DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface of Underground Coal Mine
Fatal Machinery Accident
August 16, 2000
BGS Construction, Inc. (ZAG)
Slab Fork, West Virginia
Blacksville No. 2 Mine
Consolidation Coal Company
Wana, Monongalia County, West Virginia
I.D. No. 46-01968
Richard G. Jones
Coal Mine Safety and Health Inspector (Contractors)
Chris A. Weaver
Mining Engineer, Ventilation
Richard L. Bozick
Coal Mine Safety and Health Inspector (Surface)
Gharib Ibrahim, P.E.
Mine Safety and Health Administration
5012 Mountaineer Mall
Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager
Release Date: November 9, 2000
Plan View of Accident Site|
This image depicts the portion of the accident site shown in the lower left corner of Figure 1. A portion of the chute is shown at the top of this image. The scaffold moved toward the tail end of the washer during the accident.|
|Figure 3||This image shows the perspective from the left side of Figure 2, viewing the area beyond the right side of that image. The bracket being welded by the victim is visible in the center of this image. The catwalk is shown above the bracket, with the chute and tie off point on the left.|
On August 16, 2000, Daniel Alexander Dalton, a 23-year-old classified welder for independent contractor BGS Construction, Inc. (ZAG), was welding a catwalk support bracket to the edge of an opening in the fourth floor deck of Consolidation Coal Company's Blacksville No. 2 Mine Preparation Plant, just above an operating Daniels Precision Coal Washer. This task was facilitated by a metal scaffold board which had been placed over the tail end of the washer, within inches of the washer's exposed, unguarded, and moving conveyor flights, chains, and sprockets. The bracket was accessed from a portion of the scaffold board which extended beyond the side of the washer, 12'-3" above the third floor. Therefore, Dalton attached one lanyard of his full-body safety harness to a nearby chute. His harness was equipped with two, six-foot long, safety lanyards. However, Dalton did not utilize his second lanyard, leaving both ends hooked to his harness. This created a loop that hung down to near his feet.
Just before the accident, Dalton completed a weld on the bracket and asked a co-worker, Larry Broadwater, to inspect it. Dalton backed up along the scaffold board so that Broadwater could see the weld. While Broadwater examined the weld, Dalton crouched down on the scaffold board directly above the exposed moving parts on the coal washer. This lowered Dalton's second lanyard to a location where it was caught by the chain and conveyor flights which were moving toward the tail end of the washer. As Broadwater turned to leave, he saw Dalton being pulled backward off the scaffold board. Broadwater reached for Dalton, but the tied off lanyard broke, causing Dalton to quickly disappear beneath the scaffold into the washer bath where he received fatal injuries from the moving machine parts.
A review of Dalton's work history indicated that, although he was a new miner when he began working at the Blacksville No. 2 Mine Preparation Plant, he was assigned duties without being provided with training for new miners, pursuant to 30 CFR 48.25(a). However, prior to his employment with BGS Construction, Inc., the victim had been provided with annual refresher training. A certificate of this training gave the appearance that Dalton was an experienced miner. This led to Dalton being provided with a series of inappropriate training courses; none of which covered several basic safety topics required by 30 CFR 48.25. Similar training deficiencies were found involving other employees of BGS Construction, Inc. The contributing factors which led to these training deficiencies (involving previous employers, independent contractors, and independent instructors) are a major topic of discussion in this report.
The investigation concluded that the victim's work location in close proximity to exposed, unguarded moving machine parts was the primary cause of the accident. The victim's lack of training on basic safety topics further contributed to the likelihood of the accident.
Consolidation Coal Company's Blacksville No. 2 mine is located on Route 7 near Wana, Monongalia County, West Virginia. The mine employs 446 persons, 393 work underground and 53 on the surface. An average of 15,285 tons of clean coal is produced daily from the Pittsburgh No. 8 seam by three advancing continuous mining machine sections and one retreating longwall section. Mining is conducted on three shifts per day, seven days per week. Coal is transported from the active sections by a conveyor belt system to an underground bunker, where it is transferred into a vertical skip bucket and hoisted to the surface through a production shaft.
The preparation plant was constructed near the production shaft in 1970. A dryer system and a fine coal process were added in 1985. The facility operates six to seven days a week, processing 4.2 million tons of raw coal annually.
