DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE PREPARATION PLANT)
FATAL SLIP OR FALL OF PERSON
U. S. STEEL MINING COMPANY, LLC (ID NO. 46-05868)
PINNACLE PREPARATION PLANT
Pineville, Wyoming County, West Virginia
March 14, 2001
Curtiss Vance, Jr.
Coal Mine Safety and Health Inspector
Walter C. Slomski
Mining Engineer, Technical Support
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mt. Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: July 20, 2001
On Wednesday, March 14, 2001, at approximately 10:00 p.m., a fatal slip or fall of person accident occurred on the S-3 raw coal reclaim belt system in the Shawnee side of the Pinnacle Preparation Plant, U. S. Steel Mining Company, LLC. The accident resulted in the fatal injuries to Donald Clinton Cook, 58 years old, a Preparation Plant utility man. Cook had a total of 27 years experience, including 6 years as a utility man at this plant. Cook's primary work location for the shift was the raw coal handling area identified as the Shawnee side of the facility, also known as the dump area or the reclaim area. Cook was last seen washing off the concrete pad at the mouth of the S-3 tunnel belt at about 6:45 p.m. Cook was last heard from on company radios about 7:00 p.m. talking to the Preparation Plant foreman asking the foreman to bring him some sampling bags. Cook was reported missing about 10:00 p.m. after he could not be contacted on the radio or found during a search conducted by employees. During unloading of the raw coal silos, �B' then �A', the victim was recovered from Silo �A', in feeder No. 5, on Thursday, March 15, at approximately 7:55 p.m. There were no witnesses to the accident. The victim apparently entered the raw coal handling/conveyor system upstream of the raw coal storage Silo �A' and sustained fatal injuries upon entering and being transported on the conveyor system from one of the probable accident locations, either the raw coal stockpile or falling onto the belt through the opening on the S-5 platform.
The U. S. Steel Mining Company, LLC, Pinnacle Preparation Plant is located near the town of Pineville, Wyoming County, West Virginia. The Pinnacle Preparation Plant was commissioned in 1969 along with the Number 50 deep mine. The USX Corporation is the parent corporation of U. S. Steel Mining Company, LLC. The Pinnacle Preparation Plant currently provides employment for 71 hourly and 18 salary employees.
A combination of heavy media vessels, concentrating tables, and froth flotation is used for coal cleaning. The raw coal blending, processing, and load out facilities utilize a fully automated control system with central control interfacing. The plant is rated at 1200 tons per hour and has a capacity of 23,743 raw tons per day. The primary source of raw coal is from the Shawnee Mine longwall plow face supported by continuous mining machines in the Pocahontas No. 3 seam. Currently, the Pinnacle Preparation Plant system blends Pocahontas and Sewell seam coals from deep mine and surface mine sources to provide a broad range of products. The plant works a three-shift seven-day work schedule.
Raw coal handling facilities include truck receiving facilities on the Main Plant side of the Pinnacle Plant site used for surface coals and mine mouth receiving facilities on what is referred to as the Shawnee side of the property. Surface coal is transferred from the Main Plant side truck dump via conveyors to the Shawnee rotary breakers before it is transferred to storage in two 6,000 ton silos. The deep mine coal is delivered by the Shawnee slope belt S-10 to a screen/rotary breaker head house before being transferred via conveyor S-5 to the raw coal stacker tube and raw coal stockpile. Mine personnel reported as much as 180,000 tons of storage in the reclaim stockpile. The raw mine coal is reclaimed from the stockpile by dozers pushing to two FMC Syntron stockpile feeders (�A' and �B'). Reportedly, the �A' feeder is primarily used to reclaim and feed coal onto conveyor S-3 from the stockpile at a normal rate of 1250 tons per hour. The deep mine raw coal travels from the reclaim stockpile on conveyors S-3 and S-3B and is then transferred to conveyor No. 24 which normally feeds coal into the 6,000 ton Silo �B' (deep mine silo). Conveyor belt No. 24 can deliver either strip coal or deep mine coal and can be used to deliver a blended raw coal feed. Conveyor belt No. 24 is capable of feeding into �A' or �B' Silo depending on flop gate position.
