UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 4
ACCIDENT INVESTIGATION REPORT
Underground Coal Mine
FATAL MACHINERY ACCIDENT
South Fork No. 2 Mine (ID No. 46-08505
Cow Creek Coal Co., Inc.
Richwood, Nicholas County, West Virginia
April 11, 1996
by
William H. Uhl, Jr.
Coal Mine Safety and Health Inspector
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, WV 25880
Earnest C. Teaster, Jr., District Manager
OVERVIEW
Abstract
On Thursday, April 11, 1996, about 11:30 p.m., a fatal haulage
accident occurred in the No. 6 entry of the Mains section at the
intersection of survey station No. 565, of the South Fork No. 2
Mine, Cow Creek Coal Co., Inc.
Cam Franklin Weese, roof-bolting-machine operator and general
laborer, was helping remove equipment from the mine when the
accident occurred.
Weese received fatal crushing injuries when he was caught between
the rear bumper of a bolting machine and the front bumper of a
Mac-8 rubber-tired, battery-powered personnel carrier. The Mac-8
had been parked 32 feet outby the bolting machine on a grade
averaging 16 percent, sloping inby toward the bolting
machine. The unattended personnel carrier rolled down the
grade, striking the victim and crushing him between the two
machines.
Weese had 21 years total mining experience and had worked at the
South Fork No. 2 mine 4 weeks.
It is the consensus of the investigation team that the accident
occurred due to an unsafe operating condition which existed on
the Mac-8 personnel carrier. Even though functional test
conducted indicated the emergency brake system was operating
correctly, the investigation revealed that an unsafe condition
was created over a period of time by placing extraneous materials
in the personnel and operator's deck compartments. These
materials restricted the emergency brake control lever from being
placed into a fully cam locked position which made the control
lever touch sensitive to releasing.
Background
The Cow Creek Coal Co., Inc., South Fork No. 2 mine, is located
near Richwood, Nicholas County, West Virginia. The mine is
developed from the surface by four drift entries into the Sewell
coal seam. The average coal seam thickness is 39 inches and the
mining heights range from 44 to 72 inches. The mine began
producing coal in October 1995, and had entered into
nonproducing-persons working (BA) status on April 9, 1996.
The mine previously had provided employment for 33 miners on two
production and one maintenance shifts and was producing 750 clean
tons daily from one continuous-mining section. The coal was
transported to the surface by belt conveyors. At the time of the
accident, production had ceased and only three miners and a
section foreman were working underground on equipment removal.
There were two surface personnel working.
The immediate roof is grey shale and is primarily supported with
42-inch fully grouted resin bolts.
The mine ventilation is provided by a 66-inch blowing fan which
produces about 50,000 cubic feet of air per minute. The mine has
no history of methane.
The principal officers of Cow Creek Coal Co., Inc., are James
Simpkins, President; Waldon Hatfield, Vice President; Don
Robertson, General Manager; and Ronnie Kerns, Superintendent/Mine
Foreman.
The last regular Mine Safety and Health Administration (MSHA)
inspection was completed March 18, 1996.
STORY OF EVENT
On Wednesday, April 11, 1996, David Deel, section foreman,
preshifted the mine before the 5:30 p.m. crew entered the mine.
The crew consisted of three miners: Keith Lawson, Alfred
Bennett, and the victim, Cam Weese. All were experienced miners
employed as general laborers and normally worked the 11:30 p.m.
to 7:30 a.m. shift.
According to Deel, their assigned duty at this time was to remove
the equipment from the mine. A decision had been reached by the
operator to begin closing the mine on April 9, 1996, and
equipment removal had begun on Tuesday, April 10, 1996, on the
evening shift.
Deel stated that after conducting the preshift examination, he
had returned to the surface and received instructions from Ron
Kerns, superintendent, as to what equipment was to be removed and
then proceeded underground with his crew. At this time, Kerns
left the mine site.
Deel stated that he instructed Lawson to retrieve the emergency
medical technician's box and tool carrier from the mine first as
other preparational work was being done by the crew. After
Lawson returned to the surface, Deel, Lawson, and Weese entered
the mine and set a dewatering pump at the intersection of survey
station number 565 while en route to the section.
