DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
(UNDERGROUND COAL MINE)
FATAL FALL-OF-ROOF ACCIDENT
Camp Creek Mine (ID No. 46-05121)
Rockspring Development, Inc.
East Lynn, Wayne County, West Virginia
April 10, 2002
Roger D. Richmond
Coal Mine Safety and Health Inspector
Coal Mine Safety and Health Roof Control Specialist
Originating Office � Mine Safety and Health Administration
100 Bluestone Road, Mt. Hope, West Virginia 25880
Edwin P. Brady, District Manager
Release Date: August 29, 2002
On April 10, 2002, at approximately 10:15 p.m., Brian S. Stepp, age 33, a continuous mining machine operator, was fatally injured when a portion of unbolted mine roof in the No. 4 entry/right crosscut intersection fell. The rock broke off at the first row of bolts in the crosscut and fell with a cantilevered motion, pinning the victim against the shuttle car, approximately four feet away. Measurement of the fallen rock that struck the victim was 101 � inches in length by 65 � inches wide and between 4 - 16 � inches thick. There were two violations of the approved roof control plan. Reflectors were not posted to warn persons of unsupported roof. The victim was standing in an area where persons were prohibited by the roof control plan.
The Camp Creek Mine is located in Wayne County, east of the community of East Lynn, West Virginia. The mine extracts coal from the Coalburg coal seam, locally known as the Winifrede seam, utilizing five continuous miner units on three sections. Two of these sections, including No. 3 where the accident occurred, are super-sections, consisting of two continuous miners and two twin head roof bolt machines. One section utilizes a single continuous miner. There is no over mining or undermining at the accident site.
The fatal roof fall occurred on the No. 3 working section, in the 9 South mining area. Access to the accident site is via track. The entries on the No. 3 Section were being developed on 60-foot heading centers and 70-foot crosscut centers with entry widths at a nominal 20 feet.
The principle officers for Rockspring Development, Inc. at the time of the accident were Nelson Sumpter, President and Randy McMillion, Vice President of Operations.
The last Mine Safety and Health Administration (MSHA) Inspection (AAA) was completed on March 28, 2002.
The national Non-Fatal Days Lost (NFDL) incidence rate for underground coal mines during the previous quarter was 6.56. For this period the NFDL incidence rate for this mine was 4.0.
DESCRIPTION OF THE ACCIDENT
On Wednesday, April 10, 2002, at approximately 2:30 p.m., the No. 3 section evening shift crew entered the mine via the shaft elevator accompanied by Section Foreman Jack Lovins. Lovins, and the crew traveled via the track entry approximately 29,000 feet to the No. 3 Section, 9 South mining area. Upon arriving on the section, Lovins began an on shift examination of the working faces.
During the examination Lovins encountered and spoke to Danny Stacy, roof bolt machine operator, in the No. 4 face. In the No. 5 entry, Bryan Stepp, continuous mining machine operator, (victim) was preparing to begin mining. He and Lovins discussed the mining sequence that would be followed in the Nos. 3, 4, and 5 entries. Lovins instructed Stepp to only take a 20 foot cut out of the No. 4 left crosscut. Lovins continued across the section conducting his examination. The right side roof bolt machine was in the No. 8 face and the right side continuous miner was in the No. 9 face. Stepp started mining his first cut in the No. 5 face, then mined a cut from the No. 4 left crosscut; Stepp then mined the No. 3 left crosscut. While mining the first cut from the No. 4 left crosscut, a rock fell and damaged the miner power cable. While the power cable was being repaired, Stepp and several others serviced the continuous miner. Stepp took a second cut out of the No. 4 left crosscut for a total of 4 cuts prior to the accident. Lovins stayed with him until the second cut in the No. 4 left crosscut was completed.
Stepp informed Lovins that he wanted to turn the No. 4 crosscut right instead of turning left from the No. 5 entry. Lovins agreed and helped Stepp move the continuous miner into the face of the No. 4 entry. Lovins measured and marked the rib line for the No. 4 right crosscut. He then traveled to the No. 8 entry where the right side continuous miner was mining the No. 7 right crosscut.
Operating the continuous mining machine from a position in the No. 4 entry inby the machine, Stepp advanced the machine nearly 26 feet on the left side of the No. 4 right crosscut, when the shuttle car he was loading lost power. When the shuttle car lost power, Ray Jude, shuttle car operator, left the operator's compartment and reset the breaker for the shuttle car. Jude reset the shuttle car breaker several times. The reset breaker provided power to the shuttle car, but each time the shuttle car pump motors were turned on the breaker tripped again, due to a ground in the circuit.
Meanwhile, after completing the examination of the faces, Lovins and John Brown, section electrician traveled outby to the track. Lovins and Brown moved the personnel carriers to the end of the track so the crew would not have as far to walk at the end of the shift. Lovins and Brown were at the end of the track when the accident occurred.
While Jude was resetting the breaker, Stepp walked from the No. 4 face, where he had been operating the continuous mining machine, through the narrow opening between the left rib and the shuttle car. He continued around the dump end of the shuttle car to a point immediately in front of the operator's compartment where he got a drink and began talking to Jude. Stepp, and Jude, who was sitting in the shuttle car operator's compartment, were both positioned in an area referred to as the "red zone" in the approved roof control plan.
At approximately 10:15 p.m., a large slickensided rock (slip) fell in the unsupported area of the No. 4 right crosscut and cantilevered into the supported area where Stepp was standing. The rock struck Stepp, pinning him against the shuttle car tire. Additional rock fell between Stepp and the continuous mining machine but could not be measured due to adverse conditions.
Jude exited the shuttle car and attempted to free Stepp, but was unable to move the rock by himself. Jude ran down the No. 4 entry to get help. Tim Robinson, shuttle car operator, responded, but Jude and Robinson could not move the rock. Randy Horn, continuous miner operator, and Bill Lambert, shuttle car operator, arrived and began to help. The four men attempted to move the rock but were unsuccessful. Lifting jacks were brought to the accident site and used to extricate Stepp. Stepp was examined, secured to a backboard, and transported to the shaft elevator. Brown and Horn, EMTs (Emergency Medical Technicians), performed CPR on Stepp until they were met by paramedics from Wayne Ambulance Service at the shaft bottom. Stepp was removed from the mine and transported to St. Mary's Hospital in Huntington, West Virginia. Stepp was later taken to the Charleston Medical Examiner's Office where he was pronounced dead.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 11:35 p.m., on April 10, 2002, 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 the employees. A list of those persons who participated, were interviewed, and/or were present during the investigation can be found in Appendix A of this report.
Representatives of MSHA and the WVMHST traveled to the underground accident scene to conduct an investigation of existing physical conditions. Photographs, video recordings, and relevant measurements were taken. Sketches and a survey were also conducted at the site.
The physical portion of the investigation was completed on April 12, 2002. Interviews were conducted with persons who had knowledge of the accident on April 12, 2002 at the Rockspring Development Training Room, East Lynn, West Virginia. The investigation also included a review of training records and records of required examinations.
Training records were reviewed and all required training was in compliance with 30 CFR.
Examination of records and on-site evaluations indicated that the required examinations were being conducted and recorded in accordance with 30 CFR, Part 75.
1. The roof fall fatality occurred on the 9 South mining area, No. 3 working section, at the perimeter of a right hand crosscut off the No. 4 entry at approximately 10:30 p.m. on April 10, 2002. The intersection being formed was about 55 feet north of survey station 19226, approximately 210 feet north of the submain entries, and 210 feet north of the feeder position.
2. The victim was the continuous miner operator. Prior to the accident, the continuous mining machine was advancing a deep cut eastward, forming the first cut of the intersection. The cut had been advanced 25.8 feet. While mining on the north (left) side of the crosscut, the shuttle car lost power while it was positioned under the boom of the continuous miner. The mining machine and shuttle car formed an "L" shaped configuration.
3. Reportedly, the victim was positioned in the No. 4 entry, just inby the crosscut, while operating the continuous miner. While the shuttle car malfunction was being investigated, he walked outby and around the left (west) side of the shuttle car, and then walked to the right (east) side of the shuttle car to get a drink from a plastic water bottle stored on the shuttle car. A slab of rock fell from within the crosscut while the victim was positioned alongside the shuttle car near the rear right wheel well (in front of the shuttle car cab).
4. The victim was struck by the roof rock when he was positioned between the last row and second to last row of bolts, adjacent to the cut. He was within the area designated by the roof control plan that shall not be entered (red zone) when turning crosscuts with a remote control continuous miner.
5. It appeared that the fall initiated in the unsupported cut, fell from the northeast, cantilevered off the last row of bolts and displaced itself to the southwest, under the last row of bolts, towards the shuttle car. The victim was struck by the rock while he was alongside the shuttle car. Approximately 2.6 feet of horizontal distance existed from the last row of bolts to the shuttle car frame. The rock that fell from within the cut ranged from 4 to 16 � inches thick, 65 � inches wide, and approximately 101 � inches long.
6. The roof horizon at the accident site was uneven. The immediate roof consisted of a sandy mudstone or sandy shale of undetermined thickness and contained numerous slickensides (also called slips). Slickenside surfaces bound the rock that fell from within the cut. Slickensides are fractures with typically smooth, shiny, straightened surfaces. Their surfaces possess minimal cohesion and consequently form failure surfaces conducive to roof rock fall out. The slickenside features encountered at the accident site existed in other entries and crosscuts to the southwest of the No. 4 entry. They were observed within a 40 to 60 foot wide zone that traversed through the No. 2, No. 3, and No. 4 entries that contained slickensides dipping 15� to 20� from the horizontal and that typically trended in a meandering fashion approximately N20�E.
