DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal & Nonmetal Mine Safety and Health
Report of Investigation
Surface Metal Mine
Fatal Machinery Accident
April 10, 2000
Boart Longyear Company
ID No. Y12
Getchell Mine & Mill
Getchell Gold Corporation
Golconda, Humboldt County, Nevada
ID No. 26-01801
Michael S. Okuniewicz
Supervisory Mine Safety and Health Inspector
Thomas E. Barrington
Mine Safety and Health Inspector
Eugene D. Hennen
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Claude N. Narramore, District Manager
Byron Lloyd Coates, driller, age 40, was fatally injured on April 10, 2000, when his clothing became entangled in a rotating drill rod. Coates was aligning the rod to the drill head when his coat became entangled.
The accident occurred because management had not provided mechanical devices and established procedures that required the drill to stop prior to coupling the drill rod. Coates had a total of 20 years, 10 months mining experience, all as a driller with this employer. He had received training in accordance with 30 CFR Part 48.
The Getchell Mine and Mill, an open pit gold mine, owned and operated by Getchell Gold Corp., was located at Golconda, Humboldt County, Nevada. The principal operating official was William C. Howald, exploration manager. Mining had ceased and only the mill was in operation at the time of the accident. The mill and support facilities were normally operated two, 8-hour shifts a day, seven days a week. A total of 94 persons was employed.
The victim was employed by Boart Longyear, an independent exploration drilling company, headquartered in Salt Lake City, Utah. The company operated ten diamond drills on the property and was engaged in ore body delineation for the Getchell Mine. The principal official on site was Patrick Langan, operations supervisor-Nevada Western Zone. A total of 43 persons was assigned to this job. The work schedule was two, 12-hour shifts a day, 7 days a week.
The last regular inspection of this operation was completed on December 12, 1999. Another inspection was conducted in conjunction with this investigation.
DESCRIPTION OF ACCIDENT
On the day preceding the accident, Byron Coates (victim) reported for work at 7:00 p.m., his normal starting time. His job was to operate a diamond drill which was located on hole number 00NZ152, at the time of the accident. The drill rod had been pulled from the hole on the previous shift to replace the bit. Coates and his helper, Pedro Rodriguez, spent most of the shift putting the rods back down the hole. According to the helper's statements, they would have to "muscle the rods" so they would line up with the drill head. Each rod was added and held in place by hand for coupling to the rotating drill head. Toward the end of the shift, they had managed to drill 20 feet.
At about 5:50 a.m. on the following morning, Rodriguez left the drill to get a load of water and returned about 15 minutes later. Upon arrival, he saw the drill rod spinning, with Coates entangled in the rod. Rodriguez immediately shut off the power to the drill and went for help. He ran to another drill nearby and told Larry Hill, rig supervisor, about the accident. Both men returned to the accident site. Hill attempted to call for help on a cell phone, but could not reach anyone, so he drove to the guard house. At about 6:30 a.m., Kevin Wytcherley, emergency medical technician, arrived at the scene and along with Hill, checked for vital signs. Finding none, he cut the victim's coat away from the drill rod in order to free him. David D. Lott, emergency medical technician, arrived and also checked for vital signs and found none. Coates was taken to a local mortuary by the deputy county coroner a short time later. Death was attributed to multiple blunt force trauma injuries.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 6:55 a.m., on the day of the accident by a telephone call from David Kinsey, loss control supervisor for the mining company, to Tyrone Goodspeed, field office supervisor. An investigation was started the same day. MSHA's accident investigation team traveled to the mine and made a physical inspection of the accident site, interviewed a number of persons and reviewed documents relative to the job being performed by the victim, and his training records. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of the miners. The miners did not request, nor have, representation during the investigation.
The equipment involved in the accident was a Boart Longyear Model LS 244 Core Drilling System, which included the drill rig, mud mixing system, water truck, light plant, core removal system and enclosed work area. The company designed and manufactured its own drill systems. Each individual drilling system was identified by a Contracting Service Group Number (CSG). The number identifying the system involved in the accident was CSG 3839.
The drill rig consisted of a chassis, drill mast, and all the controls needed for drilling. The drill rig contained most of the core recovery system. The work platform and enclosure was the location where the drill operator and helper operated the drill system and performed the core removal. The pipe trailer contained the drill rods used in the drilling operation. The mud mixer prepared the liquid used to cool the drill bit and used to remove the cuttings from the hole. A light plant provided light for night operation.
