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Accident Investigation and Reporting after major

disaster in India and abroad along with case study

By

Chandan Kumar

110MN0392

Department of Mining Engineering

National Institute of Technology

Rourkela - 769008, India

13 Sept 2013

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Contents Introduction ................................................................................................................................................... 3

Accident Investigation Report ...................................................................................................................... 7

Fatal Roof Fall Accident at Mine #5, Minutemen Coal Company, Virginia ................................... 7

Accident at Jagannath Opencast Project .......................................................................................... 9

Accident at Kawadi Open cast Coal Mine ...................................................................................... 12

Fatal Powered Haulage Accident at Surface Nonmetal Mine(Gypsum),Texas .............................. 13

Accident at Bagdigi Colliery ........................................................................................................... 15

Accident at Parascole West Colliery .............................................................................................. 17

Accident at Godavari Khani 7LEP Mine,Singareni Collieries CO. LTD ....................................... 18

References ................................................................................................................................................... 21

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Introduction Accident is an unplanned welcome event which interrupts normal activity. It is an unwelcome

situation when everybody gets tensed. Blame game starts .The normal activity is thrown out of

gear. Tempers flare. Industrial trauma results in stoppage/slow down or too defensive attitude in

performing the same or similar job. Depending upon the magnitude crisis develops. In case of

loss of many lives this leads to a disaster to be managed. Crisis management and Disaster

Management are post – facto scenarios and do not go in corrective measures. Accidents also lead

to guilty conscience stage when we feel that had we analyzed the risk this accident might not

have happened.

Many a time we start thinking we could have avoided all this had we taken pro active

measures. To get into a proactive stage it is not necessary that we should have come across such

an event. Analyzing each work situation and procedures, identifying the hazard, assessing the

risk, training, laying down safe operating procedures, are all required Pro Active approach.

Pro Active approach

Dissect all activities location wise/machine wise and Subject them to critical examination by

putting basic questions. This would be needed to identify and eliminate the hazard or to modify

the procedure.

When Is it the proper time

Where Is it the proper location or machine

What Is it the correct thing to do

Who Is it done by the proper person ,trained etc

Why Is it necessary to do

How Is it correctly done

Tabulate the results. They would, with unbiased state of mind and approach lead to answers to

determine whether an activity is needed, is it done correctly by the proper person, at the proper

place and at the proper time.

Another area would be discussions with Workmen inspectors. Thread bare unbiased discussions

in the pit safety committee can play quite a pivotal role in Hazard identification. Manager

should not try to underplay or suppress any meaningful discussion. Points raised however minor

they are need consideration.

Suggestion boxes unfortunately do not get suggestions at all.

Corrective methods

With all our proactive system in position still if an accident occurs we need to go in a cool frame

of mind and find out ways to ensure that it does not recur. We should need to investigate without

bias and creating fear. The purpose should be from a reactive for such an occurrence

to proactive for similar occurrences. Hence accident investigation is a tool to be used for

improvement of situation and not to punish or create a fear complex.

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The Purpose of investigation is

Exonerate individuals or management

Satisfy insurance requirements

Defend a position for legal argument

to assign responsibility

The key result should be to prevent a recurrence of the same accident. An accident investigation

should not be with blame game. Management or managers should not use this for settling scores.

Unions should not use this as an arm twisting advantage over the management or the vice versa.

In fine the approach should be with open mind without bias and in the larger interests.

Accidents can be broadly classified into

Minor accidents:

Such as paper cuts to fingers or dropping a box of materials

More serious accidents that cause injury or damage to equipment or property.

Accidents that occur over an extended time frame such as hearing loss or an illness resulting

from exposure to hazardous chemicals

Accidents have two things in common

They all have outcomes from the accident

They all have contributory factors that cause the accident

Outcomes of accidents

Negative aspects

o Death & injury

o Disease

o Damage to equipment & property

o Litigation costs

o Lost productivity

Positive aspects

o Accident investigation

o Change to safety programs

Contributing factors

Environmental

o Noise

o Vapors, fumes, dust

o Light

o Heat

Design

o Workplace layout

o Design of tools & equipment

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Systems & procedures

o Lack of systems & procedures

Inappropriate systems & procedures

Human behavior

o Common to all accidents

o Not limited to the person involved in the accident

We should need to decide the agency who can conduct the investigation. This would be

Dependent on severity of the accident

o Investigation team

Individuals involved

Supervisor

Safety supervisor

Upper management

Outside consultants

Purpose and Investigation strategy should be specified. This could be

Gather information & establish facts

Isolate essential contributory factors

Determine corrective actions

Implement corrective actions

Fact gathering

The investigating agency should be impartial & objective. It should

o Compile procedures & rules for the area

o Gather maintenance records on equipment involved

o Isolate accident scene

o Take photos & make diagrams

o Do not discard or destroy anything

o Time is of the essence

o Obtain information regarding

Injured

Witnesses

Supervisors

Other personnel

To gain confidence and to get correct information Interviews should be

conducted separately. Make it clear the object of the investigation is to avoid recurrence, not to

blame. Individuals are concerned about ridicule, punishment, singling out or any humiliation and

hence do not open out. It is therefore necessary to gain confidence with the individual. A

defensive man may turn hostile defeating the purpose of enquiry altogether.Then the exercise

becomes an eyewash without meeting the basic need that is to prevent recurrence.

