DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Report of Investigation
March 7, 2000
(Surface Coal Mine)
Fatal Machinery Accident
Dial's Branch (I.d. No. 15-18193)
Addington Mining, Inc
Pinson Fork, Pike County, Kentucky
Knuck Clearing Company (I.D. No. FKG)
South Charleston, West Virginia
By
Robert M. Bates
Electrical Engineer
Terry Marshall
Mechanical Engineer
Originating Office - Mine Safety and Health Administration
4159 North Mayo Trail, Pikeville, Kentucky 41501
Carl E. Boone, II, District Manager
OVERVIEW
On March 7, 2000, dozer operators Daniel Napier (victim) and William Mullins were working in conjunction with two timber cutters clearing a hillside in advance of surface mining operations. The dozer operators and the timber cutters were employed by two separate and distinct independent contractors. During the course of the day, the timber cutters cut trees using chainsaws and the dozer operators pushed brush and fallen timber down the hillside where it could be consolidated and burned. At approximately 10:30 a.m.,William Mullins began descending the slope, which varied from 34 to 40 degrees, and Daniel Napier followed shortly thereafter. At some point during the descent, Napier's dozer overturned and began flipping end-over-end down the slope, eventually coming to rest on a bench approximately 450 feet from the top of the hill. Two thirds of the way down the slope, Napier was ejected from the operator's compartment of the dozer, landing in a pile of brush. Because of the relative inaccessibility of the location, Mullins and the other employees loaded Napier into a pickup truck and transported him to the bottom of the hill to meet the ambulance. Napier was transported to the Appalachian Regional Hospital in South Williamson, Ky, where he was pronounced dead at 12:55 p.m.
The accident investigation team was unable to determine precisely what caused the dozer to become destabilized. However, it is most probable that the victim's dozer ran over a tree stump or a large rock, causing it to overturn.
GENERAL INFORMATION
Addington Mining, Inc., Dial's Branch surface mine, is located off Kentucky Route 1056, approximately four miles from the unincorporated town of Pinsonfork in Pike County, Kentucky (see appendix). Addington Mining, Inc. is a wholly owned subsidiary of AEI Holding Co., Inc., located in Ashland, Kentucky. The victim was employed by Knuck Clearing Company, an independent contractor located in South Charleston, West Virginia. The timber cutters who were assisting Knuck Clearing Company were employed by Virco, Inc., an independent contractor located in Charleston, West Virginia.
Dial's Branch surface mine was placed in active status on September 24, 1999. Coal is produced in two active pits using highwall drills, bulldozers, front-end loaders, and rock trucks. The company uses several methods of mining, one of which is mountain-top removal with cross-valley fills. The Camp Branch area of the mine (the area where the accident occurred) was being prepared for this type of mining.
The mine operates five days per week employing 31 persons on the day shift, and 19 persons on the night shift. Both shifts are ten hours in duration. Maintenance is conducted between shifts and on-shift as needed and/or scheduled. The mine produces an average of 3600 tons of coal daily. The last regular safety and health inspection of the mine was completed on February 2, 2000.
DESCRIPTION OF ACCIDENT
On the day of the accident, bulldozer operators Daniel Napier (victim) and William Mullins arrived at the mine site at approximately 6:45 a.m. Both Napier and Mullins were employed by Knuck Clearing Company. Because it was Napier's first day at the Dial's Branch mine site, they stopped at the mine's main entrance to inquire about training and other necessary paperwork before beginning work. (During the interview process, two conflicting accounts of the events that transpired at the guard shack were given. William Mullins contended that the guard told them to "come back around noon" and they would receive the required training. However, Addington representatives maintained that the guard instructed them to wait there until Blaine Owens, production foreman, arrived to conduct the training, and that they left on their own accord.) Napier and Mullins left the mine's main entrance and traveled to the area where timber and brush clearing operations were to be conducted. This area, known as Camp Branch, was being prepared as the next production area of the Dial's Branch surface mine.
Paul Moss, superintendent for Knuck Clearing Company, arrived at Camp Branch at approximately 7:00 a.m. and met with Napier and Mullins concerning their work assignment for the day. At 7:15 a.m. Adam Beverly and Bryan Green, timber cutters employed by Virco, Inc. also arrived at the mine site and began working.
