DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
COAL PREPARATION FACILITY
FATAL POWERED HAULAGE ACCIDENT
June 28, 2002
at
Lone Mountain Processing, Inc.
Lone Mountain Processing (I.D. 44-05898)
St. Charles, Lee County, Virginia
Accident Investigator
Arnold D. Carico
Mining Engineer
Originating Office
Mine Safety and Health Administration
District 5
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Edward R. Morgan, Acting District Manager
RELEASE DATE: September 19, 2002
OVERVIEW
On June 28, 2002, at approximately 5:50 a.m., 49-year-old Willie Holmes, Jr. was fatally injured when the truck he was operating overturned into a coal slurry impoundment. The victim was backing a Model 773B Caterpillar 50-ton off-road truck along a haulroad to a designated dumping location when the truck went through the berm approximately 25 feet short of the dump, causing the truck to roll/slide down the slope and overturn into the impoundment. The victim was recovered from the impoundment at 1:25 p.m. and was transported to the Lee Regional Medical Center in Pennington Gap, VA where he was pronounced dead on arrival.
There were no eyewitnesses to the accident. The accident occurred when the truck was apparently turned before reaching the designated dumpsite, causing it to go through the provided berm and roll/slide down the embankment and overturn into the impoundment. When the truck came to rest, the front wheels were in a hard right turn position as if the victim was attempting to back into the dump location. Contributing factors to the accident were: 1) the distance the truck had to be operated in reverse with the inherent reduced visibility, 2) the lack of any assisting markers or reflectors to aid the operator while operating in reverse, 3) poor natural lighting at the time of day of the accident, and 4) the unconsolidated material used to construct the roadway berm had become saturated and provided little, if any, warning as the truck approached the edge of the roadway.
GENERAL INFORMATION
Lone Mountain Processing's coal preparation plant is located two miles North of St. Charles, VA at the end of State Route 636. The plant was constructed and opened in 1982 under the name of Straight Creek Processing Company and operated under that name until August 1991, when purchased by Lone Mountain Processing, Inc. Catenary Coal Holdings, Inc., a subsidiary of Arch Mineral Corporation, purchased Lone Mountain in April 1992. The facility address is 636 Benedict Road, St. Charles, VA. The company mailing address is Drawer C, St. Charles, VA 24282. The principal management officials in charge at the time of the accident were:
General Manager------------------------ Thomas BaumgarthThe coal processed at this plant is produced at two Kentucky underground coal mines and transported via belt conveyor to the plant through the Lone Mountain 6-C Mine (which is a ventilated tunnel maintained to accommodate the belt conveyor). The plant employs 31 people on two 12-hour shifts, six days per week. The shifts run between 6:00 a.m. and 6:00 p.m. and between 6:00 p.m. and 6:00 a.m. Typically, the first half of the night shift is production and last half is maintenance. A normal workweek is three consecutive days of the same shift (either Monday, Tuesday and Wednesday or Thursday, Friday and Saturday) and a fourth "floating" shift sometime during the other half of the week, thus making a 48 hour workweek. These floating shifts will normally be the same shift, but not at the employee's regular duties.
Plant Manager--------------------------- Thurman Holcomb
Safety Manager-------------------------- Jim Vicini
The refuse from the preparation plant is disposed of at a combination coarse refuse pile and impoundment. The coarse refuse is used to construct the impounding structure while the filter cake ("mud") from the plant is placed upstream of the dam. The mud is produced by extruding the water from the coal refuse fines, and is stored in a bin until it can be hauled to the refuse site. The mud bin capacity is approximately four truckloads. When either the coarse refuse or the mud bin reach near capacity, an automatic warning light is actuated at the plant operator's station. Plant operation must then either be curtailed or stopped until the material in the bin can be removed.
Both the mud and the coarse refuse are hauled to the refuse site via Caterpillar 773-B 50-ton off-road trucks. As needed, a road is extended along the outer perimeter of the impounded area from which the mud is dumped into the impoundment. The most recent dumpsite (accident scene) was being accessed by operating the trucks in a forward mode for several hundred feet around the perimeter of the impoundment. The trucks then turned at a wide place and backed approximately 400 feet, since there was not adequate room to turn the trucks at the dumpsite. The dumps normally consisted of a widened spot along the roadway to accommodate turning the truck into the dump thus allowing the mud to be dumped over the stop block/berm and into the impoundment.
