DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Underground Coal Mine
Fatal Powered Haulage Accident
April 19, 2001
Powhatan No. 6 Mine (I.D. No. 33-01159)
The Ohio Valley Coal Company
Alledonia, Belmont County, Ohio
Daniel L. Stout
Charles J. Thomas
Coal Mine Safety and Health Inspector
Mine Safety and Health Administration
5012 Mountaineer Mall
Morgantown, West Virginia 26501
Timothy J. Thompson, District Manager
Release Date: August 9, 2001
At approximately 8:45 p.m. on Thursday, April 19, 2001, a fatal powered haulage accident occurred at the 2nd Main North belt conveyor take-up unit located adjacent to the 6 West track switch. Thomas M. Ciszewski, a 45 year old belt foreman with 22 years mining experience, suffered fatal injuries when he came in contact with the rotating stationary belt roller and moving belt just inby the 2nd Main North belt drive motors. The working sections were engaged in coal production. Ciszewski was assigned to conduct a routine belt maintenance examination of the 2nd Main North belt conveyor system. For unknown reasons, the victim positioned himself inside the belt take-up area by partially removing the installed guarding. Ciszewski's left arm was caught between the belt and rotating belt stationary roller ( See Figure B). His arm was detached. Bleeding profusely from the loss of the limb, Ciszewski managed to retreat a distance of 142 feet to the 6 West track switch (See Figure A). He was treated by Randy Brunner, a belt repairman in the vicinity, who responded to his cries for help. The victim died shortly after the accident at approximately 9:00 p.m.
The Powhatan No. 6 Mine, located in Alledonia, Belmont County, Ohio, is operated by The Ohio Valley Coal Company. The mine employs 389 persons underground and 49 persons on the surface. The mine is opened by one slope and 9 shafts into the Pittsburgh No. 8 Coal Seam, which averages 72 inches in thickness. The mine produces coal three shifts per day on four working sections, seven days a week. Routinely, maintenance and support work are performed on selected idle shifts when the longwall section conducts a retreat electrical power move.
The mine produces an average of 17,574 tons of coal daily. During advance mining, coal is transported from the face utilizing shuttle cars and transported from the section to the surface by conveyor belts. The roof is supported utilizing Fletcher roof bolting machines equipped with automated temporary roof support (ATRS) systems. During longwall retreat mining, the roof is controlled with Meco International 625 ton two leg shields on a 950 feet wide longwall face. Currently, the mine consists of three longwall development sections, and one longwall retreat section. The mine is ventilated by five mine fans and one slope fan. The mine liberates 1.5 million cubic feet of methane per day.
The principal officers of the operation are as follows:
John R. Forrelli .......... President and ManagerThe last Mine Safety and Health Administration (MSHA) regular Safety and Health Inspection (AAA) was completed March 29, 2001
Stephen C. Ellis .......... Secretary
Michael D. Loiacono .......... Treasurer
Roy A. Heidelbach .......... Mine Superintendent
Jerry M. Taylor .......... Corporate Safety Director
DESCRIPTION OF THE ACCIDENT
On Thursday, April 19, 2001, at approximately 5:15 p.m., while conducting a preshift examination on the return side of the belt entry, Scott Meadows and Don Meadows, Preshift Examiners, heard a flapping noise originating from the 2nd Main North belt take-up stationary roller located at 62 break. Both examined the roller by shining their cap lights through the plastic mesh guarding. For a closer observation, Don Meadows knelt to get a profile view of the rotating roller. Unable to determine the cause of the noise, they theorized that centrifugal force could be causing a loose piece of rubber lagging to partially separate from the roller. They thought that the flapping sound could be created when the rotating roller brought the loose lagging in contact with the moving conveyor belt. They did not report the condition and continued to walk along the return side of the belt line. The plastic mesh guarding around the 2nd Main North belt drive and take-up unit was reportedly in place upon their arrival and departure.
Later in the shift, at approximately 8:30 p.m., Randy Brunner and Dennis Miller, Belt Repairmen, parked their trolley jeep at the 61 break on the 6 West mainline track to repair the 1st Main North belt wings, which were located at the 60� break. The wings guide the coal onto the transfer belt as it discharges out of the chute. Because of broken supports, the wings were rubbing the belt. The work assignment was to burn two bolt holes through the supports with an oxygen/acetylene torch, so that the wings could be lifted off the belt and bolted directly to a support rail. After burning the first hole, Brunner returned to the jeep to acquire two �" bolts, washers and nuts.
While there, Brunner saw another trolley jeep approaching his location. Since the headlight of Brunner's jeep was shining in that direction, he climbed on board with the intent of flipping the light off. However, the other jeep stopped at the spur switch at the 63 break. There was only one miner on the jeep and Brunner didn't recognize him. The miner proceeded from the jeep to throw the track switch so he could park in the spur.
Knowing that their task would be completed in another 5 or 10 minutes, Brunner left his jeep and returned to his work site with the two bolts and associated hardware. While burning the 2nd bolt hole and threading the nuts on the two 2" bolts, the belt repairmen could see the cap light of the unidentified miner at the 2nd Main North belt drive take-up unit on the return side of the belt. The distance between them wasn't more than two breaks away, approximately 180' - 200'.
The belt repairmen stated they finished the job at approximately 8:45 p.m. and carried the tools to their jeep. During the estimated 15 minute repair time, the 1st Main North conveyor was reportedly never shut down.
Approximately one minute after arrival at their jeep, the belt repairmen heard a voice calling for help. Looking toward the spur switch, they saw the unidentified miner running and staggering along the track, then falling to the mine floor. Both Brunner and Miller ran to the miner. Upon their arrival, they identified him as Tom Ciszewski, Belt Foreman. Observed injuries were a missing left arm, and facial cuts.
Brunner removed his flannel shirt and used it to apply pressure to the shoulder wound, while Miller ran to a mine phone to call for help. Miller phoned Vic Harding, Dispatcher, to inform him that Ciszewski had lost his left arm, and help was needed immediately. Next, Miller phoned the underground shop and asked Jim Couch and Keith Crall, both Belt Mechanics, to provide assistance.
After being flagged by Miller and Brunner's cap lights, Jeff Kirk and Frank Dubiel, Belt Repairmen, arrived at the site on their trolley jeep. After evaluating the situation, Kirk departed on a trolley jeep to get the shift foreman and a backboard at the maintenance track spur. Dubiel stayed with Miller and Brunner. Shortly thereafter, Couch and Crall arrived from the underground shop.
Brunner, who had been pressing his shirt against the shoulder wound, stated that the victim only breathed and gasped a couple of times. For several minutes, Brunner continued to check but could not detect breathing or a pulse.
After looking for a backboard, Miller traveled to the accident site to locate the arm. The severed arm was laying outside of the guarding in the walkway on the return side of the 2nd Main North belt conveyor, adjacent to the take-up cart (See Figure B). Miller did not remember if any of the guards were down. After retrieving the arm, he returned to where the victim was located along the track.
At the time of the accident, Dave Blake, Shift Foreman, Jim Flood and Dan Palmer, both General Inside Labors, were at the One South Return, approximately 65 breaks from the accident site. Blake was conducting a supplemental workplace examination, while Flood and Palmer were setting up a pump by the maintenance track spur.
Upon arrival at their location, Kirk notified them that someone was hurt really bad - may have lost an arm. Blake told Kirk to call an ambulance and also a Life Flight, since an arm was lost. The underground EMT could not be contacted. The self-contained underground ambulance, located at 21 East Section West, was summoned by Blake.
After grabbing a first aid kit at the maintenance spur, Blake, Flood and Palmer traveled by trolley jeep to the accident site. After his arrival, Blake never left the victim. Blake told everyone to stay away from the accident site. Having been a certified EMT, Blake evaluated Ciszewski. The evaluation revealed that he was pale, unconscious, with no pulse felt at either the carotid or femur artery. CPR was not performed since the victim had been unconscious for 10 minutes or more.
The victim was transported to the surface, where he was pronounced dead by Gene S. Kennedy, M.D., Belmont County Coroner, on April 19, 2001, at 9:00 p.m.
INVESTIGATION OF THE ACCIDENT
At approximately 9:20 p.m. on April 19, 2001, Allen McGilton, Supervisory Coal Mine Safety and Health Inspector of MSHA's St. Clairsville, Ohio, Field Office, was notified by Richard Homko, Safety Director, that a serious accident had occurred. An MSHA initial response team, comprised of McGilton, Clint Fabry and Joseph Yudasz, CMS&H Inspectors, was assembled and traveled to the mine, arriving at 10:15 p.m.. A 103(k) Order was issued to ensure the safety of the miners until an investigation could be conducted. Preliminary information was collected and an underground on site investigation was initiated. Photographs, measurements, and drawings of the accident scene were collected underground. Interviews of persons having information surrounding the accident were scheduled for April 20, 2001, at the Portal of Hope conference room. An Accident Investigation Team, consisting of Daniel Stout, Electrical Engineer, and Charles Thomas, CMS&H Inspector, was dispatched to the mine on April 20, 2001, to continue the investigation and conduct the interviews. Wayne Colley from MSHA's Intrinsic Safety & Instrumentation Branch, Approval and Certification Center, was also dispatched to the mine site to offer assistance.
MSHA and State of Ohio, Division of Mineral Resources Management, jointly conducted the investigation with the assistance of mine management and the United Mine Workers of America miners= representatives. Initial interviews were conducted on April 20, 2001, in the mine conference room with six employees. An additional follow-up interview was conducted on May 23, 2001, with one miner. A list of those who were present and/or participated in the investigation is included in Appendix A.
Since there were no witnesses to the accident, all known facts relative to the accident have been evaluated.
Ciszewski had no known physical impairments or medical condition that would have contributed to his entanglement in the belt roller.Environmental Factors
No oxygen deficiency or air borne contaminants were detected at the accident site.Roof and Rib Condition
There was no evidence of a fall of roof or rib at the accident site that would have caused the victim to become entangled in the belt roller. Brattice cloth that was spaded to the roof above the belt take-up unit showed no fresh cuts or tears. The accident site was adjacent to a crosscut and the entry was approximately 12 to 14 feet high.Mine Floor Condition
The ground was dry around the 2nd Main North belt drive take-up unit. Compacted rock dust and rib sloughage, from the graded belt entry bottom and the elevated crosscut bottom, had accumulated at the take-up unit. After the accident 20 to 24 inches of compacted rock dust and coal was removed from the floor of the walkway adjacent to the accident site.Physical Factors
Investigation of the Flapping Noise
Apparently, an entangled grease hose slapping the conveyor belt caused the flapping noise heard by the preshift examiners. The investigation revealed a 14 foot long grease hose wrapped around the shaft of the stationary take-up roller on the track side of the 2nd Main North belt (See Appendix B, Figure No. 1A). At the end of the grease hose was a metallic connector (See Appendix B, Figure No. 1B). The metallic connector was used for attaching to Zerk grease fittings when equipment was being lubricated. As the end of hose rotated around the roller, the metallic connector would slap against the conveyor belting.Start and Stopping of Belt Conveyor
The mine wide monitoring system indicated the 1st Main North belt stopped at 7:28 p.m. and the slope belt stopped at 9:38 p.m. No shut down of the 2nd Main North belt was indicated near the time of the accident. Brunner and Miller stated that the belt was never off while they were working at the 1st Main North belt location. They had departed their work site only a few minutes before they heard the victim calling for help in the track entry.Equipment Guarding
The equipment guarding, installed around the 2nd Main North belt take-up unit, was constructed of substantial material. The frame of the guarding panels was fabricated from 12 inches PVC piping, configured in a rectangular shape. Stiff plastic mesh was attached to the piping with plastic wire ties. The dimensions of each guarding panel measured 9' 8" wide x 4' 4" high (See Appendix B, Figure No. 3A). The guarding was supported at the top and bottom by "L shaped" hangers. The hangers were constructed from � x 2 inch metal straps. The two preshift examiners reported that the guarding around the 2nd Main North belt take-up unit was in place when they were present, at approximately 5:15 p.m. The initial investigation at the accident site revealed that the two guard panels adjacent to take-up unit on the return side had been removed from their top hangers at one end and were hanging down on the mine floor, creating a 2 inch gap at the top and a 6 inch gap at the bottom between the panels (See Appendix B, Figure No. 3B). In the condition observed, the guard panels could be swung inward or outward. When the victim positioned himself behind the guarding, there was approximately 26 inches of space between the guarding and the moving belt (See Appendix B, Figure No. 2B). A steel jack handle measuring 1 x 24 inches was found partially inside the guarded area and partially in the walkway at the accident site (See Appendix B, Figure No. 2A).Conveyor Belt Condition
The 2nd Main North belt conveyor had several vulcanized splices, and one mechanical splice, that was recently installed. All splices were found in good repair. Since the belt continued to run for approximately 90 minutes after the accident, it was not possible to determine if the victim's clothing was caught by the mechanical splice. During the investigation, the belt was operated several cycles and was running normally. This belt conveyor is approximately one mile in length and normally operates at 700 feet per minute.Area Illumination
No illumination was provided in the 2nd Main North belt drive take-up area. Due to limited light from their cap lamps, the preshift examiners were unable to determine the source of the reported flapping noise while shining their lights through the plastic mesh. Vision was also hampered because the stationary take-up roller was approximately 20 inches from the return side guarding.Training Records and Examinations
A review of the training records indicated that training had been conducted in accordance with 30 CFR Part 48. All records indicate that the required electrical and preshift examinations were conducted and recorded in accordance with 30 CFR Part 75.
The victim contacted and was caught in the pinch point between the moving belt and the stationary roller of the belt take-up unit. The accident occurred when the victim displaced two panels of the installed guarding before removing the electrical power and blocking the machinery against motion. The victim traveled inside the confines of the installed guarding apparently to assess a maintenance concern.
1. A Section 103(k) Order, No. 7132512 , dated April 19, 2001, was issued to the operator to ensure the safety of all persons until an investigation could be completed and the 2nd Main North belt conveyor deemed safe.
