MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE OF UNDERGROUND COAL MINE)
FATAL ELECTRICAL ACCIDENT
Day Mining, Inc. ID No. 46-05437
Day Mining, Inc.
Cabin Creek, Kanawha County, West Virginia
February 18, 2000
William H. Uhl, Jr.
Coal Mine Safety and Health Inspector
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Edwin P. Brady, District Manager
On Friday, February 18, 2000, an electrical contractor was fatally injured when he contacted one phase of a 7200 volt AC three phase, energized overhead circuit in a surface high voltage substation. The victim and a company project manager had entered the substation to determine how best to remove a defective transformer and prepare it for transportation to a repair facility. The victim had climbed to the top of the de-energized transformer when the back of his head came in contact with an energized conductor. Neither the project manager nor the electrical contractor were MSHA qualified to perform electrical work. Both entered the fenced area of the surface high voltage station. The victim was performing work in close physical proximity to overhead energized high voltage conductors when he was fatally injured. He was not wearing a hard hat.
The Day Mining, Inc., mine, operated by Day Mining, Inc., is located at Cabin Creek, Kanawha County, West Virginia. The mine entered Active producing status on September 29, 1993, but was idled on May 7, 1999, and placed in BA status (non-producing, men working). Employment at the time of the accident included two miners to patrol and maintain the underground portion of the mine and two miners for surface. The mining method had been room and pillar with coal extraction and haulage utilizing continuous-mining machines, shuttle cars, and belt conveyors. The mine entered the Peerless coal seam through nine drift openings. There are no shaft or slope openings. Presently there are no active MMU's. Methane liberation was not detectable. The average height of the Peerless coal seam is 42 inches.
Mine officials for Day Mining, Inc., are listed below:
Tim Elliott PresidentThe last AAA inspection was completed on January 02, 2000.
404 Northwestern Ave.
Beckley, WV 25801
Jim Connell Secretary
430 Harper Park Dr., Suite A
Beckley, WV 25801
Kevin Whipkey Mine Manager
430 Harper Park Dr., Suite A
Beckley, WV 25801
Richard Busick Project Manager POB 658, North Sand Branch Rd.
Mt. Hope, WV 25880
DESCRIPTION OF THE ACCIDENT
Sometime between January 17 and January 28, 2000, a problem developed with one of the transformers located at the Wet Branch surface high-voltage substation. The problem was causing one of the high-voltage fuses to blow and was later determined to be an internal problem within the 46,000-volt transformer.
Richard Busick, Project Manager for Day Mining, Inc., had determined that the transformer could be repaired. The Wet Branch substation was being utilized to provide power to the clean coal preparation plant for heating purposes and supplying power to the underground mine to operate a dewatering pump.
Steven B. Williams, owner of Williams Electric Co., Inc., was contacted on February 13, 2000, and arrangements were made to have Williams Electric personnel assist American Electric Power (AEP) in making the service change, perform the tree removal, and the necessary preparations needed to remove the defective transformer.
Busick stated that the AEP crew and Williams Electric crew worked together on February 15, 2000, and all necessary changes were made to provide the service needed. Harry Norris, foreman for Williams Electric, had disconnected the 46,000-volt transformer from the system and removed all materials/hardware in preparation for removing the transformer from the site. Busick stated that everything was completed except for removing the insulators and bushings from the top of the transformer and that he remembered specifically asking Mr. Norris to remove them before he came down off the transformer. Norris had replied that he was not sure how to remove them. Busick stated that he then told Norris that he would have them removed before it was transported.
Williams was contacted by Busick on Thursday evening, February 17th, approximately 5:00 p.m., to have Williams Electric Co., Inc. personnel and equipment at the mine site on Tuesday, February 22, 2000, so the transformer could be removed. Busick stated that he and Williams had talked about taking the bushings off the transformer. Williams had stated that he had talked to Harry Norris and they were not sure as to how to remove them. On Friday, February 18, 2000, Busick called Williams between 7 and 8 a.m., to reschedule the removal of the transformer to Monday, February 21, 2000. Busick asked Williams if he had contacted Interstate Transformer about his concerns of removing the insulators/bushings, and Williams said he had not, but he intended to call them that morning. Williams said he had talked to Bill Compton of Compton Transformer and that it would not be that big of a problem to remove them.
Williams met Busick at his office to discuss the details of removing the transformers. During their conversation they talked about the insulators/bushings removal and Williams said there was no problem dealing with them. Williams specifically asked what type of covers would be used to place over the areas when the insulators/bushings were removed. Busick replied that he believed the covers were with the transformer.
Busick and Williams then traveled to the substation. Upon arriving, they stood outside the station and talked about where the crane would need to be located and the general logistics of the transformer removal. Busick said he pointed to some plates lying near the transformer and indicated to Williams that he believed they were the covers he was asking about to cover the openings when the insulators/bushings were removed.
