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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 7
ACCIDENT INVESTIGATION REPORT
(Underground Coal Mine)

FATAL FALL OF ROOF ACCIDENT

J & A Coal Corporation
No. 1 Mine
I.D. No. 15-15776
Lackey, Knott County, Kentucky

March 11, 1999

by

William R. Johnson

and

Roger D. Dingess
Coal Mine Safety and Health Inspectors

Originating Office-Mine Safety and Health Administration
HC 66 Box 1762, Barbourville, Kentucky 40906
Joseph W. Pavlovich, District Manager



OVERVIEW


Abstract


On Thursday, March 11, 1999, at approximately 9:15 p.m., a roof fall accident occurred in the No. 6 belt entry of the 001 section fatally injuring James Sturgill, a 35-year-old scoop operator, and resulting in injuries to three co-workers. Sturgill had 15 years total mining experience. However, it was his first day and shift at this mine. The victim was fatally injured when a section of the mine roof fell resulting in crushing injuries. The fallen rock measured four feet by seven feet and ranged from one to five inches in thickness.

Byron Martin and John Crisp, roof bolting machine operators, were in the process of installing roof bolts. Burl Hughes, scoop operator, was holding the drill steel for Martin while James Sturgill (victim), was preparing to hold the drill steel for Crisp. All four men were located inby permanent roof supports. The mine roof had been blasted out to a height of seven feet to create a boom hole for the future installation of a section dumping point. As a result of the additional height created, the Automated Temporary Roof Support (ATRS) system on the roof bolting machine would not contact the mine roof.

The investigators determined that the accident occurred as a result of mine management's failure to adequately supervise and direct the work force, to prevent miners from traveling under unsupported roof. A practice of traveling and working under unsupported roof was found to exist which directly contributed to the death of the 35-year-old miner and injuries to three co-workers. The investigation further revealed that three officials of the mine operator and three roof bolting machine operators were not instructed in procedures of the revised roof control plan addressing the use of ATRS's in areas where the mining height has been increased as a part of the mining process which indirectly contributed to the accident. The failure of the mine operator to instruct all persons affected by the revision, in effect, withheld valuable knowledge from the victims, about approved types and procedures of proper roof support to be utilized.

Additionally, it was determined that employees who had been assigned to rehabilitate the area, had not been instructed in the clean-up and support procedures to be followed while rehabilitating the boom hole area.

GENERAL INFORMATION AND BACKGROUND


The J & A Coal Corporation, No. 1 Mine is located at Lackey, Knott County, Kentucky. The mine is opened by three drifts into the No. 3 Elkhorn seam. The mine provides employment for 31 underground and 3 surface employees. The mine produces an average of 150 tons of coal per shift, operating two eight hour production shifts and one eight hour maintenance shift per day, five days per week. The coal reserves are owned by Knott-Floyd Land Company of Benton, Kentucky. The maximum overburden is approximately 500 feet. The mine roof is supported with conventional roof bolts, resin rods, or tension rebars, depending upon roof conditions. The minimum length for overhead roof support is 36 inches. Entries and crosscuts are advanced on 60 foot centers. Coal is mined utilizing a conventional mining section consisting of a cutting machine, coal drill, scoops for loading and transporting coal from the working faces to the belt conveyor, and roof bolting machines. Miners and supplies are transported by either scoops or battery powered personnel carriers. The mine is ventilated by a 200 hp exhausting fan. Coal is transported to the surface via conveyor belts. The mine has no history of methane liberation. The miners are not represented by a bargaining unit or organization. The last regular (AAA) Mine Safety and Health Administration (MSHA) inspection was completed on November 2, 1998.