Alfred Bennett stated that he was instructed to take the scoop
inside to retrieve some mine supplies and bring them to the
surface to be loaded for delivery to another mine. Bennett said
that after he and Ray Tincher, communications person, loaded the
material for delivery, he (Bennett) re-entered the mine taking
the scoop to a location just outby the swag at survey station
number 565. The scoop was parked at this location at Deelūs
instruction for the purpose of assisting any of the equipment
that might have trouble tramming the grade. Bennett then
proceeded on to the section and assisted in the preparation of
moving the shuttle cars and roof-bolting machine.
Bennett stated that after they had their dinner, he moved a
shuttle car and hung some cables as Lawson trammed the roof-
bolting machine off the section. The bolter was receiving power
from the section power center and was trammed outby about 900
feet before running out of cable.
Deel stated that Weese had been watching the trailing cable of
the bolting machine as Lawson trammed the bolter, and after they
reached the swag at survey station 565, Weese stayed at the
bolter.
Deel and Lawson then utilized the Mac-8 personnel carrier to pull
the roof-bolting machine cable outby to obtain power from the
power center located near the No. 2 belt head. They had pulled
the cable down the No. 6 entry about 600 feet when the battery
powered Mac-8 began to strain, and believing they were about to
run out of cable slack, decided to return to the bolting machine.
After returning, Deel parked the Mac-8 at the top of the grade
just outby the bolting machine. Deel stated that he set the
emergency brake and he (Deel) and Lawson exited the Mac-8 on the
right side.
After exiting the Mac-8, Lawson said that he walked down the
grade, crossing in front of the Mac-8, and traveled to the left
side of the bolting machine where Bennett was located. Weese
(victim) was standing at the rear bumper of the bolting machine
at the operatorūs deck. Deel had walked down the grade and
traveled along the right side of the bolting machine en route to
the dewatering pump located in the crosscut and was approaching
the pump when the accident occurred.
Lawson said that a couple of minutes elapsed after Deel parked
the Mac-8 personnel carrier at the top of the grade. Because of
the noise generated by the dewatering pump located nearby, Lawson
did not hear any noise indicating the Mac-8 was rolling down the
grade. Weese was caught between the rear bumper of the bolting
machine and the front bumper of the Mac-8 personnel carrier
around 11:30 p.m. Apparently, Weese was thrown backward upon
impact, striking his head on a projecting roof bolt
(approximately 4 inches from the roof).
At the time of the accident, no one was looking in the direction
of Weese. Deel, Lawson, and Bennett stated they did not realize
anything was wrong until Weese hollered to them, "Get this thing
off me." Bennett said that as he turned and looked in the
direction of Weese, he could see that he was caught between the
bumpers of the two machines and was still in an upright position.
Immediately, Deel went to the operator's deck of the Mac-8 and
backed it off Weese. Weese collapsed to the mine floor as the
two machines were separated. Deel said he believed he moved the
Mac-8 to the top of the grade and parked it in the crosscut.
Lawson was with Weese when Deel returned only seconds later and,
after observing Weese's condition, instructed Bennett to take the
scoop to the No. 2 belt and notify the surface personnel that a
man was hurt and ambulance service was needed.
Bennett called outside, from the No. 2 belt around 11:40 p.m.,
and contacted Houston Irvan, third-shift communications person,
and requested emergency service stating that they had a man badly
hurt. Irvan called for an ambulance, but had problems with a
busy signal. He then called the lodge where Kerns was staying
for him to call an ambulance. After this, the Craigsville
ambulance was also called. The Jan-Care service received the
call at 11:57 p.m. Bennett then parked the scoop in a crosscut
near the No. 2 belt head and crawled and/or walked back to the
accident scene and waited for Deel to return with a backboard and
first-aid equipment. Deel had taken the Mac-8 to the surface to
obtain the backboard but could not locate it. Deel then went
back to the section power center, got the backboard, and
proceeded to the scene of the accident.
Weese was placed on the backboard and transported to the surface,
arriving around 12:20 a.m. utilizing the Mac-8 personnel carrier.
Weese was checked for vital signs, and none were found.
The Jan-Care Ambulance Service from Richwood, West Virginia,
arrived at the mine at 12:25 a.m. and immediately checked the
victim for vital signs and found none. Weese was then
transported to the Richwood Hospital where he was pronounced dead
on arrival. None of the miners were trained EMTs, but all had
first-aid training.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 1:55 a.m. on April 12, 1996, that a fatal
haulage accident had occurred. MSHA personnel arrived at the
mine at 4:45 a.m. A 103(k) Order was issued to assure the safety
of the miners until the accident investigation could be
completed.
