifts per day, seven days per week. The surface area of the mine includes a large preparation plant which produces 10,000 tons of clean coal per day. Coal is cleaned, dried, stockpiled, and loaded into unit trains for transport or into trucks which deliver coal to the mine's impoundment area for storage when stockpiles are at or near capacity. The preparation plant area includes raw and clean coal silos, stockpile, and loadout facilities.

The principal management personnel in charge of the mine at the time of the accident were:

Mine SuperintendentJ. Michael Onifer
Mine ForemanRoy Duty
Plant SuperintendentTom Burton
Plant ForemanDwight Eades

The last regular Safety and Health Inspection(AAA) was completed on September 30, 1998; however, due to the size of the mine, a safety regular and health inspection is continuously ongoing.


DESCRIPTION OF ACCIDENT

On Saturday, November 21, 1998, at 11:30 P.M., the midnight shift crew comprised of twelve miners at the preparation plant began their shift under the supervision of Dwight Eades, Plant Foreman. Eades' shift began at 7:30 P.M. The plant was idle and repairs begun on the previous shift were continuing. The draw-off belt conveyor under the clean coal stockpile was operating to load coal into trucks for transportation to the impoundment area for storage. None of the draw-off belt conveyor feeders were operating as the stockpile was gravity feeding onto the belt conveyor. At approximately 1:00 A.M., Eades traveled by pickup truck to the impoundment area to check a pump and later returned to the plant.

Repairs were completed in the plant and startup procedures began at 1:30 A.M. By 2:00 A.M. the plant was operational. At 2:30 A.M. Jessie Vance Jenkins, Jr., Mobile Equipment Operator, returned to the plant office from the skip shaft area where he had been moving coal with a dozer since the start of the shift. At 3:00 A.M. Eades instructed Jenkins to assist with repairs on a floor brace in the plant. At 4:30 A.M. Eades instructed Jenkins to take a dozer to the clean coal stockpile and move coal away from the stacker.

Jenkins reported by radio to Arthur W. Booth, Jr., Control Room Operator, that he was entering the stockpile area at 4:55 A.M. Booth logged the contact. Jenkins called Scott L. Graves, Dryer Operator, and told him that the No. 2 Feeder was feeding coal. At 5:25 A.M. Booth called Jenkins on the radio and received no response. Booth contacted Graves and asked him to go to the head house and see if he could locate Jenkins. Booth also notified Eades of the situation. Eades immediately obtained a vehicle and drove around the road beside the stockpile. Neither Eades nor Graves saw Jenkins or the dozer. The plant was then shut down completely including the draw-off belt conveyor. Bobby Berry, Plant Electrician, took another dozer onto the stockpile to look for Jenkins. He was unable to locate Jenkins and realized that the dozer must be in a void over a feeder. He located dozer tracks that ended at the edge of a void over the No. 1 Feeder. Within this approximate 15 minute time frame, personnel from both the plant and mine had begun to gather. Craig Chadwell, Assistant Mine Foreman, traveled up the overhead stacker belt line catwalk and reported seeing metal in the No. 1 Feeder. Berry reported seeing two to three feet of the dozer blade at the same location.

Eades contacted Tom Burton, Plant Superintendent, at home and asked him to begin emergency procedure contacts. Burton did this by cellular phone as he traveled to the mine site. Eades brought in every available piece of earth moving equipment and immediately began moving coal away from the No. 1 Feeder area. Members of Consolidation Coal Company's mine rescue team arrived and assisted in the recovery. Personnel from the Mine Safety and Health Administration and the Virginia Department of Mines, Minerals, and Energy arrived at various times and assisted in and monitored the recovery operation.

Jenkins was extricated from the dozer at 1:12 P.M. and transported by ambulance to Buchanan General Hospital in Grundy, Virginia where he was pronounced dead by Dr. Joseph Segen, Buchanan County Medical Examiner.


PHYSICAL FACTORS INVOLVED

The investigation revealed the following factors relevant to the occurrence of the accident:

  1. There were no eyewitnesses to the accident.

  2. The accident occurred at the clean coal surge pile. The pile has one stacker tube and four feeders. The feeders are 50 feet apart, with two feeders on each of the stacker tube. The clean coal is predominantly fine-grained, with a top size of 1.75 inches.