Principal Officers are as follows:
Jody Samons .......... President
Kevin Daniels .......... Secretary
Matthew Hall .......... Mine Superintendent
DESCRIPTION OF THE ACCIDENT


On Tuesday, March 11, 1999 at approximately 3:00 p.m., the second shift crew of the 001 section began their regular shift. The crew, under the supervision of Randy Carroll, section foreman, had traveled to the 001 section to prepare for the evening's work. Prior to this shift, holes had been drilled in the mine roof and loaded with explosives to create a boom hole located in the intersection, 60 feet outby survey station No. 552 located in the No. 6 entry. This area was blasted by the day shift crew, creating an unsupported area, prior to the second shift crew entering the mine. After arriving on the working section, James Sturgill (victim), Jimmy Adkins, John Crisp, and Burl Hughes were each assigned the task of cleaning up the blasted material from the boom hole utilizing S&S and Long Airdox Model 482 scoops. The clean up of the blasted material continued without incident throughout the evening. The four miners stopped for lunch between 7:00 p.m. and 7:30 p.m., after completing clean-up of the blasted roof material. After lunch, Byron Martin, roof bolting machine operator, and Burl Hughes, scoop operator, began installing roof bolts in the unsupported area of the boom hole. Interviews revealed that Hughes was reportedly standing in front of the roof bolting machine holding the drill steel to secure it while the hole was drilled in the unsupported area of the boom hole. Approximately eight roof bolts had been installed by the No. 2 roof bolting machine crew when John Crisp, roof bolting machine operator, brought the No. 1 roof bolting machine to the area to assist in installing roof bolts in the unsupported area.

To avoid traveling around the pillars, the No. 2 roof bolting machine was trammed further into the unsupported area to allow the No. 1 roof bolting machine to pass. The No. 1 roof bolting machine was then trammed through the unsupported area to begin installing roof bolts from the other side (see sketch). Crisp, the No. 1 roof bolting machine operator, began installing roof bolts from right to left facing inby. He had completed the installation of one roof bolt and had just started another when he reportedly observed James Sturgill crawl past him and enter the unsupported area. Sturgill was apparently going to hold the drill steel for the No. 1 bolting machine while Crisp operated the controls.

At approximately 9:15 p.m., a section of the mine roof fell, striking all four men, fatally injuring James Sturgill. Crisp, Martin, and others removed the fallen rock from Sturgill. Benjie Stewart, Mine Emergency Technician, traveled underground and rendered first aid to the victims. Sturgill was removed from the mine and transported by ambulance to the McDowell Appalachian Regional Hospital (MARH) where he was pronounced dead by the Floyd County Coroner, Roger Nelson, at 11:25 p.m. Other injuries included: Byron Martin was struck on the head and was reportedly knocked unconscious momentarily, but did not seek formal medical attention. Crisp was struck on the left elbow, but did not seek medical attention. Hughes was struck on the left hand and back of the head and was subsequently transported to MARH where he was treated and released.

INVESTIGATION


At approximately 10:40 p.m. on March 11, 1999, Clarence Ritchie, Federal Coal Mine Inspector of MSHA's Hindman, Kentucky Field Office, was notified at home by Jody Samons, President of J & A Coal Corporation, that a serious accident had occurred which he believed may result in a fatality. Dave Jones, Supervisor of MSHA's Hindman, Kentucky Field Office, and Ritchie were immediately dispatched to the mine site and arrived at 12:00 a.m. At the mine, they met Samons and issued a 103-K order to insure the safety of the miners until an investigation could be conducted. William R. Johnson, Federal Coal Mine Inspector and Accident Investigator of MSHA's Harlan, Kentucky Field Office, and Roger D. Dingess, Roof Control Specialist of MSHA's Barbourville, Kentucky Field Office, were assigned and began the investigation at 7:00 a.m. on March 12, 1999. The investigation was conducted jointly with the Kentucky Department of Mines and Minerals (KDMM) with the assistance of mine management. Michael Evanto and William Gray, MSHA Pittsburgh Technical Support, Roof Control Division, provided technical assistance in the investigation. Larry Johnson, MSHA Division of Safety, Arlington, Virginia, assisted district personnel during the underground portion of the investigation and interviews. Brian Dougherty, Attorney, Office of the Associate Regional Solicitor, U.S. Department of Labor, Nashville, Tennessee, also assisted in the interviews conducted in conjunction with the investigation.

On March 15, 1999, interviews were conducted with three members of mine management and five miners to ascertain information relevant to the accident and the mine. These interviews were held at the MSHA Hindman Field Office. None of those persons interviewed requested to make confidential statements.