Busick opened the locked gate and stood there as Williams walked into the station and stopped under the cross arms. Busick said they discussed whether or not the gaskets for the bushings were there. As they went by the end of the transformer, Williams pointed and said, "I believe those are the gaskets." Busick said Williams walked on around the end of the transformer as he (Busick) walked toward the gaskets. Busick stated that the next thing he recalled was hearing an arcing sound like a switch being thrown in on high voltage. Busick said, "He (Williams) was already in the air and falling." Williams fell on the back side of the transformer.
Busick stated that he immediately realized that Williams had climbed the back side of the transformer and contacted an energized 7200-volt buss lead. Upon reaching Williams, he determined that Williams was not breathing. He began administering CPR, and after a few compressions, Williams began to breathe and a pulse was found. Busick ran to Williams' truck and called the plant office. A security guard answered the call and was instructed to call 911 because he had a man down in the high-voltage substation and hurt critically. Busick said he went back to Williams and continued administering first-aid. After only a few minutes, Busick called security again and confirmed that help was on the way.
Security had logged the call for help at 11:05 a.m. Two local ambulance services with emergency medical technicians arrived within minutes. Approximately 11:20 a.m., Williams was transported to the Charleston Area Medical Center, where he was pronounced dead at 12:20 p.m.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) was notified of the accident by Richard Busick, Project Manager for Day Mining, Inc., at 12:20 p.m., Friday, February 18, 2000. MSHA personnel arrived at the accident scene at 4:50 p.m. MSHA personnel and representatives of the West Virginia Office of Miners' Health, Safety and Training jointly conducted the preliminary investigation. A 103(k) closure order was issued to ensure the safety of all persons until the investigation could be completed.
Photographs, sketches, audio/video recordings, and an engineering survey of the area of the accident were made. Interviews were conducted in the conference room of the Day Mining, Inc., office building. Statements were taken from persons considered to have knowledge of the facts surrounding the accident. Those persons who took part in the investigation are listed in Appendix A. The on-site portion of the investigation was completed and the 103(k) order terminated on February 19, 2000.
The investigation and examination of records and interviews with management personnel revealed that neither Richard Busick nor the victim, Steven B. Williams, were MSHA-qualified to perform electrical work. Testimony and state-maintained records indicated that both individuals were at one time state certified electricians; however, neither had maintained their certifications by receiving required annual electrical retraining.
1. Approximately three weeks prior to the accident, the main 46,000 to 12,470 volt transformer in the substation developed an internal problem that required it to be taken out of service.
2. On Tuesday, February 15, 2000, preliminary work was performed to facilitate removal of the transformer so that it could be shipped to a repair facility. The 46,000- volt input to the station was de-energized and locked out approximately one fourth mile from the substation. All connections to the transformer were removed. The power company provided temporary 12,470 volt power to the substation until the transformer could be repaired.
3. Williams Electric Co., Inc., was contacted to schedule a crew to remove the transformer from the substation. They were also told that the high-voltage input terminals (bushings) on the transformer would have to be removed to provide the required clearance for transporting.
4. On the morning of the accident, Steve Williams called Jim Bowes, electrical consultant, concerning the removal of the high voltage bushings on the transformer. Bowes explained the two types of bushings, and it was determined that removal of either type would not be too complicated for Williams' crew to accomplish.
5. On the morning of the accident, Richard Busick called Steven Williams to see if the transformer could be readied for shipment on Monday, February 21, 2000. Williams told Busick that he or his Foreman, Harry Norris, would be there with the necessary people and equipment and that he had found out that removing the bushings would not be too complicated.
6. Williams called Busick between 10:00 and 10:30 a.m., on the morning of the accident. He said he was about 10 minutes away and asked if he could stop by Busick's office. Williams arrived, and after discussing the removal of the bushings and some personal items, he asked if Busick had time to go to the substation.
7. Busick and Williams traveled to the substation to see what additional steps were needed to remove the transformer from the substation. Soon after they arrived, both Williams and Busick entered the substation. Williams was working on an evaluation of how to remove the transformer.
8. Busick and Williams discussed whether the cross arm on which the transformer disconnects were mounted would have to be removed. They also found the covers to be installed over the openings left in the top of the transformer once the bushings were removed.
9. Busick was counting the gaskets for the bushing covers when he heard a sizzling noise. Busick looked and saw Williams falling to the ground at the rear of the transformer.
10. Steven Williams , the victim, came in contact with one phase of the 7200 volt ac, three phase overhead buss wires (4160 volts phase to ground) that connected the underground transformer to the circuit breaker.
11. At the time of the accident, the Wet Branch substation provided 12,470 volt ac, three phase power to the preparation plant and also provided 7,200 volts ac, three phase power to the underground mine.
