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Some of the damage in the Upper Big Branch Mine
At approximately 3:02 p.m. on Easter Monday, April 5, 2010, a powerful explosion tore through the Upper Big Branch mine, owned by Massey Energy and operated by its subsidiary, Performance Coal Company, at the convergence of Boone and Raleigh counties in southern West Virginia. Twenty-nine miners died and one was seriously injured as the enormously powerful blast rocketed through two and one-half miles of underground workings nearly 1,000 feet beneath the surface of the rugged mountains along the Coal River. The disaster has had grave consequences for a mining company, for a community and, most importantly, for the family members who lost men dear to them. On April 13, 2010, then West Virginia Governor Joe Manchin III asked J. Davitt McAteer, former Assistant Secretary of Labor in charge of the federal Mine Safety and Health Administration, to conduct an independent investigation into the disaster. The Governor said, “We owe it to the families of the 29 miners we lost last week to find out what caused this. We owe it to them and every coal miner working today to do everything humanly possible to prevent this from happening again… I fully expect that we will learn … from this and make dramatic changes to protect our miners.”1 As a result of an inquiry that continued for more than a year, the Governor’s Independent Investigation Panel has reached the following conclusions:

The explosion at the Upper Big Branch mine could have been prevented.

• The explosion was the result of failures of basic safety systems identified and codified to protect the lives of miners. The company’s ventilation system did not adequately ventilate the mine. As a result, explosive gases were allowed to build up. The company failed to meet federal and state safe principal standards for the application of rock dust. Therefore, coal dust provided the fuel that allowed the explosion to propagate through the mine. Third, water sprays on equipment were not properly maintained and failed to function as they should have. As a result, a small ignition could not be quickly extinguished.

Three layers of protection designed to safe-guard the lives of miners failed at Upper Big Branch. First, the company’s pre-shift/on-shift examination system broke down so that safety hazards either were not recorded, or, if recorded, were not corrected. Second, the U.S. Mine Safety and Health Administration (MSHA) failed to use all the tools at its disposal to ensure that the company was compliant with federal laws. Third, the West Virginia Office of Miners’ Health Safety and Training (WVHST) failed in its role of enforcing state laws and serving as a watchdog for coal miners.

• Regulatory agencies alone cannot ensure a safe workplace for miners. It is incumbent upon the coal industry to lead the way toward a better, safer industry and toward a culture in which safety of workers truly is paramount. A genuine commitment to safety means not just examining miners’ work practices and behaviors. It means evaluating management decisions up the chain of command – all the way to the boardroom – about how miners’ work is organized and performed.

The politics of coal must be addressed at both a state and national level. Coal is a vital component in our nation’s energy strategy. The men and women who mine it also are a national resource whose lives, safety and health must be safeguarded.

From Introduction to “Upper Big Branch
The April 5, 2010, explosion: a failure of basic coal mine safety practices Report to the Governor Governor’s Independent Investigation Panel
By J. Davitt McAteer and associates Katie Beall James A. Beck, Jr. Patrick C. McGinley Celeste Monforton Deborah C. Roberts Beth Spence Suzanne Weise.
May 2011. The entire document is here, via wikipedia: http://s3.documentcloud.org/documents/96334/upperbigbranchreport.pdf . Excerpts continue below. Bold has been added for emphasis. Note that some sections have endnotes, so just because you get to references does not mean it is the end. The causes of this disaster are relevant to most of the topics addressed in this blog.

The danger of methane has been known for centuries; the explosive nature of coal dust has been known for about 100 years. Lack of proper ventilation and not following protocol regarding coal dust appear to have caused this disaster. Also, government dust standards had not been updated to reflect changes in mining technology, which create finer, more dangerous coal dust particles (more explosive and we presume more dangerous for the lungs, as well). The miners had damaged lungs from coal dust at the time of death.

If governments are unable and sometimes unwilling to control the coal industry, how can they expect to control the nuclear industry which has the potential of being even more deadly? Nuclear waste storage also involves explosive gases.
[Dec. 2015 update: Since this post was written it has become clear to us, based on our research of NRC documents, that the USNRC is not interested in controlling the nuclear industry. On the contrary, they appear to give it constant exemptions and hold it to a lower standard than other industries. The recent USNRC proposal to increase radiation exposure for the general public to 400 times higher than allowed by the US EPA and 100 times higher than international standards – setting the groundwork of cancer for all Americans within 10 years or less of exposure – is their latest attempt to undermine public safety. The USDOE also appears little interested in public safety.]

29 real people with real names and faces died in West Virginia on Easter Monday 2010. Their bios are found in the original. According to this document, the same number died in 2010 in New Zealand in a coal mining accident.
Aerial map of UBB mine area, W. VA Geo Survey
[From p. 34 of the Investigation Report].

In the document appendix, we find an almost 100 year old document which remains all too relevant today. This is the reason transparency is so important:
Coal - Accident Must Not Happen

SL500 01
Picture from another, unrelated, company via Wikimedia for illustration purposes only. “Longwall mining is a form of underground coal mining where a long wall of coal is mined in a single slice (typically 0.6–1.0 m thick). The longwall panel (the block of coal that is being mined) is typically 3–4 km long and 250–400 m wide.” http://en.wikipedia.org/wiki/Longwall_mining

Investigation Report continues:
MEN AND MANAGEMENT: Why miners wouldn’t leave the longwall unless the situation was dire

The Upper Big Branch miners tolerated haphazard planning and poor engineering to produce coal. In addition, they had to deal with ineffective upper management on a daily basis. The miners understood the significant financial investment needed to operate a longwall. If the UBB miners wanted to keep their jobs they had to produce coal. Leaving the longwall face unattended was not an option unless it was quitting time or an emergency.

The physical evidence compiled and examined by investigators tells us that something dire happened on the longwall in the moments before the explosion. The shearer operators and two other victims (Joel Price, Gary Quarles, Christopher Bell and Dillard Persinger) were found about two-thirds of the way down the longwall face. These men must have seen something ominous and out of the ordinary.

The decision to either open a new longwall mine or install a longwall system in an existing mine is an expensive decision. The capital investment can be in the hundreds of millions of dollars for a new mine, or $40 to $50 million dollars for an existing mine. It is not uncommon for a large longwall system to be capable of producing thousands of tons per hour. Given today’s pricing for metallurgical coal of $200 to $300 per ton, an operator is in a position to generate huge revenue.

The pressures to produce coal and control costs exist at all mines; however, the pressure is much more intense at longwall mines. The magnitude of the financial investment and the opportunity to achieve the highest levels of profitability increases the pressure on everyone employed at the mine. From the mine’s top management to the red hat trainee, everyone knows that when the longwall is down, it costs the company money.

Longwall crews are generally comprised of workers who have been at the mine for a while and have several years of experience. It is not uncommon to find a promising young worker placed on the longwall crew to learn from the experienced men. Once crews are established, they often stay together for years. This is important to management because the crews develop a close relationship and an efficiency that leads to high production levels.

Miners who work at longwall mines know that the longwall is the heart of the operation. They take great pride in the number of passes they make on the longwall each shift, and a spirit of competiveness can be seen throughout the operation.

The longwall at Upper Big Branch had returned to the mine for the current panel after having been at the Logan’s Fork Mine for about two years. The Tailgate 1 North section was originally supposed to be a room and pillar section; the coal blocks were not designed with a longwall in mind. Somewhere along the way, a decision was made to move the longwall from Logan’s Fork and use it at UBB starting with Headgate 1 North. The Headgate 22 section would be developed for the next longwall panel and mining would progress from there. What wasn’t anticipated were bad top and bad ribs, along with water in the headgate entries. This made the headgate side of the current longwall unavailable for use as the tailgate side of the next longwall. This forced UBB management to start up the Tailgate 22 section.

