Department of Labor
Mine Safety and Health Administration
Coal Mine Safety and Health Administration
Report of Investigation
Underground Coal Mine
May 11, 2002
Eighty Four Mining Company
Eighty Four, Washington County, Pennsylvania
I.D. No. 36 00958
Thomas H. Whitehair II
Coal Mine Safety and Health Inspector
Edward J. Lewetag, Jr.
Coal Mine Safety and Health Inspector
David C. Lewetag
Coal Mine Safety and Health Inspector (Electrical)
Mine Safety and Health Administration
319 Paintersville Road, Hunker, PA 15639
Cheryl McGill, District Manager
September 30, 2002
George Shirley, coal hauler operator, was transporting coal from the face to the feeder in the South West Mains (MMU-068) section. As he attempted to make a right turn into the crosscut between the numbers four and three entries, the left rear portion of the coal hauler frame pinched the trailing cable providing power to the Joy 14 BU loading machine, between the right inby rib and the machine frame. This resulted in the frame of the rubber tired coal hauler being energized. Shirley exited the machine to check the pinch point, came into contact with the energized machine frame and received a fatal electrical shock.
The fatality occurred because the coal hauler operator deviated from the established route of travel without first examining the new travel way to ensure that all cables would be protected from damage. The root causes of the accident were: (1) the loading machine trailing cable was not protected from damage by mobile equipment; (2) the lack of an established procedure to be followed in the event of rubber tired equipment contacting electrical cables; (3) the victim's failure to follow company policy regarding the wearing of gloves.
Mine 84 is an underground coal mine operated by Eighty Four Mining Company and is located approximately one mile north from Exit 9 off Interstate 70 in Somerset Township, Washington County, Pennsylvania. The mine is opened by seven airshafts and one dual belt conveyor/track slope into the Pittsburgh bituminous coal seam, which averages 72 inches in height. Employment is provided for 439 underground and 67 surface employees.
Five continuous-mining machine sections are currently developing longwall panels and operate three production shifts per day, five days a week and two shifts on the sixth day producing an average of 3000 tons per day. The longwall section operates three production shifts per day, five days per week and two shifts on the sixth day producing an average of 15,000 tons per day. The block system of mining is utilized, with entries and crosscuts normally mined 16 feet wide on 65 to 200-foot centers. Coal is transported from the faces by shuttle cars and coal haulers and discharged onto belt conveyors. A series of belt conveyors transport the coal to the surface, via the slope belt conveyor, for processing at the preparation plant. The coal is then loaded into rail cars and trucks for delivery. Ventilation is induced by seven exhaust fans located on the surface. Permanent stoppings, overcasts, regulators, check curtains, and line brattice control ventilation underground. During the last quarter, the mine liberated approximately 5,430,497 cubic feet of methane for a 24-hour period.
A regular Safety and Health Inspection was in progress at the time of the fatal accident. The last regular Safety and Health Inspection at this mine was completed March 28, 2002. The Non-Fatal Days Lost (NFDL) Incidence rate for the mine was 4.11. The NFDL rate for the Nation for underground mines was 7.04.
The principle officers at Mine 84 at the time of the accident were:
D. R. Baker .......... President
James McCaffrey .......... Vice President
Eric V. Schubel .......... Superintendent
Todd Moore .......... Manager of Safety
DESCRIPTION OF THE ACCIDENT
On May 11, 2002, the non-traditional afternoon shift crew consisting of eight persons supervised by Bine Daisley, section foreman, entered the mine at Zediker portal at the regularly schedule starting time of 12:00 noon. The crew traveled from the shaft bottom to the SouthWest Mains Section, MMU-068-0, by trolley powered rail personnel carrier. They arrived at the section at approximately 12:45 p.m. As the miner crew checked the bits and water sprays on the continuous mining machine, George Shirley, coal hauler operator, walked his intended route of travel from the section feeder to the number four face area. Shirley also discussed with Tim Simmons, shuttle car operator, their respective routes of travel. It was agreed that since the shuttle car trailing cable was anchored in the number four entry, the shuttle car would travel directly from the loader outby in the number four entry to the feeder and return to the switchout point outby the third crosscut to wait for Shirley. Shirley would travel from the loader outby in the number four entry through the third intersection to directly in front of the waiting shuttle car. Shirley would then back into the crosscut between entries number four and five and would proceed battery-end first directly through the intersection to the number three entry, travel outby one crosscut in the number three entry, turn left into the crosscut between entries numbers three and four and travel directly across number four entry into the crosscut four to five. Then he would pull loaded end first into the number four entry and proceed to the feeder to discharge his load.
