UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 5
ACCIDENT INVESTIGATION REPORT
(SURFACE AREA-UNDERGROUND COAL MINE)
FATAL MACHINERY
Buchanan Mine #1 (ID No. 44-04856)
Consolidation Coal Company
Mavisdale, Buchanan County, Virginia
November 22, 1998
by
Benjamin S. Harding
Mining Engineer
Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, VA 24273
Ray McKinney, District Manager
GENERAL INFORMATION
Consolidation Coal Company's Buchanan Mine #1 is located two
miles south of Route 460 on State Route 632 at Mavisdale,
Buchanan County, Virginia. The mine is opened into the
Pocahontas No. 3 Seam by eight shafts. Employment is provided
for 345 persons. A total of 306 underground and 39 surface
employees work on three production shifts per day, seven days per
week. The surface area of the mine includes a large preparation
plant which produces 10,000 tons of clean coal per day. Coal is
cleaned, dried, stockpiled, and loaded into unit trains for
transport or into trucks which deliver coal to the mine's
impoundment area for storage when stockpiles are at or near
capacity. The preparation plant area includes raw and clean coal
silos, stockpile, and loadout facilities.
The principal management personnel in charge of the mine at the
time of the accident were:
| Mine Superintendent | | J. Michael Onifer |
| Mine Foreman | | Roy Duty
|
| Plant Superintendent | | Tom Burton |
| Plant Foreman | | Dwight Eades |
The last regular Safety and Health Inspection(AAA) was completed
on September 30, 1998; however, due to the size of the mine, a
safety regular and health inspection is continuously ongoing.
DESCRIPTION OF ACCIDENT
On Saturday, November 21, 1998, at 11:30 P.M., the midnight shift
crew comprised of twelve miners at the preparation plant began
their shift under the supervision of Dwight Eades, Plant Foreman.
Eades' shift began at 7:30 P.M. The plant was idle and repairs
begun on the previous shift were continuing. The draw-off belt
conveyor under the clean coal stockpile was operating to load
coal into trucks for transportation to the impoundment area for
storage. None of the draw-off belt conveyor feeders were
operating as the stockpile was gravity feeding onto the belt
conveyor. At approximately 1:00 A.M., Eades traveled by pickup
truck to the impoundment area to check a pump and later returned
to the plant.
Repairs were completed in the plant and startup procedures began
at 1:30 A.M. By 2:00 A.M. the plant was operational. At 2:30
A.M. Jessie Vance Jenkins, Jr., Mobile Equipment Operator,
returned to the plant office from the skip shaft area where he
had been moving coal with a dozer since the start of the shift.
At 3:00 A.M. Eades instructed Jenkins to assist with repairs on a
floor brace in the plant. At 4:30 A.M. Eades instructed Jenkins
to take a dozer to the clean coal stockpile and move coal away
from the stacker.
Jenkins reported by radio to Arthur W. Booth, Jr., Control Room
Operator, that he was entering the stockpile area at 4:55 A.M.
Booth logged the contact. Jenkins called Scott L. Graves, Dryer
Operator, and told him that the No. 2 Feeder was feeding coal.
At 5:25 A.M. Booth called Jenkins on the radio and received no
response. Booth contacted Graves and asked him to go to the head
house and see if he could locate Jenkins. Booth also notified
Eades of the situation. Eades immediately obtained a vehicle and
drove around the road beside the stockpile. Neither Eades nor
Graves saw Jenkins or the dozer. The plant was then shut down
completely including the draw-off belt conveyor. Bobby Berry,
Plant Electrician, took another dozer onto the stockpile to look
for Jenkins. He was unable to locate Jenkins and realized that
the dozer must be in a void over a feeder. He located dozer
tracks that ended at the edge of a void over the No. 1 Feeder.
Within this approximate 15 minute time frame, personnel from both
the plant and mine had begun to gather. Craig Chadwell,
Assistant Mine Foreman, traveled up the overhead stacker belt
line catwalk and reported seeing metal in the No. 1 Feeder.
Berry reported seeing two to three feet of the dozer blade at the
same location.
Eades contacted Tom Burton, Plant Superintendent, at home and
asked him to begin emergency procedure contacts. Burton did this
by cellular phone as he traveled to the mine site. Eades brought
in every available piece of earth moving equipment and
immediately began moving coal away from the No. 1 Feeder area.
Members of Consolidation Coal Company's mine rescue team arrived
and assisted in the recovery. Personnel from the Mine Safety and
Health Administration and the Virginia Department of Mines,
Minerals, and Energy arrived at various times and assisted in and
monitored the recovery operation.
Jenkins was extricated from the dozer at 1:12 P.M. and
transported by ambulance to Buchanan General Hospital in Grundy,
Virginia where he was pronounced dead by Dr. Joseph Segen,
Buchanan County Medical Examiner.