Everyone knew that the development of the next longwall panel was behind schedule. Management decided to prepare yet another area of the mine where they could move the longwall while the Tailgate 22 section was completed, but this, too, was behind schedule. When it was ready, it would be a very short panel so it would provide only a very brief home for the longwall.

The pressure was on at Upper Big Branch. Everyone knew it and felt it. Knowing that every pass taken on the longwall would bring it that much closer to finishing before it had a place to move to did not deter the efforts of the longwall crews. They work extra hard at trying to mine more coal and avoid such circumstances. Each crew and every member of a crew take great pride in doing their part in bringing success to the mine. They know that if the equipment is not running, coal is not being produced.

Longwall crews do not leave the face area unless it is quitting time or there is an emergency. The longwall face at Upper Big Branch was 1,000 feet wide with 176 shield bases for a miner to step over. Walking through this narrow space and having to duck in the low areas means a miner would have to have a good reason to leave the longwall face.

Our investigation tells us that these men witnessed something ominous and took steps to try to avert a disaster. Regrettably, they were not able to do so.

Some damage, incl. phone, Upper Big Branch mine
[Photo from p. 46 of the document]

Causes of Death

The bodies of the 29 victims of the Upper Big Branch Mine explosion were found in six different locations throughout the mine. By combining the results of autopsies performed by the West Virginia Medical Examiner1 with information about where the victims were found, we could determine the following:

Seven victims in a mantrip at 78 break, heading out of the mine perished as a result of carbon monoxide intoxication. Two men on this mantrip survived the explosion.

One victim, whose body was located near the 6 North Belt, died as a result of injuries suffered in the explosion.

Four victims found on Headgate 2 North outside the longwall panel, were victims of carbon monoxide intoxication. Contributory blast injuries were also present on these victims.

Eight victims were located in the longwall area. Three died as a result of carbon monoxide poisoning, with contributory injuries caused by the blast. Five victims died from injuries sustained in the explosion, with two of the five also having contributory carbon monoxide intoxication.

Six victims were found on a mantrip in the Headgate 22 area of the mine. Five of the six were victims of carbon monoxide intoxication. The sixth died as a result of injuries suffered in the explosion, with contributory carbon monoxide intoxication.

Three victims were located on Headgate 22, away from the mantrip and inby the section. Their deaths were attributed to injuries sustained in the blast.

Of the 29 men killed, 19 died as result of carbon monoxide intoxication, and the remaining ten died as a result of injuries suffered in the explosion.
1 The West Virginia Department of Health and Human Services, Medical Examiner.


Coal Workers’ Pneumoconiosis and the UBB miners

Coal workers’ pneumoconiosis (CWP), also called black lung disease, develops when respirable coal mine dust is inhaled and deposits in the lungs. It is a chronic, fibrotic, and irreversible disease that robs miners of their breath and life. CWP is wholly preventable with diligent use of dust control measures including proper ventilation, water sprays and dust collectors.

Autopsies of the 29 men who lost their lives in the Upper Big Branch explosion were performed by the West Virginia Medical Examiner.1 Lung examinations, necessary to determine the presence or absence of CWP is a specialized review, requiring physicians with expertise, additional training and practice. At our request a recognized expert in occupational diseases and with experience in lung examinations of this sort reviewed the autopsy reports and determined the presence or absence of CWP.2

Of the 29 victims, five did not have sufficient lung tissue available to make a determination relating to CWP: two due to massive injury and three due to autolysis.3 The remaining 24 victims had sufficient tissue for examination.

Seventeen of the 24 victims’ autopsies (or 71 percent) had CWP. This compares with the national prevalence rate for CWP among active underground miners in the U.S. is 3.2 percent, and the rate in West Virginia is 7.6 percent.4 The ages of the UBB victims with CWP ranged from 25 to 61 years.

Of the seven not identified as having CWP, four had what was characterized as “anthracosis” on their autopsy report. This term is often used in lieu of the term pneumoconiosis, or may refer to a black pigment deposition without the fibrosis and other characteristics needed to make a firm diagnosis of pneumoconiosis. Consequently, it is possible that upon further expert review, these four miners could have had pneumoconiosis. Three of the 24 victims had no pneumoconiosis or anthracosis noted.

Of the 17 UBB victims with CWP, five of them had less than 10 years of experience as coal miners, while nine had more than 30 years of mining experience. At least four of the 17 worked almost exclusively at UBB. All but one of the 17 victims with CWP began working in the mines after the 2.0 milligram coal mine dust limit was put in affect in 1973. This was an exposure limit that was believed at the time sufficient to prevent black lung disease. It has since been determined ineffective to protecting miners’ health.5

The victims at UBB constitute a random sample of miners. The fact that 71 percent of them show evidence of CWP is an alarming finding given the ages and work history of these men.
[Ed. note: post and document continue below references]
1 The West Virginia Department of Health and Human Services, Medical Examiner.
2 Robert Cohen, MD, F.C.C.P., Director Pulmonary and Critical Care Medicine, Cook County Health and Hospitals System; Chairman, Division of Pulmonary Medicine/Critical Care, Stroger Hospital of Cook County, Chicago, Illinois, conducted a confidential review of the UBB victims’ autopsies.
3 The destruction of cells through the action of its own enzymes.
4 National Institute for Occupational Safety and Health, US Cen-ters for Disease Control and Prevention. Table 2-12. CWXSP: Num-ber and percentage of examined employees at underground coal mines with CWP (ILO category 1/0+) by tenure, 1970-2006. The Work-Related Lung Disease Surveillance Report, 2007. Publication No. 2008-143, September 2008; Morbidity and Mortality Weekly Report (MMWR). Pneumoconiosis Prevalence Among Working Coal Miners Examined in Federal Chest Radiograph Surveillance Programs: United States, 1996—2002. April 18, 2003, 52(15); 336-340.
5 National Institute for Occupational Safety and Health, US Centers for Disease Control and Prevention. Criteria for a Recommended Standard: Occupational Exposure to Respirable Coal Mine Dust, September 1995; US Department of Labor, Mine Safety and Health Administration. Proposed rule on lowering miners’ exposure to respirable coal mine dust including continuous personal dust monitors, 75 Federal Register 64412, October 19, 2010.

cinderblock wall remains Upper Big Branch Mine
[Photo from p. 27]

ROCK DUST: ‘Keeping an explosion from leaving a trail of wreckage and death’

There are sound historic reasons for the strongly worded provisions regarding control of coal dust in both state and federal law. Although commercial mining began in the United States in 1730 in Virginia,1 it was widely believed that coal dust was not explosive until well into the first decade of the 20th century. A series of disasters in 1906 and 1907 spurred pioneering work of mining engineers J. Taffanel in France and George Samuel Rice in the U.S. Taffanel’s and Rice’s research provided convincing evidence – which became accepted fact – that coal dust was and is highly volatile.

On March 10, 1906, an explosion that ripped through the Courrières mine in northern France took the lives of 1,099 men in Europe’s most deadly mine accident. Soon after, a number of countries began examining the possible explosiveness of coal dust. Taffanel suggested that since the Courrières mines had been free from methane, the disaster “demonstrated in an indisputable manner the reality of the coal-dust danger.”2 He began conducting experiments in Lievin, France, in 1907, focusing on the chemistry of dust explosions. This work formed the foundation for continued research into mine explosions.3

In the U.S., there appeared to be little urgency about addressing the issue of coal dust explosions until the terrible month of December 1907, which began with a December 1 explosion at the Naomi Mine in Fayette City, Pennsylvania, that killed 34 miners.