Production started at 1:00 p.m. and proceeded normally until approximately 2:30 p.m. when the section belt conveyor stopped. At this time Shirley informed Simmons that he was going to the coal hauler charging station to get a fully charged machine. The section belt conveyor restarted. Simmons made several trips during the time that Shirley was changing out machines. During Shirley's second trip after he resumed hauling, Simmons was waiting in the number four entry and observed Shirley make a right turn from the number four entry into the number four to three crosscut, deviating from his normal route of travel. As Shirley was going through the intersection, Simmons heard the coal hauler contact the rib. He then observed Shirley shut off the machine, exit the operator's compartment and walk to the rear of the machine. It appeared to Simmons that Shirley looked at the back of the coal hauler, then turned around and proceeded to the front of the machine. As Shirley neared the operator's compartment, Simmons saw Shirley's hard hat fall off, heard him groan and saw him fall to the floor. Simmons immediately ran to Shirley and checked for vital signs and upon finding none, began chest compressions. After the chest compressions failed to revive Shirley, Simmons proceeded to the number four face area and alerted the face crew and section foreman that something was wrong with Shirley and he needed help. Daisley, followed by his crew, proceeded to the coal hauler. As Daisley was traveling through the crosscut between the number three and four entries, he attempted to pass between the coal hauler and the coal rib. He placed his gloved hand on the coal hauler and received an electrical shock. Daisley yelled for someone to de-energize the power on the section. Jeff Price, roof bolter operator, traveled to the section power center and de-energized the section power. As Daisley and Simmons started CPR, surface personnel were informed of the accident by telephone and an Emergency Medical Technician (EMT) was requested. Randy Lewis, EMT, located on a nearby section, was notified of the accident and told to proceed to the South West Mains Section. When he arrived on the section, he encountered Alexander Marran and Phillip Blose, mechanics, and asked who was injured. The mechanics were not aware of the accident but picked up the first aid supplies and followed Lewis to the location of the coal hauler. Lewis replaced Daisley who was performing CPR and Daisley traveled to the section telephone to call the surface to provide an update on the injured miner. Shirley was placed on a stretcher and carried by the section crew to the personnel carrier where he was transported to the surface while Lewis and Simmons continued to perform CPR. Upon arrival to the surface, the victim, was pronounced dead by Tim Warco, Washington County Coroner, and transported to the Washington Hospital.
INVESTIGATION OF THE ACCIDENT
James Bandish, Mine Safety and Health Administration (MSHA) Ruff Creek Field Office Supervisor, was notified of the accident by Tom Blaskovich, Consol Inc. Devision Safety Supervisor, at 3:30 p.m., Saturday, May 11, 2002. An accident investigation team was assembled. The team consisted of the District accident investigation coordinator, three accident investigators, an electrical engineer, and an education and field service specialist. Prior to the arrival of the rest of the investigation team, Edward Lewetag, MSHA Coal Mine Safety and Health Inspector, traveled to the mine and issued a 103(k) order to ensure the safety of the miners until an investigation could be conducted.
MSHA and the Pennsylvania Department of Environmental Protection jointly conducted the investigation with the assistance of mine management and representatives of the United Mine Workers of America. A list of those persons who participated in the investigation is contained in the appendices of this report.
