DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(SURFACE COAL MINE)
FATAL POWERED HAULAGE
K. T. Trucking, Inc. (ID No. BUB)
Pratt, Kanawha County, West Virginia
Samples Mine (ID No. 46-07178)
Catenary Coal Co.
Eskdale, Kanawha County, West Virginia
November 1, 2001
Michael G. Kalich
Coal Mine Safety and Health Inspector/Electrical
Approval and Certification
Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release date: April 9, 2002
On Thursday , November 1, 2001, a 25 year old coal truck driver with a total of 5 and 1/2 years experience as a driver, and 4 days experience at this mine site was fatally injured in a surface haulage accident. The victim started his shift at 4:30 p.m. and made one round trip from the mine to the dumping facility prior to the accident. Upon returning to the pit area he parked behind two other trucks that were waiting to be loaded. The victim appears to have exited his truck, walked around to the passenger side and positioned himself between the tractor and trailer, directly in front of the tractor's rear tires. The victim was crushed beneath the tractor tires when the truck drifted forward about 20 feet down a 9.4% grade, and struck the rear of the next truck parked in line.
The Samples Mine, operated by Catenary Coal Co., is located near Eskdale, Kanawha County, West Virginia. Multiple coal seams are mined utilizing the mountaintop removal method. Seams mined include the 7 Block, 6 Block, 5 Block, Lower Stockton, Stockton and Coalburg . Approximately 18,000 tons of clean coal are produced daily on two production and one maintenance shift by 334 employees. Coal is mined utilizing draglines, shovels, front end loaders and coal haulage trucks both off road and over the road types.
Mine officials for Catenary Coal Co. are as follows: Peter Lawson, President; Eddie Turner, Mine Manager; Willie Hudson Jr., General Superintendent; Terry W. Tolley, Safety Manager.
The victim was employed by K.T. Trucking Inc., Contractor I.D. No. BUB. K.T. Trucking owns one truck and employees 22 drivers who operate trucks for Appalachian Trucking Co. Both contractors haul coal for the Samples Mine. Walter Kincaid is the owner of K.T. Trucking Inc.
There was no AAA inspection being conducted at the time of the accident. The last AAA inspection was completed on September 28, 2001.
DESCRIPTION OF THE ACCIDENT
On Thursday, November 1, 2001, at approximately 4:30 p.m., Gary Wayne Moore, victim, reported to work at the Appalachian Trucking Co. garage, where his truck was normally parked. Walter Kincaid, owner of K. T. Trucking Inc., conducted a safety meeting with the afternoon shift drivers. After the meeting he repaired a tail light on the trailer of the victims truck . The victim and the other truck drivers then traveled to the mine site.
The victim arrived at the entrance to the mine at 6:08 p.m. and traveled to the L-South Pit to be loaded. He left the mine site at 7:08 p.m. and traveled to the Paint Creek Terminals Inc., Crown Hill Dock located along the Kanawha River. After dumping his load of coal the victim traveled back to the mine site arriving at the entrance at 7:57 p.m., and proceeded to the L-South Pit. The victim and the other drivers parked their trucks in a staging area above the pit entrance where they waited until the loader operator called for a truck to be loaded.
Richard Duncan, truck driver for Appalachian Trucking Inc., stated that at approximately 8:20 p.m. he felt a bump from the rear of his truck. Upon exiting the cab he saw that the victims truck had struck the rear of his truck resulting in considerable damage to the front of the victim's truck. The drivers side door was open but Moore was not in the cab. As Duncan walked around the truck he saw the victim lying on the ground, face up, on the passenger side of the truck. Duncan attempted to get the victim to respond but could not. Duncan then ran to his truck and used the C.B. radio to call for help. William Caudill, loader operator and EMT, arrived in a few minutes and began to treat the victim. During this time Duncan set the parking brakes and shut off the engine. He stated that the hand control valve, commonly referred to as a "hand jam", was set. This hand control valve sets the trailer brakes but does not serve as a parking brake.