Less than a week later the most deadly mining disaster in U.S. history took place in Monongah, West Virginia, when a massive explosion ripped through the Monongah No. 6 and 8 mines. The final death toll was more than 500 boys and men.4

The Monongah disaster was followed on December 16 by an explosion in Yolande, Alabama, that killed 57 miners, then by a blast on December 19 at the Darr Mine in Van Meter, Pennsylvania, which claimed 239 more lives. Finally, as the year came to a close, the Bernal mine in Carthage, New Mexico, exploded on December 31, killing 11 more miners.5

With the blood of 703 dead men spilled in the nation’s mines in one short month, the U.S. Congress took action in 1908, appropriating funds for an investigation into the causes of the explosions.6 A testing station was established in Pittsburgh, Pennsylvania, which oper-ated under the auspices of the United States Geological Survey until it was transferred to the newly formed Bureau of Mines (BOM) in July 1910.7

George Samuel Rice, the chief mining engineer for the BOM, compiled a collection of materials, papers and research studies, all of which pointed to the need to render coal dust inert. In 1913, Rice stated “coal dust is the agency that causes an explosion to sweep through a mine, leaving a trail of wreckage and death.”8

By then, Rice also had made recommendations as to how to prevent dust explosions. Most impressive was his suggestion to render the dust inert by applying rock dust to it.9 Sir William Garforth of England had suggested the use of rock dust to prevent or limit coal dust explosions as early as 1891. However, it was Rice who made the case in the U.S., based on test results that confirmed that when coal dust and rock dust had an incombustible content of 64 percent, ignitions could be prevented.10

Although Rice and the BOM advocated use of rock dust as early as 1910, most coal mines in the U.S., with the exception of a mine operated by the federal government in Colorado, did not start using it until the 1920s.11 Even then, there was no federal law mandating its use, and only the most progressive, safety-oriented coal operators opted to follow BOM guidelines and recommendations.

Through the years operators tried other methods to address the coal dust situation, but, in the end, rock dust proved to be the most successful method to address the explosiveness of coal, and its use became an industry standard.

Rock dust works because it causes a decrease in the temperature of coal dust. During an explosion, the rock dust disperses and mixes with coal dust,12 acting as a thermal inhibitor and reducing the flame temperature to the point that an explosion of coal particles can no longer occur.13 The amount of rock dust required to prevent an explosion depends on the size of the coal particles as well as the size of the rock dust. As the coal particle size is reduced, a more severe explosion hazard is present.14

On April 7, 1927, the BOM issued a safety decision recommending that all coal mines be rock dusted and


emphasizing the importance of thoroughly cleaning up the coal dust prior to the rock-dusting.15

An information circular produced by the Bureau of Mines similarly offered a conclusion that emphasized the importance of rock-dusting:

… the only safe procedure in the preventing of disastrous explosions is to rock dust thoroughly in every accessible part of a mine. Re-rock-dust immediately when the content of either floor dust or rib and timber dust falls to 55 per cent in any zone in the mine and maintain at all times the average noncombustible content of the mine dust above 65 per cent.17

Although the recommended standard was thorough and complete, containing much of what since has been written into federal laws governing coal mine safety, Congress did not grant the Bureau the authority to inspect mines or formulate a regulatory code.18 As a result, dusting was haphazard – performed to the recommended standard in some progressive mines, not performed at all in others.

In a 1939 report, the BOM concluded that rock-dusting practices in the U.S. fell far short of providing absolute protection against coal dust explosions; that state mine safety laws were inadequate with respect to rock dusting requirements; that limestone or gypsum is accessible to all coal fields in the country; and that the average cost of rock-dusting amounted to $.0089 per ton of coal mined.19 (As of October 2010, the cost per net ton of bulk mine safety dust was $28, according to Greer Industries, still a great bargain for the safety it provides.20)

In addition, BOM records for a nine-year span leading up to the 1939 report, revealed that in 60 rock-dusted mines where explosions had taken place, rock dust was credited with stopping or limiting the explosions in 26 of them.21

Still, it wasn’t until 1969 that the Bureau was granted the authority to regulate the mining industry with the passage of the Federal Coal Mine Health and Safety Act (Coal Act), passed by the Congress in the aftermath of the catastrophic explosion that killed 78 miners at Consolidation Coal Company’s Farmington No. 9 Mine on November 20, 1968. The Coal Act provided for monetary penalties for all violations and criminal penalties for knowing and willful violations. In 1973, the Mining Enforcement and Safety Administration was formed; in 1977, it became the Mine Safety and Health Administration (MSHA).

The rock-dusting standard in place when the Upper Big Branch Mine exploded on April 5, 2010, was the same standard that was established in 1927, unchanged through the years despite the increased use of machinery in the mines, which has resulted in a finer, more explosive coal dust. In September 2010, five months after the UBB explosion, MSHA issued an emergency temporary standard22 raising the percentage of incombustible content for intake airways from 65 to 80 percent.23 The Mine Act requires the agency to replace an emergency temporary standard with a permanent, final standard within nine months.24
[Ed. note: document continues after these references]
1 McCartney, Martha W., “Historical Overview of the Midlothian Coal Mining Company Tract, Chesterfield County, Virginia”
2 Transactions of the American Institute of Mining Engineers, Vol. 50, Investigations of Coal Dust Explosion, Vol. 50, 1915, p 589
3 Sapko, Michael J., Eric S. Weiss, Marcia L. Harris, Chi-Keung Man, Samuel P. Harteis, National Institute for Occupational Safety and Health, A Centennial of Mine Explosion Prevention Research, p. 2.
4 McAteer, J. Davitt, Monongah, West Virginia University Press, 2007, p. 241
5 National Institute for Occupational Safety and Health, Mining Disasters
6 U.S. Department of the Interior. Bureau of Mines. The Explosibility of Coal Dust, by George S. Rice. Washington, DC: Government Printing Office, 1911.
7 U.S. Department of the Interior. Bureau of Mines. The Explosibility of Coal Dust, 33
8 U.S. Department of the Interior. Bureau of Mines. Notes on the Prevention of Dust and Gas Explo-sions in Coal Mines, by George S. Rice, Washington, DC: Government Printing Office, 1913.
9 Rice, The Explosibility of Coal Dust, 84-6 and Ibid, 16-7.
10 U.S. Department of the Interior, Bureau of Mines, Report of Investigations: Methods of Rock-Dusting American Coal Mines, by J.J. Forbes, September 1939.
11 Ibid.
12 NIOSH, How does limestone rock dust prevent coal dust explosions in coal mines?, by C.K. Man and K.A. Teacoach, Pittsburgh, PA.
13 Ibid.
14 U.S. Department of the Interior. Bureau of Mines, Coal-dust Explosibility Factors Indicated by Experimental Mine Investigations (1911-1929), Rice, G.S. and Greenwald, H.P., Technical Paper 464, 2919
15 U.S. Department of Commerce. Bureau of Mines. Information Circular: Effective Rock-Dusting of Coal Mines, by George S. Rice, Washington, DC: 1927.
16 Ibid.
17 Ibid.
18 MSHA website, History of Mine Safety and Health Legislation.
19 U.S. Department of the Interior, Bureau of Mines, Report of Investigations: Methods of Rock-Dusting American Coal Mines, by J.J. Forbes, September 1939, p. 20
20 Correspondence with J. Davitt McAteer
21 U.S. Department of the Interior, Bureau of Mines, Report of Investigations: Methods of Rock-Dusting American Coal Mines, by J.J. Forbes, September 1939, p. 21
22 MSHA, Maintenance of Incombustible content of rock dust in underground coal mines, 75 Federal Register 57849, September 23, 2010, which became fully effective on November 22, 2010.
23 U.S. Department of Health and Human Services. NIOSH. Report of Investigations 9679: Recom-mendations for a New Rock Dusting Standard to Prevent Coal Dust Explosions in Intake Airways, Pittsburgh, PA, May 2010
24Section 101(b), Federal Mine Safety and Health Act of 1977


