Accident Report: Fatality Reference
PDF Version
FAI-6932874-1
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
REPORT OF INVESTIGATION
Surface
(Coal)
Fatal Powered Haulage Accident
July 12, 2024
Wyco Surface Mine
Pocahontas Coal Company, LLC
Helen, Wyoming County, West Virginia
ID No. 46-09627
Accident Investigators
Aaron Cline
Mine Safety and Health Inspector
Jeffrey Presley
Supervisory Mine Safety and Health Specialist
Originating Office
Mine Safety and Health Administration
Pineville District
4499 Appalachian Hwy
Pineville, WV 24874
Craig Plumley, District Manager
TABLE OF CONTENTS
OVERVIEW
On July 12, 2024, at approximately 11:10 p.m., Ashley Cogar, a 33 year-old rock truck driver with two years of mining experience, was seriously injured after being struck by the bucket of a front-end loader (loader). While walking to her parked rock truck, Cogar passed under an elevated loader bucket as it was being lowered to the ground during maintenance. On July 23, 2024, Cogar died from her injuries.
The accident occurred because the mine operator did not: 1) prevent miners from passing under buckets or booms of loaders in operation, and 2) provide adequate illumination in working areas.
GENERAL INFORMATION
Pocahontas Coal Company, LLC owns and operates the Wyco Surface Mine. This is a surface coal mine located in Helen, Wyoming County, West Virginia. The mine employs 54 miners and operates two ten-hour shifts per day, five days per week. This mine uses mountain top removal and contour mining methods in two production pits to extract coal.
The principal management officials at the Wyco Surface Mine at the time of the accident were:
Jeffrey Sammons Operations Manager
Bobby Sams Mine Superintendent
Curtis Bragg Mine Foreman
Jason Chapman Safety Director
The Mine Safety and Health Administration (MSHA) completed the last regular safety and health inspection at this mine on January 11, 2024. The 2023 non-fatal days lost incident rate for Wyco Surface Mine was zero, compared to the national average of 0.77 for mines of this type.
DESCRIPTION OF THE ACCIDENT
On July 12, 2024, the evening shift began at 5:00 p.m., and Justin Shorter, Shift Foreman, gave the evening shift crew their work assignments. According to interviews, normal mining production of loading and hauling overburden in the South Pit occurred from 5:00 p.m. until 10:30 p.m. At approximately 10:30 p.m., Cory Lane, Front-End Loader Operator, texted Jacob Lucas, Lube Truck Driver/Emergency Medical Technician (EMT), to inform him the 993K loader he was operating needed hydraulic oil. At 10:50 p.m., Lane texted Shorter and James Webb, Foreman Trainee, to inform them the loader was down. Upon arrival, Lucas filled the hydraulic oil and fuel tanks of the loader and instructed Lane to start the loader. Lucas explained to Lane that there must be a leak because this loader normally did not require any oils. After observing oil leaking from the loader, Lucas instructed Lane to call Dustin Martin and Corey Stover, Mechanics for Big Wrench Equipment Repair, to inform them of an oil leak on the loader.
According to interviews, Robert Shrewsberry, Rock Truck Driver, parked his truck on the right side of the loader. Cogar and Henry Cochran, Rock Truck Driver, parked their trucks on the left side as the loader was being serviced. Shrewsberry, Cochran, and Cogar got out of their trucks and congregated on the right side of the loader. Martin told Lane to start the loader. Lane sounded the horn before starting the loader. Martin told Lane to operate the boom by raising it up as well as rotating the bucket up and down to work the hydraulic system. Lane stated he also sounded the horn of the loader before moving the boom and bucket. Martin was positioned behind the loader operator's cab looking through an access door for the hydraulic pump trying to find the oil leak. Stover and Lucas were on the ground near the center of the loader looking for oil leaks also. Lane remained in the loader operator's cab communicating with Martin.
