DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
ACCIDENT INVESTIGATION REPORT
(UNDERGROUND COAL MINE)
FATAL ROOF FALL
No. 1 (I.D. 44-06727)
Kade Coal Co., Inc.
Whitewood, Buchanan County, Virginia
September 18, 1996
Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Ray McKinney, District Manager
A fatal roof fall occurred on Wednesday, September 18, 1996 at 9:40 a.m. during roof bolting operations in the No. 3 Right Crosscut of the 001-0 Section. The victim, Larry Damrom, was assisting the right side roof bolting machine operator. Damron traveled inby supported roof carrying a roof bolt and resin cartridge where he was struck and fatally injured by the roof fall. The fall measured twenty (20) feet long by nine (9) feet wide and ranged from one (1) to eighteen (18) inches thick.
Kade Coal Co., Inc., No. 1 is located two miles east off State Route 628 near Whitewood, Buchanan County, Virginia. The mine is opened by four drifts into the Cary Coal Seam which ranges from 60 to 96 inches in thickness. Nine employees produce approximately 400 tons of coal per shift operating one production shift five days per week. The mine has been developed by room- and-pillar methods utilizing a Joy 14-CM5 Continuous Mining Machine and Joy 10SC Shuttle Cars. A Fletcher Dual-Head Roof Bolting Machine with "H" Beam Automated Temporary Roof Support (ATRS) and a FMC 3510 Dual Head Roof Bolting Machine with ATRS are used to install roof bolts. The current Roof Control Plan was approved April 16, 1996. A supplement to the Roof Control Plan detailing the use of the Fletcher Dual Head Roof Bolting Machine with "H" Beam ATRS was approved July 26, 1996. The mine's immediate roof consists of seven (7) to eight (8) feet of shale and the main roof is sandstone. The mine has a history of roof slips which are taken down with the continuous mining machine when detected. The company reduces entry widths and offsets crosscuts in areas determined to have roof slips.
Frank Hackney is the President and Safety Director of Kade Coal Co., Inc.
The last Mine Safety and Health Administration Safety and Health Inspection (AAA) at this mine was completed on August 27, 1996.
DESCRIPTION OF THE ACCIDENT
The day shift crew under the supervision of Eddie Sparks, section foreman, entered the mine on Wednesday, September 18, 1996 at 7:00 a.m. and traveled to the 001-0 Section. Work progressed normally until approximately 9:14 a.m. when the section belt conveyor shut down. Sparks traveled from the No. 3 Entry where he met Sidney Stanley and Larry Damron, roof bolting machine operators, positioning the Fletcher Dual-Head Roof Bolting Machine to install a single roof bolt in the intersection outby the No. 3 Face. Sparks traveled to the surface to correct the belt conveyor problem while Damron and Stanley installed the roof bolt. Damron then trammed the roof bolting machine into the No. 3 Right Crosscut and Stanley began installing roof bolts with Damron assisting him on the right side of the machine. During drilling of the third roof bolt hole, Stanley observed Damron inby roof supports marking the next roof bolt installation location. Stanley instructed Damron to move outby. Damron moved to the rear of the roof bolting machine and Stanley returned his attention to drilling. A short time later, Stanley heard the roof fall inby his position and observed Damron under the edge of the fall. Stanley called for help and began moving rock off the victim. The other members of the crew, just returning to the face area after restart of the section belt conveyor, heard Stanley's call for help, gathered at the accident scene, and began recovery of the victim. Dean Rose, continuous mining machine helper, and Robbie Cook, continuous mining machine operator, obtained the first aid supplies, Rose contacted the surface by phone, requested an ambulance, and notified Sparks, who was on the surface, that an accident had occurred. Rose and Dean returned to the scene and continued to assist in recovery of the victim. After removal of the rock, Stanley, a certified First Responder, examined the victim for vital signs. Sparks arrived soon after and repeated this examination. No vital signs were detected. The victim was placed on a stretcher and transported to the surface, arriving there at 10:05 a.m. The Patterson Rescue Squad arrived at approximately 10:50 a.m. After examining the victim, squad members were instructed to wait for the coroner. Dr. Jose Abrenio, Buchanan County Coroner, pronounced the victim dead at 11:43 a.m. and the Patterson Rescue Squad transported his body to Buchanan General Hospital.
PHYSICAL FACTORS INVOLVED
- The Approved Roof Control Plan requires, in part, as a
minimum, the following: 1) Installation of 60-inch Point-
Anchor or Combination Roof Bolts on four-foot centers
beginning at the ribs and sequencing toward the middle of
the entry as each row is installed; 2) The automated
temporary roof supports (ATRS) shall be positioned firmly
against the mine roof not more than five (5) feet inby
permanently supported roof; 3) When the ATRS is positioned
more than five (5) feet from either rib, safety jacks or
posts must be set to reduce the spacing to five (5) feet or
less; 4) A crosscut turn width of 24 feet for a linear
distance of four (4) feet.
- The Fletcher Dual Head Roof Bolter is equipped with an "H"
Beam ATRS. The ATRS was firmly positioned against the mine
roof in the No. 3 Right Crosscut. The outby and inby ATRS
beams were positioned from the right rib five feet and two
inches and seven feet and one inch respectively. Safety
jacks or posts had not been set to reduce the spacing to
five feet or less. Two posts of suitable length, a saw, and
wedges were available on the roof bolting machine. If a
jack or post had been installed in line with the inby ATRS
beam, as required by the Roof Control Plan, it would have
been located at the outby edge of the slip that fell. The
jack or post would not have prevented the roof fall.
