DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Underground Coal Mine
Fatal Electrical Accident
January 24, 2002
Mackie J Coal Company, Inc.
Whitewood, Buchanan, Virginia
ID No. 44-06051
Russell Arden Dresch
Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza
Norton, Virginia 24273
Ray McKinney, District Manager
April 3, 2002
On Thursday, January 24, 2002, at approximately 10:30 p. m., a 42 year-old general inside laborer was fatally injured when he came in contact with an energized high-voltage lead inside the 001 MMU power center. The accident occurred in the No. 5 Entry of 001 MMU approximately 36 feet outby survey station No. 1089 when the crew was moving the section back due to retreat mining. During the process, a section of high voltage cable (approximately 800 feet in length) and a junction box were removed. After the cable was re-stocked into the section power center, problems were encountered with energizing the high-voltage circuit breaker at the surface substation. The foreman/electrician came outside to check the problem. Once the problem was corrected and the power was restored to the section, it was discovered that the phasing was reversed. The underground high-voltage circuit was again deenergized at the surface substation so the phasing in the 001 MMU power center could be corrected. While the victim was working to reinstall the high-voltage leads inside the power center, the circuit was energized from the surface substation, resulting in the electrocution.
The accident occurred due to a confluence of factors. The victim was exposed to electrical shock by working on the high-voltage electrical circuit without proper safety precautions. The victim relied on another person to deenergize the high-voltage circuit and visually verify that all three phases were open. A failure to lock out the disconnecting device, place a suitable tag on it and attach a grounding device to the disconnected portion of the high-voltage circuit collectively contributed to the electrocution of the victim.
The circuit was energized while work was in progress due to an apparent failure in communication. The exact nature of this failure to communicate could not be ascertained due to conflicting testimony.
The high-voltage circuit breaker installed in the surface sub-station to provide fault protection for the underground high voltage circuits was inoperative. This condition resulted in prolonged exposure of the victim to the electrical energy.
A significant factor was the foreman/electrician's continuing practice to work on electrical equipment without using lock out, tag, or grounding devices. This practice was an established habit that the foreman/electrician condoned and exercised.
Contributing to the accident is the victim's lack of qualifications. The victim was a qualified electrician for three years (1980, 1981, and 1982). He has not been a qualified electrician or received annual electrical refresher training for 19 years.
Mackie J Coal Company, Inc., No. 4, I.D. No. 44-06051, is located 1.3 miles off Rt. 363 on Semp Camp Branch near Whitewood in Buchanan County, Virginia. The mine is leased from Jewell Smokeless Coal Corporation. The high-voltage substation and the required maintenance of this station were provided to Mackie J Coal Company, Inc. by Jewell Smokeless Coal Corporation. Mackie J Coal Company, Inc. began mining operations on August 26, 1993.
The mine has three drift openings into the Jawbone coal seam. The only active section is located approximately 2,400 feet from the surface. Mining height ranges from thirty-eight to sixty inches. The last air sample collected did not show any methane liberation. The immediate mine roof typically consists of approximately 6 to 18 inches of fragile to firm shale and the main roof is composed of 10 or more feet of firm shale.
Ten underground miners and two surface personnel are employed at this mine. The mine operates one production shift and one maintenance shift daily. Coal is produced on the continuous mining section (001-0 MMU) on the day shift. At the time of the accident, the 001 MMU was retreat mining. Maintenance and utility work are performed on the evening shift. The mine normally operates five to six days per week and produces an average of 600 tons per day.
A room-and-pillar system of mining is utilized at this mine. Coal is produced using a remotely controlled Joy 14CM5 continuous mining machine, which also has a deck and on-board controls. Coal is transported by three Joy 21SC shuttle cars from the face areas to the belt conveyor and then on to the surface via a series of belt conveyors. Trucks are employed to haul the raw product from the mine. A Fletcher single-boom roof bolting machine is used to install permanent mine roof support. Employees and supplies are transported to the section via battery-powered, rubber tire haulage equipment.
