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DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Fatal Machinery Accident
September 09, 2003
T & W Enterprises, LLC
Sitka, Johnson County, Kentucky
ID No. 15-18661
Coal Mine Safety and Health Inspector
Mine Safety and Health Administration
100 Fae Ramsey Lane
Pikeville, Kentucky 41501
Franklin M. Strunk, District Manager
On Tuesday, September 09, 2003, at approximately 8:15 a.m., bulldozer operator Preston Lee Dye, age 73, was fatally injured when the Caterpillar D8-L bulldozer he was operating went over a 32-foot highwall. Dye had 42 years of mining experience operating heavy equipment, and approximately 16 weeks experience at this mine. There were no witnesses to the accident. The accident occurred as Dye was back-dragging the strip mine bench in preparation for drilling operations.
A thorough technical examination of the bulldozer identified no mechanical defects that may have contributed to the accident. Other potential causes, such as medical conditions, were considered during the investigation. Visibility issues associated with weather conditions were considered along with lighting and other factors.
The No. 1 surface mine of T & W Enterprises, LLC, is located on Daniels Branch Road, just off State Route 201, approximately 9 miles north of Sitka, Kentucky. The mine employs 3 persons and works a single, 10-hour production shift, 5 days per week. Mining is conducted in the Williamson and Springfield coal seams, each of which average 28 inches in thickness. The overburden in this area averages 35 feet between the Williamson and Springfield seams and approximately 30 feet over the Springfield coal seam. The mine produces an average of 50 tons per day from these two seams.
DESCRIPTION OF THE ACCIDENT
On Tuesday, September 09, 2003, Dye started his shift at approximately 6:45 a.m. at the mine site. He met with Billy M. Ward, General Partner and Mine Foreman for T & W Enterprises, LLC, and discussed the plans for the day. Only Dye and Ward were working at the time of the accident. Ward stated that the fog was very thick that morning. As Ward left to get a front-end loader to clean the Williamson pit, Dye began tramming the bulldozer from the previous day's location toward the upper drill bench to clear away rocks and dirt in preparation for drilling operations.
Ward returned to the Springfield pit area at approximately 8:15 a.m. and trammed the front end loader into the pit to begin cleanup work. As he was turning the front end loader around, he heard the backup alarm on Dye's bulldozer continuously beeping. As he approached the location where the sound was originating, he saw the bulldozer lying on its side on the Springfield coal seam bench.
Ward ran to the bulldozer and checked Dye for vital signs and found none. He returned to his vehicle and called 911. Ward then called Claude Stamper, agent for the operator, to inform him of the accident. Stamper told Ward to stay by the phone and he would notify MSHA and the State. Stamper notified MSHA and the Kentucky Department of Mines and Minerals at approximately 8:35 a.m.
Shortly thereafter, personnel from the Johnson County Sheriff's office and the local ambulance service arrived at the mine. The Johnson County Coroner's office was contacted and the Coroner's presence was requested. The victim was recovered from the bulldozer and transported to the Kentucky State Medical Examiner's Office in Frankfort, Kentucky.
INVESTIGATION OF THE ACCIDENT
Immediately upon receiving notification of the incident, MSHA District 6 accident investigators were dispatched to the scene. Jimmy Brown, Surface Mine Inspector, Robert H. Bellamy, Mining Engineer, and Thomas Meredith, Assistant District Manager (Technical Division) traveled to the mine site and began the investigation. Brown issued a 103(k) Order of Withdrawal to ensure the safety of all persons until an investigation could be completed and a determination made that the area was safe.
The investigation team examined the scene, took measurements, and informally interviewed employees who were at the mine at the time of the accident. Formal interviews were conducted on September 10, 2003, at the KDMM office located in Martin, Kentucky. The two co-owners were interviewed during this session.
MSHA's Approval and Certification Center was contacted, and Eugene D. Hennan, Mechanical Engineer from the Mechanical & Engineering Safety Division was dispatched to assist with the investigation. The 1986 Caterpillar D8-L bulldozer (S/N 53Y04153) was examined to determine if there were any equipment related factors that may have contributed to this accident. No evidence was found to indicate that any mechanical failure had occurred. A discussion of the examination is included in Appendix C of this report.
During the investigation, violations for conditions or practices that did not contribute to the accident were cited under a separate inspection, and are not included in this report. The investigation team and personnel from MSHA's Educational Field Services Division reviewed the operator's training records.