Beginning in April 2000, Consolidation Coal Company employed an independent contractor, BGS Construction, Inc., Contractor I.D. No. ZAG, of Slab Fork, West Virginia, to make upgrades to the preparation plant. Projects to be completed by the contractor included the installation of a new Daniels Precision Coal Washer on the third and fourth floors of the plant. The majority of the contractor's work activities were performed during the operator's scheduled vacation period from June 25 through July 8, 2000. During this period, BGS Construction, Inc., subcontracted different facets of the upgrade to numerous other independent contractors.
The principal officials for the Blacksville No. 2 Mine Preparation Plant at the time of the accident were:
- Roy Pride . . . . . . . . . . . . . . . . . . .
. . . . . Superintendent
Roland Smith . . . . . . . . . . . . . . . . . . . . . .Preparation Plant Superintendent
Fran Nickler . . . . . . . . . . . . . . . . . . . . . . Safety Director
- Lourn M. Boyce, Jr. . . . . . . . . . . . . . . . . President
Arnold Graybeal . . . . . . . . . . . . . . . . . . .Vice President and Treasurer
Douglas Sayre . . . . . . . . . . . . . . . . . . . . Vice President of Operations
Christopher A. Covington . . . . . . . . . . . . Personnel/Safety Director
Larry Flesher . . . . . . . . . . . . . . . . . . . . . .Site Supervisor
On August 16, 2000, at approximately 7:00 a.m. (Flesher 1:19), a crew of eight workers (Flesher 1:20) under the supervision of Larry Flesher, Site Supervisor for BGS Construction, Inc., reported for work at Consolidation Coal Company's Blacksville No. 2 Mine Preparation Plant. They first met in the contractor's office trailer where Flesher asked for two volunteers to travel to the McElroy Mine, located near Wheeling, West Virginia, to work on another job at that mine. (Broadwater 2:5; Flesher 1:20 - 2:2) Leeland Tennant and Ralph Boggs accepted the reassignment and left for the McElroy job. (Flesher 8:16) Flesher then assigned work to the remaining six workers.(Flesher 2:2) Joey Fowler and Davis Wolverton were assigned to pipe fitting duties on the ground floor, while Sammy Nuce and Tom Metz were to install handrails on the second floor. (R. Jones' notes for 10/11/2000) Larry Broadwater and Daniel Dalton, victim, were assigned to continue Broadwater and Tennant's tasks from the previous day. (Broadwater 2:8; Flesher 8:15) These tasks consisted of fabricating and installing toe plates and support channels for a catwalk around the edge of an opening in the fourth floor. (Broadwater 2:10) This floor opening was created by BGS Construction, Inc., to install feed chutes through which raw coal would be delivered to the Daniels Precision Coal Washer located on the third floor. The coal washer had also recently been installed by BGS Construction, Inc. Although the work assigned to Broadwater and Dalton was being done toward completion of the washer installation, Consolidation Coal Company had been operating the washer to process coal since July 10, 2000.(R. Jones' notes for 10/11/2000)
After receiving their assignment, Broadwater and Dalton walked to the preparation plant where they unlocked their job box, got out their tools and equipment, and prepared the site for the day's tasks. (Broadwater 2:12) At approximately 7:20 a.m., Flesher met with Broadwater and Dalton at their fourth floor job site where toe plates were being welded in place along the edge of the fourth floor opening, directly above the tail end of the coal washer. They discussed details for supporting the catwalk above the coal washer. (Broadwater 2:15 - 3:1; Flesher 2:5) Flesher spent 10-15 minutes with Broadwater and Dalton, afterwhich, he checked on his other four employees working on the floors below. (Flesher 2:8-13) Broadwater and Dalton then returned to work on the toe plates. (Broadwater 3:4)
To facilitate this task, Flesher, Broadwater, and Tennant had placed a 20" wide by 12'-6" long aluminum scaffold board directly on top of the washer sidewalls, spanning the width of the tail end of the washer, on the day before the accident. This positioned the scaffold board 59 inches below the top edge of the fourth floor opening, within inches of the washer's exposed moving sprockets, chains, and return conveyor flights. A portion of the scaffold board also extended beyond the side of the washer, 12'-3" above the third floor.
