OVERVIEW_NN1 
On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN at_PRP approximately_AV0 8_CRD :_PUN 00_CRD p.m._AV0 ,_PUN Dustin_NP0 Thomas_NP0 ,_PUN a_AT0 47-year-old_AJ0 drill_NN1 operator_NN1 with_PRP seven_CRD years_NN2 of_PRF mining_NN1 experience_NN1 ,_PUN died_VVN as_PRP a_AT0 result_NN1 of_PRF injuries_NN2 he_PNP suffered_VVD when_CJS the_AT0 "_PUQ J_ZZ0 wrench_VVB "_PUQ he_PNP was_VBD using_VVG to_TO0 remove_VVI a_AT0 down_AVP hole_NN1 drill_NN1 (_PUL DHD_NP0 )_PUR from_PRP the_AT0 drill_NN1 steel_NN1 moved_VVD unexpectedly_AV0 ,_PUN crushing_VVG his_DPS right_AJ0 thigh_NN1 between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 drill_NN1 mast_NN1 ._SENT 
The_AT0 accident_NN1 occurred_VVD because_CJS mine_DPS management_NN1 did_VDD not_XX0 assure_VVI that_CJT :_PUN (_PUL 1_CRD )_PUR miners_NN2 working_VVG on_PRP the_AT0 drill_NN1 stayed_VVD clear_AJ0 of_PRF moving_VVG parts_NN2 and_CJC machine_NN1 pinch_NN1 points_NN2 ;_PUN (_PUL 2_CRD )_PUR equipment_NN1 was_VBD turned_VVN off_AVP or_CJC blocked_VVN against_PRP hazardous_AJ0 motion_NN1 while_CJS conducting_VVG maintenance_NN1 activities_NN2 ;_PUN (_PUL 3_CRD )_PUR miners_NN2 followed_VVD the_AT0 equipment_NN1 manufacturer_NN1 's_POS written_AJ0 procedures_NN2 for_PRP de-tooling_VVG the_AT0 machine_NN1 ;_PUN and_CJC (_PUL 4_CRD )_PUR miners_NN2 were_VBD provided_VVN adequate_AJ0 task_NN1 training_NN1 for_PRP the_AT0 removal_NN1 of_PRF the_AT0 DHD_NN1 ._SENT 
GENERAL_AJ0 INFORMATION_NN1 
Teck_NP0 Resources_NN2 Ltd._AJ0 is_VBZ the_AT0 parent_NN1 company_NN1 of_PRF Teck_NP0 Alaska_NP0 Inc._AJ0 which_DTQ owns_VVZ and_CJC operates_VVZ Red_AJ0 Dog_NN1 Operations_NN2 (_PUL Red_AJ0 Dog_NN1 )_PUR ._SENT Red_AJ0 Dog_NN1 is_VBZ a_AT0 surface_NN1 lead-zinc_NN1 ore_NN1 mine_NN1 located_VVN near_PRP Kotzebue_NP0 ,_PUN Northwest_NP0 Arctic_AJ0 Borough_NN1 ,_PUN Alaska_NP0 and_CJC employs_VVZ 251_CRD miners_NN2 ._SENT The_AT0 mine_NN1 operates_VVZ two_CRD 12-hour_AJ0 shifts_NN2 ,_PUN seven_CRD days_NN2 per_PRP week_NN1 ._SENT The_AT0 mine_NN1 drills_VVZ and_CJC blasts_VVZ lead-zinc_AJ0 ore_NN1 in_PRP an_AT0 open_AJ0 pit_NN1 ._SENT The_AT0 ore_NN1 is_VBZ transported_VVN by_PRP haul_NN1 truck_NN1 to_PRP an_AT0 on-site_AJ0 processing_NN1 facility_NN1 where_AVQ the_AT0 ore_NN1 is_VBZ concentrated_VVN and_CJC sent_VVN to_PRP an_AT0 offsite_AJ0 refinery_NN1 ._SENT 
Principal_AJ0 Officers_NN2 for_PRP Teck_NP0 Resources_NN2 Ltd._AJ0 and_CJC Teck_NP0 Alaska_NP0 Inc._AJ0 at_PRP the_AT0 time_NN1 of_PRF the_AT0 accident_NN1 were_VBD :_PUN 
Don_NP0 R_NP0 ._SENT Lindsey_NP0 President_NP0 and_CJC Chief_NP0 Executive_NN1 Officer_NN1 ,_PUN Teck_NP0 Resources_NN2 Ltd._AJ0 
Dale_NP0 Andres_NP0 President_NP0 ,_PUN Teck_NP0 Alaska_NP0 Inc._AJ0 
Leslie_NP0 Yesnik_NP0 General_AJ0 Manager_NN1 ,_PUN Teck_NP0 Alaska_NP0 Inc._AJ0 
