February 27, 2020 Fatality - Final Report

Accident Report: Fatality Reference: 
FAI-6279867-1

    UNITED STATES

    DEPARTMENT OF LABOR

    MINE SAFETY AND HEALTH ADMINISTRATION

    REPORT OF INVESTIGATION

    Facility

    (Coal)

    Fatal Powered Haulage Accident

    February 27, 2020

    Country Roads Transport LLC (C0627)

    Morgantown, West Virginia

    at

    Federal No 2

    Phoenix Federal No 2 Mining, LLC

    Fairview, Monongalia County, West Virginia

    I.D. No. 46-01456

    Accident Investigators

    Joedy N. Gutta, P.E.

    Impoundment Specialist

    Matthew T. Taylor

    Impoundment Specialist

    Originating Office

    Mine Safety and Health Administration

    District 3

    604 Cheat Road, Morgantown, West Virginia 26508

    Carlos T. Mosley, District Manager


    OVERVIEW

    On Thursday, February 27, 2020, at 12:32 p.m., James Campbell, a 50-year-old contractor employee sustained injuries at the Federal No 2 Mine.  The victim was attempting to assist a truck driver in positioning a tractor and trailer to load a rock truck.  The victim was standing in front of the wheels on the trailer’s front axle and was struck by the trailer’s wheels as the tractor and trailer moved forward.  The victim died later that day from these injuries.

    The accident occurred because the contractor did not have an effective policy or procedure to ensure safe work practices and communications while working around mobile equipment.

    GENERAL INFORMATION

    Federal No 2 Mine is a mine facility located in Monongalia County, West Virginia.  The mine is operated by Phoenix Federal No 2 Mining, LLC (Phoenix).  The mine is currently in active, non-producing status.  The mine employs four full time employees.

    The principal officials for the Federal No 2 Mine at the time of the accident were:

    David Workman Sr............................................................................ General Manager

    Brian Craig............................................................................................. Superintendent

    Brian Kovach............................................................................. Maintenance Foreman

    Damian Fanire.................................................................................... General Foreman

    A regular MSHA Health and Safety Inspection (E0l) was in progress at the time of the accident.  The previous E01 inspection was completed on May 29, 2019.  The non-fatal days lost (NFDL) incidence rate for the mine during the calendar year 2019 was  0, compared to the national average of 3.18 for mines of this type.

    DESCRIPTION OF THE ACCIDENT

    On February 27, 2020, at 11:52 a.m., James Campbell, Maintenance Supervisor, and Jeremy Doss, Truck Driver, for Country Roads Transportation LLC (Country Roads), arrived at the mine to load a rock truck on the Kenworth tractor and trailer for transport to Trion Equipment Sales LLC in Old Forge, Pennsylvania.  Doss was operating the Kenworth tractor and trailer and Campbell drove the pilot pickup truck that would guide the escort to the delivery site.  This was the first time Doss and Campbell had worked together to transport a piece of heavy equipment. 

    Cory King, the owner of Diesel Performance, the other contractor on-site, and Howard Shriver, a helper with Diesel Performance, guided Doss and Campbell from the mine entrance to the refuse load-out area where the rock truck was located.  They briefly discussed how to load the rock truck since it was inoperative due to a missing rear tire and axle.  They decided to push the rock truck onto the trailer with a front-end loader (see Figure 1 in Appendix A).

    The loading area did not provide enough room to position the tractor and trailer directly in front of the rock truck.  King pulled the rock truck backward with the front-end loader.  Doss began to back the tractor and trailer into position.  Campbell positioned himself on the passenger side in front of the dual wheels of the trailer’s front axle.  Campbell gave hand signals to Doss as he backed up.  Investigators learned that Doss was not looking at Campbell because he was focused on his mirrors to align the tractor and trailer with the rock truck.

    Doss stopped the tractor and trailer to change direction and began to pull forward for alignment, using the driver side mirrors.  As the tractor and trailer moved forward, the front tires on the passenger side of the trailer struck Campbell.  King saw the tires strike Campbell and ran to the driver side door to get Doss’ attention.  King notified Doss that he had run over Campbell.  Doss backed the trailer off Campbell (see Figure 2 in Appendix A).  King called 911 and sent a text message to Craig about the accident.  Craig, who was also an emergency medical technician, traveled to the accident site to treat Campbell, who was still conscious.

    Monongalia County EMS transported Campbell to West Virginia University Medicine - J.W. Ruby Memorial Hospital.  Dr. Giertych pronounced the victim dead at 6:20 p.m.

    INVESTIGATION OF THE ACCIDENT

    David Workman, Sr., General Manager, reported the accident to MSHA’s Morgantown District office at approximately 1:00 p.m.  Carlos Mosley, District Manager, notified Workman of the mine operator’s duty to notify the Department of Labor National Contact Center (DOLNCC) and their duty to ensure the safety and health of the miners and to preserve the accident scene.  Workman notified the DOLNCC at 1:06 p.m., on Thursday, February 27, 2020.  The DOLNCC called Allen Rohrbaugh, Field Office Supervisor.  Michael Stark, Staff Assistant, dispatched two accident investigators, Joedy Gutta, Impoundment Specialist, and Matthew Taylor, Impoundment Specialist, to the mine.  Gutta issued a 103(k) order at 2:15 p.m. upon his arrival at the mine.

    On February 27, 2020, two Monongalia County sheriff’s department deputies arrived at the mine at 1:25 p.m. and conducted an investigation.  The deputies conducted interviews and obtained written statements from Doss, King, and Shriver.  Doss departed the mine after giving his statement to the deputies.  The deputies departed the mine at approximately 2 p.m. prior to MSHA’s arrival.  The deputies later shared the written statements and body camera videos with the federal and state investigators.