After visiting each of his employees' work sites, Flesher went to the contractor's supply area near his office trailer where he used a forklift to move and rearrange some materials. (Flesher 2:13) While performing this task, he found a piece of C-channel that Broadwater and Dalton could use for supporting the catwalk over the washer. (Flesher 2:18) At approximately 8:30 a.m., Flesher met Dalton on the ground level of the preparation plant and gave him the channel. (Flesher 2:19) Dalton then took the channel to the fourth floor and resumed working with Broadwater. (Broadwater 3:5) Meanwhile, Flesher visited the second floor work site before returning to his office trailer at approximately 9:00 a.m. (Flesher 2:22 - 3:2)
By 9:30 a.m., Broadwater and Dalton had completed work on the toe plates and were making brackets for supporting the walkway out of the C-channel. (Broadwater 3:5; Flesher 3:5) Flesher again made rounds in the preparation plant. When he arrived on the fourth floor, Flesher discovered that Broadwater and Dalton were planning to weld the support brackets to both the floor and the catwalk. Flesher instructed them to install bolts in one end of the brackets so that the catwalk could be removed, if needed. (Broadwater 3:15; Flesher 3:7) At approximately 9:45 a.m., Flesher left the fourth floor to check on the other work sites before returning to the yard for tools and materials. (Flesher 3:9)
During the next half hour, Broadwater and Dalton temporarily spot welded a bracket in place below the catwalk, burned holes in the top end of the bracket, and bolted it to the catwalk. Broadwater then began cutting a piece of metal plate at a nearby location on the fourth floor while Dalton prepared to permanently weld the bottom of the channel to the fourth floor toe plate (refer to Appendix B, Figures 4-6). (Broadwater 4:4-10) This task would require Dalton to stand on the portion of the scaffold board which extended over the side of the washer, 12'-3" above the third floor. Therefore, Dalton tied off to a support hook on the washer feed chute before climbing onto the scaffold board which was placed across the top of the washer (refer to c, Figure 7). This tie off point was approximately 3 feet above the scaffold board. He was wearing a full-body harness which was equipped with two, six-foot long, safety lanyards. However, Dalton did not utilize his second lanyard, leaving both ends hooked to his harness. This created a loop that hung down to near his feet. He then began welding the channel to permanently support the catwalk.
At approximately 10:20 a.m., Dalton had completed several welds on the channel. Dalton then asked Broadwater to look at the welds to see if they were sufficient. (Broadwater 5:1) Dalton backed up along the scaffold board so that Broadwater could see the weld from his position on the fourth floor. While Broadwater knelt down to examined the weld, Dalton crouched down on the scaffold board directly above the exposed moving parts of the coal washer. This lowered Dalton's second lanyard to a location where it was caught by the chain and conveyor flights which were moving toward the tail end of the washer. As Broadwater turned to leave, he saw Dalton being pulled backward off the scaffold board. Broadwater reached for Dalton but the tied off lanyard broke, causing Dalton to quickly disappear beneath the scaffold and into the washer bath. (Broadwater 5:7)
Broadwater did not know how to shut off the washer and ran down the steps to find help. He eventually met Fowler and Wolverton outside of the preparation plant and informed them of the accident. Fowler and Broadwater proceeded to the superintendent's office where they informed Roland Smith, Preparation Plant Superintendent, Barry Martino, Plant Supervisor, Michael Brooks, MSHA Coal Mine Inspector, and Wally Dittman, Miners' Representative, that a man had fallen into the washer. Martino called Mark Vannoy, Preparation Plant Control Room Operator, and instructed him to shut the plant down. (R. Jones and C.Weaver notes, 8/17/2000) Smith left the office and hurried toward the accident site, followed by Broadwater.
Meanwhile, Flesher was driving his truck back to the preparation plant with tools and materials for Fowler and Wolverton. Upon arrival at the plant, he was met by Wolverton who informed him that Dalton had fallen into the washer. Flesher immediately parked his truck and ran toward the plant with Wolverton. As they reached the plant, the equipment stopped and sirens sounded, indicating that the plant emergency shutdown had been initiated. By now, Smith and Broadwater were at the second floor of the plant and were climbing the stairs toward the fourth floor work site. Upon arriving at the accident site, Smith and Broadwater looked in the area where Dalton fell into the washer. Finding no sign of Dalton at this location, they walked toward the head end of the washer. The head end of the washer was only accessible from the third floor, which required Smith and Broadwater to travel back down the stairs. During this time, Flesher and Wolverton arrived at the accident site. Unable to find anyone, Flesher went to the preparation plant control room while Wolverton proceeded to the head end of the washer. In the control room, Vannoy informed Flesher that he had been paged on the intercom and ordered to hit the plant emergency stop; however, he was unaware of the reason. Flesher then left the control room and walked toward Dalton's work site.
While Flesher was in the control room, Smith and Broadwater reached the head end of the washer where they saw Dalton's boots at the top of the discharge chute (refer to Appendix B, Figure 8). Dalton's body was in the chute, concealed below the bath. As Flesher returned to the accident site, he saw Broadwater and Wolverton at the other end of the washer. Flesher then joined the others where Broadwater informed him of Dalton's location in the washer. Brooks and Dittman also arrived at the head end of the washer at this time. Dittman then proceeded to the control room and called 911 at 10:32 a.m.
