CAI 2006 27-31 UNITED STATES DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION COAL MINE SAFETY AND HEALTH REPORT OF INVESTIGATION Fatal Underground Coal Mine Explosion May 20, 2006 Darby Mine No. 1 Kentucky Darby LLC Holmes Mill, Harlan County, Kentucky ID No. 15-18185 Accident Investigators Thomas E. Light Assistant District Manager, Technical Programs, District 2, New Stanton, PA Richard C. Herndon Special Investigator, District 3, Morgantown, WV Anthony R. Guley, Jr., P.E. Supervisory Mine Safety & Health Specialist, District 2, New Stanton, PA Gerald L. Cook, Sr. Supervisory Coal Mine Safety & Health Inspector, District 4, Pineville, WV Mark A. Odum Supervisory Mining Engineer, District 8, Vincennes, IN Robert M. Bates, Jr. Supervisory Electrical Engineer, District 6, Pikeville, KY Mark E. Schroeder, P.E. Mining Engineer, Technical Support, Pittsburgh, PA Charles D. Campbell, P.E. Mining Engineer, Technical Support, Pittsburgh, PA Michael E. Pruitt Training Specialist, Educational Field Services, Pikeville, KY Originating Office Mine Safety and Health Administration Office of the Administrator Coal Mine Safety and Health 1100 Wilson Boulevard Arlington, Virginia, 22209 Kevin G. Stricklin, Acting Administrator 2007 TABLE OF CONTENTS OVERVIEW....................................................................................................................... 1 GENERAL INFORMATION .......................................................................................... 2 DESCRIPTION OF ACCIDENT .................................................................................... 4 RESCUE AND RECOVERY OPERATIONS ................................................................ 9 INVESTIGATION OF ACCIDENT ............................................................................. 15 DISCUSSION .................................................................................................................. 16 Mine Development .................................................................................................... 16 Mine Ventilation......................................................................................................... 17 Mine Ventilation Plan.............................................................................................. 18 Methane Liberation................................................................................................... 19 Barometric Pressure.................................................................................................. 19 Roof Control................................................................................................................ 20 Examinations .............................................................................................................. 21 Emergency Mine Evacuation.................................................................................... 24 Escapeways And Emergency Evacuation .............................................................. 25 Escapeway Drills/Fire Drills .................................................................................... 25 Escapeway Maps....................................................................................................... 26 Mine Emergency Evacuation and Firefighting Plan................................................ 27 Rock Dusting and Cleanup....................................................................................... 27 Mine Dust Analysis ................................................................................................... 28 Construction of Seals ................................................................................................. 29 Self Contained Self Rescuers .................................................................................... 32 Origin, Flame and Forces .......................................................................................... 38 Origin ....................................................................................................................... 38 Flame......................................................................................................................... 38 Forces ........................................................................................................................ 41 Calibration and Maintenance of Handheld Detectors.......................................... 43 Ignition Sources Considered .................................................................................... 44 Oxygen/Acetylene Torch .......................................................................................... 44 Roof Falls .................................................................................................................. 46 Lightning .................................................................................................................. 47 Mine Electrical Distribution System........................................................................ 47 Section Electrical Equipment.................................................................................... 48 Outby Electrical Equipment..................................................................................... 48 Battery-Powered Personnel Carriers ........................................................................ 49 Battery-Powered Cap Lamps .................................................................................... 50 Hand-held Methane Detector ................................................................................... 51 Training ....................................................................................................................... 52 ROOT CAUSE ANALYSIS ........................................................................................... 54 CONCLUSION............................................................................................................... 56 ENFORCEMENT ACTIONS ........................................................................................ 57 i TABLES Table 1 - MSHA Enforcement Actions .......................................................................... 3 Table 2 - Incidence Rates................................................................................................. 4 Table 3 - Results of Quantitative Analysis of SCSRs by NIOSH............................. 34 Table 4 – Comparison of Percent KO2 Used.............................................................. 35 Table 5 – Alcohol Coke Test Results ........................................................................... 39 FIGURES Figure 1 - Map of Darby Mine No. 1 ............................................................................. 2 Figure 2 - Roof Straps at the No. 3 Seal Location for A Left ...................................... 6 Figure 3 - Personnel Carrier Lodged on Overcast Debris .......................................... 7 Figure 4 - Power Center at No. 4 Belt Drive................................................................. 7 Figure 5 - Distances from SCSR Donning Points to Final Location of Miners........ 8 Figure 6 - Damaged Personnel Carrier on top of Conveyor Belt Debris ............... 14 Figure 7 - Graph of Barometric Pressure .................................................................... 20 Figure 8 - Sketch of Metal Roof Straps at the No. 3 Seal .......................................... 31 Figure 9 - No. 4 Intake Seal........................................................................................... 32 Figure 10 - SCSR Deployed........................................................................................... 33 ii APPENDICES Appendix A - List of Injured Miners Appendix B - Mine Map - Active Underground Areas Appendix C - Timeline of Rescue/Recovery Events Appendix D - List of Persons Participating in Mine Rescue and Recovery Appendix E - List of Persons Participating in the Accident Investigation Appendix F - Map of Evidence Collected During Investigation Appendix G - Mine Map – Information Gathered by the Investigation Team Appendix H - Mine Map - Detailed Information for the A Left area Appendix I - Mine Map - Detailed Information for Portions of the A Left Area and the Mains Appendix J - Mine Map - Detailed Information for portions of the B Left Section and the Mains Appendix K - Mine Map - Detailed Information for the B Left Section Appendix L - Mine Map - Detailed Information for Portion of the Mains Near the A Left seals Appendix M - Mine Map - Detailed Information for the A Left Seals Appendix N - Seal Requirements Specified in the Approved Ventilation Plan Appendix O - Typical roof strap Appendix P - Laboratory Analysis of Rock Dust Used at the Mine Appendix Q - Mine Map - Extent of Flames and Forces Appendix R - Mine Map – Results of Mine Dust Survey Appendix S - Torch Components Appendix T - Roof Strap Segments P13 and P43 Appendix U - Photograph of Amon Brock’s Notepad Appendix V - Roof Strap Flame Cutting Experiments Appendix W - Lightning Strike Analysis Report Appendix X - Location of Electrical Equipment at the Time of the Explosion Appendix Y - Selected Photographs Appendix Z – Victim Information iii DARBY MINE No. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LCC Immediate Area Affected by the Explosion DUDE DEED DEED DECIDE 5 1Victims DE .V ET DE Um Located in Ben O-ngmated?xg Jj El Conveyor gees? El I'll _F?rimery Escapeway Located in Intake parallel Mains BEBE DEEDS EB a an iV OVERVIEW On Saturday, May 20, 2006, an explosion occurred at approximately 1:00 a.m. in the sealed A Left Section of the Kentucky Darby, LLC, Darby Mine No. 1, resulting in fatal injuries to five miners and injuries to one miner. At the time of the explosion, six miners were underground during a non-producing shift. Appendix A lists miners injured or fatally injured as a result of the accident. Prior to the explosion, four miners were on the B Left Section preparing to perform routine maintenance work on equipment. Two miners from the B Left Section who had worked the afternoon shift remained after their shift and traveled to the seals which were constructed to isolate the abandoned A Left Section from the active mine. The two miners rode a non-permissible batterypowered personnel carrier (buggy) down the return airway with a set of oxygen – acetylene torches for the purpose of removing metal roof straps from the roof that intersected the No. 1 and No. 3 Seals. One of these miners was the afternoon shift section foreman. A methane explosion occurred behind the seals at A Left, which was caused by the cutting of a metal roof strap that passed through the No. 3 Seal. The forces from the explosion resulted in fatal injuries to the two miners and complete destruction of the seals. Forces from the explosion also damaged conveyor belt structure, roof supports, and ventilation controls. The four miners who were working in the B Left Section attempted to evacuate and encountered thick smoke approximately four crosscuts outby the section power center. At this point they donned their CSE SR-100 self contained self rescue (SCSR) devices and attempted to continue their evacuation. During the evacuation, at least two of the miners intermittently removed their SCSR mouthpieces to communicate. The miners eventually became separated from each other. One miner survived and three died due to carbon monoxide poisoning with smoke and soot inhalation. The accident occurred because the operator did not observe basic mine safety practices and because critical safety standards were violated. Mine management failed to ensure that proper seal construction procedures were utilized in the building of the seals at the A Left Section. Mine management also failed to ensure that safe work procedures were used while employees attempted to make corrections to an improperly constructed seal. Furthermore, mine management failed to adequately train miners in proper SCSR usage and escapeway routes. In addition to a 103(k) Order, the company was cited for six conditions and/or practices which contributed in some way to the accident. An additional thirtyseven citations and orders were issued during the investigation, but were not considered to have contributed to the accident. 1 GENERAL INFORMATION Darby Mine No. 1 (Darby) is an underground coal mine located approximately 26 miles east of Harlan, Kentucky, on State Route 38. The mine is operated by Kentucky Darby, LLC, of Middlesboro, Kentucky, under contract with Jericol Mining, Inc., of Cumberland Gap, Tennessee. The Kentucky Darby, LLC articles of organization list Ralph Napier, John D. North, and Connie G. Napier as members of the limited liability company. The principal official at the mine is Ralph Napier, who is the superintendent and the person in charge of health and safety. The mine began production on May 28, 2001, in the Darby coal seam, which has an average thickness of 56 inches. The Owl coal seam, which has an average thickness of 36 inches, is above the Darby seam and was mined with the Darby seam in various locations. The resulting mining height varied from approximately 40 inches to 144 inches. At the time of the last regular health and safety inspection, the daily methane liberation rate was 38,707 cubic feet. Figure 1 - Map of Darby Mine No. 1 The mine had one advancing room and pillar section, designated as B Left. Figure 1 provides an overview of the mine with a detailed map of the mine shown in Appendix B. Production equipment used on the section included a continuous mining machine, two shuttle cars, a battery-powered scoop, and a roof bolting machine. Coal was transported from the coal producing section to 2 the surface stockpile using a series of four conveyor belts. Coal was loaded onto trucks and transported to the Sigmon Coal Company, Inc., preparation plant in Keokee, Virginia, where it was processed and shipped to various consumers. At the time of the accident, the mine employed 31 persons underground and three persons on the surface. The mine normally conducted two production shifts and one maintenance shift daily and operated six days per week. The total coal production reported for the first quarter of calendar year 2006 was 60,058 tons. At the time of the accident, the employees of the mine were not represented by a labor union or other bargaining unit. The last complete quarterly safety and health inspection conducted by the Mine Safety and Health Administration (MSHA) was concluded on March 30, 2006. During this inspection, the operator received a total of seven citations, five of which were designated as significant and substantial. The most recent safety and health inspection was started on April 7, 2006, and was in progress at the time of the accident. Twenty-one citations were issued during this inspection prior to the accident, nine of which were designated as significant and substantial. Table 1 summarizes the enforcement actions taken by MSHA during the last six inspection quarters. An examination of the inspection records of the most recent on-going regular inspection as well as the sworn testimony of the inspector conducting the inspection show that the A Left Seals had not been examined prior to the explosion of May 20, 2006. The inspector conducting the inspection had not yet examined the A Left Seals, the return or traveled with the mine examiner during the weekly examination for hazardous conditions when the seals would have been examined. Table 1 - MSHA Enforcement Actions Fiscal Year Inspection Quarter 2005 2005 2005 2006 2006 2006 2 3 4 1 2 3* Citations, Orders, and Safeguards S&S Non-S&S Other 2 11 9 22 7 7 5 7 5 2 9 12 * Through May 19, 2006. Total Issuances 0 2 0 0 0 0 Prior to the fatal accident that occurred on May 20, 2006, the mine had not reported a lost-time accident in over two years. The last accident resulting in 3 13 33 14 12 7 21 days away from work or restricted duty occurred on April 4, 2004. Table 2 summarizes the fatal and non-fatal incidence rates at the mine for the last five years. Calendar Year 2001 2002 2003 2004 2005 2006 Table 2 - Incidence Rates Quarter(s) Darby Mine No. 1 NFDL Fatal 1-4 17.83 0 1-4 9.25 0 1-4 6.26 0 1-4 5.49 0 1-4 0 0 1 0 0 National NFDL Fatal 7.13 0.0760 7.13 0.0329 6.31 0.0330 5.68 0.0356 5.15 0.0325 5.62 0.1696 DESCRIPTION OF ACCIDENT Approximately two months prior to the accident, the company completed mining in the A Left Section and built three seals, constructed of Omega 384 blocks, to seal off the worked-out area. The seals were built over the course of three working shifts under the supervision of Amon Brock, afternoon shift foreman, and Mark Sizemore, day shift outby foreman. After construction, the seals were referred to as the “return seals” to differentiate them from another set of seals located off the intake air course. The return seals were also referred to by number, with the No. 3 Seal being the furthest inby of the three. On May 19, 2006, the weekly examination for hazardous conditions was conducted on the day shift by Mark Sizemore. During this examination, Sizemore was accompanied by Mitchell (Tom) Lunsford, mine examiner, and the two traveled to the areas requiring examination by non-permissible batterypowered personnel carrier. At approximately 9:00 a.m., they arrived at the No. 3 Seal in the return air course and Sizemore performed a visual examination and tested for methane with a hand-held instrument. The maximum methane concentration was reported to be 0.1 percent, and no hazards were noted by Sizemore. At approximately 3:45 p.m., the afternoon shift crew entered the mine to begin the scheduled production shift. The crew consisted of Amon Brock; Jimmy Lee, shuttle car operator; Travis Blevins, shuttle car operator; Randy Fields, continuous mining machine operator; Jeff Coker, roof bolting machine operator; Clark Cusick, roof bolting machine operator; James Philpot, miner helper; and Patrick Cupp, belt attendant. The shift progressed normally until the conveyor chain on the continuous mining machine broke. A new link was installed in the 4 conveyor chain and the crew continued mining throughout the remainder of the shift. At approximately 11:00 p.m., the midnight (maintenance) shift began. The midnight shift crew consisted of George (Bill) Petra, foreman; Roy Middleton, electrician; Paris Thomas, mechanic; and Paul Ledford, roof bolting machine operator. Petra and Middleton traveled by battery-powered personnel carrier to the working section. Shortly after this, Thomas and Ledford traveled underground on a separate personnel carrier to the No. 4 Belt Drive (see Appendix B) where they discussed the status of the conveyor belts with Cupp. After this discussion, they separated to observe the conveyor belt drives for the remainder of the afternoon shift. Ledford traveled to the No. 3 Belt Drive and Cupp went to the No. 2 Belt Drive. Thomas remained at the No. 4 Belt Drive area. At approximately 12:35 a.m., Ledford returned to the No. 4 Belt Drive. He and Thomas then traveled to the working section. Cupp concluded his activities at the No. 2 Belt Drive and exited the mine at approximately 12:40 a.m. At approximately 12:45 a.m., the afternoon shift crew, with the exception of Brock and Lee, boarded a battery-powered mantrip and traveled toward the surface. They passed the oncoming midnight shift crew in the vicinity of the section power center. Brock and Lee boarded a personnel carrier loaded with an oxygen cylinder, an acetylene cylinder, a cutting torch, and other tools. They traveled in the return air course to the A Left Seals. The physical evidence suggests that Brock and Lee arrived at the area of the return seals and commenced to cut metal roof straps (see Figure 2) that had been placed in the area as roof support but which had not been removed when the seals had been built. The acetylene cylinder and cutting torch were found in the area as was a piece of roof strap that gave indications that it had been cut with a torch. Brock had a methane detector with him but it is clear that it was not being used to check continuously for methane given that it was found in his pocket after the explosion. The detector was functional since it was giving off an alarm when the body was found. There is no indication that any test for methane was made behind the seals before the cutting commenced. There was no means available to sample the atmosphere behind the No. 3 Seal. Therefore, a cutting torch should not have been used in the vicinity of the seals. The afternoon shift crew arrived safely on the surface at approximately 1:00 a.m. A few seconds after exiting the mine, they were buffeted by a gust of air, dust, and debris coming out of the portals of the mine. Initially they believed that either a massive roof fall or a collapse of the highwall had occurred. The crew 5 concluded that an explosion had occurred when the odor of burned coal reached the portals. Figure 2 - Roof Straps at the No. 3 Seal Location for A Left Meanwhile, after the afternoon shift crew departed from the working section, Petra began examining the face areas for hazardous conditions. Middleton, Ledford, and Thomas dispersed to perform other duties on the section. While on the working section, they also heard the explosion. Petra gathered the crew together and informed them that an explosion might have occurred because Brock and Lee had taken tanks and a cutting torch into the return. The crew boarded two personnel carriers and began traveling in the outby direction in the intake travelway, which was the primary escapeway. They encountered dense smoke approximately four crosscuts outby the section power center, at which point they stopped and donned SCSRs. They boarded a single personnel carrier and continued traveling in the outby direction. The crew did not have a detector capable of detecting carbon monoxide. After traveling approximately 300 feet, the personnel carrier became lodged on debris from an overcast that had been extensively damaged by the force of the explosion (see Figure 3). The crew got off of the vehicle and proceeded on foot until they reached the power center located one crosscut inby the No. 4 Belt Drive. Somewhere near this point, Ledford and Middleton removed their SCSR mouthpieces and discussed how they should exit the mine. Ledford informed Middleton that he had located the high-voltage power cable and that he intended 6 to follow it to the surface. Middleton told Ledford that he was going back to find the power center (see Figure 4). After another short discussion, Ledford began walking outby in the No. 5 Entry, using the high-voltage power cable as a guide. Ledford had no further contact with the other miners. Figure 3 - Personnel Carrier Lodged on Overcast Debris Figure 4 - Power Center at No. 4 Belt Drive 7 Ledford traveled approximately 1,050 feet in the No. 5 Entry until he reached a point just inby the No. 3 Belt Drive, where he collapsed and lost consciousness. Ledford regained consciousness at approximately 3:05 a.m. and crawled into the No. 6 Entry, where he was discovered by rescuers. Ledford was taken out of the mine on a battery-powered personnel carrier. He was transported to Lonesome Pine Hospital in Big Stone Gap, Virginia, where he was treated. Petra, Middleton, and Thomas attempted to escape but eventually succumbed to carbon monoxide poisoning at different locations in the mine. Petra was found in the No. 5 Entry approximately 500 feet outby the No. 4 Belt Drive power center. Middleton was found approximately 700 feet outby the No. 4 Belt Drive power center in the left crosscut off of the No. 5 Entry. Thomas was found 800 feet outby the No. 4 Belt Drive power center in the crosscut between the No. 2 Entry and No. 3 Entry in the return air course. Figure 5 shows the distances from where the SCSRs were donned to the location where the miners were found. Figure 5 - Distances from SCSR Donning Points to Final Location of Miners Brock and Lee were located at or near the No. 3 Seal in the return air course when the ignition occurred and were both fatally injured by the forces resulting from the explosion. Brock was found 240 feet from the No. 3 Seal in the crosscut between the Nos. 4 and 5 Entries. Lee was found in the No. 5 Entry, approximately 340 feet from the No. 3 Seal and 20 feet outby where Petra was found. 