Bring the air with you

They used to say if you go to Headgate 22, bring the air with you ‘cause there ain’t none up here,” said Bobbie Pauley, the only woman employed as an underground miner at the Upper Big Branch mine at the time of the April 5 explosion. When Pauley said “they,” she was referring to experienced miners like her fiancé, Howard “Boone” Payne. Payne, a roof bolter on the Headgate 22 dayshift crew, stood 6’5” tall and had flaming red hair. Friends described him as a “man’s man.” Pauley said he was hon- est and direct — he said what he meant and meant what he said.1 A belt fireboss who retired in August 2009 after 43 years in the mines, offered a similar description of his friend. “Boone was a fellow that always said exactly what he thought,” he said. And what Boone Payne thought was that there wasn’t enough air on Headgate 22. He complained to a number of people about the problem. “He would talk about how they just didn’t have any air up there,” the fireboss said. Roof bolter Michael Ellison recounted a confrontation between Payne and UBB management during the miners’ annual refresher training class on February 23, 2010. Ellison said Payne asked Performance Coal Company President Chris Blanchard where the crew would be working after they finished the Headgate 22 panel. The response was flippant, Ellison recalled, something to the effect that the miners would be on the panel until Christmas because they weren’t running enough coal. “That made Boone mad, and he stood up, and he said, ‘Well,’ he said, ‘If you f—‘n think you can do any better … you come up there with bad top, no air, and see what you can do.’ He was very straightforward. I don’t think they [management officials] knew what to say.”2 Dennis Sims, who previously had worked as a bolter on the Headgate, said he and Payne talked with Blanchard about the lack of air. “We all knew we didn’t have enough air,” Sims said.3

Boone Payne may have been more vocal and direct than most, but he wasn’t the only miner who was concerned about the airflow on Headgate 22. Morris Hulgan, a miner with 28 years of experience, said the ventilation “was terrible.” There were times, Hulgan said, when the section boss would pull out his anemometer to measure the airflow “and it wouldn’t even turn… He pulled us off the section — and it was like that all the time. You might have a little [air] … and then all of a sudden, you wouldn’t have nothing.”4 Joshua Massey, a roof bolter on the Headgate 22 swing shift, said simply, “There wasn’t no air. It’s hard to ventilate a place when you ain’t got nothing to ventilate it with.”5 The lack of air on Headgate 22 was not an occasional problem; it was chronic. “They constantly had air problems,” said Brian “Hammer” Collins, a section foreman on Tailgate 22.6 The problems were “very common knowledge,” according to Larry Richmond, an electrician on Headgate 22 who had 28 years of experience.7 Gina Jones said her husband, Dean, the section foreman, “would come home practically every day telling me he had no air…”8 Mrs. Jones said when she asked her husband if he told his bosses about the problem, he replied that he had talked about it with mine superintendents Everett Hager and Gary May, as well as with Blanchard. “He told Chris Blanchard, you know, a dozen times that I know of,” Mrs. Jones said. She said her husband told her Blanchard would come up to the section for a short period of time and then leave.9 For about six months leading up to the explosion, Dean Jones came home so exhausted, “I’d look over at the dinner table and he would be asleep,” Mrs. Jones said.10 At one point her husband told her he shut down the section for lack of air, and “Chris Blanchard called the dispatcher and told him to tell Dean if he didn’t get the section running in so many minutes he would be fired,” she said. Being fired was a scary prospect for a man whose 14-year-old son had a serious illness. “Chris

Blanchard knows that my son has cystic fibrosis, he knew my husband needed the insurance and would have to work,” she said.11 Michael Ellison had been scheduled to work on the April 5 dayshift crew, but, in what he now considers a lucky break, he woke up early that morning gasping for breath. “My blood pressure was sky high. I told my wife … I don’t feel good today. And I called in and took a personal day. That’s the only reason I’m here,” he said.12 Ellison, a roof bolter who had been assigned to Headgate 22 early in 2010,13 said when he started work there, some of the crew members told him he should bring a big supply of water with him because there was no air, and it got really hot. “They told me I better grab me a gallon of water,” he said. “And I said, ‘No, I’ve got plenty of drinks in my bucket.’ And I got up there, and I couldn’t believe it. It literally felt like you were melting. We got up there, and usually we would get started by about 15 after 7 of the morning, and by 8:30, all of us looked like we had been standing out in a rainstorm, just soaking wet.”14 Ellison said the airflow to Headgate 22 was adversely affected when a new beltline was being put in at the mother drive. “They had our air so messed up at different times that nobody knew where actual air was, you know, coming in from,” he said.15 Ellison said the airflow improved a couple of weeks before the explosion. “You could feel it get a little bit better,” he said. “Some days it would be better. Some days it would be just like it was. They had … little signs that point over for a mandoor and things. You didn’t see them moving until about a couple weeks before the explosion, you could see them starting to move. We started getting some decent air. And then it just went right back that way again… The signs didn’t even blow.”16 Bobbie Pauley, who operated a shuttle car for the swing shift on Headgate 22, said the section had ventilation problems from the time they started driving the headgate. “You could never get enough air to the face,” she said. “Management kept trying different things. I assume the ventilation changes had been approved. But you don’t ruffle a lot of feathers when you work for Massey. If we didn’t have enough air, we ran coal.”17 Pauley said Payne told her that Blanchard was in the mine directing ventilation changes from January to March. “But they’re just trying anything, Bobbie,” Pauley said Payne told her. “They don’t know what they’re do- ing.”18