Flesher and Smith began working to recover the victim after power was disconnected from the washer. Smith climbed through an inspection door in the refuse chute where he was able to reach the victim. Flesher and Smith lowered the victim through the inspection door at 10:40 a.m., at which time Smith, an EMT, began administering CPR. Wadestown Emergency Squad arrived on the scene at 11:05 a.m. and assisted Smith with emergency treatment to the victim. The hospital advised the emergency squad to discontinue CPR at 11:15 a.m.
This investigation was conducted in cooperation with the West Virginia Office of Miner's Health, Safety and Training. Other participants included management personnel from BGS Construction Company and Consolidation Coal Company. The UMWA provided representatives of the miners during the investigation. A list of those persons who participated in the investigation is contained in Appendix A of this report.
Mike Brooks, Coal Mine Safety and Health Inspector, was in another area of the preparation plant just before the accident. Brooks reported the accident to his supervisor and issued a 103(k) Order. Jerry Johnson, Chief, Impoundments Section, soon arrived at the mine and initiated a joint investigation with officials from the West Virginia Office of Miners' Health, Safety and Training. Richard G. Jones, Coal Mine Safety and Health Inspector (Contractors), and Gharib Ibrahim, P.E., Civil Engineer, arrived on the scene at approximately 1:30 p.m. The accident site was then inspected, preliminary interviews were conducted with Broadwater and Flesher, and photographs were taken of the site.
On August 17, 2000, Richard L. Bozick, Coal Mine Safety and Health Inspector (Surface), and Chris A. Weaver, Mining Engineer, Ventilation, joined the MSHA accident investigation team. Video and digital still images were taken at this time and an interview was conducted with Roland Smith, Plant Superintendent. Formal interviews were conducted with Flesher, Broadwater and Christopher Covington, Personnel/Safety Director for BGS Construction, Inc., on August 22, 2000, at the West Virginia Office of Miners' Health, Safety and Training in Fairmont. During the investigation, Johnson and Jerry Vance, Mine Safety and Health Specialist (Training), reviewed the contractor employees' training records. This portion of the investigation included interviews with employees of BGS Construction, Inc., and the instructors who provided training to these employees. The victim's former employers were also interviewed. Brooks continued the ongoing Health and Safety Inspection and issued citations and orders for those violations and conditions found during the investigation which were determined to be non-contributing factors to the accident. Violations which were determined to be contributing factors to the accident were cited by Jones on September 15, 2000. Citations were issued to both Consolidation Coal Company and BGS Construction, Inc.
MSHA received custody of the victim's harness and lanyard assembly immediately after the accident and arranged for it to be analyzed by an independent engineering testing firm. On September 18, 2000, Matco Associates, Inc., performed tests on the lanyards at their facility in Pittsburgh, Pennsylvania. Representatives of MSHA and the harness manufacturer were present during testing. The following tests were performed during failure analysis of the lanyards: a visual examination, stereomicroscopic examination, scanning electron microscope examination, and infrared spectroscopy.
The autopsy report, provided by the West Virginia Office of the Chief Medical Examiner, stated that the victim died of multiple injuries sustained from the accident and that there was no evidence of drowning. Toxicology tests were negative for the presence of alcohol and drugs.
Physical Factors at the Accident Site
The unit 073 Daniels Precision Coal Washer (Model T26054, Serial No. 2792-367-00) was installed by an independent contractor, BGS Construction, Inc., as part of a project to upgrade the Blacksville No. 2 Mine Preparation Plant. Although the washer installation was not complete, it was capable of processing coal prior to the accident. On July 10, 2000, Consolidation Coal Company took control of the washer and began using it to process coal, exposing the contractor employees working in this area to potential mining hazards. The work to be completed on the coal washer by BGS Construction, Inc., employees included installation of the head drive guarding and completion of the fourth floor toe plates, walkway guard rails, and the catwalk adjacent to the feed chutes. Daniel Dalton, welder, was fatally injured while performing duties toward completion of this work.
The Daniels Precision Coal Washer is a trough-type unit which separates float-sink particles in a magnetite medium. Pre-wetted raw coal enters the washer through feed chutes on the fourth floor of the preparation plant. Lighter particles overflow a weir on the side of the washer opposite the feed chutes. Heavier waste particles sink in the magnetite medium to the bottom of the washer where chain-driven conveyor flights push the waste into a discharge chute at the head end of the washer. The chain and conveyor flights return to the tail end of the washer along a series of exposed sprockets located on the top of the washer, above the coal and magnetite mixture (refer to Appendix B, Figure 9).