8 RESCUE AND RECOVERY OPERATIONS Actions taken during the initial rescue and recovery operation did not follow accepted past practices that have been developed from previous rescue and recovery operations. Though the intent of these actions was to expeditiously rescue trapped or injured miners, rescuers were also at times exposed to potential danger. The following description of the rescue and recovery operations has been reconstructed based on individual recollections, testimonies, and logs which at times are in conflict. Appendix C is a timeline of the rescue and recovery events with Appendix D listing the personnel involved. Robert Rhea, MSHA District 7 Harlan, Kentucky, Field Office Supervisor, was notified of the explosion by Napier at approximately 1:05 a.m. Rhea notified John Pyles, MSHA District 7 Assistant District Manager-Inspection Division, who notified Norman Page, MSHA District 7 District Manager, and MSHA headquarters personnel. Rhea notified MSHA Inspectors Kevin Doan, Dale Jackson and Brad Sears about the explosion. Once Rhea arrived at the Harlan field office he notified MSHA Inspector Roger Wilhoit about the event. MSHA’s Mine Emergency Unit (MEU) was subsequently notified. Doan arrived at the mine and verbally issued a 103(k) order at 1:54 a.m. The mine fan was operating. He took tests for carbon monoxide at the fan, as no one at the mine site at this time had a carbon monoxide detector. Doan used a MSA Solaris multiple gas detector and detected 2.6 percent methane and over 500 ppm carbon monoxide at the fan, indicating that significant combustion from an explosion or fire had occurred underground. Doan then took an air sample at about 2:01 a.m. Air sample, D-7889, was later analyzed and found to contain 0.23 percent methane, 19.26 percent oxygen, and 6,162 ppm carbon monoxide. Rhea and Jackson arrived at the mine site at 2:00 a.m. MSHA periodically monitored the fan for explosive and harmful gases. Jackson was informed that the underground mine power was disconnected. Ronnie Hampton, Supervisor, Kentucky Office of Mine Safety and Licensing (KOMSL), arrived and along with MSHA and Napier, established a command center. Air quality readings were taken at the fan and in all mine openings. The fan readings were 0.20 percent methane, 20.8 percent oxygen and over 500 ppm carbon monoxide. The intake entry had 13 ppm carbon monoxide with no methane and good oxygen. A decision was made by the command center for the rescuers to walk one of the main intake entries barefaced until they encountered 50 ppm carbon monoxide, low oxygen, or an explosive atmosphere. Some of the rescue team members entering the mine were equipped with hand-held radios provided by KOMSL. 9 Rhea, Jackson, Doan, Inspector Todd Middleton (KOMSL), and Mark Sizemore (Kentucky Darby employee) entered the No. 5 intake entry barefaced at 2:32 a.m., leaving Napier and Hampton in the command center. J.J. White, mine rescue team member, KOMSL, was stationed at the intake portal to relay information from the team to the command center. Using a MSA Solaris multiple gas detector, the rescuers traveled the No. 5 Entry taking carbon monoxide readings every crosscut and detected 12 to 18 ppm. They arrived at the intake seals and examined all six seals. They took quality readings at all the seals and had 19.8 to 20.8 percent oxygen, 3 to 12 ppm carbon monoxide, and 0 percent methane. At 3:08 a.m., John Pyles called the command center and was informed that nonmine rescue personnel were underground. Pyles gave instructions for those persons to be withdrawn from the mine. At about the same time, a light was observed in the intake entry, and the rescuers informed the command center that they saw a light and traveled towards it. They found Paul Ledford (survivor) at about 3:10 a.m. with his SCSR donned (without goggles or nose clip in place) in the No. 6 intake entry one crosscut inby survey station No. 494. The rescuers talked to Ledford, who said that the other three miners were approximately three to four crosscuts behind him. Ledford was unable to walk so the rescue team called for a personnel carrier. Jackson and Middleton advanced to crosscut No. 15 where the equipment door between the neutral and intake entries had been blown out by the explosion. Napier and Lunsford arrived with a personnel carrier. Napier transported Ledford outside while Lunsford remained underground. Communication between the command center and the underground personnel was not always maintained. Jackson, Middleton and Sizemore then walked to the No. 3 Belt Drive. Tests for methane indicated 0 percent. The phone line installed inby that location was disconnected. The mine phone located at the belt drive was then used to establish communications back to the command center. Ventilation controls were damaged during the explosion at crosscut Nos. 17, 18, and 19 between the belt and return entries. Jackson advanced inby the No. 3 belt entry for about three crosscuts when he encountered carbon monoxide ranging from 80 ppm to off scale. The rescuers retreated to the No. 3 Belt Drive area. A fresh air base (FAB) was established at survey station No. 507 in the No. 6 Entry in the main headings; Jackson advanced in the No. 5 neutral entry about three crosscuts until he encountered approximately 80 ppm carbon monoxide. The rescuers retreated to the FAB. 10 Communications were established to the command center from the FAB using the mine phone. The FAB was manned by Doan. The rescuers advanced in the No. 7 intake entry to crosscut No. 22 where three entries were mined from the Parallel Mains to connect the Mains. At this time they encountered concentrations of 80 ppm carbon monoxide and retreated back to the FAB. Hampton and the Harlan KOSML mine rescue team arrived at the FAB. Team members went under oxygen and advanced inby the FAB. The team traveled inby the No. 3 Belt Drive one crosscut and then crossed the belt to get to the return entries, intending to explore in an outby direction or “tie back” to connect to areas previously explored. When the team reached the return air course, they observed a cap lamp light inby. They traveled toward the light and discovered Paris Thomas, Jr. at approximately 4:30 a.m. He was located one crosscut outby survey station No. 517 in the No. 3 Entry in the crosscut between Nos. 2 and 3 Entries. The team found high concentrations of carbon monoxide (actual value not specified). Thomas was checked for vital signs and none were found. No call was made to the command center at that time to report the carbon monoxide concentration or the identification and location of Thomas. Several members of the Lone Mountain mine rescue team, accompanied by an MSHA MEU team member, arrived at the FAB. Jim Vicini, Lone Mountain Mine Rescue Team Trainer, was informed by the command center to take charge of the FAB. The FAB was moved from the No. 3 Belt Drive to a location two crosscuts inby survey station No. 506 in the No. 7 Entry of the Mains. Air-quality tests were made inby and the FAB was advanced to the third location at survey station No. 523. The FAB could not be advanced any further due to high concentrations of carbon monoxide migrating out of the cut-throughs between the parallel mains and main entries. Vicini requested curtains be installed across the cut-through entries to advance the FAB. The Lone Mountain team members that arrived first and an MSHA MEU team member donned apparatus and advanced inby toward the B Left section using 1,000 feet of communication hard line with headsets. The remainder of the Lone Mountain team accompanied by an MSHA MEU team member arrived at the FAB. Until this time, mine rescue teams had been advancing inby the FAB without the presence of backup mine rescue teams at the FAB. The first Lone Mountain team advanced toward the B Left section and observed one light outby in the No. 5 Entry and two lights inby toward the section. The team explored inby toward the two lights. The tail captain traveled to the end of the communication line at the No. 4 Entry. A personnel carrier with its lights on 11 was found on top of the debris from the destroyed intake overcast. A search was made around the personnel carrier and no persons were found. End caps from two SCSRs were found on the personnel carrier. Footprints indicated someone may have traveled inby in the Mains toward the old works. The first Lone Mountain team observed a second light inby. They advanced to and found a personnel carrier located at survey station No. 1193 in the No. 3 Entry on the B Left section. A MX250 handheld detector was found in the deck of the personnel carrier and indicated over 20 percent oxygen. The end caps from two SCSRs, one pair of SCSR goggles, and footprints were found one crosscut inby the personnel carrier between the No. 3 Entry and the second room turned right. The footprints indicated someone had traveled into these rooms. The team split up to travel the No. 3 Entry and three of the rooms on the right side to the faces of the B Left entries. The team reported detecting 480 ppm carbon monoxide at the section power center and 70 ppm carbon monoxide at the faces of the B Left entries. No one was found. One team member had approximately 900 psi of oxygen remaining so the team retreated back toward the FAB. During their retreat, the first Lone Mountain team met Middleton, who was traveling inby. Middleton said that a team member from Harlan KOMSL was advancing inby in each of the seven entries of the Mains toward the B Left section. The first Lone Mountain team accompanied by Middleton then retreated to the No. 5 Entry where they had previously seen a light. The team advanced outby toward the light leaving the low man with the tail captain. At approximately 5:16 a.m. they found George “Bill” Petra and another victim that could not be identified, located about 35 feet inby survey station No. 526. Petra and the second victim were checked for vital signs, and none were found. The team then retreated to the FAB, called the command center and informed them of the location of both victims, one of which was identified. At this time, three victims had been located. The Barbourville KOMSL team arrived at the FAB with ventilation curtains. The Harlan team then returned to the surface. Vicini instructed the Barbourville team to install the ventilation controls in the three cut-through entries, at crosscut No. 17 (near survey station No. 505), and in the crosscuts inby, where stoppings had been damaged between the intake and neutral entries. The FAB was then advanced to the fourth location, one crosscut inby survey station No. 559 in the No. 7 Entry. The Barbourville team advanced from the FAB to the A Left seals and found that the seals had been destroyed. Air quality readings were taken at the seal 12 locations. The team reported readings for the No. 1 seal entry as 19.1 percent oxygen, 1.5 percent methane, and carbon monoxide over range. The team then explored the return entries inby to the mouth of B Left section. They reported what was thought to be a roof fall close to crosscut No. 21 in the belt entry. The Hazard team traveled underground to the FAB. The team was instructed to travel the return entry toward the surface and meet the Martin KOMSL team that traveled from the outside toward the sealed area. Vicini instructed three members of the Lone Mountain team to travel outby in the belt entry to check on what was reported as a roof fall. The remaining members were instructed to travel inby in the Mains to the worked out areas. The teams were instructed to check each crosscut as they advanced. The team traveling outby had two members in the belt entry and one member in the No. 3 return entry. What had been reported as a possible roof fall was actually the belt and structure deposited against the rib. They also found the personnel carrier that Brock and Lee had been using. The wreckage of the personnel carrier was located in the belt entry at survey station No. 525 (see Figure 6). During further exploration the team located the body of Paris Thomas for the second time. The Lone Mountain team advanced to the No. 3 Belt Drive. They retreated in the No. 5 neutral entry and searched each crosscut for the remaining victims. At approximately 8:45 a.m. one team member found Roy Middleton in crosscut No. 21 between the Nos. 4 and 5 Entries. Middleton was checked for vital signs and none were found. Middleton had his SCSR on with the mouthpiece dislodged from his mouth. He was wearing his goggles, but it is not known if the nose clip was in place. The team retreated to the wreckage of the personnel carrier, examined the crosscut and at approximately 8:45 a.m. found the last victim, later identified as Amon Brock, in crosscut No. 23 between the Nos. 4 and 5 Entries. Vital signs were checked and none were found. At this time, all victims had been located. The team retreated to the FAB and informed the command center of the location of both victims, one of whom was identified. The entire Lone Mountain team was then instructed to return to the surface. Pat Turner, Mike Elswick, and Todd Middleton, KOMSL rescue team members, traveled underground to make a ventilation change. A regulator was installed one crosscut inby survey station No. 470 in the No. 7 Entry at the mouth of the Parallel Mains. The stopping line was examined and repaired up to the FAB. This was done to increase the quantity of air to the FAB. 13 Figure 6 - Damaged Personnel Carrier on top of Conveyor Belt Debris The Pikeville KOMSL team arrived at the FAB. The Pikeville, Hazard, Barbourville, and Martin teams made the ventilation change and the FAB was relocated to survey station No. 523. The area where the victims were located was then cleared of high concentrations of carbon monoxide. MSHA MEU team members placed the victims in body bags. KOMSL team members transported the victims back to the FAB, where they were transported to the surface. At approximately 10:55 a.m., the victims were brought to the surface and transported to the coroner’s office. The command center made a decision to make another ventilation change. The James River mine rescue team and an MSHA MEU team member traveled underground to the FAB. The James River team advanced inby the FAB toward the second set of cut-throughs located at survey station No. 593 in the No. 7 Entry. Air quality readings were taken in the cut-throughs, in the Parallel Mains entries, and in the Mains inby the cut-throughs. The team reported 0.2 to 0.4 percent methane, 20.0 to 20.3 percent oxygen, and 85 to 150 ppm carbon monoxide. The team retreated to the FAB. A decision was made to allow the mine to ventilate without an air change over the weekend. All mine rescue personnel returned to the surface. On May 22, 2006 members from the MSHA MEU and Harlan KOMSL teams entered the mine. Quantity and quality readings were taken at specific locations to determine how to re-ventilate the mine. 14 On May 23, 2006 representatives from KOMSL, the operator, and MSHA traveled to the FAB. MSHA and KOMSL teams explored the A Left section. Air quality checks were made at every crosscut. The lowest oxygen reading obtained was 20.6 percent. The highest methane and carbon monoxide readings obtained were 0.4 percent and 14 ppm respectively. The A Left section was ventilated with approximately 30,000 cubic feet per minute (cfm). MSHA, KOMSL, and company representatives traveled the worked out areas located in the northern section of the mine. Air quality readings were taken to assure the old works were ventilated. The team encountered 0.5 percent methane and retreated. Ventilation controls were examined and it was determined that the equipment doors located at the top end of the Parallel Mains had been blown out during the explosion. The team returned to the surface. A decision was made to install curtains at these doors and allow the mine to ventilate overnight. On May 24, 2006, MSHA, KOMSL, and company representatives traveled to the FAB. MSHA and KOMSL explored the B Left section. Air quality checks were made at every crosscut. The lowest oxygen reading obtained was 20.7 percent. The highest methane and carbon monoxide readings obtained were 0.4 percent and 10 ppm respectively. The B Left section and rooms were ventilated with approximately 18,000 cfm. The worked out areas located in the northern section of the mine were traveled again after the ventilation was established and air quality readings were taken. The lowest oxygen reading obtained was 20.7 percent. The highest methane and carbon monoxide readings obtained were 0.5 percent and 40 ppm respectively. At this point, temporary ventilation controls had been established throughout the entire mine. INVESTIGATION OF ACCIDENT On May 23, 2006, MSHA commenced an investigation of the accident pursuant to Section 103 of the Mine Safety and Health of 1977. The Administrator for Coal Mine Safety and Health assigned an investigation team consisting of personnel from MSHA Coal Districts 2, 3, 4, 6, and 8; MSHA Pittsburgh Safety and Health Technology Center; MSHA Educational Field Services, and the Office of the Solicitor, Department of Labor. Thomas Light, Assistant District Manager for District 2, was assigned as the accident investigation team leader. Preliminary information was gathered and records were obtained from the MSHA District 7 office in Barbourville, Kentucky; the MSHA Field Office in 15 Harlan, Kentucky; and from the mine operator. The team conducted physical investigations at the mine from May 24 to August 17, 2006. During the on-site investigations, team personnel were accompanied by representatives from Kentucky Darby LLC, the State of Kentucky, the United Mine Workers of America, and other designated miners’ representatives. At the time of the accident, the miners were not represented by any labor organization. After the accident, several miners designated the United Mine Workers of America and other parties to act as their representatives. Persons were identified for the purpose of interviews. Thirty-two interviews were conducted by the MSHA investigation team. The interviews were attended by representatives from Kentucky Darby LLC, the State of Kentucky, the United Mine Workers of America, and other designated miners’ representatives. The State of Kentucky also conducted interviews, which an MSHA accident investigation team member and an attorney from the Office of the Solicitor attended. Other contacts were made and information was obtained from contractors and State and local authorities. Pertinent and relevant records were collected and reviewed during the investigation. Physical evidence such as methane detectors, cap lamp assemblies, cutting torch parts, and various electrical components from the battery powered mantrip were examined or tested as necessary at designated testing facilities. Interested parties were informed of, and allowed to attend, testing. Samples collected during the investigation were analyzed and evaluated through the various testing facilities. Appendix E lists those persons who participated in the investigation. Physical evidence collected in the accident area is depicted on the map in Appendix F. The A Left Section and the debris field are depicted in Appendices G through M. DISCUSSION Mine Development The mine began production in the Darby Coal Seam on May 28, 2001, using the room and pillar mining method. Mining started in the A Left Section in middle to late October 2005. A Left was developed by three entries driven from the return side of the Mains starting at crosscut No. 21. At the first crosscut in A Left, one additional entry was added to each side of the section. An additional entry was added at the third crosscut on the north side for a total of six entries. Starting at the fifth crosscut, rooms were driven to the left (south). The A Left Section was mined to a distance of approximately 1,130 feet from the Mains. Five entries were driven to the right (north) for rooms near the furthest extent of the 16 section. Mining in the rooms was discontinued on March 3, 2006 and the A Left Section was sealed with three seals constructed between March 18 and 22, 2006. These seals were referred to as the “return seals.” No retreat mining was conducted in the A Left Section. On March 6, 2006, mining started in the B Left Section. B Left was developed by three entries driven from the return side of the Mains starting at crosscut No. 30. Starting at the second crosscut in B Left, rooms were driven on each side of the section. The section had advanced to a distance of approximately 665 feet from the Mains at the time of explosion. Mine Ventilation The mine was ventilated by a single, exhaust fan installed on the surface and connected by corrugated ductwork to the No. 1 drift opening. The fan was a Vortex, Model No. 54D-1139, and was belt-driven by a 100 horsepower electric motor. Measurements during the investigation indicated the fan was exhausting 114,206 cubic feet per minute (cfm) of air from the mine at a pressure of 3.2 inches of water. The second return opening had an equipment door to provide access to the return air course and to serve as an explosion-relief door. Overall mine ventilation prior to the accident is depicted on the map in Appendix B. Air entered the mine through the remaining three drift openings, including the belt entry. The intake, return, and belt air courses were separated by 8-inch hollow-core concrete block stoppings that were dry-stacked and coated with sealant on the high pressure side. The only exception was in the sealed A Left Section where several stoppings were built of Omega blocks instead of concrete blocks. Overcasts were constructed using a combination of concrete blocks, steel plates, and steel beams. The only two overcasts in service in the mine were located at the intersection between the Mains and the B Left Section. The mine had developed a sixth entry, common with the belt entry, at the second crosscut inside the mine. A seventh entry, utilized as a third return air course, was added near the intake split point for the Parallel Mains, about 1,500 feet into the mine. In the Mains, a stopping line across the intake and belt entries directed air into the B Left Section. Three entries provided access to the B Left Section. From there, the section expanded into rooms on the left and right sides of the development starting at the third crosscut. On May 3, 2006, during an MSHA inspection, an air quantity of 18,600 cfm was measured in the last open crosscut for the B Left Section. 17 According to the approved Ventilation Plan, the airflow for the belt entry should have been coursed to the return air courses outby the section belt feeder for the B Left Section. The accident investigation team, however, did not find a regulator to direct the belt air to the return air course. The only regulator shown on the mine map was located in the return air course between the first and second crosscut for the B Left Section and consisted of an equipment door (constructed of two hinged panels) in a stopping. The return air flow in the Mains ventilated the front of the seals for the A Left area. During the recovery of the mine, line curtain was used to replace some of the damaged ventilation controls to reestablish air flow throughout the mine, including directing the entire Mains return air flow into the formerly sealed A Left area. The accident investigation team measured 51,256 cfm of return air at the mouth of A Left. Mine Ventilation Plan The Ventilation Plan in effect at the time of the explosion was approved on September 1, 2005 and included one addendum. The plan addressed specific requirements for the continuous mining machine development section using blowing face ventilation in conjunction with machine mounted scrubber. For extended cut mining, the plan required at least 8,000 cfm of air be provided at the inby end of the line curtain where coal was cut, mined or loaded. The line curtain was required to be maintained a maximum distance of 14 feet from the scrubber discharge. The plan also addressed specific requirements for the use of Omega block as an alternate method of seal construction (see Appendix N). The plan required that for the use of Omega block seals: 1. Seals will be hitched 6 inches into the bottom and 6 inches into the ribs. 2. An approved bonding and sealant agent (i.e. “BLOCKBOND” or Ritewall) shall be used between all joints (horizontal, vertical, and in-between blocks) on all surface areas including the inby and outby walls. 3. Seals and pilaster thickness will be indicated in sketches. 4. A gas sampling tube with a shutoff valve will be provided in the highest seal per set of seals. 5. A U-type drain will be provided for water drainage in the lowest seal per set of seals. 6. Seals will be constructed of Omega 384 blocks as per one of the attached three drawings. 7. Omega 384 block seals shall be wedged to the mine roof as indicated in the sketch. 18 8. All wood will be flush with walls of seal and coated with sealant passing ASTM E162-87. 9. A single layer of 1 inch thick wood planking shall be placed between the top of the seal and the mine roof. 10. When the entrances to worked-out areas are sealed, the seals shall be erected in a sequence such that positive ventilation is furnished to the affected area until the erection of the two (2) final seals, with the last seal to be erected being the furthest upwind. 