PHYSICAL FACTORS


The investigation revealed the following factors relevant to the occurrence:

1. The normal mining height in this area is approximately 35 inches.

2. The immediate roof in the area of the accident consisted of gray, thinly laminated shale and extended to a height of approximately five feet above the Elkhorn #3 coal seam. The main roof is composed of sandy shale approximately ten feet in thickness. Thirty-six inch resin roof bolts were being installed in the blasted area.

3. The entries and crosscuts were typically 20 feet wide and advanced on 60 foot centers.

4. The No. 6 entry had been blasted out to a height of approximately seven feet for a distance of approximately 38 feet to allow for the future installation of a section loading point.

5. The two roof bolting machines being used at the time of the accident were both Roof Ranger One models manufactured by J. H. Fletcher and Co. The serial numbers were 90066 and 90064. Both roof bolting machines were equipped with safety-arm-type ATRS systems. The dual safety-arm ATRS system used two, 6 inch wide by 42 inch long pads as the roof contact device. The maximum extended height of the roof bolting machines' ATRS was measured at 54 inches.

6. An extension or other means was not provided on either roof bolting machine to enable the ATRS to contact the roof.

7. The roof fall material consisted of a large slab of the thinly laminated shale varying in thickness from 0 to 5 inches.

8. The area of the charging station and shop located one crosscut adjacent and outby the accident scene was also blasted to a height of seven feet. Additionally, nine other locations were found outby the working section which had been blasted to a height higher than the maximum extension of the ATRS systems on both of the roof bolting machines used to install roof bolts.

DISCUSSION


Examination of records indicated that the victim had received all required training in accordance with Part 48, Title 30 CFR. Sturgill, who had previously received annual refresher training on April 5, 1998, received Newly Employed, Experienced Miner training on March 11, 1999, and roof bolting machine operator task training March 10, 1999, but had not been trained in the roof control plan revision dated November 2, 1998, or in clean-up and support procedures to be followed while rehabilitating the boom hole area.

On November 2, 1998, a revision to the approved Roof Control Plan was approved by Joseph W. Pavlovich, MSHA's District 7 Manager which required that when the mining height has been increased by the mining process, the ATRS must be set firmly against the mine roof. This revision additionally states "when circumstances prevent the use of the ATRS system, where the mine height has been increased by the mining process to facilitate areas such as, but not limited to, overcasts, track entries, etc., the use of temporary supports in lieu of the ATRS system is not permitted."

The investigation revealed that prior to the fatal accident, ten locations in the mine had been blasted for loading points and/or battery charging stations. Nine of the ten locations were blasted higher than the ATRS systems on both roof bolting machines would reach, indicating an unsafe practice at this mine since both roof bolting machines were in use for all ten of these locations. The operator of the No. 1 roof bolting machine at the accident scene was discovered to be in the process of installing roof bolts from right to left rather than the approved method of left to right, which placed the machine operator at greater risk due to his exposure to unsupported roof.

Physical evidence also revealed that the roof bolting machine operators were not installing roof bolts on the correct centers as stipulated in the approved Roof Control Plan which requires that roof bolts be installed on four-foot by four-foot centers.

The investigation further revealed that the No. 1 roof bolting machine had been trammed through the subject area of unsupported roof before beginning roof bolting. A concurrent inspection conducted separately from the accident investigation, disclosed that three miners had, prior to the accident, worked and traveled under unsupported roof while loading the blasted material from the loading point being created where the fatal accident occurred.

SUMMARY AND CONCLUSION


The investigators determined that the accident occurred as a result of mine management's failure to adequately supervise and direct the work force, to prevent miners from traveling under unsupported roof. A practice of traveling and working under unsupported roof was found to exist which directly contributed to the death of the 35-year-old miner and injuries to three co- workers. The investigation further revealed that three officials of the mine operator and three roof bolting machine operators were not instructed in procedures of the revised roof control plan addressing the use of ATRS's in areas where the mining height has been increased as a part of the mining process which indirectly contributed to the accident. The failure of the mine operator to instruct all persons affected by the revision, in effect, withheld valuable knowledge from the victims, about approved types and procedures of proper roof support to be utilized. Additionally, it was determined that employees who had been assigned to rehabilitate the area, had not been instructed in the clean-up and support procedures to be followed while rehabilitating the boom hole area.

