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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 3

ACCIDENT INVESTIGATION REPORT
(Underground Coal Mine)

Fatal Fall of Material Accident


Powhatan 4 Mine (I. D. No. 33-01157)
Quarto Mining Company
Clarington, Monroe County, Ohio


September 24, 1999

by

Chris A. Weaver
Mining Engineer (Ventilation)

William L. Sperry
Coal Mine Safety and Health Inspector (Electrical)

Kenneth W. Tenney
Coal Mine Safety & Health Inspector

Stanley J. Michalek, P.E.
Civil Engineer


Originating Office - Mine Safety and Health Administration
5012 Mountaineer Mall, Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager

GENERAL INFORMATION

In 1971, Quarto Mining Company opened the Powhatan 4 Mine, I.D. 33-01157, into the Pittsburgh #8 coal seam at a location near Clarington, Monroe County, Ohio. Consolidation Coal Company purchased the company in 1987 and has operated the mine since that time. However, the mine ceased coal production on May 9, 1999, and recovery work in preparation for mine closure has been ongoing since that time. By September 24, 1999, at the time of the accident, employment consisted of 17 underground and 19 surface workers. Recovery of equipment and other mining materials was being conducted on the day shift, five days per week. Examinations were being conducted three shifts per day, five days per week.

The mine is accessed by a dual compartment slope (containing a conveyor belt and a track compartment), five intake shafts, and four return shafts. Ventilation is provided by four main mine fans exhausting 802,233 cubic feet of air per minute. During the previous quarter, the mine liberated 806,680 cubic feet of methane every 24 hours. The immediate mine roof consists of 0 to 12 inches of shale below a 0 to 12-inch-thick coal rider seam. Approximately four feet of soft gray shale is present between the coal rider seam and the main sandstone roof.

The roof control plan in effect at the time of the accident was approved by the Mine Safety and Health Administration on April 25, 1997.

The principal officers for the Powhatan 4 Mine at the time of the accident were:

Peter Bieniek......................................................Assistant Superintendent
Michael E. Blevins.............................................Manager of Safety

An MSHA Safety and Health Inspection (AAA) was completed on June 30, 1999, and another was ongoing at the time of the accident. The Non-Fatal Days Lost (NFDL) incident rate during the previous quarter was 7.52 for underground mines nationwide and 0.00 for this mine.


DESCRIPTION OF ACCIDENT

On Friday, September 24, 1999, the crew assigned to recover equipment and materials from underground areas of the mine conducted a routine planning discussion for the daily work activities prior to entering the mine. Their duties on this day included the continuing recovery of a slurry pipeline which had been an ongoing project for this crew since September 13, 1999. The 10-inch-diameter (nominal), high impact PVC pipeline had been used to pump coal waste from the preparation plant into worked-out areas of the mine. The recovery crew consisted of a foreman, Allan Pruitt, and five workers: William E. Florence, Jr. (victim), Gerald Eble (victim),Harold Wayne Peters (injured), Anthony Patch (injured), and Jim Vogler. Also, Ted Hunt and Rich Boyd, Foremen, were assigned to making required examinations and pumping water in various parts of the mine. No other workers were assigned to underground activities on this shift.

The recovery crew entered the mine at approximately 8:00 a.m. They first proceeded to an area where they loaded pipe that had been previously separated and pulled to the track entry. Once this task was completed, the crew moved to the 189 passway track entry and began to recover pipe which was still suspended from the mine roof. Recovery work at this location required the pipe to be removed from the suspension chains, pulled apart, and loaded onto the supply cars. The pipe was suspended by brackets which were bolted to the mine roof. Each end of a 5/16-inch chain was attached to a bracket and looped beneath the pipe. Two bracket suspension assemblies were usually installed per pipe length. The recovery process began by removing a retaining spline from the coupler joint at the fixed end of the pipe. The chain nearest the free end of the pipe was then cut with bolt cutters. Normally, each side of a link was required to be cut to sever the chain. Next, a wire cable was attached to the end of the pipe and pulled with the locomotive to separate the section of pipe, dropping it onto a supply car. Loaded supply cars of pipe were stored and empty supply cars were obtained as the recovery proceeded.