11. Seals shall be installed at least 10 feet inby rib corners, in solid competent material. 12. Evaluations of the inby areas will continue during seal construction. 13. The middle seal will be constructed first. The presence of the metal straps made it impossible for wood planking to be placed on the top of the seal between the seal and the mine roof. This would make it impossible to comply with mine ventilation plan seal construction requirements. Methane Liberation Vacuum bottle samples and air quantity measurements taken by MSHA on January 31, 2006 revealed a total mine methane liberation of 38,707 cubic feet per day. Vacuum bottle samples and air quantity measurements taken by MSHA on February 13, 2006 in the A Left Section return when coal was being mined revealed a total of methane liberation of 6,797 cubic feet per day. Vacuum bottle samples and air quantity measurements taken by the accident investigation team in the A Left Section return after the explosion revealed total methane liberation of 4,307 cubic feet per day. The A Left area had been sealed for 63 days. Based on the liberation rate, it is estimated that 271,341 cubic feet of methane had been liberated in the sealed area indicating an average homogeneous methane concentration of 9.6 percent. However, it is unlikely that a homogenous mixture of 9.6 percent was present throughout the sealed area at the time of the explosion. Barometric Pressure Records of the barometric pressures for Abingdon, Virginia and London, Kentucky for May 17 through May 20, 2006 were obtained from the National Oceanic and Atmospheric Administration (NOAA) and are depicted in Figure 7. 19 Atmosphere Barometic Pressure 30.0 Barometric Pressure - Inches of Mercury 29.8 29.6 29.4 29.2 29.0 Time of explosion, May 20, 2006 at approximately 1:00 AM 28.8 28.6 28.4 28.2 12:00 AM 9:00 PM 6:00 PM 3:00 PM 12:00 PM May 20, 2006 May 19, 2006 Abingdon, VA 9:00 AM 6:00 AM 3:00 AM 12:00 AM 9:00 PM 6:00 PM 3:00 PM 12:00 PM 9:00 AM 6:00 AM 3:00 AM May 18, 2006 12:00 AM 9:00 PM 6:00 PM 3:00 PM 12:00 PM 9:00 AM 6:00 AM 3:00 AM 12:00 AM 9:00 PM 6:00 PM 3:00 PM 12:00 PM 9:00 AM 6:00 AM 3:00 AM 12:00 AM May 17, 2006 London, KY Figure 7 - Graph of Barometric Pressure In the five hours prior to and after the accident, the barometric pressure fluctuated over a narrow range of 0.05 inches of mercury and appeared to reverse direction and started down near the time of the accident. A decreasing barometric pressure would cause the atmosphere behind the seals to expand in accordance with Boyle’s Law, which states that the volume of a gas varies inversely with the absolute pressure. The gas expansion would cause the atmosphere in the sealed area to mitigate towards the seals and into the active workings through any openings. Roof Control The Roof Control Plan, approved on October 17, 2001, required, as a minimum, 42-inch fully grouted, 42-inch conventional, or 48-inch tension rebar roof bolts to be installed on 4-foot by 4-foot spacing. Steel roof straps could be used in conjunction with roof bolts and plates to aid in controlling the immediate roof/drawrock. Entries and crosscuts were approved to be developed a maximum of 20 feet wide and centers were to be a minimum of 70 feet by 70 feet in entries. A minimum of 50 feet by 50 feet centers was approved for rooms with 700 feet of cover or less. The maximum depth of cover over the mine was 1,400 feet. The plan required rib bolts to be installed on 4-foot centers when 50-foot centers were used. 20 In the A Left panel and in the main entries near the A Left panel, 42-inch long, 5/8 inch diameter, grade 60 fully grouted roof bolts were installed using 6 inch by 6 inch plates. Galvanized steel straps, 16-gauge, were installed in-cycle with the roof bolts in a “grid” pattern to help control the immediate roof. Each strap measured approximately 5 inches wide by 54 inches long and had two raised Ushaped ribs or channels, approximately ¼ inch deep, formed along the length of the straps (see Appendix O). Examinations Mine examinations were conducted by various certified mine examiners pursuant to the requirements of 30 CFR Sections 75.360, 75.362 and 75.364. The certified examiners included both management and non-management employees. Section 75.360 requires an examination by a certified person within 3 hours preceding the beginning of any 8-hour interval during which any person is scheduled to work or travel underground. The certified examiner is required to examine for hazardous conditions, test for methane and oxygen deficiency and determine if air is moving in its proper direction at specific locations such as travelways, working sections, and seals along intake air courses. The mine operated two production shifts that began at 7:00 a.m. (day shift) and 3:45 p.m. (afternoon shift). The midnight shift was a maintenance shift that started at 11:00 p.m. Preshift examinations were performed within the required timeframes for these shifts. The practices adopted by the mine operator for the recording and performance of preshift examinations were examined by the accident investigation team. The foreman working on the midnight shift preshifted the working section between 4:00 a.m. and 5:00 a.m. (for the oncoming day shift) and called out the results of the examination to either the mine superintendent or a surface attendant before 5:00 a.m. A record was made of this call out. The examiner called out the results of the preshift examination of the working section only, yet the records showed that the examination of the entire mine had been completed. At 5:30 a.m. a foreman and a mine examiner, traveling together, would enter the mine to conduct the preshift examination for the outby areas of the mine. Both the foreman and the examiner conducted various parts of the examination. However, only the mine examiner certified that the examination was made. This examination (for the oncoming day shift) included the travelways, intake seals, power centers, scoop battery chargers, and belt drives. The investigation revealed that the examiners’ practice was to examine the intake travelway up to the No. 2 Belt Drive, intake seals, and the No. 2 Belt Drive power 21 center and then wait for the dayshift production crew to travel to the working section. The crew would travel through an area of the mine that had not been preshifted. The production crew would call and instruct the examiners to turn on the water pressure pump for the section. After starting the pump, the mine examiners would examine the other areas that were required to be examined during the preshift examination. The day shift section foreman preshifted the working section for the afternoon shift. The preshift examination was conducted between 1:30 p.m. and 2:00 p.m. and the results called out to the surface attendant usually between 2:00 p.m. and 2:30 p.m. The mine examiner conducted the preshift examination for the outby areas. However, the mine examiner did not conduct a complete preshift examination along the entire length of the belt lines where miners would be required to work. He only examined at the belt drives and power installations. The mine examiner would travel outside and make a record of his examination. The section foreman working on the afternoon shift preshifted the working section for the midnight shift maintenance crew. The afternoon shift foreman generally conducted the preshift between 9:00 p.m. and 10:00 p.m. and called out the results of the examination to the surface attendant usually at 10:20 p.m. The called out results were inaccurate in that the examiner stated the examination of the entire mine was completed when it was not. Consequently, the required records of the examinations were also incorrect. The maintenance foreman who worked the midnight shift would enter the mine before the midnight shift started and conduct the preshift examination of the outby areas which the second shift production foreman did not examine. No records were made of these examinations. On May 19, 2006 there was no record that a preshift examination had been conducted of the outby areas which included the travelways, intake seals, power centers, scoop chargers, and belt drives prior to the afternoon shift miners traveling underground to work. Miners said their job assignments on a routine basis were to clean and maintain the conveyor belt lines. This would require them to travel along the belt lines between belt drives in order to perform their duties. The preshift record book indicates, and the mine examiners stated preshift examinations were being conducted only at the belt drives and power centers. Additionally, miners stated on two different dayshifts, they were assigned to work on completing the construction of the A Left No. 3 Seal. There was no record of any preshift examination having been made prior to the miners entering the area. Interviews indicated that Brock and Lee were staying behind at the end of the afternoon shift on May 19, 2006. Statements from miners who worked on Brock’s crew indicated Brock never left the section that afternoon. Evidence indicated 22 that Brock traveled with Lee to the A Left No. 3 Seal together. Brock’s notebook, which was found near the No. 3 Seal, included an entry referring to cutting metal straps. There was no record of a preshift examination having been made prior to Brock taking Lee to the No. 3 Seal. Two mine examiners testified they would not always record small percentages of methane detected during required examinations. Zero percent methane was routinely entered into the record book. Section 75.362(b) requires during each shift that coal is produced, a certified person shall examine for hazardous conditions along each belt conveyor haulageway where a belt conveyor is operated. This examination may be conducted at the same time as the preshift examination of belt conveyors and belt conveyor haulageways, if the examination is conducted within 3 hours before the oncoming shift. The mine produced coal on the day shift and afternoon shift. Mine Examiner Lunsford conducted the on-shift examinations on all the conveyor belts for the day shift. The record of these examinations included notations of hazardous conditions. The record book also indicated that on-shift examinations were being conducted on the afternoon shift along the conveyor belts up until June 15, 2005. No records were made after that date for the afternoon shift. Lunsford testified that he was originally the mine examiner conducting the onshift conveyor belt examinations on the afternoon shift. He performed this function until about June, 2005, when he was asked to move to the day shift by Ralph Napier. No one was designated to replace Lunsford. Section 75.364 requires a weekly examination at least every seven days of worked-out areas, the bleeder system, an examination for hazardous conditions at specific locations that include at least one entry of the intake and return air courses in their entirety, at each seal along a return or bleeder entry, and measurements of air volume and tests for methane at specific locations. A foreman and a mine examiner routinely traveled together and jointly conducted the weekly examinations. Documentation in the Weekly Examinations for Methane and Hazardous Conditions Record Book stated the first weekly examination for the A Left seals was conducted on March 27, 2006. The record indicated that the methane concentration was 0 percent, the oxygen content was 20.8 percent and no hazards were noted. Subsequent examinations were recorded as being conducted on April 3, May 5, May 12, and May 19, 2006. These records indicated consistently that there were no hazardous conditions, that the methane concentration was 0 percent and that the oxygen content was 20.8 percent. The records also revealed 23 that the A Left seals were not examined for four consecutive weeks. The examinations were required by April 10, 17, 24, and May 1. On the dayshift of May 19, 2006, the A Left seals were examined as a part of 75.364 examination of the mine. Sizemore conducted the examination. He utilized his methane and oxygen detector and traversed the perimeter of each seal checking for methane and oxygen deficiency. During these examinations no methane or low oxygen was detected. He did not observe any unusual features of the seals and no hazards were found. The record made in the weekly examination book reflected this. The accident investigation determined that proper 75.364 examinations were not being performed. Evidence and testimony indicates that several worked out areas in the mine were not being examined to the point of deepest penetration and portions of some air courses were not being examined. Emergency Mine Evacuation The Emergency Temporary Standard (ETS), entitled "Emergency Mine Evacuation", became effective on March 9, 2006. The ETS required underground mine operators to conduct emergency escapeway drills at periods of time so as to ensure that all miners participated in such drills at intervals of not more than 90 days. Miners were required to travel the primary or alternate escapeway to the surface. An evacuation drill was not to be conducted in the same escapeway as the immediately preceding drill. Mine operators were to provide lifelines in the escapeways, an additional SCSR for each miner, training as to the locations of these devices, and training in donning of SCSRs. In accordance with the ETS preamble, MSHA accepted purchase orders or contracts to buy lifelines and/or SCSRs as a means of temporary compliance with the ETS. However, MSHA expected all other requirements of the ETS to be complied with immediately. The ETS required the operator to submit a revised Mine Emergency Evacuation and Firefighting Program of Instruction (Program of Instruction) by April 10, 2006. The investigation revealed that Kentucky Darby had valid purchase orders for lifelines and additional SCSRs for the mine. The accident investigation revealed that a revised Program of Instruction was not received by MSHA prior to the date of the accident. 24 Escapeways And Emergency Evacuation Escapeway Drills/Fire Drills Section 75.380 requires that two separate and distinct escapeways be provided from the working section. One escapeway must be ventilated with intake air and be designated as the primary escapeway. The other escapeway is designated as the alternate escapeway (sometimes referred to as the secondary) and it can be ventilated with intake or return air. The two escapeways must be separated from each other for their entire lengths. The ETS required escapeway drills every 90 days for all miners. During drills required, miners are required to travel either the primary or alternate escapeways to the surface. The escapeway drills are to be alternated between the primary and alternate escapeways. The ETS required that the mine operator certify in a record book that the drills were held. The names of miners participating in the drills are required to be listed. The third shift crew began evacuation of the mine immediately after the explosion by first attempting to escape out the intake travelway (primary escapeway). After their personnel carrier became stuck on top of a damaged overcast, the crew attempted to escape out the No. 5 Entry following the highvoltage line rather than the adjacent belt entry located in the No. 4 Entry which was designated as the alternate escapeway. Ledford traveled out the highvoltage line entry for approximately 1,050 feet and then eventually crawled over to the intake entry where he was later found by rescue personnel. The other three miners apparently traveled in the high-voltage line entry before succumbing to carbon monoxide poisoning with smoke and soot inhalation at different locations in the mine. The mine operator kept a record book entitled “Fire Drill Record” of fire drills held approximately every 90 days with miners on each shift. During these fire drills, miners were instructed in some general firefighting procedures. These instructions were given in a “safety talk” fashion and included procedures to follow if a fire were to occur on various pieces of machinery or equipment. As part of the evacuation instructions given to miners, the crew was told, in case of emergency, to evacuate the mine through the primary escapeway. Typically, miners then loaded onto personnel carriers and rode out of the mine through the main travelway (primary escapeway). Proper training in the use of the alternate escapeways was not given. According to the record book and testimony, the emergency escape/fire drills were not properly conducted. The drills were not alternated between the intake 25 and the alternate escapeways. The record book did not reflect that any miners ever traveled out the alternate escapeway during drills. The drills were mostly limited to section personnel. Given that the miners had to escape on foot due to the explosion, the lack of practice relating to the alternate escapeway, more likely than not, added to the delay in evacuation of the mine. The lack of training in the location of the alternate escapeway and the unfamiliarity with the alternate escapeway most likely affected the miners’ response to the emergency of May 20, 2006. The miners did not use the designated alternate escapeway and at least one of the miners had to turn back to gain orientation. Had the miners been more familiar with the alternate escapeway, it is reasonably likely that the miners would have fared better in their escape attempt from the mine. Escapeway Maps Regulations requires a map showing designated escapeways to be posted and kept up to date on working sections and on the surface. Any changes in route of travel, locations of doors, or directions of airflow are to be shown on the maps by the end of the shift on which the changes are made, and the miners must be informed of the changes prior to entering the underground areas of the mine. The accident investigation revealed that maps designating the escapeways from the B Left working section were not provided on the surface and for miners who worked on the B Left working section (MMU 001). Two maps were posted in the mine office on the surface and a map was located on the working section. Neither the maps on the surface nor the map on the section clearly identified the escapeways or distinguished the escapeways from other available entries. Several entries were color-coded with markers or highlighters but none of these entries were labeled as escapeways or otherwise clearly designated as escapeways. The map provided on the B Left Section did not accurately show active workings of the B Left Section. None of the maps designated the escapeways and properly distinguished them from other available entries. The investigation revealed that miners were unclear as to where the alternate escapeway was actually located. Some miners thought that the alternate escapeway was in the high-voltage line entry and at least one miner testified that he thought the alternate escapeway was located in the return. 26 Mine Emergency Evacuation and Firefighting Plan The Mine Emergency Evacuation and Firefighting Program of Instruction (Program of Instruction), required by Section 75.1502(a), was approved by the District Manager on February 6, 2003. The plan contained several requirements whereby all miners were to be instructed in firefighting and evacuation procedures. Among the requirements, the plan required miners to travel the intake or secondary (alternate) escapeways from the working section to the main escapeway every 90 days. Additionally, two miners and a supervisor were to travel the intake or alternate escapeways every six weeks alternating between the two escapeways. Escapeway maps were required to be posted on sections and on the surface and were to reflect any changes made in escapeway routes. Miners were to be notified of any changes to escapeways prior to their entrance into the mine or immediately after changes were made. The plan included instruction that during emergency evacuation SCSRs were to be donned immediately upon encountering smoke. Several items of The Program of Instruction, approved February 6, 2003, had not been followed by the mine operator. Escapeway drills were not alternated between the primary and alternate escapeways and required escapeway maps were not provided. Rock Dusting and Cleanup A program for the regular cleanup and removal of accumulations of coal and coal dusts, loose coal, and other combustibles must be established and maintained by the mine operator. Rock dust is required to be applied in all underground areas of the mine to maintain specified percentages of incombustible content. Darby employed some methods to provide for cleanup and removal of accumulations of coal dust and for rock dusting the mine workings. The company employed an outby crew on the day shift that was responsible for maintaining the outby areas of the mine which included rock dusting. They used a scoop-mounted rock dusting machine to rock dust outby areas. This equipment was also used to rock dust the working section on idle shifts. The crew on the working section hand dusted the face areas as coal was being mined through the week. Rock dust was purchased in 50-lb bags. Additional dust control measures were required by the Ventilation Plan. The Ventilation Plan described the dust control practices to be implemented and maintained for conveyor belt transfer points, loading points, belt haulage systems, all roadways, roof bolting machine dust collecting systems, and the 27 continuous mining machine. The dust control measures included water sprays, water application, maintaining permissible dust collecting systems, and using rock dust. Thirteen violations of section 75.400 were issued during the 12-month period preceding the accident. Two of these citations were not terminated at the time of the accident. According to statements of miners, the return entries from near the working section to outby the A Left return seals were recently rock dusted. The incombustible content of mine dusts was determined by analyses of samples collected mine-wide after the explosion. Analyses revealed that 84.3 percent of the samples collected were below the required amount of incombustible content. Mine Dust Analysis A mine dust survey was conducted to assist in determining the cause and origin of the explosion and to determine the incombustible content throughout the affected and other areas of the mine. The incombustible content of the combined coal dust, rock dust, and other dust must be maintained to at least 65 percent in the intake air courses, and at least 80 percent in the return air courses, in the absence of methane, to meet the regulatory requirements. A total of 363 samples were collected during seven different time periods from June 6 to June 22, 2006 as the underground portion of the investigation progressed. The type of samples collected included band samples, taken around the perimeter at each location, floor-only samples, roof-rib samples, and rib-floor samples. The samples were transported to MSHA’s laboratory in Mt. Hope, West Virginia for analysis. A total of 146 samples were collected throughout the affected area which included A Left Section and a portion of the Mains. In the Mains, samples were collected from survey station No. 506 to one crosscut inby survey station No. 559 in the No. 7 Entry. Of these samples, 129 (88.4 percent) were below an incombustible content of 65 percent in the intake air courses and 80 percent in the return air courses. A total of 217 samples were collected from remaining areas of the Mains, Parallel Mains, Old East Mains, Old North Mains, and the B Left Section. A total of 54 samples were collected on the active B Left Section and in rooms off B Left. Of these, 50 (92.6 percent) were below an incombustible content of 65 percent in the intake air courses and 80 percent in the return air courses. A total of 163 samples were collected in the remaining areas of the Mains, Parallel Mains, Old East 28 Mains, and Old North Mains. Of these, 128 (78.5 percent) were below an incombustible content of 65 percent in the intake air courses and 80 percent in the return air courses. It is unlikely the samples in these areas were affected by the explosion. Sloughage is a result of coal and rock breaking and falling from the ribs and accumulating on the mine floor. Because of the characteristics of the coal and the mining method, some sloughage was present throughout the mine. This would have had very little effect on the sample results. Virtually all of the sloughage material was too large to be included in the mine dust samples because it would not pass through a No. 10 mesh sieve. Samples of the rock dust used at the mine were collected for analysis. All of the analysis results conformed to the 30 CFR 75.2 standard except that only 63 percent passed through the No. 200 