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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION


District 4


REPORT OF INVESTIGATION
(UNDERGROUND COAL MINE)

FATAL MACHINERY ACCIDENT

ISLAND FORK CONSTRUCTION, LTD. (PUL)
BECKLEY, RALEIGH COUNTY, WEST VIRGINIA

at

LAUREL FORK DEEP MINE, ID NO. 46-08836
TITAN MINING INC.
ESKDALE, KANAWHA COUNTY, WEST VIRGINIA


August 12, 2002

by

Roger D. Richmond
Coal Mine Safety and Health Inspector


James R. Humphrey
Coal Mine Safety and Health Inspector


Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Edwin P. Brady, District Manager

Release Date: November 19, 2002



OVERVIEW


On Monday, August 12, 2002, a 23-year-old contract laborer with 6 months and 10 days mining experience, received fatal crushing injuries when he was caught between the tail boom of the continuous-mining machine and the mine roof. The victim was helping move a continuous-mining machine from a working section to the outside so repairs could be performed on the ripper head drive components. About midway into the move, the continuous-mining machine trammed over an 8-inch to 10-inch ledge in the mine floor. When the front of the continuous-mining machine trammed over this ledge, the rear of the machine raised, causing the boom to suddenly strike the mine roof. The victim, whose job was to watch the continuous-mining machine trailing cable slack, was caught between the end of the continuous-mining-machine boom and the mine roof.

GENERAL INFORMATION

The Laurel Fork Deep Mine, operated by Titan Mining Inc., is located near Eskdale, Kanawha County, West Virginia. Titan Mining has owned and operated the mine since November 27, 2001. The mine operates one single producing section in the Winifred seam through five drift openings, and is rehabilitating another area of the mine for an additional unit. The coal seam thickness averages 42-to-48 inches. Approximately 818 tons of raw coal are produced daily on one 12-hour production shift and one 8-hour maintenance shift. This mine employees 36 persons. Island Fork Construction, Contractor ID PUL, furnishes 26 hourly employees, while 10 people are employees of Titan Mining Inc. The room and pillar mining method is used. Coal is extracted utilizing one continuous-mining machine, two Joy 21 shuttle cars, feeder, roof-bolting machine, and transported to the surface via conveyor belts. The mine is ventilated by a blowing, Joy 6 foot fan. The last quarterly AAA inspection was completed June 11, 2002. No methane liberation was recorded at that time.

Principal officers of Titan Mining Inc. at the time of the accident were: Clyde McComas, President; Ollie Burns, Jr., Vice President; Steve Torrico, Secretary/Treasurer; and Ronnie Mayhorn, Mine Foreman.

The non-fatal days lost (NFDL) incidence rate the previous quarter was 6.89 for underground coal mines nationwide, and 9.17 for this mine.

Principal officers of Island Fork Construction at the time of the accident were: Amon Mahan, President; Roger Ball, Sr., Safety Director; and Tammy L. Davis, Office Manager.

The 2001 non-fatal days lost (NFDL) incidence rate for contractors at underground coal mines nationwide was 3.63, and 24.14 for Island Fork Construction. This is the 2nd fatal coal mine accident involving an Island Fork Construction employee in 2002.

DESCRIPTION OF THE ACCIDENT

On Monday, August 12, 2002, at approximately 6:20 a.m., Doran Bishop, foreman, Clyde McComas, chief electrician, and William Williams, section electrician, with Bishop at the controls, started moving a Joy 14-10A continuous-mining machine from outside to the active working section, MMU 001. The machine was being taken underground to replace a Joy 14-10AA continuous-mining machine that had a ripper head in need of repair. A move box (step-up box) to increase voltage was positioned underground to supply power to the continuous-mining machine during the move. The box was relocated twice during the continuous-mining machine's movement toward the face, and would in reverse order be relocated two times while the continuous-mining machine needing repairs was being brought outside. Each position of the move box is referred to as one leg of the move.

During the third leg of the Joy 14-10A continuous-mining machine's travel from outside to the working section, McComas returned outside for a scheduled meeting, leaving Bishop and Williams to complete the continuous-mining machine move to the section. Upon reaching the section they parked the machine in a breakthrough, out of the way. At 9:00 a.m., Ollie Burns, Jr., superintendent, Ronnie Cox, section electrician and Jason Moore, greaser and victim, arrived on the working section to service equipment and prepare the section for evening shift production, which would start at 4:00 p.m.

Burns directed Williams to return outside to get feeder shear pins. He told Moore to untangle and remove the water hose from the Joy 14-10AA continuous-mining machine in preparation for its' move outside. After removing the water hose, Moore, without Burn's knowledge, joined Bishop to assist in moving the continuous-mining machine toward the outside. Moore assisted by watching the continuous-mining machine trailing cable, which involved determining when to hook and unhook cable pull ropes onto the frame of the continuous-mining machine.

