DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(UNDERGROUND COAL MINE)
FATAL FALL-OF-ROOF ACCIDENT
Cedar Grove Mine No. 1 (ID No. 46-08603)
Independence Coal Company, Inc.
Montcoal, Raleigh County, West Virginia
August 27, 2001
Roger D. Richmond
Coal Mine Safety and Health Inspector
Joseph A. Cybulski
Pittsburgh Safety and Health Technology Center
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mt. Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: February 5, 2002
On August 27, 2001, at approximately 4:50 P.M. Gregory Barron, age 47, continuous-mining-machine operator, was fatally injured when he was struck by a rock brow measuring approximately 81 inches in length, 9 � inches to 25 inches wide, and 7 to 15 inches thick. Barron had been operating a continuous miner in the face of the No. 5 entry from an unsafe position under the rock brow. The approved roof control plan was not being followed in that the roof and/or ribs were not supported or controlled to protect persons from falls of the roof and ribs. Bolt spacing in the accident area exceeded maximum allowable distances and reflectors to aid miners in determining positions for maximum safety were not hung in the No. 5 entry. The victim was recovered, brought to the surface, and transported by Whitesville Ambulance Service to Raleigh General Hospital where he was pronounced dead at 6:40 P.M. by Dr. Anita Mayback, M.D.
Independence Coal Co., Inc., Cedar Grove Mine No. 1, ID No. 46-08603, is located in Montcoal, Raleigh County, West Virginia. The mine is accessed by 6 drift portals into the Upper Cedar Grove seam. The coal seam is typically 36 to 52 inches thick and averaged 43 inches at the accident scene.
Employment is provided for forty underground and three surface employees. The mine operates three shifts per day, six days per week, producing 900 to 1200 tons of raw coal daily from two continuous-mining-machine units. Coal is transported from the face to the section dumping point by shuttle cars, and on to the surface via a belt-conveyer. Brookville track motors are used to transport employees, supplies, materials, and equipment into and out of the mine.
The Cedar Grove No. 1 mine has a blowing ventilation system, utilizing a single main fan that produces 350,000 cubic feet of air per minute (cfm). The mine liberates approximately 9,000 cubic feet of methane gas in a 24 hour period. Face areas are ventilated using exhausting line curtain during development.
The roof-control plan in effect at the time of the accident was approved by the Mine Safety and Health Administration on January 26, 2001. The immediate main roof consists of 5 to 20 feet of Shale, 1 foot coal, and 8 feet of shale. The approved roof-control plan requires fully-grouted resin bolts, a minimum length of 48 inches, to be installed on a 4-5 feet wide by 4 feet long pattern.
The principle officers for Cedar Grove Mine No. 1 at the time of the accident were Mark Clemens, President; Roger Nicholson, Secretary; Jeff Jorosinski, Treasurer; and Raymond Coleman, Safety Director. The miners were not represented by the UMWA.
The last Mine Safety and Health Administration (MSHA) Inspection (AAA) was completed on June 20, 2001.
The Non-Fatal Days Lost (NFDL) incident rate during the previous quarter was 6.31 for underground mines nationwide and 8.18 for this mine.
DESCRIPTION OF THE ACCIDENT
On Monday, August 27, 2001, at approximately 3:30 P.M., the second shift crew entered the mine accompanied by the section foreman, Freddy Terral. Upon arriving at the No. 1 main section, the employees proceeded to their respective jobs. Day shift section foreman, Bruce Gilmore, conducted the preshift examination between 2:00 P.M. and 2:30 P.M. According to Gilmore, the right rib of the No. 5 entry, approximately 80 feet inby spad No. 800, was sheared off after the preshift examination was conducted. This created a large rock brow measuring approximately 81 inches in length, 25 inches wide at the outby end, 9 � inches wide at the inby end, 7 inches thick on the inby side, and 15 inches thick on the outby side. The brow was not supported prior to the second shift continuous-mining-machine operator, Gregory D. Barron's (victim), arrival on the No. 1 mains section, No. 5 entry. Terral, the second shift section foreman, conducted his onshift examination at 3:52 P.M. and placed his initials, date, and time on the right rib of the No. 5 entry approximately 3 feet to the right of the rock brow. Barron, the continuous-mining-machine operator, began mining in the face of the No. 5 entry and had mined approximately 22 feet on the right side of the entry and approximately 24 feet on the left side when the accident occurred. Barron was standing between the 3rd and 4th row of roof bolts under the unsupported rock brow when it fell. According to the roof control plan, he should have been standing outby the 4th row of bolts. This is due to the 1st and 2nd row of bolts being rendered ineffective because of a broken bolt in the 2nd row. Warning devices (reflectors) required by the plan to show the operator the location of the last two rows of permanent support were not posted in this entry.
Brandon Davis, shuttle car operator, had hauled several loads, and needed to haul about 4 or 5 more shuttle cars to complete mining in the No. 5 face. Apparently the rock fell on Barron while Davis was en route to or from the section dumping point. Upon his return to the continuous miner for another load, Davis noticed that a large rock had fallen on Barron. Davis attempted to remove the rock, but was unsuccessful. He yelled for Larry Presley and Andrew Hall, who were installing roof bolts in the No. 4 left crosscut approximately 80 feet away for help. When Presley and Hall heard Davis yell, they ran to help. Davis and Hall lifted the rock to get the pressure of the rock off of Barron. Presley ran to get Freddy Terral, the section foreman, and Donald Farley, the section electrician, who was working on a shuttle car in the No. 3 entry, 2 crosscuts outby the No. 5 face. Paul Martin, the section scoop operator, was cleaning between the No. 6 and No. 7 entries so that the crosscut could be spot bolted. Martin heard someone yell, so he went to the No. 5 entry. Martin, Davis, and Hall were able to move the rock off of Barron. Martin went to get the first aid materials, while Farley conducted the primary assessment on Barron. Farley thought he detected a faint, weak pulse and shallow breaths. Farley continued his assessment by opening Barron's shirt. At this time, he could not detect breathing. Terral and Farley then began CPR.
To save time, Hall went back to his roof bolt machine and got some fly boards to use as a stretcher. Barron was placed on the fly boards and carried about 160 feet where he was transferred to a stretcher. He was then carried to the man bus and transported to the outside. Terral and Farley continued CPR on Barron from the time they began at the accident site until they turned his care over to the attendants of the Whitesville Ambulance Service on the surface.
Barron was transported by Whitesville Ambulance Service to Raleigh General Hospital where he was pronounced dead at 6:40 P.M. by Dr. Anita Mayback, M.D. Barron's death was the result of multiple injuries sustained from the accident.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 6:00 P.M., on August, 27, 2001, that a serious accident had occurred. MSHA accident investigators were dispatched to the mine. A 103(k) order was issued to insure the safety of the miners until the accident investigation could be completed. The investigation was conducted in cooperation with the West Virginia Office of Miners' Health, Safety, and Training (WVMHST), with the assistance of the operator and their employees. A list of those persons who participated, were interviewed, and/or were present during the investigation are listed in Appendix A of this report.
Representatives of MSHA, WVMHST, and the company traveled to the underground accident scene to conduct a thorough investigation of existing physical conditions. Photographs, video recordings, and relevant measurements were taken. Sketches and a survey were also conducted of the site.
Interviews with persons who had knowledge of the accident were conducted on August 28 and 29, 2001, in the Independence Coal Co., Inc. training building. Additional interviews of personnel who had refused to participate in earlier interviews was conducted in the conference room of the WVMHST office in Charleston, West Virginia, on September 11, 2001. The investigation also included a review of training records and records of required examinations. The physical portion of the investigation was completed on August 28, 2001.
A review of the training records indicated that training had been conducted in accordance with 30 CFR, Part 48, and was up-to-date.
Examination of records and on-site evidence indicated that the required examinations were not being conducted adequately and were not being recorded in accordance with 30 CFR, Part 75.
1. The accident occurred on the 001 Section in the No. 5 entry approximately 80 feet inby survey station 800. The 001 Section is a room-and-pillar Super Section being developed with 2 continuous-mining-machines. The 001 Section is projected as a 7 entry panel to be driven in a northwesterly direction on 80-feet by 80-feet centers. Maximum entry and crosscut width specified in the Roof Control Plan is 20 feet. Entry width at the accident site was 17.2 feet. The 001 Section was being driven off a set of submain entries that had been developed in late 2000 and early 2001.
2. The victim was operating a Joy continuous-mining-machine, via remote control, at the face of the No. 5 entry when the accident occurred. The depth of cut in the No. 5 entry at the time of the accident was approximately 24 feet. There was no eye witness to the accident.