The last regular Safety and Health Inspection (AAA) was completed on March 28, 2002. The 2001 NFDL (non-fatal days lost) national injury frequency rate for preparation plants was 2.75. The rate for this facility was 6.31 for the same period.
DESCRIPTION OF THE ACCIDENT
On Thursday, June 27, 2002, the night shift crew (6:00 p.m. to 6:00 a.m.) for the preparation plant began their workday as normal by gathering in the change room some thirty minutes before the start of the shift. At the start of the shift, the crew received their work assignments from Doug Stapleton, night Shift Foreman and work proceeded as usual. Members of the crew assumed their normal work duties while Willie Holmes, Jr., Pipe Fitter/Welder, was assigned to drive the mud truck, a job which is assigned to one of those who are working their floating shift. Holmes' normal workweek was the night shift on Monday, Tuesday and Wednesday as a Pipe Fitter/Welder and an assigned floating shift during the other half of the week.
At approximately 9:00 p.m. a pipe burst causing the plant to have to be shut down. Since the plant was not producing any refuse to be hauled, Holmes and Michael Shope, coarse refuse Hauler Operator, were assigned other duties. Since Holmes' regular classification was Pipe Fitter/Welder, he was assigned to assist in replacing the pipe and Shope hauled one load of mud to the short dumpsite. Work was also done to repair the lip of the coarse screen while the plant was down. The plant was restarted at approximately 2:20 a.m. and production proceeded normally until the end of the shift.
At approximately 5:40 a.m. Donald Edens, Preparation Plant Operator, spoke with Holmes on the citizen's band radio. At the time, Holmes was loading his truck at the mud bin. Since the truck drivers are required to report the number of loads hauled, Holmes reported to Edens that he had hauled 24 loads and would haul one more before the end of the shift. A round trip for the mud truck took approximately 15 minutes.
Shift change is performed with a "hot seat" change-out meaning that the on-coming shift employee takes over for the previous shift employee without an interruption in production. In the case of the drivers, this is accomplished while the truck is being loaded. The operator will normally do the pre-operational checks while the truck is beneath the bin or after the truck is pulled from beneath the bin. At approximately 5:55 a.m., Edens received a signal that the mud bin was almost full. Michael Hendricks, Hauler Operator (mud truck for the day shift), went to the mud bin to take over from Holmes at 6:00 a.m. He noted that the truck had not yet returned to the bin.
Vernon Collett, Hauler Operator (coarse refuse truck for the day shift), began his first trip to the coarse refuse dump area at 6:00 a.m. When he reached the impoundment area, he heard someone trying to reach Holmes on the radio. Collett was instructed by Winston Wade, day shift Plant Foreman, to try to locate Holmes. In order to see the mud dumpsite, Collett drove farther around the dam so he could see up the side drainage where the mud trucks had been dumping. He observed the truck overturned in the edge of the pond and immediately called on the radio for Wade to come to the accident scene.
Collett, Wade, and Don Sexton, Surface Foreman, met on the haulage road at the dam. They immediately proceeded along the haul road around the impoundment to the accident scene. They parked at the turning point for the mud trucks and walked the remaining distance to the scene. The truck had traveled approximately 40 feet down a 50+% grade and was resting on its left side in the edge of the impoundment, which at this location consisted of the previously dumped mud. The truck was pointing in the opposite direction of travel and the cab of the truck was almost completely submerged in the mud. When the three men reached the truck, the engine was off, the red rear running lights were on and the emergency steering hydraulic pump was running.
Robert Middleton, day shift Hauler Operator for the Monday-Wednesday crew, was also working his floating shift. When the mud truck did not return to the dump on time, he was instructed to get the third (spare) truck since the mud bin was almost full. At approximately 6:10 a.m., he loaded the truck at the mud bin and drove to the top of the dam where he saw that the road to the dump was blocked with trucks. Realizing something was wrong, he parked the truck and proceeded on foot to the accident scene. Middleton described the berm at the accident scene as "�broken off�, �.not much of it left above the road level�". Middleton and others also stated that the truck appeared to have passed through the berm at a sharp angle as if Holmes' intention was to turn into the dump area, but was some 20 to 30 feet short of the dump. Photographs taken by a company representative shortly after the accident appear to confirm this description of the area where the truck breached the berm.