The Kanawha County Ambulance Authority was called at 8:26 p.m. and arrived at 8:46 p.m. The victim was transported to the state medical examiners office where he was pronounced dead. The medical examiner determined that the victim died from multiple crushing injuries.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) was notified of the accident by Terry Tolley, Safety Manager, at 8:45 p.m., Thursday, November 1, 2001. MSHA personnel and representatives of the West Virginia Office of Miner's Health, Safety and Training immediately traveled to the mine and jointly conducted the investigation. A 103(k) order was issued to ensure the safety of all persons until completion of the investigation.
Photographs, sketches, audio/video recordings, and an engineering survey of the accident area were made on November 2, 2001. Interviews of persons considered to have knowledge of the facts surrounding the accident were conducted on November 2, 2001. The onsite portion of the investigation was completed and the 103(k) order terminated on November 3, 2001.
Training records were reviewed and required training was found to be in compliance with 30 CFR, except Part 48.27, task training. Several drivers interviewed during the investigation did not understand the trucks braking system and admitted to exiting their trucks without setting the parking brakes. A citation was issued for inadequate task training.
1. The tractor portion of the combination tractor-trailer was a 1995 Kenworth with a single steering axle and tandem drive axles, VIN 1XKWDBOX6SJ643994. The tractor was powered by a Caterpillar engine with a two stage engine brake and a Fuller 15 speed transmission. The trailer portion of the combination was a 1986 R&S tandem axle dump body trailer, S/N 1R9D32203G0011274.
2. A weigh ticket for the tractor-trailer's previous load indicated that the tare weight of the tractor-trailer combination was approximately 38,050 pounds at the time of the accident.
3. The tractor brake system consisted of 6 air applied S-cam type service brakes, with brakes on each side of the front steering axle and the two rear drive axles. A spring applied, air pressure released parking brake, integral to the service brakes, was present on all 4 brakes on the two drive axles. The service brakes of the tractor could be applied using a foot brake pedal. The parking brakes of the tractor could be applied manually with a parking brake valve in the operator's cab (yellow control knob) or automatically from a loss of primary and secondary service reservoir pressure. The brake chambers were type 20 on the front steering axle and piggyback type 30 on the two rear drive axles.
4. The trailer brake system consisted of 4 air applied S-cam type service brakes, with brakes on each side of the two axles. The service brakes of the trailer could be simultaneously applied with the tractor's service brakes using the foot brake pedal or the hand lever under the right portion of the steering wheel to apply only the trailer's service brakes. A spring applied, air pressure released parking brake, integral to the service brakes, was present on all 4 brakes on the two axles. The parking brakes of the trailer could be applied manually with a parking brake valve in the operator's cab (separate from the tractor's parking brake valve) or automatically from the loss of primary and secondary service reservoir pressure. The brake chambers were piggyback Type 30.
5. The supply reservoir used a parallel connection to supply both the primary service reservoir and the secondary service reservoir. The primary service reservoir provides supply pressure for the tractor's drive axle brakes. The secondary service reservoir provides supply pressure for the tractor's steering axle service brakes. A double check valve allows either the primary service reservoir or the secondary service reservoir to supply pressure to charge the single air reservoir on the trailer.
6. A pressure loss within either the primary or secondary service reservoirs trigger both an audible alarm and a visual warning light. Check valves within the air system allow the air from the supply reservoir to flow into the primary service reservoir in the event that the primary service reservoir experiences a pressure loss while isolating the secondary service reservoir from the supply reservoir. The same occurs when the secondary service reservoir experiences a pressure loss thus isolating the primary service reservoir from the supply reservoir. The service reservoir with the highest pressure controls the automatic application feature of the spring brake control valves for both the tractor and the trailer spring brakes. Thus a pressure loss only in the secondary service reservoir will trigger the audible alarm and the warning light but it would not provide automatic spring brake application for either the tractor or the trailer. The same response would occur if only the primary service reservoir experienced a pressure loss.
7. The accident site was surveyed by mining company personnel using Global Positioning System equipment. It was determined that the grade in the accident area was 9.4%. The truck had been parked on this grade in the downhill direction.
8. The truck engine was found running with the low air warning buzzer activated. The hand valve lever (hand jam) for the trailer's service brakes was applied. The spring applied parking brakes were not applied.
9. Brake system tests performed after the accident revealed the following: The tractors parking brake (spring brakes) held the empty tractor-trailer combination when tested on the 9.4% grade. The trailer's parking brake (spring brakes) held the empty tractor-trailer combination when tested on the 9.4% grade. The trailer's service brakes held the empty tractor-trailer combination when tested on the 9.4% grade using the hand valve lever (hand jam).