Les_NP0 Panther_NN1 Treasurer_NN1 ,_PUN Teck_NP0 Alaska_NP0 Inc._AJ0 
The_AT0 Mine_NN1 Safety_NN1 and_CJC Health_NN1 Administration_NN1 (_PUL MSHA_NP0 )_PUR completed_VVD the_AT0 last_ORD regular_AJ0 safety_NN1 and_CJC health_NN1 inspection_NN1 at_PRP this_DT0 mine_NN1 on_PRP August_NP0 24_CRD ,_PUN 2020._CRD The_AT0 2019_CRD non-fatal_AJ0 days_NN2 lost_VVN (_PUL NFDL_NP0 )_PUR incident_NN1 rate_NN1 for_PRP Red_AJ0 Dog_NN1 was_VBD 0.34_CRD ,_PUN compared_VVN to_PRP the_AT0 national_AJ0 average_NN1 of_PRF 0.79_CRD for_PRP mines_NN2 of_PRF this_DT0 type_NN1 ._SENT 
DESCRIPTION_NN1 OF_PRF THE_AT0 ACCIDENT_NN1 
On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN Thomas_NP0 started_VVD his_DPS shift_NN1 at_PRP 7_CRD :_PUN 00_CRD p.m._AV0 by_PRP attending_VVG a_AT0 pre-work_AJ0 meeting_NN1 with_PRP the_AT0 drill_NN1 and_CJC blast_NN1 crew_NN1 ._SENT After_PRP the_AT0 meeting_NN1 ,_PUN Thomas_NP0 and_CJC Casey_NP0 Buie_NP0 ,_PUN Driller_NP0 /_PUN Blaster_NN1 ,_PUN traveled_VVN to_PRP the_AT0 1225_CRD level_NN1 of_PRF the_AT0 Qanaiyaq_NP0 Pit_NN1 ._SENT Thomas_NP0 moved_VVD Company_NN1 Drill_NN1 #40-007_CRD away_AV0 from_PRP where_AVQ they_PNP were_VBD drilling_VVG on_PRP this_DT0 level_NN1 ,_PUN and_CJC Buie_NP0 began_VVD the_AT0 process_NN1 of_PRF separating_VVG the_AT0 DHD_NN1 from_PRP the_AT0 drill_NN1 steel_NN1 of_PRF Company_NN1 Drill_NN1 #40-008_CRD ,_PUN a_AT0 process_NN1 commonly_AV0 referred_VVN to_PRP as_PRP "_PUQ de-tooling_AJ0 ._SENT "_PUQ After_PRP parking_NN1 Company_NN1 Drill_NN1 #40-007_CRD ,_PUN Thomas_NP0 traveled_VVD to_PRP Company_NN1 Drill_VVB #40-008_AJ0 to_TO0 assist_VVI Buie_NP0 with_PRP the_AT0 de-tooling_AJ0 process_NN1 ._SENT 
During_PRP de-tooling_NN1 ,_PUN Thomas_NP0 retrieved_VVD a_AT0 J_NP0 wrench_NN1 (_PUL a_AT0 specially_AV0 designed_VVN wrench_NN1 to_TO0 fit_VVI on_PRP the_AT0 backhead_NN1 ,_PUN which_DTQ connects_VVZ the_AT0 DHD_NN1 to_PRP the_AT0 drill_NN1 steel_NN1 )_PUR ,_PUN and_CJC installed_VVD it_PNP on_PRP the_AT0 wrench_NN1 slots_NN2 of_PRF the_AT0 DHD_NN1 ,_PUN approximately_AV0 27_CRD inches_NN2 above_PRP the_AT0 drill_NN1 deck_NN1 ._SENT The_AT0 engine_NN1 of_PRF the_AT0 drill_NN1 rig_NN1 was_VBD running_VVG while_CJS Thomas_NP0 installed_VVD the_AT0 J_NP0 wrench_NN1 ,_PUN and_CJC the_AT0 DHD_NN1 rapidly_AV0 rotated_VVN in_PRP a_AT0 counter-clockwise_AJ0 direction_NN1 ,_PUN crushing_VVG Thomas_NP0 's_POS right_AJ0 thigh_NN1 between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 mast_NN1 of_PRF the_AT0 drill_NN1 ._SENT At_PRP the_AT0 same_DT0 time_NN1 ,_PUN Buie_NP0 was_VBD bending_VVG down_AVP from_PRP the_AT0 drill_NN1 operator_NN1 's_POS seat_NN1 to_TO0 look_VVI for_PRP a_AT0 lifting_NN1 bail_NN1 (_PUL a_AT0 tool_NN1 used_VVN to_TO0 lift_VVI the_AT0 DHD_NN1 )_PUR when_CJS he_PNP heard_VVD a_AT0 clang_NN1 and_CJC Thomas_NP0 scream_NN1 ._SENT Buie_NP0 sat_VVD up_AVP and_CJC saw_VVD Thomas_NP0 's_POS right_AJ0 leg_NN1 caught_VVN between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 drill_NN1 mast_NN1 ._SENT Buie_NP0 reversed_VVD the_AT0 drill_NN1 steel_NN1 and_CJC Thomas_NP0 fell_VVD forward_AV0 onto_PRP the_AT0 deck_NN1 and_CJC then_AV0 rolled_VVD onto_PRP his_DPS back_NN1 ._SENT 