Sexton was able to climb onto the truck where he observed the cab to be almost completely filled with mud but saw no sign of Holmes. Radio contact was made with the plant and assistance was requested in the form of dozers and cable to be used to pull the truck from the pond. Early thoughts of righting the truck from the existing roadway were soon abandoned in favor of cutting the roadway down closer to the truck before attempting to right it.
Work proceeded to recover the truck. As mentioned previously, a company representative took photographs of the accident area prior to any recovery work that would disturb the accident scene. Two dozers were used to cut the roadway elevation down immediately adjacent to the truck to a level just above the impoundment elevation. In so doing, the section of roadway and berm where the truck left the roadway was removed prior to the beginning of this investigation. Cables were then attached, and at 10:05 a.m. the dozers were used to pull the truck back onto its wheels.
The driver's side door was closed and concave from the force of the mud on that side. The mud in the cab was removed to the degree that it was apparent that Holmes was not in the cab. The truck was then dragged out of the way so that recovery work could continue. Early attempts to locate Holmes with probes proved unsuccessful. An excavator was then used to slowly back drag thin layers of mud in an attempt to locate Holmes. At 1:25 p.m. Holmes was recovered and transported by the St. Charles Volunteer Rescue Squad to Lee Regional Medical Center where he was examined and pronounced dead at 3:15 p.m. by Dr. Guy Clark, Lee County Medical Examiner.
INVESTIGATION OF THE ACCIDENT
The company notified Wayland Jessee, former Assistant District Manager-Inspection Division, of the accident by telephone at his home at approximately 6:40 a.m. Jessee then relayed the information to the District 5 office at 7:05 a.m. The information indicated that the truck had overturned into the refuse pond and that the driver had not been accounted for. They also indicated that recovery efforts would begin immediately by constructing a road down to the wrecked truck. At 7:30 a.m. John Godsey and Lannie Gilbert, Coal Mine Inspectors, and James Poynter, Conference and Litigation Representative, were dispatched to the site. Upon arriving onsite at 8:30 a.m., a closure order for the slurry impoundment, all haul roads and all haulage vehicles was issued under Section 103(k) of the 1977 Mine Act to assure the health and safety of those persons involved in the recovery operation and accident investigation.
At 10:15 a.m., Arnold D. Carico, Mining Engineer and Lead Accident Investigator, Russell Dresch, Electrical Engineer, and Norman G. Page, acting Assistant District Manager-Technical Division, arrived on site. Since the company had scheduled vacation for the week of July 1, and since the day of the accident was the last day of the workweek, a joint decision with the Virginia Department of Mines, Minerals and Energy (VDMM&E) was made to proceed with the investigation on the day of the accident. Accident team members were designated and the investigation begun. Preliminary information for the accident report was gathered and company records were examined. Observations, measurements, pictures and video were made at the accident scene. Joint interviews with VDMM&E were conducted that afternoon and evening of all persons thought to have information relevant to the accident.
Preliminary findings indicated that there were potential safety issues related to existing haulage practices, particularly relating to operation of trucks for extended distances in reverse; therefore the company was asked to generate and implement a Best Practices statement concerning these related issues prior to returning to production. A spot inspection (CAA) was conducted in conjunction with the fatality investigation (AFA) and was scheduled to begin on Saturday, June 29, 2002.
DISCUSSION
1. Refuse from the Lone Mountain Processing preparation plant consists of both coarse and fine refuse. Due to previous problems with pumping liquid slurry to the impoundment, the company had converted to a filter cake/belt press system for handling refuse fines. This process produces a "mud" which is stored in a bin at the plant and then transported by truck from the plant to the refuse disposal area.
2. Truck drivers at the plant are often miners who are working their scheduled "floating" shift during the other half of the workweek, but on the same shift as their regular shift. At the beginning of the 6:00 p.m. to 6:00 a.m. shift on June 27, Willie Holmes, Jr. was operating the mud truck and Michael Shope was operating the rock truck. Holmes' regular job was Pipe Fitter/Welder for the Monday-Wednesday crew.
