The U.S. Mine Safety and Health Administration has just issued the report on its investigation of the September 2012 death of William Mock, a 61-year-old coal miner killed in a roof fall at CONSOL Energy’s Blacksville No. 2 Mine in Monongalia County, W.Va. Here’s their conclusion:
The accident was caused by the failure to install additional support before load- bearing primary roof support was removed; management’s failure to assure persons removing roof support were located in a safe position; management’s failure to supervise the removal of roof support; management’s failure to examine the roof conditions before permanent support was removed; and, management’s failure to provide task training instructing miners in the safe working procedures of removing permanent roof support and the safety and health aspects of the task.
This is how MSHA describes what happened:
On Thursday, September 13, 2012, the day shift started at 8:00 A.M. William (Bill) Mock and Doug Ice Jr., General Inside Laborers, were assigned by Shift Foreman, Darrel Stewart, to repair the track at various locations along the Main North Haulage. Mock and Ice, along with Rocky Hartley, Supervisor Trainee, had worked together earlier in the week repairing track. However, Hartley was assigned other duties for this shift. Mock and Ice entered the mine shortly after 8:00 A.M., on the Kuhntown elevator. They travelled from the Kuhntown Portal bottom in the No. BT 24 trolley-powered jeep, to the No. 42 block of the Main North Haulage. Mock and Ice began their assigned activities of track repair work, including raising the track and repairing trolley wire hangers. This work was conducted mainly between blocks 42 and 47.
At approximately noon, Mock and Ice received a call over the trolley radio from Frank DeBardi, Dispatcher. Mock was told to call the mine dispatcher’s office using the mine phone. Mock called and talked to Anthony (Tony) DiDomenico, Outby Supervisor. DiDomenico instructed Mock to address a roof bolt and plank in close proximity to the trolley wire on the 117 side of 116 block (see Appendix No. 1). Mock was also instructed to wait until later in the shift because the trolley wire would have to be de-energized, which would prevent travel between Main North Junction and the Wana Portal. During the accident investigation interviews, DiDomenico stated he had been in the area the day before when he noticed the roof bolt and plank were getting too close to the trolley wire. The investigation revealed the area had not been identified during a pre-shift examination of the area and the condition was not recorded as a hazard or violation.
Mock and Ice continued their work between 42 and 47 blocks. Mock requested clearance from DeBardi to travel from the 42 block area to the 116 block area, sometime after 2:00 P.M. At approximately 3:00 P.M., Mock requested clearance to travel back to the Main North Junction track switch (approximately 125 block) to allow a supply trip to pass. After the trip passed, Mock requested and was given clearance to travel back to the 116 block.
Ice stated that when he and Mock arrived at the 117 block area, they noticed a ribbon on the walkway side of the entry (the side opposite the trolley wire). Mock and Ice cut off an exposed roof bolt, removed the attached plank and placed it in the crosscut at 117 block. They observed another plank that needed to be removed, but their jeep was in the way. The jeep was moved a few feet towards the Wana bottom and Mock started to cut the plank using a reciprocating saw. The plank was cut approximately half-way when they determined it was taking weight from the mine roof. Mock stopped cutting the board. A portion of a roof bolt supporting the board was exposed due to sloughing of roof material. Mock and Ice decided to cut the roof bolt with a track bonder. To avoid being exposed to a flash from the bonder, Ice turned his back. When the bolt was burned through, there was a loud “pop,” causing Ice to duck. When Ice turned back around, he saw Mock covered with a rock from the lower chest down. Ice stated that he tried to move the rock, but was unable to do so. Ice felt for a pulse from Mock, but none was detected. Ice immediately radioed to DeBardi that a miner was down and requested assistance. DeBardi sent two groups of miners, including Emergency Medical Technicians (EMT’s) from the Kuhntown bottom to the accident site to assist. Another group of miners was instructed to obtain the Automated External Defibrillator (AED) from the motor barn and go to the accident site. DeBardi phoned for an ambulance and called for anyone at the Kuhntown bottom to clear up the track from the K-3 area to the elevator. DeBardi then informed John Davis, Shift Foreman, of the accident.
After contacting DeBardi, Ice had gone to the back of the jeep, obtained a jack, and attempted to lift the fallen rock off Mock; however, he was unsuccessful in freeing the victim. Ice again called DeBardi by mine phone and informed him of the seriousness of the accident and asked if help was coming.
When assistance arrived at the accident site, Mock was checked for vital signs, but none were detected. To remove the victim from under the rock a jack and come-along were used to lift the rock. After removing the victim from under the rock, he was placed on a backboard, loaded into one of the mobiles, and transported to the Kuhntown bottom. Rescuers placed Mock in the elevator and accompanied him to the surface. The Mon County EMS Service transported Mock to the Waynesburg Hospital, where he was pronounced dead upon arrival.
MSHA investigators outlined these root causes:
– The mine operator’s policies and administrative controls did not ensure that safe work policies and procedures were in place and that basic training was in place to instruct miners on the safe work policies and procedures and safety and health aspects for the task of removing permanent roof support.