Recovery of the pipe continued, without incident, to the block between crosscuts 181 and 182 of the passway track entry, where the work area was covered by a canopy measuring approximately 50 feet in length. The canopy was constructed of 60-lb rails and wood planks beneath the site of an old roof fall. The canopy was supported by pin rails, also constructed of 60-lb rails, into both ribs. Cribs and posts were installed between the top of the canopy and the mine roof. The chain and bracket assemblies for suspending the pipe extended through the canopy to the main mine roof, holding the pipe tightly against the bottom of the canopy.

As the recovery work neared the outby end of the canopy, the crew needed one more joint of pipe to fill their last supply car of the shift. At this time, Vogler, who was operating the trolley locomotive, was parked near crosscut 182, just inby the canopy. He had been joined by Boyd who had been conducting examinations elsewhere in the mine. The supply car was attached to the outby end of the locomotive and extended beneath the canopy. Florence and Eble were removing the chain from the pipe. However, the pipe was pressed so tightly against the canopy that they needed to rotate the chain with a screwdriver to reach the link with the bolt cutters. As the chain at the inby end of the pipe joint was being cut, Patch and Peters, who had been separating and loading pipe onto the supply car, began walking outby so that the supply car could be positioned for loading. Pruitt was at the next pipe coupling attempting to remove the retaining spline, placing him just outby the canopy. Vogler was signaled to advance the supply car while Florence and Eble moved to the next pipe support chain, which was also located beneath the canopy, approximately ten feet from its outby end. As Eble positioned the bolt cutters on the chain, the entire canopy suddenly collapsed.

Patch had just reached the outby end of the canopy when he was hit by falling material and knocked to the mine floor. Peters, who was walking behind Patch, was trapped under the fallen material. Pruitt was also hit by debris which rolled out from the collapse, but did not sustain injuries which required treatment. Patch could hear Peters calling for help, but received no response from Florence or Eble. Disoriented by the dust generated by the force of the falling material, Patch experienced difficulty locating Peters. As the dust cleared, Patch found Peters and immediately began digging to free him. Peters was experiencing difficulty in breathing. Realizing he could not lift the rails and material by hand, Patch requested assistance and a lifting jack. Pruitt, Vogler, and Boyd immediately provided recovery assistance. Loose, deteriorated roof rock, along with rail and wood planks, had to be removed to reach Peters, Florence, and Eble. The jack from the locomotive was used to lift pieces of rail which extended beneath the debris. Peters was uncovered promptly and appeared stable. The four workers then began searching through the debris for Florence and Eble.

Upon notification of the accident, the dispatcher on the surface requested 911 emergency assistance. Gerald Mountain, Safety Supervisor, who was located on the surface, was notified of the accident by the dispatcher at approximately 2:00 p.m. He immediately proceeded to the accident site, arriving just before Florence was located at approximately 2:15 p.m. Florence was checked for vital signs, but none were detected. They then completed uncovering Florence and began digging for Eble. During this time, at approximately 2:30 p.m., Mountain walked back to the main line track entry to call for additional help. Hunt, who had been conducting examinations in the east end of the mine, was traveling west via a track-mounted vehicle when he met Mountain near crosscut 166. Mountain used the mine phone to request assistance from personnel at the preparation plant and then traveled back to the accident site with Hunt. Hunt administered first aid to Peters as the others continued the recovery work. Pete Bieniek, Acting Superintendent, was off the mine property at the time of the accident and arrived at the site after Eble was located. No vital signs were detected from Eble. Both victims were recovered before additional help arrived. Peters was placed on a stretcher and carried to a track-mounted vehicle.

The injured personnel were transported to the surface where Patch and Peters were treated and then sent to local hospitals. Peters was transported to Ohio Valley Hospital at 3:15 p.m. where he was treated and released. Patch was transported to Wetzel County Hospital before being transferred to Bellaire Hospital. Patch was retained overnight for observation. Florence and Eble were transported to the surface via a track-mounted vehicle prior to the arrival of the Monroe County Coroner, Dr. Geoffrey Snyder. Florence and Eble were pronounced deceased upon examination by Dr. Snyder who arrived at the mine at 4:05 p.m.


INVESTIGATION PROCEDURES

During the investigation, MSHA and ODMR cooperated to conduct a joint investigation. Management personnel from Quarto and UMWA representatives of the miners also participated in the investigation. Chris A. Weaver was appointed the lead investigator for MSHA.