The Mine Safety and Health Administration (MSHA) completed the last health and safety inspection of the mine on December 12, 2001. The mine Non-Fatal Days Lost (NFDL) rate for calendar year 2001 was 9.02, while the industry average was 7.86.
DESCRIPTION OF THE ACCIDENT
On January 24, 2002, at about 5:00 p. m., the evening crew started underground on three separate battery-powered, rubber tire mantrips. The crew consisted of Gerald Deskins, Foreman/Electrician; Ronnie Endicott (victim), General Inside Laborer; and Dwayne Keen, General Inside Laborer. Harold Osborne, Night Watchman, was on the surface. The scheduled activity for this shift was to move the 001 MMU section back one crosscut to facilitate the retreat mining process.
At approximately 7:30 p. m., Deskins used the mine phone to instruct Osborne to deenergize the 001 MMU high-voltage circuit at the surface substation. Osborne initially attempted to use the test button to deenergize the underground power circuit, but it would not operate. He pulled the load break switch lever and then the oil circuit breaker lever to its deenergized position. Once deenergized, Deskins opened the lid of the section power center and used a short length of cable to dissipate any stored energy remaining on the high-voltage cable. This cable was disconnected and set aside. The section power center was then moved outby one crosscut, a distance of about 70 feet. During the process, approximately 800 feet of high-voltage cable and a junction box were removed from the high voltage circuit supplying power to the power center. Upon completion of the move, the high-voltage cable was reconnected and the lid on the power center was put back in place. Endicott was aiding Deskins throughout this task while Keen was servicing the continuous mining machine. At approximately 9:00 p. m., Deskins called outside and instructed Osborne to energize the circuit. After several failed attempts, Osborne called underground and reported to Deskins that he could not energize the circuit.
At approximately 9:15 p. m., Deskins returned to the surface and attempted to energize the circuit. Unable to energize the circuit, Deskins called Jay Wallace, Mine Operator, for help. The telephone billing establishes this call was made at 9:50 p. m. and lasted one minute. Wallace informed Deskins that this was a reoccurring problem and to continue his efforts. Deskins returned to the substation and continued to attempt to energize the circuit until he successfully restored the power.
Endicott called outside and told Deskins to deenergize the circuit because the phasing was reversed. According to Deskins, he told Endicott he would come back underground and change the leads. But, according to other testimony, Endicott told Deskins he would change the leads. Deskins deenergized the circuit. He then called Wallace at 10:19 p. m. and informed him that the power to the mine had been restored. He also told Wallace the phasing was reversed and that he would correct the problem. This call lasted two minutes.
Once the circuit was deenergized, Endicott partially removed a lid from the section power center. He switched two of the high-voltage cable leads. The job appeared complete at the time of the accident.
Shortly after finishing the second telephone conversation with Wallace, Deskins was informed by Osborne that Endicott had called outside and asked to have the high-voltage circuit energized. Deskins asked Osborne if he was sure that was what Endicott said. After an affirmative response, Deskins again asked Osborne if he was sure that was what Endicott said. Upon receiving the second affirmative response, Deskins energized the circuit, at approximately 10:30 p. m.
Keen, who was working approximately 125 feet inby the section power center near the continuous mining machine, saw flashes of light when the circuit became energized. As he approached the power center, he saw Endicott with his hand in the high-voltage compartment. Keen ran to the mine phone, called Osborne, and instructed him to deenergize the circuit. Keen also told Osborne that Endicott had gotten into the power, and instructed him to call for an ambulance. Osborne responded by saying, okay. After Osborne deenergized the high-voltage circuit, Keen placed Endicott on a mantrip and transported him to the surface.
When Deskins observed Osborne running to deenergize the high-voltage circuit, he asked if everything was all right. Osborne told Deskins that he was going to knock the power, but he did not give Deskins a reason to be alarmed. After deenergizing the circuit, Osborne took no action to summon an ambulance. Later he stated he was not aware an accident had occurred.
