UNITED STATES                                     

                                                                  DEPARTMENT OF LABOR

                                                MINE SAFETY AND HEALTH ADMINISTRATION

                                                            COAL MINE SAFETY AND HEALTH

                                                                             

REPORT OF INVESTIGATION

Underground Coal Mine

 

Fatal Machinery Accident

May 18, 2004 

 

at

 

Air Quality #1 Mine

Black Beauty Coal Company

Wheatland, Knox County, Indiana

I. D.  No. 12-02010

 

Accident Investigators

 

Michael D. Rennie

Coal Mine Safety and Health Inspector

 

Arthur D. Wooten

Coal Mine Safety and Health Inspector (Electrical)

 

Leland Payne

Educational Field Services

 

Robert J. Holubeck

Approval & Certification Center - Technical Support

 

Brian Malin

Approval & Certification Center – Technical Support

 

 

Originating Office - Mine Safety and Health Administration

District 8

2300 Willow Street, Suite 200,

Vincennes, Indiana 47591

James K. Oakes, District Manager

 

OVERVIEW

 

On May 18, 2004, at approximately 1:50 a.m., Christopher D. Qualls, Mechanic/Electrician, was fatally injured when he was crushed between the remote controlled continuous mining machine and the coal rib. There were no eyewitnesses to the accident.  Based upon the physical evidence observed at the scene and statements obtained during interviews, the accident investigation team concludes that Qualls was moving the continuous mining machine from the face area of the No. 3 Entry on the No. 4 Working Section to allow access for servicing when the accident occurred.

 

The cause of the accident was the failure to ensure that all workers followed the safety precautions contained in the mine’s approved Roof Control Plan in regard to not standing or walking between the continuous mining machine and the coal rib while the machine is in motion.  The victim was located in a pinch point created by the continuous mining machine and the coal rib.

 

GENERAL INFORMATION

 

Black Beauty Coal Company’s Air Quality # 1 Mine is located 2.3 miles southwest of Wheatland, Knox County, Indiana and employs 206 persons underground and 36 persons on the surface. The mine is opened by one slope and five shafts into the Danville #7 Coal Seam which averages 72 inches in thickness and produces coal three shifts per day, five days a week.

 

The mine produces an average of 16,000 tons of raw coal per day from four advancing continuous mining sections.  Coal is extracted from the faces by Joy 14CM remote controlled continuous mining machines. Electric shuttle cars and/or battery ramcars transport the coal to the section loading point, where the coal is then transported from the section to the surface by a series of belt conveyors. The face areas are ventilated by blowing line curtains and scrubber-equipped continuous mining machines.

 

The mine is ventilated by two mine fans and liberates 627,217 cubic feet of methane per day.  The immediate mine roof consists of 10 to 30 feet of gray shale, and the overburden is a maximum of 350 feet.  Roof support is installed using roof bolting machines equipped with automated temporary roof support systems.

 

The Training Plan that was in effect at the time of the accident was approved on February 6, 2004. The Roof Control Plan that was in effect at the time of the accident was approved on July 25, 2000.

 

The principal officers for the Air Quality #1 Mine at the time of the accident were:

 

           President...........................................................................    Daniel Hermann

           Superintendent ..................................................................    Douglas Grounds

           Engineering Manager.......................................................    Jonathon Dever

           Safety Director..................................................................    Ronald Madlem

 

An MSHA Safety and Health Inspection, AAA, began on April 1, 2004, and was ongoing at the time of the accident. The previous MSHA Safety and Health Inspection had been completed on March 31, 2004.

 

The calendar year 2003 National Non-Fatal Days Lost (NFDL) incidence rate for underground coal mines was 5.93 and the NFDL incidence rate for this mine was 6.62.

 

DESCRIPTION OF ACCIDENT

                   

On Monday, May 17, 2004, the second-shift production crew completed the mining of the left side rooms of the No. 4 Working Section. The section foreman conducted a pre-shift examination for the on-coming shift before he and the crew left the working section.

 

The third shift maintenance crew for the No. 4 Working Section arrived on the section at approximately 12:01 a.m. on May 18, 2004. The crew consisted of Kris Robinson (Foreman), two electricians/mechanics, and three laborers. Two of the three laborers were not involved in the accident. They were scheduled to relocate the mining equipment from the completed rooms to the working section entry faces, move the belt feeder and prepare the belt for the next production shift. When the move was completed, they were to service and repair the mining equipment.

 

Robinson first examined the areas where work was to be performed, and then the maintenance crew began moving the mining equipment from the left-side rooms to the entry faces. The right-side continuous mining machine was moved to the No. 7 Entry and the left-side continuous mining machine was moved to the No. 3 Entry.  The roof bolting machine was moved to the No. 6 Entry.

 

Keith Scott and Christopher Qualls, Mechanic/Electricians, started servicing the right-side continuous mining machine.   Robinson, Tim Williams, and Ben Smith, both laborers, were working at the belt tail moving and repositioning the ratio feeder. When the servicing work was almost complete on the right-side continuous mining machine, Qualls informed Scott that he was going to go to the roof bolting machine to check the hydraulic oil level and then travel to the left-side continuous mining machine to prepare it for servicing.

 

After Scott had completed the work on the right-side continuous mining machine, he traveled directly to the left-side continuous mining machine where he found Qualls crushed between the discharge boom of the continuous mining machine and the right coal rib. Scott stated that no more than five minutes had elapsed between when Qualls had left the right-side continuous mining machine until he found him crushed against the rib.

 

After finding Qualls crushed against the rib, Scott ran to the belt entry and yelled for Kris Robinson. Scott informed Robinson that Qualls was seriously hurt.  He then proceeded to the mine phone and contacted the surface for assistance. Robinson instructed Williams to get the first aid equipment and then to meet him at the left-side continuous mining machine. Ben Smith went to the phone and notified the surface of the accident.

