On April 5, 2010, an explosion occurred at Massey Energy’s Upper Big Branch Mine in Raleigh County, West Virginia. The blast rocketed through 2.5 miles of underground chambers and tunnels nearly 1,000 feet beneath the mountains, and it killed 29 miners and severely injured another. The youngest victim was Cory Thomas Davis, age 20, who loved spending weekends hunting and fishing in the mountains, and the oldest was Benny Willingham, age 61, a Vietnam veteran of the US Air Force who had been a coal miner for 30 years and was five weeks away from retirement.

Shortly after the tragic day, then-Governor of West Virginia Joe Manchin asked J. Davitt McAteer, who headed the Mine Safety and Health Administration during the Clinton Administration, to conduct an independent investigation (separate from the investigation being conducted by MSHA) into the Upper Big Branch Mine Disaster. My fellow blogger Celeste Monforton was a member of this investigation team, which has spent the past year interviewing witnesses, examining the mine and its equipment, and poring over records.

Earlier today, the Governor’s Independent Investigation Panel released their report, and its title summarizes what they found: Upper Big Branch: The April 5, 2010 explosion: a failure of basic coal mine safety practices. “The explosion at the Upper Big Branch mine could have been prevented,” the panel explains. The mine’s ventilation system, rock dusting practices, and water sprayers were all intended to prevent fuel and sparks from becoming massive fires, but they were all inadequate. The company’s pre-shift/on-shift examination system failed to record and fix safety hazards promptly. MSHA and the West Virginia Office of Miners’ Health and Safety Training failed to enforce the federal and state laws designed to keep miners safe. Here are some of the specific problems the GIIP identified:

A Mine Disaster Waiting to Happen
Celeste often points out, “Coal miners have known for decades how to prevent mine explosions.” Coal mines produce large quantities of methane gas and coal dust, which can fuel explosions and devastating fires if given a spark. Mines reduce the risk of explosions with ventilation systems designed to keep methane levels low; regular application of rock dust, which dilutes coal dust’s explosive nature; water sprays on machines to quickly extinguish sparks and small fires; and a fireboss system for identifying and correcting unsafe conditions. A failure in any one of these components would have been a problem, the report notes — and at Upper Big Branch, they all failed. The panel writes:

The footprint left behind in the Upper Big Branch mine … 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.

Small methane ignitions do not have to turn into major explosions if mine operators adhere to basic safety measures, such as maintaining adequate ventilation 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 flareup of methane led to the nation’s worst coal mining disaster in 40 years.

One of the disturbing things about reading this report is seeing the many instances of miners having expressed fear about conditions at Upper Big Branch. They knew there were problems with coal dust accumulation and ventilation — but their complaints of being unable to breathe didn’t succeed in getting air flow problems fixed. Gina Johnson told investigators that her husband Dean, one of the men killed in the mine, had been coming home thoroughly exhausted for the past six months and complained about lack of air in the mine. Gina said Dean told Chris Blanchard — president of Massey subsidiary Performance Coal, which ran the UBB mine — about ventilation problems a dozen times; when Dean shut down a mine section due to lack of air, Blanchard reportedly threatened that Dean would be fired if he didn’t have it running again within minutes. “Chris Blanchard knows that my son has cystic fibrosis, he knew my husband needed the insurance and would have to work,” Gina Johnson said.

Inadequate Enforcement
The Mine Safety and Health Administration is required to inspect underground mines completely four times each year, and inspectors at Upper Big Branch found many violations of health and safety regulations. The mine racked up 57 MSHA citations in 2009 for ventilation problems alone, and its poor safety record stretches back for years. Drivers who keep breaking traffic laws can get their licenses revoked, so why was such a dangerous mine able to keep operating? The GIIP report explains that MSHA does have tools to address the most unsafe mines — it just didn’t use them at UBB:

Realizing that some companies are more prone to test the boundaries of safe practices, the Congress gave MSHA the power to establish a “pattern of violation” category to address mine operators who are cited over and over again for “significant and substantial (S&S)” violations. MSHA was given the authority to determine what constitutes a “pattern of violation,” and the agency is responsible for notifying mine operators when they fall into this category. After that, any S&S violation issued by an inspector within 90 days will result in miners being ordered out of the affected area.5 MSHA, however, never used this tool until April 12, 2011, when two coal mines – one in Leslie County, Kentucky, and another in McDowell County, West Virginia, were placed on pattern of violation status.