Federal and state inspection records for the mine support this view. Upper Big Branch was cited every month during 2009 – 64 citations in all (57 from MSHA, seven from the state) – for failure to ventilate the mine according to the approved ventilation plan.19 Ventilation problems were observed throughout the mine by in-spectors in 2009 and early 2010 and included such violations as insufficient air reaching the last open break off the left side of the Headgate section20; stoppings with holes in them that caused belt air not to be separated from return air21; airlock doors open on both sides22 and reversed airflow.23 Moreover, UBB was cited for the manner in which ventilation changes were made in an attempt to correct or redirect airflow. Because results for making changes to ventilation cannot be predicted, it is considered a cardinal sin to make ventilation changes with miners underground. Nevertheless, a citation issued by MSHA on September 1, 2009, noted: “Intentional change in the ventila- tion system was in the process of being implemented and unnecessary persons were working in the mine. Several re- quired ventilation controls were not yet installed and several ventilation controls were installed but not approved in the ventilation plan 8/6/09. Airflow has reversed in the longwall setup entries and airflow was reversed in neutral aircourses. [Two sections] returned to production on 9/1/09 prior to the completion of the ventilation change…”24 Every underground coal mine in the United States is required by law to have a ventilation system approved by MSHA. The West Virginia Office of Miners’ Health Safety and Training also must approve ventilation plans for state mines. Any modification to the plan must first be approved by MSHA before a change is implemented. Once the plan is approved, it is the operator’s responsibility to comply with the plan. The ventilation system is designed to push fresh air through the mine, keeping it from being stagnant, preventing the buildup of methane and other toxic gases and removing coal dust. The ventilation system also serves to keep previously mined areas free from any buildup of gases. By law, a mine is required to provide all underground working places with a current of air containing not less than 19.5 percent oxygen, not more than 0.5 percent carbon dioxide and no harmful quantities of other noxious or poisonous gases.25 The ventilation system used at Upper Big Branch is commonly referred to as a push-pull system. In the Upper Big Branch North area of the mine, air is pushed into the mine at the North Portal and pulled through the mine by the Bandytown fan. Once the air has traveled its intended course, it exits the mine through entries at Bandytown and out the return shaft, and at the North Portal and Ellis Portal through designated return entries. Fresh air and return air are directed through the mine by “ventilation controls” referred to as stoppings, overcasts, regulators, seals and airlock doors. The location, construction and maintenance of these controls are critical to the proper functioning of a ventilation system. Missing controls, poorly constructed controls or controls in need of repair will result in an ineffective or failed system. At Upper Big Branch, physical evidence indicated that ventilation controls were missing at the Ellis Portal construction site. Investigators also found that the airflow traveling to the Bandytown fan from the headgate and tailgate sides of the longwall was restricted because of buildup of water and bad roof. State, federal and independent investigators were in agreement that Upper Big Branch had an excessive number of airlock doors. Airlock doors are used to pre- vent air from short-circuiting as people and equipment enter or move into different areas of the mine. Decisions to use doors instead of overcasts may result from the fact that the doors can be installed faster and at less cost to the operator. A problem with using doors is that the air can be short-circuited if the doors are left open, as workers testified was the case on repeated occasions at UBB. Testimony also indicated that the doors were not properly maintained, resulting in leakage in and around them. Both federal and state regulations require that an operator provide a minimum of 9,000 cubic feet per minute (cfm) of air in the last open crosscut. At least 3,000 cfm must reach every working face. The Upper big Branch ventilation plan called for 15,000 cfm in the last open crosscut. The consistent testimony by a large number of witnesses suggests that this requirement was not being met on the Headgate 22 section. If sufficient air is not provided to a working section, the potential exists for methane buildup and coal float dust accumulations.

The section specific methane dust control plan for the Upper big Branch longwall required a minimum of 40,000 cfm at the intake to the longwall. A minimum of 400 linear feet per minute (lfm) was required at #9 shield, or 50 feet off the headgate. A minimum of 250 lfm was required at #160 shield, or 100 feet off the tail- gate. The quantity of air required by regulation and the plan is always the minimum for safe operation. Operators may be required to provide more than the minimum if the situation warrants – and it’s something they should do on their own to assure the safety of workers. An MSHA test conducted before the UBB disaster used smoke to track the current of air on the longwall face. The results indicated that air was traveling in and out of the shields at various locations on the face.26 This problem usually occurs because there is not enough positive pressure on the gob, and it has the potential for allowing gob air containing methane to get to the face without being detected. While methane monitors are located on the longwall equipment, they do not cover the entire face. Continuous monitoring of air quality and quantity across the longwall face by electronic monitors with the ability to automatically shut down the longwall system would provide a much safer environment for workers. It should be noted that the fans at the Upper Big Branch had sufficient capacity to adequately ventilate a mine that was as physically large as this one and that had a number of operating sections. The challenge in ventilating such a mine is that the air must be forced and directed through multiple controls to make sure all areas are adequately ventilated. The push-pull ventilation system at Upper Big Branch also had a design flaw: its fans were configured so that air was directed in a straight line even though miners worked in areas away from the horizontal path. As a result, air had to be diverted from its natural flow pattern into the working sections on the longwall, Headgate 22, Tailgate 22 and the crossover sections. Because these sections were located on different sides of the natural flow pattern, multiple diversionary controls had to be constructed and frequently were in competition with one another. For example, as a number of witnesses suggested, when the longwall was receiving sufficient air, the Head-gate 22 section had very low airflow. The competition for air at Upper Big Branch led to the dangerous practice of ad hoc modifications of the ventilation system by foremen concerned with providing adequate air for


their crews on a day-to-day or shift-by-shift basis. These changes might include opening doors or altering regula- tors, such as stoppings. This practice deviates from the basic safety tenet of maintaining an overall ventilation plan designed by engineers. If the mine’s ventilation plan is not followed by all management personnel, the risk of ignitions from methane can increase substantially. Methane gas is a natural by-product of decomposing organic matter and is the most hazardous gas found in underground mines.27 The danger of methane, which has contributed to more than 10,000 miner deaths in the United States since 1925, has been known for centuries.28 Since UBB is considered a gassy mine that liberates excessive quantities of methane, attention to ventilation is crucial. Stanley “Goose” Stewart, who operated a continuous miner on the Headgate 22 second shift, told members of the House Committee on Education and La- bor at a hearing in May 2010 there were many red flags that had prompted him to tell his wife that UBB was a “ticking time bomb.”29 “Many things were wrong at the mine, such as low air constantly,” Stewart said. “The area of the mine we were working was liberating a lot of methane. Mine management never fully addressed the air problem when it would be shut down by inspectors. They would fix it just good enough to get us to load coal again.”30 Stewart said he was particularly alarmed on July 26, 2009, when his second shift crew was “told by man- agement to make an air change from sweep air to split air in Headgate 21.” He said stoppings were removed while crews were still working. “It scared me,” Stewart said, “and when I got home I wrote it down.”31 In early January 2010 an MSHA inspector noted that Performance Coal’s senior management officials showed a “reckless disregard” for worker safety when they told a foreman to ignore a citation the mine re- ceived for faulty ventilation.32 That inspector was Keith Stone from MSHA’s Mount Hope office.33 Stone, who was assigned to Upper Big Branch for the first quarter of 2010, began his quarterly inspection on January 7 on the Headgate 22 section. As he walked down the primary escapeway, Stone noticed that the airflow wasn’t moving in the direction indicated on the map.

Canopies and shields and methane migration

The canopy of a longwall shield is the component that sits on top of the legs of the shield. The canopy is pressurized against the mine roof to support it. It is made of steel and extends over the face conveyor, towards the coal face and behind the legs of the shield on the gob side.

The shields at UBB were 1.75 meters wide and 176 shields extended across the full longwall face. Canopies are tapered in the rear to allow material to slide off of them. Each canopy has four sides, plus the top which is pressurized against the roof, and the bot-tom, under which miners travel.

This construction allows for openings in the canopy. At UBB, the openings in the canopies were used for a water spray system and space to run a water line to the sprays. In testimony, miners stated that they would store extra bits and sprays at various locations inside the openings.

Since methane is generally found near the roof of a coal mine, it is conceivable that methane could migrate into the canopies of the shields and accumulate to an explosive range. Air used to ventilate the face could travel in a direction that does not sufficiently sweep methane accumulations inside the canopy open-ings, allowing it to accumulate.

The inside portion of the canopy where methane could accumulate comes within a few feet of the cutting drum of the shearer. If the shearer is cutting rock and producing a large number of sparks, this would provide a heat source for an ignition. Moreover, the methane in these canopies would not flow in the area of the methane monitor. The methane is basically trapped in an area above a monitor and would also not flow close enough to a miner wearing a multi-gas detector.

In April 2011, investigators conducted smoke tests on the shields near the tailgate of the UBB long-wall. The tests revealed a “conduit effect” that could allow methane to migrate from the gob area through the canopy void and come in close contact with the cut-ting drums of the shearer.


