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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 6

ACCIDENT INVESTIGATION REPORT
(SURFACE COAL FACILITY)

FATAL FALL OF PERSON ACCIDENT

PREPARATION PLANT (I.D. NO. 15-14324)
EXCEL MINING, LLC
LOVELY, MARTIN COUNTY, KENTUCKY

SEPTEMBER 3, 1999

by

ROBERT M. BATES
ELECTRICAL ENGINEER

ROBERT J. NEWBERRY
MINING ENGINEER

STANLEY J. MICHALEK, P.E.
CIVIL ENGINEER

Release Date: December 01, 1999

Originating Office - Mine Safety and Health Administration
4159 North Mayo Trail, Pikeville, Kentucky 41501
Carl E. Boone, II, District Manager

GENERAL INFORMATION

Excel Mining, LLC Preparation Plant, is located on Kentucky Route 1439 approximately 10 miles from Inez, Martin County, Kentucky. Excel Mining, LLC, is a wholly owned subsidiary of Alliance Coal, LLC, based in Tulsa, Oklahoma.

The preparation plant was initially placed in active status on June 6, 1975. The facility currently processes coal from two of the company's mining operations using a heavy media vessel, heavy media cyclones, spiral classifiers, and froth flotation recovery methods. A total of 20 persons are employed at the plant which normally operates two production shifts and one maintenance shift per day, seven days per week. The plant processes approximately 12,500 tons of raw coal daily which generates 7,200 tons of clean coal and 5,300 tons of refuse daily. The last regular Health and Safety Inspection was started at this facility on June 8, 1999, and was ongoing at the time of the accident.


DESCRIPTION OF THE ACCIDENT

On Friday, September 3, 1999, at approximately 7:00 A.M., the day shift crew reported to work and began what was considered to be a normal start-up of the preparation plant. Four employees were working in the plant on the day of the accident: Danny Spence, day-shift foreman; David Stiltner, mechanic; John Callahan, plant operator; and Harry Douglas Delong, mechanic. During the morning hours, Spence and Callahan worked at the loadout hopper while Stiltner and Delong performed the steps necessary to start the thermal dryer.

Between 11:30 a.m. and 12:00 p.m., Stiltner and Delong went to the preparation plant control room and began eating lunch. During lunch Delong informed Stiltner that they were getting low on chemicals (Procol F937, flotation reagent) and requested his assistance in hoisting two or three of the chemical drums to the third floor of the preparation plant. After lunch, Stiltner went to the ground floor of the plant and began preparing the chemical drums for hoisting. The preparation plant contains a 10 ft. square machinery well (hoistway) that is open from the ground floor throughout the entire vertical dimension of the plant. The chemical drums were located on a wooden pallet (four to a pallet) near the open machinery well on the ground floor.

Delong arrived on the ground floor shortly after Stiltner, and assisted in attaching a non-metallic "choker" to one of the drums to allow it to be lifted using the five-ton material hoist. After the choker was secured to the hoist hook, Stiltner asked Delong if he needed any help unloading the drum once it had been lifted to the third floor of the plant. Delong told Stiltner that he needed no assistance in pulling the load into the third floor. Stiltner stayed on the ground floor and began raising the drum using the hoist controls located on the east side of the hoistway. Delong boarded the man-lift on the west side of the hoistway and traveled up to the third floor.

When Delong arrived on the third floor and walked over to the hoistway, the drum had already arrived and was suspended in the machinery well with the bottom of the drum being approximately at eye-level. Delong moved to the northeast edge of the hoistway opening, placed his left hand on the top handrail surrounding the hoistway, and reached out with his right hand to grab the bottom of the drum. At this point the entire section of railing on the north side of the machinery well failed and Delong fell approximately 54 feet onto the concrete ground floor.

Stiltner immediately notified Danny Spence of the accident using a two-way radio. Larry McKenzie, superintendent; Sharon Smith, safety director; and Spence responded to the accident and administered cardiopulmonary resuscitation to the victim until Martin County Ambulance Service paramedics arrived. Smith and Spence are both emergency medical technicians. No vital signs were detected by the paramedics and CPR was ceased at 12:50 p.m. Martin County Coroner Mike Crum arrived at the scene and pronounced the victim dead at 1:30 p.m. The body was removed from mine property by personnel of the Martin County coroner's office. Paul Horn, chief engineer, notified MSHA and Kentucky Department of Mines and Minerals of the accident at approximately 1:00 p.m. A joint investigation was started on September 3, 1999.

Note - The employees use the following terms when referring to direction in the preparation plant:

Dryer Side - North
Shop Side - South
Hill Side - East
Road Side - West

PHYSICAL FACTORS INVOLVED IN THE ACCIDENT

The investigation revealed the following factors relevant to the occurrence of the accident:

  1. David Stiltner, mechanic, was the only known eyewitness to the accident.

  2. The accident occurred in the preparation plant at approximately 12:15 p.m.

  3. The plant, a steel frame building with reinforced concrete floors, consists of a ground floor plus eight additional levels. A hoisting well runs through every floor on the south end of the building.

  4. The hoist is located on the top (eighth) floor and has a capacity of 5 tons. The hoist is movable; however, at the time of the accident it was positioned so the lifting hook was approximately in the center of the hoisting well.