10. An intermittent air leak was found in the glad hand service line connection on the front passenger's side of the trailer. This glad hand was supposed to be connected to one of the red lines on the tractor and was found disconnected after the accident. Disconnecting this line would immediately release the control signal to the trailer's service brake relay valves. This would cause the service brake relay valves to release the air pressure within the service brake air chambers of the trailer. There was also an air leak in the trailer gate valve.
11. There were four air supply lines in the fifth wheel area on the tractor. Two of these air lines were blue in color and two of them were red in color. Only the two red lines were needed for the trailer being used at the time of the accident. One blue line was to be used for a trailer with a cab controlled air operated tailgate and the second blue line was to be used for a trailer with an air suspension.
The accident was caused by failure to set the vehicle parking brake, block the truck against movement, inadequate task training, and air leaks on the truck. The trailer service side air supply hose was found disconnected. Disconnecting this hose would cause the brakes to release. An air leak was found in the service side air supply hose glad hand connection and the trailer dump gate valve.
A 103(k) Order, No. 7188740 was issued to Catenary Coal Company to ensure the safety of the miners until the investigation could be completed.
A 104(a) citation No. 7188743 was issued to K.T. Trucking Inc. for a violation of 77.1607(a), stating in part that the coal truck was left unattended without the parking brake being set or the wheels blocked.
A 104(a) citation No. 7188745 was issued to K.T. Trucking Inc. for a violation of 77.404(c), stating in part that repairs or maintenance were performed on the coal truck while the engine was running and the truck was not blocked against motion.
A 104(a) citation No. 7188747 was issued to the K.T. Trucking Inc. for a violation of 48.27(a), stating in part that task training was inadequate.
A 104(a) citation No. 7188744 was issued to Catenary Coal Company for a violation of 77.1607(a), stating in part that the coal truck was left unattended without the parking brake being set or the wheels blocked.
A 104(a) citation No. 7188746 was issued to Catenary Coal Company for a violation of 77.404(c), stating in part that repairs or maintenance were performed on the coal truck while the engine was running and the truck was not blocked against motion.
A 104(a) citation No. 7188748 was issued to the Catenary Coal Company for a violation of 48.27(a), stating in part that task training was inadequate.
Listed below are the persons furnishing information and/or present during the investigation:
Catenary Coal Company
Terry Tolley .......... Manager of SafetyK.T. Trucking, Inc.
Eddie Turner .......... Mine Manager
Donald Lemar .......... Superintendent
Mike Colgrove .......... Miners Representative
Bryant Fletcher .......... Miners Representative
Norris Dyer .......... Safety Technician
Jeff Calwell .......... Engineer
*Larry Dickerson .......... Loader Operator
*William Caudill .......... Loader Operator/EMT
Mark Heath .......... Attorney, Heenan, Athen & Roles
*Walter Kincaid .......... OwnerLittle Larry Trucking
*Richard Duncan .......... Truck Driver
*Thomas Barber .......... Truck Driver
Larry Dangerfield .......... OwnerWest Virginia Office of Miner's Health,Safety and Training
*Jonathan Slate .......... Truck Driver
Terry Farley .......... Health and Safety Administrator*Indicates persons interviewed
Gary S. Snyder .......... Inspector-at-Large
Terry L. Keen .......... Surface Mine Inspector
Mike Rutledge .......... Safety Instructor
Mine Safety and Health Administration
M.G. Kalich .......... CMS&H Inspector (Electrical/AI)
Sherman Slaughter .......... CMS&H Inspector (Surface/AI)
Harold Hayhurst .......... CMS&H Inspector/AI
Gilbert Young .......... CMS&H Inspector/AI
Jim Beha .......... Coal Mine Safety & Health Specialist/Accident Investigation Coordinator
Aubrey Castanon .......... Supervisory CMS&H Inspector
Terry Marshall .......... Tech Support (Mechanical Engineer)
Kirk Harmon .......... EFS Specialist
Leo Ingram .......... CMS&H Inspector (Surface)
Ron Skaggs .......... CMS&H Inspector/AI