UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 11

ACCIDENT INVESTIGATION REPORT
Underground Coal Mine

Other Fatal (Asphyxiation)

No. 4 Mine, I.D. No. 01-01247
Jim Walter Resources, Incorporated
Brookwood, Tuscaloosa County, Alabama

March 10, 1996

by

Terry Gaither
Coal Mine Inspector

Tom Meredith
Coal Mine Inspector

William J. Francart
Supervisory Mining Engineer

Originating Office - Mine Safety and Health Administration
135 Gemini Circle, Suite 213, Birmingham, Alabama 35209-5842
Michael J. Lawless, District Manager

GENERAL INFORMATION

The No. 4 Mine, Jim Walter Resources, Inc., is located in Brookwood, Tuscaloosa County, Alabama. This is a shaft mine, approximately 2,000 feet in depth, which liberates an average of 20,000,000 cubic feet of methane gas in a 24 hour period. The mine presently has six continuous mining machine sections on development and two longwall sections on retreat mining. The mine employs 598 miners and has a daily production of approximately 9,000 tons of clean coal. The mine operates three shifts per day, five to six days per week. The continuous mining machine sections are used for development of main air courses and longwall gate entries. Presently, the continuous mining machine sections develop a maximum of six entries and use various size pillars to control strata subsidence and floor heave. Coal is transported by belt conveyor to the production shaft and hoisted by skips to the surface. Men and materials enter the mine through the service elevator shaft and are then transported by rail haulage equipment. The last MSHA regular Health and Safety Inspection was completed on December 30, 1995. A regular MSHA Health and Safety Inspection which began on January 9, 1996 was in progress. Company officials are listed below.

William Carr...............President
K. J. Matlock.............Vice-President
Jesse Cooley..............Mine Manager
Frank Lee..................Deputy Mine Manager

DESCRIPTION OF ACCIDENT

The southwest bleeders were developed as the No. 5 Section. The No. 5 Section developed four headgate entries, two longwall set up entries and the three entry southwest bleeders. On December 5, 1995, during the development of the bleeders in the No. 1 entry, outby survey spad No. 14689, a rock fall occurred measuring approximately 20' wide x 60' long x 9' thick. During the investigation of the rock fall by MSHA on December 5, 1995, methane in excess of 1 percent was detected downwind of the fall area. The rock fall area was partially supported providing a safe travel way over the fall which was at this time the left return airway. The southwest bleeders were connected to the existing bleeder system. The No. 1 Longwall started production and all appeared to be normal until approximately two weeks prior to the accident.

Gregg Rowan (victim) was instructed by general mine foreman, Charles Oliver, to monitor the No. 1 Longwall tailgate regulator due to an increase in CO which occurred approximately two weeks after the longwall started production on January 25, 1996. Particular attention was being given to any rise in CO detected in the tailgate regulator due to spontaneous heating in similar seam conditions in adjacent areas. Rowan, while monitoring the CO readings in the area approximately three weeks prior to the accident, reported to Oliver that the methane concentration over the rock fall in the No. 1 entry outby survey spad No. 14689 was increasing and may become a problem. Oliver instructed Rowan to make ventilation adjustments in the area by closing the regulator in the No. 3 entry and opening the regulator in the No. 1 entry. Rowan reported to Oliver that the adjustments had corrected the problem and the methane over the rock fall had been lowered.

Rowan continued to examine the southwest bleeders almost daily to monitor the CO at the No. 1 Longwall tailgate regulator. On Sunday, March 10, 1996, at approximately 7:30 a.m., Rowan entered the mine, met John Fillebaum, Day Shift Mine Foreman and, after discussing their plans for the day, decided to ride together to the No. 1 Longwall headgate and travel to the southwest bleeder area. Rowan and Fillebaum traveled south in the No. 3 and 4 entries, then turned east, to the longwall setup entries off the No. 1 and 2 entries. From survey spad No. 14543 in the No. 1 entry, Rowan and Fillebaum proceeded south and approached the rock fall area from the west side. Fillebaum stated that Rowan was leading the way over the rock fall with his TMX 310 detector in his hand when the alarm sounded at approximately 9:30 a.m.. Rowan took three steps and fell. Fillebaum lost consciousness for an undetermined amount of time. When Fillebaum regained consciousness, he crawled to and checked and found no vital signs on Rowan.