  5. A choker sling was placed around the middle of the drum. Depending on the location of the sling, the drum's position could range from horizontal to steeply angled. During lifting, the barrel typically did not lie in a horizontal position.

  6. The drum contained Procol F937, a flotation reagent. Information on the drum's label indicated the gross weight of the drum plus contents was 400 pounds. The drum was approximately 2 feet 10 inches high and 2 feet in diameter.

  7. The hoisting well is a 10-foot square opening in every floor of the building and is surrounded by a handrail system. On the east and west sides of the well, the railing is permanently attached to the building's framework. On the north and south sides, a portion of the railing is removable. The permanent railing continues around each corner of the well so that the removable portion is approximately 9 feet in length.

  8. The railing consists of 1-inch-diameter steel rods welded together to form a fence. The bottom and top horizontal railings are approximately 19 and 38 inches above the floor level, respectively. A 6-inch-high toe plate is also part of the railing system.

  9. The vertical supports for the railing are flat bars 2.5 inches wide and 5/8 inches thick. Angle members appearing to be L6 x 4 x 3/8 designation are used to support the permanently attached vertical bars. The vertical bar is bolted to the 6-inch leg and the 4-inch leg is welded to the web of a beam located under the concrete floor around the perimeter of the hoisting well.

  10. The vertical support bars for the removable portion of the railing are placed into rectangular sleeves that are welded to the permanent bars. The sleeves are fabricated by welding steel plates of various dimensions together to form a rectangular opening that will accept the removable supports.

  11. Components of the north railing system were examined following the accident. The following conditions were observed:

  12. the east side sleeve appeared to have failed along two welds. One half of the sleeve fell down to the second floor while the other half remained attached to its vertical support bar. Scrape marks along the inside face of the plate indicate the east side removable support moved downward more than outward during the accident. There did not appear to be signs of prying action on the edges of the sleeve plates.

  13. the steel comprising the failed east side sleeve was corroded with apparent reductions in material thickness along the edges.

  14. the east side (removable) vertical support showed significant cross-section reduction due to corrosion. This was most apparent approximately 10.5 inches from the lower end.

  15. the west side sleeve appeared to have failed along the two welds holding the rear plate. This sleeve also showed heavy surface corrosion.

  16. the west side permanent vertical support fell through the hoist well to the ground floor along with the third floor removable railing. The angle member connecting this support to the floor beam failed approximately 1 inch out along the 6-inch leg. Significant corrosion resulting in loss of cross-section was apparent. The angle's thickness near the failure location was measured to be approximately 0.047 inches (original thickness was 0.375 inches).

  17. The distance from the removable railing to the closest edge of the lifted drum was measured during a re-creation of the work being performed. This distance was found to vary from approximately 2 to 2.5 feet depending on the orientation and hanging angle of the drum.

  18. No tools or devices were found in the area that could be used to pull the hanging drum over to the side of the hoisting well. The victim was not wearing a safety harness or belt and no such devices were observed in the area of the work being performed.

  19. The coroner's report listed multiple fractures and internal injuries as the cause of death.


CONCLUSION

The primary cause of the accident was the deteriorated condition of the metal railing surrounding the material hoistway on the third floor of the preparation plant. In this weakened condition, the railing could not provide the intended protection against falling. However, unsafe material hoisting procedures also contributed to the accident. The use of taglines or pull-in hooks to guide the suspended chemical drum onto the third floor would have eliminated the need to reach over the railing to pull the load onto the floor. Although a danger of falling existed in this particular instance, no safety belts or lines were used, which would have prevented the fall even after the railing failed. This accident was the result of both physical conditions and unsafe practices.


ENFORCEMENT ACTIONS

  1. 103(k) Order No. 7352477. This order was issued to preserve the accident scene and to protect other persons from possible hazards until the investigation could be conducted.

  2. 104(a) Citation No. 7367801, significant and substantial, high negligence. The railing surrounding the open material hoistway on the third floor of the preparation plant was not maintained in good repair. The metal supports and weld joints on the railing were severely corroded. A portion of the railing collapsed when a preparation plant mechanic leaned on it during a material hoisting operation. The employee fell to the ground floor of the plant, sustaining fatal injuries.

  3. 104(a) Citation No. 7367802, significant and substantial, high negligence. Taglines or other devices were not used to guide a suspended load that required guidance during a material hoisting operation. While reaching out to guide a suspended chemical barrel from the open hoistway onto the third floor of the preparation plant, an employee fell to the ground floor, sustaining fatal injuries.

  4. 104(a) Citation No. 7367803, significant and substantial, moderate negligence. A safety belt or line was not used by an employee during a material hoisting operation where a danger of falling existed. While reaching out to guide a suspended chemical barrel from the open hoistway onto the third floor of the preparation plant, the employee fell to the ground floor, sustaining fatal injuries.

  5. 104(a) Citation No. 7367805, significant and substantial, high negligence. Inadequate daily inspections were conducted on the third floor of the preparation plant. The metal supports and other structural members of the railing surrounding the open material hoistway had corroded to the point that the railing was ineffective. Although daily on-shift inspections were conducted, the condition was not reported or corrected.




Respectfully Submitted:

Robert M. Bates
Electrical Engineer

Robert J. Newberry
Mining Engineer

Stanley J. Michalek, P.E.
Civil Engineer


Approved by:

Carl E. Boone, II
District Manager


Related Fatal Alert Bulletin:
FAB99C24

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