DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE AREA OF UNDERGROUND COAL MINE)
FATAL HANDLING OF MATERIAL ACCIDENT
September 19, 1999
Virginia Pocahontas 1 (44-00246-3KA)
Dixie Railway Services, Inc.
Oakwood, Buchanan County, Virginia
Daniel S. Graybeal
Mine Safety and Health Specialist
Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Ray McKinney, District Manager
Island Creek Coal Company's Virginia Pocahontas 1 mine is located four miles west of Oakwood, Virginia off state route 638. The mine has no production; it was placed in an active, non-producing status on May 19, 1994.
On December 7, 1998, Doucett's Diesel Service, Inc. of Sunset, Louisiana made an offer to purchase from Island Creek Coal Company, two railroad locomotives (No. 1493 and 1496) located on the upper rail yard of the Virginia Pocahontas 1 mine. The purchase was finalized on January 13, 1999. Doucett's Diesel Service, Inc. is owned jointly by Danny Doucett and Steve Plant. Steve Plant also owns Plant Rail Car. Steve Plant contacted Turner Locomotive, a railway vehicle broker, for the sale of the two locomotives. Marty Turner, operator of Turner Locomotive, sold the numbers 1493 and 1496 locomotives to Dixie Engine and Equipment of Cropwell, Alabama. Shortly thereafter Dixie Engine and Equipment changed the company name to Dixie Railway Services, Inc. On August 6, 1999, Railserve of Atlanta, Georgia acquired Dixie Railway Services, Inc.
Dixie Railway Services, Inc. continued to operate under a separate corporate structure as one of six subsidiaries of Railserve. Dave Zuspan, General Director Mechanical, of Dixie Railway Services, Inc. contracted Don Adams of Don's Railway Services, Danville, West Virginia for the purpose of repairing and maintaining the locomotives to a standard acceptable to the Federal Railroad Administration for towing on mainline railroads. The original intent was to have the Norfolk Southern Railway pull the locomotives to a specific destination of sale. Don's Railway Service employees began work on the locomotives on July 20, 1999. They worked on the wheels, railings, steps, etc. on an intermittent basis until September 17, 1999. Meanwhile, Dixie Railway Services, Inc. had contracted delivery of the No. 1493 locomotive to a firm located in Marysville, Ohio. The No. 1493 was to be roadworthy and have full engine power upon delivery on October 4, 1999. This necessitated that work be done on the locomotive's diesel engine.
Two employees of Dixie Railway Services, Inc. were dispatched to the mine site and performed work from September 12 through September 19, 1999. Charles Dan Cottingham, a mechanic for Dixie Railway Services, arrived at the mine site and joined the other two Dixie employees on September 19, 1999.
A safety and health inspection (AAA) had been completed by the Mine Safety and Health Administration at the Virginia Pocahontas 1 Mine on August 13, 1999.
The principal officers for Dixie Railway Services, Inc. at the time of
the accident were:
Kevin Hauch - President
John Frazier - Vice President
Dave Zuspan - General Director Mechanical
Lennie Jester - Director of Safety
DESCRIPTION OF ACCIDENT
On Saturday, September 18, 1999, Charles Dan Cottingham departed Cropwell, Alabama in a one-ton flat bed truck loaded with various locomotive parts and three crates containing eleven locomotive power assemblies. He arrived in Grundy, Virginia and contacted Scott Barrett, mechanic, and Edward Barrett, mechanic helper, who were staying at a local motel. On Sunday, September 19, 1999, at approximately 6:00 a.m., Cottingham and the Barretts arrived at the Virginia Pocahontas 1 mine to continue the engine maintenance work on the No. 1493 locomotive. The workmen commenced unloading the power assemblies from the truck. A second truck containing an auto crane was used to lift the materials from the flat bed truck. Each crate consisted of a wooden top and bottom with no connecting sides. A maximum of four power assemblies were packed in each crate. Each power assembly weighed 625 pounds. The tops of the crates were removed and the power assemblies were lifted from the bottom portion of the crates, one or two assemblies at a time. A metal lifting bracket containing an attachment ring was bolted to the top of each single power assembly for the purpose of attaching a hook or a rope sling for lifting. The individual power assemblies were removed from the bottom portion and laid on the ground until the crate was emptied. The bottom portion of the crate was then placed on the ground and each individual power assembly was lifted and placed back on the bottom portion of the crate. Once four power assemblies had been repositioned on the bottom portion of the crate, the top portion of the crate was installed in order to stabilize the assemblies.