PHYSICAL FACTORS INVOLVED
The investigation revealed the following factors relevant to the
occurrence of the accident:
- There were no eyewitnesses to the accident.
- The accident occurred at the clean coal surge pile. The
pile has one stacker tube and four feeders. The feeders are
50 feet apart, with two feeders on each of the stacker tube.
The clean coal is predominantly fine-grained, with a top
size of 1.75 inches.
- The stockpile was approximately 600 feet long and 300 feet
wide at its base. The width of the pile is restricted by a
public road on the east side and railroad tracks on the
west. The pile was approximately 60 feet high at the time
of the accident.
- Large orange plastic balls are used as overhead markers to
identify the location of each feeder. These markers are
suspended, using a pulley system which allows the height of
the balls to be adjusted up or down as the height of the
pile varies. The marker height can be adjusted remotely by
the dozer operators using an automatic garage door type
control. Statements by dozer operators indicated that the
remote controls did not always function properly.
- The feeders are General Kinematics Un-Coalers, a vibratory
type, without gates. The feeder opening size is
approximately 4 feet by 1 foot. At the time of the
accident, none of the vibratory feeders were activated.
When Jenkins arrived on the stockpile he reported that the
No. 2 Feeder was feeding coal. The draw-off belt conveyor
was operating and coal was being conveyed to a bin which was
being used to load trucks.
- The feeders are not designed to deliver coal by gravity when
deenergized. There are no gates or other devices to prevent
gravity flow of material. According to the manufacturer,
the feeders are designed to stop gravity flow of material
utilizing an interior baffle plate and the material's angle
of repose. The size and moisture content of the material
affects the angle of repose and can allow gravity flow.
Coal is drawn off the bottom of the stockpile by the draw-off
belt conveyor, which is fed by the four identical vibratory feeders.
The draw-off belt conveyor is capable of transporting coal from
only two energized feeders at a time.
- According to various statements, all of the feeders did
gravity feed on occasion. All persons interviewed stated
that the No. 2 Feeder would normally gravity feed more than
the others. No evidence was found to explain this, as all
feeders are identical. Everyone interviewed stated if coal
was feeding onto the draw-off belt conveyor and no feeders
were energized, it was coming from the No. 2 Feeder. This
assumption was based on past examinations and experience.
According to company records, the No. 1 Feeder was last
operated on November 14, 1998.
- Plant employees utilize a notification system for the dozer
operators working on the stockpile. Before going on the
stockpile, the dozer operator contacts the control room
operator to ensure that the radios are working. While a
dozer is operating on the stockpile, the control room
operator contacts the dozer operator at half hour intervals.
Dozer operators and loadout operators communicate by radio
to establish which feeders are energized and which are
gravity feeding.
- When more coal was being discharged from the stacker than
was being loaded out on the draw-off belt conveyor, the coal
that accumulated near the stacker tube was pushed to the
outer edges of the stockpile by dozer.
- The dozer involved in the accident was a Caterpillar
D9H(Serial Number-90V4339). The dozer was equipped with an
enclosed cab, a two-way radio and two self-contained self
rescue devices. Examinations of the dozer after recovery
revealed that the machine was maintained in safe operating
condition.
- Jessie Vance Jenkins, Jr. had 20 years of mining experience,
14 years at this mine, and 2 years and 2 months as a dozer
operator. He had received all training required by 30 Code
of Federal Regulations.
- There was a heavy frost on the morning of November 22, 1998
with the temperature below the freezing level. During cold
weather, clean coal delivered straight to the stockpile from
the thermal dryer produces large quantities of steam which
can reduce visibility on the stockpile. Statements by
witnesses and observations under similar conditions indicate
that adequate levels of visibility normally exist at night
with steam generating conditions. According to statements
from equipment operators, when visibility was restricted
they were instructed to leave the stockpile. Some stated
they had to stop or slow down on occasion to allow steam to
clear, but none had ever left the stockpile due to
restricted visibility.
- The stockpile is illuminated by seven 1000 watt vapor lights
located on the overhead stacker belt conveyor structure and
support towers.
- Clean coal is delivered to the stockpile by an overhead
stacker belt conveyor which dumps through the stacker tower
located in the center of the stockpile.
- Jenkins was instructed by Eades to move coal away from the
stacker tower toward the outer edges of the stockpile.
Evidence indicated that he was not pushing coal toward the
feeders.
