Skip to content
PDF Version - (Contains All Graphics)
      Jump to Overview
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

REPORT OF INVESTIGATION

Underground Coal Mine

Fatal Machinery Accident
April 3, 2004

Mercer Deep Mine
Brooks Run Mining Company, LLC
Erbacon, Webster County, West Virginia
I.D. No. 46-08875

Accident Investigators

Roger D. Richmond
Accident Investigator/Coal Mine Safety and Health Inspector

William L. Sperry
Coal Mine Safety and Health Inspector (Electrical)

Originating Office
Mine Safety and Health Administration
District 4
100 Bluestone Road
Mt. Hope, West Virginia 25880
Jesse P. Cole, District Manager


OVERVIEW


At 11:40 p.m., on Saturday, April 3, 2004, a 47-year old continuous mining machine operator with 29 years of mining eperience was fatally injured at the Brooks Run Mining Company, LLC's Mercer Deep Mine. The accident occurred while William Brady, Continuous Mining Machine Operator, was tramming the continuous mining machine in high speed through the No. 3 left crosscut. Brady was positioned in a hazardous location and was pinned between the ripperhead of the continuous mining machine and the right (inby) coal rib of the No. 3 left crosscut.

The accident occurred because the victim was positioned in a hazardous location while tramming the continuous mining machine in high tram speed. The victim's position resulted from a failure to comply with approved roof control plan.

GENERAL INFORMATION


The Mercer Deep Mine is located in Webster County, south of the community of Erbacon, West Virginia. The mine etracts coal from the Upper Mercer coal seam. This is a one section mine, consisting of two Joy 12CM27 continuous mining machines, two dual-head Fletcher roof bolt machines, three 10SC32 shuttle cars, one S&S 602 scoop, one Fairchild scoop, one DBT 488 scoop, and one Stamler Feeder-Breaker.

The Lower Kittanning coal seam has been mined approimately 90 feet above the Mercer Deep Mine.
The Upper Kittanning coal seam is approimately 190 feet above the Mercer Deep Mine.

The fatal machinery accident occurred on the No. 1, Fifth Left, North Mains working section. Access to the accident site is via track. The entries on the No. 1 section are being developed 50-feet apart, with crosscuts connecting the entries every 60-feet of entry length. Entries are normally 20 feet in width. The coal seam height is 124 inches in the No. 2 entry at the accident site.

The No. 1 section is ventilated by a single intake split sweeping the air from right (No. 8 entry) to left (No. 1 entry), across the faces. One continuous mining machine is permitted to mine coal at any given time when using this method of ventilation.

The principal officers for the Brooks Run Mining Company, LLC, at the time of the accident were:
Samuel R. Kitts, President
Eddie W. Keely, Secretary
John Pearl, Treasurer
Prior to the accident, the Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection on March 31, 2004.

The Non-Fatal Days Lost (NFDL) injury incidence rate for the mine in 2003 was 14.06, compared to the national NFDL rate of 5.93 in 2003 for underground coal mines.

DESCRIPTION OF ACCIDENT


On Saturday, April 3, 2004, at approimately 4:00 p.m., the No. 1 section evening shift crew entered the mine via the track entry, accompanied by the Section Foreman, Brian Carpenter. Carpenter and the crew traveled approimately 7,000 feet to the working section. Upon arriving, at approimately 4:20 p.m., the crew began working at their respective jobs.

The right side Continuous Mining Machine Operator, John A. Cochran, began mining a scrap cut in the No. 5 face. When Cochran finished mining in the No. 5 entry, William Brady, left side Continuous Mining Machine Operator, (victim) began mining in the No. 2 face. The crew followed a normal mining sequence until the accident occurred.

At 11:00 p.m., approimately 40 minutes prior to the accident, Brady backed the left continuous mining machine out of the No. 3 left crosscut and into the No. 4 left crosscut. Robert Williams, left side Roof Bolt Machine Operator, trammed the roof bolt machine into the No. 3 left crosscut where he and Lowell Carpenter, Roof Bolt Machine Operator Helper, began to install roof supports. When they were ready to install the last two rows of bolts, Brady assisted them by tramming the bolt machine forward. This allowed Williams and Carpenter to stay at their work positions on the walkthrough roof bolt machine. After installing the last row of bolts, Williams trammed the roof bolt machine around the corner outby the intersection in the No. 2 entry. (See sketch)

Positioned behind the left continuous mining machine, Brady trammed the machine into the No. 3 left crosscut. He stopped the machine about 8 feet from the No. 2 intersection. With the pump motor still running, Brady walked between the machine and the right rib to the No. 2 intersection. Williams and Carpenter were in the No. 2 face installing a section of line curtain along the right rib, inby the crosscut, for a distance of approimately 20 feet. Brady told Williams not to hang the curtain. Williams told Brady that he had to hang the curtain, but that he would fold the curtain up out of the way.