 

Robinson ran to the left-side continuous mining machine where he found Qualls crushed by the discharge boom against the coal rib.  Robinson, Scott, and Williams maneuvered beneath the boom and removed the remote control unit from Qualls.  Robinson and Williams held Qualls while Scott used the remote control unit to swing the boom away from Qualls.  After freeing him from the boom, Robinson immediately checked Qualls but found no signs of life. Cardio pulmonary resuscitation (CPR) was started by Robinson and Williams.

 

Jesse Emmons, Advanced EMT, was dispatched to the working section and upon arrival took over care of the victim. CPR continued while Qualls was being transported out of the working section to the Hart Street Portal bottom, where Halter/Smith Ambulance Service paramedics assumed care of the victim. Qualls was then transported to Good Samaritan Hospital in Vincennes, Indiana where he was pronounced dead at 3:22 am by Donald Halter, Deputy Knox County Coroner. Heavy bruising was present along the right side of the victim’s chest and the Coroner’s report stated that the cause of death was blunt crushed chest injury.

 

INVESTIGATION OF THE ACCIDENT

 

Ron Madlem, Safety Director, reported the accident to the Mine Safety and Health Administration (MSHA) Vincennes Field Office Supervisor, Gary W. Jones, at approximately 2:10 a.m. (EST) on Tuesday, May 18, 2004.  Bruce D. Harris, Coal Mine Inspector, and Jones traveled to the mine. A 103(k) Order was issued to ensure the health and safety of persons in the affected areas of the mine until an accident investigation could be completed.

 

A joint investigation was conducted by MSHA and the Indiana Bureau of Mines to determine the cause(s) of the accident and to prevent a similar occurrence.  Before traveling to the accident scene, the investigation team held preliminary interviews with persons who were on the working section at the time of the accident. The team examined the immediate area where the accident occurred. The accident area and equipment were photographed and measurements were taken at the scene.  Training records, examination records, and work practices relative to the accident were reviewed. The continuous mining machine involved in the accident was put through operational tests to verify if it was functioning properly at the time of the accident.  No functional defects were observed during these tests.

 

Investigators tested and evaluated various parts of the equipment that were involved in the accident. A list of the sites, equipment, and dates of these evaluations and tests are listed below:

 

Accident Site, May 19 and 20, 2004

Magnetek – Power Control Systems, Pittsburgh, PA, July 20, 2004 (Firing Package, Left and Right SCR Bridge)

Approval and Certification Center, July 21, 2004 (Left and Right Tram Motor Directional Contactor Assemblies)

Matric Limited, Seneca, PA, July 22, 2004 (Remote Control System)

Joy Mining Machinery, Franklin, PA – July 22, 2004 (Left and Right Tram Motor Directional Contactor Assemblies)

Black Beauty Coal Co. Air Quality #1 Mine, Vincennes, Indiana, July 27, 2004 (Left and Right Tram Motor Directional Contactor Assemblies)

 

DISCUSSION

 

1.                There were no eyewitnesses to the accident.

 

2.                The victim was moving the left-side continuous mining machine located in the No. 3 Entry back from the working face.  At the accident location, the victim may have been trying to reposition or change direction of the machine when the accident occurred. (See Appendix C)

  

3.                The front of the continuous mining machine was located 87 feet from the No. 3 Entry face.

 

4.                The mine floor in the immediate area was dry and smooth with a very small change in elevation.

 

5.                The seam height in the immediate area was 6 ½ feet.

 

6.                The entry width at the rear bumper of the continuous mining machine was 19-feet 2-inches (See Appendix D) .  The diagonal measurement of the No. 29 Crosscut intersection averaged 31-feet.  

 

7.                The Joy continuous mining machine, Model No. 14CM-15-11DX, Serial No. JM 4631C, Company No. 14, was being operated by radio remote control at the time of the accident. The remote control unit was a Matric Model TX-3, S.N. 75205AD013 D, which operated on a carrier frequency of 458 MHZ.

 

8.                The remote control unit showed no visible damage.

 

9.                The light switches were found in the “On” position with both the area lights and headlights burning.

 

10.           The following components were removed from the continuous mining machine involved in the accident for further testing:

 

·                  Matric Limited Remote Control Demultiplexer, Model: 500-200, P/N 100087264, S/N 90201ADO12B, MSHA IA 457

·                  Matric Limited Permissible Radio Transmitter with strap, Model TX3 (458 MHz), P/N 100112672,S/N 75205AD013D, MSHA Approval 2G-4096-0

·                  Matric Limited Receiver, Type RX1, P/N 100016248, S/N 83810AC001 D, MSHA IA-18528-0-1br

·                  Matric Limited Antenna, P/N 00601843-0251, S/N 5024233-000.

·                  Magnetek Firing Package, P/N RP601849-1124, S/N 4040601-001

·                  Magnetek Left SCR Bridge, P/N RP 601849-0121, S/N 31295-001

·                  Magnetek Right SCR Bridge, P/N 601849-121, S/N NB 3592-1701

·                  Joy tram motor contactor assembly (left), P/N 00601525-0000

·                  Joy tram motor contactor assembly (right), P/N 00601525-0000

·                  Koehler 5000 series cap lamp, with marking “93”

 

11.           The results of the evaluations and tests that were performed on the above components are summarized below:

 

A)    The remote control system consisting of the TX3 remote station, victim’s cap lamp and battery, machine-mounted remote control antenna, remote control receiver, and demultiplexer panel all functioned properly. The following deficiencies were noted, but were unlikely to have contributed to the accident: