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UNITED STATES
DEPARTMENT
OF LABOR
MINE
SAFETY AND HEALTH ADMINISTRATION
COAL
MINE SAFETY AND HEALTH REPORT OF INVESTIGATION Underground Coal Mine Fatal Machinery Accident May
18, 2004 at Air Quality #1 Mine Black Beauty Coal Company Wheatland, Accident Investigators Michael D. Rennie Coal Mine Safety and Health Inspector Arthur D. Wooten Coal Mine Safety and Health Inspector (Electrical) Leland Payne Educational Field Services Robert J. Holubeck Brian Malin Originating Office - Mine Safety and Health
Administration District 8 James K. Oakes, District Manager On The cause of the accident was the failure to ensure that
all workers followed the safety precautions contained in the mine's approved
Roof Control Plan in regard to not standing or walking between the continuous
mining machine and the coal rib while the machine is in motion. The victim was
located in a pinch point created by the continuous mining machine and the coal
rib.
Black Beauty Coal Company's Air Quality # 1 Mine is located 2.3 miles
southwest of Wheatland, The mine produces an average of 16,000 tons of raw coal per
day from four advancing continuous mining sections. Coal is extracted
from the faces by Joy 14CM remote controlled continuous mining machines.
Electric shuttle cars and/or battery ramcars transport the coal to the section
loading point, where the coal is then transported from the section to the
surface by a series of belt conveyors. The face areas are ventilated by blowing
line curtains and scrubber-equipped continuous mining machines. The mine is ventilated by two mine fans and liberates
627,217 cubic feet of methane per day. The immediate mine roof consists of 10 to 30
feet of gray shale, and the overburden is a maximum of 350 feet. Roof support is
installed using roof bolting machines equipped with automated temporary roof
support systems. The Training Plan that was in effect at the time of the
accident was approved on The principal officers for the Air Quality #1 Mine at the time of the accident
were: President...........................................................................
Daniel Hermann
Superintendent ..................................................................
Douglas Grounds
Engineering Manager.......................................................
Jonathon Dever
Safety Director..................................................................
Ronald Madlem An MSHA Safety and Health Inspection, AAA, began on
The
calendar year 2003 National Non-Fatal Days Lost (NFDL) incidence rate for
underground coal mines was 5.93 and the NFDL incidence rate for this mine was
6.62.
On The third shift maintenance crew for the No. 4 Working
Section arrived on the section at approximately Robinson first examined the areas where work was to be
performed, and then the maintenance crew began moving the mining equipment from
the left-side rooms to the entry faces. The right-side continuous mining machine
was moved to the No. 7 Entry and the left-side continuous mining machine was
moved to the No. 3 Entry. The roof bolting machine was moved to the No.
6 Entry. Keith Scott and Christopher Qualls, Mechanic/Electricians,
started servicing the right-side continuous mining machine. Robinson, Tim
Williams, and Ben Smith, both laborers, were working at the belt tail moving and
repositioning the ratio feeder. When the servicing work was almost complete on
the right-side continuous mining machine, Qualls informed Scott that he was
going to go to the roof bolting machine to check the hydraulic oil level and
then travel to the left-side continuous mining machine to prepare it for
servicing. After Scott had completed the work on the right-side
continuous mining machine, he traveled directly to the left-side continuous
mining machine where he found Qualls crushed between the discharge boom of the
continuous mining machine and the right coal rib. Scott stated that no more than
five minutes had elapsed between when Qualls had left the right-side continuous
mining machine until he found him crushed against the rib. After finding Qualls crushed against the rib, Scott ran to
the belt entry and yelled for Kris Robinson. Scott informed Robinson that Qualls
was seriously hurt. He then proceeded to the mine phone and
contacted the surface for assistance. Robinson instructed Williams to get the
first aid equipment and then to meet him at the left-side continuous mining
machine. Ben Smith went to the phone and notified the surface of the
accident. Robinson ran to the left-side continuous mining machine
where he found Qualls crushed by the discharge boom against the coal rib. Robinson, Scott,
and Williams maneuvered beneath the boom and removed the remote control unit
from Qualls. Robinson and Williams held Qualls while Scott
used the remote control unit to swing the boom away from Qualls. After freeing him
from the boom, Robinson immediately checked Qualls but found no signs of life.
