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United States
Department of Labor
Mine Safety and Health Administration

District 6

ACCIDENT INVESTIGATION REPORT
(UNDERGROUND COAL MINE)


FATAL ROOF FALL ACCIDENT


No. 3 Mine (I.D. No. 15-16126)
M. & D. Coal Company, Incorporated
Honaker, Floyd County, Kentucky


August 15, 1996

By

James W. Poynter
Supervisory Coal Mine Safety and Health Inspector

Harold Yates
Coal Mine Safety and Health Specialist
(Roof Control)


Originating Office - Mine Safety and Health Administration
100 Ratliff Creek Road, Pikeville, Kentucky 41501
Carl E. Boone, II, District Manager

ABSTRACT



Thursday, August 15, 1996, at approximately 3:30 p.m., a roof fall accident occurred in the last open crosscut between No. 7 and No. 8 entries on the 001-0 section resulting in fatal injuries to Tracy Warren Eugene Bryant, general laborer. Bryant, age 20, had a total of 18 months mining experience, the last two days at this mine. The accident occurred as the victim was shoveling loose coal from along the ribs of the crosscut in an area which had not been supported. Roof material measuring 10 -11 feet long by 2-8 feet in width and up to 5-inches in thickness fell, striking the victim, resulting in fatal injuries. The accident was not discovered until the following morning at approximately 8:30 a.m. The accident occurred because the victim was performing work under unsupported roof.

GENERAL INFORMATION
The No. 3 Mine of M. & D. Coal Company, Incorporated is located on Morgan Branch of Little Mud Creek, near Honaker, Floyd County, Kentucky. The mine began operation in June, 1984. The principal company officials of the Kentucky corporation are: Dianna Meade, President, Muncie Meade, Jr., Mine Manager/Safety Director, and Bill Jones, Superintendent.

The mine was developed from four drift portals into the No. 3 Elkhorn coal seam. The mine produces 250-tons of coal daily with 11-underground and 2-surface employees, working one 9-hour shift per day, 5-days per week. The average mining height on the 001 section is 45 inches. At the time of the accident, the 001-0 MMU consisted of nine entries with two rooms driven left-handed off the No. 1 entry. Although the mine contains several sealed areas, the 001-0 MMU is presently located approximately 2,900 feet from the mine portals.

Coal was produced utilizing the conventional mining method, with the mining cycle proceeding from right to left across the section. One-cutting machine, one-coal drill, and two roof-bolting machines were used to produce coal on the 001-section. Nine battery-powered scoops were used to transport coal from the faces to a belt-feeder and as mantrips and supply vehicles.

The approved Roof Control Plan, dated April 22, 1992, requires roof bolts to be installed on 4-foot centers, both length-wise and cross-wise, using mechanically anchored roof bolts with a minimum length of 30-inches. The plan allows entries and crosscuts to be driven on a minimum of 60-foot centers. When rooms are being mined they are allowed to be driven on a minimum of 50-foot centers and the crosscuts to be driven on 60-foot centers. The maximum width of entries and rooms is 20-feet. The immediate roof consists of 3 to 36-inches of unconsolidated shale underlaying 10-foot of sandstone and the main roof is also sandstone.

The last regular Mine Safety and Health Administration Health and Safety Inspection was completed on June 17, 1996.

DESCRIPTION OF ACCIDENT



The following sequence of events was obtained through observations, and statements obtained during the investigation.

On Thursday, August 15, 1996, at 5:30 a.m., Randy King, section foreman, arrived at the No. 3 mine and conducted a preshift examination. The crew entered the mine at approximately 6:30 a.m. and traveled to the 001-section via battery-powered scoops in groups of 3 or 4-persons. Upon arrival on the section, each miner traveled to their respective work site. Tracy Bryant, general laborer (victim), had the daily assignment of cleaning loose coal from the ribs and applying rock dust to the mined areas. Bryant used a scoop to pick up the loose coal he had shoveled away from the ribs. During this shift, the majority of the mining activities were on the right side of the section, in the Nos. 5 through 9 entries. With the mining cycle completed in the No. 9 entry, the cutting machine and coal drill were moved across the section to the left side, to the No. 1 entry. The No. 9 entry was the last cut loaded-out on this shift. Near the end of the shift King traveled across the section. Phillip Ray, Jr., scoop operator, and King both stated they spoke with Bryant, at approximately 3:15 p. m., near the accident scene.

At approximately 4:00 p. m., the section crew began forming into small groups to travel to the mine surface. Wayne Collins, operating one scoop, with Eugene McKinney, coal drill operator, David Thornsbury, dump man, and Thomas Hall, shot-firer, traveled to the mine surface. Ronnie Cantrell, scoop operator, transported Keith Collins, cutting machine operator to the surface. King, Ray, and Bill Jones, superintendent, traveled to the section belt conveyor to make preparations to repair a damaged belt splice. Jones had been on the surface and traveled inside the mine to the section loading point to assist King and Ray. Following this, they left the section and traveled to the surface.