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Find out

What were you doing?

How do you think the accident occurred?

How were you trained for the job?

What is the safety procedure for this job?

Obtain facts not opinions.

Investigation team should

Tabulate the data collected from individuals and also scene of accident

/incident.

Look out for corroboration and grey areas

Study them and reason out if necessary by reanalyzing

Evaluate all factors concerned

Isolate essential contributory factors along with an expert if necessary by

asking the following question “Would the accident have happened if this

particular factor was not present”

Personal protective equipment is often shown as a cause of accident. Personal Protective

Equipments (PPE) is the last line of defense. A helmet cannot save a head injury due fall of

heavy object or shoes cannot prevent leg injury if a heavy objects falls down on leg while being

lifted manually.

Determination of corrective actions by investigation team

Interpret& draw conclusion

Distinction between intermediate & underlying causes

Determine corrective actions.

Recommendations based on key contributory factors and underlying

causes

Implement corrective actions

Such corrective action should be discussed in an open forum. It should have acceptance

without reservation

Recommendation(s) must be communicated clearly

Strict time table established

Follow up conducted

Benefits of accident investigation

Preventing recurrence

Identifying out-moded procedures

Improvements to work environment

Increased productivity

Improvement of operational & safety procedures

Raises safety awareness level

Builds up confidence levels

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Whenever we isolate a hazard either Proactive or reactive way and modify a procedure it is

necessary to impart training it is necessary that all concerned are made aware of such changes

and the necessity of such change. While we might have considered all aspects there could still be

some hidden lacuna to surface out. It is therefore a must to monitor health of such changed

scenario and further fine tune if need be .When an organization reacts swiftly and positively to

accidents and injuries, its actions reaffirm its commitment to the safety and well-being of its

employees and a confident system exists.

Accident Investigation Report

Fatal Roof Fall Accident at Mine #5, Minutemen Coal

Company, Virginia

GENERAL INFORMATION

Mine #5 of Minutemen Coal Company, Inc. is located one-tenth mile east of Route 823, on

Indian Creek. The mine was opened by six drifts into the Dorchester coal seam. The coal seam

averages 42 inches in height. Coal is mined from the active faces with a continuous mining

machine and transported to the belt feeder in shuttle cars. The coal is then transported to the

surface via belt conveyors. The mine operates two shifts per day, producing coal on the day shift

and performing maintenance on the owl shift. The mine has eight underground and two surface

employees. There is no production history as the accident occurred during the first production

shift after the mine was reactivated on July 14, 1997. The main mine roof strata consists of 30

feet, or more, of sandstone. The immediate roof consists of six inches, or more, of shale. The

mine floor consists of six inches, or more, of shale. The Approved Roof Control Plan, dated July

11, 1997, provides for full roof support in all entries, crosscuts, and rooms. The plan stipulates,

as a minimum, the use of 36 inch mechanically anchored roof bolts, 48 inch fully grouted resin

rods, or 60 inch point anchor/combination anchor bolts. The maximum entry and crosscut widths

are 20 feet, except for the belt entry, which is allowed a width of 22 feet. Entries and crosscuts

can be developed on 50, 55, 60, and 70 feet centers. When adverse conditions are encountered,

entry centers can be developed from 80 to 200 feet. The plan contains provisions for extending

cut depths to 30 feet during development and for partial pillar extraction during second mining

utilizing a three-cut system.

INVESTIGATION REPORT

1. Tuesday, July 15, 1997 was the first production shift by Minutemen Coal Company,

Inc. employees at Mine #5. The mine was reactivated on Monday, July 14 after being

idle for approximately four months.

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2. The Approved Roof Control Plan allowed for cut depths of 30 feet. However, the cut

taken in the No. 7 entry prior to the accident was only 20 feet deep and 20 feet wide.

3. This mine had experienced one roof fall in an out by area during the past 12 months.

4. The 001-0 Section was bolted to standard utilizing 36 inch conventional roof bolts.

5. The section of mine roof that fell was a large slip measuring approximately 50 feet

long, 1 to 17 feet wide, and from 3 inches to 4 1/2 feet thick. The slip broke at full

thickness at the face of the No. 7 entry and continued to the out by intersection. Roof

bolts were broken at the edges of the fall and the caved area was above the anchorage

horizon at the apex of the slip.

6. The slip was nearly parallel to the direction of the No. 7 entry.

7. The Joy 14CM10 Continuous Mining Machine was not equipped with an operator's

deck and was operated by remote control.