mesh sieve. The particle size of the rock dust would not change the incombustible content of any sample. However, the purpose of fine rock dust is to provide protection from explosions involving float coal dust. With only 63 percent of the rock dust passing through a No. 200 mesh sieve, the explosion protection provided by the rock dust was not as high as it should have been. A copy of the laboratory analysis is included in Appendix P. Three rock dust surveys were conducted by MSHA within the 12-month period prior to the explosion. Two of the three surveys indicated noncompliance with standards of 30 CFR 75.403. The last rock dust survey taken in A Left was on March 6, 2006. Two samples were taken in each of the 6 entries plus crosscuts, beginning at survey station No. 148 in the No. 4 Entry, and ending one crosscut outby survey station No. 189 in the No. 4 Entry. One of the eighteen samples analyzed was below the minimum level for incombustible content. The previous survey taken in this area was on November 11, 2005. One sample was taken in each of the 6 entries where A Left Section turned off the Mains. One out of six samples analyzed was below the minimum level for incombustible content. Construction of Seals The Ventilation Plan, approved by the District Manager on September 1, 2005, specified the construction sequence and installation procedures for Omega 384 blocks to be used as an alternative method of seal construction (see Appendix N). The A Left Section had been developed off the left side of the Mains such that Nos. 1 through 3 Entries were the return air course, belt entry, and intake air course respectively. The section was advanced 1,130 feet and stopped on March 3, 2006 due to bad roof and water. The section equipment was removed from A 29 Left on Saturday, March 4, and moved to the B Left Section. Mining started in B Left on March 6. Based on the results of the investigation, it appears that seal construction was started on Saturday, March 18. Miners were all assigned at some point to work on the construction of the seals using Omega 384 blocks. Testimony given by the miners indicated Brock directed the miners on how to construct the seals and the sequence in which to build them. He directed personnel to install the air sampling tube in the No. 1 Seal and the water trap in the No. 3 Seal. In testimony, Ralph Napier stated that he gave Brock and Sizemore a copy of the approved sealing plan prior to the construction of the seals. The sealing of the A Left Section began with the construction of the No. 1 Seal. The construction of the No. 1 Seal left the entire A Left Section inby the construction site unventilated. Based on information obtained through the accident investigation; a one inch or inch and a half diameter PVC pipe with a brass valve was installed in the No. 1 Seal to serve as a sampling tube. The No. 2 Seal was constructed next, across the belt entry. These seals were sprayed by TC Spray on the front and back sides. According to statements, several courses of block were laid for the No. 3 Seal but the seal was not completed due to the ending of the shift. Normal operations resumed at 11:00 p.m. on Sunday, March 19, with the maintenance crew going to work, and the production shifts following on day and afternoon shifts on Monday, March 20. Testimony from miners indicated that they completed installing the Omega blocks in the No. 3 Seal during the day shift on Tuesday, March 21. Sizemore directed the miners on how to construct the seal. Pyrochem TC spray was reported to have been applied to the outby side of the No. 3 Seal on Wednesday, March 22. A metal pipe was installed in the No. 3 Seal to serve as a water trap. Sizemore testified that he was in contact with Ralph Napier while the seal was being built. Coal was being mined in the B Left Section during the construction of the No. 3 Seal. The A Left Section was left unventilated and unsealed from March 18, 2006 until the following Wednesday, March 22, while miners were permitted to work in the mine other than those involved in the intentional ventilation change. Testimony from miners who built the seals as directed and evidence obtained during the investigation revealed that the approved plan was not being followed. The following deficiencies were identified: a. The Omega blocks were dry stacked with no mortar between the joints. 30 b. The seals were not hitched 6 inches into the solid rib and floor for the entire perimeter. c. The seals had been spray coated with a bonding and sealing agent not approved for this purpose. d. The pilaster was not properly constructed as it did not extend inby the seal as depicted in the plan and was only one 16 inch block wide. e. A single layer of 1 inch wood planking was not provided between the Omega block and the mine roof. f. The No. 3 Seal was located 6 to 7 feet from the outby rib corner whereas the plan requires a minimum distance of 10 feet. g. One metal roof strap extended through the No. 1 Seal and four metal roof straps extended through the No. 3 Seal. The use of Omega 384 block for seal construction was tested and approved by MSHA without any metal straps passing through the seal. The metal straps interfered with the installation of wood planking on the top of the seal. The wood planking could not be positioned flush with the mine roof. Figure 8 is a sketch of the metal roof straps at the No. 3 Seal. h. The seals were not built in the approved sequence. Figure 8 - Sketch of Metal Roof Straps at the No. 3 Seal The A Left seals were not the only set of Omega block seals constructed underground. During 2003, six seals were constructed across the Mains just inby where a new set of Mains was turned off to the left. This set of seals was commonly identified by mine personnel as the “intake seals.” A miner stated that he helped build these seals and that the seals were constructed in the same manner as the A Left seals. 31 After the explosion, seven solid concrete block seals were constructed which complied with 75.335(a)(1) to replace the Omega seals at the intake seals. The plan approved by the District Manager for the construction of the new seals required that the existing No. 4 Seal (Omega) be breached prior to completing the solid concrete block seal that would replace it. Figure 9 is a picture of the No. 4 Intake Seal prior to being breached. Figure 9 - No. 4 Intake Seal On June 7, 2006, team members of the MSHA’s Mine Emergency Unit, while under apparatus, breached this seal. The team observed the following deficiencies: 1. The thickness of the seal was 16 inches and not 24 inches as approved. 2. The blocks were dry stacked with no mortar between the joints. 3. The mine floor and ribs were not hitched. 4. The pilaster was undersized and did not extend to the inby side of the seal. 5. The outer wall was coated with Pyrochem TC spray. This product is not approved for use on Omega block seals. 6. The inner wall was not coated with any sealant. 7. Cap block and wedges were installed on top and sides of the seal and were in direct contact with the Omega block. Self Contained Self Rescuers Darby provided miners with the CSE SR-100 Self Contained Self Rescuer (SCSR). The SR-100 self contained oxygen breathing apparatus utilizes a bi-directional 32 rebreathing system in which exhaled gas makes two passes through a carbon dioxide (CO2) absorption/oxygen generation canister before the gas returns to the user. Potassium super oxide (KO2) and lithium hydroxide (LiOH) are used to produce oxygen (O2) and remove or scrub exhaled CO2. The unit produces approximately 100 liters of oxygen. The unit is NIOSH/MSHA approved as a one-hour SCSR in accordance with 42 CFR, Part 84. SCSR – As Deployed Oxygen Storage Breathing Hose Goggles Mouthpiece Nose Clip Breathing Bag Figure 10 - SCSR Deployed Of the four miners who donned SCSRs, only one miner survived. Accident survivor Paul Ledford donned CSE SR-100 serial number 93609. Accident victims Roy Middleton, Paris Thomas and Bill Petra, donned CSE SR-100 serial numbers 84784, 89692, and 105936, respectively. National Institute for Occupational Safety and Health (NIOSH) collaborated with MSHA in the post-incident evaluation of the five SCSRs recovered from the Darby Mine No. 1. NIOSH generated a report (“Investigation of Self-Contained Self-Rescuers (SCSRs) Recovered from the Darby Mine Disaster”, NIOSH Report to MSHA, January 2007) summarizing the SCSR evaluation. Four of these five SCSRs were used by miners during evacuation of the mine. These four SCSRs exhibited conditions consistent with partial use. The single intact SCSR failed visual inspection. A dent in the bottom case lid crossed the location of the moisture indicator. The indicator was dislodged and the case open to the external atmosphere, a condition that causes it to fail visual inspection. However, it is not possible to know that the SCSR would have failed the visual inspection prior to the explosion, or if the damage observed occurred as a result 33 of the explosion. In either event, it is in a condition that makes it unsuitable for use. The evaluation of the recovered SR-100’s was conducted at NIOSH, National Personal Protective Technology Laboratory (NPPTL) facilities in Bruceton, Pennsylvania. The evaluation was conducted by NIOSH and MSHA. Past experience with accident investigations has revealed that one of the most important products of the evaluation is an accurate visual record of the evidence. To this end NIOSH and MSHA cataloged and created a complete visual record using digital photographs and video tape. Photographs were made of all SCSRs, as received, and the inspection of the SR-100’s was recorded on video tape. During this inspection, examiners assessed the condition of both external and internal system components. To the greatest extent possible, examiners inspected each SCSR according to the manufacturer’s approved visual inspection criteria. It was not possible to follow the manufacturer’s inspection procedure completely since the units had already been opened for use and the lids were separated from the SCSRs along with the closure straps which contain the serial number and manufacturing date, but all observable aspects of the manufacturer’s visual inspection were noted. All crucial steps and observations were also documented with digital photographs. Table 3 - Results of Quantitative Analysis of SCSRs by NIOSH* Exhibit No. Location of SCSR Serial No. MFR. Date Dust Shield Cracked Canister Dented Notes Start-up Oxygen Activated Spent KO2 Evidence of Oxygen Production D-01 Paul Ledford Outside 93609 07/02 Yes YES Bottom Bushing out of place, “Jim Lewis” on dust cover. (Survivor) Yes 45% Yes D-02 Roy Middleton In Mine 84784 06/01 No Yes No Comments Yes 40% Yes D-03 Paris Thomas In Mine 89962 01/02 YES No “Pariss” on dust cover YES 75% Yes D-04 George Petra In Mine 105936 07/04 Yes No Goggles have smoke residue and scratch YES 15% Yes D-05 Amon Brock In Mine 84698 06/01 Yes N/A Unopened SCSR. Pulled freely from pouch, bottom moisture indicator dented into lid, unit open to atmosphere, dents in corner lids, Dent in middle of bottom lid. Did not attempt to open SCSR pending future tests * From NIOSH’s “Investigation of Self-Contained Self-Rescuers (SCSRs) Recovered from the Darby No. 1 Mine Disaster”. Names have been added to the table for clarification. 34 Independent testing of the Darby SCSRs was conducted by Alternative Testing laboratories, Inc. located near Uniontown, Pennsylvania. Personnel representing MSHA and NIOSH observed all tests. A chemist from CSE witnessed the tests to make sure the lab followed the proper procedures. Alternative Testing laboratories, Inc. had their Technical Director and a chemist participate. The chemical analysis revealed that Paul Ledford used approximately 30 percent of the available KO2 within the SCSR. Roy Middleton, Paris Thomas and Bill Petra used approximately 23 percent, 48 percent and 10 percent respectively. The approximate percentage used was determined by an average derived from the results of the chemical analyses performed by both laboratories. Based on the statement of the lone survivor Ledford, SCSRs were not donned at the time that the explosion occurred, but were donned after the crew began exiting the mine via a battery-powered personnel carrier and encountered smoke in the intake. Table 4 – Comparison of Percent KO2 Used Exhibit # S/N Miner Visual Estimate SCSR CSE Lab. Independent Lab. Analysis Analysis Average Lab. Analysis D-01 93609 Yes 45% 30% 29% 30% D-02 84784 Yes 40% 25% 20% 23% D-03 89962 (89692) Yes 75% 42% 53% 48% D-04 105936 Yes 15% 10% 9% 10% D-05 84698 Yes Not Used #N/A #N/A #N/A Location Notes Paul Ledford Roy Middleton (Paris Thomas) Use visual estimate - fused bed Bill Petra Amon Brock The four men donned their SCSRs and began traveling to the surface via the personnel carrier until their route was obstructed by a fallen overcast and they were forced to abandon the ride and start walking. The four men discussed their options and decided to follow the high-voltage cable due to the presence of thick, dense smoke that considerably reduced visibility. Ledford and Middleton were in the lead with Petra and Thomas following. At some point, Middleton told Ledford that he was going back to find the power center. Ledford told Middleton that they had to exit the mine. Ledford then followed the highvoltage cable to exit the mine. Ledford related that he crawled for a while then stopped and rested because he became exhausted and would have to rest. Ledford stated that when he arrived at the No. 3 coal conveyor belt head that he lost consciousness due to exhaustion. Ledford stated that after regaining 35 consciousness he crawled into the intake entry where he saw lights and was able to signal rescuers. Ledford sustained first and second degree burns to his chest, which he believed were caused by the SCSR. All self contained self rescue devices are required to be examined for damage and for the integrity of the seal after each time worn or carried by a person. During the interviews with mine personnel, it became apparent that this was not done regularly. An examination of the operator’s records of the 90-day testing and evaluation of the SCSRs at the mine revealed that the operator conducted the required examinations with an Acoustic Solids Movement Detector (ASMD); however the method used was not the method described in section four of the manufacturer’s instructions. The manufacturer prescribed that the unit be moved in an up and down motion while conducting the test. The mine personnel used a horizontal motion while conducting the test. This horizontal motion is not a reliable method of checking that the chemical bed is intact. The records of the quarterly examinations of the SCSRs indicated that units that did not pass the ASMD test were removed from service and replaced. An examination of the operator’s records indicated that at least thirteen SCSR units had been removed from service during the eighteen month period prior to the explosion. Personnel at Darby were instructed in the operation and maintenance of the CSE SR-100 SCSR by a contract safety instructor during their annual retraining class using an actual training SCSR. For training conducted at the mine site, miners were trained using an expired or damaged SCSR that had been removed from service. This SCSR was found hanging in the mine storage room and did not have its top and bottom covers, goggles, or security band. Because of the lack of these parts, miners were unable to simulate the removal of the security band and the opening of the device. These steps are part of proper SCSR donning procedures as instructed by the manufacturer and required by the standard. The instructions provided with the SR-100 SCSR state that there are several factors of concern regarding the usage of the SCSR. Persons are to be instructed that after the unit has been started, they should not remove the mouthpiece to talk. The removal of the mouthpiece would likely lead persons to breathe contaminated air. The removal of the mouthpiece typically allows the breathing bag to deflate. If it deflates, the uncontaminated oxygen is lost. Persons exposed to carbon monoxide that are actively exerting themselves or panicking will have a more rapid increase of carbon monoxide in their bloodstreams. Increased workload such as walking or carrying items will result in symptoms of exposure 36 sooner, and at lower concentrations. Carbon monoxide levels in normal nonsmokers are approximately zero to three percent of total hemoglobin. Persons who smoke can have levels of carbon monoxide ranging from four to nine percent of total hemoglobin. The medical examiner’s report revealed that Middleton, Petra, and Thomas, succumbed to carbon monoxide poisoning with smoke and soot inhalation. The carbon monoxide saturation in their bloodstreams was 55 percent, 46 percent and 45 percent, respectively. The carbon monoxide saturation in the blood of the only survivor Paul Ledford was 29.4 percent as measured at the hospital. The analysis of the SCSRs worn by Middleton, Petra and Thomas showed that the SCSRs had sufficient breathable oxygen capacity left to allow the miners to escape the mine. These factors indicate that proper SCSR usage procedures were not followed. Paul Ledford stated during his interview with MSHA that SCSRs were not donned until they encountered smoke, and not immediately after they had realized that an explosion had occurred. Ledford stated that the mouthpieces of the SCSRs were removed when he and Middleton were talking during their escape from the mine. The evidence indicates that elevated levels of carbon monoxide in the bloodstream may be accounted for because of the following factors: (1) The SCSRs were not donned until the miners encountered smoke at which time the atmosphere may have already become contaminated. (2) The removal of the mouthpiece to talk would have allowed the miners to breathe contaminated air. (3) Reports from mine rescue personnel indicate that the three deceased victims were found without nose clips on. The examination of the SCSRs indicated that the nose clips were still attached to the breathing hoses of each unit. Paul Ledford, although found wearing the SCSR, was observed by rescuers not having the nose clip in place. Without nose clips on, they would have breathed an atmosphere contaminated with carbon monoxide. An Emergency Temporary Standard (ETS) became effective on March 9, 2006. That standard requires mine operators to have at least two SCSRs for every miner underground during any shift, requires outby caches of additional SCSRs in both the primary and alternate escapeways at specific distances, and requires coal mine operators to install lifelines in the escapeways at their mines. It also mandates that flame resistant lifelines are to be equipped with cones or devices, whereby a person can distinguish the proper direction of travel to safety, even with reduced visibility. The ETS allows operators to show evidence that additional SCSRs and lifelines had been ordered, recognizing that there would be a problem in material availability. 37 A deadline of April 10, 2006, was set forth in the ETS preamble to require the mine operators to show that the material had been ordered. Darby had ordered lifeline supplies on March 8, 2006. The additional supplies of SCSRs were ordered April 24, 2006. Origin, Flame and Forces Origin During any underground coal mine explosion investigation, it is necessary to locate the origin of the explosion. Identifying the origin is essential in determining the circumstances surrounding the accident and to help prevent similar, future occurrences. The ignition source and the fuel are located at the origin of the explosion. Ignition sources that are not located at or near the origin can be eliminated as potential ignition sources. The origin would be identified as the location from where primary explosion forces propagated in all directions. Evidence was observed in the underground areas affected by the explosion at Darby Mine No. 1. This evidence was evaluated by MSHA investigators and it was used to establish the point of origin, the extent of flame, and the direction of the primary explosion forces. Appendix Q is a mine map that details the extent of flame and the direction of the primary explosion forces. The sealed area designated as A Left was sealed through the installation of only three alternative-type seals constructed of Omega blocks. During MSHA’s investigation, the locations of these three seals were meticulously evaluated, along with extensive areas on both sides of these seal locations. The direction of primary explosion forces, as shown on the mine map in Appendix Q, indicates that the explosion was initiated at the No. 3 Seal. Primary forces propagated away from the location of the No. 3 Seal in all directions, thus identifying this location as the origin of the explosion. Flame At the time the explosion occurred, there is no reason to believe that any coal dust would have been in suspension on either side of the A Left Seals. When the minimum explosive concentration of coal dust is suspended, the cloud is so dense that vision or breathing is impossible. Suspension is a necessary component of explosion propagation. Methane is naturally suspended as it enters the mine workings. Research has shown, as documented in MSHA Informational Report 1119, that the ignition of as little as 13 cubic feet of methane, diluted to within the explosive range, would be sufficient to suspend and ignite a coal dust cloud. Although methane provided the primary fuel for 38 the explosion, MSHA investigators believe that coal dust became involved to a limited degree throughout the sealed area as the flame propagated further inby into the sealed area. The extent of flame is shown on the mine map in Appendix Q. A mine dust survey was taken after the explosion. A total of 146 samples were taken on approximately 100 foot centers in the affected area which included A Left Section and a portion of the Mains. Sampling the mine dust on 100 foot intervals or less minimizes the effect of any dust transport that may occur during the explosion. The samples were all sent to MSHA’s Mt. Hope Laboratory for analysis. Each sample was subjected to an Alcohol Coke Test and each was analyzed for incombustible content. The results of the mine dust survey are recorded on the mine map in Appendix R. The results of the Alcohol Coke Test are summarized in Table 5. The results of the Alcohol Coke Test indicate the quantity of coke in each sample as either none, trace, small, large, or extra-large. MSHA has used these results to identify the extent of flame that has occurred during underground coal mine explosions. Table 5 – Alcohol Coke Test Results Location A Left B Left Mains Parallel Mains Old East Mains Old North Mains Number of Samples 66 57 149 42 27 No Coke 0 57 127 40 27 Trace Coke 0 0 21 2 0 Small Coke 3 0 1 0 0 Large Coke 34 0 0 0 0 Extra Large Coke 29 0 0 0 0 22 22 0 0 0 0 Areas containing large or extra-large quantities of coke in the post-explosion analysis are indicative of explosion flame. However, it is possible for mine dust samples within the flame zone to show none, trace, or small quantities of coke. There are a variety of reasons that this may occur. For example, the explosion flame can travel at a velocity that is too fast to allow sufficient time for coal to coke. The entire area inby the location of the three seals was involved in the flame of the explosion. Flame did not extend beyond the seals into the active workings. The flame of the explosion can be extinguished due to a lack of fuel, heat, oxygen, suspension, confinement, or a combination of these five factors. Explosion propagation occurred in the inby direction in No. 4 Entry, inby No. 3 39 Seal. As the explosion neared the inby end of the sealed area, the flame speed began to decrease. When the speed of an explosion is reduced to below approximately 150 feet per second, the explosion loses its ability to further suspend mine dust from the roof, ribs, and floor. Although coal dust was not able to be continually suspended in sufficient quantities to fuel an explosion, the explosive methane continued to be consumed as the explosion propagated inby. Therefore, the lack of sufficient suspended fuel did not help to extinguish the explosion in this case. Methane requires about 1,000 degrees Fahrenheit to ignite, whereas a suspended cloud of coal dust requires about 834 degrees Fahrenheit to ignite. Explosion flames easily exceed these temperatures. Sufficient heat remained within the area of the flame front to continue propagation for the duration of the explosion. The explosion flame was not extinguished because of a lack of heat. Coal dust and methane require 13 percent and 12 percent oxygen respectively to become, or to remain