Upon arrival on the surface, the employees traveled to the company's No. 4 mine, located approximately 2 miles away, to pick up their weekly pay checks. Randy Dotson, outside person, stated he left the mine at approximately 4:20 p.m. and did not see Bryant leave the mine.

On Friday, August 16, 1996, Randy King, section foreman, reported for work and entered the mine to perform the pre-shift examination at approximately 5:30 a.m. King stated he examined the area where the belt conveyor splice was to be made and then called outside. He instructed Daniel King, general laborer, Keith Collins, cutting- machine operator, and Davy Thornsbury, general laborer, who had reported for work early, to come in the mine. R. King then continued to conduct an examination of the working section. King stated he examined all working faces on the section, beginning with the No. 9 entry, but did not examine the connecting crosscuts. In the No. 8 entry, he encountered a scoop, parked across the intersection of the last open crosscut. King stated he had to travel around the scoop to examine the face area of the No. 8 entry. King stated when he examined the No. 7 entry, he did not observe any roof material in the last open connecting crosscut between Nos. 7 and 8 entries. After examining the working section, R. King traveled to the location where the belt was to be spliced and assisted in splicing the belt.

The section crew began arriving at the mine between 6:00 and 6:30 a.m. As the section crew arrived, they grouped together and entered the mine via the scoops and traveled to the 001-section. R. King stated the belt splicing was not completed when the men arrived on the section. He instructed the crew to rock dust and shovel loose coal from the ribs. After the splice was made, King and K. Collins traveled to the section while Thornsbury traveled to the section tailpiece. R. King stated he began production activities in the area of the No. 1 entry around 8 a.m.

Eugene McKinney, coal drill operator, stated he parked the coal drill outby and traveled up the No. 7 entry to examine the crosscut between the Nos. 7 and 8 entries at approximately 8:30 a.m. McKinney checked the area to see if any brows needed to be drilled so they could be shot down. Upon reaching the crosscut, McKinney observed an object beneath a large section of fallen roof material. McKinney first thought the object was the powder wagon, used by the shot-firer. Upon closer examination, he determined the object to be a miner's boot and realized that a person was under the fallen rock material. McKinney alerted George Adkins, roof bolter operator, of the accident, and began removing roof material to gain access to the victim. Adkins came to the accident site. McKinney then traveled to the section dumping point and informed the section foreman that someone was under a rock in the crosscut between Nos. 7 and 8 entries. McKinney told King they needed lifting-jacks and timbers. King called outside, on the mine phone, informing Jones of the accident. King also called Frank Rudder, beltman, at the section head- drive, and told him to contact Wayne Collins, scoop operator and instruct him to go outside and get the superintendent and the tools and materials needed. After notifying King, McKinney returned to the accident site.

Rudder contacted the surface and repeated the instructions he received from King. The superintendent notified Muncie Meade, Jr., mine manager, who was at the company's No. 4 mine, of the accident. Meade notified the Mine Safety and Health Administration, Martin, Kentucky Field Office of the accident at 8:44 a.m. He also contacted the Kentucky Department of Mines and Minerals, and the Respond Ambulance Service. Meade then traveled to the No. 3 mine site.

Bill Jones along with Ronnie Cantrell and Phillip Ray, Jr. loaded the requested materials into a scoop and proceeded underground to the accident scene. Upon arrival at the accident scene, Jones and the crew set three timbers in the area of unsupported roof adjacent to the fallen material. Railroad-type lifting jacks were placed under the edge of the rock.

Personnel from the Kentucky Department of Mines and Minerals and MSHA began arriving at the mine at approximately 9:10 a.m. David Martin, Tommy Hall, Vaughn Watson, Tracy Stumbo and Earl Martin, Inspectors from the Kentucky Department of Mines and Minerals, traveled underground and arrived at the accident site. Randy King and Jones remained at the accident site with the state inspectors. The section crew was sent to the surface.

The victim was extricated at approximately 10:00 a.m. and transported to the surface. Bluford Smith, Floyd County Deputy Coroner, examined the body and no vital signs were detected. The victim was pronounced dead at 10:45 a.m. and removed from mine property by personnel of the coroner's office.


PHYSICAL FACTORS
  1. The shale roof material, which fell and struck the victim, measured 10 - 11 feet in length by 2 - 8 feet in width and ranged in thickness up to 5 inches.

  2. At the time of the accident, cleanup activities were being conducted in the crosscut between Nos. 7 and 8 entries. This was being performed prior to permanent supports being installed in the last 13 feet of the crosscut. The cleanup program for the mine required loose coal and float coal dust to be removed and an application of rock dust to be applied by hand during the mining cycle. Part of the victim's assigned duties was to clean up loose coal.

  3. When the victim was recovered, an empty aluminum soft-drink can was observed attached to a roof-bolt plate in the last row of supports on the No. 8 entry side of the unsupported area. A piece of red-colored cloth was attached to a roof bolt plate in the last row of roof supports on the No. 7 entry side of the unsupported area. During the investigation, warning devices, in the form of cloth strips, were found on the last row of permanent supports in all areas where unsupported roof was observed. Neither the investigation nor the interview process revealed when or by whom the warning devices were installed.