3. At 5:37 a.m., Rick Bullock, Utility Man, was using a wash down hose to clean around the mud bin. While Holmes was loading his truck, Bullock washed the truck down, including the lights on the rear of the truck. After reporting his load total by radio, Holmes began his last trip of his shift at approximately 5:45 a.m.
4. Just prior to Holmes leaving with his last load of the shift, Shope returned to the plant after his last load and left for home. Vernon Collett took over for Shope on the rock truck and Michael Hendricks was scheduled to take over for Holmes on the mud truck. However, when Holmes did not return to the mud bin on time, Robert Middleton was instructed to get the spare truck for the mud haul. Middleton loaded the truck and was hauling his first load when the accident occurred.
5. Collett was located on the top of the dam when he heard someone on the radio trying to get a response from Holmes. Collett was instructed by Wade to try to locate Holmes. In an attempt to see if Holmes might be in need of assistance, he then drove farther out the dam where he was able to see the mud truck overturned in the edge of the impoundment. Using his radio, he immediately summoned help.
6. The accident occurred at approximately 5:50 a.m. On this date, civil twilight occurred at 5:45 a.m. and sunrise was at 6:16 a.m. Civil twilight is defined as the time at which objects on the earth's surface do not need artificial illumination to be clearly distinguished under good weather conditions. Overcast conditions were predominate during the morning of the accident, thus civil twilight would have been delayed. During twilight conditions, the gray appearance of objects affects depth perception.
7. During the five hours preceding the accident, 0.6 inch of rain fell at the Bonny Blue weather station, which is located a short distance from the accident site. One half inch of this total fell during the 1:00 a.m. to 3:00 a.m. period with the remaining 0.1 inch falling from 3:00 a.m. to 6:00 a.m. period.
8. In order to reach the designated dumping point, the mud truck drivers had to operate the trucks in reverse for approximately 400 feet. The traveled portion of this roadway averaged over 28 feet wide and had almost no grade in this area. The dump was constructed by a dozer using coarse refuse and native soils cut from the roadway embankment. This material was used to lengthen the roadway to and widen the roadway at the dump location such that the trucks could back into the dump area at an approximate 45 to 60 degree angle. Once at the dump, the operators reportedly dump the load of mud over the berm with both rear wheels in contact with the berm. The dump area and the section of roadway from the previous to the present dump had been constructed for approximately three weeks.
9. At the time of the accident investigation, the dumpsite and the berm immediately adjacent to the dumpsite where the truck breached the berm were no longer in place due to the recovery activities. The section of berm from the previous to the present dumping location was constructed approximately three weeks prior to the accident and the material used to construct this section of the roadway berm and dump berm appears to be unconsolidated material. Statements made during interviews indicate that the berm along the roadway and at the dumpsite was maintained to the required height. Photographs taken by company personnel prior to the recovery activities appear to support those statements.
10. The trucks used for hauling refuse at the plant are Caterpillar 773B 50-ton trucks with a gross vehicle weight of 204,000 pounds. The automatic transmissions have seven forward gears and one reverse gear. The trucks are approximately 13.3 feet wide at the wheels and have a 15.4-foot operating width (at the widest projections of the mirrors). The trucks are 24.3 feet long from the front bumper to the rear of the rear wheel (turning length when operated in reverse for end dumping) and are 30.4 feet long overall. The trucks are rated as having a 70.6-foot turning diameter on the front wheel track.
11. The truck involved in the accident was originally manufactured in 1985. Earlier this year, the truck underwent an overhaul at a Caterpillar facility during which many components, such as the engine, transmission, steering system and braking system were disassembled and reconditioned. The reconditioned truck was returned to service on June 12, 2002 and carried a warranty equal to a new truck. The engine hour meter showed 239.5 hours of operation since being returned to service. Following the accident, the truck was thoroughly examined and no defect was found in the brake systems, steering systems, transmission or any other system that would have contributed to the accident.
12. The truck involved in the accident was equipped with a 17" by 12" convex mirror on the right side and a 15" by 7" flat mirror on the left side. After the accident, the glass portions of both mirrors were found to be unbroken. There is no reason to believe that the mirrors were not clean and in good repair at the time of the accident. The seat belt was checked and found to latch properly. During the investigation and prior to recovering the truck, it was noted that the rear lights were clean. One of the five halogen backup lights would function only intermittently when checked after the accident. During the inspection of the truck, this was found to be due to a broken bulb base and functioned properly after being replaced.
