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DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Fatal Machinery Accident
December 2, 2004
Mountaintop Clearing, LLC (C858)
Fairdale, Raleigh County, West Virginia
Catenary Coal Company
Eskdale, Kanawha County, West Virginia
Gerald L. Cook, Sr.
Coal Mine Safety and Health Inspector
Mine Safety and Health Administration
100 Bluestone Road
Mt. Hope, WV 25880-1000
Jesse P. Cole, District Manager
At approximately 1:25 p.m. on Thursday, December 2, 2004, a 44-year old contract employee with four years of mining experience was fatally injured at Catenary Coal Company's, Samples Mine. The accident occurred while the contractors were clearing trees and brush in advance of the surface mining operations. William S. Woods, victim, was using a chain saw to cut a standing tree which contained a hanger tree (a hanger tree is a fallen tree that has become lodged or wedged into a standing tree). A standing tree that is supporting a hanger tree is also called a danger tree. As the victim cut the danger tree, the hanger tree fell and struck the victim crushing him.
The accident occurred because the danger tree, which was observed by the foreman, was neither marked nor taken down to assure that the other tree cutters would not expose themselves to the hazardous condition. Both the tree cutters and the foremen received additional training and a copy of safe work guidelines to be followed to ensure that hazardous conditions are either corrected or marked to prevent exposure.
The Samples Mine is a bituminous surface coal mine, operated by Catenary Coal Company, which is located near Eskdale, Kanawha County, West Virginia. Mountain top removal, contour mining and auger mining are all performed at this mine site. At the time of the accident Mountaintop Clearing LLC was performing brush clearing and tree removal (clear cutting) approximately 1000 feet in advance of mining operations.
The principal officer for Catenary Coal Company for this mine at the time of the accident was Jeff Bitzer, President. The principal officer for Mountaintop Clearing, LLC at time of the accident was Richard Breton, General Manager.
Prior to the accident, the Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection on September 29, 2004. The Non-Fatal Days Lost (NFDL) injury incidence rate for Mountaintop Clearing, LLC for 2003 was 0.00 compared to a National NFDL rate of 2.50 for the same time period.
DESCRIPTION OF ACCIDENT
On Thursday, December 2, 2004, at approximately 7:30 a.m., Mike McKinney, tree cutting crew foreman, and the tree cutters: Anthony Duffield, William S. Woods, Jason McKinney, Roger Holcomb, and Darrell Pritt met at Area Q of the mine site. Mike McKinney and the tree cutters were employed by Mountaintop Clearing, LLC (C858).
Prior to beginning work, they had to wait on Jimmy Prince, bulldozer operator and supervisor for MGC, Inc. (4Z6), to arrive with supplies. MGC, Inc. utilizes bulldozers to push the cut trees after felling. Upon arrival, he provided two hard hats, saw chains, and files for the tree cutters.
Mike McKinney, and the tree cutters, started to clear cut at about 8:15 a.m. They began clear cutting in Area Q, where Mike McKinney had the tree cutters working approximately 100 to 125 feet apart. Clearing began at the bottom of the mountain and progressed toward the top of the mountain.
At approximately 10:45 a.m. the tree cutters stopped for lunch. After lunch they continued to cut and were nearing the end of their second trip to the top of the mountain when Jason McKinney, Holcomb, and Pritt, went back to the truck to sharpen and fuel their chain saws. Mike McKinney, Duffield, and Woods continued to cut to the top of the mountain. Mike McKinney encountered a hanger tree at about 1:10 p.m. and decided to leave the tree. He traveled away from the hanger tree toward an old road. Duffield then approached the tree, when Mike McKinney got his attention and told him to leave it because it was near quitting time. Duffield could hear the instructions because he had his chain saw turned off and he was not wearing ear muffs.