12 All circuits leaving the substation were provided protection by suitable circuit breakers.
13. The 12,470 volt input to the substation was provided with fused disconnects with 20 amp fuses installed. The power company metered power consumption at the secondary side of these fused disconnects. The 12,470 volt input circuit was connected to the overhead buss wires that provided power to two circuit breakers and a 13,200- volt ac three phase transformer that provided power to the underground mine.
14. The underground transformer located inside the Wet Branch substation was manufactured by Sunbelt Transformer. The 12,470-volt input to the transformer was provided with fused disconnects with 140 amp fuses installed. The transformer was labeled 3750 kva, 13,200 delta to 7,200 wye/4160, 5.23% impedance. The transformer primary tap was set in position "D", 12,870 volts. The secondary wye circuit was connected to aluminum buss wires and traveled from the transformer to the circuit breaker that provided protection for the underground power circuit. The neutral circuit was grounded through a suitable grounding resistor that measured 166.2 OHMS.
15. The neutral ground bed was measured to be 2.89 OHMS, and the station ground bed was measured to be 1.42 OHMS. Proper separation was provided between the two ground beds.
16. The de-energized and disconnected 46,000 volt ac, three phase transformer located inside the substation was manufactured by Interstate Transformer. This transformer was labeled as 5,000 kva, 46,000 to 12,470 wye/7,200. This transformer was located adjacent to the buss wires between the 7,200 volt underground transformer and the underground circuit breaker.
17. The de-energized transformer was 130 inches in height. Measurements taken at the top of the transformer revealed a minimum of 30 inches and a maximum of 32 � inches vertical clearance with a minimum of 6 � inches and maximum of 12 � inches of horizontal clearance from the buss wire to the top of the transformer. Diagonal measurements along the top of the transformer revealed a minimum of 31 � inches and a maximum of 33 inches clearance between the top of the transformer and the buss wire.
18. The de-energized and disconnected transformer was still provided with a solid connection from its frame to the station ground bed.
It is the consensus of the investigation team that the accident occurred due to non-qualified persons entering the fenced area of an energized surface high-voltage substation. The victim received a fatal electrical shock while working in close physical proximity to overhead energized high-voltage conductors and came in contact with one phase of a 7,200 volt ac, three phase circuit. A contributing factor is that the victim was not wearing a hard hat.
> ENFORCEMENT ACTIONS
ISSUED TO: Day Mining, Inc.
1. A 103(k) order No. 7187513 was issued to ensure the safety of the miners until the investigation could be completed.
2. A 104 (d)1 citation No. 7187514, Section 77.501 Title 30 CFR, was issued stating, in part, that work was being performed by non-qualified persons inside the energized high-voltage substation.
3. A 104 (a) citation No. 7187515, Section 77.1710(d) Title 30 CFR, was issued stating, in part, that a suitable hard hat was not being worn where overhead hazards existed. The contractor (victim) was permitted to enter the Wet Branch substation without wearing a hard hat where overhead energized conductors were present.
ISSUED TO: Independent Contractor
Williams Electric Company, Inc., of West Virginia.
1. A 104 (a) citation No. 7187516, Section 77.501,Title 30 CFR, was issued stating, in part, that work was being performed by an unqualified person inside the fenced area of the energized Wet Branch high-voltage substation.
2. A 104 (a) citation No. 7187517, Section 77.1710(d) 30 CFR, was issued stating, in part, that a suitable hard hat was not being worn where overhead hazards existed. The victim received a fatal electrical shock when the back of his head contacted an energized high-voltage conductor.
3. A 104 (a) citation No. 7187518, Section 77.500 Title 30 CFR, was issued stating, in part, that work was being performed in close physical proximity to exposed energized high-voltage circuits inside the Wet Branch surface high-voltage substation.
Related Fatal Alert Bulletin:
The following persons were interviewed, provided information, and/or were present during the investigation.
DAY MINING, INC., OFFICIALS
Kevin Whipkey ............... Mine ManagerWEST VIRGINIA OFFICE OF MINER'S HEALTH, SAFETY AND TRAINING
Richard Busick ............... Project Manager
Edward Rose ............... Mine Foreman
James W. Bowes ............... Consultant (Self Employed)
Terry Farley ............... Health And Safety AdministratorMINE SAFETY AND HEALTH ADMINISTRATION
Frank Legg ............... Inspector At Large
Tom Harman ............... Electrical Inspector
Aubrey Castanon ............... Supervisory Mine Safety And Health
Robert L. Phillips ............... Division Of Safety Electrical
Stephen Dubina ............... Technical Support Electrical
Roy Milam ............... Supervisory Electrical Engineer
Terry Willis ............... Coal Mine Safety And Health Inspector/Electrical
Larry E. Cook ............... Electrical Engineer/Accident Investigator
William H. Uhl, Jr. ............... Coal Mine Safety And Health Inspector/ Accident Investigator