Examiner

Injured employee sustained fatal injuries resulting from head trauma after jumping or being thrown from the lead locomotive of a supply trip at crosscut 16 on east mains track.

Texto original en inglés de la MSHA

On Monday, June 19, 2017, at approximately 6:27 p.m. CDT, Marius Shepherd, a 32-year-old mine examiner with 8 years and 9 months of experience, received fatal injuries when he was thrown or jumped from the passenger seat of a runaway supply train. The supply train, consisting of a lead locomotive, three supply cars, a ballast car and a trailing locomotive, was traveling on a descending grade when the operators lost control. Neither of the locomotive operators saw the victim’s exit from the locomotive, and investigators were unable to determine whether he was thrown or jumped. After the victim exited, the train continued moving for 175 feet and derailed. The fatal accident occurred, in part, because the mine operator did not comply with previously issued safeguards. These safeguards prohibited unauthorized personnel from riding in locomotives, water over track rails, and required sanding devices to be properly maintained. Water had accumulated over the track rails, and the track sanding devices for the locomotives were not maintained and functional. The locomotive operators were not able to control the speed of the supply train due to the combination of the track grade, the non-functioning locomotive track sanders, and the slick, wet rails.

1. The mine operator’s policies and procedures did not ensure compliance with two previously issued safeguards. One safeguard requires that no person other than a motorman and brakeman ride in a locomotive without the mine foreman’s authorization. The victim was riding in the locomotive without authorization from a mine foreman. The other safeguard requires that all track mounted personnel carriers be provided with a well maintained, fully operational sanding device. The two locomotives, involved in the accident, each have four sanders (total of eight). The left front sander on each locomotive was not fully operational. Non-functioning locomotive sanders contributed to the inability of the locomotive operators to control the speed of the supply train.

   Acción correctiva: The mine operator implemented a new policy/procedure requiring locomotive operators to conduct a thorough pre-operational check, make a written record of the checks, and correct noted deficiencies before any locomotive is put into operation. Miners were trained on the new policy/procedure, as well as on the two safeguards, and the operator kept a roster of attendees. MSHA personnel monitored the training. Additionally, MSHA issued a new safeguard limiting the reasons why a passenger may ride on a locomotive. The new safeguard also requires additional training for those passengers.

2. The mine operator’s policies and procedures did not ensure compliance with a previously issued safeguard (2809080) and the operator did not have an effective procedure in place to ensure that supply trains could operate safely in the section of the track where the fatality occurred. The safeguard requires that water shall not accumulate over the rails in track haulage entries where track mounted personnel carriers and locomotives are required to travel. Wet track rails and other factors contributed to the inability of the locomotive operators to maintain the supply train at a safe speed. These factors included: a descending track grade; the differences in the locomotives’ gear ratios; locomotive track sanders not being fully operational; and the lack of standardized uniform communication between locomotive operators. All of these played a role in the train going out of control, which contributed to the mine examiner’s accident and fatal injuries.

   Acción correctiva: The mine operator implemented several written provisions/policies as corrective actions. Daily reporting of track conditions by preshift examiners will be communicated to locomotive operators. Water over the track will be corrected prior to track mounted personnel carriers and locomotives traveling in those hazards areas. The track conditions, hazards noted, and their corrective actions will be recorded in the pre-shift reports. Signs were placed along mine track grades to alert locomotive operators to observe track conditions and maintain a safe speed. A risk assessment system was developed to determine the total safe train weight for specific mine grades and rail conditions. A leading and trailing locomotive system will be used at all times and the gear ratio between the two locomotives will be compatible. An effective standardized communication system between locomotive operators of supply trains was developed, and training on these new policies and procedures was conducted, and a roster kept by the operator. This training was monitored by MSHA personnel.

Hallazgos del informe final de investigación de la MSHA, que sustituye la narrativa preliminar anterior.

Actividad al momento del incidente

Ride Equipment

Subunidad / ubicación

UNDERGROUND

Ubicación subterránea

LAST OPEN CROSSCUT

Método de minería

Longwall

Tipo de accidente

Golpeado contra un objeto fijo

Fuente de la lesión

MINE FLOOR,BOTTOM,FOOTWAL

Naturaleza de la lesión

MULTIPLE INJURIES

Parte del cuerpo afectada

HEAD,NEC

Experiencia minera total

8 years

Experiencia en esta mina

0 years

Experiencia en este puesto

0 years

Grado de la lesión

FATALITY