The coal washer measured 38'-9" long and 7'-8 ½" wide. The flights consisted of 54" wide steel plates, on 24" centers, connected to the chains by two ½" diameter bolts on both ends of each flight. Attachment plates where the flights bolted to the chains created pinch points, one of which was the structure most likely to have caught the victim's looped lanyard (refer to Appendix B, Figure 10). The chain loop was driven by a 30HP motor manufactured by TECO-Westinghouse. The on/off electrical control switch for the coal washer was located on the fourth floor wall, opposite the work site, but only accessible via the third floor.
The top of the coal washer is typically inaccessible, located 12'-3" above the third floor and 59" below the fourth floor. Guard rails being installed along the fourth floor openings to the washer were intended to prevent persons from falling into and/or contacting the moving washer parts from above. However, the work required to complete the washer installation, including the remaining guarding, placed the contractor employees in a position where they could, and did, contact the exposed moving machine parts, resulting in fatal injuries.
The aluminum scaffold board, upon which Dalton was working at the time of the accident, was 20" wide, 150" long, and 4" thick. It was placed on top of the washer by Flesher, Broadwater, and Tennant on the day before the accident to facilitate installation of the toe plates. Approximately 55" of the scaffold board extended beyond the side of the washer. To prevent the scaffold board from tipping over the side of the washer, this end of the scaffold board was tied to a 12-gauge wire which was hung from a 4" diameter pipe located above the catwalk. On the day before the accident, Flesher noticed the close proximity of the scaffold board to the exposed moving machine parts and cautioned Broadwater and Tennant of this hazard. After the accident, the distance between the top of the scaffold board and the washer conveyor flights, chains, and sprockets was measured at nine inches.
The victim was wearing his personal full-body harness. The harness and lanyard assembly were both manufactured by UVEX Safety Incorporated. The top end of the shock absorbing mechanism was fastened to a "D" ring on the back of the harness with a self-locking snap hook. The capacity of the shock absorbing mechanism was 310 pounds, with a maximum arresting force of 900 pounds and a maximum elongation of 42 inches. Two six-foot long lanyards were permanently attached to the lower end of the shock absorbing mechanism. These lanyards were also equipped with self-locking snap hooks at the free ends. At the time of the accident, the victim had one lanyard secured to a feed chute above the washer, while the second lanyard was hanging in a loop and hooked to the "D" ring on the back of his harness. The harness was received into custody by MSHA investigators immediately after the accident. Matco Associates, Inc., an independent engineering testing firm, was contracted by MSHA to perform failure analysis on the harness assembly (refer to Appendix C - Matco Associates, Inc. - Harness Analysis Report).
Both lanyards broke during the accident. The portion of the tied off lanyard which was connected to the nearby chute remained relatively clean, while the remainder of the harness was discolored by the coal and magnetite bath. One end of the second lanyard remained attached to the shock absorbing mechanism, while the other end remained attached to the "D" ring on the back of the harness. The snap hook connecting the shock absorber to the "D" ring was closed, but was no longer functional. This connection was supplemented with a loop of steel wire cable (refer to Appendix C, Matco Fig. 7). Although a slight amount of tear and abrasion were evident near the lanyard eye terminations, all of the lanyard connection points remained intact during the accident.
The shock absorbing mechanism of the body harness did not deploy during the accident. As the looped lanyard, caught by the conveyor, moved away from the other lanyard's tie off point, tensile forces developed between the two lanyards. These opposing forces exceeded the design tolerances of the lanyards and were transmitted from one lanyard to the other directly through their common connection point at the lower end of the shock absorber. The two lanyards formed a straight line as they became taut, pulling Dalton backward off the scaffold board. This is consistent with Broadwater's recollection of the accident. When tensile failure of the tied off lanyard occurred, the victim was pulled forward into the washer by the second lanyard, dragging the scaffold board toward the tail end of the washer as he passed beneath it.
A sharp, linear indentation was observed across the width of the second lanyard section which was still attached to the "D" ring, approximately 4 ½" from the fracture (refer to Appendix C, Matco Fig. 38). This indentation was only on one side of the lanyard and most likely indicates where it was caught by a moving component of the coal washer. The shape of this indentation was consistent with the edge of the washer conveyor plates where they were bolted to the chain. The victim was positioned over the exposed moving chain and flight attachment points at the time of the accident.
