The U.S. Mine Safety and Health Administration has issued the report of its investigation into the Nov. 17, 2012, death of Chad Meyers, a 30-year-old continuous mining machine operator killed at Peabody Energy subsidiary Big Ridge Inc.’s Willow Lake Portal Mine in Saline County, Illinois. Here’s the summary:

On Saturday, November 17, 2012, at approximately 3:25 a.m., Chad Meyers, a 30-year-old continuous mining machine operator, was fatally injured while repositioning a continuous mining machine on the No. 5 working section. Meyers was backing the continuous mining machine out of the first cut of a crosscut being developed to the left of the No. 4 entry. As Meyers was repositioning the continuous mining machine to mine the right side of the crosscut, he was pinned between the continuous mining machine cutter head and the outby coal rib.

The administrative controls and policies in place at the time of the accident were not adequate to prevent the practice of operating continuous mining machines from an unsafe location. Also, no engineering controls were in place to prevent this type of accident. The accident occurred because the victim operated the machine while he was located between the left side of the cutter head and the coal rib.

MSHA investigators listed these root causes:

— The mine operator did not ensure compliance with provisions of the approved roof control plan requiring that all persons be in a safe location away from any part of the continuous mining machine when the machine is being repositioned or trammed. The continuous mining machine operator was located in the “Red Zone” between the continuous mining machine and the coal rib while the machine was being repositioned.

— The operator did not enforce its Red Zone policy. Accident investigators found that Red Zone violations were a practice.

The MSHA report concluded:

To prevent this type of fatal accident, mine operators must strictly adhere to the requirements of their approved roof control plans, which includes strictly following policies and procedures that keep miners from entering Red Zones. Also, proximity detection systems should be installed on all continuous mining machines.

Not for nothing, but regarding that last part — proximity detection systems should be installed on all continuous mining machines — MSHA recently pushed back its timeline for a regulation to require proximity detection systems.