Interviews were conducted at the mine site. The onsite investigation was completed on May 20, 2002.
The following is a discussion of the relevant factors identified during the accident investigation.
The South West Mains Section is a seven-entry single unit continuous mining machine development section, operating with one Joy 14CM-12 continuous mining machine, two Oldenburg-Stamler BH20A coal haulers, one Joy 10SC32 shuttle car and one Joy 14BU loading machine.
The mining height in this area is eight feet. Entries and crosscuts were driven a maximum of 16 feet wide. During development, the inby corners of the blocks are cut off; the outby corners remain square.
The Oldenburg-Stamler BH20A coal hauler is a 128 volt D.C., battery powered, rubber-tired articulated machine. The overall dimensions of the coal hauler are 37 feet long by 11.7 feet wide (at its widest point) by 6.5 feet high. The size of the coal hauler used in the 16-foot entry makes it difficult to maneuver the machine around the corners of the blocks. The operator trams the fully loaded machine battery end first as far as possible because of limited visibility at the loaded end.
When Shirley deviated from his original route of travel, by making the turn from the number 4 entry into the 4 to 3 crosscut, Simmons observed him traveling at a slow rate of speed and looking back in the direction of the loaded end of the machine.
The rear of the coal hauler pinched the loading machine trailing cable between the machine frame and the coal rib, damaging the cable and energizing the frame of the coal hauler. The trailing cables were not adequately protected from damage by mobile equipment for all possible routes of travel.
After exiting the machine, Shirley contacted the frame of the coal hauler and received a fatal electrical shock. Shirley's gloves were found in the operator's compartment of the coal hauler. Eighty Four Mining Co. has a policy requiring that gloves be worn at all times except when such use results in a diminution of safety or sensitivity of touch is needed.
When Daisley tried to pass between the coal hauler and the coal rib to reach Shirley he received an electrical shock. Daisley was wearing leather-palmed gloves at the time.
Testing conducted underground at the scene of the accident, with the coal hauler in the same position as it was at the time of the accident, revealed the following:
1. A voltage of 360 volts was measured on the frame of the coal hauler when the loading machine trailing cable was energized at 610 volts.
2. A 1500 ohm resistor was connected between the frame of the coal hauler and ground. A current of 220 milliamps was measured through the resistor when the loading machine trailing cable was energized.
3. When a solid connection from the frame of the coal hauler to ground was made and the loading machine trailing cable was energized, the ground fault circuit caused the the circuit breaker protecting the loading machine trailing cable to open.
Testing conducted on the General Cable (Anaconda), AWG #2, 3 conductor, type G-GC, 2000 volt, loading machine trailing cable, revealed the following findings:1. The conductors within the cable showed no signs of insulation breakdown when tested with meters.
2. X-rays of the damaged section of trailing cable did not reveal any failures.
3. Resistance measurements taken after the cable was soaked in water for 24 hours indicated a decrease in resistance between the black phase conductor and the ground wires.
4. Dissection of the cable revealed a small tear in the insulation of the black conductor.
5. The ground fault circuit opened the trailing cable circuit breaker at 2.8 amps of fault current.
The operator's training plan pertaining to the operation of coal haulers requires the machine operator to examine the intended route of travel prior to hauling coal to identify and address potential hazards.
Training records were reviewed; no deficiencies were identified.
ROOT CAUSE TREE ANALYSIS
A root cause tree analysis was performed using the data from the accident. The following causal factors and root causes were identified:
1. Causal Factor- Shirley changed his previously established route of travel. Root Cause - Human Performance Difficulties - Had Shirley not deviated from the previously established route of travel, the loader cable would not have been damaged.
2. Causal Factor- The rear of Shirley`s coal hauler contacted the coal rib pinching the loading machine trailing cable. Root Cause- Human Performance Difficulties indicated that the section foreman failed to recognize that the trailing cable was not protected from damage by mobile equipment.