involved in, any combustion process. Since flame evidence existed throughout the sealed area, it is certain that oxygen concentrations at or above these minimums existed behind the destroyed seals. Also, the active workings would have contained an oxygen concentration of about 21 percent before and during the explosion. Although oxygen concentrations prior to the explosion would have been between 12 percent and 21 percent, the flame of the explosion would have consumed most of the oxygen present as it burned. The flame of a methane explosion would not be able to burn back through the same area because of the lack of oxygen immediately after the explosion. Expected oxygen concentrations after a typical methane explosion would be approximately 4 percent or less, depending on the initial methane concentration. The explosion flame propagated inby from the point of origin at the No. 3 Seal until it encountered the solid faces. As the flame front progressed inby, it consumed the available oxygen. The flame could not travel through the same area twice during the explosion because of the lack of oxygen. The lack of oxygen did not cause extinguishment of the propagating flame. The flame could not travel in the outby direction from the faces because oxygen levels were insufficient. In order for an explosion to propagate, the fuel must be suspended. Coal dust can become suspended when overpressures occur. Coal dust can remain in suspension only when sufficient flame speeds continue during an explosion. When the flame speed decreases, the ability of the explosion to suspend coal dust diminishes. Methane is naturally suspended as a gas. Methane provided the primary fuel for the explosion and remained in suspension for the duration of the explosion. The lack of suspension was only responsible for extinguishment of that portion of the flame attributed to coal dust. 40 The flame did not pass out of the sealed area into the active workings. Confinement within the sealed area remained constant. The flame remained totally confined for its entire duration. Therefore, the lack of confinement was not responsible for the extinguishment of the explosion flame. In summary, the explosion flame began at the location of the seals and propagated inby to the solid block of coal. There was an insufficient quantity of methane present outby the seals to support combustion. Extinguishment occurred because the flame could no longer propagate in the inby direction. After it reached the solid block of coal, the flame could not travel in the outby direction because oxygen levels were insufficient Forces Explosion flame heats the mine atmosphere as it propagates. This action results in rapid expansion of the mine atmosphere and the generation of forces. As the flame speed increases, the magnitude of the explosion forces increases. Explosion forces affect a larger portion of the underground workings than the flame. Forces from the explosion damaged conveyor belt structure, roof supports, and ventilation controls. The force of the explosion caused the No. 3 personnel carrier to tumble approximately 260 feet, eventually coming to rest against the rib in the No. 4 Entry. The direction of the primary explosion forces are shown on the mine map in Appendix Q. The explosion flame and forces initially propagated inby from the No. 3 Seal in the No. 4 Entry of A Left and continued to the most inby locations of the sealed area. Evidence indicated that explosion flame and forces split from the No. 4 Entry into both the No. 3 Entry and the No. 5 Entry as it propagated inby. The explosion flame immediately engulfed the Nos. 1, 2, 3, and 5 Entries and rapidly traveled throughout the entire sealed area. In order for any explosion resistant seal to withstand the forces generated during an explosion, the seal must be properly constructed. Prior to this incident, all explosion resistant seals which were allowed to be constructed in underground coal mines had passed explosion testing to 20 pounds per square inch and had been deemed suitable for the intended purpose. Properly constructed Omega block seals have been subjected to explosion pressures of up to 27 pounds per square inch without failure occurring. However, explosion resistant seals must be constructed in the same manner as those that passed explosion testing. Any deviation from this manner of construction results in an untested seal with dubious explosion resistance. 41 The Omega block seals constructed underground for A Left were not constructed according to the manner in which those seals passed explosion testing. For example, there is no evidence of a complete hitch being cut from the floor and from both ribs into which these seals were to be set. Hitching is an essential characteristic of properly constructed 24-inch thick Omega block seals. Additionally, the blocks from these seals were reportedly stacked dry, without any mortar between the joints. This is a serious deviation from the manner in which those Omega block seals previously tested had been constructed. Also, only one mortar, BlocBond, is currently allowed for the construction of Omega block seals. Although a face mortar was applied, in construction of the return seals, the mortar was not BlocBond, and therefore, was not suitable for this particular application. Also, a full, interlocking pilaster must be incorporated into this type of seal. Such a pilaster was reportedly not built into the center of any of the three Omega seals that failed. Each of these construction deficiencies resulted in seals with questionable ability to withstand explosion forces. Each of the three A Left Omega seals was completely destroyed during the explosion. Observations were made by MSHA investigators concerning the damage to the remnants of the Omega blocks. Many Omega blocks were reduced to small pieces of block and fine powder. The amount of pressure needed to cause this damage is not specifically known because the damage may be related to the strength of the mortar used for construction. Tests conducted at NIOSH’s Lake Lynn Experimental Mine confirmed that structures in the path of a propagating explosion cause the primary forces of the explosion to be reflected. If the structures fail, the magnitude of the force is reduced. The total pressure reduction is dependent on the strength of the structure. For example, an explosion against a properly constructed 40-inch thick Omega block seal at NIOSH’s Lake Lynn Experimental Mine resulted in pressures outby the seals decreasing from 51 to 6 psi and from 93 to 8 psi. However, an explosion against weaker structures, such as dry-stacked concrete block stoppings, resulted in pressures outby the stopping decreasing from 12 to 4 psi and from 8 to 6 psi. The personnel carrier that was parked at the No. 3 Seal at the time of the explosion was displaced a distance of approximately 260 feet. This distance includes a deflection of 30 feet to the left after the personnel carrier collided with a coal pillar. Utilizing information regarding the dynamic pressure, it was estimated that the minimum explosion pressure exerted on the carrier appeared to be at least 22 psi. This calculation was determined in a report by MSHA entitled “Dynamic Calculations of the Explosion Pressures Exerted on the Personnel Carrier at the Darby Mine No. 1”. This calculated explosion pressure was based on the total displacement distance of the personnel carrier. The total distance would have been greater if the personnel carrier had not impacted a coal pillar. This would have resulted in a calculated pressure greater than 22 psi. 42 Calibration and Maintenance of Handheld Detectors Several different types of multiple gas detectors were utilized at this mine site. They consisted of Industrial Scientific CMX270 and MX250; CSE 301, 102, and 102LD; CD210; and MSA Solaris. These detectors were used when making the required preshift, on-shift, weekly examinations, and the required methane test in the face area while mining coal on the producing section. Mine management statements and records provided by the contractor who performed calibration tests, revealed that the detectors were not being calibrated at least once every 31 days. The only calibration test performed on the detectors occurred when they were sent in for repairs. A MX250 detector was found on one of the personnel carriers used by the miners located on B Left Section at the time of the explosion. This detector was tested at MSHA’s Approval and Certification Center. The test results showed that when the detector was turned on, it had a low battery warning signal. After the detector was charged, calibrating gas was applied through the Horiba gas analysis machine using a MX250 calibration cup at the recommended flow rate of 0.5 liters per minute (lpm). After applying methane to the detector, the readout indicated 0.1 percent regardless of the concentration of methane being applied. It was determined that the span on methane had been turned down and the electric zero was turned up. Several tests were conducted on the MX250 using the Industrial Scientific calibration kit following the same procedure as above. The span potentiometer (pot) was returned to its original position and calibration gas was applied. The span pot was then turned 9.75 turns clockwise resulting in readings of 2.5 percent methane and 20.9 percent oxygen. These tests indicated that the MX250 was functional but was adjusted such that it would not properly detect methane. This problem with the MX250 was not an isolated incident. Four to five out of every 10 detectors sent to be repaired by Darby were found to be out of calibration. Similar to this detector, some detectors were so far out of calibration that regardless of how much methane was applied the detector would only indicate 0.0 or 0.1 percent. Information obtained during the accident investigation revealed that some of the methane detectors had been rendered in such a way that an accurate reading was not possible. An examination of the methane detector that was carried by Amon Brock on the day of the explosion showed that the detector, although reading high, was functioning properly but it did not appear to have been deployed continuously at the time of the explosion. Due to the fact it was found in his pocket, it could not have been deployed continuously at the time of the explosion. 43 Through interviews, information was obtained that miners performing some of the required methane tests had not demonstrated to an authorized representative of the Secretary that they were qualified to properly test for methane. Ignition Sources Considered Oxygen/Acetylene Torch The accident investigation team recovered several components of an oxygen/acetylene torch assembly from the debris field created by the force of the explosion (see Appendix S). The team also recovered a 251 cubic-foot oxygen cylinder, a 140 cubic-foot acetylene cylinder, and approximately 50 feet of 3/8 inch diameter torch hose from the scene of the accident. These pieces of physical evidence, along with information acquired during the formal interview process, clearly indicate that the oxygen/acetylene torch was located at or near the No. 3 Seal at the mouth of A Left Section at the time of the explosion. The torch handle (Victor Model WH36FC) was equipped with valves to control the flow of oxygen and acetylene to the cutting attachment. When the torch handle was found by investigators, the oxygen valve appeared to be open and the acetylene valve appeared to be closed. The cutting attachment (Victor Model CA35) was also equipped with a valve to control the flow of oxygen to the cutting tip. This valve appeared to be closed when found by investigators. The oxygen cylinder valve was still attached to the oxygen tank when found by investigators and it was determined onsite that this valve was in the open position. The acetylene cylinder valve was sheared off during the explosion and was separated from the tank. This valve was also determined to be in the open position by onsite investigators. The pressure regulators for the oxygen and acetylene lines were heavily damaged in the explosion and no determination could be made regarding their individual settings. The torch handle, cutting attachment, regulators, and cylinder valves were taken into custody by MSHA and transferred to MSHA Approval and Certification Center for examination and testing. The valves on the torch handle and cutting attachment were individually tested by applying compressed air (40 psi for the oxygen valves and 5 psi for the acetylene valve) to see if the valves were open or closed. The results of this test confirmed the assessment made by onsite investigators, with the exception of the acetylene valve on the torch handle, which leaked slightly when the compressed air was applied. Further testing was conducted using compressed air and a flow meter to determine how small changes in valve position affected flow rate. These tests 44 were conducted using a new cutting torch identical to the one involved in the accident. When compressed air was applied to each of the oxygen valves, approximately 90 percent of full flow was developed by turning the valves one quarter turn counterclockwise from the off position. When the acetylene valve on the torch handle was tested, approximately 56 percent of full flow was developed by turning the valve one quarter turn counterclockwise from the off position. The new torch assembly was then connected to compressed oxygen and acetylene tanks in order to determine the minimum valve settings required to sustain a neutral flame. Pressures were regulated to 5 psi for acetylene and 40 psi for oxygen. With the oxygen valve on the torch handle fully open and the acetylene valve opened 3/16 of one turn, a neutral flame was obtained when the oxygen valve on the cutting attachment was opened 1/8 of one turn. These tests demonstrated that very small changes in valve position can have a substantial affect on flow rate. The oxygen/acetylene torch found at the mine site was subjected to a violent explosion. As a result, the torch components traveled several hundred feet and inevitably contacted the mine roof, floor, and ribs many times before being deposited along the debris path. It is highly likely that the valves on the torch handle and the cutting attachment were altered to some degree by the violent motion resulting from the explosion. Therefore, the exact position of the torch valves at the instant the explosion occurred could not be determined with certainty. Four galvanized steel roof straps had been installed in the mine roof over the No. 3 Seal. Each strap was 54 inches in length and contained two “U” shaped grooves. The straps were oriented perpendicular to the seal and intersected the seal to varying degrees. A section, approximately 25 inches in length, was missing from the middle of the strap installed closest to the left rib (facing inby toward the A Left section). The remaining pieces of this strap were still attached to the mine roof when observed by investigators. This strap appeared to have been cut with an oxygen/acetylene torch at the point where the strap intersected the outby edge of the seal. The strap also appeared to have been severed (partially cut, partially torn) at a point approximately 25 inches outby the edge of the seal. A section of roof strap, roughly matching the dimensions of the missing piece, was found in the No. 5 Entry approximately 550 feet from the No. 3 Seal. This section of roof strap also appeared to have been cut with a torch and was partially covered with the type of sealant used during the construction of the seals. The section of roof strap found in the No. 5 Entry was taken into custody by MSHA and designated as Exhibit P13. A portion of the inby section of the 45 severed roof strap was removed from the mine roof and taken into custody by MSHA. This piece was designated as Exhibit P43. The outby portion of the severed roof strap could not be retrieved because it was essentially covered by the roof bolt bearing plate. A diagram depicting the sections of the roof strap is included in Appendix T. Exhibits P13 and P43 were transferred to MSHA Approval and Certification Center for analysis and testing. Microscopic analysis of the edges of the straps revealed that one of the edges of Exhibit P13 had been completely cut with an oxygen/acetylene torch and the other edge had been partially cut with a torch and partially severed by some other means. It was also determined that one edge of Exhibit P43 (“outby edge of No. 3 Seal” as noted in Appendix T) had been completely cut by a torch. During the course of the investigation, a small notepad, identified by mine employees as belonging to Brock, was discovered lying on the mine floor in the main return just outby the location of the No. 3 Seal. The phrase “Cut straps & 2 Buckets sealant” was written on the first page of the notepad. A photograph of this page of the notepad is included in Appendix U. The most likely ignition source for the explosion was the heat generated in the process of cutting the metal roof strap. Tests were conducted by engineers from NIOSH and MSHA Approval and Certification Center in which metal roof straps were cut with a torch while temperature recordings were made with an infrared camera system (see Appendix V). These tests demonstrated that the torch flame and the hot metal slag ejected during the cutting process were well above the ignition temperature of methane. This test also demonstrated that sparks and slag could be projected through the channels in the metal roof straps. The temperature of the metal edges created by the cut remained above the ignition temperature of methane for up to 20 seconds after the cut was completed. Roof Falls A roof fall can ignite an explosive methane-air mixture either by generating frictional heat or by the release of piezoelectric energy. The rocks comprising the immediate and main roof rub against one another as the roof breaks and falls. The friction from rubbing or from impact can result in temperatures above the ignition temperature of methane. The United States Bureau of Mines (USBM) has conducted rubbing friction and impact friction experiments. Under carefully controlled laboratory experiments, the USBM was only able to ignite methane-air mixtures in a small percentage of tests, even when the methane concentration was optimum for ignition. 46 An ignition can also be generated by piezoelectric discharges during certain roof falls. This situation is usually found with rock containing crystalline structures such as tourmaline, quartz, topaz, and Rochelle salt. These crystals produce electric charges on parts of their surface when they are rapidly compressed in particular directions. In coal mining, the most notable crystal formation found is the quartz content of sandstone. The immediate and main roof of the Darby Mine No. 1 was comprised of sandstone and shale; however, there was no evidence of roof falls in the A Left area. Therefore, roof falls were eliminated as an ignition source. Lightning A lightning strike analysis was performed by Vaisala, Inc., of Tucson, Arizona, to address the possibility of lightning as an ignition source. The geographic center point of the analysis was specified as 36.8786°N, 82.9525°W, which corresponds to the digitizing coordinate nearest to the A Left Section on the mine map. A 5mile radius and a 12-hour time period, from 6:00 p.m. on May 19 to 6:00 a.m. on May 20, were selected for the analysis. The resulting report, entitled STRIKEnet® Report 162412 (see Appendix W), clearly shows that there were no lightning strikes within a 5-mile radius of the mine at the time of the explosion. The closest lightning strike, with respect to time, occurred approximately 1.5 hours before the explosion, and was 12.5 miles from the specified location on the mine map. This strike had a peak current of 5,100 amperes. The closest strike, with respect to geographic location, occurred approximately 2.5 hours after the explosion, and was 1.4 miles from the specified location on the mine map. This strike had a peak current of 7,900 amperes. Based on this information, it was concluded that lightning did not contribute to the explosion. Mine Electrical Distribution System Power was supplied to the main substation through a 34.5-KV service drop from the utility company. At the substation, the voltage was transformed from 34.5 KV to 4.16 KV by a bank of three 500-KVA transformers connected in a delta-wye configuration. The wye-connected secondary side of the transformers was grounded through 96-ohm, 25-amp grounding resistor. A 600-amp oil circuit breaker (OCB) was installed in the main substation to provide protection for the 4,160-volt circuit supplying power to both the surface and underground areas of the mine. A gang-operated disconnect switch was installed on the primary side of the transformers to allow the utility power to be disconnected. Lightning arrestors were installed on the line side of the gang-operated disconnect switch. 47 Power exited the substation on a set of uninsulated overhead lines. A highvoltage branch circuit was established at a totally-enclosed switch house located on the surface between the Nos. 3 and 4 Portals. The switch house contained a vacuum circuit breaker (VCB) and a visible disconnect switch to isolate and protect the #2/0 AWG mine power feeder cable, which entered the mine at the No. 4 Portal and supplied power to all underground circuits. Lightning arrestors were installed on the surface approximately 80 feet from the point where the underground circuit branched off of the main 4,160-volt line. The underground mine power feeder cable was installed in the entry adjacent to the conveyor belt entry, which was identified as No. 4 for the first 1,500 feet and as No. 5 thereafter. The mine power feeder cable terminated at the B Left Section power center, approximately 4,100 feet from the point where it entered the mine. There was no evidence to indicate that the high-voltage distribution system contributed in any way to the occurrence of the explosion. The mine power feeder cable was, at the closest point, at least 300 feet from the A Left seals. Section Electrical Equipment The following pieces of mobile mining equipment were located on the B Left working section at the time of the accident: 1) 2) 3) 4) 5) One continuous mining machine (Joy, Model 14CM-10A). Two shuttle cars (Joy, Model 21SC). One battery-powered scoop (Long Airdox, Model 601). One coal conveyor belt feeder (Stamler, Model BF-17). One roof bolting machine (Fletcher, Model HDDR-13CF). The electrical equipment on the B Left working section was ruled out as a possible ignition source based on the distance from the origin of the explosion. The face of the B Left working section was approximately 1,500 feet from the seals located at the mouth of the A Left Section at the time of the explosion. A map of the location of all electrical equipment in the mine at the time of the explosion is included in Appendix X. Outby Electrical Equipment The mine had three underground conveyor belt drive installations, designated as No. 2, No. 3, and No. 4. The drives received power from 300 KVA power centers positioned near each of the respective belt drive installations. Two battery charging stations were present underground: one located near the No. 4 Belt 48 Drive, and the other located two crosscuts inby the portal in the intake air course. A permissible pump was positioned in the No. 1 Entry, 13 crosscuts inby the portal. A 25 hp pressure pump was installed approximately one crosscut outby the No. 2 Belt Drive in the No. 3 Entry. A battery-powered scoop (S&S, Model 488) was parked at the charging station near the No. 4 Belt Drive at the time of the explosion. All of these potential ignitions sources were also ruled out based on the distance from the origin of the explosion. The No. 4 Belt Drive, located approximately 750 feet from the mouth of the A Left Section, was the unit of outby electrical equipment nearest to the point of origin of the explosion. Battery-Powered Personnel Carriers There were four battery-powered personnel carriers underground at the time of the explosion, none of which were approved as permissible. Two of the personnel carriers, designated as “No. 1” and “No. 2”, were located just outby the B Left Section power center. A three-wheeled personnel carrier, referred to as the “maintenance buggy”, was parked three crosscuts from the face in the B Left working section. The other personnel carrier, designated as “No. 3”, was located at or near the No. 3 Seal and was heavily damaged in the explosion. The electrical components from the No. 3 personnel carrier, with the exception of the batteries (which were completely destroyed in the explosion), were recovered from the mine and taken to MSHA Approval and Certification Center for analysis. The vehicle was manufactured by Johnson Industries of Pikeville, Kentucky, and the model was specified only as “super car”. There was no visible serial number printed or stamped on the frame of the vehicle. The unit was equipped with a 5 horsepower, totally enclosed, direct current motor, which received power from a set of six, 6-volt, deep cycle, 260 ampere-hour batteries connected in series (36 volts). The motor was controlled by a solid state controller in conjunction with forward and reverse contactors. A potentiometer operated by the foot pedal provided speed control for the vehicle. A single light, operated by a toggle switch, was mounted on the front of the vehicle. The force of the explosion caused the No. 3 personnel carrier to tumble approximately 260 feet, eventually coming to rest against the rib in the No. 4 Entry. The motor and one of the contactors separated from the vehicle and were found lying approximately 30 feet from the personnel carrier (see Appendix F). 