Shortly after being notified by Lane, Webb traveled to the South Pit and radioed Robert McClung, Front-End Loader Operator, and told him to bring his 992K loader to the South Pit. As Webb pulled into the South Pit, he parked his pickup truck toward the front of the loader and walked over to Shrewsberry, Cochran, and Cogar. According to interviews, Webb observed the loader bucket being raised and lowered while mechanics looked for the oil leak and he talked to the rock truck drivers. When McClung arrived at the South Pit, Webb told Shrewsberry, Cochran, and Cogar to get back in their trucks to resume hauling. He did not advise the drivers to avoid the bucket of the loader or take any steps to danger off the area. The other two drivers were parked so that their paths back to the trucks were beside and behind the loader, but Cogar's direct route went in front of the loader. As she walked back to her truck, Martin located a leak and instructed Lane to lower the loader bucket to the ground. Cogar was walking toward her rock truck, passing directly under the loader bucket as it was being lowered. The loader bucket struck Cogar, knocking her to the ground and crushing her lower extremities.
According to interviews, Cochran was standing on the catwalk of his rock truck and saw the loader bucket strike Cogar. Cochran and Lucas began yelling at Lane to raise the bucket and back up the loader. Webb heard them yelling and threw his hard hat at the loader operator's cab to get Lane's attention. Lane raised the bucket, backed up the loader, and shut it off. Lucas rushed to Cogar and began administering first aid. Webb retrieved a first response kit from his pickup truck. Stover and Shrewsberry ran to the mantrip bus and brought the first aid boxes. McClung joined Lucas in assisting with first aid treatment. Webb called out Code Blue (Emergency) on the radio to alert all equipment operators at the mine. Shorter heard the emergency call over the radio as he traveled to the South Pit in his pickup truck. After arriving at the accident scene and observing the severity of Cogar's injuries, Shorter called JanCare Ambulance Service at 11:12 p.m. Lucas treated Cogar's wounds, administered oxygen, and treated her for shock. On July 13, 2023, at 12:02 a.m., JanCare paramedics arrived at the accident site and assessed Cogar's injuries. Cogar was transported to Charleston General Hospital in Charleston, WV. On July 23, 2024, Cogar passed away from injuries sustained in the accident.
INVESTIGATION OF THE ACCIDENT
On July 12, 2024, at 11:59 p.m., Jason Chapman, Safety Director, called the Department of Labor National Contact Center (DOLNCC) to report the accident. On July 13, 2024, at 12:18 a.m., the DOLNCC contacted Kenneth Butcher, Supervisory Mine Safety and Health Inspector. Butcher contacted Mark Muncy, Assistant District Manager, who contacted and assigned Aaron Cline, Mine Safety and Health Inspector, as lead investigator. Muncy also contacted Jeffrey Presley, Supervisory Mine Safety and Health Specialist, to assist Cline in the investigation. At 2:30 a.m., Cline and Presley arrived at the mine and met with Rusty Keen, Safety Coordinator. Cline issued an order under the provisions of Section 103(k) of the Mine Act to ensure the safety of the miners and the preservation of evidence.
MSHA's accident investigation team, along with the West Virginia Office of Miners' Health Safety and Training, conducted an examination of the accident scene, interviewed miners and mine management, and reviewed conditions and work procedures relevant to the accident. See Appendix A for a list of persons who participated in the investigation.
DISCUSSION
Location of the Accident
The accident occurred in the South Pit (see Appendix B).
Weather
The weather at the time of the accident was 64 degrees Fahrenheit with no wind or fog. Investigators determined the weather did not contribute to the accident.
Equipment Involved
The front-end loader involved in the accident was a Caterpillar 993K. Investigators measured the loader to be 18 feet, 4 inches tall; 50 feet long; and 16 feet, 7 inches wide. Based on the examination of the accident scene, the loader operator had limited visibility in the area around the loader while positioned in the operator's seat (see Appendices C and D). This area of limited visibility, referred to as the “safety zone,” was not barricaded to prevent miners from entering areas out of view of the loader operator or passing under the bucket of the loader while it was in operation. Investigators determined this contributed to the accident.
Illumination
During normal operation, no miners are on foot and equipment operators use their equipment lights to illuminate the South Pit. Once maintenance began on the 993K loader, production stopped, and equipment was shut down. According to interviews, a light plant was in the area but was out of service. The lights from the loader and the mechanic's truck did not provide adequate illumination for Cogar to recognize the location of the elevated loader bucket at the time of the accident. Investigators determined this condition contributed to the accident.
Examinations
Lane conducted a pre-operational examination of the 993K loader prior to the start of his shift with no deficiencies reported. Shorter conducted an on-shift examination of the South Pit at 9:00 p.m. and reported no hazards. Investigators determined all examinations were adequate.