Buie_NP0 observed_VVD blood_NN1 on_PRP Thomas_NP0 's_POS insulated_AJ0 coveralls_NN2 and_CJC called_VVD Emergency_NN1 Medical_AJ0 Services_NN2 (_PUL EMS_NP0 )_PUR on_PRP the_AT0 radio_NN1 ._SENT Buie_NP0 then_AV0 made_VVD a_AT0 tourniquet_NN1 using_VVG a_AT0 rope_NN1 and_CJC tied_VVD it_PNP around_PRP Thomas_NP0 's_POS upper_AJ0 right_AJ0 thigh_NN1 ._SENT EMS_NP0 arrived_VVD on_PRP scene_NN1 and_CJC transported_VVD Thomas_NP0 to_PRP the_AT0 mine_NN1 's_POS medical_AJ0 clinic_NN1 ._SENT Resuscitative_AJ0 efforts_NN2 were_VBD not_XX0 successful_AJ0 ,_PUN and_CJC Jim_NP0 Duchenin_NP0 ,_PUN Physician_NN1 's_VBZ Assistant_AJ0 ,_PUN in_PRP consultation_NN1 with_PRP Dr._NP0 Donald_NP0 Hudson_NP0 in_PRP Anchorage_NP0 ,_PUN Alaska_NP0 ,_PUN pronounced_VVD Thomas_NP0 dead_AV0 at_PRP 9_CRD :_PUN 15_CRD p.m._AV0 
INVESTIGATION_NN1 OF_PRF THE_AT0 ACCIDENT_NN1 
On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN at_PRP 9_CRD :_PUN 15_CRD p.m._AV0 ,_PUN Tyler_NP0 Martin_NP0 ,_PUN Safety_NN1 &_NN1 Health_NN1 Lead_NN1 ,_PUN called_VVD the_AT0 Department_NN1 of_PRF Labor_NN1 National_AJ0 Contact_NN1 Center_NN1 (_PUL DOLNCC_NP0 )_PUR ._SENT The_AT0 DOLNCC_NN1 contacted_VVD Bart_NP0 Wrobel_NP0 ,_PUN Supervisory_AJ0 Mine_NN1 Safety_NN1 and_CJC Health_NN1 Inspector_NN1 ._SENT Wrobel_NP0 contacted_VVD Robert_NP0 C_NP0 ._SENT Wood_NP0 ,_PUN Supervisory_AJ0 Mine_NN1 Safety_NN1 and_CJC Health_NN1 Inspector_NN1 ,_PUN and_CJC Wood_NP0 contacted_VVD Gary_NP0 Hebel_NP0 ,_PUN Assistant_AJ0 District_NN1 Manager_NN1 ._SENT Hebel_NP0 dispatched_VVD Mathew_NP0 S._NP0 Johnson_NP0 ,_PUN Mine_NN1 Safety_NN1 and_CJC Health_NN1 Inspector_NN1 ,_PUN to_PRP the_AT0 mine_NN1 ._SENT At_PRP 9_CRD :_PUN 45_CRD p.m._AV0 ,_PUN Wood_NP0 issued_VVD an_AT0 order_NN1 to_PRP the_AT0 mine_NN1 operator_NN1 ,_PUN under_PRP the_AT0 provisions_NN2 of_PRF 103_CRD (_PUL k_ZZ0 )_PUR of_PRF the_AT0 Federal_AJ0 Mine_NN1 Safety_NN1 and_CJC Health_NN1 Act_NN1 of_PRF 1977_CRD ,_PUN to_TO0 ensure_VVI the_AT0 safety_NN1 of_PRF miners_NN2 and_CJC rescue_NN1 personnel_NN2 prior_AJ0 to_PRP the_AT0 investigation_NN1 team_NN1 's_POS arrival_NN1 at_PRP the_AT0 site_NN1 ._SENT 
