DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface of Underground Coal Mine
Fatal Machinery Accident
September 21, 2000
Humphrey No. 7 Mine
Consolidation Coal Company
Maidsville, Monongalia County, West Virginia
I.D., No. 46-01453
Richard G. Jones
Coal Mine Safety and Health Inspector (Contractors)
Chris A. Weaver
Mining Engineer, Ventilation
Daniel L. Stout
Eugene D. Hennen, P.E.
Mine Safety and Health Administration
5012 Mountaineer Mall
Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager
Release Date: January 11, 2001
Fatal Machinery Accident - September 21, 2000
Consolidation Coal Company
Humphrey No. 7 Mine, I.D. No. 46-01453
Consolidation Coal Company
Humphrey No. 7 Mine, I.D. No. 46-01453
Figure 1: This drawing shows the location of equipment and persons near the rotary dump immediately prior to the accident. The accident occurred when the cars were moved from the positions depicted above, toward the loaded side of the dump.
|Figure 2: This image shows the accident site, as viewed from the empty side of the rotary dump. The rotary dump control room is visible on the right side of the image.|
|Figure 3: Closeup of the accident site.|
|Figure 4: This image shows the empty side of the rotary dump facility.
The coal hualge cards shown in the foreground were moved approximately three feet toward the empty side of the rotary dump to free the victim.
On September 21, 2000, at approximately 3:00 p.m., David W. Gamble, a 51-year-old mechanic at Consolidation Coal Company's Humphrey No. 7 Mine, I.D. 46-01453, received fatal injuries when he was crushed between the corner of the surface rotary dump and a coal haulage car on the empty track side of the dump.
Prior to the accident, Gamble had been assigned to troubleshoot a track alignment problem which was caused by a loose rail on the empty side of the rotary dump. After making observations in the affected area, Gamble asked the rotary dump operator, Allen Snyder, to help him separate the coal haulage cars on the empty side of the rotary dump. As Snyder walked to the rotary dump control room, Gamble picked up the cut-off extension bar (a custom hand tool used to separate the coal haulage cars without positioning persons between the cars) and walked toward the empty track side of the rotary dump. Snyder intended to first move the cars a short distance toward the loaded track in order to prevent the last car from becoming disengaged from the haul chain. He then intended to move them back toward the empty track while Gamble separated the cars using the extension bar. When Snyder arrived in the control room, he moved the cars a few feet toward the loaded track, anticipating that Gamble would be preparing to separate the cars with the cut-off extension bar. However, Gamble had just stepped between the rotary dump and the adjacent car on the empty track side. As the cars moved toward the loaded track, Gamble was caught between the corner of the rotary dump and the first car on the empty track side, causing crushing injuries to his upper body. After moving the cars, Snyder looked through the control room door to see if Gamble was in position to uncouple the cars, at which time he saw Gamble standing partially inside the rotary dump. Snyder ran toward Gamble and observed that he was pinned between the dump and adjacent car, still holding the cut-off extension bar in his hand. Snyder then went back to the control room and jogged the cars toward the empty track to free Gamble. When Snyder returned to Gamble, he was conscious and laying next to the rails, clear of the rotary dump. Snyder then telephoned emergency services and notified mine management of the accident. Gamble was flown by helicopter to Ruby Memorial Hospital where he was pronounced dead at 4:08 p.m.
The fatal accident occurred because a signal or other means was not used to be certain that all persons were clear before moving the coal haulage cars.
Consolidation Coal Company's Humphrey No. 7 underground mine is located near Maidsville, Monongalia County, West Virginia. The mine employs 81 persons, 76 underground miners and 5 surface employees. An average of 2,400 tons of clean coal is produced daily from the Pittsburgh coal seam by two advancing continuous mining machine units on a single super-section. The mine produced 322,838 tons in 1999. Coal is mined two shifts per day, six or seven days per week.
Coal is transported from the active section by a conveyor belt system to an underground tipple where it is loaded into 20-ton coal cars and transported to the surface by two 50-ton, trolley-powered, locomotives via a track haulage system in trips of up to 30 cars. Once on the surface, the coal haulage cars are emptied by a rotary dump and transferred to a conveyor system. The material is then belted to either a storage yard or river barges. The track haulage system is also used to transport supplies, materials, equipment, and employees into and out of the mine.