8. There was no unusual roof activity during the mining of the cut in the No. 7 entry. All

crew members stated that the roof appeared in good condition. A shuttle car operator

small crack in the mine roof over his shuttle car. The crack had not been there, he

thought, before his lunch break. He stated that there were no audible or visible signs

of roof movement and that he felt the mine roof was in a safe condition.

9. The Dorchester Coal Seam averages 42 inches in thickness at this mine. The mining

height at the scene of the accident was 68 to 70 inches.

10. Examination of a test hole located in the intersection of the last open crosscut and the

No. 7 entry approximately 45 feet out by the face, revealed a horizontal crack in the

mine roof at 39 inches.

11. All face areas were supported in accordance with the Approved Roof Control Plan.

12. There were no training deficiencies relevant to the accident.

CONCLUSION

The accident occurred when mining was conducted beneath an area of roof that contained a

large, undetected roof slip. The roof, weakened by the slip, fell without warning, starting in the

freshly mined and unsupported face area. The fall continued out by, where the momentum of the

falling roof overcame the permanent roof support installed in the intersection.

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Accident at Jagannath Opencast Project Date of the accident – 24.6.1981

Owner – Central Coalfields Ltd.

Number of persons killed – 10

Place – Talcher Coalfield, Orissa

GENERAL INFORMATION

Jagannath Colliery had two quarries, namely, the Pilot Quarry and the Main Quarry. The

accident occurred in Pilot quarry which was located in the trough of two strike faults running

east-west. The strata dipped at 40 to 50 in northerly direction. No.3 seam was 9 m thick and

occurred at a depth of about 12 m. No.2 seam (also called Jagannath seam) was about 35 m thick

and occurred 6 m below No.3 seam. The quarry was worked with draglines, shovels, pay loaders

and dumpers and was 52 m deep.

The coal seams were of poor quality and non-gassy, but highly susceptible to spontaneous

heating. Coal dumped in the stockyard was reported to catch fire within 2-3 months. The coal

benches in the south-side of the Pilot Quarry (which was close to a major fault) almost always

had problems of fire since 1977. Attempts to dig out the fire and quench it rarely proved

successful as the fire used to flare up again after some time. At the time of the accident the south-

side face was on fire in patches over a length of 270m. In the opinion of the CFRI scientists the

fire could have travelled to a depth of 15 m from the face. According to DGMS the fire could

have penetrated to about 6 to 7 m inbye in the bottom bench. As a result of the burning away of

the coal seams, there had been a number of side falls and large cracks had developed on the

surface.

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INVESTIGATION REPORT

Conclusions from the DGMS inquiry

There was a slide in which about 800 tons of material came down along the south side over a

width of about 20 m. This slide might have been caused by fire, heavy rain, presence of fault-

plane, water entering through wide cracks on the surface, etc. or more probably by a combination

of these. But the slide alone could not have thrown 6 to 8 cm pieces up to a distance of 60 m or

so. Moreover, the scattered material was thrown from places which were on fire. Therefore there

must have been an outburst also. As to the cause of the outburst, the most probable appeared to

be an explosion of water gas (a mixture consisting mostly of H2 and CO).

The Management's view

The management's findings were more or less similar to that of the DGMS. They concluded that

there was a slide on the southern side as well as an outburst and that the slide occurred prior to

the outburst. However, they claimed to have seen at least one piece of stone weighing about 1.5

kg thrown to a distance of nearly 130 m from the site of the slide. As regards the cause of the

outburst also their conclusion was the same; that is, the outburst could have occurred due to

water gas explosion only. The possibility of high pressure steam being generated was ruled out

because the pressure developed could not have been high enough to throw clinker and stones

over such larger distances. The possibility of coal dust explosion was also ruled out because the

heavy rain in the previous four days had completely saturated all the coal dust with water.

The water gas must have formed in the void created by the burning of the coal seam, and air

entering the fire area must have rendered the mixture explosive which was ignited by the burning

coal. Only the explosion of water gas could explain the degree of violence witnessed in this

case.

The case put forward by CMRS

Like one of the Trade Unions, CMRS first considered the possibility of the incident having been

caused by a simple slide. They assumed 24 m thickness of coal to have burnt completely

reducing the original volume to one-third (as the ash content in coal varied form 30 to 35%).

Assuming all favorable conditions, the velocity of the sliding mass could not have exceeded 18

m/s. Then assuming that any clinker might have attained this initial velocity, the maximum throw

of a projectile at an angle of 450 would come to 33 m only. Therefore, the scattering of stone

pieces beyond 33 m could not be justified by simple sliding and projectile ejection. They,

therefore, concluded that there was an outburst also.

In trying to find out the cause of the outburst they considered the following possibilities:-

1. Accumulation of methane along the fault plane and its explosion.

2. Production of inflammable gases and methane by distillation of coal and their explosion.

3. Coal dust explosion

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4. Hydraulic stimulation of crushed and permeable coal seam which may increase gas

outflow upto 20 times.