Infrared spectroscopy of the lanyards determined that their fibers were composed of the polyamide variety, i.e., a nylon. This conformed to the material requirements of paragraph 188.8.131.52 of ANSI Z359.1-1992.
Stereomicroscopic examination of the lanyards indicated that most of the fibers fractured perpendicular to their columnar axis, with a few of these fibers exhibiting localized swelling at the fracture. During testing, a small bundle of fibers was cut from the fractured end of the clean lanyard and two bundles of fibers were cut from fractured ends of the second lanyard for examination by a scanning electron microscope (SEM). Half of the fibers examined by SEM exhibited localized swelling, which is characteristic of a high speed tensile break (refer to Appendix C, Matco Fig. 58). This indicated that these fibers were among the last to fail. The other half of the examined fibers exhibited fractures that were nearly perpendicular to their axis, with an occasional small fibril projecting from one side of the fiber circumference (refer to Appendix C, Matco Fig. 69). This profile is characteristic of a ductile tensile overload, consistent with being pulled apart by the opposing forces developed between the moving conveyor flights and the stationary chute.
Dalton was a new miner when he began working for BGS Construction, Inc., at the Blacksville No. 2 Mine Preparation Plant on June 13, 2000. Although he was previously employed in construction projects at other mines, none of his prior work classified him as a miner, as defined in 30 CFR 48.22. Nonetheless, Dalton had received annual refresher training on December 22, 1999, even though he had not received training for new miners, as prescribed by 30 CFR 48.25. Once provided with a record of annual refresher training, Dalton was presumed to be an experienced miner by his subsequent employers. This initiated a chain of inappropriate training being given to Dalton which ultimately resulted in his lack of required training on several basic topics, some of which were relevant to the fatal accident.
Dalton's first certificate of training pursuant to Title 30 resulted from a job interview on December 20, 1999, with Paul Tenney, Owner, of P.T. Mine Service, Contractor I.D. No. HWM. According to Tenney, during this interview, Tenney asked Dalton if he had received the proper training. Dalton replied that he had been moving around a lot and did not have records with him. Tenney advised Dalton to get the proper training as a precondition for employment and referred him to David Stanley Consultants, Contractor I.D. No. YBV. However, when Dalton reported to David Stanley Consultants on December 22, 1999, he was provided with eight hours of annual refresher training, pursuant to 30 CFR 48.28, instead of 24 hours of training for new miners, as required by 30 CFR 48.25. This training was provided by Roy L. Anderson, Instructor for David Stanley Consultants. According to Anderson, Dalton claimed that he was an experienced miner. However, Anderson appears to have made no independent inquiries regarding Dalton's work experience.
On December 27, 1999, Dalton returned to P.T. Mine Service with the certificate of annual refresher training provided by Anderson. Based only on this certificate of training, Tenney hired Dalton as an experienced miner, without checking Dalton's prior work history, and provided him with newly employed experienced miner training pursuant to 30 CFR 48.26. Dalton worked at this job through January 27, 2000, and again from February 5, 2000, until March 10, 2000. During these periods of employment, Dalton worked on new construction jobs at surface areas of two non producing coal mines. Since neither job exposed Dalton to mining hazards, he would not have been classified as a miner, as defined by 30 CFR 48.22, at either job site. On February 23, 2000, during his second period of employment with P.T. Mine Service, Dalton again received annual refresher training from Anderson.
Dalton started working for BGS Construction, Inc., at the Blacksville No. 2 Mine Preparation Plant on June 13, 2000, at which time Consolidation Coal Company provided him with hazard training in accordance with their approved surface hazard training plan. In addition to hazard training, Sections 30 CFR 48.25 and 48.26 would have required newly employed miners to complete a minimum of 24 hours of training for new miners and eight hours of training for experienced miners on prescribed topics before beginning work duties. However, Dalton did not receive further training until June 23, 2000, when he and several other BGS Construction, Inc., employees were provided with training for newly employed experienced miners by an independent instructor, Frederick L. Hayes. This training lasted only one hour and consisted of instruction in the following topics: (1) Murphy's Law, (2) Hazards of Cutting Materials Loose, (3) Buddy System, (4) Get Help if You Think You Need It, (5) Ask Inspectors's Opinions, if available, and (6) Gases. These topics were not consistent with those required by 30 CFR 48.25(b), 30 CFR 48.26(b), and the approved training plan for BGS Construction, Inc.