Wood_NP0 arrived_VVD at_PRP the_AT0 mine_NN1 on_PRP January_NP0 17_CRD ,_PUN 2021_CRD ,_PUN and_CJC began_VVD gathering_VVG information_NN1 in_PRP preparation_NN1 for_PRP Johnson_NP0 's_POS arrival_NN1 ._SENT Johnson_NP0 arrived_VVD at_PRP the_AT0 mine_NN1 site_NN1 at_PRP 4_CRD :_PUN 30_CRD p.m._AV0 on_PRP January_NP0 18_CRD ,_PUN 2021_CRD ,_PUN to_TO0 continue_VVI the_AT0 investigation_NN1 ._SENT MSHA_NP0 's_POS accident_NN1 investigation_NN1 team_NN1 conducted_VVD a_AT0 physical_AJ0 examination_NN1 of_PRF the_AT0 accident_NN1 scene_NN1 ,_PUN interviewed_VVD miners_NN2 ,_PUN and_CJC reviewed_VVD conditions_NN2 and_CJC work_NN1 procedures_NN2 relevant_AJ0 to_PRP the_AT0 accident_NN1 ._SENT See_VVB Appendix_NN1 A_ZZ0 for_PRP a_AT0 list_NN1 of_PRF persons_NN2 who_PNQ participated_VVD in_PRP the_AT0 investigation_NN1 ._SENT 
DISCUSSION_NN1 
Location_NN1 of_PRF the_AT0 Accident_NN1 
The_AT0 accident_NN1 occurred_VVN on_PRP the_AT0 1225_CRD bench_NN1 of_PRF the_AT0 Qanaiyaq_NP0 Pit_NN1 ._SENT 
Equipment_NN1 Involved_AJ0 
The_AT0 drill_NN1 involved_VVN in_PRP this_DT0 accident_NN1 is_VBZ a_AT0 track-mounted_AJ0 Atlas_NN1 Copco_NP0 drill_NN1 (_PUL see_VVB Appendix_NN1 B_ZZ0 )_PUR ._SENT The_AT0 DHD_NN1 is_VBZ an_AT0 air-driven_AJ0 ,_PUN piston-powered_AJ0 device_NN1 used_VVN for_PRP drilling_VVG hard_AJ0 rock_NN1 ._SENT The_AT0 manufacturer_NN1 's_POS manual_NN1 states_VVZ that_CJT the_AT0 J_NP0 wrench_NN1 must_VM0 be_VBI placed_VVN on_PRP the_AT0 backhead_NN1 so_AV0 that_CJT the_AT0 J_NP0 wrench_NN1 is_VBZ slightly_AV0 above_PRP the_AT0 deck_NN1 when_CJS being_VBG used_VVN ._SENT Investigators_NN2 found_VVD the_AT0 J_NP0 wrench_NN1 27_CRD inches_NN2 above_PRP the_AT0 deck_NN1 on_PRP the_AT0 backhead_NN1 ._SENT 
Investigators_NN2 inspected_VVD the_AT0 drill_NN1 ,_PUN observed_AJ0 drill_NN1 function_NN1 ,_PUN including_PRP drill_NN1 rotation_NN1 ,_PUN and_CJC did_VDD not_XX0 find_VVI defects_NN2 that_CJT contributed_VVD to_PRP the_AT0 accident_NN1 ._SENT The_AT0 investigators_NN2 were_VBD unable_AJ0 to_TO0 replicate_VVI or_CJC determine_VVI the_AT0 cause_NN1 of_PRF the_AT0 rapid_AJ0 counter-clockwise_AJ0 rotation_NN1 ._SENT 
Weather_NN1 
At_PRP the_AT0 time_NN1 of_PRF the_AT0 accident_NN1 ,_PUN the_AT0 weather_NN1 was_VBD 10_CRD degrees_NN2 Fahrenheit_NN1 and_CJC partly_AV0 cloudy_AJ0 ._SENT Investigators_NN2 determined_VVD that_CJT weather_NN1 was_VBD not_XX0 a_AT0 contributing_AJ0 factor_NN1 in_PRP the_AT0 accident_NN1 ._SENT 
Training_NN1 and_CJC Experience_NN1 
Dustin_NP0 Thomas_NP0 had_VHD seven_CRD years_NN2 of_PRF mining_NN1 experience_NN1 ,_PUN all_DT0 at_PRP this_DT0 mine_NN1 ._SENT Thomas_NP0 had_VHD approximately_AV0 three_CRD years_NN2 of_PRF experience_NN1 as_PRP a_AT0 driller_NN1 /_PUN blaster_NN1 ._SENT He_PNP received_VVD annual_AJ0 refresher_NN1 training_NN1 in_PRP 2020_CRD ,_PUN in_PRP accordance_NN1 with_PRP MSHA_NP0 's_POS Part_NN1 48_CRD training_NN1 regulations_NN2 ._SENT He_PNP had_VHD received_VVN task_NN1 training_NN1 on_PRP the_AT0 drill_NN1 ,_PUN but_CJC the_AT0 training_NN1 regarding_PRP