5. Generation of steam which could mechanically eject the ash and clinkers.

Scientific analysis of all factors eliminated these possibilities. Last of all, they discussed the

possibility of water gas explosion and considered it probable. According to them, hot water and

steam may pass over burning coal and change into water gas. Small amount of this gas with wide

explosive limit (5-70%) may explode deep in the cut created by the fire and initiate scattering of

the burnt ashes and clinkers over a fan-shaped area as reported by witnesses.

The color of the smoke in this case will be grey (like that of ash), violence will be less severe but

overall temperature of the bed of already heated ash will then rise because of its exothermic

reaction. This seems to justify the burning of victims even at 90 m distance without excessive

violence, smoke or sound.

The case put forward by CFRI

CFRI did not take into consideration any possibility other than explosion of gases. Their

contention was that the smoldering fire in the seam might have been gradually covered up by

self-generated ash and cinders and subsequently further blanketed by a huge amount of rock

debris falling from the top. Heavy blanketing of the fire zone might have led to a number of

chemical reactions in the coal-bed, namely, combustion, gasification and carbonization, all of

which culminated in the continuous generation of gases which might have built up a tremendous

pressure deep within the fire zone. Eventually, when a critical pressure was reached, the cover of

rock debris was thrown out creating an opening through which air rushed into the gas zone and

caused an explosion of inflammable mixtures of CH4 air, CO-air and H2-air. Such an explosion,

deep within the fire zone, had perhaps led to the sliding of enormous quantity of rock debris and

the shooting of very hot spent gases accompanied by hot ash and cinders.

Commenting on the CFRI report, the management argued that if the gases produced by pyrolysis

of coal not escape, it follows that no air could enter such a zone. Therefore the coal burning

would have stopped and the fire would have died out in course of time.

The Court did not consider the case put up by CFRI as a probability.

The Court's analysis

The Court based its analysis on the following three facts:

1. A clinker weighing 1.5 kg was thrown over a distance of 130 m. The pressure required to

do this would be about 350 p.s.i. Such a high pressure could not have been developed by

a gas explosion.

2. About 250 tons of material was thrown over a distance of 250 ft. The kinetic energy

required to do this would be 17.9 mil Btu.

3. "Whoa-whoa" sound was heard immediately after the incident.

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The Court contended that in the circumstances prevailing at the time of the incident, there was a

possibility of generation of superheated steam at high pressure. The heavy rain on four days prior

to the incident could have clogged the cleavage planes and other natural fissures in the coal and

associated rocks and steam superheated to about 800°F could be entrapped at pressures of 350

p.s.i. or more in the interstices of ash and strata. CMRS had not considered superheated steam

and its entrapment in interstices of ash. Superheated steam can explain the high pressure required

in this case and confinement in interstices explains how a large volume of steam could be stored.

The "whoa-whoa" sound is explained by the escape of steam after the initial outburst.

It appears that a slight movement in the coal face was the fore-runner of the outburst and large

scale slide of the side occurred only after the ejection of material from within the fire zone.

Conclusion

The incident could have occurred by a combination of circumstances. Probably high-pressure

steam confined within the fire zone played the main role in the ejection of hot ash and cinders.

But the contribution of other factors, such as the explosion of water-gas, cannot be ruled out.

This incident is a pointer to the grave danger that a blazing fire in a coal bench of an opencast

mine can bring about. It is therefore necessary that such fires must be quenched as soon as

noticed.

Accident at Kawadi Open cast Coal Mine

Date of the Accident- 24.6.2000

Owner: Western Coalfields Ltd.

Number of persons killed-10

Place- Majri Area

INVESTIGATION REPORT

The accident:

The accident occurred on 24.6.2000 in the second shift when 13 workers, under the supervision

of an overman and two mining sirdars, were engaged at the floor of the coal bench in various

activities like drilling, unloading of explosives from the explosive van, working the hydraulic

excavator, etc. At about 3.50 p.m., one of the workers noticed loose debris falling from the top of

the benches on the rise (barrier) side. By the time he could raise an alarm, loose debris and

boulders started sliding down rapidly into the quarry. 5 persons tried to run away while 10 others

took shelter behind the HEMM and the explosive van. One person had left the area earlier.

The total volume of material that slid down was more than 20,000 m3. All the 10 persons who

had taken shelter behind the HEMM and explosive van were completely buried under the debris.

The 5 persons who had tried to run away were partially trapped but could escape with minor

injuries.

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Machines were deployed immediately for removal of the debris. All the 10 dead bodies could be

recovered by 5 a.m. on 25.6.2000. About 1000 m3 of material had to be removed to take out the

bodies.

Observations:

1. Height of benches in the black cotton soil was as much as 12 m with width of only 3 m to

8 m.The next two benches in sandstones were 12 m to 15 m high and had widths of less

than 5 m.The coal bench was 15 m to 18 m high and was almost flush with the sandstone

bench above, the combined height at places being as much as 52 m.

2. The strata had sets of geological discontinuities, parallel as well as at an angle to the fault

plane.

3. Heavy rainfall had occurred in the area on 6th

, 10th

, 11th

and 17th

June prior to the

accident.

