# Presentation: 396667

## This presentation is for illustrative and general educational purposes only and is not intended to substitute for the official MSHA Investigation Report analysis nor is it intended to provide the sole foundation, if any, for any related enforcement actions. 

## GENERAL INFORMATION

- Operator:		Black Castle Mining Co.
- Mine:		Black Castle Mining Co.
- Accident Date:	February 1, 2006
- Classification: 	Ignition of Gas
- Location: 		Dist. 4, Boone County, West Virginia
- Mine Type: 	Surface Coal Mine
- Employment:	234
- Production:	11,700 Tons/Day

## ACCIDENT DESCRIPTION

- At approximately 2:10 p.m. on Wednesday, February 1, 2006, a 58-year old bulldozer operator with 15 years experience was fatally injured due to an ignition of natural gas. As the bulldozer operator was developing a drill bench, the blade of the machine contacted and ruptured a 16-inch low-pressure, high-volume natural gas line which immediately burst into flames.

- Hydraulic Oil Puddle

## ROOT CAUSE ANALYSIS

_*Causal Factor*_: Mine management directed the bulldozer to work in close proximity to a known but unlocated active gas line. Although aware of the gas line and potential hazard, mine management did not accurately locate and mark the gas line before directing the bulldozer to operate in the area. This exposed the bulldozer operator to a hazardous condition. There were no policies or procedures in place to address hazards associated with working near active gas lines.
_*Corrective Action*_: The Ground Control Plan was revised to establish safety precautions to be taken when gas lines are in close proximity to active work areas. The Ground Control Plan has been received and acknowledged by the District Manager, District 4, Mine Safety and Health Administration.

## ROOT CAUSE ANALYSIS cont’d.

_*Causal Factor*_: The required on-shift examinations for the active work area were not conducted. The hazardous condition was not properly identified or corrected. The person designated by the mine operator to perform the examinations did not travel onto the access road where Moss was operating the bulldozer. There was no effective management system in place to assure that required examinations were being conducted in all work areas.
_*Corrective Action*_: Mine management conducted retraining for all persons designated to conduct on-shift examinations. The retraining focused on the topic of hazard recognition.

## ENFORCEMENT ACTION

**§104(d)(1) Citation, No. 7247101** was issued to Black Castle Mining Co. for a violation of 77.1713(a).
- An adequate daily examination for hazardous conditions was not made of the active working area in the East of Stollings Area of the mine. A bulldozer operator was working in this area developing a drill bench at the Clarion coal seam level. The area was not adequately examined by a certified person for hazardous conditions and an existing hazardous condition, which was neither reported nor corrected, contributed to a fatal accident.

## ENFORCEMENT ACTION, Cont’d.

**§104(d)(1) Citation, No. 7247101**
- .....An active 16-inch diameter gas line was buried and was not adequately marked in the area where the bulldozer was being operated. The area was not adequately examined to determine the location and extent of the gas line. Mine management knew that the gas line was located in the general area where the bulldozer was being operated and knew that the gas line was not marked. The presence of the unmarked gas line constituted a hazardous condition which should have been reported and corrected during the required daily inspection. Although management conducted an on-shift examination of the general area, this hazardous condition was neither reported nor corrected. Management instructed the bulldozer operator to locate the clarion coal seam crop and to develop a drill bench at that level. While carrying out this task, the bulldozer contacted the gas line causing it to rupture. The natural gas was ignited, flames engulfed the bulldozer and the operator received fatal injuries.

## BEST PRACTICES
Identify and mark all right-of-ways for pipelines and other buried utilities in the proposed mining area before mining begins. 
Ensure that utility markers are installed, maintained conspicuous, and not removed for any reason. 
Maintain a safe distance between active mining and right-of-ways. 
Ensure that certified mine maps accurately depict the location of all active and abandoned gas wells and buried utilities. 
Utilize an independent utility location contractor to verify utility locations. 
Review the identification and location of buried utilities with all employees (additional information at; 
 http://www.msha.gov/Accident_Prevention/Tips/gaslines.htm 

- Identify and mark all right-of-ways for pipelines and other buried utilities in the proposed mining area before mining begins.
- Ensure that utility markers are installed, maintained conspicuous, and not removed for any reason.
- Maintain a safe distance between active mining and right-of-ways.
- Ensure that certified mine maps accurately depict the location of all active and abandoned gas wells and buried utilities.
- Utilize an independent utility location contractor to verify utility locations.
- Review the identification and location of buried utilities with all employees (additional information at;
-  _[http://](http://www.msha.gov/Accident_Prevention/Tips/gaslines.htm)__[www.msha.gov/Accident_Prevention/Tips/gaslines.htm](http://www.msha.gov/Accident_Prevention/Tips/gaslines.htm)__[ ](http://www.msha.gov/Accident_Prevention/Tips/gaslines.htm)_