… Several provisions of the MINER Act, passed in the aftermath of the [Sago, Aracoma, and Kentucky Darby] 2006 disasters, gave MSHA tough new enforcement tools to use with recalcitrant mine operators. Among these was the authority to issue “flagrant” violations, with fines of up to $220,000, against companies which repeatedly failed “to make reasonable efforts to eliminate a known violation of a mandatory health or safety standard that … reasonably could have been expected to cause death or serious bodily injury.”

MSHA has used the authority more than 125 times at coal mines during the last five years, issuing fines of $19.5 million. But, despite the fact that the Upper Big Branch mine was cited dozens of times in the year preceding the disaster for violating ventilation plan requirements, MSHA never cited Upper Big Branch for a flagrant violation. Even as they have asked for more enforcement tools, MSHA officials have not explained why they failed to use the “flagrant” tool at UBB. An MSHA spokesperson said it is a matter being examined by MSHA’s “internal review” team.

The report also notes that MSHA hasn’t used its authority as extensively as it could to require mining companies to adopt technologies that can improve mine safety. For instance, rock dust monitoring is currently conducted by MSHA inspectors, who take samples, send them to a lab, and get the results in two or three weeks. An instrument capable of producing real-time, in-mine analysis of rock dust exists — but until mines are required to use such instruments, they won’t be widely adopted.

The report’s overarching criticism of MSHA in the UBB disaster, though, is its failure to see the “big picture” at the mine:

The ultimate failure of MSHA at UBB, however, was the agency’s inability to see the entire picture, the inability to connect the dots of the many potentially catastrophic failures taking place at the mine — especially the operator’s failure to properly ventilate the mine, to control methane, to apply sufficient amounts of rock dust. The failure to consider the previous methane outbursts when addressing the current ventilation woes points to a disconnect which suggests the whole picture is not being considered by MSHA’s enforcement. If they had pressed for the use of technology that allowed the immediate testing of rock dust application, they may have been aware that UBB’s rock dusting was woefully inadequate. If they had the technology to put all of the information about the mine in an electronic, easily accessible format, they might have acted much more quickly and dealt more severely with the operator, placing UBB in pattern of violation status, issuing “flagrant violation” citations or even closing down the mine.

The ability to stand back and take a long look — to see the red flags, to connect the dots – and the ability and willingness to take quick action when necessary distinguishes a regulatory agency which can prevent disaster from one which only reacts. Enforcement aimed at prevention is what Congress envisioned for MSHA when it passed the federal Mine Law …

Massey Energy and the “Normalization of Deviance”
Don Blankenship was chairman and CEO of Massey Energy from 1992 to 2010; if you want to learn more about him, Jeff Goodell’s Rolling Stone profile is an engrossing read. Blankenship retired in December 2010 (a week after the Rolling Stone piece was published), and the following month the sale of Massey to coal giant Alpha Natural Resources was announced. Whether the company’s safety culture improves under this new ownership remains to be seen, but the GIIP paints a convincing picture of a Massey culture that valued coal production above safety — and made sure everyone working there knew what the priority was.

The report references a study by the Investigative Reporting Workshop at American University’s School of Communications; it found that Massey Energy had the worst fatality record among US coal companies from 2000 to 2010. During that time, 54 workers were killed in Massey mines, including the UBB victims. The company had an average of one fatality per 17.5 million tons of coal produced — compared to one fatality per 296 million tons at Peabody energy, the top US coal producer. The AU team calculated that between 2000 and 2010, Massey was cited for 62,923 violations, and 25,612 of those were “significant and substantial.” MSHA proposed $49.9 million in fines for these violations — although, as the GIIP notes, the company made a habit of contesting proposed penalties, and so far has paid only one-third of the penalties proposed for violations at UBB between 2000 and 2009.

To explain the culture that bred the disastrous Upper Big Branch conditions, GIIP refers to a book about a previous disaster — the explosion of the space shuttle Challenger moments after its launch:

In The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, sociologist Diane Vaughan, professor of sociology and international and public affairs at Columbia University, challenged the theory that the disaster was simply a technological failure coupled with a failure of middle level management, as suggested by an investigatory Presidential Commission.

While the technology and management did indeed fail, Vaughan probed deeper into the political and managerial culture of NASA to offer a richer understanding of why, in the face of overwhelming evidence that it was extremely risky to do so, the agency made the fateful decision to launch the Challenger.