4. Active fire was noticed in the exposed underground galleries as well as in the pillars on

all sides.

5. An earthquake measuring 4.0 on the Richter scale was reported to have occurred in the

area on 22.6.2000 at about 4 p.m. The epicenter of the tremor was probably 35 km west

of Kawadi mine.

6. From the disposition of the collapsed material at the accident site, it appeared that the

slide had started from the bottom of the quarry and extended to the fault plane in the

barrier.

Conclusion:

The benches failed because of their excessive height and very small width. The following factors

might have contributed to the instability of the benches:

1. Sets of geological discontinuities in the strata

2. The fault plane along the barrier between Kawadi and New Majri mines.

3. Presence of water in the strata due to heavy rainfall prior to the accident.

4. Failure of pillars on fire in the belowground workings under the benches.

The management was held responsible for the accident as it failed to maintain proper benches as

per the conditions stipulated in the permission letter.

Fatal Powered Haulage Accident at Surface Nonmetal

Mine(Gypsum),Texas

GENERAL INFORMATION

On April 27, 2013, James D. Winegeart, Mechanic, age 58, was killed when he became

entangled in the discharge belt conveyor of a mobile crusher. Winegeart was reaching into the

belt conveyor, attempting to dislodge a large rock that was lodged between the belt conveyor and

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the frame of the crusher. The belt conveyor, which was stalled but had not been turned off or

locked out, resumed movement after Winegeart dislodged the rock.

INVESTIGATION REPORT

Location of the Accident

The accident occurred at the processing area of the mine. Rock was crushed, screened and loaded

into customer trucks in this area. This area was relatively flat and dry at the time of the accident.

Mobile Crusher

The mobile crusher involved in the accident was a track-mounted impact-type crusher equipped

with a large feeder, a discharge belt conveyor that folded for transportation, and a magnet to

remove metallic waste from the crushed material. The mobile crusher weighed 101,100 pounds

with all of the attached equipment.The mobile crusher was powered by a diesel engine that

required two keys for starting.The diesel engine also powered a hydraulic system that powered

the 12-inch diameter head pulley of the 48-inch wide discharge belt conveyor. To prevent

unintended startup during maintenance, management had developed a procedure requiring

persons performing maintenance to remove both diesel engine keys and lock them together

before beginning work. However, this procedure was not followed at the time of the accident.

When the rock became lodged between the belt conveyor and the frame, the belt conveyor stalled

but resumed movement when the rock was dislodged because these established procedures were

not followed.

The mobile crusher could be operated by using on-board hydraulic controls or by using a hand-

held remote radio control unit. The on-board controls could be used to operate the feeder and the

discharge belt conveyor. There was no emergency stop button on the onboard hydraulic controls.

The remote control unit could be used to tram the mobile crusher and to operate the feeder and

discharge belt conveyor. The remote control unit had one red emergency stop button that could

disengage the diesel motor, which would stop the mobile crusher and all hydraulic-powered

movement of the feeder and discharge belt conveyor. The remote control unit for the mobile

crusher was still in the front-end loader Dampier was operating at the time of the accident. The

emergency stop button had not been activated.

Weather

The weather at the time of the accident was clear with a temperature about 60 degrees

Fahrenheit. Weather was not considered to be a factor in the accident.

ROOT CAUSE ANALYSIS

The investigators conducted a root cause analysis and the following root cause was identified:

Root Cause: Management failed to ensure that persons followed previously established

procedures to deenergize the crusher before performing maintenance work. Additionally, the

discharge belt conveyor was not blocked against hazardous motion.

Corrective Action: Management retrained all miners regarding established procedures to

deenergize the mobile crusher and block moving machine parts against hazardous motion before

maintenance work begins.

CONCLUSION

The accident occurred due to management’s failure to ensure that all persons followed

established procedures, which required deenergizing the mobile crusher before performing

maintenance work on it. Additionally, moving parts on the belt conveyor were not blocked

against hazardous motion.

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Accident at Bagdigi Colliery

GENERAL INFORMATION

On 2.2.2001 at about 12.30 PM. a disaster took place in VII seam underground workings of

Bagdigi Colliery situated at a distance of about 15 KMs, from Dhanbad town of Jharkhand State

as a result of inundation by water from adjoining old workings of Jayrampur Colliery, wherein

29 persons lost their lives.

INVESTIGATION REPORT

Accident

It was reported that on 02.02.2001 during the 1st

shift workers were engaged in working of the

mine in the VII seam south section at the 3rd

, 4'" and 5th

level. Besides the miners the Manager,

Late Upadhayaya and Asstt. Manager, Late P.R.Singh were also present in the mine in between

12 noon to 12.30 P.M. There was a sound of loud explosion followed by gushing of water into

the 3rd

level. The workers were taken by surprise. Some of them managed to escape through cage

but others could not. Within moments the 3rd

level was completely submerged with water and

those workers/officers who could not escape, were trapped inside. Those workers who managed

to come out of the mine alerted the management. Simultaneously information was communicated

to the Directorate-General or Mines Safety. Officers from D.G.M.S. visited the place of accident

and engaged themselves straight away in rescue operation. It was reported that on account of

certain defects in reaching underground at the site of accident, naval divers from

Vishakhapatanam were requisitioned for the rescue operation. Dewatering the inundated mine

was simultaneously commenced. The rescue and recovery operation had continued for about

fifteen days after the accident. After 7 days of the accident Sri Salim Ansari was rescued and

brought out of the mine alive on 8.2.2001. Dead bodies of 29 persons could be recovered by

16lh

of Feb. 2001.

