On Friday, the U.S. Mine Safety and Health Administration released the report of its investigation into the February death of Glen L. Clutter Jr., 51, of Baxter, who was killed at CONSOL Energy’s Loveridge Mine in Marion County, W.Va.  Here’s the report’s overview section:

On February 12, 2013, at approximately 9:35 p.m., Glen Clutter (victim), a 51-year-old general inside laborer and acting motorman, with 31 years of mining experience sustained fatal injuries. A slate bar struck the victim as he attempted to re-rail a supply car. Clutter and Scott Shay, General Inside Laborer, were attempting to re-rail the first of four cars that had de-railed. The car shifted and the slate bar struck Clutter on the right side of his face and on the forehead. The accident was caused by the failure to assure the supply car was secured or blocked against motion before it was lifted, failure to perform adequate task training, failure to maintain the track, and failure to perform an adequate preshift examination.

Here’s what MSHA says happened:

On February 12, 2013, the afternoon shift started at 4:00 p.m. Kevin Carter, Shift Foreman (Sugar Run) assigned Clutter and Scott Shay, General Inside Laborers, to transport supplies from Sugar Run to Miracle Run. Clutter and Shay entered the mine at the Miracle Run Portal shortly after 4:00 p.m. They each took a locomotive (motor) and travelled from Miracle Run to Sugar Run. Shay operated the No. 55B motor (lead) and Clutter was operating the No. 51 motor (tail). They were delayed at No. 55 block near the Sugar Run Portal bottom due to water over the track. Upon arrival at Sugar Run, Clutter and Shay spoke with Tim Shaffer, Shift Foreman (Sugar Run). Shaffer told them to transport a trip of supplies needed for the Metz Portal to Miracle Run and bring back empty supply cars. The Metz motor crews would then take these supplies from Miracle Run to the Metz Portal. Shaffer instructed Clutter and Shay to evaluate the weight of the contents of the supply cars and determine if it was possible to transport everything in one trip. Clutter and Shay decided the supplies needed taken in two trips of four cars.

The slope crew dropped the first four cars down the tail track. Clutter and Shay retrieved the four cars on Sugar Run bottom. Before leaving, they spoke with Shaffer again to decide where to place the empty supply cars when they returned. Shaffer instructed them to place the empty supply cars in the crossover entry. Clutter and Shay coupled the first trip and proceeded to Miracle Run where they transferred the supplies to the Metz supply motor crew. There were no issues encountered on the first trip. They then picked up six empty supply cars to take back to Sugar Run. Upon returning to Sugar Run, they put the empty cars in the crossover and waited for the slope supply crew to drop the cars for their second trip. The slope crew dropped the other cars into the mine. Clutter and Shay discussed where to place the cars on the Miracle Run side. It was decided to place the cars from the second trip in the 60-pound spur at Miracle Run. They believed the 60-pound track spur was more level than the loaded track, and Clutter was concerned the trip could get away from them due to its weight and placing the trip in the spur with one motor. Clutter and Shay hooked onto the supplies and proceeded towards Miracle Run.

The No. 55B motor was the lead motor heading toward Miracle Run. The trip was composed of four longwall shield carriers. The carrier behind the No. 55B motor contained a longwall tailgate drive motor, the next carrier contained a longwall shearer drum and ranging arm, the third carrier contained longwall hydraulic hoses, and the last carrier contained electrical cables and reels. The No. 51 motor completed the trip. Just before reaching the Miracle Run bottom, the cars behind the No. 55B motor derailed between the No. 124 and 126 blocks. Clutter and Shay evaluated the derailment and decided to put the cars back on the track one at a time beginning with the end of the first car adjacent to the No. 55B motor (See Appendix I). They decided to use cribbing materials and airbags. Clutter and Shay began by separating the cars to make room for the airbag. Working on the “wire side” of the track, the air hose was extended and the airbag was placed under the coupler with the intention of lifting the car straight up. They placed the air bag on the mine floor and placed cribbing between the airbag and the coupler. When the car was lifted with the airbag, the trucks (wheels) were turned and the flange of the wheels would not clear the top of the rail. A slate bar was used to straighten the wheels to align them with the rail and force the flange over the rail. Shay stated that when Clutter barred the wheel, the car suddenly shifted approximately 3 to 4 inches toward the wire-side with “tremendous force.”  When the car shifted, it contacted the slate bar, causing it to strike Clutter on the right side of his face and forehead. Shay asked Clutter if he was okay and received no response. Shay checked Clutter and saw that he was seriously injured and called Jack Saurborn, Dispatcher, for help. Saurborn radioed for anyone in the area to provide assistance and called for an ambulance.

