CAI-2009-01

UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

REPORT OF INVESTIGATION

Surface Coal Mine

Powered Haulage
February 6, 2009

Medford Trucking (B106)

Charleston, Kanawha County, West Virginia

at

Republic Energy
Elk Run Coal Company
Mahan, Fayette County, West Virginia
ID No. 46-09054

Accident Investigators

Andrew Sedlock
Coal Mine Health and Safety Inspector

Terry Marshall
Technical Support

Originating Office
Mine Safety and Health Administration
District 4
100 Bluestone Road
Mt. Hope, West Virginia 25880
Robert G. Hardman, District Manager
 TABLE OF CONTENTS

OVERVIEW........................................................................................................................1

GENERAL INFORMATION ...........................................................................................2

DESCRIPTION OF THE ACCIDENT ............................................................................2

INVESTIGATION OF THE ACCIDENT .......................................................................3

DISCUSSION .....................................................................................................................4

ROOT CAUSE ...................................................................................................................5

CONCLUSION..................................................................................................................6

ENFORCEMENT ACTIONS ...........................................................................................8

APPENDIX A: Persons participating in the investigation..........................................9

APPENDIX B: Victim Information ………………………………………………........11

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 OVERVIEW

At 9:10 a.m., on Friday, February 06, 2009, a 70-year old coal truck driver with
eight weeks of mining experience was fatally injured at Republic Energy Mine.
The accident occurred when the victim lost control of the Kenworth coal truck he
was operating, struck the left embankment and turned over on the haul road,
trapping the victim beneath the cab.

The accident occurred because: (1) the trailer brakes failed to operate effectively,
(2) the contractor failed to provide an effective safety program for the pre-shift
inspection to identify unsafe conditions, and (3) the victim had not received new
miner training.

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 GENERAL INFORMATION

The Republic Energy mine I.D. No. 46-09054 is located near Mahan, Fayette
County, West Virginia. The principal officers for the mine at the time of the
accident were:

James V. Wood ...................................................................................................President

Bryan K. Anderson ................................................................................. Superintendent
Doug Robinson......................................................................................... Safety Director

The principal officers for Medford Trucking at the time of the accident were:

Kevin Medford ...................................................................................................President

Dale Medford........................................................................................Truck Supervisor

Prior to the accident, the Mine Safety and Health Administration (MSHA)
completed its last regular safety and health inspection on June 2, 2008. Four
accidents were reported at this mine in 2008. The mine’s Non Fatal Days Lost
(NFDL) rate for 2008 was 1.37, compared with the 2008 National rate of 1.25 for
this type of mine. A regular safety and health inspection was ongoing at the time
of the accident.

DESCRIPTION OF THE ACCIDENT

William D. Wade, victim, began his shift on Friday, February 6, 2009, at

approximately 4:00 a.m., at the Medford Trucking parking lot at Belle, West
Virginia. After completing the vehicle inspection/pre-trip portion of the daily
report, he proceeded to the Elk Run Coal Company, Republic Energy mine.
While descending the approximate two mile long haulroad during the second
trip of the day, he began to experience what witnesses described as “losing his
brakes.” Mr. Wade warned other drivers by CB radio of his situation. The
victim proceeded down the haulroad to a point near the bottom, where he
attempted to “ditch” the truck in an attempt to slow or stop it. The truck’s left
front wheel dropped into a drainage sump in the ditch line. The front wheel
then struck the downhill end of the sump, folding the wheel unit underneath the
tractor. Unable to control the truck’s direction, it ran up the embankment at
approximately a 45 degree angle for approximately 87 feet. The truck then rolled
over to the right onto the haulroad, trapping the victim beneath the cab’s right
side. Mr. Wade was pinned from the waist down, lying on his back. Miners and
mine management responded immediately with first aid and extraction efforts
while awaiting emergency medical assistance. Mr. Wade lost consciousness and
required CPR, at the scene as well as on the way to the hospital, where he was
pronounced dead upon arrival.

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Ricky Hovater, a Medford Trucking driver, was traveling up the haulroad when
he passed Wade at Marker No. 46. Hovater could hear the “Jake” brake of the
victim’s truck as he passed and estimated Wade was traveling at normal speed.

Arthur Goble, another Medford Trucking driver, was returning to the mine on
the haul road and had just switched the CB channel at Marker No. 39 when he
heard the victim over the radio say he had lost air pressure.

Goble proceeded up the road to Marker No. 41 where he saw Wade coming
down the road at approximately Marker No. 42. Goble told Wade, by CB radio,
to hit an axle berm or ditch the truck. Wade passed Goble at Marker No. 41,
where Goble described the victim as in control of the truck.