– The mine operator’s policies and administrative controls did not ensure that persons removing roof support were supervised by management personnel. A management official should have been present, who was experienced in the removal of permanent roof support, to designate where the roof supports were to be removed, and to designate each support that was to be removed.
– The mine operator did not ensure that prior to the removal of permanent roof supports, an examination of the roof conditions were conducted by a supervisor or certified examiner.
- The mine operator did not ensure that a row of temporary supports was installed prior to the removal of permanent roof supports and that the support be set as close as practical to the support being removed.
And here are the enforcement actions taken by MSHA:
– A 104 (a) Citation for a violation of 30 CFR, § 75.213(a)(1): On September 13, 2012, the operator failed to assure a member of mine management person supervised the removal of permanent roof support. The removal of the support resulted in a fatal accident when a large piece of rock fell on the victim who had just cut a bolt with a bonder. The bolt was part of a three part system consisting of two 9 foot conventional roof bolts installed though a two inch wooden plank. The accident occurred at approximately 3:30 pm near the 117 block of the North Mains Haulage. Witness interviews reveled that before the bolt was cut an attempt to cut the plank was made but it showed signs of taking weight so they cut the bolt first. A supervisor must be available to address any unusual circumstances that may arise and to direct all phases of roof support removal.
– A 104 (a) Citation for a violation of 30 CFR, § 75.213(b): A supervisor did not make an examination of the roof conditions in the area prior to removal of the support nor was each roof support removed specific by a management person before the support was removed. On September 13, 2012, at approximately 3:30 P.M., a fatal accident occurred when a miner removed permanent roof support by cutting a roof bolt with a bonder. The bolt was one part of a three part system consistent of two 9-foot bolts installed on each end of a 2 inch thick wooden plank. The accident occurred near the 117 block on the North Mains Haulage. During interviews, a supervisor stated that the day before the accident he observed a bolt getting close to the trolley wire and had sent the crew to remove the support. He also stated he had not marked the support to be removed nor had he recorded the condition in the any book. During the investigation at least four ribbons (markings) were observed in the area, including one on the plank causing the accident. All four ribbons appeared to have been in place for several days since they were cover with dust. The investigation also revived that at least five bolts had been recently cut at the accident site. None of the bolts had been replaced nor was any temporary support been installed.
– A 104 (a) Citation for a violation of 30 CFR § 75.213(c)(2): On September 13, 2012, temporary support was not installed prior to the removal of permanent roof support at 117 block of the North Mains Haulage. At approximately 3:30 P.M., a fatal accident occurred when a large piece of roof rock fell pinning a miner on the floor. The victim was in the process of cutting a roof bolt with a bonder. The bolt was a part of a 3 part system consisting of two 9-foot conventional bolts installed though a 2 inch wooden plank. Temporary support shall be installed as close as practicable to each roof bolt being removed to prevent being exposed to unsupported roof during removal. Neither temporary nor permanent supports were provided or available at the accident site or on the jeep used by the two man crew assigned to do roof support removal.
– A 104 (a) Citation for a violation of 30 CFR, § 75.213 (f)(3): Permanent roof support was removed after indications of the roof being structurally weak. The removal of the support resulted in a fatal accident on September 13, 2012, when a large portion of rock fell from the roof on a miner. The accident occurred near the 117 block of the North Mains Haulage when the miner cut a roof bolt which was part of a three part system consisting of two 9-foot conventional bolts installed in a wooden plank. Interviews revealed the victim first attempted to cut the plank using a reciprocating saw. Half-way though the board the roof showed signs of taking weight and he proceeded to cut the bolt in an attempt to relieve pressure from the board.
– A 104 (a) Citation for a violation of 30 CFR, § 75.202(a): The mine roof was not adequately supported or otherwise controlled at the 117 block of the North Mains Haulage. On September 13, 2012, a fall of roof accident occurred resulting in fatal injuries. The fallen material measured approximately 137 inches long, 44 inches wide, and 4 to 11 inches thick. The victim and another miner were in the process of removing permanent roof support at the time of the accident. A plank with two bolts had also been removed. With both planks removed an area between the rib (trolley side) and middle of the entry is left without any support. Also, in this area from middle of the entry to the other rib was not supported. No attempt was made to install new bolts or to add temporary support before cutting the bolts. The entrance to the area was not provided with a warning sign or physical barrier to block entrance to the area.
– A 104 (a) Citation for a violation of 30 CFR, § 48.9(a) A record of training for the task of removing roof support could not be produced by the company for the victim of the accident which occurred on September 13, 2012. At the time of the accident the victim was removing permanent support when a large portion of rock fell from the roof resulting in fatal injuries.
– A 104 (a) Citation for a violation of 30 CFR, § 48.7(c): The company did not provide training to Douglass Ice Jr., for the task of removing roof support. On September 13, 2012, this miner was part of a two man crew assigned to the removal of roof support along the North Mains Haulage when a fall of roof accident occur resulted in fatal injuries to his co-worker.