The drill rig was mounted on a Ford, Model LNT 800 Chassis with a Model 6C-8.3 Cummins 300-hp engine. The weight of the drill rig was approximately 46,000 pounds. The engine in the chassis supplied power for moving the drill rig from place to place and for driving the hydraulic pumps that supplied power for drilling and core removal. The mast of the drill rig could be lowered onto the top of the chassis for highway transportation. The mast and all of the drill controls and gauges were mounted on an adjustable control panel-mounted on the rear of the machine. The control panel could be moved to different locations on the side of the work platform to the left of the drill head. The control panel was L-shaped with a horizontal and vertical section. Some of the controls and gauges did not function. One nonfunctional control was for the power Vee. If this control was not functioning prior to the time of the accident, it could have contributed to conditions leading up to the accident. However, it could not be determined if these controls and gauges did not work prior to the accident or stopped working because of damage obtained during the accident.
The work platform where the drill operator controls were located, was mounted directly behind the drill rig. The work platform had a plexiglass enclosure to protect the operator and helper from the elements. The center section of the enclosure was open for handling the drill rods. The plexiglass enclosure was damaged during the accident.
The drill rods used for drilling were stored on a trailer that was positioned immediately adjacent to the work enclosure on the opposite side from the drill rig. From this location, additional drill rods were moved forward to be connected to the drill head. When drill rods were being removed, they were placed back onto the trailer for storage.
Each drill rod section was 10 feet long with female threads at one end, and male threads at the other end. The drill head shaft had male threads that threaded into the drill rod female threads. The rod was nicked and contained numerous burrs, that could ensnare loose clothing.
The procedure used for adding drill rods prior to the accident involved power-rotation of the drill head shaft and was described as follows: The drill head was rotated until the shaft that threads into the drill rod was in a horizontal position. The helper slid the drill rods from the pipe trailer to the drill head, and then held the female threads of the drill rod against the male threads of the drill head shaft with his hands while the drill operator power-rotated the drill head shaft using the rotate control on the control panel. The connection between the drill head and the drill rod was not tightened at this point. This connection was tightened after the drill rods were lifted to the vertical position and threaded into the drill rods that were already in the hole. Interviews revealed this procedure was an accepted practice. At the time of the accident, the helper had left the platform to get water, and the drill operator was attempting to thread a 20-foot section of two drill rods to the drill head by himself using the same procedures. It appears he was holding the drill rods under his right arm while using his left hand to activate the drill head power-rotation control when his clothing became entangled with the rotating drill rods.
The drill head rotate control was mounted on the right side of the lower section of the control panel. This placed the control on the side of the panel closest to the drill head. The drill head rotate control was a variable speed control that set the speed within the range of 13 rpm to the maximum rpm. The maximum speed was not determined because the digital readout for speed did not work at the time of the investigation. The drill rotate control was designed to stay in the position in which it was placed, allowing the drill to continue turning at the set speed when the control was released by the operator.
A small green start/stop button was located on the upper left section of the control panel, opposite the side that the drill head was located. When this button was pulled out, the hydraulics needed for drilling was turned on. When the button was pushed in, it acted as a stop button, causing all the hydraulic functions of the drill rig to stop. Two field tests were conducted to determine if this button functioned acceptably as a stop button. With the drill rods rotating, the button was pushed and the drill rods rotated less than 1/2 turn before stopping in both tests. Although the rpm of the drill rods was not known at the time of these tests, mine personnel stated that the drill rods were rotating considerably faster than they are rotated when drill rods are being threaded onto the drill head shaft. There was no stop button on the right side of the drill head where the helper usually worked.
The drill system involved in the accident had rollers designed to assist in the handling of the drill rods while they were being added and taken away. When properly adjusted these rollers assisted in supporting the drill rods while they were being held in place for attachment to the drill head shaft. Interview statements from company personnel and observations made at the accident site indicated that these rollers were not being used at the time of the accident and were not adjusted properly to allow for their intended use.
There were two sets of rollers on the drilling system. Each set consisted of two rollers positioned at 90 degrees to each other. Each set of rollers was mounted in such a way to form a Vee. One Vee was stationary and the other was a power Vee which could be raised or lowered using a hydraulic cylinder operated from the control panel on the drill rig. When adding drill rods, the helper would place one end of the rod into the stationary Vee and the other end over the power Vee. The drill operator would then raise the power Vee to level the drill rods with the shaft on the drill head. The helper could then roll the drill rods forward and thread them onto the drill head shaft. The reverse procedure could be used when drill rods were being removed. In order to use the Vee rollers effectively, they must be properly aligned with the drill head. A review of the core drilling system involved in the accident revealed two features which made alignment of the Vees with the drill head difficult during the set up. One of these features was the fact that there were no interlocks or markings on the drill rig, work platform or pipe trailer which showed when the Vees would be aligned with the drill head. The other feature was that it was not possible to make small adjustments of the drill system components during the set-up process.