- The dozer was found directly over the No. 1 Feeder on its
left side with the blade facing the railroad on the
southwest edge of the stockpile. The dozer was in a void
over the feeder which was approximately 30 to 35 feet deep
and was completely covered with coal except for a small
portion of the blade. All windows were broken or pushed out
of the frames and the operator's compartment was full of
loose coal. Tracks remaining after the recovery indicated
the dozer was traveling away from the stacker tower toward
the southwest edge of the stockpile. Elongated tracks from
the right side dozer treads and a compacted area caused by
the bottom pan of the machine indicated that the material
collapsed below the left side of the dozer, rolling it to
the left and into a void over the No. 1 Feeder.
- The victim was not wearing a seatbelt when recovered. The
male section of the seatbelt was found behind and to the
right of the operator's seat. The seatbelt was functional
and adjusted to a length adequate to reach around an MSHA
Technical Support Engineer when examined after the dozer was
recovered.
- Company policies do not allow the operation of any equipment
directly over any feeders and require that a safe radius be
allowed around any active feeder which is not visually
breaking coal into the void over the feeder. Additionally,
if visibility makes safe operation impossible, no one is
allowed on the stockpile. These and other policies are
included in a company handbook containing safe work
procedures which was provided to all employees during
initial training and reviewed in subsequent training. These
written policies do not refer to situations when feeders are
deenergized, but are still gravity feeding coal.
- The clean coal stockpile contains very fine material.
Evidence of compacting layering due to the random pattern of
dozer travel was observed. The void over the No. 1 Feeder
contained layers of various degrees of compaction.
Compacted layers were observed overhanging less compacted
layers below. This type of layering can create bridged
areas over feeders. No person interviewed stated they had
ever known of a completely bridged void. One dozer operator
witnessed voids which were bridged except for a small (1 to
2 feet) opening that quickly collapsed over the feeder. He
stated that this type of void usually contained much steeper
sides than those over energized feeders.
- Examinations required by 30 Code of Federal Regulations were
being properly conducted and recorded.
CONCLUSION
The accident occurred when the dozer operated by Jenkins traveled
into a hazardous area near the No. 1 Feeder containing a bridged
over void in the stockpile. The bridged material collapsed
causing the dozer to tumble into the underlying void where it was
subsequently engulfed with loose coal. The layering effect of
the fine coal and the fact that deenergized feeders gravity fed
onto the draw-off belt conveyor without being positively
identified led to a steep-sided void completely bridged over the
No. 1 Feeder which was unobserved by the victim or any other
personnel on the midnight or preceding shifts.
VIOLATIONS
A 103(k) Order(No. 7303388) was issued to insure the safety of
all personnel until an investigation of the accident was
completed.
Citation No. 7297191 was issued under 30 CFR 77.404(a). The
clean coal stockpile and draw-off tunnel system including
vibratory feeders were not maintained in a safe operating
condition. When the draw-off belt conveyor was in operation coal
would gravity feed through all four of the feeders when they were
deenergized increasing the potential for voids to form in the
stockpile where persons and machinery were working. Equipment
operators communicated by radio with the loadout operator to
identify active and inactive feeders. Deenergized feeders that
fed coal by gravity could not always be positively identified.
Written company safe work procedures addressed energized feeders
but made no reference to deenergized feeders that were feeding by
gravity. Additionally, statements given during the investigation
indicated that the remote control system for raising and lowering
the visual markers for each feeder did not always function
properly.
Citation No. 7297192 was issued under 30 CFR 77.209. A
hazardous condition, by way of a bridged cavity, was present on
the coal storage stockpile. This undetected void was created by
coal reclaiming operations beneath the storage pile. Jenkins'
exposure to this hazard resulted in fatal injuries when he and
the dozer he was operating were drawn into the void and
subsequently covered by coal.
RECOMMENDATIONS-IMPLEMENTED
The Nos. 2 and 3 Feeders were blocked with steel plates. The
Nos. 1 and 4 Feeders alone will be used until hydraulic doors are
installed on all feeders to eliminate gravity flow.
The Nos. 1 and 4 Feeders will be energized before dozers enter
the stockpile. Examinations will be made in the draw-off tunnel
to verify that coal is feeding properly until the hydraulic doors
are installed.
A visible void must be present above the Nos. 1 and 4 Feeders.
If not, all employees will leave the stockpile and not return
until the condition is corrected.
ADDITIONAL RECOMMENDATIONS
Hydraulic doors are to be installed that will eliminate gravity
flow.
A lighting system will be installed in conjunction with the
existing plastic ball feeder marker system which will indicate
which feeders are energized. This system will be electrically
interlocked with the hydraulic doors such that when each door is
opened a light visible to persons on the stockpile will energize.
Each feeder will have a separate indicator light.
Electrical interlocks will be installed such that the draw-off
belt conveyor cannot be energized independently from vibrating
feeders.
Submitted by:
Benjamin S. Harding
Mining Engineer
Ray McKinney
District Manager
Related Fatal Alert Bulletin:
 FAB98C25
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