Conclusions

On studying the working plan, admittedly prepared by the surveyors, Sri R.N. Kundu and Sri

R.C. Das, there appear glaring defects and infirmities. To mention a few, working plans do not

indicate any spot levels at all. The sizes of the pillars in the galleries of 4th and 5lh

levels are also

not truthfully depicted. The above defects are not only glaring, but also conspicuous and should

have been observed even by a cursory glance at the working plans. It is intriguing as to how

these defects had escaped the notice and attention of not only the surveyors themselves, but also

the manager and the agent of the colliery, as well as the team of officials, who claim to have

conducted check survey of the colliery.

It is apparent from the above that the working plans were never prepared by conducting actual

survey. Rather, the positions of the levels, dips and rises were simply marked on the approved

projection plan on the presumption that the actual workings do correspond with the original

projection plan. The underground working plan seems to have been prepared in this manner and

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further extensions of workings were also similarly plotted on the projection line already marked.

The surveyors, Sri R.N.Kundu and Sri R.C.Das have tried to explain that the error in survey and

preparation of corresponding working plans had occurred on account of faulty survey

instruments. No doubt, it has come in evidence even from the admission of Area Survey Officer,

Sri J.S. Mahal Witness No.-44 that the survey instruments including Microptic dial, Miners dial,

Theodolite and Dumpy Level used to be repaired from time to time. This plea of surveyors does

not appear convincing enough as because the deviation in workings was apparent even with

naked eye without any assistance of any survey instruments at all. The variation in the size of

pillars was more than conspicuous. The surveyors have not explained as to why the essential

requirements including the spot levels, base line connecting the National Grid as well as the

distorted sizes of the pillars have not been correctly shown in the working plan at all. In fact,

defective instruments, cannot give the closing error within permissible limits and plans cannot be

prepared without manipulating the data. The area Survey Officer, namely, Sri Mahal has tried to

explain that there could be possibility of workings being started after survey from a wrong point

without making prior co-relation from the surface to the underground base line and this may

have been the cause of the accident. This explanation again begs the same question as to why and

how were errors in the working plans made and why were the same not detected and rectified at

any point of time. It further appears that though the officials of the management as well as the

surveyors were fully aware of the fact that at a distance of less than hardly 78m due east there

existed a water logged old workings of Jayrampur Colliery, yet none of them were conscious

enough to ensure that the statutory provisions relating to safety and prevention from inundation

should be meticulously observed. Need to make a joint survey of Bagdigi and Jayrampur

Collieries was never felt by management and even after being prompted to do so, no sincere

effort was made to get the joint survey conducted. A vain attempt appears to have been made by

the management to explain that the joint survey could not possibly be conducted without first

dewatering the Jayrampur Colliery. This explanation again does not appear to be convincing. It

may be recalled that Sri Swapan Adhikari, Director of Mines Safety, Witness No. 55 during his

inspection of the colliery had specifically stated in his report of inspection that he had felt barrier

between Bagdigi and Jayrampur Collieries to be doubtful. He has stated in his deposition that he

had felt workings of Bagdigi Colliery to be doubtful. He had however instructed agent of

Bagdigi Colliery to prepare a fresh plan after consultation with the management of Jayrampur

Colliery. The above suspicions were reason enough for the Agent and the concerned officials of

Bagdigi Colliery management to be alerted and to take proper action for preparation of fresh plan

after conducting a fresh survey in consultation with the management of Jayrampur Colliery. In

the least, the agent and concerned officials of Bagdigi Colliery ought to have taken immediate

steps for check survey within its own Colliery, but strangely enough the urgency was never felt

by them. A feeble attempt to conduct a check survey appears to have been made for the 1st time

on 27.1.2000, but necessary diligence and sincerity appears to be conspicuously lacking. The

above conduct of the concerned officials indicate that they were either totally oblivious, of the

impending danger or had allowed themselves to remain complacent on the basis of their

presumption that the distance of 78m of the workings of their colliery from the adjoining water-

logged workings of Jayrampur Colliery was constantly maintained. The reason for such

complacence on the part of the officials and their obvious indifference towards the need to

ensure the essential protective and safety measures and their willful neglect to conduct even the

check survey appears to be owing to the fact that the workings were easily yielding abundant

17

coal. This was perhaps the main motive for extending the workings at such vigorous speed which

is reflected from the quantum of production made during that period.