A check of the control system for the power Vee revealed that the control on the drill rig control panel would raise the power Vee, but would not lower it. Further evaluation of the system showed that the electric switch on the control panel that controlled the hydraulic solenoid-operated valve for the power Vee was defective. It could not be determined if this control was defective prior to the accident, or if it was damaged during the accident. Visual observation showed that the power Vee was out of adjustment. With the power Vee in the completely raised position, the power Vee did not raise high enough to contact the drill rod being added at the time of the accident. If the control for the power Vee did not work when the drill system was set up for the hole being drilled at the time of the accident, the nonfunctioning control could have contributed to the reason the set up crew did not adjust the Vees.
The root cause of the accident was management's failure to implement safe work procedures and to provide mechanical devices that required drill rotation to be stopped prior to drill rods being added. Numerous burrs and gouges on the drill were contributing factors.
Order No. 7975416 was issued on April 10, 2000, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on the surface with a core drill. The accident happened at the northwest zone 159 hole. This order is issued to assure the safety of the persons at this operation until the mine or affected area can be returned to normal operations as determined by an authorized representative of the Secretary. The mine operator shall obtain approval from an authorized representative for all actions to recover persons, equipment and/or return the affected areas of the mine to normal operations.This order was terminated on April 11, 2000, after it was determined that the drill could safely resume normal operations.
Citation No. 7907233 was issued on April 12, 2000, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.7005:
A diamond drill operator was fatally injured at this operation on April 10, 2000, when his clothing became caught in the rotating drill stem while coupling the stem to the drill head. The mine operator's failure to provide a safe method for coupling stems while the drill head was in motion, and to eliminate the practice of manually changing the drill stems, is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.This citation was terminated on April 13, 2000. The mine operator has revised the procedure for adding/changing rods to eliminate the practice of doing so while the drill head is rotating.
Order No. 7907234 was issued on April 12, 2000, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.7002:
A diamond drill operator was fatally injured at this operation on April 10, 2000, when his clothing became caught in the rotating drill stem while coupling the stem to the drill head. The drill stem was defective in that numerous burrs and gouges existed on the stem where the driller's clothing became entangled. The procedure for adding stems required the driller to be in contact with the rotating stems. The mine operator's failure to correct equipment defects is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.This order was terminated on April 12, 2000. The mine operator removed all burrs from the drill stems prior to attachment to the drill head and initiated a hands-off procedure for adding/changing drill rods.
Order No. 7907235 was issued on April 12, 2000, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.18020:
A diamond drill operator was fatally injured at this operation on April 10, 2000, when his clothing became caught in the rotating drill stem while coupling the stem to the drill head. The procedure for adding stems required the driller to be in contact with the rotating parts. The driller was working alone where hazardous conditions existed. A second person was not present at the controls in case of an emergency. Allowing or assigning a person to work alone in an area where hazardous conditions exist is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard. This order was terminated on April 12, 2000. The mine operator does not allow employees to work alone when coupling drill rods.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Boart Longyear Company
Thomas Joiner, safety managerGetchell Gold Corporation
Nicholas Toney, safety supervisor
Patrick Langan, operations supervisor - Nevada Western zone
David Kinsey, loss control supervisorPlacer Dome Exploration Inc.
William Howald, exploration managerState of Nevada Department of Business and Industry
Division of Industrial Relations, Mine Safety and Training Section
James Frei, mine inspector Joseph Roades, mine inspectorMine Safety and Health Administration
Michael S. Okuniewicz, supervisory mine safety and health inspectorAPPENDIX B
Thomas E. Barrington, mine safety and health inspector
Richard Wilson, mine safety and health inspector
Eugene D. Hennen, mechanical engineer
Boart Longyear Company
Pedro Rodriguez, drill helperPlacer Dome Exploration
Larry Hill, drill supervisor
Hugh Briggs, job supervisor
Patrick Langan, operations supervisor
Dennis Reed, drill supervisor
David Lott, emergency medical technician
Kevin Wytcherley, emergency medical technician