As Williams walked back to the roof bolting machine after he finished folding up the curtain, he heard the continuous mining machine pump motor shut off. Williams turned and saw Brady walking from the No. 2 entry around the inby corner of the crosscut, toward the continuous mining machine. Stephen Rider, Shuttle Car Operator, walked up the No. 3 entry and asked Brady if he was ready to start mining. Brady replied, "just a second old buddy." Williams and Rider heard the continuous mining machine start up and rumble three times, as though it was in fast speed and immediately shut off. Both men recalled that the machine did not run more than a couple of seconds.

Williams and Rider saw the continuous mining machine tram forward and pin Brady between the ripperhead and the right rib. Williams ran to Brady and checked for a pulse, but could not detect one. Unable to free Brady, Williams ran around the continuous mining machine and approached Brady from the other side of the machine. He wanted to use the remote control bo to move the continuous mining machine to free Brady, but found it pinned between the ripperhead and Brady. Williams knocked the remote control bo out of Brady's hands, but due to the damage sustained in the accident, it failed to operate the continuous mining machine.

At this time, B. Carpenter, section foreman, was operating a shuttle car in the number 5 entry, when he was notified that something was wrong. Williams went to the right side of the section and notifies Cochran, right continuous miner operator of the accident. Cochran then attempted to use the left continuous mining machine's manual controls in order to free Brady. He engaged one of the tracks, but the machine would not move. Cochran decided against engaging both tracks, because he was concerned with causing further injury to Brady.

B. Carpenter decided to use the shuttle cars and a chain to move the continuous mining machine away from Brady. The No. 1 shuttle car pulled the ripperhead end of the continuous mining machine while the No. 2 shuttle car pushed the boom end of the machine toward the right rib, slewing the machine away from the victim.

The victim was placed on a backboard and transported along the mine track to the surface, where the Webster County Ambulance Service was waiting. The victim was transported to the Webster County Hospital in Webster Springs, West Virginia, where he was pronounced dead at 12:44 a.m. by Dr. Kawi. The victim was then transported to the Charleston Medical Eaminer's Office in Charleston, West Virginia.

INVESTIGATION OF THE ACCIDENT


MSHA was notified at 12:25 a.m. on April 4, 2004, that a serious accident had occurred. MSHA accident investigators were dispatched to the mine. A 103 (k) order was issued to insure the safety of all persons at the mine. 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 employees.

An investigation of the physical conditions at the accident site was conducted. Photographs and relevant measurements were taken and a sketch of the accident scene was made. The physical portion of the investigation was completed on April 8, 2004. Interviews were conducted with persons who had knowledge of the accident on April 5, 2004, at the Brooks Run Preparation Plant conference room, Erbacon, West Virginia. A list of those persons who participated, were interviewed, and/or were present during the investigation, can be found in Appendi A of this report.

DISCUSSION


Location of the Accident

The fatality occurred on the north main, off of the Fifth Left panel of the No. 1 working section, in the No. 3 left crosscut, between Survey Station Nos. 49380 and 49381, at approimately 11:40 p.m., on April 3, 2004.

Equipment Involved

The continuous mining machine involved in the accident was a Joy remote-controlled Model 12CM-27, Serial No. JM5370, MSHA Approval 2G-4023A-00.

The remote control unit being used for this continuous mining machine at the time of the accident was a Matric Limited permissible radio transmitter, Model TX3, P/N 100112672, Serial Number 75205A0033C, MSHA Approval 2G-4096-0.

The continuous mining machine involved in the accident was field tested for possible malfunctions on April 5, 2004. Additional tests of the machine's remote control system were conducted by Matric Limited, at Seneca, Pennsylvania, under the direction of the MSHA Approval and Certification Center, Triadelphia, West Virginia on May 25, 2004 and July 19, 2004. Testing revealed no malfunctions of equipment. Test results can be found in Appendi D of this report.