de-tooling_VVG the_AT0 DHD_NN1 was_VBD inadequate_AJ0 ._SENT Red_AJ0 Dog_NN1 Operations_NN2 did_VDD not_XX0 train_VVI their_DPS drill_NN1 operators_NN2 to_TO0 place_VVI the_AT0 J_NP0 wrench_NN1 on_PRP the_AT0 backhead_NN1 so_AV0 that_CJT the_AT0 J_NP0 wrench_NN1 is_VBZ slightly_AV0 above_PRP the_AT0 drill_NN1 's_POS deck_NN1 ,_PUN and_CJC to_TO0 remain_VVI clear_AJ0 of_PRF any_DT0 pinch_NN1 points_NN2 while_CJS operating_VVG the_AT0 Atlas_NN1 Copco_NN1 drills_NN2 as_CJS stated_VVN in_PRP the_AT0 manufacturer_NN1 's_POS manual_NN1 ._SENT 
Examinations_NN2 
Constantine_NP0 Lestenkof_NP0 ,_PUN Jr._NP0 ,_PUN Mine_NN1 Operations_NN2 Shifter_NN1 ,_PUN conducted_VVD a_AT0 workplace_NN1 examination_NN1 of_PRF the_AT0 1225_CRD bench_NN1 before_PRP work_NN1 commenced_VVN in_PRP this_DT0 area_NN1 and_CJC did_VDD not_XX0 note_VVI any_DT0 deficiencies_NN2 ._SENT 
Illumination_NN1 
It_PNP was_VBD dark_AJ0 at_PRP the_AT0 time_NN1 of_PRF the_AT0 accident_NN1 ._SENT Work_NN1 lights_NN2 in_PRP the_AT0 area_NN1 provided_VVD adequate_AJ0 illumination_NN1 on_PRP the_AT0 drills_NN2 ._SENT 
Policy_NN1 and_CJC Procedures_NN2 
The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 have_VHI policies_NN2 or_CJC procedures_NN2 in_PRP place_NN1 for_PRP de-tooling_VVG the_AT0 DHD_NN1 ._SENT The_AT0 mine_NN1 operator_NN1 had_VHD a_AT0 general_AJ0 standard_AJ0 operating_NN1 procedure_NN1 (_PUL SOP_NN1 )_PUR in_PRP place_NN1 for_PRP drill_NN1 operation_NN1 and_CJC removal_NN1 of_PRF drill_NN1 steel_NN1 ,_PUN but_CJC the_AT0 SOP_NN1 did_VDD not_XX0 provide_VVI specific_AJ0 information_NN1 for_PRP the_AT0 safe_AJ0 removal_NN1 of_PRF the_AT0 DHD_NN1 using_VVG the_AT0 J_NP0 wrench_NN1 ,_PUN nor_CJC did_VDD it_PNP reference_VVI the_AT0 manufacturer_NN1 's_POS instructions_NN2 for_PRP the_AT0 procedure_NN1 ._SENT 
ROOT_NN1 CAUSE_NN1 ANALYSIS_NN1 
The_AT0 accident_NN1 investigation_NN1 team_NN1 conducted_VVD an_AT0 analysis_NN1 to_TO0 identify_VVI the_AT0 underlying_AJ0 causes_NN2 of_PRF the_AT0 accident_NN1 ._SENT The_AT0 team_NN1 identified_VVD the_AT0 following_AJ0 root_NN1 causes_NN2 ,_PUN and_CJC the_AT0 mine_NN1 operator_NN1 implemented_VVN the_AT0 corresponding_AJ0 corrective_AJ0 actions_NN2 to_TO0 prevent_VVI a_AT0 recurrence_NN1 ._SENT 
1._CRD Root_NN1 Cause_NN1 :_PUN The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 have_VHI adequate_AJ0 policies_NN2 and_CJC procedures_NN2 to_TO0 ensure_VVI miners_NN2 stayed_VVD clear_AJ0 of_PRF moving_VVG drill_NN1 parts_NN2 ._SENT 
Corrective_AJ0 Action_NN1 :_PUN Red_AJ0 Dog_NN1 Operations_NN2 updated_VVD their_DPS written_AJ0 policies_NN2 and_CJC procedures_NN2 to_TO0 include_VVI periodic_AJ0 field_NN1 reviews_NN2 of_PRF de-tooling_NN1 and_CJC drill_NN1 maintenance_NN1 activities_NN2 ,_PUN to_TO0 assure_VVI that_CJT miners_NN2 stay_VVB clear_AJ0 of_PRF moving_VVG drill_NN1 parts_NN2 ._SENT The_AT0 mine_NN1 operator_NN1 trained_VVD all_DT0 miners_NN2 and_CJC managers_NN2 on_PRP the_AT0 new_AJ0 policies_NN2 and_CJC procedures_NN2 ._SENT 