2. A Section 104 (a) Citation, No. 7088894, dated May 30, 2001, and modified on June 28, 2001, was issued to the operator for a violation of 30 CFR 75.1722(a). The violation, as modified, reads as follows: ATwo of the rectangular machinery guards installed on the return side of the take-up unit for the 2nd Main North belt drive had been removed from the top hangers at one end and were in contact with the mine floor, indicating that the guards had been swung outward to give persons access to the moving belt and take-up stationary roller. The cited regulation requires that except when testing machinery, guards shall be securely in place while machinery is being operated. Thomas M. Ciszewski, Foreman, was fatally injured on April 19, 2001 at sometime before 9:00 p.m. while conducting assigned duties on the 2nd Main North 54-inch electrically-powered belt conveyor. Apparently during an assessment of the source of a noise at the stationary belt roller, two substantially constructed mesh guarding panels installed on hangers around the belt take-up unit were displaced or repositioned so that he could position himself within the confines of the guarding. Evidence indicates that Ciszewski=s left arm was detached from his body at the shoulder when he became caught in the pinch point between the moving belt and take-up stationary roller and his injuries caused his death shortly thereafter. Based on evidence revealed during the accident investigation, the agent of the operator failed to comply with the regulation by removing or displacing protective guards around the belt take-up unit while the belt and take-up unit were still in operation exposing his body to the moving machinery parts. A loose grease hose that measured over 14' long was discovered wrapped between the bottom belt and the stationary roller located just inby the belt drive motors.
3. A Section 104 (a) Citation, No. 7089484, dated May 30, 2001, and modified on June 28, 2001, was issued to the operator for a violation of 30 CFR 75.1725 (c). The violation, as modified, reads as follows: "Based on evidence revealed during the accident investigation, Thomas M. Ciszewski failed to comply with the cited regulation, when he attempted to repair or perform maintenance on the belt take-up unit, while the belt and take-up unit were still in operation and not blocked against motion. Thomas M. Ciszewski, Foreman, was fatally injured on the April 19, 2001, while conducting assigned duties on the 2nd Main North belt conveyor. While attempting to assess or repair a noise problem on the return walkway side of the belt take-up roller. Mr. Ciszewski had displaced two guarding panels installed on hangers around the belt take-up unit so that he could position himself within the confines of the guarding. Evidence indicates that his left arm was detached from his body at the shoulder, when he became caught in the pinch point between the moving belt and the take-up stationary roller causing his death shortly thereafter."
Related Fatal Alert Bulletin:
Listed below are the persons furnishing information and/or present during the investigation:
The Ohio Valley Coal Company Officials
* Jerry M. Taylor .............. Corporate Safety Director Roy A. Heidelbach .............. Superintendent Robert Sandidge .............. Assistant Mine Foreman * Dave Blake .............. Afternoon Shift Foreman * Edward Bryan .............. Master Mechanic * James Saffell .............. Maintenance Foreman William Benline .............. Belt Coordinator William McLane .............. Belt Coordinator * Don Meadows .............. Support Foreman/Belt Preshift Examiner Scott Meadows .............. Support Foreman/Belt Preshift Examiner Trainee * Richard Homko .............. Safety Director Steve A. Davidovich .............. Safety Inspector
The Ohio Valley Coal Company, Powhatan No. 6 Mine Employees
* Randy Brunner .............. Belt Repairman * Dennis Miller .............. Belt Repairman * Jim Couch .............. Belt Mechanic Vic D. Harding .............. Dispatcher on Surface Jeff Kirk .............. Belt Repairman Frank Dubiel .............. Belt Repairman * Dan Palmer .............. General Inside Laborer * Jimmy Flood .............. General Inside Laborer
United Mine Workers of America
* Ronnie Marquardt .............. Local Union #1810 President * Bob Houston .............. Safety Committeeman Larry Milhoan .............. Safety Committeeman Ted Holland .............. Safety Committeeman
Belmont County Official
Gene S. Kennedy, M.D. .............. Belmont County Coroner
State of Ohio, Division of Mineral Resources Management
Jerry Stewart .............. Manager/Mine Safety Bruce Dean .............. Deputy Mine Inspector, Roof Control Mike Panepucci .............. Deputy Mine Inspector, Electrical
Mine Safety and Health Administration
William A. McGilton .............. Supervisory Coal Mine Safety and Health Inspector Joseph Yudasz .............. Coal Mine Safety and Health Inspector Clint Fabry .............. Coal Mine Safety and Health Inspector Charles J. Thomas .............. Coal Mine Safety and Health Inspector Daniel L. Stout .............. Electrical Engineer Wayne Colley .............. Chief, Intrinsic Safety & Instrumentation Branch, Approval and Certification Center* Denotes persons interviewed