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CAI-2008-16
DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION COAL MINE SAFETY AND HEALTH REPORT OF INVESTIGATION Underground Coal Mine Fatal Machine Accident July 11, 2008 Nolo Mine AMFIRE Mining Company LLC Nolo, Indiana County, Pennsylvania MSHA ID 36-08850 Accident Investigators Robert E. Roland Coal Mine Safety and Health Inspector Donald R. Foster Coal Mine Safety and Health Inspector, Electrical Specialist Robert Bodenschatz Coal Mine Safety and Health Inspector Stephen Dubina MSHA, Electrical Engineer Anthony Guley Assistant District Manager, Inspections Originating Office Mine Safety and Health Administration District 2 319 Paintersville Road Hunker, Pennsylvania 15639 William Ponceroff, District Manager OVERVIEW
At approximately 3:50 P.M. on Friday, July 11, 2008, a 62 year old shift foreman was fatally injured at AMFIRE Mining Company's Nolo Mine. The accident occurred while the victim was preparing to tram a belt feeder back onto the belt tail after adding belt to the belt conveyor. The trailing cable, supported by tie wires from the mine roof, was lowered to the mine floor. In the process of lowering the cable, it dropped inadvertently behind the control levers holding the right tram valve in the open position. When the victim started the feeder, it pivoted abruptly pinning him between the feeder and the mine rib. The accident occurred because the trailing cable was inadvertently positioned behind the hydraulic control levers holding the right cat tram lever in the open position. When the start switch was activated, the machine suddenly pivoted. No means to deenergize the machine was available at the start switch location. GENERAL INFORMATION
The Nolo Mine, operated by AMFIRE Mining Company LLC, was located at 1127 Simons Rock Road, Penn Run, Indiana County, Pennsylvania. The mining operation utilized continuous mining machines with shuttle car haulage to produce coal from the Lower Kittanning seam. The average mining height was 48 inches. Total employment at the mine was 100, including 95 underground miners. The mine operated two production shifts and one maintenance shift on a five to six days per week schedule. Three continuous mining sections, two on advance and one on retreat, produced an average of 2,400 tons per day. A system of conveyor belts transported coal from the working sections to the surface where it was trucked to other locations for processing. The principal officers for the mine at the time of the accident were:
Gary O. Deemer ................ General Manager Ricky D. Smith ................ Superintendent George R. Bonneau ................ Mine Foreman DESCRIPTION OF ACCIDENT
On the evening of July 10, 2008, William Pardee, shift foreman, reported for the 11 P.M. to 7 A.M. shift. Pardee instructed workmen on their work assignments for the shift which would consist of advancing the section power center and adding 175 feet of conveyor belt in the 3 West section of the mine. A crew of seven miners and the section foreman entered the mine at approximately 11:30 P.M. and proceeded to the 3 West Section. The section foreman, Stanley Kubat, along with Daniel Huey, Thomas Dyson, and James Strenko started to move the section power center. Daniel Wojno, Joseph Cochran, Raymond McClain, and Paul Whitaker prepared to extend the 3 East section conveyor belt. Pardee traveled to the section via the belt entry to pick up supplies and arrived on the section after the crew. In preparation to move the belt feeder, Cochran and Wojno cleaned up spilled coal, unblocked the feeder, and disconnected the sequence control cables. Cochran trammed the feeder off the belt tail and moved the machine inby approximately 200 feet in the No. 4 entry to a point just inby Survey Station 7390. The feeder was parked at this location and Cochran hung the feeder trailing cable from the roof bolts because the scoop tractor would be traveling through this area. Hanging the cable would assure that it was placed out of the way. Pardee arrived on the section and joined the belt addition activities already in progress. As the shift progressed the power move was nearly completed. The cables had been disconnected and pulled around the coal pillar to the new set-up location. The power center had been moved to the new location and cables were being re-connected and power restored. The belt advancement progressed as expected without incident. At approximately 3:45 A.M. Pardee told Wojno that they would prepare to set the belt feeder back on the belt tail. Pardee dropped the trailing cable to the mine floor as Wojno waited at the belt tail, some 30 feet away, to help direct the feeder onto the belt tail. Pardee positioned himself between the feeder and the coal rib in preparation to operate the feeder. As he pushed the start button, the feeder abruptly moved, pivoting against the rib pinning him between the machine and the rib. Wojno, realizing immediately that Pardee was pinned, ran