Rocky Polce, Maintenance Foreman, arrived first at the accident scene. Shortly thereafter, Ernie Payne and John Nicholson, Mechanics, and Bob McBee, General Inside Laborer, also responded. First aid was administered and the victim was placed on a backboard and transported to the Miracle Run Bottom. While en route, Polce called the dispatcher and instructed him to call for a life flight. Clutter was taken to Miracle Run bottom, transferred to a mobile cart, placed in the elevator, and transported to the surface. The Grant Town Fire Department arrived approximately three minutes after Clutter arrived on the surface. Clutter was transferred to an ambulance and taken to a helicopter. Clutter was taken to Ruby Memorial Hospital where he was pronounced dead at 3:27 p.m. on February 14, 2013.

Among other things, the MSHA investigation team found:

A pre-shift examination was required in the haulage way where the accident occurred because persons were scheduled to work or travel during the oncoming shift. The mine operator conducted an examination by travelling through the area in a track-mounted vehicle. However, the examination noted no deficiencies with the track or its components.

The accident investigation revealed the track and its components were not maintained to prevent a derailment. Additionally, the mine operator was required to examine the remaining portions of underground rail haulage “on foot” and record and correct any deficiencies. A noncontributory citation was issued to the mine operator for failure to conduct an adequate examination of the track.

And here’s what MSHA said about the root causes of the death:

Root Cause
The operator did not train the supply motormen on the task of using air bags and blocking when re-railing track mounted equipment.
 
Corrective Action
The operator developed a written procedure to re-rail track mounted equipment. The operator trained all motormen in this new procedure which included the proper procedures for using air bags and blocking to re-rail track mounted equipment.

Root Cause
The mine operator’s policies and procedures did not ensure that safe work policies and procedures were followed regarding the proper use of airbags and blocking raised equipment when re-railing derailed cars.
 
Corrective Action
A Notice to Provide a Safeguard issued to the mine operator requires each locomotive operator to block and secure raised cars. Abatement of the Safeguard notice included training each locomotive operator in the requirements of the safeguard.

Root Cause
The mine operator did not maintain the track to prevent a derailment between the No. 124 and No. 126 blocks of the Main West Haulage. The wire-side rail rolled out for a distance of approximately 112 feet and there were no steel ties. The track was spiked to wooden track ties and the rail was rusted and deteriorated.
 
Corrective Action
The operator has submitted a plan to the District Manager that requires the operator to perform enhanced examinations from 9-South Mains to the St. Leo haulage. The purpose of the examinations will be to detect any loose ties, deteriorated rail, loose material under the rails, and other track defects.

Root Cause
The operator did not perform an adequate pre-shift examination of the track. This could have prevented the derailment because the track deficiencies would have been repaired. The Main West haulage between the No. 124 and the No. 126 block had missing track ties. When a supply crew traveled across this area, 112 feet of rail rolled out on the wire side of the track.

Corrective Action
All pre-shift examiners have been retrained on the requirements for pre-shift examinations and on how to properly examine the track during pre-shift examinations. Additionally, 30 CFR § 75.363(e) requires the mine operator to review with mine examiners, on a quarterly basis, citations and orders issued in areas where preshift, supplemental, on-shift, and weekly examinations are required.