Cardio pulmonary resuscitation (CPR) was started by Robinson and Williams. Jesse Emmons, Advanced EMT, was dispatched to the working
section and upon arrival took over care of the victim. CPR continued while
Qualls was being transported out of the working section to the Hart Street
Portal bottom, where Halter/Smith Ambulance Service paramedics assumed care of
the victim. Qualls was then transported to Good Samaritan Hospital in
Ron Madlem, Safety Director, reported the accident to
the Mine Safety and Health Administration (MSHA) Vincennes Field Office
Supervisor, Gary W. Jones, at approximately A joint investigation was conducted by MSHA and the
Indiana Bureau of Mines to determine the cause(s) of the accident and to
prevent a similar occurrence. Before traveling to the accident scene,
the investigation team held preliminary interviews with persons who were
on the working section at the time of the accident. The team examined the
immediate area where the accident occurred. The accident area and
equipment were photographed and measurements were taken at the scene. Training
records, examination records, and work practices relative to the accident
were reviewed. The continuous mining machine involved in the accident was
put through operational tests to verify if it was functioning properly at
the time of the accident. No functional defects were observed
during these tests. Investigators tested and evaluated various parts of
the equipment that were involved in the accident. A list of the sites,
equipment, and dates of these evaluations and tests are listed below: Accident Site, May 19 and 20, 2004 Magnetek � Power Control Systems, Approval and Matric Limited, Joy Mining Machinery, Black Beauty Coal Co. Air Quality #1 Mine,
1.
There were no eyewitnesses to the accident. 2.
The victim was moving the left-side continuous mining
machine located in the No. 3 Entry back from the working face. At the
accident location, the victim may have been trying to reposition or change
direction of the machine when the accident occurred. (See Appendix C) 3.
The front of the continuous mining machine was
located 87 feet from the No. 3 Entry face. 4.
The mine floor in the immediate area was dry and
smooth with a very small change in elevation. 5.
The seam height in the immediate area was 6 �
feet. 6.
The entry width at the rear bumper of the continuous
mining machine was 19-feet 2-inches (See Appendix D) . The diagonal measurement of the No. 29
Crosscut intersection averaged 31-feet. 7.
The Joy continuous mining machine, Model No.
14CM-15-11DX, Serial No. JM 4631C, Company No. 14, was being operated by
radio remote control at the time of the accident. The remote control unit
was a Matric Model TX-3, S.N. 75205AD013 D, which operated on a carrier
frequency of 458 MHZ. 8.
The remote control unit showed no visible damage. 9.
The light switches were found in the �On� position
with both the area lights and headlights burning. 10.
The following components were removed from the
continuous mining machine involved in the accident for further
testing: �
Matric Limited Remote Control Demultiplexer, Model:
500-200, P/N 100087264, S/N 90201ADO12B, MSHA IA 457 �
Matric Limited Permissible Radio Transmitter with
strap, Model TX3 (458 MHz), P/N 100112672,S/N 75205AD013D, MSHA Approval
2G-4096-0 �
Matric Limited Receiver, Type RX1, P/N 100016248, S/N
83810AC001 D, MSHA IA-18528-0-1br �
Matric Limited Antenna, P/N 00601843-0251, S/N
5024233-000. �
Magnetek Firing Package, P/N RP601849-1124, S/N
4040601-001 �
�
�
Joy tram motor contactor assembly (left), P/N
00601525-0000 �
Joy tram motor contactor assembly (right), P/N
00601525-0000 �
Koehler 5000 series cap lamp, with marking �93� 11.