The MSHA investigators conducted a pre-investigation conference at the Powhatan 4 Mine on September 24, 1999. During this conference, the format of the investigative procedures was discussed with the representatives of the state, company, and miners. The underground investigation of the accident site also began on September 24, 1999. All existing conditions were evaluated and recorded on maps and notebooks by investigation team members. Photographs, electronic images, and video recordings were also made of the accident site. The investigation also included a review of training records, examination records, and compliance history. A structural evaluation of the failed canopy structure was also conducted. Information from the investigative findings is contained in the "PHYSICAL FACTORS" section.

As part of the investigation, MSHA and ODMR conducted interviews of persons with knowledge of the facts surrounding the accident. Initial interviews of persons present during the accident were conducted on September 27, 1999. Additional interviews were conducted by MSHA with former Quarto employees on November 5, 1999, which provided historical information regarding physical conditions at the accident site.


PHYSICAL FACTORS

The investigation revealed the following factors relevant to the occurrence:
  1. The accident occurred in the area of the mine known as the 189 passway, between crosscuts 181 and 182. This entry is a secondary track haulageway that paralleled the main line track entry way from crosscuts 178 to 189.

  2. The entry width varied from approximately 24.3 feet at crosscut 181 to 22.5 feet at crosscut 182. Reportedly, the entry width was approximately 18 to 19 feet when originally mined in 1977.

  3. The mine is located in the Pittsburgh coal seam. The original entry height was approximately 75 inches. Roof deterioration in the passway entry between crosscuts 181 and 182 resulted in a dome shaped cavity approximately 35 feet long and ranged in height from 6 to 8 feet above the coal seam. Subsequently, a canopy was constructed beneath the cavity (construction date prior to 1986).

  4. The canopy consisted of the following components:

  5. Horizontal pin rail holes were drilled approximately 5 feet apart into the coal pillars on both sides of the entry and approximately 52 inches above the floor.

  6. Pin rails, measuring approximately 80 to 90 inches long and weighing 60 pounds-per-yard, were inserted into the holes in the pillars on both sides of the entry, such that approximately 2 to 3 feet of the rail cantilevered into the entry. These rails were installed upside down (base flange facing up). The original depth of the drilled holes was specified to be 50 inches. However, at the time of this investigation, some rails appeared to be tight in their hole while others appeared loose. In several instances, large gaps were measured (10 to 16 inches) between the rail and the back of the hole.

  7. Running rails, measuring approximately 33 feet long and weighing 60 rounds-per-yard, were placed on the pin rails, parallel to the entry. These rails were placed right-side up (base flange resting on the inverted flange of the pin rails).

  8. Spanning rails, measuring approximately 16 feet long and weighing 60 pounds-per-yard, were then placed on top of the running rails. These rails spanned the track haulageway and were placed right-side up. These rails were placed on approximately 48-inch centers.

  9. Wooden lagging, consisting of planks approximately 2 inches thick by 10 inches wide by 48 inches long, was then placed between the spanning rails. The lagging was supported by the base flange of the spanning rails. This arrangement essentially created a solid canopy above the track haulageway.

  10. Wooden cribs and posts were then placed on the canopy and extended to support the mine roof. The height of the cribs and posts varied depending on the location over the canopy.


  11. The slurry pipeline was installed approximately three years prior to the accident, through the 189 passway on the clearance side of the entry. The pipeline was hung using welded 5/16-inch-diameter chains suspended from steel brackets which were bolted to the mine roof. This suspension extended through the canopy to the main roof at the accident site. At the outby end of the canopy, the pipe was installed directly beneath the pin rails. Farther inby, the pipe was installed beneath the spanning rails, tightly against the canopy to maximize clearance above the track. Labeling on the pipe identified it as "Aquamine High Impact PVC" manufactured by Aquamine, LLC. Weighing 11.25 pounds per foot, the pipe specifications were 10.75 inches in diameter with a wall thickness of 0.511 inches.

