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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
Air Quality #1 Mine
Black Beauty Coal Company
Michael D. Rennie
Coal Mine Safety and Health Inspector
Arthur D. Wooten
Coal Mine Safety and Health Inspector (Electrical)
Educational Field Services
Robert J. Holubeck
Originating Office - Mine Safety and Health Administration
James K. Oakes, District Manager
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.
Black Beauty Coal Company's Air Quality # 1 Mine is located 2.3 miles
southwest of Wheatland,
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
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
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.
The third shift maintenance crew for the No. 4 Working
Section arrived on the section at approximately on
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
Ron Madlem, Safety Director, reported the accident to
the Mine Safety and Health Administration (MSHA) Vincennes Field Office
Supervisor, Gary W. Jones, at approximately (EST) on
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,
Joy Mining Machinery,
Black Beauty Coal Co. Air Quality #1 Mine,
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 � 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
� 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:
i) The right-tram control lever had a torn protective rubber boot. The tear measured approximately 0.90 mm by 3.25 mm.
ii) The right-tram control lever was found to be out of parallel with the left tram control lever. The distance between the levers at the top was approximately 15.10 mm, and the distance between the levers at the bottom was approximately 18.90 mm.
iii) The area beneath the remote control toggle switches contained fine coal dust.
iv) The receiver was out of tune beyond the acceptable Matric range of 5 kHz +/- 100 Hz.
v) On the machine-mounted remote control antenna, there was a crack along the base of the plastic dome, extending from one side of the dome to the other.
Rust was noticeable on the heat sink on the bottom
case of the
vii) There was a cut, approximately 5.4 mm long, in the cable jacket of the power cable from the cap lamp battery to the TX3 remote station, near the PTO connector. This cut did not extend into any wire inside the cable.
viii) The victim's cap lamp and battery were fully functional. However, there were two notches cut, one on each side of the plastic base of the PTO connector on the top of the battery jar. On the �belt-loop� side of the battery, the notch measured approximately 5.4 mm long by 6.4 mm high. On the opposite side, the notch measured approximately 6.5 mm long by 5.9 mm high. On the �belt-loop� side, the notch provided access to an electrical connection inside the PTO connector. The full battery voltage is available between the electrical connection inside this notch and the bolt in the center and extending above the PTO connector. This is a permissibility discrepancy of 30 CFR 19.7(f).
B) Testing revealed that another TX3 remote station did not cause cross-activation with the continuous miner.
C) Testing revealed that handheld radios or magnets did not cause unintentional continuous miner machine movement.
D) Functional testing of the firing package and left and right SCR tram bridges demonstrated these components to function properly.
E) Functional testing of the continuous miner was conducted after the accident and demonstrated the machine to be functioning properly.
F) The left motor's forward contactor was not adjusted correctly to actuate the interlock. During laboratory testing, when voltage was applied to energize the forward coil, the interlock would intermittently not actuate. If this malfunction were to occur on the continuous miner, when an operator attempted to tram the machine with both motors in the forward direction, only the right motor would respond. This right tram forward movement is identical to the last movement of the machine involved in the accident. However, during functional tests on the continuous miner on the day after the accident, and with the contactor assembly installed on the training panel and on another continuous miner, this malfunction was not witnessed.
Functional testing showed that the right tram motor's
reverse function could be precluded if the right tram forward interlock
inadvertently actuated. During testing at the Air Quality #1 Mine on
H) No evidence was found to suggest that a tram motor or motors could become inadvertently energized, or to tram in a direction opposite to that selected by an operator.
12. The continuous mining machine discharge boom and remote control unit had been moved from their original positions to free the victim. The position of each switch on the remote control unit at the time of the accident could not be determined since all the switches return to a neutral position when released. Mine personnel stated that the pump motor was off, and the machine lights were on when they arrived at the accident scene. This indicates that the remote control Shutdown Bar, Circuit Breaker Trip, or Pump Start/Off switch had been activated.
13. The continuous mining machine was designed with the following tram speeds:
� 15 ft/min- �SLOW�
� 30 ft/min- �2nd�
� 68 ft/min- �3rd�
� 85 ft/min- �HIGH/TURBO�
14. The continuous mining machine was designed such that when the tram switches were split (one forward, one reverse) the highest tram speed possible was 30 ft/min. However, if only one of the tram switches was operated, the highest tram speed was 68 ft/min.
15. Tests were conducted to determine the time for the right corner of the machine discharge boom to contact the rib. The results are tabulated below:
16. Sometimes when the operators of remote controlled continuous mining machines are operating this type of equipment from locations in front of the machine and/or are looking in the direction outby the machine, they can become disoriented with the machine tramming lever control function.
17. A review of the victim's training records showed that the required task training was not complete and up-to-date. No record was available to indicate that the victim had been trained in the task of operating the continuous mining machine.