The results of the evaluations and tests that were
performed on the above components are summarized below: A)
The remote control system consisting of the TX3
remote station, victim's cap lamp and battery, machine-mounted remote
control antenna, remote control receiver, and demultiplexer panel all
functioned properly. The following deficiencies were noted, but were
unlikely to have contributed to the accident: i)
The right-tram control lever had a torn protective
rubber boot. The tear measured approximately 0.90 mm by 3.25 mm. ii)
The right-tram control lever was found to be out of
parallel with the left tram control lever. The distance between the levers
at the top was approximately 15.10 mm, and the distance between the levers
at the bottom was approximately 18.90 mm. iii)
The area beneath the remote control toggle switches
contained fine coal dust. iv)
The receiver was out of tune beyond the acceptable
Matric range of 5 kHz +/- 100 Hz. v)
On the machine-mounted remote control antenna, there
was a crack along the base of the plastic dome, extending from one side of
the dome to the other. vi)
Rust was noticeable on the heat sink on the bottom
case of the vii)
There was a cut, approximately 5.4 mm long, in the
cable jacket of the power cable from the cap lamp battery to the TX3
remote station, near the PTO connector. This cut did not extend into any
wire inside the cable. viii) The victim's cap lamp and battery were fully
functional. However, there were two notches cut, one on each side of the
plastic base of the PTO connector on the top of the battery jar. On the
�belt-loop� side of the battery, the notch measured approximately 5.4 mm
long by 6.4 mm high. On the opposite side, the notch measured
approximately 6.5 mm long by 5.9 mm high. On the �belt-loop� side, the
notch provided access to an electrical connection inside the PTO
connector. The full battery voltage is available between the electrical
connection inside this notch and the bolt in the center and extending
above the PTO connector. This is a permissibility discrepancy of 30 CFR
19.7(f). B)
Testing revealed that another TX3 remote station did
not cause cross-activation with the continuous miner. C)
Testing revealed that handheld radios or magnets did
not cause unintentional continuous miner machine movement. D)
Functional testing of the firing package and left and
right SCR tram bridges demonstrated these components to function
properly. E)
Functional testing of the continuous miner was
conducted after the accident and demonstrated the machine to be
functioning properly. F) The left motor's forward contactor was not adjusted
correctly to actuate the interlock. During laboratory testing, when
voltage was applied to energize the forward coil, the interlock would
intermittently not actuate. If this malfunction were to occur on the
continuous miner, when an operator attempted to tram the machine with both
motors in the forward direction, only the right motor would respond. This
right tram forward movement is identical to the last movement of the
machine involved in the accident. However, during functional tests on the
continuous miner on the day after the accident, and with the contactor
assembly installed on the training panel and on another continuous miner,
this malfunction was not witnessed. G)
Functional testing showed that the right tram motor's
reverse function could be precluded if the right tram forward interlock
inadvertently actuated. During testing at the Air Quality #1 Mine on H)
No evidence was found to suggest that a tram motor or
motors could become inadvertently energized, or to tram in a direction
opposite to that selected by an operator. 12.
The continuous mining machine discharge boom and
remote control unit had been moved from their original positions to free
the victim. The position of each switch on the remote control unit at the
time of the accident could not be determined since all the switches return
to a neutral position when released. Mine personnel stated that the pump
motor was off, and the machine lights were on when they arrived at the
accident scene. This indicates that the remote control Shutdown Bar,
Circuit Breaker Trip, or Pump Start/Off switch had been activated. 13.
The continuous mining machine was designed with the
following tram speeds: �
15 ft/min- �SLOW� �
30 ft/min- �2nd� �
68 ft/min- �3rd� �
85 ft/min- �HIGH/TURBO� 14.
The continuous mining machine was designed such that
when the tram switches were split (one forward, one reverse) the highest
tram speed possible was 30 ft/min. However, if only one of the tram
switches was operated, the highest tram speed was 68 ft/min. 15.
Tests were conducted to determine the time for the
right corner of the machine discharge boom to contact the rib. The results
are tabulated below:
16.
Sometimes when the operators of remote controlled
continuous mining machines are operating this type of equipment from
locations in front of the machine and/or are looking in the direction
outby the machine, they can become disoriented with the machine tramming
lever control function. 17.
A review of the victim's training records showed that
the required task training was not complete and up-to-date. No record was
available to indicate that the victim had been trained in the task of
operating the continuous mining machine. 18.