“Air flow according to the map, should have been coming in by toward the face,” he said. “Air was going outby.”34 When the air split at the crossover, it went down toward the mouth of the longwall and met with the longwall intake. “That air was supposed to be coming up that way towards 22 section, but it had reversed…”35 Stone informed UBB foreman Terry Moore, who was traveling with him that day, that the primary escapeway air was backwards. As a result, Stone explained, workers who were trained to exit by that route – the shortest route out of the mine – instead would have to exit by the other intake, which was feeding the section. In the case of a fire or other emergency, miners would have to travel a longer distance and go deeper into the mine before they could exit.36 Stone told Moore to immediately withdraw miners from the section. He issued a D2 order, removed the miners from the face and “shut the immediate section down – because their men did not have a safe access to the surface in the event of an emergency.”37 Stone said Moore told him that he knew about the problem with the airflow. “He stated it had existed for at least three weeks when he took the foreman’s job. He informed me that he had mentioned it to the superintendent (Everett Hager),” Stone said. “And he was told not to worry about it.”38,39 Stone also talked to members of the crew “and they had expressed concern over this condition themselves,” he said.40 “They said they had mentioned it a couple weeks prior to some management officials; they was told it was fine, not to worry about it. I asked them … who they questioned. The names they give me was Chris Blanchard, who is president of the company, and Jamie Ferguson, who was the vice president of the company at that time.” Later that day, after the order was lifted, Stone found air in the belt entry traveling the wrong direction, so he issued another order, this time removing men from the longwall face.41 Keith Stone had been a federal mine inspector for less than a year when he was assigned to UBB. It took an immense amount of courage for the young inspector to shut down production and withdraw miners from sections twice during his first trip into the mine. When Performance Coal President Chris Blanchard learned that the Headgate 22 section was shut down, he called Stone on the mine phone to challenge the inspector’s findings and argued that the situation was unacceptable. Keith Stone didn’t cave. When he found a problem, he took the appropriate action to ensure the safety of workers until the situation was remedied. The last time Stone went to UBB was to terminate an order for air flow reversal in the tailgate of the longwall issued by Keith Sigmon, a ventilation specialist out of MSHA’s Mount Hope office.42 “The regulator that’s shown on this map at the mouth of the longwall tailgate – was not installed and that was one of the contributing factors to the air reversal. It was not letting air feed the tailgate,” Stone said.43 UBB was down two and a half days while workers knocked a stopping and built a regulator.44 Stone said his greatest concern at UBB was always ventilation. “I don’t know if the first day set the tone for that, you know, issuing the two [orders],” he said. “And then you do it again and…. A couple other inspectors issue it, so it’s just a recurring thing, you know, and it’s hard to stay on top of.”45 Stone was so concerned that he spoke with the ventilation specialists in MSHA’s Mount Hope office. He feared that UBB officials might be engaged in a practice not unheard of in the industry – that of operators manipulating the air during ventilation inspections in order to have plenty of air in the section being inspected at that time. In effect, air is “stolen” from sections that are not being inspected. As the inspection moves to another section, the air is shifted so the air on that section complies with the required ventilation plan. In response to Stone’s request for help, ventilation supervisor Joe Mackowiak sent ventilation specialists Keith Sigmon, Benny Clark and Clyde Gray to UBB on March 9, 2010. Field office supervisor Tom Moore, and a new MSHA trainee accompanied Stone, Sigmon, Clark and Gray. One ventilation specialist was sent to each section with one person staying outby, Stone said.46 “Joe wanted to make sure that each section, the longwall and both headgate sections had a … ventilation specialist there to make sure they weren’t stealing air, or you know, just make sure they had enough air top right,“ Sigmon said.”47 “Joe wanted one of us at each section, you know, because if they were changing the air, he wanted us there, all three of us, to make sure that if they knew we were coming, they couldn’t do anything.48 Sigmon said UBB submitted requests for ventilation plan changes frequently. “I started in ventilation in December,’” he said. “I would imagine, say, since Decem-

ber 30, probably 20-some revisions went through our ventilation department.” He said he had cited the mine a couple of times for using a ventilation plan that had not been approved. Before working for MSHA, Sigmon worked for CONSOL Energy, where the mines had resident engi- neers and survey crews. “And so here, you deal a lot with Massey operated coal mines, especially out of Mount Hope,” he said. “And so it was a culture shock to me that they were not engineered as well.”49 Sigmon said he believed Massey was “well understaffed in all their engineering department. They’ve got a lot of young engineers who seem to be hard workers but just not the knowledge level that they need to be at probably, you know. I always said this mine needs a resident engineer … they need somebody there constantly, but that’s something you don’t see, you know, is resident engineers at any of the mines.”50 Eric Lilly, who invoked his Fifth Amendment right against self-incrimination and declined to be interviewed, was assigned to UBB as resident engineer in the six months leading up to the explosion.

Richard Kline, the assistant district manager for MSHA’s Mount Hope office, expressed concern about troubling trends he had witnessed with respect to engineering in the industry as a whole. “I don’t think we have the engineers in these mines that we used to have,” he said. “We’re not engineering mines. They’re trying to use duct tape to fix things instead of engineering. They’re not taking the time to look ahead at what they have.”51 Testimony from members of Massey’s Route 3 Engineering work force support Sigmon’s and Kline’s characterization of the perception that inadequate engineering was being done by people who had very little experience. Of those interviewed, Heath Lilly said he had very little involvement with the UBB mine; Ray- mond Brainard said he traveled underground at UBB only once every couple of years; Matthew Walker had never been underground at UBB. Keith Trent and Daniel Snodgrass both said they had no degrees, only on-the-job training. Trent had been underground one time in the previous eight years and Snodgrass hadn’t been underground in two years.

Inspector Keith Sigmon’s notes from March 9, 2010, report that he discussed air reversal with Massey officials Harold Lilly and Wayne Persinger, who agreed that the air was not right and needed to make ventilation changes. Persinger asked if they could do it with men underground. Sigmon advised that federal law required that work-ers be brought outside. Sigmon warned that this was a dangerous situation and, if the reversal continued, “the air could pull from the gob pulling return air, CH4 or other gases across the tail.” [redactions made by MSHA]

Mackowiak said he was aware that Keith Stone had cited UBB for the low airflow on Headgate 22 in early March. “I found that shocking the first time it was issued because the mine is basically sitting on top of a bleeder fan, and, therefore, should’ve had plenty of operating volume.”52 Given the location of the mine’s fans, it should have had sufficient air. The second time it occurred, Mackowiak picked up the telephone and called Bill Ross, a former MSHA ventilation specialist and Mackowiak’s one-time boss, who had taken a position with Massey. “He’d asked me on several previous occasions that any time there was a problem to give him a call and he would be more than happy to go to that mine and help,” Mackowiak said. “So I called Bill Ross … and I said there is a problem, here’s what it is, low operating air volume on Headgate 22. This is the second time that’s happened and it’s inexcusable.”53 Mackowiak recalled that Ross told him he’d love to go to UBB, but “they won’t let me.” Mackowiak said when he asked Ross who wouldn’t let him, “he stated it was Chris Blanchard.”54 Ross suggested that it might help if Mackowiak emailed Massey Energy’s senior Vice President and Chief Operating Officer, Chris Adkins, asking for Ross’s assistance. Mackowiak said he did so on March 17.55 The following email exchange took place: Mackowiak to Adkins, March 16, 2010, 1:40 p.m.: “Low air on the headgate section again, despite last week’s shut down. I called Bill Ross and he is on anoth-er project right now. I think they could use some help. Good luck. Ross to Mackowiak, March 16, 2010, 2:32 p.m.: “What’s the verdict?” Mackowiak to Ross, March 17, 2010, 5:37 a.m.: “I haven’t received a reply yet.” Ross to Mackowiak, March 17, 2010, 7:30 a.m.: “What did you say to him? I want to help out at the mine if they will listen.” Mackowiak to Ross, March 17, 2010, 7:44 a.m.: “I emailed him and told him that the headgate was out of air again despite last week’s shutdown. I called u and u were on another project, and they seemed like they needed some help.”56