7. Roof support at the accident site consisted of � inch x 6 foot, grade 75, fully grouted tensioned rebar. Bolts were installed in 1 inch drill holes on a pattern of 4 foot spacing between rows and 4 to 4.5 foot spacing between bolts within each row. The resin grout included a 2 foot equivalent length cartridge of fast setting Dupont Fasloc resin at the top portion of the hole and 4 foot equivalent length cartridge of slow setting Dupont Fasloc resin in the lower portion of the hole. The roof bolt plate assembly consisted of a 16.75 inch x 16.75 inch Excel Spider I oversize bearing plate used in conjunction with an 8 inch x 8 inch B5 bearing plate. No roof bolt failure was observed at the accident site. One oversize bearing plate was bent at the perimeter of the roof fall.
8. Mining height in the vicinity of the intersection was approximately 12 feet. The No. 4 entry width immediately outby the turn position was 20 feet. The crosscut width at the junction with the No. 4 entry was 28.5 feet. (This excessive width was cited under 30 CFR 75.220 but is not believed to be a contributing factor to the roof fall.) Survey spads were not found in the intersection at the time of the accident . An entry centerline for the No. 4 entry was painted and positioned along the eastern (right hand) portion of the No. 4 heading indicating that the No. 4 entry was initially mined off center in a northwesterly trend. The pillars surrounding the accident site were nominally 40 foot wide x 50 foot long with the overburden 430 feet in depth.
9. No evidence of excessive pillar loading or cutter roof failure (stress related damage) was observed in the face area. Severe grade changes existed in the No. 7, No. 8, and No. 9 entries where the mining faces encountered an east-west trending fault. The fault system appeared to be an independent geological feature not associated with the slickenside zone found in No. 2 to No. 4 entries.
ROOT CAUSE ANALYSIS
A root cause analysis was performed on the accident. The following root cause was identified:
1. Causal factor - Warning devices (reflectors) were not installed to warn miners of the hazardous areas as required by the approved roof control plan.
Root cause - Human performance difficulties indicated that no one knew who was responsible for installing the reflectors at the mouth of a crosscut when taking a deep cut.
2. Causal factor - Victim entered hazardous area.
Root cause - Hazardous area was not identified as required by approved roof control plan.
The Investigation team concluded that the direct causes of the accident were: the victim positioned himself in a hazardous area described in the roof control plan as "the red zone", and warning devices (reflectors) were not used to indicate the location of the next to last row of permanent roof supports, to warn miners of the hazardous area. Root causes of the accident were determined to be: personnel did not have a clear understanding of provisions in the roof control plan regarding the "red zone" and the use of reflectors when turning crosscuts. There was also a lack of a standard operating procedure that defined responsibility for hanging reflectors.
1. A 103(k) Order No. 4805462 was issued to ensure the safety of all persons in the mine until an investigation is completed and all areas and equipment are deemed safe.
2. A 104(a) Citation No. 7217084 was issued to Rockspring Development, Inc. for a violation of 75.220(a)(1) stating in part that reflective materials were not being used to indicate the location of the next to the last row of permanent roof supports while mining a deep cut.
3. A 104(a) Citation No. 7217085 was issued to Rockspring Development, Inc. for a violation of 75.220(a)(1) stating in part that the continuous mining machine operator was fatally injured while standing in an area defined in the approved roof control plan as the "red zone," an area where no one shall enter when deep cuts are taken.
Related Fatal Alert Bulletin:
The Mine Safety and Health Administration conducted an investigation and those present and/or participating were as follows:
Rockspring Development, Inc.
Nelson Sumpter .............. President, Rockspring Development, Inc.West Virginia Miner's Health, Safety, and Training
Randy McMillion .............. Sr. Vice President of Operations
Randy Hansford .............. President of Riverton
Ed Rudder .............. Safety Manager
Elmo Ellis .............. Mine Foreman
Les Fox .............. Superintendent
Bernie Ferell .............. Miner's Rep.
Donald Stallings .............. Second Shift Mine Foreman
Terry Farley .............. AdministratorMine Safety and Health Administration
Mike Rutledge .............. Photographer
Richard Boggess .............. District Inspector
Harry Linville .............. District Inspector
Roger Richmond .............. Coal Mine Safety and Health Inspector/AIPittsburgh Safety and Health Technology Center
James Beha .............. Coal Mine Safety and Health Specialist/Investigation Coordinator
Don Winston .............. Roof Control Specialist
Jim Humphrey .............. Coal Mine Safety and Health Inspector/AI
Dennis Holbrook .............. Coal Mine Safety and Health Inspector
Loyd Belcher .............. Coal Mine Safety and Health Inspector
Mike Gauna .............. Mining EngineerThe following persons were interviewed during this investigation:
Jack Lovins .............. Section Foreman
Donald Stallings .............. Second Shift Mine Foreman
Ray E. Jude .............. Shuttle Car Operator
Johnny R. Brown .............. Electrician
Randy Horn .............. Continuous Miner Operator
Danny Stacy .............. Roof Bolt Machine Operator