However, the jack or post could have broken or deflected the
edge of the slip that struck the victim. Additionally, the
post or jack could have served as a visual and/or physical
barrier against traveling inby supported roof as it would
have been located approximately six to twelve inches outby
the victim's location at the time of the roof fall.
- The width of the turn into the No. 3 Right Crosscut was
measured as 26 feet and 7 inches. The Roof Control Plan
allows a turn of 24 feet in width not to exceed four (4)
feet linearly. The excessive width was created by mining
the inby corner of the 3 Right and No. 3 Entry intersection.
The coal removed from the corner was under the slip of the
mine roof that fell.
- The No. 3 Entry had been started "off centers" beginning one
crosscut outby and had been mined to the left to regain a
proper centerline. Survey Station No. 278 was installed
prior to turning the No. 3 Right Crosscut. The turn was
made "on centers" and was properly marked prior to mining.
- The investigation revealed that Larry Damron was an
experienced miner with adequate training. During six months
of his ten years of mining experience he had been classified
as an operator of Fletcher Dual Head Roof Bolting Machines.
Damron started work at the mine on Tuesday, September 17,
1996 and worked four hours before the crew was sent home due
to equipment failure. Damron received Newly Employed
Experienced Miner and Hazard Training from Eddie Sparks,
foreman, on September 17, 1996. This training was given in
accordance with a Training Plan approved December 14, 1995.
The training included, in part, a review of the Roof Control
Plan, which contained provisions prohibiting travel inby
permanently supported roof for any reason other than
installation of temporary roof supports, and a discussion of
the numerous roof slips at this mine. Damron also observed
a demonstration of the controls of the Fletcher Dual Head
Roof Bolting Machine with "H" Beam ATRS given by Sidney
Stanley, roof bolting machine operator. According to
Stanley, Damron demonstrated a familiarity with the
machine's controls and operating procedures.
- On Tuesday, September 17, 1996, Eddie Sparks, foreman,
marked the right rib for the right turn in the No. 3 Entry.
He preshifted the No. 3 Entry on Wednesday, September 18 and
was present during the turning of the No. 3 Right Crosscut
for the loading of four (4) shuttle cars. He observed the
continuous mining machine being trammed out of the No. 3
Entry and the roof bolting machine being positioned to spot
a roof bolt on the corner of the intersection outby Survey
Station No. 278. Sparks stated that he observed no unusual
roof conditions during any of these visits. He did not re-
enter the No. 3 Entry prior to the accident. Sparks then
traveled to the surface after the mine's belt conveyor shut
down and was on the surface at the time of the accident.
- On September 18, Damron was instructed by Sparks to assist
and observe Sidney Stanley, roof bolting machine operator.
Damron installed one roof bolt at the left outby corner of
the intersection of the No. 2 Right Crosscut and the No. 3
Entry one crosscut outby the accident location.
- Stanley and Damron were both present and observed the
extraction of the first cut from the No. 3 Right Crosscut.
Stanley and Robbie Cook, continuous mining machine
operators, both stated that they observed no unusual roof
conditions during extraction of the cut.
- According to Stanley, Damron then trammed the roof bolting
machine into the No. 3 Right Crosscut and Stanley began
installing roof bolts with Damron assisting him on the right
side of the machine. During drilling of the third roof bolt
hole, Stanley observed Damron inby roof supports marking the
next roof bolt installation location. Stanley instructed
Damron to move outby and stated "We don't do that here."
- The roof slip that fell was twenty (20) feet long, nine (9)
feet wide, and ranged from one to eighteen inches thick.
- Damron's hard hat, a bent roof bolt with bearing plate, and
a cartridge of resin were observed at the accident scene
four and one-half (4 1/2) feet inby permanent roof support.
A chalk mark was observed on the underside of a piece of the
fallen mine roof.
- The evidence indicates that, at the time of the roof fall,
Damron was standing inby supported roof, with his back to
the newly developed No.3 Right Crosscut, observing the
drilling of the third roof bolt hole. Apparently Damron,
after being warned to move outby by Stanley, traveled to the
outby end of the roof bolting machine, obtained a roof bolt,
bearing plate, and resin cartridge and returned to the area
where he had been observed marking a roof bolt location.
- There was no written company policy concerning traveling inby supported roof. Employees stated that they had not previously observed persons inby supported roof. Stanley's actions upon observing Damron marking a roof bolt location inby supported roof indicate that such activities were not condoned.
The accident occurred because the victim was working under unsupported roof.
A contributing factor was the failure to install a post or jack to reduce the spacing between the ATRS and the right coal rib to five (5) feet or less. A jack or post at the required location would not have prevented the roof fall. However, one might have broken or deflected the falling roof or served as a physical/visual barrier against travel under the section of roof that fell.
- A 103(k) Order (No. 3799176) was issued to insure the safety
of all persons until an investigation was completed.
- A 104(a) Citation (No. 3787043), citing 30 CFR 75.202(b),
was issued for a person working inby roof supports.
- A 104(a) Citation (No. 3787042), citing 30 CFR 75.220, was issued for a violation of the approved Roof Control Plan. The "H" Beam ATRS System was positioned seven (7) feet and one inch from the right rib and a jack or post had not been set to reduce the spacing to five (5) feet or less as required by the plan.
Respectfully submitted by:
Benjamin S. Harding
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