DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
Report of Investigation
May 18, 2000
(Surface Coal Mine)
Fatal Natural Gas Ignition
Dial's Branch (I.d. No. 15-18193)
Addington Mining, Inc
Pinsonfork, Pike County, Kentucky
Coal Mine Safety and Health Inspector
Kenneth A. Murray
Supervisory Coal Mine Safety and Health Inspector
Originating Office - Mine Safety and Health Administration
4159 North Mayo Trail, Pikeville, Kentucky 41501
Carl E. Boone, II, District Manager
On May 17, 2000, at approximately 9:00 p.m., front-end loader operator, Michael E. Moore (victim), and rock truck drivers, Adam Gross and Randall Clark, began removing rock binder from between the No. 3 and No. 4 coal splits in the Fire Clay coal pit. The victim was loading the rock binder with a Model 992D Caterpillar front-end loader into Model 777 Caterpillar rock trucks. A 20-inch diameter high pressure natural gas transmission line, which was relocated at the company's request in October 1999, had been installed parallel to the pit in this area. Work progressed routinely until 12:00 midnight, at which time loading operations ceased while the crew ate lunch. The work of removing the rock binder in the Fire Clay pit resumed at 12:30 a.m., and continued without incident until approximately 12:45 a.m. At that time, the victim was in the process of loading the third bucket load of rock binder into the truck driven by Gross when the bucket of the front-end loader struck and penetrated the natural gas transmission line. The escaping gas was ignited, resulting in a fire which engulfed the loader and the rock truck. Gross, who was not injured, drove his truck through the flames to a safe location. The victim, whose clothes were completely engulfed in flames, jumped from the burning loader and ran across the pit to an area approximately 150 feet from the accident site. First aid was rendered to the victim by several employees, and he was placed on a stretcher. He was then transported in the bed of a pick-up truck to a safe location away from the intense heat being generated from the burning loader and gas line. He was transported by ambulance to the Appalachian Regional Hospital in South Williamson, Kentucky and then air-lifted to the Cabel Huntington Hospital in Huntington, West Virginia. The victim died on May 19, 2000, as a result of the injuries.
The accident investigation team determined the 20-inch diameter natural gas transmission line was ruptured by the loader bucket causing a natural gas ignition which resulted in a fire. The practice of working within the right-of-way of the gas line was being conducted on a regular basis during the previous 3-week period. However, the on-shift examination of the area did not identify the hazard of working in close proximity to the gas line. Warning signs were not posted to depict the exact location of the line and no illumination, other than the equipment lights, was provided in the area. An accurate and up-to-date map of the mine was not being maintained to show the new location of the gas line.
Addington Mining, Inc., Dial's Branch surface mine, is located off Kentucky Route 1056, approximately four miles from the unincorporated town of Pinsonfork in Pike County, Kentucky (see appendix). Addington Mining, Inc. is a wholly owned subsidiary of AEI Holding Co., Inc., located in Ashland, Kentucky.
Dial's Branch surface mine was placed in active status on September 24, 1999. Coal is produced in one active pit using highwall drills, bulldozers, front-end loaders, and rock trucks. The company uses several methods of mining, one of which is mountain-top removal with cross-valley fills. The area where the accident occurred is referred to as the Fire Clay Coal Pit, which consists of five splits of coal. At the time of the accident, the rock binder was being removed from between the No. 3 and No. 4 splits.
The mine operates five days per week employing 31 persons on the day shift, and 19 persons on the night shift. Each shift is ten hours in duration. Maintenance is conducted between shifts and on-shift as needed and/or scheduled. The mine produces an average of 3600 tons of coal daily. The last regular safety and health inspection (AAA) of the mine was completed on February 16, 2000.
DESCRIPTION OF ACCIDENT
On May 17, 2000, at approximately 5:45 p.m., loader operator, Michael E. Moore (victim), and rock truck drivers, Adam Gross and Randall Clark, arrived at the mine site for the 6:00 p.m. to 4:00 a.m. shift. At approximately 6:00 p.m., Paul Hamilton, production foreman, instructed the 3-man crew to remove rock binder from the coal seams in three different areas of the operation, utilizing a Model 992D Caterpillar front-end loader and two Model 777 Caterpillar rock trucks. The first pit area was adjacent to the mine office, where they worked from approximately 6:05 p.m. to approximately 8:00 p.m. They then traveled to the Mud Lick coal pit area, where they worked from approximately 8:05 p.m. to approximately 8:55 p.m. Upon completing the work in these two areas, they traveled to the Fire Clay coal pit, arriving shortly after dark at approximately 9:00 p.m.