The above facts and circumstances clearly indicate that the accident was avoidable and could

have been averted had proper care and diligence been shown by the concerned officials in course

of development of the seam. This leads to the issue as to who should be blamed and on whom

responsibility should be fixed for the accident.

Accident at Parascole West Colliery

Date of the Accident – 6.7.1999

Owner- Eastern Coalfields Ltd.

Number of persons killed – 5

Place – Kajora Area, District – Barddhaman, West Bengal

The accident occurred in Panel 23-I in Jambad seam top and bottom sections worked through

No.1 and No.6 Pits. Jambad seam, about 12.6 m thick and dipping at about 1 in 16, has been

developed in two sections leaving a parting of 5 m between the sections. The seam is overlain by

50 m to 55 m thick massive sandstone which is very difficult to cave.

Cause of the accident:

The panel was being worked in grass violation of the conditions stipulated in the depillaring

permission. The management had failed to install instruments to monitor the compression of the

yield pillar and barrier pillars. No convergence recorders had been installed in the vicinity of the

pillars under extract in to obtain indication of an impending roof fall. If these instruments had

been installed and regular readings were taken as stipulated in the permission letter, the officials

would have got prior warning of the fall and could have withdrawn the workers to safe places.

Therefore the entire responsibility for the accident lay with the management.

Investigation report

No strata movement in the goaf had been observed in the panel during the third shift of 5.7.1999.

In the morning shift of 6.7.1999, the top and bottom sections had been inspected by the mining

sirdars of the two sections, the senior overman, assistant manager and the manager himself and

upto about 10.40 a.m. there was no indication of any strata movement or weighting on the

supports or on pillar sides either in the top section or bottom section. At about 10.40 a.m., a

dresser, who was dressing the roof in the top section, felt the effect of impending fall of roof in

the goaf and he immediately informed the mining sirdar. At the same time, the manager, the

overman and mining sirdar, who were standing together in the bottom section, felt that the air

was being sucked into the goaf. The mining sirdar blew his whistle to warn the workers and he

himself lay down on the floor. Suddenly the overhanging roof in the goaf came down causing an

air-blast. The fall was so sudden that the mining sirdar of the top section did not get time to warn

the workers.

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Subsequent inspection and inquiry revealed that the main roof in the goaf over an area of 75 m x

75 m in the working panel and about 130 m x 78 m in the adjoining sealed off panel had fallen

suddenly without any prior indication, causing an air-blast which resulted in the death of two

persons on the spot and serious bodily injuries to six persons of whom two died on the same day

and one the following day in the hospital. Twenty others received reportable or minor injuries.

Accident at Godavari Khani 7LEP Mine,Singareni Collieries CO.

LTD

Accident- 16TH

JUNE, 2003

In early afternoon of June 16, 2003 a fatal accident due to inundation occurred in the

underground workings of the Godavarikhani 7 LEP mine of M/s. Singareni Collieries Company

Limited, a government owned company, in the Karimnagar district, Andhra Pradesh. In this,

accident seventeen miners lost their live.

During the accident, Panel Nos.4S/SS-4 and Panel No.4S/SS-2 in No.4 Seam were under

extraction in conjunction with hydraulic sand stowing. Extraction commenced on 4th November

2002 in panel 4S/SS-4 and on 5th June 2003 in panel 4S/SS-2 and was continuing when we

inspected the mine.

An entry to 2 Dip development district (i.e. the district where accident took place) in No. 3 seam

Top Section was made along 2nd dip from 17L in Bottom Section of No. 3 Seam. The 8m throw

fault had brought no.3 seam Top section on the dip side of the fault very close to the Bottom

section workings on the rise of the fault. Development in 2 Dip district in Top Section of No.3

Seam commenced from 28th April 2003. Part of this development, was made above the already

extracted panel No.3S/SS-1A in No.3 Seam Bottom Section. In this district, at the time of

accident, 18 level north gallery had progressed by 50m from 2dip, 18 level south gallery had

advanced about 65m from No.2 Dip and No.3 dip had progressed by about 7m off 18LN. No.1

and 0 Dips had progressed for about 17m and 7m respectively from 18LS, measured from centre

lines of galleries. No.2 dip had progressed about 18m to the dip of 19 level. 19 LN and 19 LS

had progressed by about 24m and 17m respectively from No. 2 dip. A 2m upthrow fault was

encountered in the No. 2 dip gallery, at about 20 m to the dip off the No. 18 level junction, as a

result of which the gallery height was reduced. To facilitate movement of tubs, the stone portion

in the fault area was blasted down. Seepage water of 2 Dip development district in Top Section

of No. 3 Seam used to accumulate in 2nd dip poty buffer off 19L and was being pumped out by a

15HP pump installed just above 19L in No. 2 dip.

The above water along with stowing water of Panel No.4S/SS-4 was coming out through a total

of 8 pipes (7 pipes of 6 inch diameter and one pipe of 8 inch diameter) fitted in the isolation

stopping in 16 LN off No.2 dip in No.4 seam. This water was flowing to a sump at 19 south level

off No.5t dip in No. 4 Seam. From here water was being pumped by two-75 HP pumps to main

sump at No.8 level in the same seam. From 8th level main sump two pumps, one-240 HP and the

other 190 HP were pumping water to surface.

