A foreman on the site also came in for some particular attention from investigators.

Mechanic Clyde Dolin, 57, was working at the Liberty Processing preparation plant in Uneeda, Boone County, on May 17 when the 14-foot fiberglass extension ladder he was using became unstable and slid across an I-beam.

It caused him to fall through the preparation plant hoist well to the facility’s concrete floor, a distance of approximately 39ft.

In its just-released final investigation report, US Mine Safety and Health Administration investigators confirmed that Dolin – who had 39 years mining experience and 12 years at the Liberty plant – was preparing to torch-cut and remove a 12 inch steel trolley beam located above the plant’s third floor, adjacent to a hoist well opening.

The I-beam was no longer useful and was being removed to prevent it interfering with the movement of material and supplies that were hoisted into the plant, officials said.

In its probe of the accident scene and staff records, the agency found no training or experience issues.

MSHA concluded Alpha was at fault for the fatal incident.

“The accident occurred because of management's failure to ensure equipment was used and maintained in safe working order and in accordance with the ladder manufacturer's recommendations,” investigators said.

“A practice existed of using extension sections throughout the plant, separate from ladder base portions.

“The ladder section being used was not properly secured to prevent it from slipping or falling and the use of personal fall protection equipment was not ensured where there was a danger of falling.”

To rectify the issues, federal officials ordered the removal of the ladder extension sections – which were found by investigators separated from their bases – and new ones confirmed to be in proper working order were put into service.

The company has developed a formal fall protection training program and submitted it to MSHA.

Alpha was required to give classroom instruction and hands-on application of properly securing ladders to all miners, including management.

It also needed to provide classroom and hands-on instruction to allow all employees an opportunity to inspect, correctly adjust and secure fall protection harnesses.

The producer was given a 104(d)(1) citation for a violation of CFR 77.206(a) for improper use and condition of the mine’s extension ladder sections, a factor said to have contributed directly to the fatality.

“[Foreman James] Maynard allowed the ladders to be used despite their condition and despite the presence of conspicuous warning labels attached to the ladder extensions,” MSHA said.

“Maynard engaged in aggravated conduct constituting more than ordinary negligence … an unwarrantable failure to comply with a mandatory standard.”

Officials also handed down a 104(a) citation for a violation of CFR 77.205(a) because the operator did not provide a safe means of access to a working place.

Finally, a 104(d)(1) order was issued for a CFR 77.1710(g) violation, as workers were not required to wear a safety belt and line while working at elevations at the site.

Again, investigators pointed to the mine’s foreman.

“Maynard … was present at the work area immediately prior to the accident and helped a witness stabilize a ladder while the victim climbed it to perform the work necessary to remove a 12in I-beam,” MSHA said.

“[He] observed the victim climbing the ladder without fall protection and was aware that the work was to be accomplished from an elevated location above the third floor of the plant and was also located adjacent to an open hoist well that was 39 feet above the basement floor.

“Maynard engaged in aggravated conduct constituting more than ordinary negligence.”

Liberty Processing, operated by Alpha subsidiary Independence Coal, has a total workforce of 45.

It processes about 36,000 tons of raw coal daily.

Prior to the accident, MSHA completed the last regular inspection of the Liberty plant on October 17, 2011.

The facility’s non-fatal days lost incident rate in 2011 was 1.78, versus the 1.68 national average.