The Fire Clay pit area consists of 5 splits of coal, ranging in thickness from approximately 8 inches to 32 inches. Each coal split is separated by a rock binder, ranging in thickness from approximately 8 inches to 12 inches. A 20-inch diameter natural gas transmission line is installed parallel to the pit in this area. The crew had been instructed to remove the rock binder from between the No. 3 and No. 4 coal splits and haul it to the hollow fill. Work progressed routinely until 12:00 midnight, at which time loading operations ceased while the crew ate lunch.
Hamilton stated he was located approximately 100 yards from the Fire Clay pit area in his pick-up truck where he could observe the entire operation. His last visit to the pit area was between 8:30 p.m. and 9:00 p.m., when he conducted the on-shift examination. Although Hamilton did not identify any hazards during the examination, he stated that at approximately 12:30 a.m., he attempted, without success, to contact the victim via CB radio from his truck to caution him about working in close relationship to the gas line.
The work of removing the rock binder in the Fire Clay pit resumed at 12:30 a.m. Following the lunch break, Gross hauled two loads of rock to the hollow fill, returned to the loading area, and positioned his truck adjacent to the loader in preparation for the next load. Clark had also hauled two loads of rock to the hollow fill, returned to the coal pit, and positioned his rock truck in an area approximately 160 feet from the loading area, where he would wait for his turn to be loaded. Gross stated that at approximately 12:45 a.m., as the victim was in the process of loading his truck, he saw dirt and rocks blowing into the air and heard a loud noise. Within seconds fire had engulfed the loader and his truck. Gross immediately drove his truck through the flames to a safe location. Clark was facing the front-end loader and also witnessed the natural gas ignition. He stated that the flame from the initial flash was so bright, he was temporarily blinded in one eye. Gross stated that he observed the victim, whose clothes were completely on fire, run across the pit to an area approximately 150 feet from the accident site. Gross dismounted his truck and ran to the victim where he assisted in rendering first aid. The victim was placed on a stretcher and transported in the bed of Hamilton's pick-up truck to a safe location away from the intense heat being generated from the burning loader and gas line. The foreman contacted 911, and Appalachian First Response ambulance service was dispatched to the scene. The victim was transported to the Appalachian Regional Hospital in South Williamson, Kentucky and shortly thereafter he was air-lifted to the Cabel Huntington Hospital in Huntington, West Virginia, where he died on May 19, 2000, as a result of the injuries.
Clark was also transported by Appalachian First Response ambulance to the Appalachian Regional Hospital, where he was treated for shock and released.
INVESTIGATION OF THE ACCIDENT
James Rowe, coal foreman, called Danny Harmon, MSHA supervisor, and reported the accident at approximately 4:00 a.m., on May 18, 2000. At the time of the initial notification, it was known that life threatening injuries had occurred. Accident investigators Jimmy Brown and Kenneth Murray were dispatched to the scene, arriving at approximately 5:30 a.m. Representatives from the Kentucky Department of Mines and Minerals (KDMM), Addington Mining Inc., Columbia Gas and Transmission and the .Belfry Volunteer Fire Department were present at the accident scene. A 103(k) Order was issued by MSHA to assure the safety of all persons until an investigation could be completed and the Fire Clay coal pit area determined to be safe. A 107(a) Order was discussed with Blaine Owens, Superintendent, concerning the work practice of mining in close proximity to the natural gas transmission line.
The immediate area of the accident was photographed, sketched, and measured to the extent possible. The physical investigation of the accident was hindered by the smoke and fire from the loader and gas line. With the fire extinguished the investigation proceeded with the aid of the KDMM and Columbia Gas personnel.
Interviews were conducted on May 19, 2000 and May 22, 2000 at the KDMM office located at Pikeville, Kentucky. Twelve persons deemed to have relevant information concerning the accident were interviewed jointly by MSHA and KDMM. The sessions were recorded on audio tape with the consent of the interviewees, and a written transcript was later produced for the accident investigation file.
The 103(k) Order was terminated on May 26, 2000, when the barrier that separates the coal pit area from the gas line right-of-way was completed. The 107(a) Order was terminated on May 31, 2000, when all employees were instructed of the "Best Practices" that were implemented at the operation concerning working in the vicinity of gas lines.