Victim's Actions

Brady was preparing to mine the No. 2 left crosscut, which was directly in front of the continuous mining machine. He was going to operate the machine from the face of the No. 2 entry which would reduce his eposure to the continuous mining machine and shuttle cars as the crosscut was mined. He was ready to tram the machine across the entry to begin mining when the pump motor shut down. He walked around the corner of the crosscut toward the machine, leaving his safe position, and was seen operating the remote controls in an apparent effort to restart the machine. When Brady was approimately 4 feet from the ripperhead, the machine started and trammed in a straight line, pinning him against the rib.

Continuous Mining Machine Operation

Speed

The tram speed of the continuous mining machine contributed to the accident. The design of the continuous mining machine allows the operator to select from three tram speeds. Williams and Rider both stated that they heard the machine start up and rumble three times as if it were in fast speed (Speed 3) and then immediately shut off after a couple of seconds. Design speeds for this machine are; 15 ft/min. in Speed 1, 30 ft/min. in Speed 2, and 85 ft/min. in Speed 3. If the machine were in fast speed, as witnesses Williams and Rider both believed it to be, Brady had little time to react.

In order to determine the machine's actual tramming speeds, the time for the machine to travel from its estimated starting point to ending point (approimately 4 feet) was measured as tabulated below:

Tram Condition Time
Speed 1 12 seconds
Speed 2 5.5 seconds
Speed 3 2.5 seconds


Signal Loss

Williams heard the continuous mining machine pump motor shut off. A loss of transmission signal between the remote control unit and the continuous miner would cause the machine to shut down. It is not known why Brady left his safe location in the No. 2 entry, however, it is possible that he was attempting to restart the machine. Witnesses said that the machine unepectedly shut down earlier in the shift when Brady was positioned on the left side of the machine. The cause of the shut down is unknown as are Brady's actions to restart the machine.

During performance testing of the machine after the accident, the pump motor inadvertently de-energized on one occasion. This was caused by loss of power to the remote control unit and was corrected by readjustment of the slider portion of the remote control power cord to the battery power take-off (PTO). The battery was located in the operator's coat pocket during the testing, which may have placed added strain on the connection. The Company Maintenance Superintendent indicated that the operators typically used yellow wire to secure the battery to the handles of the remote control. Yellow wire was found around the right side handle of the victim's remote control unit.

A battery recovered at the accident scene (believed to be the one used by the victim), when used with a spare remote control, operated the machine from around the corner where the victim was first positioned, without loss of signal.

Operator Disorientation

Operator disorientation was considered as a possible contributing factor during the investigation. Operator disorientation can occur as the operator moves to different locations around the machine.

Remote-controlled continuous mining machine operators normally operate from a position behind or to the side, looking toward the front of the machine. At the time of the accident, the victim was standing in front, looking toward the rear of the machine, creating the possibility of operator disorientation.

Operating the machine from the front can result in right or left machine movement that is opposite to what the operator intends.. Right and left movement of the machine is accomplished by splitting the tracks (one track moves forward, the other backward). From behind the machine, pushing the left lever forward, pulling the right lever backwards turns the machine to the operator's right. From in front, looking toward the rear of the machine, the same movement of the control levers moves the machine to the operator's left.

Operator disorientation is generally not as significant in forward and reverse machine movement. Pushing the levers forward always causes the machine to move forward, pulling the levers backward causes the machine to move in reverse, regardless of operator position.

There is no indication that operator disorientation contributed to the accident. Physical evidence and witness statements show that the continuous mining machine moved in a straight line toward the victim. This shows that Brady did not operate the controls in a manner to cause the machine to move right or left.

Victim's Operating Location

Brady's proimity to the machine violated the approved roof control plan which prohibited prohibiting persons from being near the continuous mining machine while tramming. The approved roof control plan general safety precautions, Page 5, Item No. 14 states:
"Persons shall be in a safe location from the continuous mining machine while tramming in the remote mode, so miners will not be endangered by the machine."
Interviews with miners revealed that the requirements and safety precautions of the approved roof control plan were frequently discussed during weekly safety meetings. All miners interviewed were aware of, understood, and said they followed the safety precaution. The miners indicated that they had "never seen the victim place himself in an unsafe location."