  3. The stockpile was approximately 600 feet long and 300 feet wide at its base. The width of the pile is restricted by a public road on the east side and railroad tracks on the west. The pile was approximately 60 feet high at the time of the accident.

  4. Large orange plastic balls are used as overhead markers to identify the location of each feeder. These markers are suspended, using a pulley system which allows the height of the balls to be adjusted up or down as the height of the pile varies. The marker height can be adjusted remotely by the dozer operators using an automatic garage door type control. Statements by dozer operators indicated that the remote controls did not always function properly.

  5. The feeders are General Kinematics Un-Coalers, a vibratory type, without gates. The feeder opening size is approximately 4 feet by 1 foot. At the time of the accident, none of the vibratory feeders were activated. When Jenkins arrived on the stockpile he reported that the No. 2 Feeder was feeding coal. The draw-off belt conveyor was operating and coal was being conveyed to a bin which was being used to load trucks.

  6. The feeders are not designed to deliver coal by gravity when deenergized. There are no gates or other devices to prevent gravity flow of material. According to the manufacturer, the feeders are designed to stop gravity flow of material utilizing an interior baffle plate and the material's angle of repose. The size and moisture content of the material affects the angle of repose and can allow gravity flow. Coal is drawn off the bottom of the stockpile by the draw-off belt conveyor, which is fed by the four identical vibratory feeders. The draw-off belt conveyor is capable of transporting coal from only two energized feeders at a time.

  7. According to various statements, all of the feeders did gravity feed on occasion. All persons interviewed stated that the No. 2 Feeder would normally gravity feed more than the others. No evidence was found to explain this, as all feeders are identical. Everyone interviewed stated if coal was feeding onto the draw-off belt conveyor and no feeders were energized, it was coming from the No. 2 Feeder. This assumption was based on past examinations and experience. According to company records, the No. 1 Feeder was last operated on November 14, 1998.

  8. Plant employees utilize a notification system for the dozer operators working on the stockpile. Before going on the stockpile, the dozer operator contacts the control room operator to ensure that the radios are working. While a dozer is operating on the stockpile, the control room operator contacts the dozer operator at half hour intervals. Dozer operators and loadout operators communicate by radio to establish which feeders are energized and which are gravity feeding.

  9. When more coal was being discharged from the stacker than was being loaded out on the draw-off belt conveyor, the coal that accumulated near the stacker tube was pushed to the outer edges of the stockpile by dozer.

  10. The dozer involved in the accident was a Caterpillar D9H(Serial Number-90V4339). The dozer was equipped with an enclosed cab, a two-way radio and two self-contained self rescue devices. Examinations of the dozer after recovery revealed that the machine was maintained in safe operating condition.

  11. Jessie Vance Jenkins, Jr. had 20 years of mining experience, 14 years at this mine, and 2 years and 2 months as a dozer operator. He had received all training required by 30 Code of Federal Regulations.

  12. There was a heavy frost on the morning of November 22, 1998 with the temperature below the freezing level. During cold weather, clean coal delivered straight to the stockpile from the thermal dryer produces large quantities of steam which can reduce visibility on the stockpile. Statements by witnesses and observations under similar conditions indicate that adequate levels of visibility normally exist at night with steam generating conditions. According to statements from equipment operators, when visibility was restricted they were instructed to leave the stockpile. Some stated they had to stop or slow down on occasion to allow steam to clear, but none had ever left the stockpile due to restricted visibility.

  13. The stockpile is illuminated by seven 1000 watt vapor lights located on the overhead stacker belt conveyor structure and support towers.

  14. Clean coal is delivered to the stockpile by an overhead stacker belt conveyor which dumps through the stacker tower located in the center of the stockpile.

  15. Jenkins was instructed by Eades to move coal away from the stacker tower toward the outer edges of the stockpile. Evidence indicated that he was not pushing coal toward the feeders.

  16. The dozer was found directly over the No. 1 Feeder on its left side with the blade facing the railroad on the southwest edge of the stockpile. The dozer was in a void over the feeder which was approximately 30 to 35 feet deep and was completely covered with coal except for a small portion of the blade. All windows were broken or pushed out of the frames and the operator's compartment was full of loose coal. Tracks remaining after the recovery indicated the dozer was traveling away from the stacker tower toward the southwest edge of the stockpile. Elongated tracks from the right side dozer treads and a compacted area caused by the bottom pan of the machine indicated that the material collapsed below the left side of the dozer, rolling it to the left and into a void over the No. 1 Feeder.

  17. The victim was not wearing a seatbelt when recovered. The male section of the seatbelt was found behind and to the right of the operator's seat. The seatbelt was functional and adjusted to a length adequate to reach around an MSHA Technical Support Engineer when examined after the dozer was recovered.

  18. Company policies do not allow the operation of any equipment directly over any feeders and require that a safe radius be allowed around any active feeder which is not visually breaking coal into the void over the feeder. Additionally, if visibility makes safe operation impossible, no one is allowed on the stockpile. These and other policies are included in a company handbook containing safe work procedures which was provided to all employees during initial training and reviewed in subsequent training. These written policies do not refer to situations when feeders are deenergized, but are still gravity feeding coal.

  19. The clean coal stockpile contains very fine material. Evidence of compacting layering due to the random pattern of dozer travel was observed. The void over the No. 1 Feeder contained layers of various degrees of compaction. Compacted layers were observed overhanging less compacted layers below. This type of layering can create bridged areas over feeders. No person interviewed stated they had ever known of a completely bridged void. One dozer operator witnessed voids which were bridged except for a small (1 to 2 feet) opening that quickly collapsed over the feeder. He stated that this type of void usually contained much steeper sides than those over energized feeders.

  20. Examinations required by 30 Code of Federal Regulations were being properly conducted and recorded.


CONCLUSION

The accident occurred when the dozer operated by Jenkins traveled into a hazardous area near the No. 1 Feeder containing a bridged over void in the stockpile. The bridged material collapsed causing the dozer to tumble into the underlying void where it was subsequently engulfed with loose coal. The layering effect of the fine coal and the fact that deenergized feeders gravity fed onto the draw-off belt conveyor without being positively identified led to a steep-sided void completely bridged over the No. 1 Feeder which was unobserved by the victim or any other personnel on the midnight or preceding shifts.


VIOLATIONS

A 103(k) Order(No. 7303388) was issued to insure the safety of all personnel until an investigation of the accident was completed.

Citation No. 7297191 was issued under 30 CFR 77.404(a). The clean coal stockpile and draw-off tunnel system including vibratory feeders were not maintained in a safe operating condition. When the draw-off belt conveyor was in operation coal would gravity feed through all four of the feeders when they were deenergized increasing the potential for voids to form in the stockpile where persons and machinery were working. Equipment operators communicated by radio with the loadout operator to identify active and inactive feeders. Deenergized feeders that fed coal by gravity could not always be positively identified. Written company safe work procedures addressed energized feeders but made no reference to deenergized feeders that were feeding by gravity. Additionally, statements given during the investigation indicated that the remote control system for raising and lowering the visual markers for each feeder did not always function properly.

Citation No. 7297192 was issued under 30 CFR 77.209. A hazardous condition, by way of a bridged cavity, was present on the coal storage stockpile. This undetected void was created by coal reclaiming operations beneath the storage pile. Jenkins' exposure to this hazard resulted in fatal injuries when he and the dozer he was operating were drawn into the void and subsequently covered by coal.


RECOMMENDATIONS-IMPLEMENTED

The Nos. 2 and 3 Feeders were blocked with steel plates. The Nos. 1 and 4 Feeders alone will be used until hydraulic doors are installed on all feeders to eliminate gravity flow.

The Nos. 1 and 4 Feeders will be energized before dozers enter the stockpile. Examinations will be made in the draw-off tunnel to verify that coal is feeding properly until the hydraulic doors are installed.

A visible void must be present above the Nos. 1 and 4 Feeders. If not, all employees will leave the stockpile and not return until the condition is corrected.


ADDITIONAL RECOMMENDATIONS

Hydraulic doors are to be installed that will eliminate gravity flow.

A lighting system will be installed in conjunction with the existing plastic ball feeder marker system which will indicate which feeders are energized. This system will be electrically interlocked with the hydraulic doors such that when each door is opened a light visible to persons on the stockpile will energize. Each feeder will have a separate indicator light.

Electrical interlocks will be installed such that the draw-off belt conveyor cannot be energized independently from vibrating feeders.



Submitted by:

Benjamin S. Harding
Mining Engineer

Ray McKinney
District Manager

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB98C25