The investigation revealed the following factors relevant to the occurrence of the accident:
1. Adam Gross and Randall Clark, rock truck drivers, were eyewitnesses to the accident.
2. The weather was dry on this date with no abnormally foggy conditions.
3. The training records were reviewed and no deficiencies were found.
4. According to the blasting records, blasting began in this area on April 14, 2000, and concluded on April 26, 2000.
5. The Fire Clay pit area was being used as a spare pit and mining was conducted on an intermittent basis. Mining in close proximity to the gas line had begun three weeks prior and continued until the time of the accident. When the Nos. 1, 2, and 3 coal splits and their associated rock binders were removed, mining was conducted directly over the gas line for a distance of approximately 140 yards.
6. The Fire Clay pit area consists of 5 splits of coal, each separated by rock binders. Prior to the day of the accident, the Nos. 1, 2, and 3 splits and their associated binders had been removed. At the time of the accident, the crew was removing the rock binder between the Nos. 3 and 4 coal splits.
7. The characteristics of the Fire Clay coal pit strata are as follows:
No. 1 split measures 8 inches in thickness8. The transmission line had been relocated at a point around the perimeter of their permit boundary by Columbia Gas and Transmission at the expense of the coal company in October 1999, to access more coal in the pit area. The new gas line was put into service on October 10, 1999.
No. 2 split is 8 inches below No. 1 and measures 14 inches in thickness
No. 3 split is 12 inches below No. 2 and measures 30 inches in thickness
No. 4 split is 10 inches below No. 3 and measures 32 inches in thickness
No. 5 split is 12 inches below No. 4 and measures 30 inches in thickness
9. The pipeline extended throughout the mine property and was visible due to the freshly planted grass of the right-of-way. White plastic markers were placed at several locations to identify the location of the gas line. The markers were installed in such a manner that at least two markers could be seen from any location along the gas line. The normal permanent right-of-way for operation and maintenance of the gas line is 50 feet, 25 feet to the left and right of the center line of the pipe. The pipeline may be located anywhere within the 50-foot right-of-way. An additional 25 feet of easement is maintained during the construction and installation of the pipeline. Once the construction is completed, the 25 feet reverts back to the property owner.
10. The 20-inch diameter gas transmission line had a yield-strength rating of 42,000 PSI and had an inside wall thickness of 0.25 inch. The maximum allowable operating pressure in the gas line was 374 PSI. The normal operating pressure on the line ranged from 250 to 320 PSI. At the time of the accident, there was approximately 275 PSI on the pipeline. The pipeline classifications range from Class 1 to Class 4, depending on the population and number of dwellings in relationship to the line. The pipeline in the affected area is Class 1, which is in an unpopulated and undeveloped area.
11. The immediate supervisor of the rock loading crew, Paul Hamilton, had been in the Fire Clay pit area on three separate occasions on May 17, prior to the accident :
4:00 p.m. to 4:30 p.m. to discuss mining plans with Superintendent, Blaine Owens.Hamilton knew the gas line was installed parallel to the pit area and was aware of the hazard associated with working in close proximity to the line. However, corrective action was not taken to ensure that the mining operations were conducted a safe distance from the gas line.
5:00 p.m. to 5:30 p.m. to check on the conditions of the pit area.
8:30 p.m. to 9:00 p.m. to conduct the on-shift examination.
12. Work instructions were given to the rock loading crew by Paul Hamilton, production foreman, at the beginning of the shift at approximately 6:00 p.m., as follows:
6:05 p.m. to 8:00 p.m., they removed rock binder at the pit area adjacent to the mine office.13. The crew arrived at the Fire Clay pit area shortly after dark at approximately 9:00 p.m. The only means of illumination in the pit area was from the headlights of the mobile equipment being operated to remove the rock binder.
8:05 p.m. to 8:55 p.m., they removed rock binder at the Mud Lick coal pit area.
9:00 p.m. till the time of the accident, they were removing rock binder at the Fire Clay coal pit area.
14. When mining operations in this area removed the grass and tree line from the right-of-way, the exact location of the gas line could not be determined. Numerous trees and spoil material were found lying in the right of way after the accident. Additional warning signs or other warning devices depicting the location were not installed.
15. Scott Sturgill, coal foreman, stated that the coal company removes overburden to the outcrop of the coal seam. The investigation revealed that the pipeline was buried within the coal seam of the Fire Clay Pit area.
16. An accurate and up-to-date mine map was not being maintained to depict the location of the line after it was relocated in October 1999. The current map posted at the mine office and the copies provided to each foreman indicated the original location of the gas line.
17. The accident occurred at 12:45 a.m., on May 18, but was not reported to MSHA until 4:00 a.m., when a KDMM Inspector informed the company that MSHA should be notified. The Operator had been cited previously for violations of 30 CFR Part 50 concerning immediate notification of accidents to MSHA. The Department of Surface Mining Reclamation and Enforcement (DSMRE) was also not immediately notified of the accident, as required by their regulations. A citation was issued by DSMRE for violating the reporting requirement.