Mackowiak admits that reaching out to Ross was “out of the ordinary” but his intent was not to interfere with an order issued from an inspector. “My purpose in doing that,” Mackowiak explained, “I wanted to supplement that order and essentially elevate this issue from a mine level to a corporate level to where someone would respond to this appropriately, because the second time I have a low – low operating air volume on a section is inexcusable.”57 In Mackowiak’s view, Massey took a “band-aid approach” to ventilation. “As an inspector would find issues in the mine, and they would issue violations or citations and orders, the company would react to that with generally a plan change, but you would only see a small component of it, whatever was necessary to abate that condition and then move on,“ Mackowiak said. “And that was done a myriad of times.”58 Beginning on December 18, 2009, Massey and MSHA discussed ventilation changes in the Upper Big Branch mine in a series of meetings and written communications. The Governor’s Independent Investigation Panel made repeated and numerous requests of MSHA for records relating to these communications. The GIIP’s interest was in determining the veracity of Massey Energy’s claims that the ventilation problems at UBB were caused by MSHA.59 In public statements, Massey CEO Don Blankenship asserted that MSHA forced UBB to institute ventilation changes with which the company disagreed.60 The GIIP initially requested MSHA’s records re- lated to UBB’s ventilation plan submissions and the agency’s denial letters in mid-July 2010. MSHA provided some records on March 31, 2011. Based on a review of the documents provided by MSHA, the GIIP found no evidence to suggest or support any company officials’ assertions to MSHA’s ventilation plan requirements for UBB would make the mine less safe or put miners’ lives at risk. Nor did GIIP investigators identify any records indicating that UBB management or Massey Energy of- ficials expressed such a concern to MSHA. Mackowiak pointed out that federal regulations call for operators to develop and follow a ventilation plan “and a plan revision is necessary when it’s – basically can have a material effect on health and safety.” In Mack-owiak’s view, any time the company “would reverse an air course, change its direction or change its type from intake to return or return to intake,” the action would have a material effect on health and safety.61 Mackowiak said Massey submitted revisions at

such a quick pace that often multiple changes were occurring, with no mechanism to track the changes other than quarterly inspections.62 “I receive more pressure for plan approvals from Massey subsidiaries than the entire rest of the district mines combined, and that’s not just this mine. This mine was fairly bad with regard to that. The other mine that is the worst in the district would be the Justice Mine, which is also a Massey Energy subsidiary,” Mackowiak said, adding that there were “three or four plans” pending for UBB at the time of the explosion.63 MSHA district officials were so frustrated with Massey’s actions with regard to annual ventilation maps that the district actually changed its procedures. Previously, MSHA allowed operators three submittals before the agency issued a violation. “Well … it took four separate submittals in order to approve that map,” Mackowiak said of Massey’s 2009 submission. “So it took 11 months to get an annual map. So as soon as an annual map was acceptable at this location, one month later they would do their next annual map. To say the least, I was upset.” According to Mackowiak, because of the ongoing problems with Massey, MSHA changed its policy so that the agency no longer allowed three submittals before issuing a violation. Violations could be issued on the first submittal if “there was a ventilation issue shown on the map that could materially affect health and safety.” That was, according to Mackowiak “exclusively due to the poor submittals from Upper Big Branch Mine.”
[ed. note, post and document continues after references]
64 1 Personal communication with Bobbie Pauley, April 30, 2010 2 Michael Ellison testimony, p. 59 3 Dennis Simms testimony, p. 52 4 Morris Hulgan testimony, p. 18 5 Joshua Massey testimony, p. 17 6 Brian Collins testimony, p. 52 7 Larry Richmond testimony, p. 32 8 Gina Jones testimony, p. 11 9 Gina Jones testimony, p. 12 10 Personal communication with Gina Jones 11 Gina Jones testimony, p. 14 12 Michael Ellison testimony, p. 77 13 Michael Ellison testimony, p. 18 14 Michael Ellison testimony, p. 21 15 Michael Ellison testimony, p. 27 16 Michael Ellison testimony, p. 33 17 Personal communication with Bobbie Pauley, April 30, 2010 18 Bobbie Pauley testimony, p 87 19 Federal MSHA standards: 75.320 (air quality detectors and measurement devices), 75.323 (actions for excessive methane), 75.325 (air quantity), 75.333 (ventilation controls), 75.337 (construction and repair of seals); State of West Virginia standards: 22A-2-2 (Plan of ventila- tion); and 22A-2-4 (Ventilation of mines in general). 20 Citation No. 8072754, July 8, 2009 21 Citation No. 6612472 , July 15, 2009 22 Citation No. 8080099, October 28, 2009 23 Citation No. 8100144, December 30, 2009 24 Citation No. 6612936 , September 1, 2009 25 West Virginia Underground Mining Laws, Rules and Regulations22A-2-4 (a); MSHA 30 CFR 75.321 26 Keith Sigmon testimony, p. 18; Clyde Gray testimony, p. 12 27 Dictionary of Mining, Mineral, and Related Terms. Washington DC: US Department of Interior, Bureau of Mines, 1968 28 Historical Summary of Mine Disasters in the United States, Volume I, Coal Mines (1810-1958), Washington DC: US Bureau of Mines, 1960; and Volume II Coal Mines (1959-1998) Beckley WV: Mine Safety and Health Administration, 2000. 29 Stanley Stewart before the U.S. House Committee on Education and Labor, May 24, 2010 30 Stanley Stewart before the U.S. House Committee on Education and Labor, May 24, 2010 31 Stanley Stewart before the U.S. House Committee on Education and Labor, May 24, 2010 32 The Washington Post, Steven Mufson, April 23, 2010; MSHA Citation No. 8087709, January 6, 2010 33 Jerome Keith Stone testimony, p. 12 34 Jerome Keith Stone testimony, p. 22 35 Jerome Keith Stone testimony, p. 23 36 Jerome Keith Stone testimony, p. 24 37 Jerome Keith Stone testimony, p. 25 38 Jerome Keith Stone testimony, p. 26 39 This is also noted on the citation, Citation No. 8087709, dated 1/7/2010. The citation says, “Terry Moore, mine foreman, state he was aware of this condition and that it has existed for approximately three weeks.” 40 Jerome Keith Stone testimony, p. 26 41 Jerome Keith Stone testimony, p. 32 42 Jerome Keith Stone testimony p. 50 43 Jerome Keith Stone testimony, p. 51 44 Jerome Keith Stone testimony, p. 52 45 Jerome Keith Stone testimony, p. 56 46 Jerome Keith Stone testimony, p. 55 47 Keith Sigmon testimony, p. 12 48 Keith Sigmon testimony, p. 56 49 Keith Sigmon testimony, p. 82 50 Keith Sigmon testimony, p. 54 51 Richard Kline testimony, p. 14 52 Joseph Mackowiak testimony, May 18, 2010, p. 25 53 Joseph Mackowiak testimony, May 18, 2010, p. 26 54 Joseph Mackowiak testimony, May 18, 2010, p. 26 55 Joseph Mackowiak testimony, May 18, 2010, p. 26 56 Email exchange provided by MSHA 57 Joseph Mackowiak testimony, May 18, 2010, p. 27 58 Joseph Mackowiak testimony, May 18, 2010, p.13 59 MSHA provided in March 2011 some of the documents we requested. We learned from career agency staff that our request reached a standstill in the Office of the Assistant Secretary or further up the Department of Labor’s chain of command. We confirmed with the US Department of Justice that they were not the cause of the delay. 60 e.g., Don Blankenship testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, May 20, 2010; Don Blankenship letter to Governors of IL, KY, VA, WV, June 7, 2010 61 Joseph Mackowiak testimony, May 18, 2010, p. 14 62 Joseph Mackowiak testimony, May 18, 2010, p. 14 63 Joseph Mackowiak testimony May 18, 2010, p. 32 64 Joseph Mackowiak testimony, May 18, 2010, p. 17
Upper Big Branch Mine fire boot
[Photo from p. 33 of the document]