Mike McKinney and Duffield were located in the old road, approximately 30 feet from the danger tree, when Woods approached it. A danger tree is a standing tree that has a hanger tree leaning against it. Mike McKinney observed Woods placing a notch in the danger tree. Mike McKinney got Woods' attention through hand signals and pointed up to indicate to Woods the presence of the hanger tree. At this time, Woods' chain saw was running and he was wearing ear muffs, which may have hindered his ability to hear. Woods nodded as if he understood not to cut the tree. Mike McKinney and Duffield turned to leave when they heard Woods' chain saw start to cut. Both Mike McKinney and Duffield thought Woods was cutting underbrush on his way out of the work area. They heard the tree crack and turned to see the hanger tree fall on Woods.
Mike McKinney told Jason McKinney to notify Prince about the accident and to send for help. Prince told Leroy Darby, bulldozer operator employed by MGC, Inc., to radio for help. Mike McKinney and Duffield ran to the accident site and cut the tree off of the victim, and checked for a pulse. No pulse could be detected, therefore Prince started CPR. Darby used a bulldozer to make an access road to the accident site to assist in the recovery efforts. Samples Mine emergency medical technicians arrived, and continued CPR as the victim was placed on a backboard. The victim was transported by truck to an active pit where they met a Kanawha County Ambulance. The victim was immediately transported to Charleston Area Medical Center.
INVESTIGATION OF THE ACCIDENT
The MSHA District Office located in Mt. Hope, West Virginia was notified of the accident at approximately 3:00 p.m. on Thursday, December 2, 2004. MSHA accident investigators traveled to the mine site and a 103(k) order was issued to assure the safety of all persons at the mine site.
The investigation was conducted in cooperation with the West Virginia Office of Miner's Health, Safety, and Training (WVOMHST) with the assistance of the mine operator and employees. During the investigation interviews were conducted with five persons.
Mountaintop Clearing, LLC conducts clear cutting activities incidental to the mining activities of Catenary Coal Company. The clearing crew utilizes chainsaws, to clear trees and brush. MGC, Inc. utilized bulldozers to pile the material after the tree cutting activities.
Catenary Coal Company holds the permit for Area Q where Mountaintop Clearing, LLC employees were working. Mountaintop Clearing, LLC management conducts examinations of work areas for the clearing crews and Catenary Coal Company performs examinations up to the clearing crew's work areas. Catenary Coal Company does not exercise any supervisory control over the contract employees.
Mike McKinney conducted an examination of the work area prior to the accident. Mike McKinney was the certified person designated by Mountaintop Clearing, LLC to conduct workplace examinations. The examination record indicates stumps, hangers, and dead trees into other trees. The examination record does not indicate the degree of the hazards or that any of the hazards were corrected. The examination record was neither signed nor countersigned.
In addition to being a tree cutting crew foreman, Mike McKinney is also a tree cutter and works closely with the other tree cutters throughout the working shift.
The danger tree contained a hanger that had been determined by the foreman as dangerous, however; he had not marked the tree to identify it as a danger tree.
The victim had notched the danger tree when the foreman gained the victim's attention and attempted to communicate and point out that a hanger was present. The victim's response indicated to the foreman that the communication was understood. Both Mike McKinney and Duffield believed that Woods understood not to cut the tree, therefore they turned away and started to leave. They did not realize the victim misunderstood the directions, until they heard the tree crack and turned to see the hanger tree fall on the victim. The victim's actions may have been affected by his inability to hear due to the use of ear muffs and the running chainsaw.
The foreman and the victim were provided with annual refresher training on June 18, 2004. The annual refresher training included procedures to be used for the manual felling of trees. The training material used during annual refresher training states in Item 12 of Section 3, "Never leave a lodged tree, also called a 'danger tree,' because it may fall unexpectedly. Never work in the area of a lodged tree. Each danger tree shall be felled using mechanical or other techniques that minimize employee exposure before work is commenced in the area of the danger tree. Always have lodged trees safely pulled or pushed down with the aid of a skidder, tractor, or other heavy equipment."