During the course of the morning, Beverly and Green cut trees and brush with chainsaws while Napier and Mullins used bulldozers to push the fallen material down the hillside in order to consolidate and burn it. Napier was operating a John Deere 650H bulldozer and Mullins was operating a Komatsu D39. Moss assisted the dozer operators by using an excavator to place the cleared material into manageable piles for burning. Moss ignited two brush fires that morning; one near the bottom of the hollow, and another approximately half way up the slope. The slope of the hillside varied from 34 to 40 degrees.
The dozer operators were using two techniques to push brush and timber down the hillside. One technique, referred to as "yo-yoing", involves attaching the hoist rope of a stationary dozer to another dozer which in turn pushes material down the slope. The hoist of the stationary dozer then helps pull the other dozer back up the slope so that the process can be repeated. This process is normally used on steep slopes where it is difficult for the dozer to travel back up the slope in order to make another run. On the day of the accident, Napier was operating the stationary dozer when this technique was employed. The other technique, referred to as a "double shove", uses both dozers to push the material down the slope at the same time.
At approximately 10:30 a.m. Napier and Mullins were operating their dozers on the top bench of the Camp Branch hollow when they decided to go down to the lower bench in order to help contain a fire that was spreading. To avoid a "wasted trip", they agreed to detach the hoist rope and do a "double shove" on their way down. According to eyewitness testimony, both Napier and Mullins were wearing their seatbelts before initiating the descent. Mullins started descending the slope first and Napier followed shortly thereafter.
Mullins' dozer had traveled to a point just above the middle bench when Napier's dozer tumbled past him on the left side, flipping end-over-end. As Napier's dozer traveled past the middle bench, he was ejected from the operator's compartment and landed in a pile of brush between the middle and lower benches.
Mullins immediately stopped his dozer and ran down the slope to search for Napier. Because the fire had reduced visibility in the immediate vicinity of the accident, Mullins had trouble finding Napier, and called out to the timber cutters for assistance. Beverly and Green, who were working in the area below the bottom bench, ran up the hill and assisted Mullins in finding the victim. Paul Moss, who was working on the left side of the hollow at the time, also heard Mullins shouting and came to the accident scene. When Moss was informed of the situation, he immediately ran to his truck to call for help using the radio. Moss contacted Blaine Owens, production foreman, who in turn called 911 for assistance.
Because of the limited visibility and breathing difficulties caused by the smoke, it took approximately 15 minutes to locate the victim. When Napier was finally located, he was not breathing and had no discernible pulse. Due to Napier's physical size, it was extremely difficult to remove him from the hillside, so Beverly and Green traveled to the bottom of the hollow to request assistance from loggers who were working in the vicinity. Moss used the excavator to clear the accident scene of fallen timber so that the victim could be reached more easily. The victim was then loaded into the back of Green's pickup truck and transported to the bottom of the hollow where the Appalachian First Response ambulance was waiting.
The victim was transported via ambulance to the Appalachian Regional Hospital in South Williamson, Kentucky, where he was pronounced dead at 12:55 p.m.
INVESTIGATION OF THE ACCIDENT
Caleb Hampton, safety director for Dial's Branch, called the MSHA District 6 office and reported the accident at 11:45 a.m. on March 7, 2000. John South, supervisory special investigator, received the call. At the time of the initial notification, the condition of the victim was unknown. Accident investigators Robert Bates and Mark Bartley were dispatched to the scene, arriving at approximately 1:30 p.m. Representatives from the Kentucky Department of Mines and Minerals (KYDMM), Addington Mining, Inc., Knuck Clearing Company, and Virco, Inc. were present at the accident scene. At approximately 2:00 p.m. the investigation team was informed by telephone that the victim had died as a result of the injuries sustained in the accident. A 103(k) Order was issued by MSHA to protect persons against possible hazards until an investigation could be completed.
The immediate area of the accident was photographed, sketched, and measured to the extent possible. The physical investigation of the accident was hindered by smoke from the fires that had been started earlier in the day. (After the accident, the fires had apparently spread beyond their original boundaries because the employees stopped tending the fire in order to help locate and transport the victim.) The investigation team returned to the scene on March 8, 2000 (after the fires had subsided) in order to take additional photographs and measurements. Terry Marshall, a mechanical engineer from MSHA Technical Support, examined the dozer on-site for mechanical defects that may have contributed to the accident. To facilitate a more detailed inspection of the dozer involved in the accident, the machine was removed from the mine site and transported to Leslie Equipment Company in Beaver, West Virginia on March 13, 2000. Terry Marshall, in conjunction with Leslie Equipment Company and John Deere representatives, performed a more in-depth examination of the dozer to determine if the mechanical systems were functioning properly at the time of the accident. The 103(k) Order was terminated on March 13, 2000 after the dozer was removed from mine property.
