UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 10

ACCIDENT INVESTIGATION REPORT
(Preparation Plant)

Fatal Machinery
Dotiki Preparation Plant (I.D. No. 15-02132)
Webster County Coal Corp.
Clay, Webster County, Kentucky

September 11, 1995

by

Robert L. Meadows
Coal Mine Safety & Health Inspector
and
Darold Gamblin
Coal Mine Safety & Health Inspector

Originating Office - Mine Safety and Health Administration
100 YMCA Drive, Madisonville, Kentucky 42431-9019
Rexford Music, District Manager

GENERAL INFORMATION AND BACKGROUND

The Dotiki Preparation Plant is a surface facility located at Clay, in Webster County, Kentucky. This plant, which processes coal from one underground mine, includes a deep mine coal stockpile area, a truck loading haulage road, and a coal train loading point. The raw coal from the underground mine is transported to the surface by a 5 foot belt conveyor, and then deposited into two raw coal silos; one of which is of 5000 ton capacity and the other a 1500 ton capacity. When necessary, these two silos can be bypassed and coal transported directly onto the raw coal stockpile. Coal from this stockpile is then deposited via the No. 7 and No. 10 hoppers onto the draw off tunnel conveyor belt, and transported approximately 500 feet to the coal train loading point.

The plant employs 26 persons. Coal is processed on two production shifts, five days each week, and maintenance is conducted on third shift. As many as five trains, averaging from 50 to 75 rail cars each, are loaded weekly. The operation processes an average of 12,500 tons of coal daily, and up to 3.1 million tons annually.

The principal officers of Webster County Coal Corp. are as follows:

Joseph W. Craft, III.........President
James B. Gill....................Vice President
Alan Boswell....................Manager of Operations
Joel R. Reid......................Plant Manager

The last regular safety and health inspection was completed on June 26, 1995. A regular inspection was ongoing at the time of the accident.

DESCRIPTION OF ACCIDENT

On Monday, September 11, 1995, at approximately 7:00 a.m., the Dotiki Preparation Plant crew began their scheduled day's work. After conducting a safety meeting, Ricky Reid, plant foreman, assigned work duties to the surface employees and informed them that the first train to be loaded was expected to arrive at approximately 10:00 a.m.

Brian Keith Liles (victim) was sent to the rotary breaker building to inspect a water line which had been installed during the weekend. Jeff Throgmorton, David Cowans, Bobby Daniels, and Neil Rhye were assigned to inspect and clean the load out tunnel before the train arrived. James Berry was sent to load coal trucks using the 988 front end-loader. David Threlkeld, plant electrician, was instructed to check the plant computer and ensure that all other functions of the plant were operating properly.

After checking the water line, Liles joined Throgmorton, Cowans, and Rhye in cleaning and examining the draw off tunnel. After they were finished, they went to the bathhouse to eat lunch.

The coal train arrived at 10:00 a.m., so the crew drove the company pickup truck to the train loading point and inspected the coal car hopper doors before loading. In preparation for loading the train, Cowans took the D9L bulldozer to the top of the raw coal stock pile and began pushing coal away from the west side of the stacking tube to make room for additional coal. Throgmorton drove Liles to the raw coal stockpile at about 10:30 a.m., where Liles started the D9H dozer and trammed up the west side of the raw coal stockpile.

As Liles approached the top of the stockpile, Cowans received word over the radio that he was to drive the D9L dozer to the toe of the stockpile and relieve Berry on the front end-loader. Threlkeld then took Cowans' place on the D9L dozer and trammed back up the stockpile where he encountered Liles. Using hand and arm signals because of the noise, Liles indicated to Threlkeld that he would go to the east side of the stockpile, and Threlkeld should continue pushing coal on the west side. As Liles trammed the dozer around the stockpile and out of sight, Threlkeld noticed that the time was about 10:40 a.m. Also at 10:40 a.m., Jeff Throgmorton energized the tunnel fan, monitors, and charts, started the No. 7 and No. 10 coal hoppers, and activated the draw off tunnel conveyor belt to transport the raw coal into the first train car.

Approximately 10 minutes later, Threlkeld noticed heavy smoke rising from the other side of the stockpile near the stacker tube. He reversed the bulldozer and attempted to see the source, but the stacker tube blocked his vision. Grabbing his fire extinguisher, Threlkeld stepped down from the dozer and walked around the stockpile where he saw approximately 2 feet of the blade of Liles' D9H dozer protruding from the coal, pointing upward. The engine of the dozer was still running.

Threlkeld raced back to his dozer and radioed Throgmorton to shut down the load out hoppers and bring help because Liles' dozer was submerged in the coal. Surface Manager Reid heard the radio transmission from the desk at his office. He immediately drove to the 988 front end-loader and motioned for Cowans to follow him up the coal pile. Throgmorton, Daniels, and Rhye also overheard the reports of the accident over the radio and rushed to the scene.

By the time that Reid arrived, the dozer had completely disappeared beneath the surface of the coal pile. Reid directed Rhye to notify Manager of Operations Allen Boswell and to call for an ambulance. Webster County Ambulance Service and the Life Flight Helicopter arrived shortly afterward.

Reid then told Throgmorton and Daniels to get steel ropes and bring the other two dozers. Threlkeld began removing coal from near the accident scene with D9L dozer, while Cowans assisted with a D8N dozer. Berry started the 988 front end-loader and proceeded to help.