to the feeder to push the emergency stop switch located on the opposite side of the machine. Wojno yelled to Pardee and received no response. Pardee's position could not be reached due to the close proximity of the machine to the mine rib. Kubat was summoned and informed of the accident. A call was placed to the surface, reporting the accident and requesting medical assistance. Gary Deemer, General Manager, was contacted and instructed the underground miners, via telephone, to take whatever measures necessary to free Pardee. A scoop tractor was used to pull the feeder away from the rib and free Pardee. Strenko, an emergency medical technician (EMT), was located and brought to the scene. Once the feeder was pulled away from the rib, the victim was freed and access to his location was possible. The EMT made an assessment and no signs of life were found. The victim was placed on a backboard and transported to the surface where he was pronounced dead at 5:39 A.M. by the Indiana County Coroner. The victim was transported to Conemaugh Hospital by Citizens Ambulance Service. INVESTIGATION OF THE ACCIDENT
On July 11, 2008, at 4:20 A.M, David Weakland, MSHA Field Office Supervisor for the Indiana Field Office, was notified that an accident had occurred at the Nolo Mine. MSHA personnel were dispatched to the mine. A 103(k) order was issued to ensure the safety of all persons during the accident recovery and investigation. The accident investigation was conducted in cooperation with Pennsylvania Bureau of Deep Mine Safety, the mine operator, and MSHA's Technical Support Branch. The investigation consisted of visits to the accident scene and other locations within the mine, a review of pertinent mine records, and interviews conducted with ten miners. DISCUSSION
Mining Type and Equipment The 3 East section is an advancing section with six entries spaced on 60 foot centers utilizing various pillar lengths. The entries are numbered 1 through 6. left to right. The belt entry and loading point (belt feeder/belt tail) is located in the No. 4 entry at the end of the section belt. The coal is mined with a Joy 14CMAA continuous mining machine and transported to a belt feeder by three Joy 21SC shuttle cars. A Fletcher twin boom roof drill and a Lee Norse single head drill are utilized to install roof supports. The belt feeder was a Stamler; model CF44LPH1CAE, serial number 04-011, rebuilt by Cogar Mine Products, Beckley, West Virginia. It is a self-propelled, track mounted machine, designed with a floor level conveyor bed onto which the coal is dumped from the shuttle car. The belt feeder is positioned with the boom end (discharge end) over the belt tail. The coal is fed, at a regulated rate, by a flight chain from the conveyor bed, over the boom end of the feeder and onto the conveyor belt which transports the coal to the surface. MSHA Technical Support personnel did not identify mechanical equipment defects affecting operation of the belt feeder. The section power distribution center (power center) was located in the No. 5 entry, adjacent to the feeder/belt tail. The power center receives high voltage (typically 7200 Volts AC) and reduces it to the desired voltage to operate the section equipment. The power center also contains the required electrical safety devices for each circuit on the working section. The addition of belt and advancement of the power system is typically done for every one to three hundred feet of section advancement. Depending on the rate of section advancement, the frequency of this process will vary from a few days, up to two weeks. Physical Factors 1. The accident occurred 25 feet inby Survey Station 7390 in the No. 4 entry of the 3 East section. 2. The feeder was parked on a roll or raised hump in the mine floor, which greatly increased the ease with which the machine would pivot when trammed. 3. The mining height at the accident location measured 51 inches and the width of the entry was 19 feet 4 inches. 4. The area was dry. 5. No obstructions were present in the area along the rib where the accident occurred. STAMLER BELT FEEDER (Cogar rebuild): a. The belt feeder measured 9 feet in width by 31 feet in length. b. The reset (start) button was located 63 inches inby the operator control levers and the emergency stop switch (panic bar). c. The hydraulic control levers extended two inches beyond the top pan (or cover) of the machine. * d. The trailing cable entered the electrical control panel on the end of the panel located by the hydraulic control levers. * e. The position of the strain clamp on the trailing cable was such as to align the cable with the control levers when the cable was under tension. * f. The feeder trailing cable was positioned behind the hydraulic control levers with the weight of the cable holding the right tram control valve in the open position. * *See Appendix C (In Printer Friendly Version) Training and Experience William Pardee had a total of 40 years underground mining experience, with 20 years experience as a shift foreman. Of Pardee's 40 years of underground experience, the last 4 years and 32 weeks were at AMFIRE's Nolo Mine. Pardee possessed the following certifications from the Commonwealth of Pennsylvania: Assistant Mine Foreman, Mine Foreman, Miner's Certificate of Qualification and Machine Operators Certificate. Pardee was given required training as per the applicable MSHA approved training plans. 