ENFORCEMENT ACTIONS


1. 103-K Order, No. 7480893, was issued to assure the safety of the miners until the investigation could be completed.

2. A 104(d)(1) Order, No. 7453149, for violation of Title 30, Part 75 .202(b) was issued stating, in part, that "four employees were in the process of installing roof bolts in a boom hole or section belt dumping point 60 feet outby survey station No. 552. All of the noted employees were working and traveling under unsupported roof. The investigation revealed that miners traveled and worked under unsupported roof on previous occasions. The practice of traveling under unsupported roof directly contributed to the death of a 35 year old roof bolting machine helper."

3. A 104-D-1 Order, No. 7458050, for violation of Title 30, Part 75.220(a)(1) was issued stating, in part, that the operator was not following the approved roof control plan in that: "(1) The roof control plan, approved on December 1, 1997, requires a maximum of four foot by four foot centers for roof bolt spacing. Nine roof bolts had been installed on five foot centers in the boom hole located 60 feet outby survey station No. 552 on the MMU 001 section in the No. 6 belt entry. This cavity had been previously blasted to allow room for a section belt dumping point; (2) the approved roof control plan supplement, dated November 2, 1998, was not being followed. The ATRS systems on the two Fletcher Model Roof Ranger One roof bolting machines would not reach firmly against the mine roof during the installation of permanent roof supports. The roof bolting machines were being used to install roof bolts in the boom hole located as described above. This supplement requires that when circumstances prevent the use of the ATRS system, where the mine height has been increased by the mining process to facilitate areas such as, but not limited to, overcasts, track entries, etc., the use of temporary supports in lieu of the ATRS system is not permitted. The mine roof inside the boom hole was increased to seven feet in height and the ATRS systems on both roof bolting machines extended to a maximum of 54 inches; (3) The roof bolting machine operators were not installing roof bolts in the proper sequence as required in the approved roof control plan. The operator of the No. 1 roof bolting machine was installing roof bolts from right to left which placed the machine operator under unsupported roof. The operator of the No. 2 roof bolting machine had installed roof bolts in the following sequence, Nos. 1, 2, 3, and 7 prior to installing Nos. 4, 5, 6, and 11. The installation was completed without the ATRS system in place. This sequence of installation also placed the No. 2 roof bolting machine operator under unsupported roof. The failure of the mine operator to comply with the provisions of the approved roof control plan directly contributed to the death of a 35 year old roof bolting machine helper."

4. A 104(d)(1) Order, No. 7453151, for violation of Title 30, Part 75.220(d) was issued which stated, in part, that "there were three officials of the mine operation including the president of the company, and three roof bolting machine operators who were not instructed in the requirements of a revision dated November 2, 1998 to the Approved Roof Control plan prior to implementation. This revision requires that where the mining height has been increased by the mining process the ATRS must be firmly set against the mine roof while the unsupported area is being bolted. The plan does not permit the use of temporary supports in lieu of the ATRS system. Note; the three officials noted above conducted the training at this mine. The failure of the mine operator to instruct all persons affected by the revision contributed to the death of a 35 year old roof bolting machine helper."

5. A 104(d)(1) Order, No. 7458066, for a violation of Title 30, Part 75.212(a)(2) was issued stating, in part, that "persons assigned to perform rehabilitation work in the area of the boom hole, 60 feet outby survey station No. 552, were not instructed in the clean-up and support procedures."

Respectfully submitted:

William R. Johnson
Coal Mine Safety and Health Inspector

Roger Dingess
Coal Mine Safety and Health Inspector

Approved by:

John M. Pyles
Assistant District Manager for Enforcement
CMS&H, District 7

Joseph W. Pavlovich
District Manager
CMS&H, District 7

Related Fatal Alert Bulletin:
FAB99C08


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