DESCRIPTION OF THE ACCIDENT
On Wednesday, March 14, 2001 at 4:00 p.m., as the afternoon shift began, miners met in the plant mine office where each miner was assigned duties by Earl Farmer, plant foreman. Donald C. Cook was assigned to walk the mountain refuse belt down to the Preparation Plant at the start of the shift. Cook, along with James Harmon, a mobile equipment operator, drove a company pick up truck to the top of the refuse dump. Harmon went to his assigned duty of operating a dozer and Cook began his assigned duties of walking the mountain refuse belt down to the Preparation Plant.
Cook arrived back at the plant office between 5:45 p.m. and 6:00 p.m., where he met with Farmer who sent Cook over to the Shawnee side of the plant to work as the dump attendant to watch the slope system and clean around the reclaim tunnel. Cook arrived at the old rotary dump a little after 6:00 p.m. placing his cap light and belt on a tool box and his lunch bucket in the old dump control room where he spoke briefly with three miners that were in the control room. At 6:15 p.m., Farmer saw and talked briefly with Cook at the reclaim tunnel where he had been assigned to work. A short time later Cook was heard on the company radio talking with the plant control room operator Ron Rose, indicating that the S-6 chute was clear to start the system back up. Randy Blankenship, mobile equipment operator, saw Cook between 6:30 and 6:45 p.m. washing off the concrete pad at the mouth of the S-3 tunnel with a one and one-half inch fire hose. Cook was later heard at about 7:00 p.m. talking with Farmer on the company radio about needing coal sampling bags brought over to the Shawnee dump. Dave Wilson, mechanic, heard the conversation between Cook and Farmer and told Farmer that he and Mills would get the bags after lunch and bring them back over to the Shawnee dump for Cook. Wilson and Mills went to get the bags for Cook. On their way over to the plant, they ran into Blankenship who was bringing the sampling bags. Blankenship gave Wilson and Mills the sampling bags. They delivered the bags to the dump location about 9:00 p.m. They did not see Cook at this time. About 10:15 p.m., Wilson and Mills were loading their truck with parts to take back to the Preparation Plant side when they realized they had not heard or seen Cook for a long period of time. Wilson called for Cook on the company radio and Ron Rose, the control room operator, called with no answer. Wilson and Mills made a quick search through the Shawnee dump facility trying to locate Cook with no success. Wilson contacted Farmer about 10:30 p.m. and told him they could not locate Cook. Farmer took Johnny Stone and Payton Hale, two plant employees, to the Shawnee side of the plant and along with personnel at the dump made another search of the dump and area around the dump. Farmer had the Shawnee Side of the plant shut down at 11:15 p.m. while plant employees continued searching for Cook. At 11:40 p.m. the midnight shift foreman, Johnny Vance and Farmer began notifying Preparation Plant managers that an employee was missing.
The Mine Safety and Health Administration was notified at 12:15 a.m., March 15, 2001 by Chris Presley, manager of safety for the plant. Donald Kelley, a dog handler for the West Virginia Forestry Service brought a trained search and recovery dog to the Preparation Plant at the operator's request. The dog's search of the Shawnee side of the plant revealed all areas the victim had traveled during his shift (see sketch). While the dog searched the Shawnee dump location, personnel sifted through the new refuse deposited on the impoundment, nothing was found. After the dog completed two searches of the Shawnee side, plant managers directed personnel to sift through the raw coal stock pile around a stacker tube with end loaders, but nothing was found. The raw coal feeder in the reclaim tunnel was emptied and the reclaim belts were searched with nothing being found. The West Virginia State Police arrived about 9:30 a.m. Their search and rescue team had been put on notice along with cadaver dogs.
At 10:00 a.m. MSHA personnel equipped with a thermal imaging camera, along with plant personnel, began to search the raw coal silos and raw coal stacker and surrounding areas for heat sources in an effort to locate the missing miner. All heat sources identified were examined with nothing being found. At 11:00 a.m. a decision was made by plant management to start unloading the �B' raw coal silo with personnel watching the plant feed belt. The �B' silo is fed by the belt system from the Pinnacle raw coal feeders located on the Shawnee side of the plant where the victim was last seen working. This silo had been used during the time they thought the victim disappeared. The silo had approximately 4000 tons of raw material in it at the time the unloading began. Plant management had employees conduct another search of all transfer points, chutes, belts and breakers in the system during the time the �B' silo was being unloaded. The �B' silo was unloaded with nothing found; and unloading of the �A' silo began.
