Utility/diesel locomotive operator Joe Saunders, 44, was working at the Buchanan No. 1

operation in Mavisdale, Buchanan County on January 11 when he received the traumatic injury from a steel water outlet he was repairing.

“Saunders and two other miners were working to reinstall a 1.5-inch fire hose outlet to the 6in fresh water supply pipe,” MSHA said in its report.

“As the miners were working to reinstall the outlet, water pressure built up in the 6-inch fresh water pipe due to the inby 6in valve not closing properly.

“The increase in pressure caused a previously damaged 1.5in valve on the outlet to fail catastrophically, propelling the steel water outlet into the victim's face and head.”

Saunders, who had one year and eight months of mining experience, was hospitalized for seven days in an intensive care unit before he died as a result of his injuries.

The failed equipment was sent to the MSHA Approvals and Certification Center for review.

The mine’s operator Consol energy was issued a non-contributing 104(a) citation for the use of firefighting equipment at Buchanan that was not rated for the operation’s high water pressure.

Witness interviews also revealed that contacting and damaging fire valves along the belt/track haulageway was common at the Buchanan mine during equipment moves and that miners who previously engaged in equipment moves at Buchanan recollected fire valves being hit and torn off.

Additionally, investigators said, some miners interviewed had identified the crosscut #61 fire valve and manifold as being a problem area in the past. They said workers had disassembled fire valves and/or manifolds in the past to prevent them from contacting wide loads.

“Miners had witnessed this same type of separation [body and tailpiece] during similar incidents prior to the day of the accident,” MSHA said.

“Many of the fire outlets in this mine were originally installed, projecting the fire outlet toward the mine track. When these fire outlets were damaged, they were repaired and/or replaced without improving the design.”

Federal officials concluded the incident occurred because the mine’s management failed to recognize hazards associated with the high water pressure and location of water valves along the Buchanan mine’s haulage track.

“The water valves located between the mine track and the belt conveyor had been damaged repeatedly during transportation of equipment on the mine track haulage way,” MSHA said.

“Mine management failed to develop effective policies and procedures for movement of large equipment and repair of high pressure water lines.”

The mine was ordered to develop written safe work instructions including standard and specific policies, procedures and training for tasks related to the January accident.

The written policies specify directions both during the transportation of large mining equipment on the track haulage as well as during the repair and/or replacement of high-pressure water lines and their components.

Also, Buchanan management has taken the defective #62 crosscut closure valve out of service. It has been replaced with a ball type closure valve and leverage bar that can properly close to prevent bypass water flow.

Finally, the mine retrofitted all fire hose outlets in the mine to project the fire hose outlets away from the mine track, preventing them from being contacted with equipment as it passes.

MSHA issued a 104 (d)(1) citation for a violation of 30 CFR Section 75.1725(a) for Consol’s failure to maintain equipment in safe operating condition.

The producer also received a 104 (d)(1) citation for a violation of 30 CFR Section 75.1100-3 because the firefighting equipment in service at the time was not being maintained in usable and operable condition.

Finally, Consol was given a Section 316 (b) safeguard in accordance with 30 CFR Section 75.1403, requiring the operator to evaluate and address track haulage clearance when moving oversized loads, to maintain adequate clearance in all areas where there is not a permanent fixed obstacle such as a coal rib and head drive and to establish a written plan to provide manpower resources, supervisory oversight and specific guidance to move oversize loads through the mine.

The Buchanan mine’s last regular health and safety inspection before the accident was December 22, 2011. A regular safety and health inspection commenced January 3, 2012 and was ongoing at the time of the accident.

The operation’s non-fatal days lost injury incidence rate for the mine in 2011 was 0.78, versus the national average of 3.73.