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 are root causes identified during the analysis and their corresponding corrective actions implemented to prevent a recurrence of a similar accident: 1. Root Cause: The START switch of the belt feeder was located 63 inches away from the operator's control station, which placed the victim out of reach of the operator controls and the emergency stop switch while starting the feeder. Corrective Action: The mine operator has made modifications to all belt feeders used at Nolo Mine. The change assured that any feeder operator is capable of easily reaching a stop switch and deenergizing the machine, if needed, while starting or tramming the feeder. The operator developed written Safe Job Procedures for each type belt feeder in use at Nolo Mine. A revision of the operator's Part 48 Training Plan was submitted and approved by the District Manager. The task of Belt Feeder Operator and Safe Job Procedures for the task was added to the plan. The mine operator re-trained all belt feeder operators per the operator's approved training plan under Part 48.7(a), which included modifications made to the feeders. 2. Root Cause: The hydraulic control levers extended beyond confines of the feeder frame, exposing the levers to unexpected activation. When the trailing cable was lowered from its supported position, the cable fell onto the hydraulic levers and held the tram lever in the open position. Corrective Action: The mine operator fabricated a metal guard over the hydraulic control levers to prevent unexpected activation of the levers. 3. Root Cause: The trailing cable for the belt feeder entered the end of the electrical control box near the hydraulic control levers. A strain clamp attached to the cable was installed in a manner that aligned the trailing cable with the control levers when the cable was under tension. When taken down from its suspended location, the cable fell behind the control levers, holding the tram lever in the open position. Corrective Action: The trailing cable was repositioned away from the hydraulic control levers. The mine operator re-routed the cable to the inby end of the electric control box and installed a strain clamp on the cable at this location. CONCLUSION
The accident occurred because a means was not provided to prevent unintentional activation of the hydraulic controls. The machine operator (victim) did not see the trailing cable positioned behind the right tram lever, which held the tram lever in the open position. When the start switch was pushed, the sudden, unintentional movement pinned the victim between the coal rib and the feeder unit. The emergency stop switch (panic bar) was located 63 inches from the start switch, making it difficult to deenergize the machine quickly in an emergency. ENFORCEMENT ACTIONS
1. A 103(k) Order No. 7048350 was issued to AMFIRE Mining Company, LLC. Nolo Mine to ensure the safety of all persons at this mine until MSHA has determined that it is safe to resume normal mining operations. 2. Safeguard No. 7054957 was issued:
Related Fatal Alert Bulletin: 
FAB08C16
APPENDIX A
Persons Participating in the Investigation Listed below are persons furnishing information and/or were present during the investigation: Company Officials
Gary Deemer ..General Manager Ricky Smith .Superintendent George Bonneau . Mine Foreman Samuel Marra .....Mine Electrician Allen Dupree ..V.P. Safety, Alpha Natural Resources James Pablic ....Safety Director Richard Kinter Assistant Safety Director Stanley E. Kubat .Section Foreman
Thomas K. Dyson .......General Labor Scott D. Huey ..........Prep Crew Raymond D. McClain Mechanic Gregory T. Shultz ...Outby Laborer James A. Strenko .Scoop Operator Paul Whitaker ...........General Laborer Daniel E. Wojno .General Laborer
Alan Martin Approval and Certification Program Manager Robert Ceschini ..Electrical Inspection Supervisor Dennis Walker Bituminous Division Program Manager Jeffry Kerch .Underground Mine Inspection Supervisor David Stalnaker ..........................District Inspector John Kuzio ...Electrical Inspector
Anthony Guley ..Assistant District Manager, Inspections Edward Tersine ..Coal Mine Safety and Health Inspector, Ventilation Specialist Donald Foster. ....Coal Mine Safety and Health Inspector, Electrical Specialist Robert Roland ... Coal Mine Safety and Health Inspector, Accident Investigator Robert Bodenschatz .. Coal Mine Safety and Health Inspector Stephen Dubina ......Electrical Engineer, Technical Support
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