3. Causal Factor- Shirley exited the coal hauler to observe the loader cable. Root Cause-Human Performance Difficulties indicated management did not have a policy in place that addressed actions to take when rubber tired equipment contacts energized electrical cables.
4. Causal Factor- Shirley was not wearing gloves, having left them in the operators compartment. Root Cause - Human Performance Difficulty indicated management had a policy in place that required the wearing of gloves at all times except when such use results in a diminution of safety or sensitivity of touch is needed. Shirley may have not followed this policy due to the distraction of pinching the cable between the coal rib and the frame of the machine.
The fatality occurred because the coal hauler operator deviated from the established route of travel without first examining the new travel way to ensure that all cables would be protected from damage. The root causes of the accident were: (1) the loading machine trailing cable was not protected from damage by mobile equipment; (2) the lack of an established procedure to be followed in the event of rubber tired equipment contacting electrical cables; (3) the victims failure to follow company policy regarding the wearing of gloves.
The following citations/orders were issued due to conditions revealed during the investigations:
(1). A 103(k) order was issued to ensure the safety of all persons in the mine until an investigation was completed in all areas and equipment was deemed safe.
(2). A 104(a) citation was issued for a violation of 30CFR75.606. The trailing cable providing 600 VAC power to the Joy 14BU loading machine, SN10113, being operated in the South West Mains (MMU-068) working section was not adequately protected from damage by mobile equipment. The trailing cable was damaged when the frame of the Oldenburg-Stamler coal hauler, SN 1203, pinched the trailing cable between the right inby rib and the machine resulting in the frame of the rubber tired coal hauler becoming energized. This damage occurred in the number four entry three crosscuts outby the face as the coal hauler operator attempted to make a right turn into the crosscut between the numbers four and three entries.
Related Fatal Alert Bulletin:
The following persons provided information and/or were present during the investigation:
Eighty Four Mining Company
Elizabeth Chamberlin .............. Corporate Safety DirectorUnited Mine Workers of America
Thomas Blaskovich .............. Division Safety Supervisor
Eric Schubel .............. Superintendent
Todd Moore .............. Manager of Safety
John Burr .............. Electrical Engineer
Brad Debusk .............. Safety Inspector
James Wood .............. Coal Hauler Operator
James Lamont .............. UMWA International RepresentativePennsylvania Department of Environmental Protection
Joseph Marcinek .............. Chairman Mine Safety Committee
Mark Segedi .............. President of Local 1197
Danial Smizick .............. Supervisory InspectorMine Safety and Health Administration
Robert Ceschini .............. Supervisory Inspector (Electrical)
Paul Eckenrode .............. Mine Inspector
Steven F. Gaida .............. Mine Inspector (Electrical)
Paul Keruskin .............. Mine Inspector (Electrical)
Carol M. Boring .............. Staff AssistantCounty of Washington
Thomas Whitehair II .............. Coal Mine Safety and Health Inspector
Edward J. Lewetag, Jr. .............. Coal Mine Safety and Health Inspector
David C. Lewetag .............. Coal Mine Safety and Health Inspector (Electrical)
Steven Dubina .............. Electrical Engineer, Techical Support
Linda Herbst .............. Education and Field Services Training Specialist
Timothy Warco .............. Coroner
List of persons interviewed
Eight Four Mining Company
Bine Daisley Sr. .............. Section Supervisor
Timothy Simmons .............. Shuttle Car Operator
John T. Smith .............. Continuous Mining Machine Operator
Daniel M. Makowski .............. Loading Machine Operator
Phillip Blose .............. Mechanic
Donald I. Robinson .............. Loading Machine Operator
William Ramsden Jr. .............. Roof Bolter Operator
Alexander J. Marran .............. Mechanic
Kenneth Mego .............. Mechanic
Thomas Jeffrey Price .............. Roof Bolter Operator