18. The fire was being controlled by the Blackberry and Belfry Volunteer Fire Departments and was extinguished at approximately 8:30 a.m.
19. An investigation was conducted by Bennie Andrews, State Liaison, from the U. S. Department of Transportation, Office of Pipeline Safety. The investigation revealed no violations of 49 CFR, relative to the installation, maintenance and record keeping requirements of the Columbia Gas and Transmission pipeline.
The accident occurred when the 20-inch diameter natural gas transmission line was ruptured with the bucket of the front-end loader being operated, resulting in a natural gas ignition and fire. The accident investigation team determined management had not taken proper safety precautions to prevent such an occurrence. Adequate on-shift examinations were not conducted in an area where a known hazard existed to ensure mining operations were not conducted in close proximity to the gas line. Warning signs or other devices were not in place to depict the exact location of this line in relationship to the work area. Additional illumination was not provided in this area where it was evident work was being performed in close proximity to this line. The mine map available to all management personnel and posted at the mine office did not depict the gas line in its present location.
1. 103(k) Order No. 7373521 was issued to assure the safety of all persons until the investigation could be conducted.
2. 107(a) Imminent Danger Order No. 7373603 was issued as a result of the practice of working within the right-of-way of the natural gas transmission line. The location of the gas line was known by management and work had been conducted on a regular basis during the previous 3-week period. The order was determined to be a contributing factor to the accident.
3. 104(d)(1) Citation No. 7373601 was issued for a violation of 30 CFR 77.1713(a). The examination of the Fire Clay Coal Pit area did not reveal the hazard associated with working in close proximity to the gas line. Management was aware of the location of the gas line, but failed to take corrective action to ensure that the front-end loader was operated a safe distance from it. The citation was determined to be a contributing factor to the accident.
4. 104(d)(1) Order No. 7373602 was issued for a violation of 30 CFR 77.207. Sufficient illumination was not provided at the Fire Clay Coal Pit area to reveal the location of the natural gas transmission line. The order was determined to be a contributing factor to the accident.
5. 104(d)(1) Order No. 7367653 was issued for a violation of 30 CFR 77.1600(c). The natural gas transmission line was not provided with warning signs or other warning devices to depict the exact location of the line. The order was determined to be a contributing factor to the accident.
6. 104(a) Citation No. 7367652 was issued for a violation of 30 CFR 77.1200. An accurate and up-to-date map was not provided to depict the location of the natural gas transmission line. The citation was determined to be a contributing factor to the accident.
7. 104(a) Citation No. 7367651 was issued for a violation of 30 CFR 50.10. The accident occurred at 12:45 a.m., but was not reported to MSHA until 4:00 a.m.
Related Fatal Alert Bulletin and Accident & Injury Report(s):
FAB00C13 A & I Reports - (File is PDF)
Drawing of Accident Site
Photo of Loader
Photo of Bucket and gas line
List of Persons Participating in the Investigation
Addington Mining Inc. Officials
Blaine Owens ............... Production Foreman/SuptColumbia Gas and Transmission
Caleb Hampton ............... Trainer
Paul Hamilton ............... Production Foreman
Scott Sturgill ............... Coal Foreman
Maverick Bentley ............... Operations ManagerKentucky Department of Mines and Minerals
James Poling ............... Project Manager
Tracy Stumbo ............... Chief Accident InvestigatorMine Safety and Health Administration
Greg Goins ............... Accident Investigator
Raymond Slone ............... Accident Investigator
Stephen Cole ............... Mechanical Engineer, Technical Support BranchList of Persons Interviewed
Jimmy Brown ............... Coal Mine Inspector
Kenneth A. Murray ............... Supv. Coal Mine Inspector
John South ............... Supv. Special Investigator
Harold Thornsbury ............... Training Specialist
Addington Mining Inc.
Blaine Owens ............... Production Foreman/Supt.Columbia Gas and Transmission
Paul Hamilton ............... Production Foreman
James Rowe ............... Coal Foreman
Scott Sturgill ............... Coal Foreman
Adam Gross ............... Truck Driver
Randall Clark ............... Truck Driver
Ricky Jones ............... Dozer Operator
Kevin Adams ............... Loader Operator
Floyd Blackburn ............... Loader Operator
Charles Barber ............... Loader Operator
Maverick Bentley ............... Operations Manager
James Poling ............... Project Manager