This procedure continued throughout the day until nine power assemblies had been removed from the truck. Scott Barrett stood on the ground at the rear of the driver's side of the flat bed truck and operated the auto crane through the use of a hand held controlling device. Edward Barrett stood on the ground on the driver's side of the flat bed truck and unhooked each power assembly as it was unloaded. Cottingham stood on the flat bed truck and connected the crane hook and the lifting devices to the individual power assemblies.
The top of the third crate had been removed and the ninth power assembly was placed on the ground. Two free standing uncrated power assemblies were left in an unstable position on the truck. The power assembles were twelve inches in diameter at the top end, six inches in diameter at the bottom end, and were 46 inches high. Each power assembly stood vertically on the small end in the bottom portion of the crate. This caused the top heavy power assemblies to be unstable in the uncrated position. The truck bed sloped five degrees downward toward the passenger side of the vehicle, further contributing to the instability of the power assemblies. At approximately 4:45 p.m., Cottingham, standing on the passenger's side of the truck bed, was attempting to make a connection to unload the tenth power assembly. Scott Barrett swung the crane hook and cable over the truck. Cottingham grabbed for the swinging hook and missed. Cottingham lost his balance and began falling backward. Instinctively Cottingham grabbed the two power assemblies. Cottingham and the two unstable power assemblies fell from the bed of the truck to the ground. Cottingham suffered fatal head injuries when struck by one of the power assemblies. Scott and Edward Barrett ran to where Cottingham was lying. Scott Barrett called the victim's name, checked the victim and found no vital signs. Edward Barrett immediately drove about one mile to the nearest telephone to summon emergency medical assistance.
The Grundy Ambulance Service, Inc. received the call. A rescue unit arrived at the site at 4:57 p.m.. James Burke and other rescue squad members checked the victim for vital signs. The victim was unresponsive and attempts to revive him were unsuccessful. The rescue squad members called the Buchanan County Sheriff's Department. Deputy Sheriff Ron Tiller received the call at 5:15 p.m. and immediately drove to the scene. Tiller talked to rescue squad members and took statements from Scott and Edward Barrett. Drema Marshall, of the Buchanan County Sheriff's Department, notified MSHA personnel of the accident at approximately 5:40 p.m. on September 19, 1999. Tiller contacted the Buchanan County Coroner's Office. Tiller was instructed to have the victim transported if there was no evidence of foul play. Finding no evidence of foul play, the victim was transported by the Grundy Ambulance Service, Inc. to Buchanan General Hospital in Grundy, Virginia, where he was pronounced dead at 6:30 p.m. by Dr. Joseph Segen.
INVESTIGATION OF THE ACCIDENT
MSHA's investigation began at approximately 9:00 a.m., on Monday, September 20, 1999. The investigation was conducted jointly by members of teams from the Mine Safety and Health Administration and the Virginia Department of Mines, Minerals and Energy. Photographs, video and relevant measurements were taken by both teams. The investigation teams reconstructed the events of the accident with the assistance of eyewitnesses.
Interviews began at 2:00 p.m., on September 20, 1999. The two eyewitnesses, employees of Dixie Railway Services, Inc., described the events surrounding the accident. Contractual information was provided by officials of Dixie Railway Services, Inc., and Island Creek Coal Company. The Buchanan County Sheriffs' Deputy who investigated the accident, provided post accident information.