13. Witness statements indicate that, immediately after the accident, the emergency steering control pump was operating, the red rear running lights were on and the bed was in the lowered position. When the truck was recovered, the transmission shift lever was found in the "neutral" position, the parking brake was found in the "off" position and the retarder control was down one to two inches.
14. Statements indicated that the truck did not ride along or upon the berm but went through the berm at a steep angle. One witness indicated that very little of the berm remained where the truck left the roadway. Company photographs appear to confirm this statement, particularly where the right rear wheels went through the berm.
ROOT CAUSE ANALYSIS
A root cause analysis was performed on the accident. The following causal factors were identified:
1. Causal Factor - The dumping operation was so designed that the trucks had to be operated for almost 400 feet in reverse. The inherent restricted visibility of reverse operation was further exacerbated by the lack of clear delineation of the roadway and the required night/dawn operation of trucks along this portion of roadway.
2. Causal Factor - The provided roadway berm was not properly maintained. The berm was recently constructed and was composed of unconsolidated material. Since this section of roadway was almost zero percent grade and had no outlet for drainage, any water falling or flowing onto the roadbed was impounded. This caused the berm to become saturated and thus lose its function as a warning that the truck was nearing the outer edge of the roadway.
3. Causal Factor - The victim was not wearing his seat belt at the time of the accident. This is evidenced by: (a) the victim was recovered from beneath the overturned truck and, (b) statements made during the investigation by co-workers to the effect that the victim had a fear of overturning into the impoundment and would unfasten his seatbelt when dumping.
CONCLUSION
The accident occurred when the victim apparently turned the truck into the roadway berm before reaching the designated dumpsite. Contributing factors were: 1) the distance the truck had to be operated in reverse with the inherent reduced visibility, 2) the lack of any assisting markers or reflectors to aid the operator while operating in reverse, 3) poor natural lighting at the time of day of the accident, and 4) the unconsolidated material used to construct the roadway berm had become saturated and provided little, if any, warning as the truck approached the edge of the roadway.
ENFORCEMENT ACTIONS
Section 103(k) Order No. 7314817 was issued on June 28, 2002 and reads as follows: The coal cleaning plant has experienced a fatal truck haulage accident at the slurry impoundment; this order is issued to assure the safety of any person in the slurry impoundment and haul road areas until an examination or investigation is made to determine that the slurry area and haul road is safe. Only those persons selected from the company officials, state and any other person who is deemed by M.S.H.A. to have information relevant to the investigation may enter or remain in the affected area.
The order was later modified to allow for: the removal of the truck, recovery of the victim, repair of berms, implementation of Best Practices for haulage trucks identified during the investigation, returning other trucks to normal production, evaluation and making necessary repairs to the truck (relative to later functional testing), and do functional testing of the truck.
On September 9, 2002, the following two citations were issued under Section 104(a) of the Act as significantly and substantially contributing to the cause of the fatality:
Citation No. 7322288 read as follows: On June 28, 2002, Willie Holmes, Jr. was fatally injured when the Caterpillar 773B 50-ton hauler he was operating traveled backwards through a roadway berm, rolled/slid down an embankment and overturned into the edge of the slurry impoundment Holmes was recovered some seven hours later from the slurry beneath where the truck had come to rest. These facts indicate that the seat belt was not used while the vehicle was in motion in an area where there was a hazard of overturning. (The truck was provided with Roll Over Protection.)
Citation No. 7322289 read as follows: On June 28, 2002, Willie Holmes, Jr. was fatally injured when the Caterpillar 773B 50-ton hauler he was operating traveled backwards through a roadway berm, rolled/slid down an embankment and overturned into the edge of the slurry impoundment. The berm at the location where the truck left the roadway was inadequate in that it was constructed of unconsolidated material which had become saturated, giving the operator little if any warning that he was approaching the edge of the roadway. The roadway and berm were so constructed that drainage was not provided for the approximately zero percent grade roadway/dump area. Within the 5 hours prior to the accident, 0.6 inch of rain had fallen in this area (Bonny Blue weather station). Drainage from the embankment above the roadway and in the roadway would have accumulated in the roadway/dump area (as is confirmed by photographs taken just after the accident) thus causing the berm to become saturated. The investigation revealed that the right rear truck tires went through the berm without riding upon the berm material and that the material was of a "muddy" consistency.