  12. Roof and rib deterioration eventually caused debris to build up on the canopy and along the ribs on each side of the track haulageway. This condition caused the spanning rails to sag, which loosened and dislodged the cribs and posts on top of the canopy. Debris along the ribs was such that it contacted the sides of coal haulage cars. On September 2, 1998, both conditions were cited by MSHA during a Safety and Health Inspection. The operator then rebuilt the cribs and removed the debris from the top of the canopy. After the canopy was unloaded, the cribs were intentionally loosened and then re-tightened to remove some of the sag from the spanning rails. However, noticeable deflection (approximately 10 inches) remained at the center of the spanning rails on the outby end of the canopy. A track cleaner was then used to remove the sloughage. Both citations were terminated on September 30, 1998. By May 1999, additional sloughage was evident along the ribs, particularly near the outby end of the canopy on the clearance side (the side nearest the slurry pipeline).

  13. During the investigation, conditions were observed that indicated significant pillar sloughing had occurred since the canopy was installed. In several areas, it appeared that as much as 2 to 3 feet of pin rail has been exposed. Accessible pin rails were measured which extended from 8 to 26 inches into the horizontal holes drilled into the coal ribs.

  14. Loose rock had continued to accumulate on the canopy since it was cleaned off. Most of the rock which fell during the collapse was highly weathered, indicating that it had fallen from the mine roof before the accident.

  15. Witnesses reported hearing a loud "ping" immediately before the canopy collapsed which was perceived as originating from the location of Florence and Eble. This "ping" would be consistent with the sound of the pipe-support chain failing under tension as cutting was initiated. Eble was observed with the bolt cutters in the ready position to cut the last chain at the outby end of the canopy immediately before the failure. A portion of the chain, recovered after the accident, showed no visible signs of overloading.

  16. Debris observed on the mine floor during the investigation indicated that the collapse originated from the corner nearest Eble's location.

  17. After the collapse, pin rails in the rib opposite the pipeline appeared to be unaffected. These pin rails appeared to be level and the running rails were still in place. Pin rails in the pipeline side rib were deflected downward or missing.

  18. A bolt cutting tool was found at the accident scene. Witnesses reported that the cutting tool was moved during rescue operations and that it was initially found at the location of the victims.


CONCLUSION

The accident occurred because of the following factors: The coal ribs supporting the pin rails of the canopy deteriorated over time. This deterioration transferred a portion of the load from the rib to the slurry pipeline, making it a load bearing member and a stabilizing component of the canopy. This transfer of support was undetected by the preshift examiners and the miners involved in the recovery activities. As the pipe support chains were cut during the recovery process, the load was increased on the remaining suspension chain. The severing of the last suspension chain beneath the canopy caused the sudden and immediate collapse of the structure.


ENFORCEMENT ACTION

  1. A 103(k) Order (No. 4869381) was issued to ensure the safety of all persons in the mine until an investigation was completed and all areas and equipment were deemed safe.

  2. A 104(a) Citation (No. 7142392) was issued citing 30 CFR 75.360(b)(1). The preshift examination for hazardous conditions conducted on September 24, 1999, between the hours of 5:00 a.m. to 7:00 a.m., for the 189 passway track area, where persons were scheduled to work or travel during the oncoming shift recovering slurry pipeline, failed to identify existing hazardous conditions in this area. The provided record as to the results of required examinations, identified as "Tracks and Outby Areas", did not indicate any hazardous conditions that existed along the area designated as "Mainline 222 to East Tail".

    Hazardous conditions existed in the Mainline 222 to East Tail area, along the 189 passway track haulage between crosscuts 181 and 182 as follows: The coal rib into which pin rails had been installed to support a canopy structure at this location had sloughed and deteriorated until the load of the canopy structure was transferred to a slurry pipe suspended under the canopy by chains from the mine roof. Failure to detect hazards in this area where severe conditions existed resulted in two workers being fatally injured by the sudden collapse of the canopy, at approximately 2:00 p.m., when they attempted to recover the slurry pipeline at this location.

Respectfully Submitted:

Chris A. Weaver
Mining Engineer (Ventilation)

William L. Sperry
Coal Mine Safety and Health Inspector (Electrical)

Kenneth W. Tenney
Coal Mine Safety & Health Inspector

Stanley J. Michalek, P.E.
Civil Engineer


Approved by:

Timothy J. Thompson
District Manager

Related Fatal Alert Bulletin:
FAB99C27


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