On October 7, 1999, William Don Adams, of Don's Railway Service provided additional information about work at the mine site prior to the accident. Adams provided information regarding his companies procedures for safe handling of power assemblies. Members of the Grundy Ambulance Service, Inc. provided information regarding emergency medical assistance administered to the victim at the accident scene. The field portion of the investigation was concluded on October 7, 1999.
PHYSICAL FACTORS INVOLVED
- Scott Barrett and Edward Barrett were eyewitnesses to the
- The weather was clear on the day of the accident. There was no
evidence of slipping hazards on the bed of the Dodge truck. The
victim was standing on the passenger side of the truck bed in an area
16 inches wide and 33 inches long. The truck bed contained equipment
in addition to the un-crated power assemblies.
- A Dodge Ram 3500 flat bed truck having a 10,500 pound load
capacity was used to transport the crates of power assemblies. The
truck bed was eight feet wide and 10 feet, 9 inches long. The bed had
12 inch high wooden side rails which ran the full length of the bed.
At the time of the investigation, the truck bed sloped five degrees
downward toward the passenger side of the vehicle.
- The wooden crates were 30 inches wide, 30 inches long, and 48
inches high. The crates consisted of a top and bottom with no
interconnecting sides. Each power assembly weighed 625 pounds. Each
crate contained up to four power assemblies with a maximum weight of
2600 pounds per crate. A forklift was used to load each crate onto
the truck at the origin of shipping.
- The power assemblies were 12 inches in diameter at the top end,
six inches in diameter at the bottom end, and were 46 inches high.
Each power assembly rested on the small end in a recessed area in the
bottom portion of the crate.
- Workmen removed the top of each crate and the power assemblies
were extracted from the bottom portion one unit at a time. The power
assemblies were recrated at ground level by reversing the process.
- The vertically positioned power assemblies were unstable in the
un-crated position on the sloping truck bed. At the time of the
accident the truck was parked on inclining terrain which caused the
truck bed to slope five degrees downward toward the passenger side of
the vehicle. The remaining cargo was located on the passenger side of
the truck. The sloping bed and cargo location further tilted the
truck bed toward the passenger side. This condition increased the
instability of the power assemblies.
- Statements from employees of Don's Railway Service revealed that
they require power assemblies used by them (Don's Railway Service) be
shipped in a horizontal position. This eliminated the possibility of
falling from an unstable vertical position.
- A nylon sling, six feet long and two inches wide, was being used
to unload the power assemblies. The sling was not long enough to
encircle an entire crate for unloading.
- A 1989 model Ford F-700 truck with an auto crane attachment was
used to unload the power assemblies. The auto crane was rated at 8600
pounds lifting capacity. The three-eighths inch wire rope used on the
auto crane had a safe workload rating of 7700 pounds. The auto crane
had the capability of lifting a complete crate of power assemblies.
- A sling or other lifting device suitable for lifting the entire
crate as one unit was not provided.
- During unloading procedures, the victim lost his balance, grabbed
the unstable power assemblies in an attempt to break his fall. The
victim continued falling to the ground, and suffered fatal head
injuries when struck by one of two falling power assemblies.
- Dr. Joseph Segen, Buchanan County Medical Examiner, listed the
cause of death as a penetrating wound to the skull.
- Deputy Sheriff Ron Tiller saw no evidence of foul play.
The accident occurred when the victim lost his balance and grabbed the unstable power assemblies. The victim fell to the ground and was struck in the head by one of two falling power assemblies. The lack of suitable lifting devices caused the employees to resort to a work procedure which required them to uncrate and handle the power assemblies singularly. This method exposed workmen to hazards induced by the unstable cargo.
A 103(K) order No. 4879286 was issued to ensure the safety of all persons at the mine until an investigation was completed and all areas and equipment were deemed safe.
Daniel S. Graybeal
Mine Safety and Health Specialist
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