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

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

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 Where What Who Why How Is it the proper time Is it the proper location or machine Is it the correct thing to do Is it done by the proper person ,trained etc Is it necessary to do 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 Death & injury Disease Damage to equipment & property Litigation costs Lost productivity Positive aspects
o o o o o o o

Accident investigation Change to safety programs

Contributing factors Environmental o Noise o Vapors, fumes, dust o Light o Heat

Design
o o

Workplace layout Design of tools & equipment

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.

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.

 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 southside 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.

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 faultplane, 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 800F 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. 2. 3. 4. Sets of geological discontinuities in the strata The fault plane along the barrier between Kawadi and New Majri mines. Presence of water in the strata due to heavy rainfall prior to the accident. 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 handheld 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 managements 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 5lhlevels 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 waterlogged 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

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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
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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.

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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/

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