DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Coal Mine Safety and Health
Report of Investigation
(Surface Coal Mine)
Fatal Machinery Accident
December 17, 2001
Mine # 8
Carbon River Coal Corp.
Carrie, Knott County, Kentucky
I.D. No. 15-18317
By
Lester Cox, Jr.
Coal Mine Safety and Health Inspector
Harlan, Kentucky
Originating Office:
Mine Safety and Health Administration
District 7
3837 S. U.S. Hwy. 25 E, Barbourville, Ky 40906
Joseph W. Pavlovich, District Manager
Report Release Date: May 16, 2002
OVERVIEW
At approximately 11:50 a.m. on Monday, December 17, 2001, a fatal machinery accident occurred along the access road leading to the flooded Number 1 pit of the Carbon River Coal Corp., Mine # 8, near Carrie, Knott County, Kentucky. Kenneth R. Potter, a 47 year old general laborer with 17 years of mining experience, suffered fatal crushing injuries when he was pinned underneath the Caterpillar Model D6D bulldozers rollover protective structure (ROPS) after it overturned on the access roadway. There were no eyewitnesses to the accident.
As there were no eyewitnesses to the accident it is unknown whether the victim was thrown or jumped from the machine. Also, the mechanism by which the machine over-turned is unknown. It is the consensus of the investigation team that the large rock found in the work area either caused, or contributed to, a change in the operating center of gravity of the machine, which resulted in its over-turning. It is the further consensus of the investigation team that the degree of injury sustained by the victim was compounded due to the fact that he was not wearing a seat belt at the time of the accident.
The Mine # 8, located near Carrie, Kentucky, is owned and operated by Carbon River Coal Corp. The mine employs 31 persons and utilizes surface contour mining methods, including augering. The Hazard Coal Seam is mined, which underlies the surface in two separate layers. Overburden is removed utilizing front-end loaders which load the excavated material onto Caterpillar rock trucks. The coal seams are augered utilizing a Superior-10 highwall miner. Bulldozers assist in both the mining and reclamation processes.
The mine produces an average of 1500 tons of raw coal, two shifts per day, from three open pits and three highwall miners. Coal is produced six days per week. There is no separate maintenance shift, maintenance being done during the production shifts. Coal is loaded onto trucks with front-end loaders and transported from the mine for further processing.
The Principal Officers of the operation are as follows:
Ricky Kirk .......... PresidentPrior to the accident, the last Mine Safety And Health Administration (MSHA) Regular Safety and Health Inspection (AAA) was completed on September 6, 2001.
Jerry Wells, Jr. .......... Vice- President.
The day shift began, as scheduled, at 7:00 a.m. on December 17, 2001 under the supervision of Danny Mullins, Foreman. Each of the workers was assigned their duties for the shift. Kenneth R. Potter, general laborer, was instructed to construct an access road down the spoil bank to the flooded Number 1 pit in order to provide for the transportation and placement of de-watering pumps. For this construction, Potter utilized and operated a Caterpillar Model D-10 bulldozer. The grade or slope of this access road was measured at approximately 13 percent and extended approximately 270 feet in length.
Upon completion of the road, Potter next used a Caterpillar Model D6D bulldozer, provided with a trailer hitch, to place the trailer-mounted gasoline-powered six inch diameter de-watering pump near the lower limit of the access road at the edge of the water. Arthur Johnson, general laborer, assisted Potter in setting this pump. A second de-watering pump was to be installed approximately 100 feet downhill from the crest of the access road in an area which was yet to be leveled.
Potter and Johnson spoke briefly to each other. Potter then returned to the level area at the crest of the access road while Johnson began preparing and unrolling flexible water line which was to be installed on the pumps. Potter then returned down the access road with the bulldozer to complete the preparation of the area for the second de-watering pump.
At approximately 11:50 a.m. Johnson walked to the crest of the access road, and looked down toward the area where Potter was to be working. Johnson stated that he observed that the bulldozer laying on its left side, at the location being prepared for the second pump. Johnson further stated that he ran down the access road to the bulldozer and found Potter pinned between the bulldozer's Rollover Protection Structure (ROPS) and the ground. Johnson stated that he did not check for vital signs. Johnson went to his truck and immediately called Danny Mullins, Foreman, via mobile phone, and informed him of the accident. Mullins, who was located off-site at a local store, called Delmen Childers, welder/mechanic, via mobile phone, and informed him of the accident and directed him to the site. Mullins then called Mike Fields, safety department worker, via mobile phone and informed him of the accident and instructed him to notify an ambulance and the coroner.
Childers, also a certified Mine Emergency Technician (MET) arrived at the site via service truck. Childers stated that upon his arrival, he observed Potters body pinned against the ground and said that he observed no vital signs. The victim was pronounced dead at 12:55 p.m. by Knott County Coroner Jeff Blair.