2._CRD Root_NN1 Cause_NN1 :_PUN The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 have_VHI policies_NN2 to_TO0 assure_VVI that_CJT miners_NN2 turned_VVD off_AVP or_CJC blocked_VVD equipment_NN1 against_PRP hazardous_AJ0 motion_NN1 while_CJS conducting_VVG maintenance_NN1 activities_NN2 ._SENT 
Corrective_AJ0 Action_NN1 :_PUN Red_AJ0 Dog_NN1 Operations_NN2 developed_VVD new_AJ0 written_AJ0 policies_NN2 and_CJC procedures_NN2 to_TO0 include_VVI periodic_AJ0 field_NN1 reviews_NN2 of_PRF de-tooling_NN1 and_CJC drill_NN1 maintenance_NN1 activities_NN2 to_TO0 ensure_VVI that_CJT miners_NN2 de-energize_VVB and_CJC block_VVB equipment_NN1 against_PRP hazardous_AJ0 motion_NN1 during_PRP this_DT0 activity_NN1 ._SENT The_AT0 mine_NN1 operator_NN1 trained_VVN miners_NN2 and_CJC managers_NN2 on_PRP the_AT0 new_AJ0 written_AJ0 policies_NN2 and_CJC procedures_NN2 ._SENT 
3._CRD Root_NN1 Cause_NN1 :_PUN The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 have_VHI policies_NN2 to_TO0 assure_VVI miners_NN2 were_VBD de-tooling_VVG the_AT0 DHD_NN1 within_PRP the_AT0 scope_NN1 of_PRF the_AT0 manufacturer_NN1 's_POS instructions_NN2 ._SENT 
Corrective_AJ0 Action_NN1 :_PUN Red_AJ0 Dog_NN1 Operations_NN2 implemented_VVN a_AT0 new_AJ0 written_AJ0 policy_NN1 in_PRP conformance_NN1 with_PRP the_AT0 manufacturer_NN1 's_POS manual_NN1 for_PRP de-tooling_VVG the_AT0 DHD_NN1 ._SENT The_AT0 mine_NN1 operator_NN1 trained_VVN miners_NN2 and_CJC managers_NN2 on_PRP the_AT0 new_AJ0 written_AJ0 policy_NN1 ,_PUN which_DTQ includes_VVZ placing_VVG the_AT0 J_NP0 wrench_NN1 on_PRP the_AT0 backhead_NN1 so_AV0 that_CJT the_AT0 J_NP0 wrench_NN1 is_VBZ slightly_AV0 above_PRP the_AT0 drill_NN1 's_POS deck_NN1 ,_PUN and_CJC remaining_VVG clear_AJ0 of_PRF pinch_NN1 points_NN2 as_CJS stated_VVN in_PRP the_AT0 manufacturer_NN1 's_POS manual_NN1 ._SENT 
4._CRD Root_NN1 Cause_NN1 :_PUN The_AT0 mine_NN1 operator_NN1 's_POS task_NN1 training_NN1 program_NN1 had_VHD a_AT0 deficiency_NN1 that_CJT allowed_VVD inadequacies_NN2 in_PRP the_AT0 miners_NN2 '_POS training_NN1 ._SENT 
Corrective_AJ0 Action_NN1 :_PUN Red_AJ0 Dog_NN1 Operations_NN2 revised_VVD their_DPS task_NN1 training_NN1 plan_NN1 to_TO0 require_VVI management_NN1 observation_NN1 of_PRF new_AJ0 drill_NN1 operators_NN2 '_POS performance_NN1 of_PRF drilling_VVG procedures_NN2 ,_PUN including_PRP de-tooling_VVG the_AT0 DHD_NN1 ,_PUN during_PRP non-production_AJ0 sessions_NN2 ._SENT If_CJS any_DT0 hazardous_AJ0 conditions_NN2 or_CJC practices_NN2 are_VBB observed_VVN ,_PUN management_NN1 will_VM0 immediately_AV0 conduct_VVI re-training_NN1 ._SENT The_AT0 mine_NN1 operator_NN1 provided_VVN task_NN1 training_NN1 to_PRP all_DT0 drill_NN1 operators_NN2 on_PRP how_AVQ to_TO0 safely_AV0 operate_VVI ,_PUN and_CJC de-tool_NP0 ,_PUN an_AT0 Atlas_NN1 Copco_NN1 drill_NN1 ._SENT 