The surface rotary dump has been in service since the mine opened in 1956. Coal haulage cars are moved through the rotary dump by a haul chain located beneath the track on the loaded side of the dump. After all but the last four or five cars in a trip pass through the rotary dump, the empty cars are separated from the remaining loaded cars and stored on a side track. All but one of the remaining cars are then emptied. The last car must remain attached to the haul chain at this time and cannot be pulled into the rotary dump (as shown on Figure 1). These cars are then pulled back through the dump and connected to the next trip of loaded cars. This procedure enables the rotary dump operator to retrieve the next trip of loaded cars without assistance from the trailing locomotive.
The mine is ventilated by one exhausting main fan located on the surface. The mine liberates approximately 289,981 cubic feet of methane every 24 hours.
The principal officials for the Humphrey No. 7 Mine at the time of the accident were:
Kent Wright .......... SuperintendentThe last MSHA regular Health and Safety Inspection (AAA) was completed on June 29, 2000, and another was ongoing at the time of the accident. The non-fatal days lost (NFDL) incident rate during the previous quarter for the nation was 6.68 and 0.00 for this mine.
Lloyd Shomo .......... Mine Foreman
Darrell Shaffer .......... Master Mechanic
Mike Nestor .......... Safety Supervisor
DESCRIPTION OF THE ACCIDENT
On the morning of September 21, 2000, the day shift crew at Consolidation Coal Company's Humphrey No. 7 mine reported for work prior to their scheduled 7:00 a.m. starting time. During this period, Douglas McMillen, Shift Maintenance Foreman, assigned David Gamble, Mechanic, to work with Ron Phillips, Pumper. Gamble then traveled underground with McMillen, via a track-mounted mantrip, to a work site located near the working section where they met Phillips. McMillen then explained the job details to Gamble and Phillips, which included the installation of water lines and pumps. These tasks were performed, uneventfully, throughout the shift.
The dispatcher, Allen Snyder, also served as the surface rotary dump operator. When the morning's first trip of loaded cars was brought out of the mine, Snyder backed the five remaining cars from the previous trip through the rotary dump to retrieve the loaded trip. Snyder noticed that the empty cars were dragging against the rotary dump as he backed them toward the next trip of loaded cars. He assumed that a damaged car was causing the problem. However, the problem persisted when he backed the next trip of cars through the rotary dump. At this time, the lead motorman, Frank McFadden, noticed that the empty track rail on the far corner of the dump from the control room was four to five inches higher than the adjacent rail in the dump (refer to Appendix B, Figure 5). This caused the top of the cars to hit against the end of the vertical hold-down angle in the rotary dump (refer to Appendix B, Figure 6) when being moved toward the loaded side. McFadden told Snyder that he would push the next loaded trip closer to the rotary dump, so that fewer empty cars would pass through the facility when retrieving the loaded cars. Snyder then decided to report the condition to Darrell Shaffer, Master Mechanic.
At approximately 2:45 p.m., Gamble left his work site and was riding to the surface with Shaffer in a track-mounted mantrip. While en route, Shaffer received a radio call from Snyder, who informed him that there was a problem tramming coal cars through the rotary dump. When Shaffer arrived on the surface, he assigned Gamble to assess the reported condition and to perform the required monthly electrical examinations on the rotary dump facility. Gamble traveled to the rotary dump control room where he and Snyder discussed the problem. As they started walking toward the empty track side of the rotary dump, Snyder received a radio transmission from underground and had to return to his dispatcher duties in the control room. While the men were apart, Gamble continued toward the empty track side of the rotary dump where he observed the high rail. At this time, a partial trip of five cars was located at the rotary dump facility. The partial trip consisted of three empty cars on the empty track side, one empty car on the rotary dump platform, and one full car on the loaded track side (as shown on Figure 1). Snyder rejoined Gamble at approximately 3:00 p.m., at which time Gamble told Snyder that he wanted to separate the empty coal haulage cars from the one in the dump. Snyder told Gamble that there was no sense in separating the cars, because he felt that Gamble could not fix the problem by himself. However, Gamble persisted and Snyder agreed to help separate the cars. As Snyder walked to the control room, Gamble picked up the cut-off extension bar (a custom hand tool used to separate the coal haulage cars without positioning persons between the cars) and walked toward the empty track side of the rotary dump.