ROOT CAUSE ANALYSIS


A root cause analysis was conducted to identify the most basic causes of the accident that were correctable through reasonable management controls. During the analysis, casual factors were identified that, if eliminated, would have either prevented the accident or mitigated its consequences.

Listed below are causal factors identified during the analysis and their corresponding corrective actions implemented to prevent a recurrence of the accident.

Causal Factor: The approved roof control plan was not being complied with when the continuous mining machine operator was positioned in a hazardous location and was pinned between the ripperhead of the continuous mining machine and the coal rib. The approved roof control plan requires persons to be in a safe location from the continuous mining machine while tramming in remote mode.

Corrective Action: Prior to resuming operations, training sessions were conducted by mine management, emphasizing adherence to the safety precaution. Management initiated a more stringent policy regarding the proimity of personnel to continuous mining machines. It states:
"No person shall be positioned between the continuous mining machine and the coal ribs when the continuous miner pump motor are enabled (on), including cutting and tramming and loading. The only eception to this policy is when maintenance and troubleshooting are necessary, and then the tram breakers shall be knocked, when possible. Additionally, no person shall position themselves within two (2) rows of roof bolts in front of the continuous mining machine cutting head. Section foreman duties will not include equipment operation on a regular basis."
Causal Factor: The continuous mining machine was being trammed in Speed 3 (High) at the time of the accident. This resulted in the victim having little time to react to the machine's movement due to his hazardous position.

Corrective Action: Training on the functions of the radio remote-control and machine speed settings was given to all persons by the chief electricians before production resumed.

CONCLUSION


The accident occurred because the victim was positioned in a hazardous location while tramming the continuous mining machine in high tram speed. The victim's position resulted from a failure to comply with approved roof control plan.

ENFORCEMENT ACTIONS
1. A 103(k) Order was issued to ensure the safety of all persons in the mine until the investigation was completed.

2. A 104(a) Citation No. 7226824, was issued to Brooks Run Mining Company, LLC, for a violation of 75.220(a)(1).

Condition or Practice: Facts obtained during the investigation of a fatal machinery accident, that occurred on April 3, 2004, indicated that the approved roof control plan was not being complied with on the 001-0 working section. The approved roof control plan requires persons to be in a safe location from the continuous mining machine while tramming in the remote control mode. While standing in front of the continuous mining machine, the continuous mining machine operator attempted to tram the continuous miner by remote control, in the number 3-2 crosscut. The continuous mining machine operator was fatally injured when he was pinned between the cutting head of the continuous mining machine and the coal rib.

Action to Terminate: The operator retrained and instructed all employees on the safe location of persons around mobile equipment, including continuous miners.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB04c07

Fatality Overview:
Fatal Alert Bulletin Icon  PowerPoint / PDF




APPENDIX A

List of persons furnishing information and/or present during the investigation:

Brooks Run Mining Company, LLC
Richard Henderson Mine Manager
Steve Haga Maintenance Supervisor
Bobby Evans Chief Electrician
Brian Carpenter Second Shift Section Foreman
Richard A. Toler Third Shift Foreman
David Hickman Superintendent
Steve Rider Shuttle Car Operator
Robert Williams Roof Bolt Machine Operator
West Virginia Office of Miner's Health, Safety, and Training
Gary S. Snyder Inspector-at-Large
Tom Harmon Electrical Inspector
Terry Casto Deep Mine Inspector
Lloyd Collins Deep Mine Inspector
Mike Rutledge Safety Instructor
Mine Safety and Health Administration
John Pyles Acting District Manager
Roger D. Richmond Lead Accident Investigator/Inspector
Larry Cook Electrical Supervisor
William L. Sperry Electrical Inspector
Paul Hess Field Office Supervisor
Harold Hayhurst Accident Investigator/Inspector
Mike Woodrum Tri-State
Joe Mackowiak Coal Mine Safety and Health Inspector
Chad Huntley Approval & Certification Center
(Triadelphia, West Virginia)
APPENDIX B


List of Brooks Run Mining Company, LLC, personnel interviewed:
Brian Carpenter Section Foreman
Robert Williams Roof Bolt Machine Operator
Stephen Rider Shuttle Car Operator
Nathan A. Lee Roof Bolt Machine Operator
Daniel Brian Harper Roof Bolt Machine Operator
Edward L. McCoin Section Electrician
Gary Lee Brown Scoop Operator
John A. Cochran Continuous Miner Operator
Lowell Carpenter Roof Bolt Machine Operator