CONCLUSION_NN1 
On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN at_PRP approximately_AV0 8_CRD :_PUN 00_CRD p.m._AV0 ,_PUN Dustin_NP0 Thomas_NP0 ,_PUN a_AT0 47-year-old_AJ0 driller_NN1 with_PRP seven_CRD years_NN2 of_PRF mining_NN1 experience_NN1 ,_PUN died_VVN as_PRP a_AT0 result_NN1 of_PRF injuries_NN2 he_PNP suffered_VVD when_CJS the_AT0 "_PUQ J_ZZ0 wrench_VVB "_PUQ he_PNP was_VBD using_VVG to_TO0 remove_VVI a_AT0 down_AVP hole_NN1 drill_NN1 (_PUL DHD_NP0 )_PUR from_PRP the_AT0 drill_NN1 steel_NN1 moved_VVD unexpectedly_AV0 ,_PUN crushing_VVG his_DPS right_AJ0 thigh_NN1 between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 drill_NN1 mast_NN1 ._SENT 
The_AT0 accident_NN1 occurred_VVD because_CJS mine_DPS management_NN1 did_VDD not_XX0 assure_VVI that_CJT :_PUN (_PUL 1_CRD )_PUR miners_NN2 working_VVG on_PRP the_AT0 drill_NN1 stayed_VVD clear_AJ0 of_PRF moving_VVG parts_NN2 and_CJC machine_NN1 pinch_NN1 points_NN2 ;_PUN (_PUL 2_CRD )_PUR equipment_NN1 was_VBD turned_VVN off_AVP or_CJC blocked_VVN against_PRP hazardous_AJ0 motion_NN1 while_CJS conducting_VVG maintenance_NN1 activities_NN2 ;_PUN (_PUL 3_CRD )_PUR miners_NN2 followed_VVD the_AT0 equipment_NN1 manufacturer_NN1 's_POS written_AJ0 procedures_NN2 for_PRP de-tooling_VVG the_AT0 machine_NN1 ;_PUN and_CJC (_PUL 4_CRD )_PUR miners_NN2 were_VBD provided_VVN adequate_AJ0 task_NN1 training_NN1 for_PRP the_AT0 removal_NN1 of_PRF the_AT0 DHD_NN1 ._SENT 
Approved_VVN By_PRP :_PUN James_NP0 M_NP0 ._SENT Peck_NP0 District_NN1 Manager_NN1 
ENFORCEMENT_NN1 ACTIONS_NN2 
1._CRD A_ZZ0 103_CRD (_PUL k_ZZ0 )_PUR Order_NN1 No._NN1 7982434_CRD was_VBD issued_VVN to_PRP Teck_NP0 Alaska_NP0 Inc._AJ0 on_PRP January_NP0 17_CRD ,_PUN 2021._CRD 
A_AT0 miner_NN1 was_VBD fatally_AV0 injured_VVN on_PRP drill_NN1 no._NN1 4008_CRD on_PRP the_AT0 1200-670_CRD pattern_NN1 of_PRF the_AT0 1225_CRD bench_NN1 at_PRP 8_CRD :_PUN 00_CRD pm_AV0 ,_PUN and_CJC died_VVD at_PRP 9_CRD :_PUN 15_CRD pm_AV0 on_PRP 1_CRD /_PUN 16_CRD /_PUN 2021._CRD All_DT0 persons_NN2 are_VBB prohibited_VVN from_PRP entering_VVG the_AT0 1225_CRD bench_NN1 ,_PUN or_CJC entering_VVG /_PUN operating_VVG drill_NN1 number_NN1 4008_CRD or_CJC 4007._CRD This_DT0 order_NN1 was_VBD initially_AV0 issued_VVN at_PRP 9_CRD :_PUN 45_CRD pm_AV0 on_PRP 1_CRD /_PUN 16_CRD /_PUN 2020_CRD by_PRP MSHA_NP0 Supervisory_AJ0 Inspector_NP0 Robert_NP0 Wood_NP0 ,_PUN and_CJC is_VBZ now_AV0 being_VBG reduced_VVN to_PRP writing_VVG ._SENT 
2._CRD A_ZZ0 104_CRD (_PUL a_AT0 )_PUR Citation_NN1 was_VBD issued_VVN to_PRP Teck_NP0 Alaska_NP0 Inc._AJ0 for_PRP violation_NN1 of_PRF 30_CRD CFR_NP0 §_NN0 56.14105_CRD ._SENT 
