Accident Report: Fatality Reference
PDF Version
FAI-4407722-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Coal)
Fatal Carbon Monoxide Poisoning Accident
December 22, 2022
SNF Mining, Inc. (X948)
Pikeville, Kentucky
at
Wellmore #8 Prep Plant
The Black Diamond Company
Big Rock, Buchanan County, Virginia
ID No. 44-04982
Accident Investigators
Troy Brown
Mine Safety and Health Inspector
John Hughes
Mine Safety and Health Inspector
Larkin Clevinger
Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
Norton District
716 Spring Avenue SE
Wise, VA 24293
Brian Dotson, District Manager
OVERVIEW
On December 22, 2022, at approximately 12:00 p.m., Aidan Coon, a 21 year-old contract freeze treater with approximately two years of mining experience, was found unresponsive in his personal vehicle beside the mine office.
The accident occurred because the mine operator and the contractor did not ensure the vehicle, used by the miner during his shift, was maintained in safe operating condition.
GENERAL INFORMATION
The Black Diamond Company, a subsidiary of Metinvest U.S., Inc, owns and operates the Wellmore #8 Prep Plant. The mine is located in Big Rock, Buchanan County, Virginia.
Wellmore #8 Prep Plant employs forty-five miners and operates three eight-hour shifts per day, six days per week. This plant cleans and treats bituminous coal. Belt conveyors transport the clean coal to a silo which loads the coal into train cars for shipment to various locations. The Black Diamond Company contracts SNF Mining, Inc. (SNF) to spray the trains’ coal cars with an anti-freezing chemical. Coon was employed by SNF.
The principal management officials at the Wellmore #8 Prep Plant at the time of the accident
were:
Gary Horn General Manager
David McCracken Plant Superintendent
The principal management official for SNF at the time of the accident was:
Randall Rosiek, Sr. Corporate Accounts Manager
The Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection at this mine on September 27, 2022. The 2021 non-fatal days lost incident rate for the Wellmore #8 Prep Plant was zero, compared to the national average 1.00 for mines of this type.
DESCRIPTION OF THE ACCIDENT
On December 22, 2022, Coon began his shift at 12:00 a.m. His normal duties included making sure the proper amount of anti-freezing chemical was being applied to coal that came from the prep plant. Coon monitored the amount of coal coming from the prep plant and make the necessary adjustments for chemical application based on coal flow rates. Anti-freezing chemical was necessary due to cold temperatures. According to interviews, the mine was expecting a train the night of the accident. However, the train did not arrive on time. Investigators learned during interviews that it was common for the contract miners to remain in their personal vehicles when trains ran late.
According to interviews, Anthony Hurley, Freeze Treater for SNF, arrived for his shift around 12:00 p.m. to relieve Coon but could not wake him. Coon was in his personal vehicle with the engine running and the doors locked. At 12:14 p.m. Hurley called 911. Anthony Deel, Plant Foreman; and Kypros Rees, Service Tech Supervisor for SNF, arrived at Coon’s personal vehicle. Deel broke the window out of the passenger side door, removed Coon from the vehicle, and began cardiopulmonary resuscitation. An ambulance arrived on scene and took Coon to
Buchanan General Hospital where Gabriela Nunez, M.D., pronounced him dead at 2:09 p.m.
INVESTIGATION OF THE ACCIDENT
On December 22, 2022, at 12:41 p.m., Brett Childress, Safety Director, called the Department of Labor National Contact Center (DOLNCC). The DOLNCC called Barbara Soard, Office Assistant. Paul Smith, Supervisory Mine Safety and Health Inspector, sent John Hughes, Mine Safety and Health Inspector, to the mine. At 1:30 p.m., Hughes arrived at the mine and issued an order under the provisions of Section 103(k) of the Mine Act to ensure the safety of the miners and preservation of evidence. Hughes conducted an examination of the accident scene and took notes and photographs. Initial findings indicated medical related issues as the cause of death.
On January 3, 2023, Paul Smith, Supervisory Mine Safety and Health Inspector, assigned Troy Brown, Mine Safety and Health Inspector, as the lead investigator. Brown reviewed the notes and photographs from Hughes. Brown conducted interviews with miners, mine management, contractors, and contractor management, and photographed different areas of the mine property.
Brown also requested a copy of the Buchanan County Sheriff’s Office and Buchanan General Hospital records and reports.
On March 31, 2023, MSHA received the death certificate and on April 12, 2023, MSHA received the autopsy report; both stated that Coon died from carbon monoxide poisoning. After further investigation and review, MSHA determined that this death should be charged to the mining industry.