At 11:58 a.m., Reid told Throgmorton to energize the load out feeder in an attempt to remove some of the coal from around the trapped dozer, but this activity was not productive and was halted within a few minutes. The two dozers and front end-loader continued their excavation efforts and, a short time later, the blade of the trapped dozer was uncovered. The D8N dozer was then hooked to the blade with a steel rope, but efforts to pull the D9H free were unsuccessful. The D9L dozer was then hooked in tandem with the D8N dozer and together, the two dozers pulled the trapped dozer from the coal pile at 12:30 p.m.

As soon as the dozer was pulled free of the coal, Department of Mines and Minerals Electrical Instructor Bill Perkins rushed to the cab, uncovered the victim's face, and began mouth to mouth resuscitation. Liles was then removed from the cab and the Life Flight Crew continued resuscitation efforts at the accident site, while keeping Welborn Hospital officials in Evansville, Indiana, informed of the activities via radio. At 1:02 p.m., Liles was pronounced dead by Dr. Lee Newbury from Welborn Hospital.

INVESTIGATION OF THE ACCIDENT

At 11:20 a.m., on September 11, 1995, CMSH Inspector George Newlin notified Assistant District Manager Richard L. Reynolds by telephone that a dozer and its operator were trapped in the raw coal stock pile at the Dotiki Preparation Plant. Mine Safety and Health personnel, supervised by Assistant District Manager Reynolds, began arriving at 12:15 p.m., and assisted in the recovery. A 103(k) Order was issued to ensure the safety of the miners until the accident investigation could be completed.

The Mine Safety and Health Administration and the Kentucky Department of Mine and Minerals jointly conducted an investigation.

The Mine Safety and Health Administration and the Kentucky Department of Mines and Minerals conducted interviews of five individuals who had knowledge of facts surrounding the accident. These interviews were conducted at the Webster County Coal Corp., Dotiki Mine training room at Lisman, Kentucky, on September 12, 1995.

The physical portion of the investigation was completed on September 18, at 1400 hrs, and the 103(k) Order which had been issued by the Mine Safety and Health Administration on September 11, was terminated.

TRAINING

The records indicated that all training had been conducted in accordance with Part 48.

PHYSICAL FACTORS INVOLVED

The investigation revealed the following factors relevant to the accident:

1. There were no eyewitnesses to the accident.
   
   
2. The raw coal stockpile where the accident occurred is approximately 200 feet long, 175 feet wide, and 60 feet high.
   
   
3. The draw off tunnel is 525 feet long.
   
   
4. The five raw coal feed hoppers are hydraulically controlled, but only two of the hoppers were in use at the time of the accident.
   
   
5. All equipment on the raw coal stockpile was provided with two-way communications.
   
   
6. Coal had last been drawn through the No. 10 hopper on September 7, 1995. Since that time, approximately 15,000 tons of coal had been deposited onto the raw coal stock pile.
   
   
7. On the morning of September 11, four railroad cars had been loaded before the accident occurred.
   
   
8. The victim had been pushing coal on top of the raw coal stock pile for approximately 10 to 15 minutes before the dozer fell into the No. 10 hopper.
   
   
9. The Pressure Loadout Feed Chart established that the No. 10 hopper was activated at approximately 10:43 a.m., and was stopped after the accident was discovered at about 10:55 a.m.
   
   
10. The Pressure Loadout Feed Chart also confirmed that the No. 10 hopper was reactivated at approximately 11:59 a.m. in an attempt to remove coal from around the trapped dozer, and then de-energized again at 12:01 p.m. when this effort failed.
    
    
11. The rear glass, side glass, door glass, and front windshield of the driver's compartment collapsed as the dozer submerged into the coal pile, allowing the cab to fill with loose coal.
    
    
12. The Kentucky Medical Examiner established suffocation as the cause of death.
    
    
13. Company procedures prohibited the operation of dozers above hoppers during loading operations. These procedures were verbal, however, and had not been prescribed in any written form.
    
    
14. Statements from workers established that they had been informed by management of the hazards of operating equipment above hoppers during loading operations. Workers also described the victim as being a particularly safety-minded individual who habitually took extraordinary steps to remain aware of his work related surroundings.
    
    
15. After the accident, the company implemented the following precautions;
    
    
    1. A radio check system was established to ensure that communications procedures among the workers are functional.
       
       
    2. The loadout operator is required to notify personnel operating equipment on the stockpile before loading operations commence.
       
       
    3. In order to provide dozer operators with an oxygen source in case of entrapment, a one hour self contained self rescuer (SCSR) will be kept in the cab of each dozer.
       
       
    4. The company is studying the feasibility of placing metal grids over cab windows to prevent their collapse in the event of an entrapment.

CONCLUSION

The accident sequence began when the loadout operator energized the No. 10 hopper. The potential was increased when the victim trammed the dozer onto the raw coal above this hopper. The accident occurred when the dozer that the victim was operating fell into a hidden cavity which had opened as coal was drawn through the No. 10 coal hopper.

VIOLATIONS

1. 103(k) Order No. 4062007 was issued to assure the safety of all persons in the affected area.
   
   
2. No violations of 30 CFR were observed during this investigation.

Respectfully submitted:

Robert Meadows
Coal Mine Safety and Health Inspector

Donald Gamblin
Coal Mine Safety and Health Inspector

Approved by:
Rexford Music
District Manager
District 10

Related Fatal Alert Bulletin:
[FAB95C29]