Maintenance_NN1 activity_NN1 was_VBD being_VBG performed_VVN on_PRP the_AT0 Atlas_NN1 Copco_NP0 DML_NP0 HP_NN1 900_CRD drill_NN1 ,_PUN Company_NN1 #40-008_CRD ,_PUN while_CJS the_AT0 machine_NN1 's_POS power_NN1 was_VBD not_XX0 off_AVP ,_PUN nor_CJC was_VBD it_PNP blocked_VVN against_PRP hazardous_AJ0 motion_NN1 ._SENT On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN a_AT0 driller_NN1 died_VVD while_CJS assisting_VVG another_DT0 drill_NN1 operator_NN1 in_PRP removing_VVG the_AT0 down_AVP hole_NN1 drill_NN1 (_PUL DHD_NP0 )_PUR from_PRP Company_NN1 Drill_NN1 #40-008_CRD ._SENT The_AT0 driller_NN1 was_VBD installing_VVG a_AT0 J_NP0 wrench_NN1 on_PRP the_AT0 DHD_AJ0 wrench_NN1 slots_NN2 when_CJS the_AT0 DHD_NN1 rapidly_AV0 rotated_VVN in_PRP a_AT0 counter-clockwise_AJ0 direction_NN1 ,_PUN crushing_VVG his_DPS right_AJ0 thigh_NN1 between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 drill_NN1 mast_NN1 ._SENT The_AT0 machine_NN1 power_NN1 was_VBD on_AVP ,_PUN and_CJC no_AT0 action_NN1 was_VBD taken_VVN to_TO0 prevent_VVI unplanned_AJ0 movement_NN1 of_PRF the_AT0 DHD_NN1 ._SENT The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 have_VHI a_AT0 procedure_NN1 in_PRP place_NN1 for_PRP this_DT0 process_NN1 on_PRP the_AT0 drill_NN1 ._SENT 
3._CRD A_ZZ0 104_CRD (_PUL a_AT0 )_PUR Citation_NN1 was_VBD issued_VVN to_PRP Teck_NP0 Alaska_NP0 Inc._AJ0 for_PRP a_AT0 violation_NN1 of_PRF 30_CRD CFR_NP0 §_NN0 48.27_CRD ._SENT 
The_AT0 mine_NN1 operator_NN1 did_VDD not_XX0 provide_VVI adequate_AJ0 new_AJ0 task_NN1 training_NN1 for_PRP the_AT0 removal_NN1 of_PRF the_AT0 down_AVP hole_NN1 drill_NN1 (_PUL DHD_NP0 )_PUR on_PRP the_AT0 Atlas_NN1 Copco_NP0 DML_NP0 HP_NN1 900_CRD drill_NN1 ._SENT On_PRP January_NP0 16_CRD ,_PUN 2021_CRD ,_PUN a_AT0 driller_NN1 died_VVD while_CJS assisting_VVG another_DT0 drill_NN1 operator_NN1 in_PRP removing_VVG the_AT0 DHD_NN1 from_PRP Company_NN1 Drill_NN1 #40-008_CRD ._SENT The_AT0 victim_NN1 had_VHD installed_VVN the_AT0 J_NP0 wrench_NN1 on_PRP the_AT0 backhead_NN1 approximately_AV0 27_CRD "_PUQ above_PRP the_AT0 deck_NN1 of_PRF the_AT0 drill_NN1 ,_PUN resulting_VVG in_PRP his_DPS right_AJ0 thigh_NN1 being_VBG crushed_VVN between_PRP the_AT0 J_NP0 wrench_NN1 and_CJC the_AT0 drill_NN1 mast_NN1 when_CJS unexpected_AJ0 movement_NN1 occurred_VVD ._SENT The_AT0 operator_NN1 's_POS manual_NN1 states_VVZ that_CJT while_CJS installing_VVG the_AT0 J_NP0 wrench_NN1 on_PRP the_AT0 DHD_NN1 that_CJT the_AT0 backhead_NN1 will_VM0 be_VBI slightly_AV0 above_PRP the_AT0 deck_NN1 ._SENT The_AT0 operator_NN1 did_VDD not_XX0 have_VHI a_AT0 procedure_NN1 in_PRP place_NN1 on_PRP the_AT0 removal_NN1 of_PRF the_AT0 DHD_NN1 during_PRP the_AT0 de-tooling_AJ0 process_NN1 ._SENT 