Item 13 of Section 3 of the training material further explains the identification of danger trees that have not been taken down, "If the danger tree is not felled, it shall be marked and no work shall be conducted within two tree lengths of it unless the employer demonstrates that a shorter distance will not create a hazard to anyone. Safely mark the lodged tree, preferably with high visibility colored plastic tape, and move two tree lengths away from the tree before resuming work."
ROOT CAUSE ANALYSIS
An analysis was conducted to identify the most basic causes of the accident that were correctable through reasonable management controls. During the analysis, causal factors were identified that, if eliminated, would have either prevented the accident or mitigated its consequences. Listed below is the causal factor identified during the analysis and the corresponding corrective action implemented to prevent a recurrence of the accident:
1. Causal Factor: During the examination of the work area, a danger tree was observed by the foreman, however; the foreman did not mark the danger tree to assure that other cutters would not cut the tree. Established work procedures were not followed. Work procedures described in the annual refresher training material requires that danger trees, which have not been corrected by mechanical means, be marked to eliminate exposure to the hazard.
Corrective Action: The contractor, Mountaintop Clearing, LLC, revised the safety training guidelines portion of the annual refresher training and all workers for Mountaintop Clearing, LLC had the new safety training provided to them on December 6, 2004. A list of the new safety procedures, which includes the marking of danger trees, was distributed, reviewed and signed by each employee.
2. Causal Factor: The examination of the working area by the certified person designated to conduct the examination did not correct or report the hazardous condition to the operator.
Corrective Action: Persons conducting workplace examinations were reinstructed in their responsibilities to identify, correct and report hazardous conditions to the operator. All tree cutter foreman received training in the identification, correction and reporting of tree cutting hazards.
3. Causal Factor: The communication of the presence of the hanger tree between the foreman and the victim was misunderstood.
Corrective Action: The presence of hazardous conditions should be communicated effectively to all persons who may be exposed to the hazard. Hand communication, if used, should be standardized to eliminate the potential for misunderstanding. Verbal communication of hazards should be confirmed before allowing persons to work in a hazardous location.
The accident occurred because the danger tree, which was observed by the foreman, was neither marked nor taken down to assure that the other tree cutters would not expose themselves to the hazardous condition. Neither was the hazardous condition reported to the operator nor corrected. The failure to confirm communication concerning the danger tree between the foreman and the victim was also a factor in the accident.
1. A 103(k) Order No. 7235452 was issued to Mountaintop Clearing, LLC on December 2, 2004, to insure the safety of persons at the mine until and investigation of the accident could be completed.
2. A 103(k) Order No. 7235453 was issued to Catenary Coal Company on December 2, 2004, to insure the safety of persons at the mine until an investigation of the accident could be completed.
3. A 104(a) citation was issued to Mountaintop Clearing, LLC for a violation of 77.1713(a). The operator conducted an inadequate daily examination of Are Q of this mine site. A hazardous condition was not reported and corrected by the operator. The foreman of the tree cutters found a hanger tree (a fallen tree that had become lodged/wedged into a standing tree), but failed to mark it as a danger tree or to remove it. Another tree cutter felled the danger tree and was killed.
Related Fatal Alert Bulletin:
PowerPoint / PDF
List of persons furnishing information and/or present during the investigation:
Catenary Coal Company
Jeff Bitzer .......... General ManagerMountaintop Clearing, LLC
Conrad Larrabee .......... Supervisor
Terry Tolley .......... Safety Manager
Robert Hill .......... Assistant Safety Manager
Mark Heath .......... Attorney
Richard Breton General ManagerWest Virginia Office of Miners Health, Safety and Training
Jimmy Prince .......... Supervisor
Mike McKinney .......... Foreman
Anthony Duffield .......... Tree Cutter
Gary S Snyder .......... Inspector-At-LargeMine Safety and Health Administration
Terry Keen .......... Inspector
Gerald Ellison .......... Inspector
Link Selfe .......... Assistant District Manager
Gerald L. Cook, Sr .......... CMS&H Inspector
Leo Inghram .......... CMS&H Inspector