3. The portion of the brow that fell and struck the victim was created when the right rib in the No. 5 entry just inby the last open crosscut was slabbed on the previous shift. Prior to slabbing, the roof and ribs in the No. 5 entry had been bolted. It appeared that a previously installed rib bolt was cut during the slabbing of the right rib in the No. 5 entry. A portion of the rebar was visible in the rib and a 29-inch-long section of threaded rebar was observed in the rubble at the accident scene.
4. The section of brow that struck the victim was approximately 81-inches-long, 9 � -to 25-inches-wide, and 7 - 15-inches thick. The rock that struck the victim was a continuation of large brow that extended from the left rib in the No. 5 entry (at the outby corner of the last open crosscut) across the entry toward the right rib and continued up the entry to the accident scene. The majority of the brow appeared to have been created during the completion of the crosscut between the No. 4 and No. 5 entries.
5. Coal seam height at the accident site was approximately 43 inches. About 4 to 5 feet of rock immediately above the coal was also mined, resulting in a typical mining height of 8 to 9 feet. Mining height at the accident site was approximately 43 inches. The strata above the coal seam consists of shale with coal streaks and carbonaceous shale.
6. Primary roof support consisted of 6-feet-long, 3/4 inch-diameter, grade 60, threaded rebar installed in conjunction with a mixing/tensioning nut and an 8-inch by 8-inch donut- embossed bearing plate. Grouted length was 3 feet.
7. The maximum bolt spacing specified in the Roof Control Plan is 4 feet between bolt rows, 5 feet between bolts in the same row, and 4 feet between the rib and the outside bolts. Bolt spacing at the accident site exceeded the maximum specified in the Roof Control Plan. The distances from the rib to the three outside bolts adjacent to the failed rock brow were 50, 56, and 58.5 inches respectively. In addition, the tensioning nut and bearing plate of one of the middle bolts in the second bolt row outby the face in the No. 5 entry had been knocked or cut-off.
8. A portion of the larger brow along the right rib in the No. 5 entry immediately outby the accident scene had been supported with roof bolts.
9. Roof bolts had been installed to within 15-18 inches of the rib at various locations on the 001 Section.
10. Significant pillar sloughage was observed on the 001 Section. Rib support, using the same type threaded rebar bolts installed in the roof, was being installed in some locations of the 001 Section. Overburden at the accident site is approximately 700 feet. Overmining and undermining exist near the current operations at the Cedar Grove Mine No. 1. The Powellton seam, approximately 280 feet below, has been mined in the vicinity of current mining operations in the Cedar Grove No. 1 Mine. Mining has also been conducted in the Winifrede seam which is about 600 feet above Cedar Grove No. 1 Mine.
11. Reflectors, required by the Roof Control Plan, had not been placed on the second row of bolts outby the face in the No. 5 entry.
It is the consensus of the investigation team that the fatal accident occurred because provisions of the approved roof control plan were not followed and adequate workplace examinations were not conducted prior to Gregory Barron, continuous mining machine operator, beginning mining in the No. 5 entry. Barron was positioned under an unsupported rock brow when it fell. The rock brow was created when the right rib of the No. 5 entry was sheared to increase entry width. The brow was not reported or corrected during required preshift and onshift examinations. Reflectors required by the approved plan to aid equipment operators "in determining their positions for maximum safety" during mining operations were not hung in the active face of the No. 5 entry.
1. A 103(k) Order No. 7205801 was issued to ensure the safety of all persons in the mine until an investigation was completed and all areas and equipment were deemed safe.
2. A 104(d)(1) Citation No. 7205804 was issued citing 30 CFR 75.202(a). The roof and/or ribs were not supported or otherwise controlled to protect persons from hazards related to falls. A large rock brow measuring approximately 81 inches in length, 9 � inches to 25 inches wide, and 7 inches to 15 inches thick fell and hit the continuous-mining-machine operator who was working under the unsupported brow. This violation occurred on August 27, 2001 and was a contributing factor in a fatal accident.
3. A 104(d)(1) Order No. 7205805 was issued citing 30 CFR 75.220(a)(1). The approved roof control plan was not being followed in that reflectors were not placed on the 4th row of bolts outby the face to aid the continuous-mining-machine operator to determine his position for maximum safety during mining operations. The integrity of the 1st and 2nd rows was destroyed when a bolt was sheared off in the 2nd row outby the face. This violation occurred on August 27, 2001, and was a contributing factor to a fatal accident.