A survey of the Camp Branch area was performed on March 9, 2000 by Abbott Engineering Inc., primarily to determine the slope of the hillside that the victim was descending at the time of the accident. Copies of the survey were forwarded to MSHA and KYDMM.
Interviews were conducted on March 8, 2000 at the MSHA field office located in Phelps, Kentucky. Five persons deemed to have relevant information concerning the accident were interviewed jointly by MSHA and KYDMM. The session was recorded on audio tape with the consent of the interviewees, and a written transcript was later produced for the accident investigation file.
John South and Robert Bates visited the victim's mother on March 14, 2000, and the victim's spouse on March 16, 2000 to discuss preliminary information gathered during the accident investigation.
DISCUSSION
The investigation revealed the following factors relevant to the occurrence of the accident:
1. William Mullins, bulldozer operator, was the only known eyewitness to the accident.
2. The coroner's report listed multiple fractures and internal injuries as the cause of death. The official autopsy report confirmed the cause of death.
3. Toxicology testing, on a perimortem urine sample, at Williamson Appalachian Regional Hospital, South Williamson, Kentucky, was significant for presence of opiates (morphine) and THC. Toxicology testing, of postmortem samples, at the Department of Public Health, Division of Laboratory Service, Frankfort, Kentucky, was significant for positive cannabinoids in urine. Blood and vitreous fluids were negative. No confirmatory testing was done.
At MSHA's request, the autopsy results were reviewed by the United States Department of Defense Armed Forces Institute of Pathology. The resulting opinion was that the detection of drugs in the urine was indicative of historical use only. The opinion further stated that it was impossible to make a determination as to the time of consumption, dose, or impairment. According to the Institute, the use of marijuana has not been forensically established because of the lack of specific confirmatory tests. Therefore, there is no basis upon which to conclude that the victim was impaired due to drug use at the time of the accident.
4. The slope on which the victim was operating the dozer varied from 34 to 40 degrees.
5. The area was generally dry, and there were no unusual soil conditions. However, there was a partially uprooted tree stump located in the path that the victim's dozer allegedly traversed on the day of the accident. A large rock that had apparently been dislodged from a higher elevation on the slope, was lying near the location where the victim's dozer finally came to rest. Either of these objects would have had the potential to destabilize the dozer as it descended the steep slope.
6. SEAT BELT: The machine was equipped with the "Deluxe Seat Package". This included a three-inch wide pelvic-style, or lap-style, seat belt. According to the manufacturer's product literature, this belt was built to Society of Automotive Engineers (SAE) J386 Standard, Operator Restraint System for Off-Road Work Machines. The operator of the other dozer stated that both he and the victim had latched their seat belts prior to descending the grade. The victim was thrown from the dozer during the accident and the seat belt was found unlatched after the accident. No visual damage or deformation was observed during examination of the seat belt assembly. The seat belt latching mechanism functioned when tested and the release button unlatched the buckle assembly with minimal finger pressure.
7. CRAWLER TRACTOR (DOZER) INFORMATION: The dozer involved in the accident was a John Deere 650H LT model, Serial Number T0650HX878432. It was powered by a John Deere 4045T four cylinder diesel engine rated at 90 SAE net hp at 2,200 rpm. The engine hour meter located on the dash panel showed 225 hours. The dozer was purchased by Knuck Clearing Co. from Leslie Equipment Co. of Beaver, WV, in January 2000. The machine came equipped from the factory with a 105 inch wide clearing blade, extreme-duty grille screen, tank guards, 18 inch wide grouser shoes, and a Roll Over Protective Structure (ROPS). Prior to delivery to the contractor the equipment dealer had installed a rear-mounted hydraulic winch, limb risers, driving & work lights, and brush screens for the front, rear and sides of the operator's compartment. The machine weight was estimated from product literature to be approximately 21,000 pounds. The machine's power train and hydraulic systems allow 45-degree maximum operation in its current form according to product literature.