The two men had worked together at the rotary dump on numerous occasions and did not discuss the details of their intended procedure for separating the cars. The empty coal haulage cars were normally separated while moving in the direction of the empty track. However, the last car would disengage from the haul chain if moved more than six feet in that direction from its current position. Therefore, Snyder intended to first move the cars a short distance toward the loaded track. He then intended to move them back toward the empty track while Gamble separated the cars using the extension bar.
When Snyder arrived in the control room, he jogged the cars a few feet toward the loaded track. However, Gamble had just stepped between the rotary dump and the adjacent car on the empty track side. As the cars moved toward the loaded track, Gamble was caught between the corner of the rotary dump and the first car on the empty track side, causing crushing injuries to his upper body.
After moving the cars, Snyder looked through the control room door to see if Gamble was in position to uncouple the cars, at which time he saw Gamble standing partially inside the rotary dump. Snyder ran toward Gamble and observed that he was pinned between the dump and adjacent car, still holding the cut-off extension bar in his hand. Snyder then went back to the control room and jogged the cars toward the empty track to free Gamble. When Snyder returned to Gamble, he was conscious and laying next to the rails, clear of the rotary dump. Snyder then telephoned emergency services and notified mine management of the accident. The 911 call was received at 3:05 p.m. Snyder then returned to Gamble who was having difficulty breathing.
Because a shift change was in progress, numerous miners from both shifts responded to the accident. Shaffer, McMillen, Dwight Jeffrey (Mechanic/EMT), and Roger Boring (Roof Bolting Machine Operator) were the first to arrive at the accident site. When they arrived, Gamble was sitting up with both hands against the end of the coal car in the dump. They were soon followed by Baige Casto (Afternoon Shift Foreman/EMT) who began emergency treatment, assisted by Jeffrey and the other miners. Ricky Jarrell (Continuous Mining Machine Operator) and Ron Jarrell (Section Foreman) also responded to the accident and helped secure Gamble to a back board. At 3:17 p.m., the Granville Volunteer Fire Department Emergency Squad arrived at the accident site. Two additional units from Monongalia County arrived at 3:21 p.m., with a fourth unit arriving at 3:32 p.m. A HealthNet Aeromedical helicopter arrived at approximately 3:35 p.m. The victim was flown to Ruby Memorial Hospital in Morgantown, West Virginia, where he was pronounced dead at 4:08 p.m.
INVESTIGATION OF THE ACCIDENT
This investigation was conducted in cooperation with the West Virginia Office of Miner's Health, Safety and Training. Other participants included management personnel from Consolidation Coal Company. The United Mine Workers of America provided representatives of the miners during the investigation. A list of those persons who participated in the investigation is contained in Appendix A of this report.
Kent Wright, Superintendent, notified the MSHA District 3 office of the accident at 3:20 p.m. on September 21, 2000. A 103(k) Order was issued on the rotary dump facility at 4:00 p.m. as the investigation team was being assembled. At 7:00 p.m., the MSHA investigation team arrived at the mine site. A pre-investigation conference, including a preliminary interview with the witness, was conducted and photographs and measurements were made of the accident site. The investigation also included a review of training records by Educational Field Services personnel.
On September 22, 2000, persons having knowledge of the facts regarding the accident were interviewed and video recordings, photographs, and electronic images were taken of the rotary dump. On the same day, the 103(k) Order was modified, in accordance with the operator's plan to return the affected area to normal, to permit work on the rotary dump. This work included repairing the loose rail and performing functional tests. These tests, including a complete electrical inspection of the rotary dump, were conducted on September 23, 2000.
