Coal Age

APR 2016

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The victim, who was unresponsive when found, was carried about 6,700 ft to the escape elevator and taken to the surface follow- ing CPR attempts. He was pronounced dead about 90 minutes post- accident at the South West Regional Medical Center in neighboring Waynesburg. Federal officials said that each set of air-lock doors measured 14 ft wide and 5.5 ft high. Combined, all components of the door weighed a total of 980 lb. The two door sets involved in the incident were installed about 85 ft apart, and their placement had been com- pleted just five days prior. As for why Kelly had opened both sets of doors, MSHA deter- mined that, as he was operating a train of equipment measuring 96 ft, it would not fit into the 85 ft length between the air locks. "Each set of…doors would see an incremental increase or decrease in external pressure across each set of doors as they were being opened or closed when used and installed properly," officials said. "This sudden increase in external airflow pressure caused the outby set of air-lock doors to become dislodged due to not being properly installed per manufacturer's recommendations." The investigating group were clear in their findings that it was "evident" that the doors had not been installed correctly, noting several issues, but added that the doors' incorrect use by having two open at once only compounded the condition. "There was mine sealant on the top of the two outside support columns, and five out of the six T-handle set screws were not installed in the lintels and columns. Without the required T-handle set screws, the air-lock doors would not be adequately secured," the report stated. "The roof cleat was missing from the top of the left column (looking outby) of the outby set of air-lock doors. When the set of inby air-lock doors at the number 64.5 cross-cut was inspect- ed, similar conditions were found. "There was one T-handle set screw present in the left side of the air-lock lintel (looking outby) at the outby set of air-lock doors, and there was one T-handle set screw present in the left side of the air- lock column (looking outby) at the inby set of air-lock doors. Both T-handle set screws were not tightened. "The manufacturer's installation instructions require that a hydraulic jack be used to tighten the columns between the mine floor and roof to secure the frame in place; afterward, all T-handle set screws are to be secured very tight to anchor the air-lock doors in place." MSHA additionally found that the three miners tasked with the door installations less than a week prior had not been task trained on correct installation procedures. It was that lack of training, along with incorrect installation, that was found to be the cause of the accident; Kelly's incorrect use of the doors was also a contributory factor. In its root cause analysis, federal investigators ordered the oper- ator to develop a policy requiring all persons to install the mine's ventilation controls, including air locks, in accordance with manu- facturer's instructions; that policy includes initial training, super- vised instruction and documentation that training was completed. Additionally, the mine trained its brattice men and masons post-accident on how to build all types of ventilation controls, including air locks, to manufacturer's spec. This, too, includes train- ing, supervised instruction and completion documentation. All workers were retrained all miners in the proper use and operation of air-lock doors as well. The 4 West Mine received three significant and substantial (S&S;) violations, two 104(d)s and one 104(a), as a result of the fatal accident. One 104(d)(1) S&S; citation cited 30 CFR Section 48.7(c) for the failure to train employees on safe work procedures. The second 104(d)(1) S&S; order cited 30 CFR Section 75.333(d)(2) for a failure to install both pairs of air-lock doors to be of sufficient strength to serve their intended purpose of maintaining separation and per- mitting travel between or within air courses or entries. The single 104(a) S&S; citation, for a violation of 30 CFR Section 75.333(d)(3), was issued due to the improper operation of the door sets. April 2016 www.coalage.com 35 s a f e t y r e p o r t c o n t i n u e d In its final findings, MSHA cited the installation of air-lock doors as a root cause for a June 2015 death of a 55-year-old scoop operator in West Virginia.

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