  4. According to statements, roof bolting generally followed coal loading activities. However, the location of the victim and the cleanup activities being performed indicated that a routine cycle of mining was not being followed.

  5. The victim was transported to the coroner's office at Martin, Kentucky, for further examination and then transported to the Kentucky Medical Examiner's Office, located at Frankfort, Kentucky, where an autopsy was performed. The cause of death was determined to be blunt force (crush) injuries of the head. Roger Nelson, Floyd County Coroner, fixed the time of Bryant's death at approximately 3:30 p.m., on Thursday, August 15, 1996.

  6. According to statements of the individuals interviewed, Bryant was not observed leaving the mine on Thursday, August 15, 1996, nor was he observed arriving for work on Friday, August 16, 1996. Muncy Meade, Jr., Mine Manager, stated that the victim did not pick up his paycheck on the evening of August 15, 1996, when the paychecks were available. He stated this did not alert him to anything, out of the ordinary, because there were three other employees who did not pick up their checks.

  7. According to statements, employees at this mine used a spiral-bound paper notebook as a check-in form, which was required by the operator, to sign their name and the time they started to work each day. The employees stated they did not use the notebook to sign out at the end of their work-shift. The operator also provided a check-in and check-out board with a metal tag for each employee. Some employees stated they did not use the check-in and check-out board.

  8. The victim had a tag on the check-in and check-out board and had an identification tag on his mining belt. The check-in tag had the victim's name imprinted. The identification tag, on the victim's mining belt had an imprint of his name and social security number. The tag on the mining belt was attached with two pieces of wire. The observations of the mining belt were made Wednesday, August 22, 1996, by MSHA investigators at the coroner's office.

  9. Randy King, section foreman, stated that the victim's identification check was in the 'out' column at the end of the working shift, Thursday, August 15, 1996. The check-in sheet for August 15, contained an entry where Tracy Bryant had signed-in. There was no time listed beside the signature.

  10. Statements by co-workers revealed that the victim either walked to work or caught a ride with one of the other employees. George Adkins, roof bolter operator, stated he observed the victim walking en route to the mine on the morning of Thursday, August 15, 1996. He stated he stopped and picked up Bryant and transported him to the mine. Adkins stated he did not see Bryant when he(Adkins) arrived on the mine surface that same evening. He stated he assumed that Bryant had either caught a ride or had left the mine walking.

  11. The Koehler Manufacturing 'Wheat' brand battery lamp, worn by the victim, was not emitting light at the time the victim was discovered. When examined by MSHA investigators, the lamp bulb and cord and terminals were operable. The lamp battery was in a discharged but operable condition.

  12. According to statements, the last cut taken in the connecting crosscut between the Nos. 7 and 8 entries (accident site) occurred between 12:30 and 1:00 P.M., Thursday, August 15, 1996.

  13. The victim had worked at this mine from March through May 1996, quit, and had returned to this mine on August 14, 1996. The accident occurred on his second day of his return to reemployment at the No. 3 mine. Prior to returning to the No. 3 mine, the victim had worked approximately one week at the company's No. 4 mine.

  14. The victim was not provided with Newly-Employed Experienced Miner Training upon his reemployment at this mine.

  15. An incomplete pre-shift examination was conducted on August 16, 1996. Randy King, section foreman and pre-shift examiner stated he did not examine connecting crosscuts where persons would be required to work installing permanent roof supports.

  16. Evidence observed during the investigation indicated persons had worked or traveled under unsupported roof at three locations on the 001-section. The crosscut developed between No. 7 and No. 8 entries had been mined from the No. 8 entry. The roof had not been supported for a distance of 13 feet. The victim's body was found 7 to 8 feet inby the last row of permanent roof supports. The face of the No. 1 entry had been mined 15 feet past the last full row of permanent roof supports. Evidence indicated that the person who had loaded explosives into the drilled holes had proceeded a minimum of 6 feet beyond permanent roof supports before the coal face was mined to its existing depth. The roof bolting machine, located in the No. 6 entry, was positioned where the operator would have been under unsupported roof while operating the tram controls.



CONCLUSION


The accident occurred when the victim traveled inby permanent roof supports while performing cleanup activities. The accident occurred due to the failure of the operator to establish a program which would assure that employees would not work or travel in areas not permanently supported. This practice was indicated by evidence that persons had worked or traveled inby permanent roof supports at three separate locations on the 001-section.


VIOLATIONS
  1. A 103-k Order, No. 4591573, was issued to assure the safety of all persons in the mine until an inspection or investigation was conducted and the area was deemed safe to enter.

  2. A 104-d-1 Citation, No.4518681, was issued due to an exhibited practice of working or traveling under unsupported roof on the 001-section at this mine.

  3. A 104-d-1 Order, No. 4518577, was issued for the operator's failure to provide the victim with Newly-Employed Experienced Miner Training prior to assigning work duties.




Respectfully submitted:

James W. Poynter
Supervisory CMS&H Inspector

Harold Yates
CMS&H Inspector (Roof Control)


Approved: Carl E. Boone, II
District Manager


Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB96C20