8. SERVICE AND PARKING BRAKE SYSTEMS: The dozer was equipped with a hydrostatically applied service brake and a spring applied, hydraulically-released (SAHR) parking brake. The parking brake consisted of two SAHR wet disc brake assemblies, one on each of the two final drive hydraulic motors. Application of the service brake pedal provided hydrostatic braking and it also released hydraulic pressure within the parking brake system to spring apply the parking brake. A hand lever controlled the application of the parking brake by causing a valve to release the hydraulic pressure within the parking brake system when the lever was moved to the �locked' or applied position. Tests conducted indicated that the parking brake fully released at a pressure of approximately 200 psi and that this pressure was released to reservoir to apply this brake when either the service brake pedal was fully depressed or the parking brake control lever was moved to the �locked' position. The parking brake was tested by pushing and pulling the accident dozer with a larger dozer on level ground with the parking brake applied. The accident dozer's grouser shoes fully penetrated the hard-packed ground surface and both tracks skidded when tested in either direction. The parking brake control lever was found in the �un-locked' or released position after the accident.
9. ROPS AND BRUSH SCREENS: Visual inspection of the ROPS showed no obvious cracking of the welds on the major structural members and minimal deformation of the ROPS. All of the brush screens were intact on the machine with only a few of the screen-to-ROPS weld areas damaged during the rollover.
10. TRANSMISSION AND HYDRAULIC IMPLEMENT SYSTEMS: Reportedly, the engine was not running after the accident, but the key switch was found in the run position. The fuel injectors were pulled from the engine to check for oil in the cylinder. Oil was found in three of the four cylinders. Attempts were made to crank the engine with the starter and by mechanical means after up-righting the machine and removing the fuel injectors, but both means failed. Functional testing of the transmission and hydraulic systems could not be performed without an operational engine, however, some evaluation of the transmission controls was conducted without mechanically driving the transmission system's hydraulic pumps.
The dozer was hydrostatically driven by two final-drive hydraulic motors, one for each track. Machine tramming and available power were electronically controlled by a transmission controller by using inputs, outputs, and feedbacks. The operator used a combination of four controls to send inputs into the transmission controller from a steering sensor, a Forward-Neutral-Reverse (FNR) sensor, a decelerator sensor, a transmission speed control sensor, and an engine speed control sensor. An engine speed hand control lever and a decelerator foot pedal were used in combination to control engine rpm. A speed control lever controlled both left and right hydraulic motor output ratios and had a speed range of first through third. The selector lever contained no detent positions and was designed to provide infinitely variable track speeds throughout the entire speed range. A joystick control lever controlled both directional movements and steering functions. The directional control included Forward, Neutral and Reverse while the steering control included straight tram, right steer, right counter rotate, left steer and left counter rotate. The steering control aspect of the joystick control lever was self-centering to the straight tram position. The directional control aspect of the joystick control was a detent type that would retain it in the position selected. After the accident the engine speed hand control lever was found in the �rabbit' or high idle position, the speed control lever was found in �third' position and the joystick control lever was found in the �forward' position.
The electronic control module had the ability to store fault codes corresponding to parameters outside any of the sensors' calibrated ranges, however, the system could not determine if the sensors and valves react proportionally within their respective ranges. The electronic control module microprocessor did not have any fault codes stored within its memory when checked. The output values of the operator's five input sensors were compared to their calibrated range values. This included the decelerator control sensor, the Forward-Neutral-Reverse (FNR) sensor, the transmission speed control sensor, the engine speed control sensor and the steering sensor. All of the five sensors were found to be within their calibrated ranges when tested and the output values were proportional to the control positions selected.
The transmission controller settings indicated that the maximum machine speed was set at medium speed, or 5 mph. This setting can only be changed to the low or high speed settings by an authorized dealer.
11. FOOT PEDAL AND HAND LEVER CONTROLS: Both the service brake foot pedal and the decelerator foot pedal moved smoothly throughout their ranges and returned to position when released. The hand lever controls moved smoothly throughout their ranges, including the blade's joystick control lever and the winch control lever. All control linkages were visually examined and were determined to be intact.
12. FLUID LEVELS: The fuel level prior to the accident could not be determined. Fuel had leaked from the tank's fill area after the accident as evidenced by fuel on the machine and ground during the machine's initial inspection at the accident site.
The hydraulic fluid level for the implement system was checked after the machine was up-righted. The level in the sight tube was above the full mark. The filter for this system was removed to take fluid samples (estimated to be a total of less than one fluid ounce) and the fluid level dropped to the full mark once the system was open to atmosphere.