At approximately 11:50 a.m. on Monday, December 17, 2001, Charles Henderson, MSHA inspector of the Hazard Field Office, who was conducting an inspection of the highwall miner located in another area of the operation, was notified by Willie Reynolds, general laborer, of the accident. Henderson hurriedly traveled to the accident scene and observed Potter pinned under the bulldozer=s ROPS. Henderson was then informed by Childers that Potter had no vital signs. Henderson immediately issued a 103(k) order, to insure the safety of the miners and to preserve the accident scene. Next, Henderson notified Hazard MSHA field office personnel, who subsequently notified John M. Pyles, District 7 Assistant District Manager for Enforcement.
Pyles promptly assembled an Accident Investigation Team consisting of Lester Cox, Jr., Coal Mine Safety and Health (CMS&H) Inspector, Dan Johnson, Supervisory CMS&H Inspector, and Argus Brock, CMS&H Surface Inspector. The team was then dispatched to the mine to begin the investigation. Preliminary information was gathered and the accident scene was examined.
MSHA and the Kentucky Department of Mines and Minerals (KDMM) jointly conducted the investigation with the assistance of mine management and the miners. Formal interviews were conducted at the MSHA field office in Hindman, Ky., in conjunction with KDMM on December 19, 2001. Four interviews were conducted. None of those interviewed requested that their statements be kept confidential.
On December 18, 2001, Ronald Medina, Mechanical Engineer, Mechanical Safety Division, of MSHA's Approval and Certification Center assisted in the on-site investigation and subsequent testing and evaluation of the Caterpillar Model D6D bulldozer. On December 19, 2001 the subject bulldozer was up-righted, utilizing a Caterpillar Model D10 bulldozer. The subject bulldozer was next pulled to a level location where it was further examined by Medina and Brock.
All components tested on December 18 and 19, 2001 were found to be functioning properly. The condition of the engine did not permit operational testing until January 8, 2002, at which time the engine was serviced and boosted off. This work was conducted by Authur Johnson, general laborer, and Willie Reynolds, general laborer, and was then operated by Delmen Childers. Cox and Brock observed the operational testing and the machine was found to be operating properly. The results of the evaluation are discussed further in this report. (See Appendix B)
A list of those who were present and/or participated in the investigation is included. (See Appendix A)
Interviews were conducted with mine personnel who were determined to have potential information related to the prior operational condition and maintenance of the Caterpillar Model D6D bulldozer. Based upon statements obtained during these interviews, the bulldozer=s right side final drive had been repaired on December 8, 2001. No mechanical problems were reportedly experienced with the bulldozer since that date or on the day of the accident.
Based upon further statements obtained there was no indication of any history of operational problems with the subject bulldozer.
The following physical factors were determined to be relevant to the occurrence of the accident.
1. The accident occurred along the access road leading to the flooded Number 1 pit.
2. The slope of the access road was measured at 13 percent grade.
3. It was reported that rainy, muddy conditions existed at the time of the accident. However, the work area was rocky and well-drained.
4. A ROPS was provided on the subject bulldozer, but the operator=s compartment was not enclosed.
5. A properly functioning seat belt was provided on the subject bulldozer, however the victim was not wearing it at the time of the accident.
6. There were no bulldozer tracks present on the ground, due to its rocky characteristics and due to the rain.
7. When the subject bulldozer was up-righted it was observed that its right track came to rest on a large rock approximately 32 inches high that was located along the right edge of the work area.
8. When examined at the accident scene, the transmission lever was found in the second reverse position.
As there were no eyewitnesses to the accident it is unknown whether the victim was thrown or jumped from the machine. Also, the mechanism by which the machine over-turned is unknown. It is the consensus of the investigation team that the large rock found in the work area either caused, or contributed to, a change in the operating center of gravity of the machine, which resulted in its over-turning. It is the further consensus of the investigation team that the degree of injury sustained by the victim was compounded due to the fact that he was not wearing a seat belt at the time of the accident.
1. A 103(k) Order, No. 7471080, was issued to ensure the safety of the miners until an investigation could be conducted.
2. A 104(a) Citation, No. 7530842, was issued for violation of Title 30, Part 77.403(a), stating, "A seatbelt was not worn by the operator of mobile equipment that is provided with Rollover Protection Structures (ROPS). On December 17, 2001 the operator of the Caterpillar D6D bulldozer, serial number 4X5755, was not wearing the provided seatbelt while the bulldozer was being operated along the access road leading to the flooded 01 strip pit. The bulldozer overturned on its left side, pinning the victim between the Rollover Protection Structures (ROPS) and the ground."
FAB01C42
APPENDIX A
List of persons furnishing information and/or present during the investigation.
Danny Mullins ......... Foreman
Arthur J. Johnson ......... General Laborer
Willie Reynolds ......... General Laborer
Delmen Childers ......... Repairman/EMT
Tracy Stumbo ......... Chief Accident Investigator
Johnnie Greene ......... Inspector, Accident Investigator
Bob Banks ......... Inspector, Accident Investigator
David Mullins ......... Inspector
Robert Ashworth ......... Inspector
Dan Johnson ......... Supervisory, CMS&H
Lester Cox, Jr. ......... CMS&H Inspector/Accident Investigator
Argus Brock ......... CMS&H Inspector, Surface
Ronald Medina ......... Mechanical Engineer, Mechanical Safety Division, MSHA Approval and Certification Center