    MSHA performed the accident investigation in conjunction with the West Virginia Office of Miner's Health, Safety and Training, Diesel Performance, Phoenix, Country Roads, and the United Mine Workers of America (see Appendix B).  Investigators spoke to Doss during a telephone call the following day.  The investigation team traveled to the accident scene to make observations, take measurements, and obtain photographs.

    On Thursday, March 5, 2020, the investigation team traveled to the accident scene to obtain additional measurements, photographs, video, and to function test the Kenworth tractor and trailer involved in the accident.  Chad Vandevender, owner of Country Roads, was onsite with Doss to function test the tractor.

    On Tuesday, March 10, 2020, the investigation team conducted interviews at the West Virginia Office of Miner's Health Safety and Training office located in Westover, West Virginia.

    DISCUSSION

    Communication

    Doss informed investigators that he told Campbell, King, and Shriver that he was going to position the tractor and trailer in front of the rock truck and Campbell, King, and Shriver said “ok.”  King and Shriver observed Campbell using hand signals to direct Doss as he was backing the tractor and trailer into positon.  However, Doss was positioning the tractor on his own and was not communicating with Campbell.  Doss stated during interviews that he was using his driver’s side mirror while pulling forward to align the tractor and did not see Campbell.  The angles between the tractor and trailer created blind spots reducing the field of view of the trailer’s axles on the passenger side.  Country Roads did not have effective procedures to address communications with all persons involved in the movement of the equipment and safe work practices.

    Equipment Involved

    The tractor unit involved in the accident was a 2009 Kenworth Tractor, VIN No. 1XKDD40X0AJ273742.  The equipment trailer was a 1988 Talbert Manufacturing Inc. 50-ton Semi-Trailer (beam trailer), VIN 40FWK5243J1007597.  The accident team performed function tests on the equipment and did not identify any conditions that contributed to the accident.

    Examination

    An on-shift examination of the area was conducted on the morning of the accident with no hazards observed.

    Training and Experience

    Investigators received information from Country Roads that showed Campbell and Doss had been task trained to load and haul equipment.

    Accident Site

    The accident occurred near the refuse loadout area.  The ground in this area is graveled and relatively level.  In addition to the rock truck, several items were located in the area that included a refuse belt, refuse loadout bin, refuse garage, several storage tanks, and the front-end loader.

    ROOT CAUSE ANALYSIS

    The accident investigation team conducted a root cause analysis to identify the underlying cause of the accident.  The team identified the following root cause and the contractor implemented the corresponding corrective action to prevent a recurrence.

    Root Cause:  Country Roads did not have an effective policy or procedure in place to ensure safe work practices and communications with all persons while working around mobile equipment.

    Corrective Action:  Country Roads developed a written procedure to address safe work practices and communications when persons are working around mobile equipment.  This procedure includes information about job-specific work plans, communication plans, and general safety measures including keeping clear of mobile equipment when the equipment is engaged.  Country Roads trained their employees in this procedure.

    CONCLUSION

    On Thursday, February 27, 2020, at 12:32 p.m., James Campbell, a 50-year-old contractor employee sustained injuries at the Federal No 2 Mine.  The victim was attempting to assist a truck driver in positioning a tractor and trailer to load a rock truck.  The victim was standing in front of the wheels on the trailer’s front axle and was struck by the trailer’s wheels as the tractor and trailer moved forward.  The victim died later that day from these injuries.

    The accident occurred because the contractor did not have an effective policy or procedure to ensure safe work practices and communications with all persons while working around mobile equipment.

     

     

    _________________________                                  Date:___________________

    Carlos T. Mosley

    District Manager

    ENFORCEMENT ACTIONS

    1. A 103(k) Order, Number 9187406, was issued to Federal No 2 Mine at 2:15 p.m. to ensure the safety of all persons at the operation and to prevent the destruction of any evidence which would assist in investigating the cause or causes of the accident until an investigation was completed and the area deemed safe.
       
    2. A 104(a) Citation, issued to Country Roads Transport LLC for violation of 30 CFR 77.1607(g)

    A fatal accident occurred on February 27, 2020, at approximately 12:30 p.m.  The accident occurred because all persons were not in a safe location prior to moving the Kenworth tractor and trailer.


    APPENDIX B
    Persons Participating in the Accident Investigation

    Phoenix Energy Resources

    Brian Craig............................................................................................................... Superintendent

    Brian Kovach............................................................................................... Maintenance Foreman

    David Workman, Sr. ........................................................................................... General Manager

    Diesel Performance LLC.

    Cory King.............................................................................................................................. Owner

    Howard Shriver..................................................................................................................... Helper

    Country Roads Transportation LLC

    Jeremy Doss................................................................................................................ Truck Driver

    Chad Vandevender................................................................................................................ Owner

    United Mine Workers of America

    Ron Bowersox.............................................................................................................. International

    Jack Frazier.................................................................................................................... Local 1570

    John Palmer.................................................................................................. President, Local 1570

    West Virginia Office of Miner's Health Safety and Training

    Jeff Bennett........................................................................................................... District Inspector

    James Bowman................................................................................................. Electrical Inspector

    David McCullough............................................................................................... Safety Instructor

    John Meadows................................................................................... Assistant Inspector at Large

    Ed Peddicord...................................................................................................... Inspector at Large

    Mike Southern...................................................................................................... Surface Inspector

    Mine Safety and Health Administration

    Joedy Gutta............................................................................................... Impoundment Specialist

    Michael Stark........................................................................................................... Staff Assistant

    Matthew Taylor................................................................................... Impoundment Specialist