On September 24, 2000, the affected area was returned to normal after work was completed to ensure safe operation of equipment associated with the rotary dump. The 103(k) Order was modified at this time to permit normal operation of the rotary dump, only after all miners (assigned to work the shift in which such operations were being performed) had been instructed on safe work practices in the affected area. This instruction was conducted at the start of each shift in accordance with an outline of topics developed by the operator. By September 27, 2000, instruction was completed for all miners on all shifts working at the mine, at which time the 103(k) Order was terminated. Additional interviews were conducted on September 27, 2000.
Rotary Dump Design and Operation
The surface rotary dump has been in service since the mine opened in 1956 and was manufactured by The Nolan Company of Bowerstown, Ohio. It is housed in a roofed shed which provides protection from the elements. The rotary dump is operated from a console within the control room, located on the loaded track side of the facility (refer to Figure 1). The rotary dump operator uses either a manual or automatic mode for controlling movement of the coal haulage cars through the rotary dump facility. Each coal haulage car is emptied as it revolves 360 degrees within the gear driven, rotary dump drum. A rotating shank is provided on the Willison automatic couplers which permits the coal haulage cars to be dumped without being uncoupled from the trip. The rate at which coal haulage cars are emptied by the rotary dump averages approximately one car per minute.
A coal haulage car is properly located for dumping when the wheels of the front dolly on the adjacent loaded car align with reference marks painted on the side of the loaded track rail, directly in front of the rotary dump control room. The rotary dump operator can see this mark through the control room window from his position at the control console. In the manual mode, the operator positions coal haulage cars for dumping according to this reference mark. Also, the control logic operates lights on the console which indicate proper alignment of the rotary dump drum and proper position of the coal haulage car. When the rotary dump is operated in the automatic mode, a program logic controller (PLC) governs the actions of the haul chain and rotary dump drum motors. During the functional test, the wheels of the next loaded car stopped on the painted marks while dumping in the automatic mode, consistent with the preferred position during manual operation. The last car was positioned on these marks when Snyder initiated movement of the coal haulage cars at the time of the accident.
The coal haulage cars are moved through the rotary dump facility by a haul chain, which is located in the center of the track on the loaded side of the rotary dump. The haul chain is equipped with dogs (latches) that engage pockets under the coal haulage cars, causing the cars to move in the direction of chain movement. The dogs disengage from each coal haulage car as it enters onto the rotary dump platform, requiring the next car on the loaded side (still attached to the haul chain) to push it into the dumping position. Therefore, the last car in a trip is not emptied until additional cars are available to push it through the dump. Since the empty track slopes away from the rotary dump, maintaining at least one car attached to the haul chain also prevents the trip from unintentionally drifting off the rotary dump. Snyder indicated that he was concerned that moving the last car toward the rotary dump to facilitate uncoupling could result in the last car disengaging from the haul chain. Therefore, he first moved the cars toward the loaded side of the rotary dump before intending to jog the cars in the opposite direction. Measurements conducted during the investigation indicated that the last car will disengage from the haul chain if the trip is moved approximately six feet toward the empty track from the final dumping position.
The coal haulage cars are uncoupled by pressing down on a cut-off bar located at one end of each car. A custom hand tool is maintained at the rotary dump facility which enables miners to uncouple cars without reaching between them. This aluminum extension bar is slid over the cut-off bar and extends approximately one foot beyond the side of the car (refer to Appendix B, Figure 7). The last five cars are typically separated from the front of the trip as they exit the rotary dump in automatic mode. This task is normally performed by the rotary dump operator, at a location approximately one-half car length beyond the empty side of the rotary dump platform. Due to the tight clearance (approximately 3 inches) on either side of a car within the rotary dump, the extension bar cannot be used until the car's cut-off bar moves out of the rotary dump. Therefore, at the time of the accident, the last empty car was not yet positioned for Gamble to use the extension bar.
When a coal haulage car is in the dumping position, such as was the case immediately prior to the accident, a gap of 21 inches exists between the first car on the empty track and the side of the rotary dump. Snyder stated that Gamble appeared to be caught within this space, with his arms above the level of the cars. This suggests that Gamble may have been standing on a stirrup located on the lower corner of the car on the empty side of the rotary dump. The nature and location of Gamble's injuries were consistent with him being caught in this location. The haul chain moves the coal haulage cars at a speed of approximately one foot per second. At this rate, Gamble, located within the 21-inch space, would have had very little time to react before being caught between the corner of the coal haulage car and the corner of the rotary dump.
Rotary Dump Electrical Equipment Evaluation
Electric power for the rotary dump facility originates at a nearby substation, which is maintained by Consolidation Coal Company. Electricity enters the substation at 23,000 volts and is stepped down to 480/240 volts, 3 phase, 60 cycle. This power is transmitted to the rotary dump switch room where it feeds the main switch. From the main switch, power is distributed to the haul chain and rotary dump motors through Ben Shaw silicon-controlled rectifier (SCR) power units. The electrical control logic for the haul chain and rotary dump originates from a PLC located in the switch room.
On September 23, 2000, functional tests were conducted on the equipment and electrical control circuits associated with the rotary dump. The results of these tests were as follows:
These tests did not identify malfunctions in the electrical system which would have contributed to the accident. Also, no hazards or malfunctions were listed in the records of electrical examinations of the rotary dump during the month preceding the accident. However, the tests demonstrated that there was no signal, such as that which could have been utilized for compliance with 30 CFR 77.1607 (Loading and Haulage Equipment; Operation), which would warn of impending movement of the coal haulage cars in the rotary dump facility.
The ground fault circuit in the substation, which provided power to the surface rotary dump facility, functioned properly.
The rotational alignment, last car, and car position control logic circuits functioned properly. However, one of the indicator lights on the operator's control console did not function. The purpose of this light was to indicate that the last car in the trip was engaged by the haul chain and it did not affect the control logic, which stops the trip at the proper location when being operated automatically. The light was repaired and functioned properly when tested on September 24, 2000. This condition did not appear to contribute to the accident. Snyder's actions and statements demonstrated that he was aware that the last car was on the haul chain. Also, the last car was clearly visible from the rotary dump operator's position in the control room.
The emergency stop switch located near the empty side of the rotary dump functioned properly.
The start and stop cycle buttons and the immediate stop and jog tram switches on the operator's control console functioned properly.
The tram direction and speed switches on the operator's control console functioned properly.
The horn (which provides warning to persons that the conveyor beneath the dump will be started) sounded properly when the rotary dump was energized.
The pull cord switches to the haul chain (for use when working in the pit below the facility) were electrically functional. However, one of these switches experienced a mechanical failure when tested. This switch was replaced and functioned properly when tested on September 24, 2000.
The electrical circuit for the red, flashing, warning lights (which indicate that the rotary dump is energized) functioned properly. However, the light on loaded track side of the facility was burned out. The bulb was replaced and the light functioned properly when the rotary dump was energized on September 24, 2000. The lights remained on whenever the rotary dump was energized, regardless of whether the haulage cars in the rotary dump facility were being moved.
Track Alignment Problem
The track alignment problem was caused by a loose empty track rail, located immediately adjacent to the rotary dump, on the far side of the track from the rotary dump control room (refer to Appendix B, Figure 5). A metal bracket and plate which anchored the end of this rail had deteriorated, causing the end of the rail to spring upward by approximately four inches. As an empty car was pulled back onto the rotary dump platform, its wheels passed over the end of the rail. The weight of the car then pressed down on the rail, lessening the displacement by approximately two inches. The remaining two inches of vertical displacement raised the cars sufficiently to cause them to strike against the end of the vertical hold-down angle when being pulled back into the rotary dump (refer to Appendix B, Figure 6). The cars could still be pulled through the rotary dump, although, with some difficulty, since they would bounce beneath the vertical hold-down angle after impact. Normally, only one inch of clearance exists between the top of a car in the rotary dump and the vertical hold-down angles. This close clearance prevents the cars from being displaced when rotated in the rotary dump.
During functional tests conducted on September 23, 2000, it was determined that the dump platform track rails could be aligned to all of the rails on either side of the rotary dump, except for the loose rail. The plate and bracket were then replaced and the remaining rail was aligned with the adjacent rail on the rotary dump platform.
Snyder indicated that he and Gamble disagreed on the preferred action for correcting the track alignment problem. Subsequent communication problems between the two men appear to have affected their understanding of each other's intended actions immediately prior to the accident.
Snyder had made arrangements with McFadden to spot the next loaded trip closer to the rotary dump, so that the empty cars would not have to be pulled as far through the rotary dump to retrieve the loaded cars. This action would have minimized the effect of the problem until arrangements were made to repair the rail on the empty side of the rotary dump and could have permitted Snyder to complete his shift without interrupting normal activities. Snyder had correctly determined that the problem was caused by the loose rail on the empty side of the rotary dump and told Gamble that he could not fix the rail at that time. However, Gamble had been assigned to assess the problem and wanted to proceed with troubleshooting, including separating the cars at the rotary dump facility.
Snyder stated that he did not understand Gamble's reason for wanting to separate the cars or why Gamble was located between the cars and the rotary dump at the time of the accident. Snyder assumed that Gamble would separate the cars at the normal location for this task, approximately one-half car length beyond the empty side of the rotary dump. The two men had worked together while separating cars at this location on numerous occasions and did not discuss the details for performing the task prior to the accident. Therefore, determining Gamble's intended actions was a major focus of the investigation. Two distinct scenarios regarding this matter were developed and are discussed in the following paragraphs.
The first scenario is based on the conjecture that Gamble intended to remove the cars from the portion of the empty track containing the loose rail in order to evaluate or repair the problem. This could have been accomplished by pulling all of the empty cars back through the rotary dump. However, by first separating the cars on the empty side of the rotary dump, only one car needed to be pulled over the loose rail. If this was his intention, Gamble could have chosen to separate the cars at two locations: at the coupler located one car length from the rotary dump, or at the coupler located over the end of the rotary dump. After separating the cars, using the former option, the car on the empty track nearest the rotary dump would have needed to be pulled back through the rotary dump to clear the loose rail for maintenance. This would have caused the car to hit the vertical hold-down angle as it trammed onto the rotary dump platform. In the latter option, the cars would have been separated only after moving them far enough toward the empty track so that the remaining cars would not interfere with maintenance to be performed on the loose rail. However, since the length of movement in this direction was limited to approximately six feet (to prevent the last car from disengaging the haul chain), the location for cutting the cars would have been critical and confined to a narrow range. This method would have realized the advantage afforded by leaving one end of the last empty car beneath the vertical hold-down angles, avoiding impact when being pulled back through the rotary dump. Also, this method would have placed the coupler at a location where the extension bar could be utilized. In either case, Gamble may have decided to quickly recheck the rail alignment to ensure that the car on the empty track would clear the vertical hold-down angle (former option) or to determine the proper distance from the rotary dump for separating the cars (latter option). The loose rail was difficult to see from Gamble's position on the far side of the track. He could have obtained a better view of the problem area by standing on the stirrup of the car located immediately on the empty side of the rotary dump. Both options are consistent with Gamble's apparent intent to use the extension bar to separate the cars, his injuries, and his position during the accident.
The second possible scenario was developed from a statement made by Snyder, in which he alluded to the possibility that Gamble may have thought that the problem (or a potential solution) was related to the rotational settings on the rotary dump drum. Measurements of the track displacement indicated that adjusting the rotation stop setting by approximately one inch (in relation to the loose rail) could have temporarily alleviated the problem. An over-adjustment, however, would have caused the same problem on the opposite corner of the rotary dump. To facilitate such adjustments, a car could have been left on the empty side of the rotary dump as a reference. This would have depressed the loose rail to the same elevation as when backing cars through the rotary dump. Removing the car from within the rotary dump would have permitted better viewing of the track alignment from the control room side of the rotary dump while making adjustments. To accomplish this, Gamble would have needed to separate the car located in the rotary dump from the adjacent car on the empty track (without moving the car on the empty track). Since the cut-off bar for separating these cars was located within the confines of the rotary dump, Gamble could not use the extension bar for this task. To activate the cut-off bar, he would have needed to either reach through the 21-inch space between the empty car and the side of the rotary dump, or stand between the cars. The former possibility is consistent with Gamble's injuries but does not explain why Gamble appeared to be trapped above the cars. Also, if Gamble was actuating the cut-off bar at the time of the accident, the cars should have separated when Snyder moved them toward the loaded side of the rotary dump (the couplers functioned properly during the investigation). The latter possibility is consistent with these factors if Gamble was in the process of stepping through the 21-inch space at the time of the accident, with the intent of standing on the couplers while activating the cut-off bar. However, Gamble had considerable experience working on the rotary dump and would have likely known that the extension bar could not be used to separate the cars at this location. Also, separating the cars in this manner would have required moving the trip in the loaded direction only; yet Gamble did not discuss such a departure from the normal procedure with Snyder.