49 The motor was disassembled at MSHA Approval and Certification Center and examined for indications that an ignition occurred inside of the enclosure. No evidence of flame or burning of any kind was found inside of the motor enclosure. The enclosed solenoid was also disassembled and examined for signs of ignition. None were found. The remaining components were thoroughly examined and no evidence was found to indicate that the No. 3 personnel carrier caused an ignition of methane. Furthermore, it is unlikely that an explosive mixture of methane and air would have been present at the probable location of the vehicle at the time of the explosion, due to the ventilating current in the main return and the fact that the water trap valve in the seal was closed. The three personnel carriers located on or near the B Left Section were ruled out as possible ignition sources due to their distance from the point of origin of the blast. Battery-Powered Cap Lamps At the time of the explosion, there were two Koehler battery-powered cap lamps in use at or near the No. 3 Seal at the mouth of the A Left Section. The components of these cap lamps were found deposited at various locations along the debris path created by the force of the explosion, indicating that the lamps were being worn by Amon Brock and Jimmy Lee at the time of the accident. The cap lamp components recovered from the mine included portions of two headpieces, two cap lamp cables, two plastic battery covers with electrical accessory receptacles, and one intact battery. The battery for the other cap lamp was not recovered from the mine because only a portion of the external shell was located by the investigation team. The cap lamp components taken into custody by MSHA were analyzed at MSHA Approval and Certification Center in an effort to determine if they contributed to the ignition. The examination of the cap lamp cables revealed no short circuits or other conditions indicating the cables were the source of a spark or thermal ignition. The electrical accessory receptacle (PTO) on one of the battery covers had been altered in such as way as to permit external access to both the positive and negative contacts. Battery-powered cap lamps are required by 30 CFR Part 19 to be constructed such that both polarities of the battery are not accessible externally. While this alteration was a violation of 30 CFR 75.507-1(a), it could not be determined whether or not the PTO was used in a manner that contributed to the explosion, though the low voltage of the lamp made it an unlikely ignition source. One of the headpieces, designated as Exhibit P-18, contained a short circuit within it, but it was not possible to determine if the condition was caused by the explosion or if it was pre-existing. This type of headpiece, when maintained in 50 permissible condition, was previously found to be capable of containing an ignition when filled with an explosive mixture and ignited with an external source. The bulb ejection mechanism on the other headpiece, designated as Exhibit P-39, did not initially function due to dust on the interior of the socket. However, after the mechanism was operated several times, the bulb would eject properly from the socket. The dust was most likely deposited in the socket as a result of the explosion. Due to the condition of the headpieces recovered from the accident site, it was not possible to conclusively rule them out as possible ignition sources. Bulb filaments are capable of causing a thermal ignition of an explosive methane-air mixture under certain conditions. However, in order for a bulb filament to present an ignition source in an assembled cap lamp, the following sequence of events must occur: (1) the bulb filament must be energized; (2) the lens must be broken; (3) the bulb envelope must be broken; and (4) the ejection mechanism must fail or the lens must be broken in a manner that retains the bulb in the socket. The cap lamp battery recovered from the mine was subjected to spark ignition testing in an 8.3 percent methane-air mixture, with a cadmium disc, and two #24 AWG wire electrodes. The battery underwent 800 cycles of spark testing using the ISIB spark test apparatus. The battery was fully charged at the beginning of the test and was charged for one hour every 200 cycles during the testing to restore it to a fully charged condition. There were no ignitions of the methaneair test gas within the spark test apparatus throughout the testing process. Hand-held Methane Detector Following the accident, an Industrial Scientific, Model MX250 (MSHA Approval # 8C-59), was found in the right front pocket of the pants worn by Amon Brock. The unit was taken into custody by MSHA at the Harlan Funeral Home and transferred to MSHA Approval and Certification Center for examination and testing. The detector was checked for calibration and functionality, which is discussed elsewhere in this report, and as a possible ignition source. The worst-case short circuit current was calculated based on open-circuit battery voltage and internal resistance. The results clearly indicated that the 4.8-volt, nickel-cadmium battery pack could not produce a spark with sufficient energy to ignite an explosive mixture of methane and air. The two internal backlight bulbs, with glass envelopes intact, were temperature tested after being energized continuously for two hours. The temperature of both bulbs was found to be less than 30 degrees Celsius at the end of the two- 51 hour period. The minimum ignition temperature of methane is approximately 537 degrees Celsius. A visual examination of the unit revealed no evidence of faults or overheated components within the detector that would be the source of a spark or thermal ignition. Finally, the unit was energized and placed in a 7.7 percent methane-in-air mixture for 2.5 hours to see if the catalytic sensor would become hot enough to cause an ignition. The detector did not cause an ignition in the test mixture. Training Training records were reviewed for all underground and surface miners who were employed at the mine at the time of the accident. Approved Part 48 training plans with lesson plans and training material used to conduct training were also reviewed. Darby employees received their annual refresher training at the Sigmon Training Center. The annual refresher training classes were conducted by George Carr. Experienced miner training was conducted at the mine by Ralph Napier, a certified MSHA Instructor. Brock also conducted experienced miner training. The mine map was reportedly reviewed with participants regarding the colors on the map used to indicate the escapeways. Napier stated that when he went over the color code with the employees, they often forgot by the next day what the colors indicated. The mine map did not clearly distinguish which of the entries were designated as escapeways. Company health and safety rules were discussed with a tour of the mine at completion of the class. Management and non-management personnel conducted task training at the mine. Task and hazard training were both recorded on the same MSHA form 5000-23. An explanation of the types of training required and the proper method of recording that training was given to the operator, who did not differentiate the types of training required for persons specified by Part 48.2 (a)(1) and 48.2 (a)(2). Part 48 training was recorded on MSHA form 5000-23 for the annual refresher training. A CSE SR-100 SCSR specially designed by the manufacturer to be a training model was not provided at the mine. The operator used a SCSR that had been taken out of service to train miners. The unit could not be donned using the 3+3 method because the end caps and goggles were missing. The unit was normally stored in the changing room, hanging on the wall in an open position. Because of this, miners received inadequate SCSR training during hazard, new miner, and experienced miner training sessions. However, this unit was not used to 52 train the miners who died as a result of the accident as those miners received their training at another facility. The annual refresher training the miners received on December 10, 2005, was significantly deficient. Training in the Mine Emergency Evacuation and Firefighting Plan did not include the use of non-verbal communication techniques when using a SCSR device. In addition, the SCSR 3+3 donning procedures training did not include complete donning procedures where the miners assumed a donning position and opened the device. 53 ROOT CAUSE ANALYSIS 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. The following root causes were identified as a result of the investigation. In each case, an effective management system, procedure or policy was not in place to assure compliance with the regulation or safe mining procedure. 1. Root Cause: Mine management failed to ensure that prudent seal construction procedures were utilized in the building of the seals at the mouth of A Left Section. The top of the No. 3 Seal at A Left was intersected in several locations by metal roof straps. The metal straps interfered with the installation of wood planking on the top of the seal. The wood planking could not be positioned flush with the mine roof. The metal roof straps each contained longitudinal channels which, under certain conditions, could create a conduit for gases to flow from the sealed area into the active workings. It is most likely that such a conduit was created on May 20, 2006, when one of the metal straps was cut with an oxygen/acetylene torch, allowing an explosive mixture of methane and air to come into contact with either the torch flame or materials heated by the torch flame. One metal roof strap extended through the No. 1 Seal and four metal roof straps extended through the No. 3 Seal. The use of Omega 384 block for seal construction was tested and approved by MSHA without any metal straps passing through the seal. Corrective Action: Mine management should assure either the straps are removed prior to seal construction, or seals are located to avoid contact with straps. 2. Root Cause: Mine management failed to ensure that safe work procedures were used while employees attempted to make corrections to an improperly constructed seal. On May 20, 2006, an oxygen/acetylene torch was used to cut through a metal roof strap installed at the No. 3 Seal at the mouth of A Left Section. Mine management allowed the use of the torch in an area where there was an obvious ignition hazard. In addition to this, proper tests for methane were not continuously made while the torch was being used. A proper test for methane would have included testing on both sides of the seal. A gas detecting instrument was available at the time the cutting was performed, but evidence indicates that it remained in the pants pocket of the afternoon shift foreman. 54 Corrective Action: Mine management should consider hazards and select safe work practices, such as the use of non-sparking cutting tools where methane hazards may exist. Management should assure that welding, burning or cutting operations are not performed where proper tests for methane cannot be conducted. Because of the inability to conduct adequate tests for methane inby the No. 3 Seal, there would have been no safe mechanism for cutting the metal strap intersecting the No. 3 Seal. 3. Root Cause: Proper SCSR usage procedures were not followed while four miners attempted to escape from the mine following the explosion that occurred on May 20, 2006. After the devices were donned, at least two of the miners removed their mouthpieces for some period of time in order to communicate verbally. Evidence indicates that the miners did not immediately don the SCSR units after the explosion, but waited until smoke was encountered several minutes later. Three of the four miners eventually succumbed to carbon monoxide poisoning with smoke and soot inhalation. The fourth miner survived the incident, but required medical treatment for carbon monoxide poisoning. Tests conducted on the SCSR units used by the victims indicated that the units were capable of providing sufficient oxygen to allow unimpaired miners to escape from the mine. Corrective Action: Management should train and retrain miners, in realistic conditions, to increase the likelihood that they will react and perform properly should an actual emergency occur underground. 4. Root Cause: Management failed to provide adequate training regarding escape procedures. Escapeway drills were not properly conducted, in that, alternate escapeways were never traveled. Maps serving as escapeway maps, required to be used for training miners, did not identify the escapeways or show the current working section. This lack of training and familiarity with the alternate escapeway most likely delayed the escape of the miners following the explosion. Corrective Action: Management should train and retrain miners to assure that they are familiar with all emergency escape procedures, and requirements. The mine did not resume production following the accident. On November 14, 2006, MSHA personnel confirmed that the mine was sealed. The mine was placed in abandoned status on November 15, 2006. 55 CONCLUSION An explosion occurred at approximately 1:00 a.m. on May 20, 2006, inby the A Left No. 3 Seal. The explosion resulted in the immediate deaths of two miners who were located at the seal. Three of four miners evacuating from the B Left Section succumbed to carbon monoxide poisoning with smoke and soot inhalation. The accident occurred because the operator did not observe basic mine safety practices and because critical safety standards were violated. Mine management failed to ensure that proper seal construction procedures were utilized in the building of the seals at the A Left Section. Mine management also failed to ensure that safe work procedures were used while employees attempted to make corrections to an improperly constructed seal. Furthermore, mine management failed to adequately train miners in escapeway routes and proper SCSR usage. 56 ENFORCEMENT ACTIONS In addition to a 103(k) Order, the company was cited for six conditions and/or practices which contributed in some way to the accident. Thirty-seven other citations and orders were issued during the investigation, but were not considered to have contributed to the accident. 1. 104(d)(1) Citation No. 7061230, 30 CFR 75.333(h), S&S, Reckless Disregard Condition or Practice: “On May 20, 2006 the integrity of the No. 3 Seal in A Left was compromised when a metal roof strap intersecting the seal was cut with a torch. As a result of the cutting of the metal strap, this seal was not being maintained for its intended purpose of separating the sealed area in A Left from the active portion of the mine. This resulted in methane from behind the seal coming into contact with the ignition sources that resulted from the cutting of the metal strap. The resulting methane explosion contributed to the deaths of five miners.” 2. 104(d)(1) Order No. 7061231, 30 CFR 75.1106, S&S, Reckless Disregard Condition or Practice: “Evidence indicates that adequate tests for methane were not continuously performed during the cutting operation of a metal roof strap at the No. 3 Seal of the A Left section. A methane explosion occurred resulting in five fatalities. Four metal roof straps extended through the No. 3 Seal. On May 20, 2006 cutting of a metal roof strap located at the No. 3 Seal in A Left was performed with an acetylene/oxygen torch adjacent to an atmosphere containing an explosive mixture of methane and oxygen.” 3. 104(d)(1) Order No. 7061232, 30 CFR 75.370 (a)(1), S&S, Reckless Disregard Condition or Practice: “Results of a fatal accident investigation revealed that the three Omega block seals installed to seal the A Left Section from the active workings were not constructed to comply with page 14 “Omega Block Seals” of the Ventilation Plan approved September 1, 2005. This portion of the approved plan specifies specific construction procedures to meet the requirements of 30 CFR 75.335 “Construction of Seals”. Omega blocks were used to construct the seals, but the construction did not follow the plan as follows: a. The Omega blocks were dry stacked with no mortar between the joints. b. The seals were not hitched 6 inches into the solid rib and floor for the entire perimeter. c. The seals had been spray coated with a bonding and sealing agent not approved for this purpose. 57 d. The pilaster was not properly constructed as it did not extend inby the seal as depicted in the plan and was only one 16 inch block wide. e. A single layer of 1 inch wood planking was not provided between the Omega block and the mine roof. f. The No. 3 Seal was located 6 to 7 feet from the outby rib corner whereas the plan requires a minimum distance of 10 feet. g. The Omega 384 lightweight block were approved to be used for underground mine ventilation seals without any metal roof straps or other extraneous metal passing through the seal. The metal straps interfered with the installation of wood planking on the top of the seal. The wood planking could not be positioned flush with the mine roof.” 4. 104(d)(1) Order No. 7488601, 30 CFR 75.383(a), S&S, High Negligence. Condition or Practice: “On May 20, 2006, an explosion occurred at the No. 3 Seal for the A Left worked out area which resulted in the deaths of five miners. Two of the miners died immediately from the force of the explosion and three miners died while attempting to escape from the mine. The accident investigation revealed that escapeway maps showing the designated escapeways were not provided on the surface and for miners who worked on the B Left working section (MMU 001). Two maps were posted in the mine office on the surface and a map was located on the working section. Neither the maps on the surface nor the map on the section clearly identified the escapeways or distinguished the escapeways from other available entries. The map on the working section did not show the active workings of the B Left Section.” 5. 104(d)(1) Order No. 7488603, 30 CFR 75.383(b)(1) S&S, High Negligence Condition or Practice: “On May 20, 2006, an explosion occurred at the No. 3 Seal for the A Left worked out area which resulted in the deaths of five miners. Two of the miners died immediately from the force of the explosion and three miners died while attempting to escape from the mine. The accident investigation revealed that during the emergency evacuation drills, escapeways were not alternated so that the alternate escapeway was traveled by miners. The records indicated and testimony revealed that miners only traveled out the intake escapeway during drills.” 6. 104(d)(1) Order No. 7168187, 30 CFR 48.8(b)(8); S&S, High Negligence Condition or Practice: “On May 20, 2006, an explosion occurred at the No. 3 Seal for the A Left worked out area which resulted in the deaths of five miners. Two of the miners died immediately from the force of the explosion and three miners 58 died while attempting to escape from the mine. Based on information gathered during the course of a fatal accident investigation, it was determined that the annual refresher training the miners received on December 10, 2005, was significantly deficient. Training in the Mine Emergency Evacuation and Firefighting Plan did not include the use of non-verbal communication techniques when using a SCSR device. During evacuation following the explosion, at least two miners removed the mouthpieces of their SCSRs to verbally communicate. In addition, the SCSR 3+3 donning procedures training did not include complete donning procedures where the miners assumed a donning position and opened the device.” 59 Appendix A List of Injured Miners Amon “Cotton” Brock Multiple Blunt Force and Thermal Injuries (Deceased) Jimmy Lee Multiple Blunt Force and Thermal Injuries (Deceased) Roy Middleton Carbon Monoxide Poisoning w/ Smoke and Soot Inhalation (Deceased) George William Petra Carbon Monoxide Poisoning w/ Smoke and Soot Inhalation (Deceased) Paris Thomas, Jr. Carbon Monoxide Poisoning w/ Smoke and Soot Inhalation (Deceased) Paul Ledford Burn to Chest; Carbon Monoxide Poisoning and Smoke Inhalation (Survivor) E3 E4 E6 E2 0929 9 1/7 0928 0920 22 0916LJ 915 0838 842 0 0 0 0850 0 0856 0 68 0874 0879 l690 - 0889 0836 0 0841 0 0849 0855 01 67 0 173 0878 0883 89900 g/g 229020: yto 0137 0843 9180 0846 0848 999 0854 9990 866 L8 882 0 a CD 0339 0844 0851 0857 0870 76 0881 0885 0894 0906(0140 0847 0852 08 0869/ 0875 0880 0886 0895 0809 0808 0791 0 790 0788 0789 0787 8 0783 798 0797 0796 0807 76799LO 0 LLO 7766a. 0780V8L0 5 786 ZSLO 07951010 06029090 0104919 0799 0800 0 i? ?8 a> 0782 0 81 0 77 Old North Mains .9 n2 0770 0754 0742 QVLO 0749 0'50 9L0 07586510 0 0747 0751 Old East Mains 0692 069 0669 0683 0691 0 I 0 12 0670 0682 0 88 069?1? /l ?1 7 - 7?31." . 0713 0724 0 0939 0658 1 l?d?x 1/ 11 1 1 L. 109 91 0 lb II Regulator 0,00 00? OVO ??66 Belt line 0 0 Seal 2? 0% 0% 96? 0510 Survey Station Number 2? a <9l>gl? E8 Entry Number 0 7% 090? C80 Crosscut Number 2? 0 ?1970- Contour Lines With Elevation 0 6&0 Intake Air 6% ea Belt Air 0 V0 1 Return Air 1 (9 0 o? 200? 400? 96 SCALE ,9 APPENDIX MINE MAP 20? 1211131119815 04, 0t 09 KENTUCKY DARBY LLC Exhaust fan 06 6 Active Underground Areas Box Check Equipment Door Appendix C – Timeline of Rescue/Recovery Events May 20, 2006 01:05 a.m.---MSHA and the Kentucky Office of Mine Safety and Licensing (OMSL) were notified by Ralph Napier, superintendent, about an accident at the mine. 01:54 a.m.---MSHA personnel arrived at the mine site and a 103(k) order was issued. 02:00 a.m.---The Lone Mountain Mine Rescue team was notified about the explosion and was dispatched to the mine site. 02:01 a.m.---MSHA personnel using a MSA Solaris (Solaris) multiple gas detector took quality readings at the mine fan and had 20.8 percent oxygen, 2.6 percent methane, and over 500 ppm CO. 02:05 a.m.---MSHA was informed by the company that the underground power had been disconnected. Readings at the fan were 20.8 percent oxygen, 2.2 percent methane, and over 500ppm CO. 02:15 a.m.---OMSL personnel arrived at the mine. MSHA, OMSL, and company personnel established a command center in the mine office. 02:30 a.m.---Quality air readings were taken. At the fan the readings indicated 20.8 percent oxygen, 0.2 percent methane, and over 500 ppm CO. At the portals the readings indicated 20.8 percent oxygen, 0 percent methane, and from 13-24 ppm CO. 02:32 a.m.---The first response personnel traveled the main intake airway toward the active section. Communications were maintained by using hand held radios. 02:50 a.m.--- The James River Coal mine rescue team was notified about the explosion and was dispatched to the mine site. 03:00 a.m.--- The Lone Mountain mine rescue team arrived at the mine site and was briefed at the command center. 03:10 a.m.---Paul Ledford was found at crosscut No. 13 in the main intake entry. Ledford could not walk. A call was made to the outside to bring a personnel carrier (buggy) to this location in order to transport Ledford to the surface. 03:30 a.m.---Ledford arrived on the surface. 03:31 a.m.---Examinations were made in the area of the No. 3 Belt Drive and three breaks inby in the belt and neutral entries. 03:40 a.m.---The phone line inby the No.3 Belt Drive was disconnected. The mine phone was utilized for communications outby the No. 3 Belt Drive. A fresh air base (FAB) was established at crosscut No. 17 in the No. 6 Entry at survey station No. 507. 04:00 a.m.---The Harlan OMSL mine rescue team started underground and traveled to the FAB. They donned their apparatuses and traveled to the return entries. 04:15 a.m.---When the team arrived in the return a light was observed and they advanced toward the light. Paris Thomas, Jr. was found in the crosscut between the No. 3 and No. 2 Entries at crosscut No. 20. 