Deskins departed the surface and traveled underground where he met Keen about four crosscuts inby the portal on the way to the surface with Endicott. They traveled to the surface. Upon arriving on the surface, Endicott was taken to the outside shop where Deskins performed cardiopulmonary resuscitation (CPR) on him. Keen called the home of a rescue squad worker but was unable to reach him. Osborne drove to the home of another rescue squad worker to seek help but he too was unsuccessful. Keen then called several people. He contacted Wallace at 10:38 p. m.; Farley Cantrell, day shift Superintendent/Foreman, at 10:46 p. m.; and Joe Altizer, Mine Inspector for Virginia Department of Mines, Minerals, and Energy (VDMM&E), at 10:50 p. m. Cantrell arrived at the mine at about 11:00 p. m. and assisted Deskins in performing CPR. From his residence, Altizer notified the Dismal River Volunteer Rescue Squad, Inc. and MSHA.
The rescue squad arrived at the mine site at 11:43 p. m. and transported Endicott to the Clinch Valley Medical Center, Richlands, Virginia. Endicott was pronounced dead at 12:25 a. m., on January 25, 2002.
INVESTIGATION OF THE ACCIDENT
A 103(k) Order was issued to ensure the health and safety of persons in the affected areas of the mine until the investigation could be completed. Preliminary information concerning the fatality was gathered and a preliminary investigation of the accident was conducted. Officials from MSHA, and VDMM&E arranged a joint investigation to continue at the mine the next day.
The on-site portion of the accident investigation continued on the morning of January 25, 2002. The accident scene was inspected and a scale drawing, photographs, and a video were made. A spot inspection (CAA) and a complete electrical inspection (CBA) were conducted concurrently with the investigation to address enforcement issues that did not contribute to the fatality. Interviews of eleven people were conducted between January 26 and January 29. Due to conflicting testimony two additional interviews were held on January 31, with both persons being put under oath.
- The mine receives power through a 12,470 VAC, three phase service drop. The surface substation is a self-contained Line Power, model number 1000 SS. The transformer bank for underground power has a 1:1 ratio (underground power is also 12,470 VAC, three phase) and is rated 1,000 KVA. It is configured delta-wye with the neutral resistance grounded. The resistor is 15 Amps and measured 490 Ohms.
- The substation has a load break switch that can deenergize the transformer bank and underground power. The switch is model number 1300-20-20 and rated for 17.5 kV and 460 Amps. It serves as the visible disconnect. It was found in the open (deenergized) position at the start of the investigation.
- An oil circuit breaker is also installed in the substation. Its purpose is to deenergize the underground power. This breaker is designed to automatically deenergize when a protective device senses an abnormal condition. It is a General Electric breaker, type FK-143-7.5-50, rated for 7,200 VAC, and 600 Amps. It was found in the open (deenergized) position at the start of the investigation.
- No indicators (flags) on the protective devices to alert personnel as to which abnormal condition was present to cause the substation to deenergize were showing except for the ground check monitor. The ground check monitor manufactured by Line Power provides under-voltage protection and ensures the ground circuit is intact. When the load break switch is open this relay is designed to deenergize the oil circuit breaker and display its flag.
- The substation has two General Electric IAC relays used to detect either an overcurrent or short circuit condition. They are connected to two 150:5 current transformers. Under primary injection testing, both relays activated at 106 Amps and released their flags. Short circuit relays activated at 25 and 23 Amps and released their flags.
- The substation uses a General Electric IAU relay to detect a grounded phase condition. It is connected to a 60:1 potential transformer. Under secondary testing the relay would not activate at any voltage from 0 to 120 Volts. Therefore, the ground fault relay would not detect a grounded phase condition, release its flag, or deenergize the oil circuit breaker.