Regardless of Gamble's reason for entering the space between the car and the rotary dump, he did not effectively communicate his intentions to Snyder. If Gamble was attempting to observe the loose rail, as suggested in the first scenario, he may have decided to take this action after his last communication with Snyder. In such a case, Gamble would have had little time to consider the possible consequences of his actions. Likewise, Snyder did not communicate the timing or direction for his intended movement of the coal haulage cars. Furthermore, the rotary dump facility was not provided with a signal which would have warned Gamble of the impending motion of the coal haulage equipment. Although the location where cars were normally separated was visible from the rotary dump control room, Snyder did not attempt to ascertain Gambles' position prior to moving the cars.
The fatal accident occurred because a signal or other means was not used to be certain that all persons were clear before moving the coal haulage cars.
ENFORCEMENT ACTIONS A 103 (k) Order, No. 7088631, was issued to Consolidation Coal Company to ensure the safety of all persons during the investigation and until the affected area was returned to normal.
A 104 (a) Citation, No. 7088632, was issued to Consolidation Coal Company for violation of 30 CFR 77.1607(g), which requires equipment operators to be certain, by signal or other means, that all persons are clear before starting or moving equipment. The body of this citation reads as follows:
The operator of the rotary dump is not provided with a means to be certain that all persons are clear before moving cars through the rotary dump. On September 21, 2000, David Gamble, mechanic, was fatally injured when a car was moved by the rotary dump operator, crushing Gamble between the corner of the rotary dump and a coal car. During the investigation of this accident, it was determined that several areas around the rotary dump, including the accident site, were not visible from the rotary dump operator's position. The rotary dump requires routine maintenance which may require equipment motion during adjustments. As installed, the motion of the rotary dump can only be controlled from the operator's control room which is located on the end of the rotary dump opposite that of the fatal accident.The operator instructed all miners on safe work practices in the affected area. Also, a video monitor was installed in the control room which was linked to a camera placed over the rotary dump. .
Related Fatal Alert Bulletin:
Listed below are the persons furnishing information and/or present during the investigation:
Consolidation Coal Company
Kent Wright .......... Superintendent - Humphrey No. 7
Darrell Shaffer* .......... Master Mechanic - Humphrey No. 7
Doug McMillen* .......... Maintenance Shift Foreman - Humphrey No. 7
Eric Clark .......... Maintenance Shift Foreman - Humphrey No. 7
Charles Harper* .......... Day Shift Foreman
Baige Casto* .......... Afternoon Shift Foreman
Mike Blevins .......... Manager - Safety Group 2
Jack A. Holt .......... Vice President of Safety
Craig Yanak .......... Corporate Safety Director
Mike Nestor .......... Mine Safety Supervisor - Humphrey No. 7
Robert M. Vukus .......... Senior Counsel
United Mine Workers of America
Allen Snyder* .......... Rotary Dump Operator* Persons Interviewed.
Dave Brown .......... Rotary Dump Operator
Franklin McFadden* .......... Motorman
Raymond Johnson* .......... Continuous Mining Machine Helper
Ricky Jarrell* .......... Continuous Mining Machine Operator
Roger Boring* .......... Roof Bolting Machine Operator
Dwight Jeffrey* .......... Mechanic
David Laurie .......... Safety Committee Chairman
Tom Winston .......... Safety Committeeman
Charles Weaver .......... Safety Committeeman
Dennis O'Dell .......... International Health and Safety Representative
Terry Osborne .......... Director of Region 1 - UMWA