At the end of the first leg of the move toward the outside, the continuous-mining machine was parked in a breakthrough near survey station 429, to allow the move box to be relocated for the second leg of the move outside. When the move box was repositioned to a location outby the continuous-mining machine, a portion of the trailing cable

looped around the machine from its' right rear where the cable connected to the machine, lay on the mine floor along the left side of the entry, and crossed in front of the machine, back to the right rib line. The trailing cable was hung across the travelway to allow the continuous-mining machine to tram under it on the way outside. Before the continuous-mining machine was reenergized to start the second leg, repairs were made to the power cable which supplied voltage to the move box. McComas returned to the area at this time and assisted in making the repairs.

After some delay, the continuous-mining machine was energized, and the second leg of the move began. Carl Lilly, section foreman, and Williams, en route to the section from the surface, pulled the personnel carrier they were riding into a crosscut to allow the continuous-mining machine to pass. While seated in the personnel carrier, parked in the crosscut, watching the continuous-mining machine pass, Lilly observed Moore holding onto the back end of the continuous-mining-machine boom with both hands. According to Lilly, Moore said something like, it is a shame a person has to push this miner outside. Lilly stated that before he could talk to Moore about the danger of being close to the boom, Bishop yelled for Moore to get away from the boom of the continuous-mining machine.

Moore moved away from the boom of the continuous-mining machine and walked over to the personnel carrier where he asked Williams to bring the personnel carrier back later because his tools were on it. That was the last communication anyone had with Moore prior to the accident. As Lilly and Williams left the area, they noticed Moore walking back toward the continuous-mining machine while it was being trammed outby, down the No. 5 entry.

At the time of the accident, Bishop was operating the continuous-mining machine from a position in front of the machine along the left rib, standing in a dip in the mine floor. He and Moore were at opposite ends and opposite corners of the machine. Bishop's back was turned toward the boom as he watched to make sure the head of the continuous-mining machine cleared the trailing cable hanging from the roof, as the machine passed under. Bishop was also observing the continuous-mining machine's movement towards the airlock doors located just outby the accident scene. As the continuous-mining machine moved under the trailing cable and through the air lock doors, Bishop called out to Moore checking on the condition of the trailing cable being dragged by the machine. Moore did not respond to Bishop. At approximately 1:45 p.m., Bishop walked toward the rear of the continuous-mining machine and found Moore, lying unconscious on the mine floor, approximately 33 feet, 10 inches from the end of the boom, bleeding from the head area. Upon seeing Moore's condition, Bishop went outby about 180 foot, toward the move-box area to get McComas, who is an EMT, to help with Moore. McComas checked for vital signs but found none. During this time, Bishop called Burns on the mine phone and told

him of the accident and instructed him to bring the first-aid box and additional help to the accident site.

Moore was placed on a stretcher and transported outside where he was pronounced dead by the ambulance attendant.

INVESTIGATION OF THE ACCIDENT

The Mine Safety and Health Administration (MSHA) was notified at 2:15 p.m. on Monday, August 12, 2002 that a serious accident had occurred. MSHA accident investigators were immediately dispatched to the mine. A 103(k) order was issued to ensure the safety of all persons until completion of the investigation. The investigation was conducted in cooperation with the West Virginia Office of Miners' Health, Safety and Training (WVMHST), with the assistance of the operator and the employees. A list of those persons who participated were interviewed and/or were present during the investigation can be found in Appendix A of this report.

Representatives of MSHA and the WVMHST traveled to the underground accident scene to conduct an investigation of existing physical conditions. Photographs, video recordings, and relevant measurements were taken. Sketches and a survey were also conducted at the site.

Interviews were conducted with persons who had knowledge of the accident on August 13, 2002. The physical portion of the investigation was completed on August 16, 2002.

DISCUSSION

Training

Records of training were reviewed and mine personnel were interviewed regarding training provided to Mr. Moore and other employees. Evidence indicated that the victim had received the required training. A violation of 30 CFR, Part 48.9 was issued to the mining company for failure to maintain a record of task training provided to the victim; however, the lack of record was not deemed to be a contributing factor to the accident.

Examinations

Observation of records of mandatory examinations and on-site evaluation of conditions indicated that the required examinations were being conducted and recorded in accordance with 30 CFR, Part 75.

Physical Factors

1. The machinery fatality occurred on the 001 mechanized mining unit in the No. 5 entry near survey station No. 398 at approximately 1:45 p.m. on August 12, 2002. Survey station 398 is 1480 feet from the drift opening.

2. Mining height in the accident area was 58 inches.

3. The victim was assisting the continuous-mining-machine operator in moving a Joy 14-10 AA continuous-mining machine from the working face to the outside for repairs. The victim's duties included looping and unlooping cable slack as necessary.