04:32 a.m.---Part of the Lone Mountain mine rescue team (designated as first) accompanied by a MSHA Mine Emergency Unit (MEU) team member traveled to the FAB. 04:40 a.m.---The second team from Lone Mountain accompanied by a MEU team member traveled to the FAB. 04:46 a.m.---The FAB was advanced to crosscut No. 22 in the No. 7 Entry. 04:50 a.m.---The first Lone Mountain team donned apparatuses and advanced toward the active section. They communicated using 1,000 feet of hard line (communication cable with headsets). 05:05 a.m.---The first Lone Mountain team observed a light outby in the No. 5 Entry and another one inby toward the section. The team advanced toward the inby light. A buggy with its lights on was found on the debris from the blown out intake overcast. The top and bottom lids for two SCSRs were found on the buggy. 05:10 a.m.---The team retreated and then traveled to the light located outby in the No. 5 Entry. 05:16 a.m.---Bill Petra was found between crosscuts No. 23 and 24 in the No. 5 entry. Approximately 20 feet outby this location another victim was found (later identified as Jimmy Lee). 05:25 a.m.---Lone Mountain team members accompanied by a MEU member advanced toward the B Left Section. The team observed a light in the direction of the section. A second buggy was found at the second crosscut on the section with the lights on. One crosscut inby the buggy, the top and bottom lids for two SCSRs were found. 05:43 a.m.---The Lone Mountain team traveled in four entries and advanced to the faces. 05:45 a.m.---The Barbourville OMSL mine rescue team traveled to the FAB. 06:19 a.m.---The Barbourville team advanced to the location of the A Left Seals. 07:05 a.m.---Hazard OMSL mine rescue team traveled to the FAB. 07:08 a.m.---All seals were blown out. Quality readings at the No. 1 seal location were 19.1 percent oxygen, 1.5 percent methane, and CO was off scale. 07:30 a.m.---The FAB was advanced to the No. 31 crosscut in the No. 7 Entry. 07:35 a.m.---The Barbourville team advanced in the return entries from the A Left Seals to the B Left section. 07:50 a.m.---Seven members of the Lone Mountain team advanced inby toward the main headings and three members of the team advanced outby in the belt entry to locate the remaining missing miners. 08:00 a.m.---The James River Coal mine rescue team arrived at the mine site and was briefed by the command center. 08:25 a.m.---The Hazard OMSL team advanced from the return seals location outby in the return airways. The Martin OMSL team advanced in the return airways from the outside. These two teams traveled the entire return searching for the remaining miners. 08:45 a.m.---The three members from the Lone Mountain team found Roy Middleton in the crosscut between the No. 5 and No. 4 Entries at crosscut No. 21. 08:50 a.m.---In the crosscut between the No. 5 and No. 4 entries at crosscut No. 23 a body was found (later identified as Amon Brock). 10:55 a.m.---The victims were transported to the surface. Note: Times are estimates based on interviews and notes. Appendix D – List of Persons Participating in Mine Rescue and Recovery Initial Rescue Effort Robert Rhea, MSHA Kevin Doan, MSHA Dale Jackson, MSHA Brad Sears, MSHA Todd Middleton, OMSL Ralph Napier, Kentucky Darby Mark Sizemore, Kentucky Darby Mitchell Lunsford, Kentucky Darby Subsequent Recovery Efforts Kentucky Office of Mine Safety and Licensing Mine Rescue Ronnie Hampton Sherril Fouts Charles Kirk Todd Middleton Jim Owens Ronald Patrick Turner Ricky Johnson George Hollis Michael Partin Ralph Crawford Randy Partin Kenneth Morgan David Mullins Bob Banks Randy Campbell Daniel Bentley Mike Eldridge Martin Holbrook Randall Smith Ricky Blackburn Jerome Howard Freddie Moore Earl Martin David Slone John Ferrari Mike Elswick Tony Casebolt Chester Flint Freddie Lewis Randy Bentley Glenn Mace E.B. Sanders James Tackett Keith Conley Lone Mountain Processing, Inc. Mine Rescue Ronnie Smith Greg Brashears John Rutherford Freeman Crosby Jim Vicini Jude Johnson Tim Gooden B.J. Foster David Shackleford Ronnie Biggerstaff James River Coal Mine Rescue Lou Mills Pat Schoolcraft Jeff Roberts Mike Sharp Rick Wallen Steve Shell Pearl Farler Johnny Riley Buddy Howard Clifton Priest Scott Daniels Craig Lewis MSHA Mine Emergency Unit Virgil Brown Tony Sturgill Otis Matthews Chuck Barton Robert Clay Greg Ison Gerald Cook Jim Langley Kentucky Darby LLC James Philpot Jamie Johnson Jeff Coker Appendix E - Persons Participating in the Investigation Kentucky Darby LLC Elmer D. Burgan Jamie H. Johnson Mitchell T. Lunsford Gabriel S. Middleton Ralph Napier James C. Roark Mark Sizemore General Laborer Section Foreman Mine Examiner Continuous Mining Machine Operator Superintendent General Laborer Outby Foreman United Mine Workers of America Max W. Kennedy Edgar Oldham UMWA International Representative UMWA International Representative Designated Miners’ Representatives Kenney Johnson Tony Oppegard Representative Attorney Kentucky Office of Mine Safety and Licensing Timothy Fugate Ronnie Hampton Earnest Hawkins Ronald Hughes George Johnson Todd Middleton Tracy Stumbo Ronald Patrick Turner Mine Inspector Supervisor Underground Mine Safety Analyst Director, Division of Investigation Inspector Principal Mine Inspector Chief Accident Investigator Roof Control Specialist MSHA Accident Investigation Team Robert M. Bates, Jr. Mary Beth Zamer Bernui Charles D. Campbell Gerald L. Cook, Sr. Anthony R. Guley, Jr. Richard C. Herndon Thomas E. Light Mark Malecki Supervisory Electrical Engineer Attorney Mining Engineer CMS&H Specialist Supervisory CMS&H Specialist Special Investigator Assistant District Manager, District 2 Attorney Mark A. Odum Michael E. Pruitt Mark E. Schroeder Supervisory Mining Engineer Training Specialist Mining Engineer National Mine Health Safety Academy Lynn Carr Photographer Pittsburgh Safety and Health Technology Center Scott K. Johnson Thomas A. Morley Gary J. Shemon Clete R. Stephan Richard T. Stoltz John E. Urosek Mining Engineer Mining Engineer Mining Engineer Principal Mining Engineer Supervisory Mining Engineer Chief, Ventilation Division MSHA District 5 Robert D. Clay Fred R. Martin Supervisory CMS&H Inspector CMS&H Inspector MSHA District 6 Greg Ison Tony Sturgill Supervisory CMS&H Inspector CMS&H Inspector MSHA District 7 Roy T. Cornelius Kenny Dixon Kevin L. Doan Shelby Fields Anthony Lucas Clayton E. Sparks Engineering Technician CMS&H Inspector CMS&H Specialists CMS&H Inspector CMS&H Inspector CMS&H Inspector Approval and Certification Center Jim Angel Kevin Dolinar Michael A. Hockenberry Chad D. Huntley Stephen M. Murtaugh Mechanical Engineer Electrical Engineer Fire Protection Engineer Electrical Engineer Electrical Engineering Technician Donald P. Pieffer Frank J. Prebeg Physical Scientist Electrical Engineer NIOSH William D. Monagham Donald Sellers Electrical Engineer Physical Science Technician Appendix F - Map of Evidence Collected During Investigation Note - The location of specific items shown on the map are approximate. This map shows evidence collected in this immediate area only. 092 0925 9 0 1 :1 71 0929 0919 0923 0920 0925 0915 0914 0917 0922 0918 0892 0896 00 0899 0898 0901 a- HWWFI aim A 08 0838 00842 0810 0 9 0 0836 01135 0841 0 0849 0855 67 0873 0883 I H3?x2' Hole .- u? d) (0 (D - 0\0 98908 1:90 0137 0843 9180 0846 0848 1:990 0854 9990 0866 3290 0171 89800882 Fly Hole 0 8 0139 0844 0651 0857 0870 0876 0881 0885 0894 090661; 0 07 0? I0 0 0140 0847 0852 085 0569 0875 0880 0886 0895 IllConcrete block stopping, . 3 damaged With 5' 9' hole \Concrete block stopping, damaged with 3.2' 5' hole ?5 '8 Concrete block stopping, Crushed stopping with damaged with 4.9' 10.6' hole ?3 ui ment door EaSt Mams Concrete block stopping, [damaged with 4.5' 9' hol 0676 0684 0692 0698 0703 710 0719 '5 0 094 0 0669 0P1 0675 0683 0691 0697 0702 709 0718 0726 0733 0S38 0941 /l I '3 0670 0674 0682 0 186 0696 0701 708 0717 0725 0732 0136 0940 ., WM, .8.-. H. v. .., - 0731 0935 0939 .., hole 6 g?g . 3 0666 0672 80 0687 0694 0704 0711 0720 0727 0735 0913 0943 9 6 - 9 8 0665 0 71 0678 01188 0695 0705 07 2 0721 0726 0736 OS 31 0 44 1. 0668 0677 0946 0179 \0948 0690 0699 0706 0713\ 0722 0729 0737 0932 0945 8 Concrete block stopping, .. I Equipment DoorS. destroyed damaged with 11' 99' hole lnby 81' 4. 8! edge offall 8 Concrete block stoppng, destroyed 10:11: L. 3% L. 510616 0617 0614 0613 Mains 0615 Parallel Mains 0660 CAM 8860 9960 9960 L960 14" 3660 ?660 ?660 1660 11 1 ?Ir 1! 9660 9660 9660 0 010003X8 31010 hole 01010 006 60010 90010 Du 1 91010 0 11010 0 9. (II II 3' 5' hole 0595 0594 0593 1 C40 5 91010 12010 :1 if /r 61010 Concrete block 9 stopping. ?6 damaged with Concrete block stopping, damaged 058 1A 1 0584 0179\1 0580: i 0586 r?Inl?u?1 Ir 1 I BLeft E1 E2 E8 0; 0571 GPO 70 0569 0567 0 (JD 01 85010 0 69010 0 0562 560 0561 2 2 3 ?3.g 01235 61232 61231 01230 01220 ?1205 ?1197 01234 01226 61219 91204 1?1?199 5 .a 9 2 C30 0 1:1 61233 01229 @1228 01227 01218 01206 ?1207 ?1205 51202 3? ?5 ,2 . a, 0 Eggig [Concrete block stoppingdamaged, with 11' 8.4' hole APPENDIXJ 0 83 APPENDIXK 1:1 1:1 1:1 1:1 :1 I: FOR DETAIL 0 3 a Concrete block stopping, FOR a Belt 8% Kl l??I a; 3 tailpiece n In In DDEI II '9 oc25 a a 1 SEALED 61195 01195 61194 ?119301190 01177 01171 ?1199 ?1179 ?1170 ?1157 I 3% ?11 ?1 I r1 FITDUC 1 Mb 71?1198 ?1179 ?1172 ?1156 ?1147 ?1139 ?1135 ?1136 ?02 ?103 ?17 "1121 I IV ii I DI [Cf/70 a 11??1 DU c1187 ?1193 ?1173 at 2 '?11 ?1143 ?1131 5 "1106 "?1125 01186 61180 61174 61 145 61154 61141 61132 01133 9601? C1. 91? E2 Equipment 2 0 'doors I: AD 11 CI 17601? 16011: Z6010 8601? ?mm? DEED SEE APPENDIX FOR DETAIL I: E1 ?r I 0516 LEGEND Stopping :1 C1 (go Roof fall occurred prior to explosion Damaged equipment doors Overcast removed for 9E APPENDIX i 0 FOR DETAIL A C) ?06 Stopping with door Check Curtoin Milmelbll I Overco st (6 05. new roadway during 20 mine recovery Belt line 6? 0 Seal 0510 Survey Station Number E8 Entry Number CEO Crosscut Number Check curtain partially down Overcasts and stopping blown towards the outside Check curtain down 0? 200? 400? SCALE APPENDIX MINE MAP DARBY MINE No. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Information gathered by the investigation team 00 Exhaust fan . . . . Note: Location of speCIfIc Items shown a on the map are approximate. Roof fall occurred after explosion Ventilation controls damaged by the explosion are orange in color. CD LLI In LIJ Roof strap on ?oor Header board Header board Roof straps on ?oor A ?1196 01195 ?1194 01193 ?1190 Several roof straps hanging from roof in this area. Roof straps on the ?oor Piece of 2 inch plastic pipe -J Cu rtain on heat damage Plastic bucket covers M189 Oil cans, smashed Roof straps on ?oor Roof straps on floor Crib block Cardboard box, no heat damage 1-gallon waterjug, heat damage Curtain on ?oor, heat damage Rock dust bag, heat damage Cardboard box, heat damage 2-inch plastic pipe Oil cans, smashed Pile of scooped-up concrete blocks Belt roller tops Roof strap on ?oor Header board Oil can, smashed Crib Miner drive shaft Roof straps on ?oor If block 2 inch plastic pipe Plastic ?d cover 00 strap on par Curtain on floor, heat damage ?l Crib block Oil cans, smashed Header boards I I I Oil can, smashed Piece of W??d \1 Roof straps on ?oor I Pieces of concrete blocks Roct dust bags scattered in this crosscut of strap on ?oor Metal bucket Plastic ket Concrete block Left Roof strap on ?oor Partial pallets Roof strap on ?oor Piece of concrete block Piece of concrete block Concrete block Roof strap on ?oor Concrete block 3 ?lters Roof straps on ?oor 7 Pieces of 2 inch plastic pipe Roof straps on ?oor Roof straps on ?oor Roof straps on ?oor Roof straps on ?oor Roof straps on ?oor Roof strap on ?oor Grease buckets, smashed Piece of cable splice jacket, possible heat damage Roof strap on ?oor Header board Roof straps on ?oor Header board Roof straps on ?oor Oil can, smashed Oil cans, smashed Header board \76\ Oil cans, smashed Roof straps on ?oor Oil can?I Roof straps on ?oor Oil can, smashed Pile of lumber 2-inch mastic pipe Crib blocks Crib blocks R0 Roof strap on ?oor 4/ Plastic bucket can Plastic buckets Crib block Header board Crib blocks Header board Plastic water bottle, heat damage Cardboard tube from roll of curtain 2 concrete blocks Roof strap on ?oor Pieces of concrete blocks Oil can 011865 Roof straps on ?oor 2 roof straps on ?oor Roof straps on ?oor Roof plate, bent double Roof straps on ?oor Roof straps on ?oor 5-gallon bucket/ Wood plank Crib block Roof straps on ?oor Es :4 Roof straps on ?oor Roof straps on ?oor Roof straps on ?oor Header board Oil can, crushed \LRoof straps on ?oor Concrete blocks Roof straps on ?oor \ch PVC pipe coupler Roof strap on ?oor Naps on ?oor bottle, heat damage Conveyor belt splice Spray paint can 1/79 12-ounce water Roof strap on ?oor Buckets Piece of conveyor belt Plastic bucket lid 1- l?Pl gallon plasticjug Belt structure astic lid Oil can, smashed Roof straps on ?oor Header board LEGEND 01150 Survey Stot'on Number E2 Entry Number Gob rnoter'ol Approx'rnote debr'e t'eld for concrete block vent ot'on controls Approx rnote debr's t'eld tor ornego 384 block vent ot'on controls 0 Roof strap on ?oor Sump 6 roof straps on ?oor We, ?oor Roof straps on ?oor Roof straps 8 header boards Bucket lid 5-gallon buckets on ?oor Roof straps on ?oor Roof straps on ?oor Post, broken Roof strap on ?oor 2 concrete blocks Roof straps on ?oor d185 $184 Roof straps on ?oor Roof Roof straps on floor Roof straps on ?oor Face area not bolted Roof straps on ?oor Roof straps on ?oor straps on ?oor Roof straps on ?oor Roof strap Plastic buckets Roof straps on ?oor 2 pieces of concrete blocks Roof strap on ?oor/ BUCket, smashed 2 pieces of concrete blocks Concrete block Plastic buckets i. Roo DJ Shut Pieces of concrete block on ?oor 7 Roof straps on ?oor 2 roof straps on ?oor Roof straps on ?oor Roof straps on ?oor Header board Mortar bucket Woof straps on ?oor Piece of 4' 8' metal fstrap on ?oor Edge of bottom mining Pieces of oil can A Piece of metal tle car drive shaft Piece of conduit Roof straps on ?oor Oll can, damaged Roof straps on ?oor ?7 Roof straps on ?oor Roof straps on ?oor 176 <91 Piece of concrete block Piece of oil can Crib block Pieces of roof strap on floor Piece of curtain on floor, heat damage Water bottle Roof straps on ?oor Crib block 3 pieces of concrete blocks]\ Roof straps on ?oor 1 Piece of curtain on_ Piece of Drive shaft Full plastic floor, heat damage conveyor belt bucket of sealant Piece of metal Piece of metal Belt stand Pieces of concrete blocks Piece of concrete block t' ucket Crib block Roof straps on ?oor I Piece of metal can Plastic bucket Roof straps on ?oor Header board Metal can Roof straps on ?oor 6-inch water coupler Belt splice Metal can A Piece of conveyor belt?l Pallet Roof straps on ?oor Roof straps on ?oor Plastic bucket Roof strap on ?oor 1 Pieces of roof straps on ?oor 175\ Piece of rock dust bag, no heat damage *i Piece of oil can Piece of curtain on ?oor, no heat damage Piece of rock dust bag, no heat damage?. Piece of rock dust bag, no heat damage Oil can, smashed Damaged oil can Roof strap on ?oor Roof strap on ?oor Roof straps on ?oor Header boards Piece of roof straps on ?oor CO mt?i Olli- Plastic bucket 6" water coupler Pieces of omega blocks Piece of conveyor belt Roof straps on ?oor Omega blocks Belt stand Pile of roof bolts /m14 Bucket Piece of co or belt Omega block Piece of omega block Omega blocks 46 /1 Roof strap on ?oor Piece of concrete blocks Piece of conveyor belt, 2 foot 2 foot I) an Piece of roof strap on ?oor Oil ?lter 2 roof straps on ?oor Pieces of concrete blocks Oil can, crushed Roof straps on ?oor Pieces of concrete blocks Concrete blocks 4151 Belt roller Roof straps on ?oor 3 pieces of omega blocks Pieces of concrete block Oil can PVC pipe Pieces of concrete block 4" PVC pipe Belt stand VPieces of concrete blocks ?1169 01 64' ?1163 Roof straps on ?oor Roof strap on ?oor 1C Roof strap on ?oor Oil can, smashed 4159 d160W Miner shear shaft, 35' long Roof strap on ?oor Note: Location of specific items shown on the map are approximate. Roof strap on ?oor Pieces of omega blocks Piece of conveyor belt, 24' 28.5' Crib blocks Belt roller Pieces of concrete blocks Header board Pallet Bucket Roof strap on ?oor $155 $16 Roof strap on ?oor Roof bolt on ?oor Pile of concrete blocks 2 pieces of omega blocks Pallets Pieces of omega blocks Torn pallet Header board Piece of concrete block 4-inch PVC pipe,? broke on inby side Pallet Concrete blocks Pieces of concrete blocks Rib roll OI APPENDIX MINE MAP DARBY MINE N0. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Detailed information gathered by the investigation team for the A Left area 25 SCALE 50' Piece of concrete block Debris, pallet and dirt 14 50 SEE APPENDIX FOR DETAIL Debris on top of gob pile included about 40 crushed oil cans, a piece of curtain, 5 wood pallets, and pieces of cardboard and paper @139 Roof strap on ?oor Pieces of pallet Piece of omega block Pieces of omega blocks Piece of omega block Oil can and hydraulic hose Debris, including welding rods Pallets Welding rods Seat Roll of belting 2 Oil cans Gob pile with concrete blocks Roof bolts on floor 3 belt rollers Roof bolt on ?oor $131 JaCk Stand Roof bolt on floor Pieces of concrete blocks Concrete Concrete block Cribs 1m Pieces of concrete blocks Pieces of concrete blocks Piece of concrete block 32 Roof strap on floor LEGEND Stopping I I ID Stopping w'tn door Belt structure 61120 510 C20 Survey Stot on Number Crosscut Number Cob rnoter'ol 9 Approx mote debr's f'eld for concrete block ventilot'on controls Approx mote debr?s f'eld for ornego 384 block vent? ot'on controls rnote locot ners OB Approx of rn? 0' 25' 55555:: SCALE 50' APPENDIX I MINE MAP DARBY MINE N0. 1 MSHA ID NO. 15-18185 KENTUCKY DARBY LLC Detailed information collected by the investigation team for portions of A Left and Mains Note: Location of specific items shown on the map are approximate. Pallet Oxygen and Acetylene hose No. 3 Seal Location No. 2 Seal Location $133 No. 1 SealJ Location 4" Yellowmine pipe Old twisted pipe Flagging on spad, heat damage 14/3 Cable 4-inch Yellowmine pipe Fire extinguisher bracket Old ?re extingusher\ Old sump, pump removed 4" Yellowmine pipe 529 QBOBZB (3524 SEE APPENDIX FOR DETAIL Piece of concrete block Open thermos with SCSR pouch Distribution box Top of distribution box Concrete blocks Piece of concrete block Belt tailpiece Pallet Belt rollers Concrete blocks <3526 C25 Escapeway signs elt raI Header board Mandoor 3 belt rollers 3 belt stands Pallets 4' 8' steel plate Concrete block 544 _Belt structure, stands, rails, and rollers Piece of wood Metal sheet master bucket Piece of belt 5 header boards Supply car of 4-inch yellowmine pipe Mandoor Concrete block stopping, destroyed bottom row of blocks in place Concrete block closely laying on top of each other Concrete block stopping, destroyed with only bottom row of blocks in place Concrete block stopping, damaged, V5 out Concrete blocks Door Door frame High voltage cable hung Scoop Debris ?eld from stopping laying on top of supplies Power center Amon Brock's tool box Plastic piece of @559 ml co to (3557 Belt tailpiece personnel carrier High voltage cable on ground Top belt back on rollers Piece of metal from buggy, 1' 1' against belt structure Metal box ?1 It A A Top belt rolled Bottom belt on rollers, top belt rolled on the right side of structure Top belt on ?oor Top belt laying on ?oor, touching structure High voltage cable hung Roof straps on ?oor Bucket Diamond plate (3545 Tool box turned over 9 M53, standing Mandoor _l Concrete bloc heavily dama stoppingJ ged, 2/3 out Thermos cap - Piece of roof strap, 2 Equipment lid Oil cans, crushed Cap lamp re?ector Oil can, crushed Equipment door Concrete block stopping heavily damaged, out Pallet with pump cable .05' long Bucket Cover for cap lamp battery Concrete block Piece of metal Bottom belt stand Roof strap on ?oor rstopping, damaged @557 550 (3558 (D548 Concrete blocks Metal box Header board Small opening above gob pile Concrete blocks Header board @558 (D559 (D549 (D540 Concrete blocks LEGEND Stopp Stopp'ng vv'tb door Belt Survey Stot'on ne Survey Stot?on Entry Number Crosscut Number Gob moter'ol Approxmote debr's t'eld for concrete block vent'ot'on controls 25' mg: SCALE 50' APPENDIX MINE MAP DARBY MINE No. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Detailed information collected by the investigation team for portions of Left and Mains Note: Location of specific items shown on the map are approximate. Number Number Face area not bolted Curtain Curtain Curtain Curtain Curtain Curtain rolled up to roof Face area _not bolted Continuous mining machine Remote control unit _Curtain on ?oor against rib 8 Scoop, 601-1059 Joy shuttle car, ET-14758, loaded with coal Curtain rolled up on floor Left Curtain T-008 Fletcher twin Empty oil can 8 crib blocks boom roof bolter, less than half supplied 2 Empty resin boxes and 2 Bit boxes 2 curtains on floor Ladder Power center with the following items on it: Jacket, no name on it 0 Pair of gloves a First aid kit 0 Grease gun Hydraulic hoses 0 Microwave oven 0 Zipper bag with ?rst aid materal 0 Coffee can with food 0 4 jugs of water 0 Tool box with various tools and cutting torch Locked tool box a Bucket of spads Empty oil can 3 wheeled battery powered supply and parts car for maintenance Joy Shuttle Car, ET-4759 Empty oil can Bit bucket 3 oil cans Curtain on floor 4 empty oil cans 2 Rib roll Rib roll Rib roll Curtain hanging on 1 bolt Rib roll Oil can, smashed Rib roll Rib roll Curtain on ?oor Resin boxes Crib block Oil can, crushed Piece of curtain Rib roll 3-way belt feeder Curtain on ?oor Located between the entry and the stopping 2 shuttle car ?ights Pile of cables 32 masonry blocks 1 pallet 1 bucket of sealant 1 empty oil bucket 4 boxes of resin 1 crib block 10 empty oil cans Ladder Roll of curtain block out near bottom of stopping Concrete block Concrete blocks 4-inch water line ends Connection for miner water line, coil 2?3 loops I 9 empty resin boxes and 2 oil cans Rib roll Can of liquid wrench Rib r0" Rib roll Rib roll Resin box Rolls of brattice cloth Header boards Pallet Concrete blocks Belt roller I Bucket (b Crib block Rib roll I_Bit bucket Roll of brattice - hanging 0? rib Rib rolls Crib blocks Concrete block 8? bUCket Arc We'de? Crib block Box of resin Pa et Box of full Header Ward water jugs Power center (see detail above) Full can gear grease Garbage - Belt Splice Oil can, crushed Box of full I 2 waterjugs I 5 Rib r0? Chain drive guard i i i i al own Header board for belt head Garbage bag Pallet of roof 2 belt 8 em ty Bucket bolt plates High voltage Bag of o" capns Gear case Metal piece cable hung Rock Dusts Pallets deile Empty Crib block Ladder 4 car ?a ?Xes 4 drill rods Crib 14 coils of high voltage .b bl Bucket of sealant cable on ground 00 Flight bar 8 concrete blocks on pallet and another 8 concrete blocks around the pallet 1 block missing from stopping LEGEND Stopong w'th door Check Curtoh Belt Stoop ne Roll of brattice cloth 4 oil cans Shovel Joy shuttle car, parts missing Bucket Roll of curtain Pile of 16 blocks 2 pallets of rock dust Rib roll Rolled-up curtain Curtain half rolled to roof Oil can? Canvas Concrete block Header board 4 4 empty sealant buckets [?Belt roller Rib Roll belt rollers Survey Stot'on Number Gob moter'ol 0' 25' 50' 55555:: SCALE APPENDIX MINE MAP DARBY MINE N0. 1 MSHA ID NO. 15-18185 KENTUCKY DARBY LLC Detailed Information collected by the information team for Left Section Note: Location of specific items shown on the map are approximate. Oxygen cylinder cap . Oil cans, crushed Top rollers back on structure, bottom belt rolled up in structure, top belt rolled up on ?oor, next to the rib Small omega fragments throughout entry Pallet Concrete block 0" can, crushed Bulb socket from #3 buggy headlight Concrete blocks LEGEND Stopp?og vv'th door Concrete blocks Stoop Piece of concrete block Belt structure Gob moter'ol Piece of belt conveyor Belt Drive and Head Roller Chain cover Pieces of concrete blocks Metal box Bottom belt rolled up in structure, top Roof strap on ?oor . belt rolled up on ?oor next to rib High voltage cable A Cl Jl: t'eld tor block vent?ot'on Location of George Petra, with SCSR Pieceofconcreteblock . SCSR breathing tube l?S SCSR hose, mouthpiece, and noseclip t: Small fragments of omega bIOCks throughom this area Section of torch hoses under rock Oxygen cylinder Oil can, crushed Power plug receptical Oil can, crushed Header board RUbber glove Pieces of concrete block Location of Jimmy Lee . . Piece of waterline 0mg? Bottom belt roller Roof strap on ?oor Belt no longer against rib, top belt rolled up on ?oor Concrete block stopping, destroyed Piece of steel Oxygen valve from torch Large amount of debris at corner, 3:16:33]:th including acetylene regulator, headlight for #3 buggy, equipment door, 4 SCSR google crushed oil cans and roof straps. Regulator for oxygen tank Pieces of regulator gage Belt rail Piece of concrete block Top belt roller Roof strap on ?oor Stand Piece of pant Acetylene valve Personnel carrier from torch Buggy) on side Roof bolt on ?oor Piece of Plug connector housing conveyor belt Coat with labels of "Jimmy Lee" and "Kentucky Darby water trap 0f Piece of belt and - Belt rail steel pipe 2 top belt rollers Section of torch hoses Pile of belt Pants hanging from roof strap #3 buggy motor and contactor Brass hose end connector Strap to MX250 Piece of cable Piece of watch band Concrete block stopping, intact 52 Location of Amon Brock, Piece of water trap handle W'th MX250 pocket Bucket R00f Straps 0? ?oor Large stand Roof straps Acetylene on ?oor geelltteroller Debrispile from_exp 0_sion, Cy'mer value SCSR "d 2 0":335' Acetylene tank and tire tra handle Header boards 0? 