The Mine Safety and Health Administation (MSHA) recently conducted an investigation into a fatal accident at the Blue Knob Surface Mine in Greenbrier County, West Virginia.
On Thurs., March 7, a 38-year-old front-end loader operator Adam P. DeBoard was fatally crushed between a metal support post on a highwall mining machine and a moving push beam.
“West Virginia lost one of our dedicated coal miners today, and Cathy and I are deeply saddened at the news," said West Virginia Governor Jim Justice and his wife Cathy Justice, in a statement shortly after the incident. "We encourage everyone to join us in praying for the family, friends, and co-workers of Adam DeBoard of Craigsville. Brave and courageous miners like Mr. DeBoard are heroes to us all.”
MSHA stated DeBoard, who had 10 years of mining experience, began his shift at 6 a.m. Workers completed mining a hole between 11:30 a.m. and 12:00 p.m., after it was mined to a depth of 560 ft. DeBoard was an employee of South Fork Coal Company, which operates Blue Knob Surface Mine.
The miners then began removing the underground components of the highwall mining machine. According to the agency, a highwall mining machine is used to mine holes that are several hundred feet deep, while miners remain on the surface. The system involves a cutter module that operates like a continuous mining machine, a push beam that is connected to the cutter module, and additional push beams connected to the first push beam and each other, forming a train of push beams.
DeBoard parked his front-end loader and came to the highwall mining machine to assist with the work. He shoveled mud from the rails, located beside the chain, after each push beam was removed, according to MSHA.
At approximately 1:30 p.m., while standing near the push beam holder (holder) on the side of the machine, DeBoard’s head was caught between the 14th push beam being removed and a stationary metal support post.
Foreman Wade Nichols witnessed the fall and immediately pressed the emergency stop button to de-energize the machine. He then instructed a coworker to get an emergency medical technician (EMT). Richie Milam, the maintenance superintendent/EMT, arrived at the accident scene and began instructing others to get first aid supplies. While cardiopulmonary resuscitation (CPR) was performed, Mine Superintendent Josh Sturgill was notified.
According to MSHA, Redi-Care Ambulance Service from Craigsville, W. Ya., arrived at the accident scene at 2:02 p.m. Emergency personnel ruled DeBoard to be in traumatic cardiac arrest and contacted Dr. Jerry Edwards at Medbase. Dr. Edwards gave 2:44 p.m. as a time of death and DeBoard was transported to Greenbrier Valley Medical Center in Ronceverte, West Virginia.
Root Cause Analysis
MSHA conducted an analysis to identify the most basic causes of the accident that were correctable through reasonable management control. Root causes were identified that, if eliminated, would have either prevented the accident or mitigated its consequences.
Listed below are the root causes identified during the analysis and the corrective actions that were implemented to prevent a recurrence.
- Root Cause: The task training provided by the mine operator was not adequate because the training did not address areas to avoid in or near pinch areas that exist between moving parts as stated in the Superior Highwall Miners Safety, Operation, and Maintenance Manual.
Corrective Action: The mine operator provided an 8 hour training class for all miners which covered the Superior Highwall Miners Safety, Operation, and Maintenance Manual and identified the areas to avoid during operation. Additionally, the mine operator revised their training plan to include a task training check list, and all miners have been task trained in accordance with the newly approved training plan.
- Root Cause: The mine operator did not identify the work location where the accident occurred as a pinch area that needed to be avoided.
Corrective Action: The mine operator has identified red zone areas that exist when push beams are being installed or removed. A red zone drawing has been added to the ground control plan with the following requirement, “No persons may enter red zone areas unless the highwall mining machine is idle.”
The area where the fatal accident occurred has been brightly painted and posted with warning signs. Also, physical barriers have been installed to prevent entry. The back access steps on the holder side that provide access to this area from the ground have been removed. A handrail has been installed across the access steps at the second level so no one can enter from the top area. Cameras were installed with monitors located in the operator’s compartment so the highwall mining machine operator can see if persons enter the red zone areas.
MSHA determined that the accident occurred because the mine operator did not identify the location of the accident as a pinch area and did not train the victim to avoid the pinch area.
The agency issued the following citations to South Fork Coal Company:
A Section 103(K) Order No. 9169757 was issued to South Fork Coal Company, HWM 61, ID 33-04642.
This 103K order is issued to assure the safety of all persons at this operation and to preserve any evidence to aid in the investigation. It prohibits all work activity except for onshift exams and water pumping until MSHA determine it is safe to resume normal mining operations. The mine operator must obtain prior approval from an authorized representative for all action in affected area.
104(a) Citation No. 9169768 was issued to South Fork Coal Company, HWM 61, for a violation of 30 CFR § 77.1504(b).
The mine operator did not ensure that all miners were kept clear of push beams being moved into position. Mine management was aware of the hazardous location of the victim.
104(a) Citation No. 9169767 was issued to South Fork Coal Company, HWM 61, for a violation of 30 CFR § 48.27.
The mine operator did not provide adequate task training in that the training did not address the small area where the victim was standing as a pinch area. The Superior Highwall Miners Safety, Operation, and Maintenance Manual contains a warning, in the safety section of the manual, to avoid pinch areas. The mine operator did not have the safety section of this manual. Mine management only had the section of the manual necessary to maintain the highwall mining machine in operating condition. The mine operator did not recognize this violation as a hazardous condition and take corrective actions.