The Best Practices that were identified and implemented during the investigation were:
1. Vehicles shall not be permitted to travel in reverse for extended distances when it is possible to travel forward.
2. Dump locations shall be clearly marked with reflectors and/or markers.
3. Dump locations shall be arranged so that drivers may use the driver's side mirrors for visibility while backing.
4. Proper berms will be maintained along all haulage roads and adequate berms will be maintained at dumping points to prevent overtravel or overturning of haulage vehicles.
5. Prior to entering or remaining in the affected area, and presently excepting those necessary under Section 104(c) of the Act for recovery activities, all preparation plant personnel will be trained in these procedures. A record certifying that the miners have received the subject training will be maintained and made available to MSHA, the miner's representative, and the state agencies.
Related Fatal Alert Bulletin:
FAB02C16
APPENDIX A
List of persons providing information and/or present during the investigation:
LONE MOUNTAIN PROCESSING, INC.
Charles Russell .......... Director Corporate SafetyWYATT, TARRANT, AND COMBS
Jim Vicini .......... Manager of Safety
Thurman Eugene Holcomb, Jr. .......... Plant Superintendent
Donald Wayne Sexton .......... Surface Foreman
Winston Nolan Wade, Jr. .......... Day Shift Foreman
Douglas Lee Stapleton, Sr. .......... Night Shift Foreman
Donald Lawrence Edens .......... Plant Operator
Danny Joe Stapleton .......... Pipe Fitter/Welder
Danny Joel Peace .......... Floc Man
Harold Richard Bullock .......... Utility Man/Floater
Michael David Shope .......... Hauler Operator
Vernon Collett .......... Hauler Operator
Michael Edward Hendricks .......... Hauler Operator
Robert Dale Middleton .......... Hauler Operator
ATTORNEYS AT LAW
Marco Rajkovich .......... AttorneyVIRGINIA DEPARTMENT OF MINES, MINERALS AND ENERGY
Frank Linkous .......... Chief, Department of MinesMINE SAFETY AND HEALTH ADMINISTRATION - DISTRICT 5
Carroll Green .......... Mine Inspector Supervisor
John Thomas .......... Mine Inspector Supervisor
Danny Mann .......... Mine Inspector
Sammy Fleming .......... Mine Inspector
Philmore Skorupa .......... Mine Inspector
Daniel Perkins .......... Technical Specialist
Edward R. Morgan .......... Acting District ManagerMSHA APPROVAL AND CERTIFICATION CENTER
Norman G. Page .......... Acting Assistant District Manager,-Technical Division
Benjamin Harding .......... Inspection Supervisor
James W. Poynter .......... Conference and Litigation Representative
Arnold D. Carico .......... Mining Engineer
Russell Dresch .......... Electrical Engineer
Wade T. Gardener .......... Mine Safety and Health Specialist-Surface
John F. Godsey .......... Coal Mine Inspector
James A. Baker .......... Coal Mine Inspector
Lannie D. Gilbert .......... Coal Mine Inspector
Ronald Medina .......... Mechanical EngineerMSHA -PITTSBURGH SAFETY AND HEALTH TECHNOLOGY CENTER
Michael C. Superfesky .......... Civil Engineer
Michael J. Murawski .......... Civil Engineer
LIST OF PERSONS INTERVIEWED
Thurman Eugene Holcomb, Jr. .......... Plant Superintendent
Donald Wayne Sexton .......... Surface Foreman
Winston Nolan Wade, Jr. .......... Day Shift Foreman
Douglas Lee Stapleton, Sr. .......... Night Shift Foreman
Donald Lawrence Edens .......... Plant Operator
Danny Jo Stapleton .......... Pipe Fitter/Welder
Danny Joel Peace .......... Floc Man
Harold Richard Bullock .......... Utility Man/Floater
Michael David Shope .......... Hauler Operator
Vernon Collett .......... Hauler Operator
Michael Edward Hendricks .......... Hauler Operator
Robert Dale Middleton .......... Hauler Operator