- A mechanical activation test was conducted on the test button on the substation, the emergency stop button on the section power center, the grounded phase relay, both overcurrent relays and both short circuit relays. This method tests the operation of the trip circuit and the oil circuit breaker. The substation failed all of the mechanical activation tests. The trip circuit was functioning properly as determined by the noise it produced when tested. However, the oil circuit breaker would not open the circuit. The electrical to mechanical connection between the two systems was not functioning. The mechanical linkage was not properly adjusted. No protective devices at the substation would be able to deenergize the underground high-voltage circuit under any abnormal condition.
- In addition to these protective devices, two sets of three fuses were installed in the circuit. One set of fuses is located on the last pole before entering the substation and rated at 40 Amps and 15 kV. The other set is between the load break switch and the underground transformer bank. Two of these fuses are rated 40 Amps and 15.5 kV. The third fuse is rated 30 Amps and 15.5 kV.
- Osborne stated that the emergency button would not deenergize the underground circuit the week prior to the accident.
- Two electricians from Jewell Smokeless Coal Corporation adjusted and repaired the mechanical linkage on January 21, 2002. Proper mechanical activation tests were conducted that day and proved the oil circuit breaker would operate correctly.
- Joshua Meadows, day shift Shuttle Car Operator, stated he was instructed to test the emergency stop button on the section power center on January 21, 2002. The button deenergized the high-voltage circuit when tested.
- The high-voltage underground circuit was deenergized before performing electrical work on it but was not locked out, tagged, or grounded.
- The high-voltage cable is rated at two AWG and 15 kV.
- The section power center, model number 600 PC, located in the No. 5 Entry of the 001-0 Section was manufactured by Line Power. The power center transforms the incoming 12,470 VAC power to 995, 560, and 480 VAC three phase power and is rated at 600 KVA.
- The disconnect switch, which provides a visual means to deenergize the section power center's transformer bank and low-voltage circuits was in the closed (energized) position. This switch does not affect the incoming high-voltage circuit.
- The emergency stop button provided in the high-voltage ground check monitor circuit located on the outby side of the section power center was in the closed (energized) position.
- There were no extra safety devices, such as lid switches, on this power center.
- Tools were located on top of the power center, as well as in toolboxes near this area.
- The No. 1 shuttle car cable coupler was connected to its labeled breaker.
- When tested, the power center would deliver properly phased power.
- The lid guarding the high-voltage compartment of the section power center was slid to one side 24 inches, exposing the high-voltage disconnect switch and the connections to the high-voltage cable.
- The high-voltage connection closest to the low-voltage compartment wall had arc burns and bubbled metal around the hex bolt. There were two spots of arcing on the inner compartment wall. There were several arcing spots along the edge of the power center's lid.
- A hard hat and a hex wrench were found inside the enclosure. Also in the enclosure were a screw, washer and nut that came from the emergency stop switch. These parts were removed from the normally open contacts of the emergency stop button and were not needed.
- The victim was found with his hand in the high-voltage compartment of the power center. The high-voltage circuit did not automatically deenergize.
- The victim had contacted one phase of the 12,470 VAC circuit where the high-voltage cable terminates at the disconnect switch.
- The interviews revealed that Endicott had not previously performed electrical work without the presence of Deskins. Endicott was more of an aid than an electrician.
- Keen stated he was located inby the section power center at the closest intersection (about 40 feet from the section power center) when he heard Endicott on the phone. Keen heard him say deenergize the circuit because the phase rotation is reversed and that he would change the leads.
- Keen was working on the cable for the continuous mining machine. He moved approximately 125 feet away from the section power center and was near the continuous mining machine. Keen stated he did not hear any other phone conversations. He did not hear Endicott ask anyone to energize the circuit, however his location may have been too far for the conversation to be overheard.
- Deskins stated he did not hear the mine telephone page when Endicott asked that the circuit be energized. He was out of the mine office talking to Wallace on the cordless telephone.
- Osborne stated he was holding the mine telephone receiver when Endicott requested the circuit be energized. The mine telephone did not page but made a clicking noise. Osborne recognized the voice of Endicott.
- The mine telephones are manufactured by Pyott Boone. They are battery operated and have paging capabilities.
- The section mine telephone was located in the No. 4 Entry at the loading point. A spare mine telephone and a battery were also in this area. The distance from the mine telephone to the section power center is approximately 130 feet.
- During the interviews of mine personnel, no one stated there were any problems with the mine telephone system prior to the time of the accident. Days before the accident a battery was replaced in one telephone.
- No mine officials expressed any problems using the mine telephone system during the accident investigation on January 25 and 28, 2002.
- VDMM&E and MSHA tested the mine telephone system on January 30, 2002. The section telephone did not page audibly or visually. The conversation from the surface could be heard at the section mine telephone. The page to the surface telephone was insufficient. Only slight clicks were heard. The conversation from the section telephone to the surface was not complete. Only the first seconds of the conversation were heard on the surface telephone.
The accident occurred due to a confluence of factors. The victim was exposed to an electrical shock by working on the high-voltage electrical circuit without proper safety precautions. The victim relied on another person to deenergize the high-voltage circuit and visually verify that all three phases were open. A failure to lock out the disconnecting device, place a suitable tag on it and attach a grounding device to the disconnected portion of the high-voltage circuit led to the electrocution of the victim.
The circuit was energized while work was in progress due to an apparent failure in communication. The person who energized the power circuit did not have any direct communication with any underground employee prior to energizing the circuit. The exact nature of the failure in communication between the victim and the surface employee could not be ascertained. Before the accident several calls were initiated from the surface and the section without incident. No one interviewed stated there were problems with the telephone system. While used during the first two days of underground investigation no problems were encountered with the telephone system. However, on January 30, 2002 the mine telephone system was tested and found to be defective. The section telephone did not page audibly or visually. This defect was obvious and would prevent personnel on the section from receiving calls.
The high-voltage circuit breaker installed in the surface sub-station to provide fault protection for the underground high voltage circuits was inoperative and would not clear any fault. This condition resulted in prolonged exposure of the victim to the electrical energy.
A significant factor was the foreman/electrician's continuing practice to work on electrical equipment without using lock out, tag, or grounding devices. This practice was an established habit that the foreman/electrician condoned and exercised.
Contributing to the accident is the victim's lack of qualifications. The victim was a qualified electrician for three years (1980, 1981, and 1982). He had not been a qualified electrician or received annual electrical refresher training for 19 years.
- 103(k) Order No. 7324710 was issued January 25, 2002: The mine has experienced a fatal electrical accident on the 001 active section in the number five entry involving the section power center. This order is issued to ensure the safety of any person in the coal mine until an examination and/or investigation is made to determine that the affected area is safe. Only those persons selected from company officials, state officials, the miner's representative and other people deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area.
- 104(a) Citation No. 7293099 was issued March 6, 2002, for a violation of 30 Code of Federal Regulations (CFR) 75.800: The high-voltage circuit entering the underground area of this coal mine did not have an effective device to provide protection against under-voltage, grounded phase, short circuit or overcurrent as tested on January 25, 2002. This information was obtained during a fatal accident investigation which commenced January 25, 2002.
- 104(d)(1) Order No. 7293100 was issued March 6, 2002, for a violation of 30 CFR 75.705-1(b): The high-voltage circuit supplying 12,470 VAC, three phase power to the underground areas of the mine was not determined to be properly deenergized by a qualified person before electrical work was performed on it. Gerald Deskins, evening shift foreman and electrician was the only qualified person at the mine on January 24, 2002. Deskins deenergized the underground high-voltage visual disconnect but did not ensure that each ungrounded conductor of the high-voltage circuit upon which work was to be done was properly connected to the system-grounding medium. Ronnie Endicott, general inside laborer performed electrical work on this circuit. This information was obtained during a fatal accident investigation which commenced January 25, 2002.
- 104(d)(1) Order No. 7323521 was issued March 6, 2002, for a violation of 30 CFR 75.511: The visual disconnecting device at the surface substation for the underground high-voltage circuit at this mine was not locked out or suitably tagged by the person performing electrical work on this circuit on January 24, 2002. Ronnie Endicott, general inside laborer performed electrical work on the underground high-voltage circuit without locking out or tagging the disconnecting device. The disconnecting device at the surface is the only means to disconnect the circuit. Also, electrical work was performed on a high-voltage distribution circuit by a non-qualified person not under the direct supervision of a qualified person at this mine. This resulted in fatal injuries to Ronnie Endicott, general inside laborer. Gerald Deskins, evening shift foreman and electrician was the only qualified electrician at the mine. Deskins was on the surface during this procedure and was aware that Endicott was performing electrical work. Endicott has not been a qualified electrician since January 01, 1983. This information was obtained during a fatal accident investigation which commenced January 25, 2002.
- 104(d)(1) Order No. 7323522 was issued March 6, 2002, for a violation of 30 CFR 75.705: The high-voltage lines supplying 12,470 VAC, three phase power to the section power center located underground at this mine were not grounded before work was performed on them on January 24, 2002. Ronnie Endicott, general inside laborer performed electrical work on the underground high-voltage lines without installing a grounding device that provides a solid connection from the three power phases to the system ground for the duration of the repair. No protective grounding device was found, and according to statements no such device had been utilized by the electricians. This information was obtained during a fatal accident investigation which commenced January 25, 2002.
Related Fatal Alert Bulletin:
Diagrams Accompanying Report*:
Scene of Accident
Appendix B: Diagram (p. 16)
Appendix B: Diagram (p. 17)
(*All are Acrobat (PDF) files)
List of Persons Participating in the Investigation
Virginia Department of Mines, Minerals, and Energy
Frank Linkous .......... Chief, Division of MinesMine Safety and Health Administration
Carroll Green .......... Mine Inspector Supervisor
Opie McKinney .......... Mine Inspector Supervisor
David Elswick .......... Coal Mine Technical Specialist
Robert Garret .......... Coal Mine Technical Specialist
Dwight Miller .......... Coal Mine Technical Specialist
Joseph Altizer .......... Mine Inspector
Danny Altizer .......... Mine Inspector
Terry Ratliff .......... Mine Inspector
Ray McKinney .......... District Manager, District 5Glem Company
Wayland M. Jessee .......... Assistant District Manager, Inspection Division
James W. Poynter .......... Conference Litigation Representative
Andrew C. Moore III .......... Supervisor Electrical Division
Russell A. Dresch .......... Electrical Engineer
Luther T. Ward .......... Coal Mine Inspector - Electrical
James R. Baker .......... Educational Field Services Specialist
Dennis W. Carter .......... Coal Mine Inspector
Joseph W. Ray .......... Coal Mine Inspector
Gary Roberts .......... Coal Mine Inspector
*Jack Harris .......... Manager
*James R. Mills .......... Lineman
*Richard Harris .......... Lineman Helper
List of Persons Interviewed
Mackie J Coal Company, Inc.
Mack Stiltner .......... PresidentMackie J Coal Company, Inc.
Jay Wallace .......... Secretary/Treasurer
Farley E. Cantrell .......... Superintendent
Gerald Deskins .......... Foreman/Electrician
Harold Osborne .......... Night WatchmanJewell Smokeless Coal Corporation
Dwayne Keen .......... General Inside Laborer
Allen Lynn Cooper .......... Continuous Mining Machine Operator
Joshua Meadows .......... Shuttle Car Operator
Bill Spencer .......... General Outside Laborer
Carl Evans .......... Jewell Smokeless Electrician
Joseph Keen .......... Jewell Smokeless Electrician