Training and Experience
Cogar had two years of mining experience with four months at the Wyco Surface Mine. Cogar received Experienced Miner training on March 18, 2024, and task training for Caterpillar 785 rock trucks on March 19 and 20, 2024. Investigators determined Cogar received all training in accordance with MSHA Part 48 training regulations.
Webb had approximately 19 years total mining experience and seven months of experience at the Wyco Surface Mine. Webb was hired as an equipment operator and received Experienced Miner training on October 31, 2023. Training records indicate Webb was also task trained to operate various types of equipment between October 31, 2023, and February 3, 2024. Webb had been a foreman trainee for approximately three weeks before the day of the accident.
ROOT CAUSE ANALYSIS
The accident investigation team conducted an analysis to identify the underlying causes of the accident. The team identified the following root causes, and the mine operator implemented the corresponding corrective actions to prevent a recurrence.
- Root Cause: The mine operator did not prevent miners from passing under buckets or booms of loaders in operation.
Corrective Action: The mine operator submitted a revision to their Ground Control Plan and revised their Surface Mobile Equipment Program. The revisions include requiring a conspicuous safety zone around equipment undergoing maintenance outside of the designated maintenance area. The mine operator trained all miners on the revisions.
- Root Cause: The mine operator did not provide adequate illumination in working areas.
Corrective Action: The mine operator submitted a revision to their Ground Control Plan and revised their Surface Mobile Equipment Program. In low light conditions, light plants will be used during equipment maintenance, and all miners outside the equipment will wear reflective material and personal strobe lights. The mine operator trained all miners on the revisions.
CONCLUSION
On July 12, 2024, at approximately 11:10 p.m., Ashley Cogar, a 33 year-old rock truck driver with two years of mining experience, was seriously injured after being struck by the bucket of a front-end loader (loader). While walking to her parked rock truck, Cogar passed under an elevated loader bucket as it was being lowered to the ground during maintenance. On July 23, 2024, Cogar died from her injuries.
The accident occurred because the mine operator did not: 1) prevent miners from passing under buckets or booms of loaders in operation, and 2) provide adequate illumination in working areas.
Approved By:
__________________________________ _____________
Craig Plumley Date
District Manager
ENFORCEMENT ACTIONS
- A 103(k) order was issued to Pocahontas Coal Company, LLC.
A fatal accident occurred on July 12, 2024, at approximately 11:10 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.
- A 104(a) citation was issued to Pocahontas Coal Company, LLC for a violation of 30 CFR 77.1607(k).
On July 12, 2024, a rock truck driver was seriously injured after being struck by the bucket of a front-end loader (loader). While walking to her parked rock truck, the rock truck driver passed under an elevated loader bucket as it was being lowered to the ground during maintenance. On July 23, 2024, the rock truck driver died from her injuries. The mine operator did not prevent miners from passing under raised buckets or booms of loaders in operation.
- A 104(a) citation was issued to Pocahontas Coal Company, LLC for a violation of 30 CFR 77.207.
On July 12, 2024, a rock truck driver was seriously injured after being struck by the bucket of a front-end loader (loader). While walking to her parked rock truck, the rock truck driver passed under an elevated loader bucket as it was being lowered to the ground during maintenance. On July 23, 2024, the rock truck driver died from her injuries. The lights from the loader and the mechanic's trucks did not provide adequate illumination for the rock truck driver to recognize the location of the elevated loader bucket at the time of the accident.
APPENDIX A – Persons Participating in the Investigation
Pocahontas Coal Company, LLC
Jeffrey Sammons Operations Manager
Bobby Sams Mine Superintendent
Jason Chapman Safety Director
Rusty Keen Safety Coordinator
Curtis Bragg Mine Foreman
Justin Shorter Shift Foreman
James Webb Foreman Trainee
Cory Lane Front-End Loader Operator
Robert McClung Front-End Loader Operator
Jacob Lucas Lube Truck Driver/EMT
Henry Cochran Rock Truck Driver
Robert Shrewsberry Rock Truck Driver
Big Wrench Equipment Repair
Dustin Martin Mechanic
Corey Stover Mechanic
West Virginia Office of Miners' Health Safety and Training
Christopher Dawson Inspector-at-Large
Benjamin Mullens Surface Inspector
Steven Phares Surface Inspector
Mine Safety and Health Administration
Jeffrey Presley Supervisory Mine Safety and Health Specialist
Aaron Cline Mine Safety and Health Inspector