4. A 104(d)(1) Order No. 7205806 was issued citing 30 CFR 75.220(a)(1). The approved roof control plan was not being followed. The approved roof control plan requires cross-wise spacing of bolts not to exceed 5 feet and stipulates that under no condition shall any person proceed inby the next to last row of permanent roof supports. A bolt in the 2nd row of bolts outby the face in the No. 5 entry was sheared off. This resulted in 2 of the remaining bolts in this row being 8 feet apart. This rendered the last 2 rows of bolts ineffective. The 4th row of bolts then became the next to the last row of permanent supports. The continuous-mining-machine operator positioned himself inby the 4th row of bolts in violation of the plan. This violation occurred on August 27, 2001, and was a contributing factor in a fatal accident.
5. A 104(d)(1) Order No. 7205807 was issued citing 30 CFR 75.360(b)(3). An inadequate preshift examination was conducted by the day shift section foreman on the No. 1 section on 08/27/2001. Obvious hazards were not reported or corrected in the No. 5 face of the No. 1 section. Obvious hazards also existed throughout the No. 1 section that should have been recorded in the preshift examiner's log, including sloughing of the ribs, wide bolt spacing, and deteriorating roof around the existing roof bolts resulting in bearing plates not being firm against the mine roof. Also, a large rock brow was created by the shearing of the right rib of the No. 5 face of the No. 1 section on the day shift. This condition was not reported in the preshift examiner's log prior to the evening shift starting to work. This was a contributing factor to a fatal accident.
6. A 104(d)(1) Order No. 7205808 was issued citing 30 CFR 75.362 (a)(1). An inadequate onshift examination was conducted in the No. 5 entry of the No. 1 section by the evening shift section foreman. Date: 8/27/01, time: 3:52 P.M., and initials: F.T. of the examiner were present at the accident scene. Obvious hazards were not corrected prior to the continuous-mining-machine operator commencing mining in the No. 5 face. A large unsupported rock brow was created by the day shift's shearing of the right rib in the No. 5 entry. This condition should have been observed and corrected by the section foreman prior to mining the No. 5 face. This was a contributing factor to a fatal accident.
Related Fatal Alert Bulletin:
The Mine Safety and Health Adminstration conducted an investigation and those present and/or participating were as follows:
Independence Coal Co., Inc.
Chris Adkins ............... Director of ProductionWest Virginia Miners' Health, Safety, and Training
Richie Henderson ............... Vice President, Independence Coal Co., Inc.
Raymond Coleman ............... Safety Director
Roger Marcum ............... Chief Electrician
Jim Gay ............... Vice President of Engineering
Shane Harvey ............... Attorney
Dave Hardy ............... Attorney
H. Drexel Short ............... Massey Coal Services
Mark Clemens ............... President, Independence Coal Co., Inc.
Norman Hill ............... Superintendent, Justice Mine
Frank Foster ............... Safety Director for Massey Coal Sales
Larry Ward ............... Vice President, Marfork Coal Co.
David Miller ............... Safety Technician
Freddy Terral ............... Second Shift Foreman
Doug Conaway ............... DirectorMine Safety and Health Administration
Terry Farley ............... Health & Safety Administrator
Davitt McAteer ............... Consultant
Jerry Pauley ............... District Underground Inspector
Alvin Sowder ............... Roof Control Inspector
Gary Snyder ............... Inspector At Large
Mike Rutledge ............... Safety Inspector
Bill Tucker ............... District Underground Inspector
Eugene White ............... District Underground Inspector
Kerry Heron ............... District Underground Inspector
Roger Richmond ............... CMS & H Inspector/Accident Investigator
John A. Braenovich ............... CMS & H Inspector/Mining Engineer/ Accident Investigator
Jim Beha ............... CMS & Health Specialist/Accident Investigation Coordinator
Charlie Woolridge ............... CMS & H Inspector
Fred Wills ............... CMS & H Inspector
The following persons were interviewed during this investigation:
Richie Henderson ............... General Manager, Independence Coal Co., Inc.
Steve Linkous ............... Mine Superintendent
Freddy Terral ............... Second Shift Foreman
Bruce Gilmore ............... Day Shift Foreman
James Clark ............... Third Shift Foreman
Larry Presley ............... Roof Bolter Operator
Andrew Hall ............... Roof Bolter Operator
Donald Farley ............... Electrician
Paul Martin ............... Scoop Operator
Jeremy Burdette ............... Shuttle Car Operator
Brandon Davis ............... Shuttle Car Operator
George Bailey ............... Miner Operator
Danny Dickens ............... Miner Operator