The hydraulic fluid level for the hydrostatic system was checked after the machine was up-righted. The level in the sight tube was above the full mark. The filter was removed to take fluid samples (estimated to be a total of less than one fluid ounce). The fluid level in the sight gauge remained above the full mark range after the system was open to atmosphere.
The engine oil level was checked after the machine was up-righted. The engine oil dipstick showed the level to be midway between the �add' mark and the end of the dipstick. Samples were taken when the engine oil was drained. Engine oil had apparently leaked out of the engine after the accident as evidenced by oil on the engine, in the engine compartment and on the ground during machine inspection at the accident site. As noted previously, some oil loss into three of the four cylinders was observed.
13. MISCELLANEOUS: A packet was found in the compartment integral to the operator's seat. This included an operator's manual, a safety manual for operators and mechanics of crawler tractors/loaders from Equipment Manufacturers Institute (EMI), and training material from the manufacturer on undercarriage wear and tear. The operator's manual found in this packet was still wrapped in the original plastic and had not been opened.
No defects in the machine's systems were found that would have caused or contributed to the accident. Tests conducted indicates that the dozer operator would have been capable of skidding the tracks by using either the parking brake lever or the service brake foot pedal.
CONCLUSION
The accident occurred when the victim apparently lost control of the John Deere 650H dozer while descending a steep slope. The accident investigation team was unable to determine precisely what caused the dozer to become destabilized. However, it is most probable that the victim's dozer ran over a tree stump or a large rock, causing it to overturn. No defects in the machine's systems were found that would have caused or contributed to the accident.
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to protect persons from possible hazards until the investigation could be conducted.
2. A 104(a) citation was issued to Addington Mining, Inc. because the victim had not received hazard training required by 30 CFR 48.31. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
3. A 104(a) citation was issued to Knuck Clearing Company because the victim had not received hazard training required by 30 CFR 48.31. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
4. A 104(a) citation was issued to AddingtonMining, Inc. because the victim had not received experienced miner training required by 30 CFR 48.26. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
5. A 104(a) citation was issued to Knuck Clearing Company because the victim had not received experienced miner training required by 30 CFR 48.26. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
6. A 104(g)(1) order was issued to Addington Mining, Inc. because William Mullins, and Paul Moss had not received experienced miner training required by 30 CFR 48.26. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
7. A 104(g)(1) order was issued to Knuck Clearing Company because William Mullins, and Paul Moss had not received experienced miner training required by 30 CFR 48.26. This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
8. A 104(a) citation was issued to Addington Mining, Inc. because the Camp Branch area was not being examined by a certified person as required by 30 CFR 77.1713(a). This violation did not directly contribute to the accident, and so was cited under a concurrent inspection event (# 6144107).
Related Fatal Alert Bulletin:
FAB00C06
Sketch of Accident Scene
APPENDIX A
Addington Mining Inc. Officials
Blaine Owens ............... Production ForemanKnuck Clearing Company Employees
Caleb Hampton ............... Trainer
Keith Smith ............... Safety Director
Paul Moss ............... SuperintendentVirco, Inc. Employees
William Mullins ............... Bulldozer Operator
Adam Beverly ............... Timber CutterKentucky Department of Mines and Minerals
Bryan Green ............... Timber Cutter
Tracy Stumbo ............... Chief Accident InvestigatorMine Safety and Health Administration
Greg Goins ............... Accident Investigator
Stanley Tackett ............... Accident Investigator
Robert Bates ............... Electrical EngineerList of Persons Interviewed
John South ............... Supv. Special Investigator
Terry Marshall ............... Mechanical Engineer
Gerald W. McMasters ............... Conference Litigation Representative
Harold Thornsbury ............... Training Specialist
Michael Wolford ............... Coal Mine Inspector
Joseph Luckett ............... Attorney
Ray Compton ............... Assistant District Manager
Benny Freeman ............... Supv. Coal Mine Inspector
1. Blaine Owens, Production Foreman, Addington Mining, Inc.
2. Paul Moss, Superintendent, Knuck Clearing Company
3. William Mullins, Bulldozer Operator, Knuck Clearing Company
4. Adam Beverly, Timber Cutter, Virco, Inc.
5. Bryan Green, Timber Cutter, Virco, Inc.