DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
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
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
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.
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 Deel's 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 operator's 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.
Records indicated that training had been conducted in accordance with Part 48, Title 30 CFR.
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.
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.
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.
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
Richard J. Kline
Assistant District Manager
Earnest C. Teaster, Jr.
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