Fillebaum then proceeded down the east slope of the rock fall and returned to the headgate of the No. 1 Longwall where he called for help. Reuben Curb, Longwall Maintenance Foreman, was supervising his maintenance crew on the No. 1 Longwall face when he was contacted by Fillebaum and informed of the accident at approximately 12:10 p.m.. Fillebaum called Oliver at home using the Bell phone system extended underground. Oliver instructed Fillebaum on necessary air changes to increase the air quantity over the rock fall. Curb, not being familiar with the area, let Fillebaum lead him and five crew members back into the southwest bleeders.

When the recovery team reached the bleeders, Fillebaum instructed Keith Herren, Longwall Helper, to open the door in the stopping between No. 1 and No. 2 entries at survey spad No. 14642; Mike Burchfield, Longwall Helper, to remove three boards from regulator No. 1 in No. 1 entry; David Tibbs to open the door in No. 1 regulator and Kenneth Hubbard, Longwall Helper, to install a check curtain across the No. 3 entry. Meanwhile, Curb approached the rock fall from the east side, and detected 18% O2 and 3.5% CH4. Curb retreated 50 feet, donned his self-contained self rescuer (SCSR) and traveled up the east slope of the fall where he checked for vital signs on the victim. Finding no vital signs, Curb and the recovery team transported the victim to the surface where he was pronounced dead by Dr. Krishnan. Fillebaum was transported to a local hospital where he was treated and released after 24 hours.

At approximately 1:00 p.m. on March 10, 1996, Jerry Early, Supervisory Coal Mine Inspector, Hueytown Field Office, was notified that an accident had occurred at the Jim Walter Resources Inc., No. 4 Mine in the southwest bleeders. MSHA personnel were dispatched to the mine to begin the accident investigation. Terry Gaither was appointed the investigation team leader. An investigation conference was conducted with Jim Walter officials, a State of Alabama Official and representatives of the U.M.W.A. During this conference the format of the investigation procedures was discussed with all interested parties.

The primary focus of the investigation was the determination of the source of the irrespirable atmosphere, the cause and conditions leading up to the accident, and compliance with the Code of Federal Regulations. The investigation was conducted by a team consisting of representatives from each participating organization. The underground investigation was conducted in all accessible locations surrounding the accident area. All existing conditions were evaluated and recorded on maps and in notebooks by team members. The physical examination of the underground areas of the mine began with the "mapping" of ventilation controls. The team conducted a survey of the ventilation system of the southwest bleeders. The location of present ventilation controls, pressure drop readings, methane liberation rates and direction of air flow was documented. Evidence was collected, identified, and tagged for further inspection, testing or analysis.

As part of the investigation, MSHA conducted interviews of persons with knowledge of the facts surrounding the accident. Representatives of the State of Alabama, Jim Walter Resources, Inc. and the U.M.W.A., were present during the interviews. Copies of interviews of individuals were made available to the interested parties.

PHYSICAL FACTORS INVOLVED

1. Ventilation: The southwest bleeders were developed off the No. 1 Longwall headgate entries from December 1995 through January 1996 and connected to the existing southwest bleeder system. The three entries were developed by the use of a two yield pillar configuration. The roof fall occurred on December 5, 1995. Interviews of witnesses indicated the following changes were made to the ventilation system:
   
   
   1. Curtains in the No. 2 headgate entry were partially opened.
      
      
   2. The door between entries three and four in the headgate was propped open.
      
      
   3. A check curtain was installed across the No. 3 bleeder entry.
      
      
   4. Brattice cloth was removed from the face of the regulator in the No. 1 bleeder entry. Three boards were removed from this regulator, and the door was opened.
   
   
2. Investigation Evaluations: On March 11, the bleeder ventilation system was briefly restored to the pre-accident condition to simulate the conditions present at the time of the accident. Airflow through the No. 1 bleeder entry inby the caved area was measured, as well as the airflow through and pressure differential across the three inby regulators.
   
   The following table lists the air readings at the selected locations:
   
   

   LOCATION	POST ACCIDENT		SIMULATED CONDITIONS
   	Quantity cfm	Pressure inches	Quantity cfm	Pressure inches
   Inby Caved Area	30,780		11,800
   Bleeder Regulator 1	82,800	2.00	24,660	3.10
   Bleeder Regulator 2	10,800	1.90	14,400	3.10
   Bleeder Regulator 3	22,500	1.85	30,420	3.10
   Total Bleeder Quantity	116,100		69,480

   While conducting the pre-accident tests, methane levels approached 2 percent just before the ventilation was restored to the post accident condition. From air readings and methane concentrations measured, the methane liberation rate within the cavity was approximately 250 cfm on March 11 during the ventilation survey. With the estimated liberation rate of 250 cfm, a methane concentration of 2.1 percent inby the cavity could reasonably be expected at the indicated sampling location for the airflow estimated at the time of the accident. Oxygen deficiency may not have been suspected when monitoring this location.
   
