UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION


Southeast District
Metal and Nonmetal Mine Safety and Health

Accident Investigation Report
Underground Nonmetal Mine

Fatal Electrical Accident

Dravo Lime Company
Black River Mine
Butler, Pendleton County, Kentucky
Mine I.D. 15-00062

July 11, 1997

By

Larry R. Nichols
Supervisory Mine Inspector


Clarence F. Holiway
Mine Safety and Health Inspector (Electrical)


Originating Office
Mine Safety and Health Administration
135 Gemini Circle, Suite 212
Birmingham Alabama 35209

Martin Rosta
District Manager

GENERAL INFORMATION

John A. Miller, mine mechanic, age 42, was electrocuted at approximately 6:20 p.m. on July 11, 1997, when he contacted the metal wand of a high pressure washer that was energized with approximately 277 volts AC. The victim had 9 years, 3 months experience at this mine, with 9 of these years as a journeyman electrician and the last 3 months as a mine mechanic. Records indicated the victim had received annual refresher training in February, 1997, in accordance with 30 CFR, Part 48.

David Feagan, employee relations manager for Dravo Lime Company, notified the Birmingham, Alabama, district office of the accident at 7:40 p.m., on July 11, 1997. An investigation was started the same day.

The Black River Mine, an underground limestone operation, owned and operated by Dravo Lime Company, was located adjacent to State Highway 8, about 12 miles northeast of Butler, Pendleton County, Kentucky. The principal operating official was Mark Davis, vice president of operations, Black River Division. The mine normally worked two, 10 to 12 hour shifts per day, 7 days a week, and employed 145 persons.

Mining method was room and pillar, with conventional drilling and blasting. Blasted material was loaded by front-end loaders into haulage trucks and transported to two underground primary crushers. Crushed material was conveyed to the surface by a series of conveyor belts to the mill surge pile.

The last regular inspection of this operation was conducted May 19-22, 1997.

PHYSICAL FACTORS INVOLVED

The accident occurred in the underground equipment wash bay area which was 24 feet high, 35 feet wide, and 40 feet long. Equipment could access the area through several openings.

Underground power was supplied from a 480 volt AC, 3 phase wye connected solid grounded system.

The equipment involved in the accident was a three phase, 480 volt AC, Silverjet high pressure washer, Model No. XHWK, manufactured by Upstream Technology, Incorporated. The washer produced a water pressure of 2100 psi, with options of hot, cold or soap water dispensed through a braided hose and a metal wand.

Power for the washer was supplied from a combination starter consisting of a 600 volt AC, 60 amp, 3 phase Westinghouse circuit breaker and a size one motor starter. The combination starter was equipped with a 4 conductor Hubbellock female plug. An electrical control panel mounted on the washer was equipped with a 6 foot, 4 conductor cable with a male Hubbellock plug.

An older Silverjet high pressure washer in the wash bay area had components that were interchangeable with the washer involved in the accident. Neither of the pressure washers was working prior to the day of the accident.

DESCRIPTION OF ACCIDENT

John A. Miller, victim, reported to work on July 11, 1997, at 7:00 a.m., his regular starting time. Miller was instructed by his supervisor, Rick McElfresh, to repair one of the washers and if necessary, combine components from both to make one operable. Miller proceeded to the wash bay area and began working on the washer.

The washer Miller chose to repair was the newer model. He worked on the pressure washer throughout the day, at times conversing with his supervisor and other employees about parts and repairs that were needed to complete his task.

At approximately 2:00 p.m., Pam Hargett, laborer, went to the wash bay area with a forklift to remove the older washer. Miller cut the power cable off the old washer before it was moved.

Gary Green, mine mechanic, arrived at the wash bay area at approximately 4:15 p.m., to clean the engine of a roof bolting machine. Miller had completed repairs enough to enable Green to use the washer; however, every time Green released the trigger on the hand-held wand that controlled the water flow, the heater for the hot water would shut off. In order to finish the job, Miller would operate the heater switch manually so they could complete cleaning the engine.

Green left the area at approximately 4:50 p.m. and Miller continued to work on the washer. Sometime after Green left, Miller removed the power cable from the washer and replaced it with the longer one he had cut from the old washer. When he connected the cable into the control panel, the red and green wires were switched. The red power wire was connected to the equipment ground and the green ground wire was connected to the insulated connector block.

Rick McElfresh, supervisor, passed by the wash bay area at approximately 6:15 p.m., and in passing, yelled to Miller and asked how he was doing. Miller informed him that he was about ready to try the washer.

When the combination starter was energized, 277 volts were directed onto the washer frame and its metal parts. Moments later Miller picked up the hand-held wand and was electrocuted.

At approximately 6:20 p.m., Chris Spencer, mine mechanic, went to the wash bay area and found Miller lying on the ground near the washer with the wand in his hand. He touched Miller and received a shock. Spencer ran to the shop calling for help. Lonnie Adams, electrician, immediately ran to the combination starter and de-energized the circuit. They checked Miller's vital signs but were unable to detect a pulse. CPR was began immediately, and continued as Miller was being transported to the surface where emergency personnel continued efforts to resuscitate him. He was transported by ambulance to St. Luke East, Hospital in Ft. Thomas, Kentucky where he was pronounced dead at 7:45 p.m.

CONCLUSION

The cause of the accident was the power cable being wired incorrectly and continuity of the grounding conductor not being checked after repairs were made.

VIOLATIONS

Order No. 4554730

Issued on July 12, 1997, under the provisions of Section 103(k):

John A. Miller, an employee, was discovered by a fellow employee lying on the mine floor in the wash bay apparently unconscious and with no vital signs. The cause of his death was unknown at the time. This Order is issued to insure the safety of persons at the mine and includes the Silverjet high pressure washer and the wash bay area until the equipment and the affected area have been investigated by the MSHA investigation team and this Order has been modified or terminated.

This order 103-K on the Silverjet high pressure washer is modified on July 14, 1997, to allow the company to remove the high pressure washer for rewiring and repair as needed or the company may rewire and repair washer with own qualified employees. This also allows company to rewire primary power supply which is 480 volts, 3 phase. This high pressure washer can not be energized without the approval of MSHA. Also, a complete list of defective parts and replacement parts, including wiring, shall be provided before washer will be released for service.

This order was terminated on July 29, 1997. The Silver jet pressure washer was rewired and properly grounded. The repair of the washer required no replacement parts. The continuity of the washer's grounding system was tested. The washer was energized and no voltage appeared on the unit.

Citation No. 4355178

Issued July 15, 1997, under provisions of Section 104a of the Mine Act for violation of Standard 57.12028:

A fatal accident occurred at this operation on July 12, 1997, when an employee came into contact with the wand of the Silverjet high pressure washer, after he had made repairs to the washer. The Hubbell twist lock plug, which connects the washer to the disconnect, was improperly wired at the washer control box. The 480 volt, 3 phase plug, was wired with a power wire connected to the grounding wire, putting approximately 277 volts onto the washer frame, and its metal attachments. The continuity of the grounding conductor was not checked after repairs were made.

This citation was terminated on July 29, 1997. The Silverjet pressure washer was rewired and properly grounded. No voltage was present on the frame of the washer when tested. The continuity of the grounding was tested before being energized.

[FAB97M37]