Training materials were reviewed from previous safety
meetings and from annual refresher training that was received by the
victim. Four safety meetings had been conducted since A root cause analysis was conducted and the following
causal factors were identified: 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 crushed between the discharge boom of the
continuous mining machine and the coal rib. The approved Roof Control Plan
requires the continuous mining machine operator be positioned so as to
avoid danger from pinch points and moving equipment. Corrective action: Before resuming operations, training sessions were
conducted by mine management emphasizing adherence to the safety
precautions in the approved Roof Control Plan. Causal Factor: The approved Training Plan was not
being followed. Task training required by the plan for the operation of
remote controlled continuous mining machines was not being conducted. Corrective Actions: Mine management shall ensure that all persons who
are required to operate continuous mining machines are task trained in
accordance with the approved Training Plan. Causal Factor: Deficiencies were found in the records required for
task training. Corrective actions: Mine management shall ensure that all persons receive
the proper task and proficiency training and the results are recorded and
kept on file. The cause of the accident was the failure to ensure
that all workers followed the safety precautions in regard to not standing
or walking between the continuous mining machine and coal rib while the
continuous mining machine is in motion. While moving the left-side continuous
mining machine out of the face area of the No. 3 Entry, the machine pivoted for some
undetermined reason(s) and crushed the victim between the continuous
mining machine discharge boom and the coal rib causing fatal injuries. A contributing factor to the cause of the accident
was that the victim had not been task trained on remote control continuous
mining machines nor had he
demonstrated that he could safely operate remote control
continuous mining machines at this mine. In addition, other contributing factors were the
victim's possible disorientation relative to the location of the
continuous mining machine and the remote control unit tram lever function,
the high tram speed, the possible malfunction of auxiliary contactors on a
tram control contactor assembly, and the slight unevenness of the mine
floor. Section 103(k) order No. 7595722 was issued on May
18, 2004 stating: The mine has experienced a fatal accident wherein a
miner was pinched between the boom of the Joy continuous miner and the
coal rib. This order is issued to ensure the safety of any person in the
coal mine until an examination or investigation is made to determine that
the continuous miners and associated remote control equipment are safe.
Only those persons selected from company officials, state officials,
miner's representatives, or other persons who are deemed by MSHA to have
information relevant to the investigation may enter or remain in the
affected area. Section 104(a) citation No. 7579717 was issued on
January 5, 2005, stating: 75.220(a) (1) Mine management did not ensure their mine personnel
were complying with the approved Roof Control Plan. The Roof
Control Plan safety precautions stipulate that mine personnel are not to
stand or walk between the continuous mining machine and the coal rib while
the continuous mining machine is in motion. A fatal machinery accident occurred on
Section 104(a) citation No. 7579718 was issued on
January 5, 2005, stating: 48.7(a) A review of the mine operator's training records
revealed that task training in the safe operation of remote controlled
continuous mining machines was not provided to a miner who was fatally
injured on Related Fatal Alert
Bulletin: Listed below are those persons who participated
and/or were present during the investigation: BLACK BEAUTY COAL COMPANY Douglas R. Grounds
Mine Superintendent Greg Xanders
Administration Manager Dave Joest
Mark Swain
Maintenance Foreman
Terry Marsh
General Mine Foreman Jon Dever
Mine Engineer Terry L. Courtney
Ron Madlem
Safety Supervisor
Joe Batson
Chief State Mine Inspector
MINE SAFETY AND HEALTH
ADMINISTRATION James K. Oakes District
Manager
Coal Mine Safety and Health Gary R. Jones Supervisory
Coal Mine Safety and Health Inspector Bryan P. Sargeant
Staff Assistant / Supervisory Coal Mine Safety and Health
Inspector
MINE SAFETY AND HEALTH ADMINISTRATION
(Cont.) Michael D. Rennie
Coal Mine Safety and Health Inspector Arthur D. Wooten
Coal Mine Safety and Health Inspector (Electrical) Bruce D. Harris
Coal Mine Safety and Health Inspector Leland Payne
Mine Safety and Health Specialist
Educational Field Services Robert Holubeck
Electrical Engineer Bryan Malin
Electrical Engineer
Listed below are those persons who provided
information that was pertinent to the investigation: KNOX Gordon Becher
Donald Halter
Deputy Knox County Coroner BLACK BEAUTY COAL COMPANY Brian Keith Scott
Mechanic/Electrician Timothy Edward Williams
General Underground Laborer Kris A. Robinson
Foreman Mark Bedwell
Maintenance Foreman Denny Gibbons
Continuous Mining Machine Operator Greg Swinney
Continuous Mining Machine Operator Gregory R. Hunt
Mechanic/Electrician Steve Rich
Mechanic/Electrician Mike Sutton
Mechanic/ Electrician Mike Boyer
Continuous Mining Machine Operator Sammy Marcroft
Foreman
JOY
MANUFACTURING COMPANY Dave Thomas
Electrical Certification Engineer John L. Dodd
Sales / Service Engineer Clint Glover
Design Engineer Samuel G. McDowell
Senior Electrical Engineer STAMLER John Duty
Field Representative MATRIC LIMITED Russell Cataldo
Electronic Technician Wally Goughler
Electronic Technician Donnie Cousins
Electronic Technician MAGNETEC POWER ELECTRONICS GROUP Joe Ley
Facility Manager Gary Bolbat
Sales and Marketing Engineer Mayibeth Walter Buyer/Planner Rick Bender
Electronic Technician |