During the investigation, a copy of the approved training plan for BGS Construction, Inc., was not available at the work site and had to be obtained from the contractor's office in Slab Fork, West Virginia. The approved training plan included provisions for instruction on hazard recognition and how to avoid such hazards. Dalton would have been instructed on this topic if he had received the proper training in accordance with the contractor's approved training plan.
According to Christopher Covington, Personnel/Safety Director for BGS Construction, Inc., Dalton was hired as an experienced miner based on the work experience listed on his job application. The contractor made no attempt to contact Dalton's previous employers to verify his status as a miner, nor did they have copies of his previous training records. This resulted in Dalton being exposed to mining related hazards while working at the Blacksville No. 2 Mine Preparation Plant without first receiving the required training for new miners pursuant to 30 CFR 48.25. A review of Dalton's training history indicated that he did not receive training in the following topics required by 30 CFR 48.25:
- (1) Instruction in the statutory rights of miners and their representatives under the Act; authority and responsibility of supervisors. The course should have included instruction in the statutory rights of miners and their representatives under the Act, including a discussion of section 2 of the Act; a review and description of the line of authority of supervisors and miners' representatives and the responsibilities of such supervisors and miners' representatives; and an introduction to the operator's rules and the procedures for reporting hazards.
- (2) Introduction to work environment. The course should have included a visit and tour of the mine, or portions of the mine which are representative of the entire mine. The method of mining or operation utilized should have been observed and explained.
- (3) Hazard recognition. The course should have included the recognition and avoidance of hazards present in the mine.
Dalton's situation was not an isolated case. Two other BGS Construction, Inc., employees, Michael Logan and Davis Wolverton, were also new miners who lacked training pursuant to 30 CFR 48.25. In addition, Joey Fowler, Ralph Boggs, Matthew Canada, and Jim Weber, Jr., were among the BGS Construction, Inc., employees who were experienced miners, but did not receive adequate training pursuant to 30 CFR 48.26 when assigned to work at the Blacksville No. 2 Mine. On August 23, 2000, during an ongoing health and safety inspection, 104(g) Orders were issued which declared these miners to be a hazard to themselves and to others and required these miners to be withdrawn from the mine site.
The fatal accident occurred because the victim's assigned work site placed him in close proximity to exposed moving machine parts which were not guarded. The accident occurred when one of the lanyards on the victim's safety harness contacted the exposed end of a moving conveyor flight in the Daniels Precision Coal Washer, causing him to be pulled into the machine where he suffered fatal injuries from the moving machine parts.
The victim's lack of training pursuant to 30 CFR 48.25(a) further contributed to the likelihood of the accident. The victim did not receive the required training because his employers and instructors did not verify the victim's work experience in order to determine his training needs.
• A 103 (k) Order, No. 4884460, was issued to Consolidation Coal Company to ensure the safety of all persons until an investigation was completed and the area and equipment were deemed safe.
• Consolidation Coal Company began operating the Daniels Precision Coal Washer prior to all of the necessary guarding being installed, including guarding intended to protect Consolidation Coal Company employees from hazards related to the washer's exposed moving machine parts. BGS Construction, Inc., further exposed its employees to these hazards in an attempt to complete this work while the washer was being operated by Consolidation Coal Company. Since both the production operator's and the contractor's employees were affected, and since both parties' actions contributed to the violation, 104(a) Citations were issued to both BGS Construction Inc., (Citation No. 7088628) and to Consolidation Coal Company (Citation No. 7088629) for violation of 30 CFR 77.400(a). The body of these citations read as follows:
- Sprockets, chains, and other exposed moving machine parts associated with the Daniels Precision Coal Washer, Model T26054, which were contacted by a BGS Construction, Inc., employee, Daniel Alexander Dalton, and which caused fatal injuries to Mr. Dalton, were not guarded. On August 16, 2000, Mr. Dalton was performing welding work in Consolidation Coal Company's Blacksville No. 2 mine preparation plant while standing on a scaffold board which was placed directly on top of the coal washer, within one foot of unguarded, moving sprockets, chains, and conveyor flights. Mr. Dalton was fatally injured when the secondary lanyard on his safety harness was caught by the moving machine parts associated with the return side of the coal washer flight conveyor system, causing him to be pulled into the machine. The scaffold board was placed on the coal washer by BGS Construction, Inc., employees on August 15, 2000, in order to facilitate the welding work being conducted at the time of the accident.