5 raps - plug, and 1 inch socket on ?oor Str'ker and a SCSR Roof strap on ?oor Section of cap lamp cord Torch handle and - 0 cutting attachment Piece of water trap handle xygen regulator Oil can, crushed 28 inch long twisted Cap lamp battery cover Belt structure pushed against rib r??f Strap 0? ?oor Cresent wrench Wrench #3 buggy contactor 2 roof straps on ?oor High voltage cable Belt Stand Piece of concrete block Bucket Belt rolled up against rib A Belt Stand Pallet 0' 10' 20' Belt structure in center of entry Pieces of concrete blocks TOP belt r0?e ' Header board Crib block Hand prints on loop Concrete block Pieces of omega blocks sweatsmn hanging 0f h'gh Vonage cable Pieces of concrete blocks Crib b ock from roof strap Belt rail Pail, crushed Belt and structure P'l ff'ne and turned over ?Laid Ired Cid Roof strap on ?oor 4" Plastic pipe doors Roof strap on ?oor bet panels Opene I DARBY MINE N0. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Detail information collected by the investigation team for portion of Mains near A Left seals Note: Location of specific items shown on the map are approximate. Hand prints on high voltage cable High voltage cable looped to crosscut Debris and dust piled against rib High voltage cable hung Belt structure rolled over and pushed against the rib Hand prints on high voltage cable\ Front of Seal 6.2 feet from corner Roof bolts in rib/ No. 3 Seal, Destroyed Cable roof bolts _Roof strap ripped and bent out l: Roof strap removed Front of Seal 7.3 feet from corner No. 3 Seal Location El?? Not hitched 0.2' to 0.3' hitched 0.5' to 0.3' hitched 7.8 feet 7.9 feet 8.0 feet 0.0' to 0.5' hitched Not hitched 18.9 feet Not hitched Wide Not hitched Bottom not hitched Front of Seal Roof bolt in rib 8'6 feet from Visegripes comer Strap broke in half Strap broke and bent out Roof bolt in rib Front of Seal 10.0 feet from corner Left Right rib No.2 Seal Location nb 0.0' to 0.0' hitched 0.0' to 0.8' hitched 425 0.0' to 0.7' hitched NO 324' 0.0' to 1.4' hitched 7_7feet 821.th 82 feet Hitcmn 223' 0.0' to 1.6' hitched 0.0' to 1.0' hitched . 17.6f 0.0' to 1.0' hitched widget Bottom not hitched LEGEND Roof Bolt Seal Roof Strap Left rib hitched only on inby (back) side of the seal. This spot is where it appears the continuous mining machine out further into the rib line. Front of Seal 8.8 feet from corner Roof strap over kettle bottom into seal location 0' 10' 20' SCALE Front of Seal 9.8 feet from corner APPENDIX MINE MAP DARBY MINE N0. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Pet No. 1 Seal Location rib 0.6' to 1.0' hitched 0.3' to 0.5' hitched 0.3' to 0.4' hitched N0 0.6' to 0.8' hitched 8.3 feet 8.5 feet 8.5 feet Hitching 0.1' to 0.4' hitched 0.0' to 0.4' hitched 16.8 feet No hitching WIde Detailed information collected by the investigation team for the A Left Seals Bottom hitched 0.2 feet deep, 5.3 feet from left rib toward center Note - The location of specific items shown on the map are This map shows evidence collected in this Investigation Appendixapproximate. F - Map of Evidence Collected During immediate area only. erOX NM: r?z: Appendix 0 - Typical Roof Strap (not to scale) Channels Appendix - Map of Evidence Collected During Inves United States Decal-unont of Labor Mine Safety and Health Administration National Air and Dust Laboratory 100 Bluestone Road Momt Hope. West Virginia 25330 Phone: 304-577-3900 Fax: 304-31'7-3927 MOUNT HOPE NATIONAL AIR AND DUST LABORATORY REPORT OF ANALYSIS COLLECTED BY: Jerry Cook MINE ID: 1518185 FIELD OFFICE CODE: 20702 MINE: Darby Mine #1 FIELD OFFICE NAME: Harlan, KY COMPANY: Kentucky Darby Coal DATE OF SAMPIINO: August 22, 2006 SAMPLING AREA: dust used at mine. LAB NUMBER: 506001 (REF: 699797) RECEIVED: August 22, 2006 SIZE DISTRIBUTION Through 20 Mesh Through 200 Mesh ANALYSIS: 99.7 lncombustible FREE AND COMBINED ILICA: 0.77 I Torry G. Montgomery, Chemist MSHA National Air and Dust Laboratory Stun Input-In of tour MSHA ?Mimi? wm mm in mama DUMB Hi T: Em\m MD m?W?m?mfmmImalmq 1 ?ol ?fi?oam DD M0 O?Tmo um mm?u mm . ED 4 0+ HEITSO Jm cacao?? 859% HMDW DE MD H7 Hf 2 CCDEDDG 1 LUBE Um 1 >_u_umZ_u_X U>mw< Zo. 20. 3-34%? U>mw< 323 m3 mo?omm :03 :5 56.8.0: I 55 Ll V7 I JULLHJ 50 IWWTP IDTP IHI I HIHI WU . 0 .8050.2 WET 49.90499 56 :jr a l? 7 HHIH 53.2 0 51.9 Old North Mains 070.3 057.5 53.0 62.0 54.5 051.7 Old East Mains 4y '3m?1 WET 49-5 45-10 423,5 1 V. 50.0 58.1 ?g O. H0000f: 4.6 47.9 I 68.4 89f A 39.3 4.5 5.1 057.8 061.5 ?ll 2E NVAV TWWPUHIE 601 3 88 92.70649 57.50 54.1 . 50. 03 . I 049.9 066.7 0 (D on 01 WM 040.0 047.3 Ir C50 096.7 067.7 55.1 55.7 61.9 64.9 0 . 70.1 I I C45 Ir mg??g?i aim Irma Ir IL gal? @Wk 47.0 45.5 WET I 45.0 68.8 0.2 t? C40 35% 09.8 55.1 1.2 HI IN 73BET UMJDEL .000 IE Hi II 78.6 Left E1 E2 Ell5.8 55. 54.8 '10 A . 9e . 38.3 m?wm 40.3 058.00 57.20 0. . IU UEUDUU ~39 .63. 7.5 9.2 58.5 67.9 47.1052.10@069.0 63.2 56.9 '15 44,9 4347.8 El - ?9 40.2 38.8 37.5 C25 a EU . @002 Dam .. lear rig. Ev. LC- 4.45 @454 I. II DD 4040049460609? 3 EDGE .. JDEID AL 5- LJLIIJDDCID EDD . - a. . 57. 2.78. 073.2 a I 7494415ED?jt @079 70. . DDUDI QUEST LEDD do 5% WP ?3 33?- 2 '11 OLD #4 SEAL BREACHED LEGEND E2 Entry Number C20 Crosscut Number INTAKE NEW IEI Seal 0 No coking 9 Trace quantity of coking 0 Small quantity of coking Large quantity of coking 0 Extra large quantity of coking 80.0 Percent incombustible 0' 200' 400' 55555:: 0 SCALE APPENDIX MINE MAP DARBY MINE No. 1 MSHA ID No. 15-18185 KENTUCKY DARBY LLC Results of Testing on Mine Dust Samples Appendix S – Torch Components Recovered from the Accident Scene Cutting Attachment (Victor Model CA35) Oxygen Valve Torch Handle (Victor Model WH36FC) Oxygen Valve Acetylene Valve (MFR Unknown) (MFR Unknown) Oxygen Regulator Acetylene Regulator (Metalcraft Model 350-125-540-06) (Metalcraft Model 350-15-510-06) Oxygen Cylinder Valve Acetylene Cylinder (Sherwood TV Series) Valve (MFR Unknown) 4.63" 0.5" P43 P13 Bent portion of roof strap 1.5" 1.5" 54" P43 P13 4" Inby edge of No.3 Seal Outby edge of No.3 Seal * The bottom side of the strap is depicted. Segments are positioned as they would appear to a person looking up at the mine roof. 24" Appendix T - Roof Strap Segments P13 and P43 Recovered from Darby Mine No.1 17.75" 24.75" Appendix - Photograph of Amon Brock?s Notepad 715?- Appendix F - Map of Evidence Collected During Investigation Roof Strap Flame Cutting Experiments at the National Institute for Occupational Safety and Health Lake Lynn Experimental Mine William D. Monaghan Pittsburgh Research Laboratory National Institute for Occupational Safety and Health 626 Cochrans Mill Road Pittsburgh, PA 15236 Introduction Flame cutting experiments were conducted on a metal roof strap (figure 1) on August 22, 2006 at the National Institute for Occupational Safety and Health (NIOSH), Lake Lynn Experimental Mine (LLEM) by NIOSH researchers. These experiments were requested by the Mine Safety and Health Administration (MSHA). The objectives of these experiments were to determine the temperatures histories of hot particles and hot metal strips during and after flame cutting. The instrumentation used in these experiments was an AGEMA Thermovison 550 infrared camera (IR) system and a laptop computer running the software ThermaCamTM Researcher 2001. FIGURE 1. MSHA EMPLOYEE HOLDING METAL ROOF STRAP 1 Emissivity Experiments at PRL In order to get accurate temperature measurements from the metal roof strap flame cutting experiments, emissivity experiments were conducted on samples of each metal roof strap that was flame cut at LLEM at NIOSH Pittsburgh Research Laboratory (PRL). The samples were painted (approximately 50 % of the area) with high temperature black paint. These strips were placed on a hot plate and heated until thermal equilibrium was reached. The IR camera emissivity was set to 1.0 and the black painted area temperature was measured and recorded. The temperature of the unpainted area was then measured and recorded. The emissivity was then readjusted so that the unpainted area temperature was equal to the initial temperature of the black painted area. Figure 2 show the experimental setup and Table 1 shows the results of these experiments. The average emissivity of the unpainted metal strips was 0.87. This value was used for analysis of the thermal data from the LLEM flame cutting experiments. FIGURE 2. EXPERIMENTAL SETUP TO OBTAIN EMISSIVITY VALUE OF A METAL ROOF STRAP 2 Cut Metal Roof Strip ID 4 6 7 9 10 11 Average Emissivity 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Painted Temperature ° F 717 700 694 722 670 753 709 Adjusted Emissivity 0.85 0.85 0.8 0.9 0.88 0.95 0.87 Unpainted Temperature °F 715 700 690 720 670 750 708 Table1. Emissivity Experimental Results Omega Block/Steel Strap Experiments at LLEM In these series of experiments, an Omega block was placed on top of the metal roof strap and an infrared camera was positioned on the opposite side of the Omega block where the flame cutting was performed (figure 3). The metal strap was cut from underneath. A NIOSH employee performed the flame cutting. Some of the hot particles traveled thru the two troughs located on the metal roof strap (figure 4), underneath the Omega block to the other end metal roof strap, and fell to the mine floor. The thermal histories of several hot particles, shown in figure 5, were recorded with the thermal imaging camera. In figure 5, the hot particles are identified as AR01-ARO6. The maximum temperatures are shown in table 2 and ranged from 931 °F – 1403 °F. The maximum temperature observed was 1403 °F for the particle identified as AR05. FIGURE 3. EXPERIMENTAL SETUP OF OMEGA BLOCK AND METAL ROOF STRAP 3 FIGURE 4. TROUGHS LOCATED IN THE METAL ROOF STRAP FIGURE 5. HOT PARTICLES TEMPERATURE THAT WERE RECOREDED 4 Particle ID AR01 AR02 AR03 AR04 AR05 AR06 Maximum Temperature °F 1378 1369 1400 931 1403 1088 Table 2. Maximum Temperatures of the Hot Particles Areas 1 - 6 Hot Metal Strip Experiments In these experiments, metal strips ranging from ½ -in to 1.5-in were flame cut from a metal roof strap (figure 6). The infrared camera was positioned to view the hot metal strips being cut (figure 7). The time-temperature was recorded every 200 milliseconds during these experiments. The temperature history of a 1.5-in hot metal strip that was cut at a normal cutting speed is shown in figure 8. The temperature of the strip remained above 1000 °F for 19 seconds. Figure 9 shows the time-temperature history of a ½” hot metal strip cut at a slower cutting speed. In this experiment, the temperature remained above 1100 °F for 10.5 seconds. Figure 10 shows all strips cut from a metal roof strap. FIGURE 6. METAL STRIPS BEING MARKED 5 FIGURE 7. INFRARED CAMERA POSITIONED TO VIEW METAL ROOF STRIPS TO BE CUT 2000 Series1 Temperature (deg F) 1800 1600 1400 1200 1000 0 2 4 6 8 10 12 14 16 18 20 Time (seconds) FIGURE 8. TEMPERATURE VERSUS TIME FOR A 1.5-in METAL ROOF STRIP 6 2200 Series1 Temperature (deg F) 2000 1800 1600 1400 1200 1000 0 2 4 6 8 10 12 Time (seconds) . FIGURE 9. TEMPERATURE VERSUS TIME FOR A ½-in METAL ROOF STRIP FIGURE 10. STRIPS CUT FROM THE METAL ROOF STRAP Summary Flame cutting experiments were performed on a metal roof strap to determine the timetemperature histories and maximum temperatures of hot particles and hot metal strips during the flame cutting operations. In the hot particle experiments, maximum hot particle temperatures ranging from 931 °F to 1403 °F were observed. In the hot metal strip experiments, temperatures of the hot metal strips remained above 1100 °F for 10.5 to 19 seconds depending on the size of the metal strip and the rate at which it was cut. 7 Appendix F - Map of Evidence Collected During Investigation Jun 22 2006 7:27:57 PM Robert Bates Thank you for using Vaisala's STRIKEnet® to validate the referenced claim. Your report was generated using data from Vaisala's National Lightning Detection Network®, the most comprehensive archive database in North America. STRIKEnet Report 162412 Claim Number: Insured/Claimant Name: Approx. Claim/Loss Value: Items Damaged/Loss Type: Claim Address: N/A N/A Search Period: May 19 2006 6:00:00 PM US/Eastern May 20 2006 5:59:00 PM US/Eastern 36.878600° N (Latitude), 82.952500° W (Longitude) 5 mi/8 km around the given location. Search Center Point: Search Radius: Comments: 4 strikes were detected by the National Lightning Detection Network for the given time period and location. Thank you again for selecting STRIKEnet. If you have any questions please contact us at 1 800 283 4557 or thunderstorm.support@vaisala.com. Best Regards, The Vaisala STRIKEnet Team Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 1 of 6 STRIKEnet Report 162412 Report Title: Holmes Mill, KY Total Lightning Strokes Detected: 4 Lightning Strokes Detected within 5 mi/8 km radius: 2 Lightning Strokes Detected beyond 5 mi/8 km whose confidence ellipse overlaps the radius: 2 Search Radius: 5 mi/8 km Time Span: May 19 2006 6:00:00 PM US/Eastern to May 20 2006 5:59:00 PM US/Eastern Location Points For Lightning Strokes Lightning data provided by Vaisala's NLDN® and/or Environment Canada's CLDN. Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 2 of 6 STRIKEnet Report 162412 Report Title: Holmes Mill, KY Total Lightning Strokes Detected: 4 Lightning Strokes Detected within 5 mi/8 km radius: 2 Lightning Strokes Detected beyond 5 mi/8 km whose confidence ellipse overlaps the radius: 2 Search Radius: 5 mi/8 km Time Span: May 19 2006 6:00:00 PM US/Eastern to May 20 2006 5:59:00 PM US/Eastern Confidence Ellipses For Lightning Strokes Lightning data provided by Vaisala's NLDN® and/or Environment Canada's CLDN. Note: These ellipses indicate a 99% certainty that the recorded lightning event contacted the ground within the bounds of the ellipse. Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 3 of 6 STRIKEnet Report 162412 Area Of Study With Center Point Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 4 of 6 STRIKEnet Report 162412 Report Title: Holmes Mill, KY Total Lightning Strokes Detected: 4 Lightning Strokes Detected within 5 mi/8 km radius: 2 Lightning Strokes Detected beyond 5 mi/8 km whose confidence ellipse overlaps the radius: 2 Search Radius: 5 mi/8 km Time Span: May 19 2006 6:00:00 PM US/Eastern to May 20 2006 5:59:00 PM US/Eastern Lightning Stroke Table (Note: All events shown. Events ordered by time.) Peak Distance From Date Time Current (kA) Center (mi/km) Latitude Longitude May 19, 2006 May 20, 2006 May 20, 2006 May 20, 2006 11:33:55 PM 3:02:25 AM 3:31:17 AM 3:38:28 AM -5.1 -4.7 -6.0 -7.9 12.5/20.2 12.0/19.3 2.0/3.2 1.4/2.2 37.0102 36.7621 36.8856 36.8777 -82.7961 -83.1136 -82.9877 -82.9279 Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 5 of 6 STRIKEnet Report 162412 Report Title: Holmes Mill, KY Total Lightning Strokes Detected: 4 Lightning Strokes Detected within 5 mi/8 km radius: 2 Lightning Strokes Detected beyond 5 mi/8 km whose confidence ellipse overlaps the radius: 2 Search Radius: 5 mi/8 km Time Span: May 19 2006 6:00:00 PM US/Eastern to May 20 2006 5:59:00 PM US/Eastern Lightning Stroke Table (Note: All events shown. Events ordered by distance.) Peak Distance From Date Time Current (kA) Center (mi/km) Latitude Longitude May 20, 2006 May 20, 2006 May 20, 2006 May 19, 2006 3:38:28 AM 3:31:17 AM 3:02:25 AM 11:33:55 PM -7.9 -6.0 -4.7 -5.1 1.4/2.2 2.0/3.2 12.0/19.3 12.5/20.2 36.8777 36.8856 36.7621 37.0102 -82.9279 -82.9877 -83.1136 -82.7961 Vaisala Inc. Tucson Operations 2705 E. Medina Road Tucson, AZ 85706, USA thunderstorm.vaisala.com Tel. +1 520 806 7300 Fax +1 520 741 2848 thunderstorm.sales@vaisala.com Jun 22 2006 7:27:57 PM GMT Page 6 of 6 Continuous Miner Shuttle Car AK um Scale: 1" 500' i i A i?mjmma?iaa Qm?jm?m 4/2 VS iNi iVT?Persoh? Gamma" Shuttlg Data of 77? mm jc 1 Jimnf ;WDUHWBaum: BL Diggiziwn No.3 Head Drive 300 KVA Power Center 0 0 No.2 Head 300 KVA Power Center\ High-Voltage Cable Conveyor Belt Appendix - Map of Evidence Collected During Investigation Appendix Y – Selected Photographs Photograph 1 – No.1 personnel carrier on damaged overcast Photograph 2 – No.1 personnel carrier on damaged overcast Photograph 3 – No. 3 personnel carrier in the No. 4 Entry Photograph 4 – No. 3 personnel carrier in the No. 4 Entry Photograph 5 – Inby segment of roof strap at A Left No. 3 Seal Photograph 6 – Inby segment of roof strap at A Left No. 3 Seal Photograph 7 – Outby segment of roof strap at A Left No. 3 Seal Photograph 8 – Middle segment of roof strap found in No. 5 Entry Photograph 9 – Oxygen cylinder found in the No. 5 Entry Photograph 10 – Acetylene cylinder found in the No. 5 Entry Photograph 11 – Debris from stopping near B Left Section Photograph 12 – Damaged roof straps near A Left No. 3 Seal Appendix F - Map of Evidence Collected During Investigation U.S. Department of Labor Accident Investigation Data - Victim Information Event Number: 4 2 4 0 1 0 5 Victim Information: 1 1. Name of Injured/III Employee: 2. Sex 3. Victim's Age a. Date: 5/20/2006 5. Degree of Injury: 6174 01 7. Date and Time Started: b.Time: 1:00 Fatal a. Date: 5/19/2006 b.Time: 15:45 10. Was this work activity part of regular job? 9. Work Activity when Injured: 8. Regular Job Title: 087 Afternoon Shift Foreman 11. Experience Years Weeks Days a. This Work 29 0 0 Activity: 12. What Directly Inflicted Injury or Illness? 045 4. Last Four Digits of SSN 51 Amon Brock M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 049 Mine Safety and Health Administration b. Regular Job Title: Supervising Years Weeks 29 0 Yes Days c. This Mine: 0 Years Weeks Days 4 44 5 d. Total Mining: X No Years 37 Weeks 0 Days 0 13. Nature of Injury or Illness: 370 Explosion Forces and Heat Multiple Injuries 14. Training Deficiencies: Annual: New/Newly-Employed Experienced Miner: Hazard: Task: 15. Company of Employment:(If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: Not Applicable: First-Aid: CPR: EMT: 17. Part 50 Document Control Number: (form 7000-1) Victim Information: 2. Sex 3. Victim's Age a. Date: 5/20/2006 9999 None (No Union Affiliation) 5. Degree of Injury: 01 Fatal 5022 7. Date and Time Started a. Date: 5/19/2006 b.Time: 1:00 b.Time: 15:45 9. Work Activity when Injured: 8. Regular Job Title: 093 Shuttle Car Operator a. This Work Activity: 4. Last Four Digits of SSN: 33 Jimmy D. Lee M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 11. Experience X None: 2 1. Name of Injured/III Employee: 150 Medical Professional: 18. Union Affiliation of Victim: Years 15 Weeks 0 Days 0 10. Was this work activity part of regular job Cutting with Acetylene Torch b. Regular Years Weeks Days Job Title: 15 0 0 Yes Years c. This Mine: Weeks 3 6 Days 0 X No d. Total Years Mining: 15 Weeks 0 Days 0 13.Nature of Injury or Illness: 12. What Directly Inflicted Injury or Illness? 045 Explosion Forces and Heat 370 Multiple Injuries 14. Training Deficiencies: New/Newly-Employed Experienced Miner: Hazard: Task: Annual: 15. Company of Employment: (If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: CPR: First-Aid: Not Applicable: EMT: 17.Part 50 Document Control Number: (form 7000-1) Victim Information: 2. Sex 3. Victim's Age a. Date: 5/20/2006 None (No Union Affiliation) 9999 5. Degree of Injury: 6664 01 7. Date and Time Started a. Date: 5/19/2006 b.Time: 1:00 8. Regular Job Title: Fatal b.Time: 23:00 9. Work Activity when Injured: 022 Foreman Years Weeks 0 0 0 Activity: 12. What Directly Inflicted Injury or Illness? 045 4. Last Four Digits of SSN 49 George W. Petra M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 049 X None: 3 1. Name of Injured/III Employee: 11. Experience: a. This Work Medical Professional: 18. Union Affiliation of Victim: Days b. Regular Job Title: 10. Was this work activity part of regular job? Attempting to escape from the mine Years Weeks 4 0 Days 0 c. This Mine: Yes Years 4 Weeks 5 Days 3 d. Total Mining: No X Years Weeks 26 0 13. Nature of Injury or Illness: 280 Smoke, Carbon Monoxide Carbon Monoxide Poisoning 14. Training Deficiencies: Hazard: New/Newly-Employed Experienced Miner: Task: Annual: 15.Company of Employment:(If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: Not Applicable: First-Aid: 17. Part 50 Document Control Number: (form 7000-1) MSHA Form 7000-50b, Dec 94 CPR: EMT: Medical Professional: 18. Union Affiliation of Victim: 9999 Printed None: X None (No Union Affiliation) 1/28/2007 2:03:58 PM Days 0 U.S. Department of Labor Accident Investigation Data - Victim Information Event Number: 4 2 4 0 1 0 5 Victim Information: 4 1. Name of Injured/III Employee: 2. Sex 3. Victim's Age a. Date: 5/20/2006 b.Time: 1:00 Fatal a. Date: 5/19/2006 b.Time: 23:00 10. Was this work activity part of regular job? 9. Work Activity when Injured: 022 Electrician Years Weeks Days a. This Work 0 0 0 Activity: 12. What Directly Inflicted Injury or Illness? 045 5. Degree of Injury: 6466 01 7. Date and Time Started: 8. Regular Job Title: 11. Experience 4. Last Four Digits of SSN 35 Roy Middleton M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 020 Mine Safety and Health Administration b. Regular Job Title: Attempting to escape from the mine Years Weeks 2 46 Days c. This Mine: 2 Yes Years Weeks Days 2 31 1 d. Total Mining: No X Years Weeks 12 0 Days 0 13. Nature of Injury or Illness: 280 Smoke, Carbon Monoxide Carbon Monoxide Poisoning 14. Training Deficiencies: Annual: New/Newly-Employed Experienced Miner: Hazard: Task: 15. Company of Employment:(If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: Not Applicable: First-Aid: CPR: EMT: 17. Part 50 Document Control Number: (form 7000-1) Victim Information: 2. Sex 3. Victim's Age a. Date: 5/20/2006 9999 None (No Union Affiliation) 5. Degree of Injury: 01 Fatal 8431 7. Date and Time Started a. Date: 5/19/2006 b.Time: 1:00 b.Time: 23:00 9. Work Activity when Injured: 8. Regular Job Title: 022 Mechanic a. This Work Activity: 4. Last Four Digits of SSN: 53 Paris Thomas M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 11. Experience X None: 5 1. Name of Injured/III Employee: 004 Medical Professional: 18. Union Affiliation of Victim: Years 0 Weeks 0 Days 0 10. Was this work activity part of regular job Attempting to escape from the mine b. Regular Years Weeks Days Job Title: 23 0 0 Years c. This Mine: No X Yes Weeks 3 33 Days 0 d. Total Years Mining: 23 Weeks 0 Days 0 13.Nature of Injury or Illness: 12. What Directly Inflicted Injury or Illness? 045 Smoke, Carbon Monoxide 280 Carbon Monoxide Poisoning 14. Training Deficiencies: New/Newly-Employed Experienced Miner: Hazard: Task: Annual: 15. Company of Employment: (If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: CPR: First-Aid: Not Applicable: EMT: 17.Part 50 Document Control Number: (form 7000-1) Victim Information: Medical Professional: 18. Union Affiliation of Victim: 2. Sex 3. Victim's Age 4. Last Four Digits of SSN 35 Paul E. Ledford M 6. Date(MM/DD/YY) and Time(24 Hr.) Of Death: 5. Degree of Injury: Days away from work only b.Time: 23:00 9. Work Activity when Injured: 022 Roof Bolter Operator Years Weeks 0 0 0 Activity: 12. What Directly Inflicted Injury or Illness? 045 9999 4645 03 7. Date and Time Started a. Date: 5/19/2006 8. Regular Job Title: 047 None (No Union Affiliation) 6 1. Name of Injured/III Employee: 11. Experience: a. This Work X None: Days b. Regular Job Title: 10. Was this work activity part of regular job? Escaping from the mine Years 14 Weeks 3 Days Yes c. This Mine: 0 Years 2 Weeks 39 Days 0 d. Total Mining: No X Years Weeks 16 3 13. Nature of Injury or Illness: 280 Smoke, Carbon Monoxide Carbon Monoxide Poisoning 14. Training Deficiencies: Hazard: New/Newly-Employed Experienced Miner: Annual: X Task: 15.Company of Employment:(If different from production operator) Independent Contractor ID: (if applicable) Operator 16. On-site Emergency Medical Treatment: Not Applicable: First-Aid: 17. Part 50 Document Control Number: (form 7000-1) MSHA Form 7000-50b, Dec 94 CPR: EMT: X Medical Professional: 18. Union Affiliation of Victim: 9999 Printed None: None (No Union Affiliation) 1/28/2007 2:04:20 PM Days 0