Training materials were reviewed from previous safety
meetings and from annual refresher training that was received by the
victim. Four safety meetings had been conducted since
A root cause analysis was conducted and the following causal factors were identified:
Causal Factor: The approved Roof Control Plan was not being complied with when the continuous mining machine operator was positioned in a hazardous location and was crushed between the discharge boom of the continuous mining machine and the coal rib. The approved Roof Control Plan requires the continuous mining machine operator be positioned so as to avoid danger from pinch points and moving equipment.
Corrective action: Before resuming operations, training sessions were conducted by mine management emphasizing adherence to the safety precautions in the approved Roof Control Plan.
Causal Factor: The approved Training Plan was not being followed. Task training required by the plan for the operation of remote controlled continuous mining machines was not being conducted.
Corrective Actions: Mine management shall ensure that all persons who are required to operate continuous mining machines are task trained in accordance with the approved Training Plan.
Causal Factor: Deficiencies were found in the records required for task training.
Corrective actions: Mine management shall ensure that all persons receive the proper task and proficiency training and the results are recorded and kept on file.
The cause of the accident was the failure to ensure that all workers followed the safety precautions in regard to not standing or walking between the continuous mining machine and coal rib while the continuous mining machine is in motion. While moving the left-side continuous mining machine out of the face area of the
No. 3 Entry, the machine pivoted for some undetermined reason(s) and crushed the victim between the continuous mining machine discharge boom and the coal rib causing fatal injuries.
A contributing factor to the cause of the accident was that the victim had not been task trained on remote control continuous mining machines nor had hedemonstrated that he could safely operate remote control continuous mining machines at this mine.
In addition, other contributing factors were the victim's possible disorientation relative to the location of the continuous mining machine and the remote control unit tram lever function, the high tram speed, the possible malfunction of auxiliary contactors on a tram control contactor assembly, and the slight unevenness of the mine floor.
Section 103(k) order No. 7595722 was issued on May 18, 2004 stating:
The mine has experienced a fatal accident wherein a miner was pinched between the boom of the Joy continuous miner and the coal rib. This order is issued to ensure the safety of any person in the coal mine until an examination or investigation is made to determine that the continuous miners and associated remote control equipment are safe. Only those persons selected from company officials, state officials, miner's representatives, or other persons who are deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area.
Section 104(a) citation No. 7579717 was issued on January 5, 2005, stating:
Mine management did not ensure their mine personnel
were complying with the approved Roof Control Plan. The Roof
Control Plan safety precautions stipulate that mine personnel are not to
stand or walk between the continuous mining machine and the coal rib while
the continuous mining machine is in motion. A fatal machinery accident occurred on
Section 104(a) citation No. 7579718 was issued on January 5, 2005, stating:
A review of the mine operator's training records
revealed that task training in the safe operation of remote controlled
continuous mining machines was not provided to a miner who was fatally
Listed below are those persons who participated and/or were present during the investigation:
BLACK BEAUTY COAL COMPANY
Douglas R. Grounds Mine Superintendent
Greg Xanders Administration Manager
Mark Swain Maintenance Foreman
Terry Marsh General Mine Foreman
Jon Dever Mine Engineer
Terry L. Courtney Shift Mine Foreman
Ron Madlem Safety Supervisor
Joe Batson Chief State Mine Inspector
MINE SAFETY AND HEALTH ADMINISTRATION
James K. Oakes District Manager
Coal Mine Safety and Health
Gary R. Jones Supervisory Coal Mine Safety and Health Inspector
Bryan P. Sargeant Staff Assistant / Supervisory Coal Mine Safety and Health Inspector
MINE SAFETY AND HEALTH ADMINISTRATION (Cont.)
Michael D. Rennie Coal Mine Safety and Health Inspector
Arthur D. Wooten Coal Mine Safety and Health Inspector (Electrical)
Bruce D. Harris Coal Mine Safety and Health Inspector
Leland Payne Mine Safety and Health Specialist Educational Field Services
Robert Holubeck Electrical Engineer
Bryan Malin Electrical Engineer
Listed below are those persons who provided information that was pertinent to the investigation:
Donald Halter Deputy Knox County Coroner
BLACK BEAUTY COAL COMPANY
Brian Keith Scott Mechanic/Electrician
Timothy Edward Williams General Underground Laborer
Kris A. Robinson Foreman
Mark Bedwell Maintenance Foreman
Denny Gibbons Continuous Mining Machine Operator
Greg Swinney Continuous Mining Machine Operator
Gregory R. Hunt Mechanic/Electrician
Steve Rich Mechanic/Electrician
Mike Sutton Mechanic/ Electrician
Mike Boyer Continuous Mining Machine Operator
Sammy Marcroft Foreman
JOY MANUFACTURING COMPANY
Dave Thomas Electrical Certification Engineer
John L. Dodd Sales / Service Engineer
Clint Glover Design Engineer
Samuel G. McDowell Senior Electrical Engineer
John Duty Field Representative
Russell Cataldo Electronic Technician
Wally Goughler Electronic Technician
Donnie Cousins Electronic Technician
MAGNETEC POWER ELECTRONICS GROUP
Joe Ley Facility Manager
Gary Bolbat Sales and Marketing Engineer
Mayibeth Walter Buyer/Planner
Rick Bender Electronic Technician