At 6:00 p.m. a miner's black hard hat was observed on top of material in the �A' raw coal silo by personnel located on top of the silo using a flood light looking into the silo as it was being unloaded. The silo draw down was stopped and discussions were held with all persons involved in the recovery on how to proceed. At 6:30 p.m. the unloading of the �A' silo resumed and at 7:55 p.m., March 15, 2001, the victim was recovered from the conveyor feed belt unloading the �A' silo. The victim was transported by ambulance to the Charleston Medical Examiner's office for autopsy.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration was notified at 12:15 a.m., on March 15, 2001, that a Preparation Plant employee was missing. MSHA personnel arrived at the plant site at 7:00 a.m. to assist in the search and secure the accident site. A 103(k) Order was issued at 8:00 p.m. to ensure the safety of the miners. The MSHA investigation team arrived at 10:00 a.m. on March 16, 2001 and along with the West Virginia Office of Miners' Health, Safety and Training, jointly conducted the accident investigation with the assistance of mine management and representatives of the United Mine Workers District office and representatives of the Pinnacle Preparation Plant personnel. A list of those who were present and/or participated in the investigation is included in the Appendix.
At this time, all parties were briefed by mine management personnel as to the circumstances surrounding the accident and all the efforts made to locate the victim.
On March 16, 19, and 20, 2001 representatives from all parties conducted the on-site investigations. Photographs were taken and relevant measurements and sketches were made of the accident site.
Interviews of individuals known to have knowledge of the facts before and after the accident were conducted in the U. S. Steel Mining Company, LLC, Pinnacle Preparation Plant conference training room at Pinnacle, Wyoming County, West Virginia on March 16 and 19, 2001 and April 9, 2001.
The physical portion of the investigation was completed March 19, 2001 and the 103(k) Order was terminated.
All records provided showed that training given to Cook was in accordance with 30 CFR Part 48.
The examination record books indicated that daily examination of surface areas and surface facilities were being conducted in accordance with 30 CFR Part 77.
1. The victim could have fallen from the raw coal conveyor S-5 catwalk, the top of the stacker tube at the head chute area, or could have been accidently pushed into the reclaim feeder by a dozer after falling on or near the stockpile.
> 2. A dozer operated by Ed Tolliver was used to push coal to the S-4A feeder. Tolliver stated he did not make any contact with the victim that evening except for a sighting at the mechanic's shack and he heard radio communications involving the victim.
3. Conveyor S-5 is 317 feet long and 54 inches wide extending from the rotary breaker area to the top of the stacker tube.
> 4. Equipment guarding, grating, and handrails were in place along the entire length of conveyor S-5.
5. Reportedly, the utility personnel regularly clean the S-5 area, but it was not identified as one of the clean up areas or problem areas on that shift, nor did anyone see the victim at the S-5 location.
> 6. The victim could have entered the reclaim, stockpile feeders by walking directly onto the stockpile from ground level. The search dog from the West Virginia State Division of Forestry tracked the victim's trail in and around his work area including a trail leading from the old mine car rotary dump to a point on the B feeder side of the reclaim stockpile.
7. All mine personnel indicated that the victim would have no reason to go onto the stockpile. Mine personnel are aware of the dangers of a reclaim stockpile and indicated that stockpile safety is emphasized in safety training.
8. Personnel interviewed indicated that once per shift the Utility Man is required to check the reclaim tunnel fan house and escape tunnel, but this does not require walking onto the stockpile. These facilities are accessible from the perimeter of the stockpile.
Factors Associated with the S-3 Platform Location:
1. The platform is located approximately 9 feet above a concrete pad at the mouth of the raw coal stockpile reclaim tunnel. Structural steel supporting conveyors' S-3, S-5, and the S-5 take up towers is located on, above, and adjacent to this pad. A fire deluge facility is located on the pad.
> 2. This concrete pad is a major clean up area assigned to the Utility Man and is reportedly cleaned at least twice per shift. The victim was last seen by a fellow employee (Randy Blankenship) at approximately 6:30p.m. or 6:45p.m. washing the pad/take-up area with a fire hose. Raw coal falls from the S-5 belt onto the pad when conditions cause material to spill.
The last radio contact was at approximately 7:00p.m.
3. Three water hoses were available to clean up the pad area, but the 1-� inch cloth covered fire hose is primarily used.
> 4. According to Thurman Chapman (day shift Maintenance Foreman), he found the 3/4 inch diameter yellow mine service hose the day following the accident over the edge and through the opening in the platform grating, laying along the top of the S-3 conveyor between the roller bracket(s) and the roller(s). Water was dripping slowly from the nozzle and the valve was in the off position.
> 5. The 3/4 inch yellow hose was worn from the rubbing caused by the rollers. The hose was most noticeably rubbed in the area approximately 22 inches to 28 inches from the end of the nozzle. It was estimated that the hose was found extended along the conveyor 12 to 15 feet downstream of the opening in the platform grating.
6. The investigation team found no reason why the 3/4 inch hose would have been left through the platform opening and along the S-3 conveyor. A Utility Man on the day shift reported that the 3/4 inch hose nozzle was laying on the platform at the end of the day shift. It was placed there to keep it out of the way and to keep it from getting covered up in the coal. This Utility Man stated that on occasion he used the platform for access during "down shifts" (conveyors not operating) to perform his clean up duties. The Utility Man also reported that the hose will operate at increased pressure when the booster pump kicks on causing the hose to fling and jerk.
> 7. The platform was dangered off with a "Do Not Enter" sign roped across the bottom of the stairway access and guard rails (hand rails) were in place on the sides of the platform. However, the platform could be accessed by ducking under the sign on the stairs, walking up the stairs, and climbing between the top rail and mid rail of the guard near the stairway landing.
> 8. Reportedly, the platform remained in place after a major conveyor modification about two years ago when conveyors S-5A and S-5B were removed and replaced with the existing S-5 conveyor. A 56 and 3/4 inch by 80 inch opening in the platform grating was the result of removing a chute that was part of the old conveyor system. The opening was 55 inches above the center of the S-3 conveyor belt.
> 9. Illumination was found to be adequate in the platform/concrete pad work area.
1. The weather conditions at the time of the accident were reported to be clear with a bright moon, and cool, with temperatures in the 40's.
2. Inspection of the system revealed that there are few places where a worker could accidentally enter the system in the normal course of duties.
> 3. Primary communication at the site is by radio. The victim carried a radio and his last radio communications were with the Control Room Operator (Ron Rose) and the shift foreman (Earl Farmer) at about 7:00 p.m. Several people reported hearing Cook on the radio concerning the S-8 to S-6 (rotary breaker) chute plugging and the victim requesting sample bags.
4. The victim left his lunch bucket, belt and cap lamp in the meeting and lunch area of the old mine car rotary dump building. Fellow workers, reported that he was very punctual about lunch at 8:00 p.m. His bucket, light, and lunch were found untouched.
> 5. The victim was last seen washing the concrete pad at the mouth of the reclaim tunnel at approximately 6:30 or 6:45 p.m. mine personnel began searching for the victim at about 11:15p.m. and the Main Plant side of the facility was shut down at about 11:50 p.m. the victim was recovered the following day, Thursday, March 15, 2001, at 7:55 p.m.
> 6. The victim was recovered from the plant raw coal feed conveyor under the 6,000 ton raw strip coal Silo �A'. Rescuers reported that the body appeared relatively normal without obvious bruising, cuts, or lacerations and without missing or torn clothing and scuffed shoes. Reportedly, the victim was still wearing his radio (microphone missing) and velcro leg bands.
> 7. The investigating team requested all records and data associated with the PLC (programmable logic controller) automated plant process control system. The company informed the team that these records were not available because the computer system operates on a FIFO (first in first out) system and the data was not captured. The information may have been useful in determining equipment status and reconstructing the sequence of events at the time of the accident and after the accident.
8. The S-3 raw coal reclaim tunnel belt had a capacity of 2500 tons per hour.
9. Signs warning of stockpile danger were posted along the roadway approaching the reclaim stockpile.
> 10. The certificate of death and autopsy by the Medical Examiner of West Virginia stated the cause of death was multiple injuries attributed to a crushing injury to the torso.
It is the consensus of the investigation team that the accident occurred when the victim entered the raw coal conveyor system from one of the following possible locations: 1) fell from the elevated S-5 conveyor belt walkway, 2) walked into the raw coal stockpile and was pushed by a dozer into an active coal feeder, 3) fell onto the S-3 conveyor belt while standing on the side of the belt structure trying to place a 3/4 inch hose on the S-5 platform, 4) fell onto the running S-3 conveyor while pulling the 3/4 inch water hose off the S-5 platform, 5) fell through the opening in the platform grating onto the S-3 conveyor belt while standing on top of the S-5 platform washing the S-5 belt structure and take-up with the 3/4 inch water hose. From any of these possible locations the victim could have been transported over the raw coal conveyor system into the raw coal Silo "A", which resulted in fatal injuries. The direct cause of the accident could not be determined.
1. A 103(k) Order, No. 7162028, was issued to ensure the safety of all miners until the investigation was completed and all areas and equipment were deemed safe.
Related Fatal Alert Bulletin:
The Mine Safety and Health Administration conducted and investigation, and those present and/or participating were as follows:
U. S. Steel Mining Company, LLC
Dan L. Slickel .......... Vice President OperationsPinnacle Preparation Plant Employees
John L. Schroder .......... General Manager
Robert L. Pickett .......... Organization Development Manager
Lacy P. O'Brien .......... Manager Coal Preparation Plant
D. C. Presley .......... Manager of Safety
John T. O'Brien .......... Safety Inspector
F. J. Boskoviclt .......... Director Employee Relations
Jim Bennett .......... Employee Relations
Richard C. Kim .......... Engineer
Eric Gavin .......... Engineer
John W. Smyth .......... Engineer
*Earl R. Farmer .......... Plant Foreman
*Roy O'Neal .......... Plant Foreman
*Troy K. Perry .......... Maintenance Foreman
*Thurman M. Chapman .......... Maintenance Foreman
*James E. Harmon .......... Mobile Equipment Operator*Employees Interviewed
*Allen Couch .......... Mechanic
*Edsel E. Tolliver .......... Mobile Equipment Operator
*Randy E. Blankenship .......... Mobile Equipment OperatorRepresentatives of Miners
*Toney W. Kenneda .......... Utility Man
*Johnny Belcher .......... Utility Man
*Ron L. Rose .......... Central Control Room Operator
*David L. Wilson .......... Mechanic
*Ralph Mills .......... Mechanic
United Mine Workers of America
Gary Trout .......... District 17 RepresentativeWest Virginia Office of Miners' Health, Safety and Training
Greg Norman .......... Local 1713 Safety Committee
James R. Patsey .......... Local 1713 Safety Committee
Allen Palmer .......... Local 1713 Safety Committee
Larry Tolliver .......... Local 1713 Safety Committee
Terry Farley .......... Administrator*Employees Interviewed Mine Safety and Health Administration
Fred B. Stinson .......... Inspector-at-Large
Milton Smallwood .......... District Inspector
Kendall Smith .......... District Inspector
Mike Rutledge .......... Safety Instructor
Donald L. Dickerson .......... Assistant Inspector-at-Large
Jules Gautier .......... Supervisory Coal Mine Safety and Health Inspector
Douglas M. Smith .......... Education Field Services
Jon Braenovich .......... Coal Mine Safety and Health Inspector
Gerald J. Cook .......... Coal Mine Safety and Health Inspector
Jerry Trent .......... Coal Mine Safety and Health Inspector
Curtiss Vance, Jr. .......... Coal Mine Safety and Health Inspector
Walter C. Slomski .......... Mining Engineer, Technical Support