8 The footprint of a disaster

Every mine explosion leaves behind a footprint that offers clues to investigators as to where the blast originated and how the force traveled from the ignition point. Conflicting theories have been put forth as to whether the April 5, 2010, explosion at the Upper Big Branch mine was triggered by methane or natural gas; whether it was solely the result of an immense methane inundation; or whether coal dust aided in propagating the blast. Massey Energy’s assertion is that the explosion was caused by a massive and unforeseen inundation of methane or natural gas from a crack in the mine floor. In a report to President Obama released on April 27, 2010, MSHA officials offered the opinion that the UBB explosion was caused by “the combustion of accumulations of methane, combined with combustible coal dust mixed with air.” Although both theories were put forth before investigators had been allowed to enter the mine, MSHA looked to the past to find answers. “Historically,” the April 27 report stated, “blasts of this magnitude have involved propagation from coal dust. When methane and coal dust levels are controlled, explosions from these sources can be prevented.”1 The footprint left behind in the Upper Big Branch mine supports MSHA’s theory. It tells the story of an explosion that started with the ignition of a small amount of methane gas and then was fueled by coal dust that had been allowed to build up for miles through the mine. When a mine explodes suddenly and with great force, as happened at Upper Big Branch, methane is immediately suspected as a primary source. Odorless, colorless and highly combustible, methane is the most common hazardous gas found in underground coal mines. Created naturally by the decomposition of organic materials – the same process that creates coal – methane is lighter than air and tends to rise to the roofs of mines. It can migrate into voids in the earth created when coal seams are removed. Because methane is universally recognized as highly explosive, mine operators are required to keep levels under one percent of the mine’s atmospheric content. Concentrations between 5 percent and 15 percent pose the greatest threat of explosions, with the most explosive mixture at 9.5 percent. Methane explosions occur when a buildup of methane gas comes into contact with an ignition source, such as a flame or spark. Because sparking is common in the mining process, history is replete with methane explosions. Small methane ignitions do not have to turn into major explosions if mine operators adhere to basic safety measures, such as maintaining adequate ventila- tion systems, removing explosive coal dust from mining operations, spreading required amounts of rock dust and ensuring that water sprays on mining equipment are kept in good repair and function properly. Because these basic safety systems failed at UBB, a minor flare-up of methane led to the nation’s worst coal mining disaster in 40 years. The footprint of an explosion caused by natural gas is not dramatically different from that of one caused by methane. Methane and natural gas have similar, but not identical, chemical composition, and both occur naturally in underground mines. Methane is the primary gas in natural gas, making up approximately 90 percent of its content. Because natural gas also contains other hydrocarbons, such as hydrogen, ethane, propane and butane, the explosive range for natural gas is slightly lower than that of methane. The composition of the gas has an effect on flame heat and speed, and it has an effect on the amount of coking that can be produced in an explosion. How- ever, because natural gas is primarily methane, the


difference between methane explosions and natural gas explosions can be measured only in slight degrees and is not significant. One of the reasons investigators suspected that the April 5 explosion involved methane is that the Upper Big Branch mine had a history of methane inundations and outbursts reaching back to 1997……


“Some pretty hard questions have got to be asked. The families need answers, and we, as a country, need answers. Something has gone drastically wrong – and we need to find out what it is, what happened, and we need to do our best to make sure it doesn’t happen again,” said Kate Wilkinson, New Zealand Minister of Conservation, on the loss of 29 miners at the Pike River coal mine in November 2010.1 “MSHA is launching a full investigation to determine the cause of this tragedy and will take the necessary steps to ensure that this never happens again,” said U.S. Labor Secretary Elaine Chao, on the loss of 12 miners in the Sago mine, in Buckhannon, West Virginia, January 4, 2006.2 “We just have got to find the answers to what caused this and to make sure whatever it takes that this never happens again,” West Virginia Governor (now U.S. Senator) Joe Manchin III, said on April 11, 2010.3 Following all man-made disasters, such as coal mine explosions, government officials stand in front of the public and grieving family members and promise to take steps to ensure that such tragedies don’t happen again. For a while people pay attention. Investigative bodies like this one are formed and spend months sifting through evidence to attempt to pinpoint the causes of the disaster and offer recommendations aimed at preventing another one. We have done so in this report, again with the genuine hope that reforms can be instituted and that the Upper Big Branch disaster is the last coal mining disaster ever in this country. However, we offer these recommendations with reservation. We have seen similar reports, written with the same good intent, gathering dust on the bookshelves of the national Mine Health and Safety Academy.

We also have witnessed times when this country rolled up its sleeves and went to work with a steely determination to improve workplace conditions. Some of the most dramatic improvements for miners’ health and safety in the United States came after some of the worst human tragedies – the disaster at Monongah in 1907 and the explosion at Farmington in 1968 – when big, bold reforms were put in place by courageous lawmakers at both the state and federal level. These reforms have given us, among other things, quarterly inspections of underground coal mines, imminent danger withdrawal orders, greatly expanded miners’ rights, respirable dust limits and mandatory minimum hours of safety training for min- ers. And they have saved miners’ lives. The 1969 Coal Mine Health and Safety Act was the most comprehensive occupational safety and health law ever enacted in this nation and perhaps in the world. In the five years after its passage, the rate of coal mine fatalities declined 37 percent; the fatality rate again dropped 25 percent in the five years after passage of the Federal Mine and Health Act of 1977.4 This tells us we can mine coal safely in this country. Disasters are not an inevitable part of the mining cycle. There are not preordained numbers of miners who have to perish to produce the nation’s energy. While we are all in God’s hands, the safety and health of our miners is also in the hands of the mining community. However, laws and regulations are effective only if they are respected by companies and enforced with diligence by regulators. “The Upper Big Branch disaster laid bare the loopholes that riddle our mine safety laws. These loopholes allowed dubious mine operators like Massey


Energy to violate mine safety rules repeatedly with impunity,” said U.S. Rep. George Miller (D-CA), the senior Democrat on the House Education and Workforce Com- mittee.5 Ultimately, the responsibility for the explosion at the Upper Big Branch mine lies with the management of Massey Energy. The company broke faith with its workers by frequently and knowingly violating the law and blatantly disregarding known safety practices while creating a public perception that its operations exceeded industry safety standards. The story of Upper Big Branch is a cautionary tale of hubris. A company that was a towering presence in the Appalachian coalfields operated its mines in a profoundly reckless manner, and 29 coal miners paid with their lives for the corporate risk-taking. The April 5, 2010, explosion was not something that happened out of the blue, an event that could not have been anticipated or prevented. It was, to the contrary, a completely predictable result for a company that ignored basic safety standards and put too much faith in its own mythology.
1 “No survivors in New Zealand Pike River coal mine after second explosion,” Herald Sun (Australia), November 24, 2010 2 U.S. Department of Labor news release, January 4, 2006 3 Brown, K., WV Public Broadcasting, April 12, 2010 4 Comparing the five-year fatality rate for 1965-1969 to the five-year rate for 1969-1973 5 Ward, Ken, Jr., Coal Tattoo, April 15, 2011

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