Method of Mining
T&W Enterprises, LLC, utilizes the contour method of strip mining at the No. 1 Mine with 2 front-end loaders, 2 trucks, 1 bulldozer and 1 highwall drill. After the bulldozer is used to prepare a drill bench, a pattern of 6 �" diameter holes are drilled with an Ingersoll DM-45 highwall drill. The holes are loaded with an Ammonium Nitrate/Fuel Oil Mixture (ANFO) and electric or non-electric detonators. Blasting is performed by either Mountain Valley Explosives or Austin Powder on a contract basis. The resulting highwall is limited by the ground control plan to a maximum of 60 feet in height and is required to be slanted away from the coal pit at an angle greater than 90 degrees to prevent overhanging rock. The top of the highwall is cleaned and cleared of trees, debris, and hanging materials as it is taken.
The operator was following the acknowledged ground control plan. Neither the method of mining nor mining practices appeared to have contributed to the accident.
Examination of the equipment on site did not reveal any defects that could have contributed to the accident. A detailed report of the examination of the bulldozer is included in Appendix C.
According to testimony, workplace examinations were performed routinely by Billy Ward, Co-Owner and Foreman, but examination records were not being kept as required by 30 CFR 77.1713. An examination of the accident scene and work site did not reveal any hazards. Failure to record the results of workplace examinations was not a contributing factor to the accident.
On the day of the accident, the weather was dry, but visibility was impaired by moderate to heavy fog that was present until approximately 9:15 a.m. After returning to the Springfield pit area, Ward heard the bulldozer's backup alarm, but due to the fog, he did not see the bulldozer until he was within 40 feet of the machine.
A lack of records for experienced miner training and task training for the victim was cited as a part of this investigation. Although other deficiencies relating to training for this mine were found, they were cited as part of a separate inspection because they were determined not to be contributing factors to the accident. Dye had 42 years of total mining experience, most of which was operating bulldozers, and 16 weeks experience at this mine.
It is possible that the physical condition of the victim may have contributed to the accident. The victim suffered from diabetes and was 73 years of age. Although the victim was known to be a severe diabetic, the autopsy report did not identify this as a contributing factor to the accident. The cause of death was listed as "Blunt impacts and crushing injuries of head, trunk and extremities with multiple skeletal and visceral injuries."
ROOT CAUSE ANALYSIS
A root cause analysis was conducted and the following potential causal factors were identified:
1. Causal Factor: The victim may have misjudged the distance to the edge of the highwall.
Corrective Action: Continual focus on work activities, and adherence to all safety factors related to the task being performed. A procedure should be established to prohibit activities when visibility is inadequate to permit safe operation.
2. Causal Factor: The victim may not have been able to see the edge of the highwall due to heavy/thick fog conditions.
Corrective Action: Adequately marking the edge of the highwall, or performing other, less hazardous duties until weather conditions/visibility improve. A procedure should be established to prohibit activities when visibility is inadequate to permit safe operation.
3. Causal Factor: The victim was not wearing a seat belt where there was a danger of overturning and where ROPS were provided.
Corrective Action: Management must enforce all safety regulations and safety practices.
At approximately 8:15 a.m. on September 9, 2003, a 73-year old bulldozer operator with 42 years of mining experience traveled off a highwall in heavy fog while back-dragging the bench. The bulldozer operator was fatally injured during the 32-foot fall from the highwall. Based on information gathered during the investigation, the most likely cause of the accident was a misjudgment or inability to see the edge of the highwall due to heavy fog. The fog made visibility difficult. This misjudgment or inability to see the highwall edge may have been aggravated by a lack of any visible point of reference.
Additionally, the operator failed to meet the requirement for wearing a seat belt where there is a danger of overturning. The failure to wear a seat belt likely contributed to the severity of the victim's injuries.
1. 103(k) Order No. 7402131 was issued to ensure the safety of any person in the mine until an examination or investigation is made to determine that the mine is safe.
2. 104(a) Citation No. 7402155 was issued to T&W Enterprises, LLC, because evidence obtained at the scene of the accident indicated that seat belts provided in the cab of the Caterpillar D8L bulldozer were not in use when the accident occurred.
3. 104(a) Citation No. 7402156 was issued to T&W Enterprises, LLC, because testimony taken during the investigation along with evidence obtained at the mine site revealed that the victim had not received the required training prescribed by 30 CFR, Part 48. There were no records to indicate that the victim received experienced miner training for the specifics of this operation, nor had task training for this particular occupation been given by an approved instructor.
Related Fatal Alert Bulletin:
List of Persons Participating in the Investigation
T & W Enterprises, LLC.
Michael D. Trimble ................ Co-Owner, Coal BrokerKentucky Department of Mines and Minerals
Randy Smith ................ District Supervisor - Martin DistrictMine Safety and Health Administration
Robert H. Bellamy ................ Mining Engineer
List of Persons Interviewed
T & W Enterprises, LLC.
Michael D. Trimble ................ Co-Owner, Coal Broker