4. The continuous-mining machine cable hook was attached to the frame of the machine.

5. The victim was observed with his hands on the boom of the continuous-mining machine as it was being trammed approximately 10 minutes prior to the accident.

6. The victim and continuous-mining-machine operator were the only personnel in the vicinity at the time of the accident.

7. The continuous-mining machine was being trammed forward toward the outside at the time of the accident. The continuous-mining-machine operator was stationed in front of the machine and was controlling its movements using the remote-control unit.

8. Elevations of the mine floor in the accident area prevented the continuous mining machine operator from seeing the victim.

9. The continuous-mining machine operator first became aware of the accident when he walked to the back of the machine.

10. The boom of the continuous-mining machine was positioned straight, approximately 30 inches off the mine floor at the time of the investigation.

11. There was an 8 to 10 inch ledge in the mine floor running perpendicular to the No. 5 entry approximately 14 feet inby Survey Station No. 398.

12. A reenactment of the machines' movement at the time of the accident revealed the following: As the continuous mining machines' center of gravity crossed over the ledge, the front of the machine tilted downward and the boom at the rear of the machine tilted upward, contacting the mine roof. The location where the boom contacted the roof during the reenactment was where the victim was found lying on the mine floor.

13. The distance from the victim to the boom of the continuous mining machine was 33 feet, 10 inches.

14. All continuous mining machine controls were tested and found to work properly.
ROOT CAUSE ANALYSIS

A root cause analysis was performed using evidence obtained during the accident investigation. The following root causes were identified:
1. Lack of established procedures - Procedures for equipment moves of the type being performed at the time of the accident were not clearly established and hazards associated with the move were not discussed with all personnel involved.

2. Lack of communication - Communication among management officials and between management officials and miners was deficient. Mine officials who made work assignments did not know that the victim was assisting with the move until the accident occurred. Different personnel assisted with the equipment move depending on their availability at different times throughout the move.

3. Lack of experience - The victim's lack of mining experience contributed to his lack of recognition of the hazards associated with equipment moves of the type in progress at the time of the accident.
CONCLUSION

The investigation team concluded that the direct causes of the accident were: The victim positioned himself too close to the continuous mining machine while it was in motion, and the operator was controlling the machine from a position that prevented him from seeing persons at the rear of the machine. Root causes of the accident were determined to be the absence of an established procedure for making the move, deficiencies in communication among those directing the work force as well as those involved with the move, and lack of the victim's experience in making such moves, which could have affected his ability to fully recognize and appreciate the associated hazards.

ENFORCEMENT ACTION

A 103(k) Order, No. 3982736, was issued to Titan Mining Inc. to ensure the safety of the miners until the investigation could be completed.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB02C18




APPENDIX A


The following persons provided information, and/or were present during the investigation:

TITAN MINING INC.
Clyde McComas .......... President/Chief Electrician
Ollie Burns, Jr. .......... Vice President/Superintendent
Steve Torrico .......... Secretary/Treasurer
Doran Bishop .......... Foreman
Carl Lilly .......... Foreman
ISLAND FORK CONSTRUCTION
Roger Ball .......... Safety Director
William Williams .......... Electrician
Kevin Vincent .......... Electrician
CATENARY COAL CO.
Peter Lawson .......... President
Mark George .......... Personnel Director
Norris D. Dyer .......... Safety Specialist
ARCH COAL, INC.
Frank Stover .......... Manager-Underground Operations
Don Vickers .......... Manager-Underground Planning
WEST VIRGINIA OFFICE OF MINERS' HEALTH, SAFETY AND TRAINING
Doug Conaway .......... Director
Mike Rutledge .......... Safety Instructor
Bill Tucker .......... Assistant Inspector-at-Large
Gary Snyder .......... Inspector-at Large
Randy Smith .......... Electrical Inspector
C. A. Phillips .......... Deputy Director
Wayne Wingrove .......... Deep Mine Inspector
Clark Gilliam .......... Deep Mine Inspector
MINE SAFETY AND HEALTH ADMINISTRATION
Roger Richmond .......... Coal Mine Safety and Health Inspector/Accident Investigator
James Humphrey .......... Coal Mine Safety and Health Inspector/Accident Investigator
Marcus Smith .......... Electrical Engineer
Jon Braenovich .......... Mining Engineer (Roof Control)/Accident Investigator
Thomas Cummings .......... Coal Mine Safety and Health Inspector
James Beha .......... Mine Safety and Health Specialist/Accident Investigation Coordinator
Kevin Dolinar .......... Technical Support Group
The following persons were interviewed during this investigation:
TITAN MINING, INC.
Clyde McComas .......... President/Chief Electrician
Ollie Burns, Jr. .......... Vice President/Superintendent
Doran Bishop .......... Foreman
William Williams .......... Electrician
Carl Lilly .......... Foreman
ISLAND FORK CONSTRUCTION
Roger Ball .......... Safety Director