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INVESTIGATION REPORT

Cause of the accident:

There is no doubt or dispute about the cause of the accident. This disastrous accident occurred

due to sudden inrush of water from panel No.3S/SS-1A in No.3 seam bottom section, which had

been extracted earlier by splitting as final operation in conjunction with hydraulic sand stowing,

into the workings of No.2 dip development district in top section of No.3 seam, due to sudden

rupture of the parting between the two sets of workings

The quantity of water causing the accident:

The water that rushed into No.2 dip development district in No.3 seam top section after filling up

the dip side workings stabilised at a point about 7 metres below 17L in No.2 dip. The survey of

the area and subsequent calculation indicate that total amount of 2640 cu.m (5,80,800 gallons)

flowed in from No.3 seam bottom section causing this accident.

Involvement of senior management:

The Board of Directors headed by a Chairman runs the Singareni Collieries Company Ltd. The

Chairman, an IAS Officer, is appointed by Govt. of Andhra Pradesh. He is assisted by two

Directors in the technical field called Director (Operations) and Director (Project & Planning).

Each of these Directors is declared owner under Section 76 of the Mines Act, 1952, for different

mines. The Chairman of the Board of Directors who is appointed by the Government of Andhra

Pradesh has no responsibility in terms of any law. In considering his position as an IAS and

being the Chairman of the Board of Directors, one can perceive the influence he would be

exercising over the working of the company. This is unfair as Chairman is not responsible, but he

will have considerable powers. The Chairman is so detached from the affairs of the company that

he did not even think it proper to meet the Court of Enquiry at any stage.

The owner was not effecting adequate supervision and control in the safety of running mines as

indicated by a few examples given below:

As mentioned earlier, work in an area declared non-workable by the owner, was re-started by

the agent and manager of Godavarikhani No.7 LEP Mine without informing him. In fact, he was

unaware that work was going on in No.2 Dip district until the occurrence of accident.

Apparently, detail review of the safety was not being undertaken by the owner.

The Agent and Manager also informed that before starting of 2 dip development district in No.3

seam top section, clearance from the Internal Safety Organisation was not obtained as

recommended by National Conference on Safety in Mines. The owner had not ensured such

compliance.

There appears to be no system in place whereby owner could supervise work in a systematic

way. The owner was not keeping a check on amount of stowing being done in any district. It is

really surprising that such an important activity which involves not only safety of work persons

but also requires heavy expenditure is ever monitored by the owner. Lack of proper system is

20

also brought to the fore by the fact that a major inrush of sand and water after breaching an

isolation stopping did not come to the knowledge of the owner and attempts were made to

explain the breach by poor excuses.

From the above, it would appear that the owner who was a qualified mining engineer with First

Class Mining Certificate was abdicating his responsibilities and created systems which were not

conducive to safety.

Conclusion

1. Large quantity of water, estimated to be several thousand gallons, had accumulated in

panel No.3S/SS-1A in No.3 seam bottom section which was extracted in the year 2000 by

splitting as final operation in conjunction with hydraulic sand stowing. The accumulation

was due to inter-granular space in sand, shrinkage of stowed sand with time, inadequate

stowing.

2. In an area which was declared non-workable by the owner in 1999, development in 2 dip

district in No.3 seam top section was started in April, 2003, without the knowledge of the

owner.

3. This 2 dip development district in No. 3 seam top section was being worked within 60

metres of the No.3 seam bottom section workings in panel No.3S/SS-1A. This work was

done without taking prior permission from the Regional Inspector of Mines and without

taking due precautions against the danger of inundation arising out of working close to

water-logged workings.

4. The parting between top and bottom sections of 3 seam which was to have been kept 5

metres, got reduced by roof falls occurring in 3 seam bottom section along the 2 metres

throw fault plane. The parting must have been reduced to a few centimetres just before

the rupture.

5. The head of water, which was calculated to be about 15 metres, was enough to cause the

rupture leading to sudden inrush in top section.

6. The water rushed along 18L through the puncture in the form of a wall of a height of

about 1 metre. After traveling southwards, it entered No. 2 dip where 17 workers who

were working in and below 19L and who were drowned in the inrushing water.

7. Lack of Supervision in mining in general and stowing of sand in particular.

8. There is no system in place whereby after stowing any responsible officer would certify

that stowing was proper and adequate before the District could be closed.

21

References:-

http://www.msha.gov/

http://www.maptek.com/training/

http://www.sysd.cn/qysp_02_en.do

http://www.greatmining.com/

http://www.miningiq.com/

http://www.infomine.com/

http://www.mining.com/

http://www.astralmining.com/

https://sites.google.com/site/hindustancopperlimitedsite/

http://www.rcrkopex.com.au/

http://www.usmra.com/

http://www.novamining.com/