   

3. Gas Detector Operation: The detectors were carried by Fillebaum and Rowan. Both detectors were found to be operating properly for the measuring methane concentrations and detecting oxygen deficient atmosphere.

   Based on interviews, the investigators believe the deceased victim did make a gas check. Fillebaum stated that the multi-gas detector was alarming as he and Rowan walked up the rock fall, indicating a methane concentration exceeding the alarm level of 2.0 percent. Based on the laboratory testing of the handheld instruments, an oxygen deficiency condition would have been indicated on the instrument display if the reading was taken in a location where this condition existed. Either the gas check was made in a location where low oxygen was not present, or the deceased did not read the oxygen concentration on the detector. If there was not an oxygen deficiency, it is likely that the reading was taken in the fringe of the cavity gas body, and the victim, while crossing the fall, rose into higher methane concentrations and lower oxygen concentrations than he expected.
   
   

4. Methane Liberation Rate: It is possible that the methane liberation rate was changing for the period from the start of the retreat of No. 1 Longwall and the time of the accident. Because the majority of methane is liberated from the strata, it is conceivable that the fracturing of the strata from retreat mining increased the methane liberation in the roof fall cavity. As indicated by interviews, methane liberation was likely to have increased three weeks prior to the fatality. Ventilation regulation changes were made to take care of the methane problem encountered, the extent of which is unknown.

   Methane liberation in the absence of effective ventilation can present a serious hazard to miners. In addition to being an explosive gas, an accumulation of methane in high concentrations can result in a mine atmosphere that is deficient in oxygen. Atmospheres with oxygen concentrations below 19.5 percent can have adverse physiological effects, and atmospheres with less than 16 percent oxygen can become life threatening. The following are the likely effects of depressed oxygen levels in air:
   
   

   Percent Oxygen in Air	Effect
   17	Faster, deep breathing
   15	Dizziness, buzzing in ears, rapid heartbeat
   13	May lose consciousness with prolonged exposure
   9	Fainting, unconsciousness
   7	Life endangered
   6	Convulsive movement, death

5. Weekly Examinations: A review of the weekly examination record book and information provided during the interviews revealed that the required examinations had been conducted, however, the examination was ineffective for the following reasons.
   
   
   1. Specific locations designed to determine air direction and flow were not known to examiners.
      
      
   2. The location of all regulators were not known to examiners.
      
      
   3. The location of the beginning and end of the bleeder system was not known to examiners.
      
      
   4. The route of travel could not be identified to ensure that the assigned areas were completely examined.
      
      
   5. The location of seals to be examined were not known to the examiners.
      
      
   6. Examiners were not aware of the specific hazards which needed to be recorded.

CONCLUSION

A rock fall occurred during development of the southwest bleeders on December 5, 1995. On March 10-11, 1996, data obtained during the investigation of the accident revealed the methane liberation rate within the cavity was approximately 250 c.f.m. A methane concentration of 2.1 percent at the indicated sampling location inby the cavity (see line drawing included in the Fatal Alert Bulletin) could be expected from the airflow estimated at the time of the accident. The removal of the methane was dependent upon the air quantity in the No. 1 entry of 11,800 cfm.

Through testing, interviews and evaluation, it was determined that when the accident occurred, the atmosphere present in the breathing environment of the victim contained approximately six percent oxygen. An atmosphere containing six percent oxygen would be necessary to cause death in the manner indicated.

ENFORCEMENT ACTIONS

Three of the conditions and practices noted in the report contributed to the accident andconstitute violations of the Federal Mine Safety and Health Act of 1977, and mandatory standards contained in 30 CFR Part 75.

1. A 103-K Order No. 4476403 was issued to ensure the safety of the miners until the investigation was complete.
   
   
2. A 104-A Citation No. 2806923 was issued because the Southwest bleeders were not functioning properly in that an oxygen deficient atmosphere existed.
   
   
3. A 104-A Citation No. 4471736 was issued because weekly examinations for the southwest bleeders were ineffective in that six deficiencies were noted.
   
   
4. A 104-A Citation No. 4471737 was issued because record books were inadequate in that examinations for the week of March 3 thru March 9, 1996, were not recorded.

Respectfully submitted by:

Terry Gaither
Coal Mine Inspector

Thomas Meredith
Coal Mine Inspector

William J. Francart
Supervisory Mining Engineer

Approved by:

Frank C. Young for Michael J. Lawless
District Manager

Related Fatal Alert Bulletin:
FAB96C08

Related Program Information Bulletin: PIB96-19