Joshua Bowe, a fuel delivery truck driver for Rogers Petroleum, was starting up
the haul road at Marker No. 39 when he heard Wade on the CB radio state he
was losing his brakes. Bowe moved over in a wide spot off the paved road
between Markers No. 39 and 40 and stopped. Bowe heard other drivers advising
the victim to ditch the truck or put it into an axle berm. As Wade approached
Bowe’s position, Wade appeared to be traveling at normal speed. As the victim’s
truck passed Bowe, it seemed to speed up to 25 to 30 miles per hour. Bowe
observed smoke coming from the wheels. At approximately 9:10 a.m., Bowe
observed the victim’s truck cross over to the left, go into the ditch line, and ride
up onto the hillside. The truck hesitated and then the trailer began to roll over.
As the trailer rolled over, it pulled the tractor over with it. Bowe was the first
person to the scene of the accident, where he found the victim lying on his back,
pinned from the waist down beneath the tractor’s right exhaust stack and cab.
He stated that the victim was conscious and complaining of back pain, while
attempting to sit up.

INVESTIGATION OF THE ACCIDENT

Doug Robinson, safety/security director at Republic Energy, notified MSHA of

the accident at 9:38 a.m., on Friday, February 6, 2009, via a telephone call to the
MSHA notification hotline.

MSHA accident investigators were immediately dispatched to the mine. A

103(k) Order was issued to ensure the safety of all persons at the mine. The
investigation was conducted with the assistance of the mine operator, the
contractor, miners, and the West Virginia Office of Miners’ Health Safety, and
Training (WVOMHS&T).

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Photographs and relevant measurements were taken and a sketch of the accident
scene was made. Interviews were conducted with persons who had knowledge
about the accident at the Medford Trucking office at Belle, West Virginia. Those
persons who were interviewed and/or participated in the investigation are listed
in Appendix A of this report.

The physical portion of the investigation was completed on April 2, 2009, and the
103(k) Order was terminated.

DISCUSSION

The truck involved was a 2006 Kenworth Model W900L tandem drive axle
tractor, VIN No. 1XKWDBOX96J122158, with a 2005 MAC rear dump body tri-
axle trailer, VIN No. 5MADS353396C010834. The tractor had a Caterpillar C15
diesel engine, an engine brake, and an Eaton-Fuller Model RTL0-1891 B, 18 speed
transmission. The tractor had a gross vehicle weight rating of 59,200 pounds.
The trailer had a Gross Axle Weight Rating (GAWR) of 69,000 pounds. The
tractor trailer combination had a gross combination weight rating of 128,200
pounds. Weigh slips for the first load hauled by the victim show the truck gross
combined weight was approximately 125,000 pounds. The gross combined
weight at the time of the accident was approximately 120,000 pounds.

The haul road is approximately 2 miles long with approximately 1¾ miles, which
consists of grades ranging from 6 to 13 percent. This 1¾ mile section is paved.
The posted speed limit for this section of haulroad is 18 miles per hour. There
are six axle or center berms constructed for emergency use along the paved
portion of the road. One axle berm was approximately 500 feet upgrade from the
site of the accident between curve markers No. 40 and No. 41. The curves are
numbered in ascending order from No. 13 at the guard house to No. 55 at the
end of the paved road near the top to the mountain. Drivers call out these
numbers on the CB radio as they approach them to alert one another of their
position along the haul road.

Robert Johnson, a Medford Trucking driver, had driven the truck involved in
this accident on the previous shift without problems, making three round trips
from the Republic Mine to a load out on the Kanawha River. He finished his
shift at approximately 3:30 a.m.

Upon inspection of the truck tractor, all six of the service brake chamber pushrod
strokes were within the readjustment limits. One of the five brake chambers on
the trailer was damaged during the accident. The remaining four service brake
chamber pushrod strokes for the trailer exceeded the maximum allowable
pushrod stroke readjustment limit. All the brake lining thicknesses on both the

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tractor and trailer were within the acceptable limits. None of the brake linings on
the trailer showed signs of effective contact with their respective drums. Four of
the six brake drums on the trailer were measured to be worn beyond the wear
limits recommended by the drum manufacturer, including the left intermediate
axle drum and all three right side drums. When lifted off the ground, except for
the left rear axle due to the damaged brake chamber, all trailer wheels tested
could be manually turned with a four foot slate bar with either the parking brake
or service brake applied.

The right intermediate trailer axle brake chamber had an internal defect,
adversely affecting its reserve stroke, even though it was within readjustment
limits. The lack of reserve stroke in all five of the intact trailer brake chambers
created conditions in which none of the five intact brakes produced any effective
braking.

During the investigation it was discovered that a practice of manually

readjusting automatic slack adjusters existed. This practice gives the operator a
false sense of security about the effectiveness of the brakes. The manufacturer
warns against making manual adjustments of an automatic slack adjuster.

The investigation found that Mr. Wade, the victim, had not received 24 hours of
New Miner Training before being assigned to work duties. This is a contributing
factor to the accident. Medford Trucking’s training form, shown to the mine
operator, indicated that the training had been completed. After investigating
further, it was determined that the form was marked in error and the training
had not been given. It could not be determined if the victim jumped or was
thrown out of the truck.

ROOT CAUSE

An analysis was conducted to identify the most basic causes of the accident that
were correctable through reasonable management controls. During the analysis,
root causes were identified that, if eliminated, would have either prevented the
accident or mitigated its consequences.

Listed below are root causes identified during the analysis and their
corresponding corrective actions implemented to prevent a recurrence of the
accident:

1. Root Cause: An effective, comprehensive, and enforced program for pre-

operational inspection to identify, report, and correct unsafe conditions was
not in use by Medford Trucking at the time of the accident.