MSHA and the West Virginia Office of Miners' Health, Safety and
Training jointly conducted an investigation.
All parties were briefed by mine management personnel as to the
circumstances surrounding the accident. Representatives from all
parties traveled to the accident scene where a preliminary
examination was conducted. Photographs, videos, and relevant
measurements were taken and sketches were made at the accident
site.
Interviews of individuals known to have knowledge of the facts
surrounding the accident were conducted at the MSHA Summersville
Field office on April 16, 1996.
The physical portion of the investigation was completed on April
16, 1996, and the 103(k) Order was terminated.
DISCUSSION
Training
Records indicated that training had been conducted in accordance
with Part 48, Title 30 CFR.
Examinations
The Mac-8 personnel carrier was purchased new and placed into
service at this mine on December 12, 1995. Records indicate that
examinations were being conducted in accordance with Part 75,
Title 30 CFR.
Physical Factors
The mine was in a (BA) nonproducing-persons working status.
Equipment was being removed from the mine, and the mine was to be
closed for an indefinite period of time.
Only the three crew members and section foreman were working
underground and assigned to remove the equipment.
The accident occurred in the No. 6 neutral entry of the mains
section at survey station 565 about 1800 feet inby the mine
portal.
The crew was in the process of removing a DDO-13 Fletcher roof-
bolting machine and had trammed the machine about 900 feet outby
the mains section power center when the accident occurred.
All four members of the crew were present at the accident scene
when the accident occurred, however, no one saw the accident.
The grade at the accident scene averaged 16 percent and ranged
from 4.75 to 23 percent. The distance between the rear bumper of
the roof-bolting machine to the front bumper of the Mac-8 parked
at the top of the grade outby measured approximately 32 feet.
The Mac-8 rubber-tired, battery-powered personnel carrier weighed
approximately 2740 lbs.
The mining heights in the area of the accident scene ranged from
49 to 58 inches. The mining height at the bumper of the roof-
bolting machine measured 58 inches.
The section foreman, David Deel, was the operator of the Mac-8
prior to the accident and stated that he had set the emergency
brake when he had parked it at the top of the grade; however, he
said it was in the released position when he moved it away from
the victim.
An inspection of the Mac-8 revealed that the service brake and
the emergency brake would function; however, an unsafe operating
condition was allowed to exist on the machine due to extraneous
materials being placed in the operators deck and personnel
compartment. These materials, which consisted of two pieces of
mine conveyor belt and cardboard paper, restricted the emergency
brake control lever from being placed in a fully cam locked
position. This resulted in the brake lever being touch
sensitive, due to the obstructions.
The restriction in the movement of the emergency brake control
lever, caused by the presence of materials in the deck, was
measured to be 9/16 of an inch. After cleaning the area under
the brake handle, the movement to horizontal increased 9/16 of an
inch and allowed the handle to move to a locked position.
The removal of the extraneous material from the deck and beneath
the emergency brake control lever did not affect the tension
applied to the brake caliper.
After removing the extraneous materials, a functional test was
made and the emergency brake control lever was no longer touch
sensitive. Greater pressure was required to release the brake
lever from the cam locked position.
The victim received multiple injuries, crushing his waist and
hip, and had a laceration on the back of his head.
CONCLUSION
It is the consensus of the investigation team that the accident
occurred due to an unsafe operating condition which existed on
the Mac-8 personnel carrier. Even though functional tests
indicated the emergency brake system was operating correctly, the
investigation revealed that an unsafe condition was created over
a time frame of about 4 months by placing extraneous materials in
the personnel and operator's deck compartments. These materials
restricted the emergency brake control lever from being placed in
the fully cam locked position which made the control lever touch
sensitive to releasing.
CONTRIBUTING VIOLATIONS
A 104(a) Citation No. 2737744 was issued, stating in part that
the Mac-8 personnel carrier was not being maintained in a safe
operating condition due to extraneous materials being placed in
the operating deck of the vehicle. The materials prohibited the
emergency brake control lever from being placed in the fully cam
locked position as indicated when functional tests were
conducted, a violation of Section 75.1725 (a), Title 30 CFR.
Respectfully submitted by:
William H. Uhl, Jr.
Coal Mine Safety and Health Inspector
Approved by:
Richard J. Kline
Assistant District Manager
Earnest C. Teaster, Jr.
District Manager
Related Fatal Alert Bulletin: FAB96C13
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