On April 20, 2023, and April 25, 2023, Brown and Larkin Clevinger, Mine Safety and Health Inspector, reinterviewed miners, mine management, contractors, and contract management, and reviewed conditions and work practices relevant to the accident. See Appendix A for a list of persons who participated in the investigation.
DISCUSSION
Location of the Accident
Coon was found in his personal vehicle, which he was using during the shift, adjacent to the
mine office (see Appendix B).
Weather
Temperatures dropped into the low teens that night before the accident and the high was in the lower twenties the day of the accident. Investigators determined weather did not contribute to the accident.
Equipment Involved
Coon’s personal vehicle was a 2011 Ford Escape. Investigators observed the vehicle had preexisting damage to the rear passenger side. The light assembly was missing, and the exhaust system was damaged, allowing exhaust fumes to enter the interior of the vehicle. The mine operator and contractor did not ensure the vehicle, which was used by the miner during his shift, was maintained in safe operating condition. Investigators determined that this contributed to the accident.
Training and Experience
Coon had approximately two years of mining experience, worked for SNF approximately one
year, and as a freeze treater for eight weeks. Investigators reviewed Coon’s training records and determined he had all required training in accordance with MSHA Part 48 training regulations.
Examinations
An on-shift exam was conducted in the area where Coon was parked. The examination did not reveal any hazards and investigators determined that examinations did not contribute to the accident.
Communication
The mine operator did not maintain constant communication with the SNF contractors. When the SNF contractors were needed, they could be found in their personal vehicles. The SNF contractors would go into the mine office to check the flow rate of the coal periodically.
ROOT CAUSE ANALYSIS
The accident investigation team conducted an analysis to identify the underlying cause of the accident. The team identified the following root cause, and the mine operator and contractor implemented the corresponding corrective action to prevent a reoccurrence.
Root Cause: The mine operator and the contractor did not ensure the vehicle, which was used by the miner during his shift, was maintained in safe operating condition.
Corrective Action: The mine operator and contractor developed and implemented a new written procedure that does not allow any miner or contractors to stay in their personal vehicles and trained all miners and contractors on the new written procedure. The mine operator also provided an area for the employees to monitor the tonnage on the clean coal belt and an area to spray the railroad coal cars.
CONCLUSION
On December 22, 2022, at approximately 12:00 p.m., Aidan Coon, a 21 year-old contract freeze treater with approximately two years of mining experience, was found unresponsive in his personal vehicle beside the mine office.
The accident occurred because the mine operator and the contractor did not ensure the vehicle, used by the miner during his shift, was maintained in safe operating condition.
Approved by:
____________________________ ________________
Brian Dotson Date
District Manager
ENFORCEMENT ACTIONS
1. A 103(k) order was issued to The Black Diamond Company.
A fatal accident occurred on December 22, 2022, at approximately 12:00 p.m. This order is being issued under the authority of the Federal Mine Safety and Health Act of 1977, under Section 103(k) to insure the safety of all persons at the mine, and requires the operator to obtain the approval of an authorized representative of MSHA of any plan to recover any person in the mine or to recover the mine or affected area. This order prohibits any activity
in the affected area. The operator is reminded of the obligation to preserve all evidence that would aid in investigating the cause or causes of the accident in accordance with 30 CFR 50.12.
2. 104(a) citation was issued to The Black Diamond Company for a violation of 30 CFR 77.404(a). On December 22, 2022, a fatal accident occurred when a contract freeze treater died from carbon monoxide poisoning while in his personal vehicle (Ford Escape Tag No. UAP-7533). The operator did not ensure the vehicle, which was used by the miner during his shift, was maintained in safe operating condition. The exhaust system was damaged, allowing the
exhaust fumes to enter the interior of the vehicle.
3. 104(a) citation was issued to SNF Mining, Inc. for a violation of 30 CFR 77.404(a). On December 22, 2022, a fatal accident occurred when a contract freeze treater died from carbon monoxide poisoning while in his personal vehicle (Ford Escape Tag No. UAP-7533). The contractor did not ensure the vehicle, which was used by the miner during his shift, was maintained in safe operating condition. The exhaust system was damaged, allowing the
exhaust fumes to enter the interior of the vehicle.
APPENDIX A – Persons Participating in the Investigation
The Black Diamond Company
David McCracken Plant Superintendent
Anthony Deel Plant Foreman
Brett Childress Safety Director
William Altizer Safety Department Surface
Johnnie Lester Foreman
Ethan Sage Mechanic
Jimmy Young Mechanic
Austin Smith Bulldozer Operator
SNF Mining, Inc.
Kypros Rees Service Tech Supervisor
Anthony Hurley Freeze Treater
Mine Safety and Health Administration
Troy Brown Mine Safety and Health Inspector
Larkin Clevinger Mine Safety and Health Inspector
John Hughes Mine Safety and Health Inspector