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 Corrective Action: A 12 point, pre-shift inspection procedure has been
implemented with instructions for drivers not to leave a location if defects are
found; and to ensure brakes, air systems, and safety devices, are in good
working condition. During the shift, a brake and air supply check area has
been designated before proceeding down steep grades.

2. Root Cause: The victim was not wearing a seat belt when the tractor rolled
over.

Corrective Action: Drivers were instructed to never operate a truck or any

type equipment without wearing a seat belt.

3. Root Cause: The victim passed by at least one axle berm, designed to stop
equipment when the operator is experiencing brake or control problems,
while descending the haul road.

Corrective Action: Drivers were instructed to be alert to quickly changing

conditions and utilize escape ramps or axle berms before equipment becomes
totally out of control. An escape ramp has been constructed by Republic
Energy at an appropriate location on the haulroad.

4. Root Cause: Automatic slack adjusters were being readjusted manually.

Corrective Action: All brake canisters will be from the same manufacturer
and the manufacturer’s recommendations for adjusting brakes will be
followed.

CONCLUSION

This accident occurred because (1) the trailer brakes failed to operate effectively,
(2) the contractor failed to provide an effective safety program for the pre-shift
inspection to identify unsafe conditions, and (3) the victim had not received new
miner training.

Approved by:

____________________________ ___________________
Robert G. Hardman Date
District Manager

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 ENFORCEMENT ACTIONS

1. A 103(k) Order, No. 6620636, was issued to Republic Energy on February

06, 2009, to ensure the safety of persons at the mine until all areas and
equipment were deemed safe.

2. A 103(k) Order, No. 6620637, was issued to Medford Trucking on

February 07, 2009, to ensure the safety of all persons at the mine until all
areas and equipment were deemed safe.

3. A 104(a) Citation, No. 8079384, was issued to Medford Trucking for a

violation of 30 CFR, §77.404(a). The Kenworth Coal Truck, Co. No. 21,
Model W900L, VIN No. 1XKWDBOX96J122158, and MAC tri-axle trailer,
VIN No. 5MADS353396C010834, was being operated on the mine property
and not maintained in safe operating condition. When tested, all six of the
trailer service brakes were not effective due to over stroke or defective
brake chambers. Four of the six brake drums on the trailer were measured
to be worn beyond the wear limits recommended by the drum
manufacturer. Maximum brake drum internal diameter is 16.620 inches.
The four trailer brake drums measured 16.960, 16.870, 16.866, and 16.990.

4. A 104(a) Citation, No. 8079385, was issued to Medford Trucking for a

violation of 30 CFR, §77.1708. An effective program of instruction with
regard to the safety regulations and procedures to be followed at the mine
has not been established. The operator was adjusting automatic slack
adjusters, contrary to manufacturer’s recommendations.

5. A 104(a) Citation, No. 8079408, was issued to Medford Trucking for a

violation of 30 CFR, § 48.25. The miner had not received 24 hours of New
Miner Training before being assigned to work duties.

6. A 104(a) Citation No. 8079410 was issued to Medford Trucking for a

violation of 30 CFR, §77.1606(a). An adequate pre-shift inspection was not
performed on the Kenworth Coal Truck, Company Number 21, operating
on the mine property, prior to placing the truck into operation. An
adequate inspection would have revealed that six trailer brakes were
ineffective.

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 APPENDIX A

List of persons furnishing information and/or present during the investigation:

Medford Trucking

Arthur Goble............................................................................................................Driver
Larry Winter .......................................................................................................... Lawyer
W. W. Croye.............................................................................................. Safety Director
Dale Medford................................................................................Truck Superintendent
Kevin Medford ....................................................................................................... Owner
Robert Johnston .......................................................................................................Driver
Rickey W. Hovater ..................................................................................................Driver

Republic Energy

Mike Proctor ........................................................................................................Engineer

Roy Johnson ..................................................................................Coal Loader Operator
David Hardy ......................................................................................................... Counsel
Bryan Anderson ...................................................................................... Superintendent
Jimmy Wood .......................................................................................................President
Doug Robinson.........................................................................................................Safety

Rogers Petroleum

Joshua Bowe.............................................................................................................Driver

Massey Coal Service

Phillip Monroe....................................................................... Senior Corporate Council

DeMuth Court Reporting

Connie DeMuth ........................................................................................Court Reporter

West Virginia Office of Miners’ Health Safety, and Training

Elaine Skovich .................................................................... Assistant Attorney General

Terry Farley.................................................................... Administrator of Enforcement
Gary S. Snyder ....................................................................................Inspector-at-Large
Gerald Ellison ..................................................................................................... Inspector
Gary Wolfe .......................................................................................................... Inspector
Henry Armentrout............................................................................................. Inspector

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 Mine Safety and Health Administration

Andrew Sedlock ........................................ CMS&H Inspector/Accident Investigator

Vincent Nicolau..................................................................................CMS&H Inspector
Terry Marshall .................................................................................... Technical Support

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Appendix B

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