The Daniels Precision Coal Washer, which contained the moving machine parts associated with the hazardous condition, was being controlled and operated by Consolidation Coal Company at the time of the accident. During the past few months preceding the accident, Consolidation Coal Company has been upgrading on this preparation plant using independent contractors while continuing to process coal.
- Daniel Dalton, a new miner and an employee of BGS Construction, Inc., was assigned to work duties at Consolidation Coal Company's Blacksville No. 2 Mine preparation plant without first being given a minimum of 8 hours training which must include the following topics: Introduction to work environment, hazard recognition, and health and safety aspects of the tasks to which he would be assigned. While performing his assigned duties on August 16, 2000, Mr. Dalton was exposed to mining hazards which resulted in fatal injuries when he contacted exposed moving machine parts. These moving machine parts were an integral part of a Daniels Precision Coal Washer which was being used to process coal at the time of the accident. Through interviews with Christopher Covington, Personnel/Safety Director and Fred Hayes, instructor for BGS Construction, Inc., it was determined that Mr. Dalton did not receive training in the required subjects. They stated that Mr. Dalton was given "Newly Employed Experienced Miner Training" lasting approximately 1 hour. The subjects that Mr. Dalton received in this training were none of the required subjects in 30 CFR Part 48 Training and Retraining of miners. The victim had received hazard training from Consolidation Coal Company on June 13, 2000, which did not cover the subjects required in 30 CFR Part 48.25 - Training of new miners.
Mr. Dalton should have received as a minimum at least seven (7) more hours of training which should have included the required subjects of 30 CFR 48.25(a). Also, through interviews with former employers of the victim, it has been determined Mr. Dalton was not an experienced miner as defined in 30 CFR 48.22(b)(1), (2) and (3).
Related Fatal Alert Bulletin:
Listed below are the persons furnishing information and/or present during the investigation:
- Roy Pride . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . Superintendent - Blacksville No. 2 Mine
Roland Smith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Preparation Plant Superintendent - Blacksville No. 2 Mine
Mike Blevins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Manager - Safety Group 2
Jack A. Holt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Vice President of Safety
Don Gibson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Director of Contractor Compliance
Elizabeth Chamberlin . . . . . . . . . . . . . . . . . . . . . . . . .Corporate Safety Director
Fran Nickler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mine Safety Supervisor - Blacksville No. 2 Mine
- Lourn M. Boyce, Jr. . . . . . . . . . . . . . .
. . . . . . . . . . . President
>Arnold Graybeal . . . . . . . . . . . . . . . . . . . . . . . . . . . Vice President and Treasurer
Douglas Sayre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vice President of Operations
Christopher A. Covington . . . . . . . . . . . . . . . . . . . . . .Personnel/Safety Director
Larry Flesher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Site Supervisor
Larry Broadwater . . . . . . . . . . . . . . . . . . . . . . . . . . . .Employee/Eyewitness
Donna C. Kelly . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Attorney, Heenan, Althen & Roles
- Frederick L. Hayes* . . . . . . . . . . . . . .
. . . . . . . . . . . .Independent Instructor
>Paul Tenney* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P.T. Mine Service, Owner
>Roy L. Anderson* . . . . . . . . . . . . . . . . . . . . . . . . . . . David Stanley Consultants, Instructor
- Larry Kuharcik . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .Safety Committee Chairman
>Wally Dittman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Miners' Representative
Charles Weaver . . . . . . . . . . . . . . . . . . . . . . . . . . . . Safety Committeeman
Dennis O'Dell International Health and Safety Representative
- John Larry . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . .Assistant Inspector-at-Large
Brian Mills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .District Mine Inspector
Bennie Comer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . District Electrical Inspector
Albert M. Lechiaria . . . . . . . . . . . . . . . . . . . . . . . . . District Mine Inspector
Terry Farley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Health and Safety Administrator
- Richard G. Jones . . . . . . . . . . . . . . . .
. . . . . . . . . . . .Coal Mine Safety and Health Inspector (Contractors)
Chris A.Weaver . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mining Engineer, Ventilation
Richard L. Bozick . . . . . . . . . . . . . . . . . . . . . . . . . . . Coal Mine Safety and Health Inspector (Surface)
Gharib Ibrahim, P.E. . . . . . . . . . . . . . . . . . . . . . . . . . Civil Engineer, Pittsburgh Safety and Health Technology Center
Jerry Johnson. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supervisory Coal Mine Safety and Health Inspector
Jerry Vance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mine Safety and Health Specialist (Training)
- * Persons Interviewed
APPENDIX B - IMAGES APPENDIX C - Matco Associates, Inc. - Harness Analysis Report