Vaughan explored organizational rather than individual misconduct and found answers in the theory of “normalization of deviance” as it pertained to a culture of production and structural secrecy at NASA. “Normalization of deviance” refers to a gradual process through which unacceptable practices or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization. Individuals who challenge the norm — from within the organization or outside it — are considered nuisances or even threats

.

We may shudder to hear about miners struggling to get enough air and working around dangerous accumulations of coal dust (as well as the many other hazards detailed in the report). But at UBB, such deviant practices apparently became the norm — and, evidently, workers who complained, or who failed to produce enough coal, faced belittling messages and intimidation. Part IV of the report includes a long list of ways Massey sustained this culture, from “enhanced employment agreements” that create disincentives for complaining about unsafe conditions to heavy spending on local elections.

A Few More Disturbing Items
Here are a few more things from the report that disturb me:

• Autopsies on 24 of the victims, ranging in age from 25 to 61, found that 17 of them (71%) had coal workers’ pneumoconiosis, or black lung disease. Five of them had less than 10 years of coal mining experience. The current limits on coal mine dust, put in place in 1973, were intended to be sufficient to prevent CWP, but have apparently not succeeded in eliminating this irreversible respiratory disease.
• After the 2006 mine disasters, mine operators were required to install electronic systems for tracking miners’ whereabouts within their mines. Some miners though such a system was already in use at Upper Big Branch, but its installation was still in progress — 20% complete, by one estimate. In the meantime, the company didn’t maintain the older system, which involved metal “in” tags at the mine entrance and a backup written log. This led to uncertainty for several hours after the explosion about which miners were actually in the mine.
• This tragedy evidently didn’t prompt major safety improvements at Massey mines. Last month, MSHA found 20 instances of aggravated misconduct at the Randolph coal mine, run by Massey subsidiary Inman Energy. Inspectors found accumulations of combustible materials in active areas, inadequate use of ventilation curtains, and insufficient equipment water pressure to suppress dust and prevent methane ignitions.

Recommendations
The report ends with 52 recommendations. Here are some of the ones I found most interesting:

3. Adopt provisions similar to those contained in the Sarbanes-Oxley Act to make a Board of Directors accountable for mine safety compliance. Boards of Directors should utilize existing health and safety committees or form a committee to oversee health and safety aspects of the mines under the company’s control. The committee would be responsible for ensuring compliance with all federal and state regulations and would be required to certify that the mines are in compliance each quarter. A criminal penalty should be assessed on these board members who certify, negligently or willfully, that the mine is in compliance when it is not.

4. Specifically use a “pattern of violation” and/or “flagrant violation” authority for violations of key standards designed to prevent explosions, and apply meaningful sanctions, such as revoking the operator’s ventilation plan. If an operator’s plan is revoked for reckless or repeated behavior, he should be offered a brief period of time (e.g., five days) to make the safety case to MSHA as to why the mine’s ventilation plan should not be revoked.

11. Mine operators should be required to adopt computer-based monitoring of air quality, quantity and direction of flow throughout a mine. A suitable system would alert not only the mine operator and miners to impending danger, but it would also alert the state and federal regulatory agencies. Regulatory agencies would have the authority to shut down an operation based on data provided by the system.

28. Inspectors are responsible for elevating to their supervisors problems or concerns that the inspectors believe impede their ability to enforce the law. Likewise, supervisors and district managers are responsible for elevating issues to senior officials in the agency.

29. When either state enforcement agencies or MSHA recognize a significant or persistent problem at a mine, the agencies should coordinate their responses. State and MSHA district offices should meet periodically to review problematic mines and formulate strategies to best protect miners. Cooperative efforts would maximize the effectiveness of the agencies against recalcitrant violators.

37. When a mine is closed by a state or federal inspector’s order, all affected miners would be entitled to full compensation by the operator at their regular rates of pay and work schedule for the entire period they are idled.

44. The U. S. Department of Labor should adopt a public investigation process for major mine disasters. Procedures should be established to provide for public hearings, including interviews of witnesses.

45. If the investigations continue to be under the MSHA’s direction, the agency should have subpoena power to compel witnesses to appear to testify under oath and for companies and individuals to produce evidence, including documents, data, correspondence and physical evidence.

The men who lost their lives in the Upper Big Branch Mine on April 5, 2010 are remembered on pages 6- 9 of the report. And the report’s Foreword offers this hope:

… it is our hope that this frank and unvarnished presentation of what transpired on April 5, 2010, offers a clear picture of the real and constant risks associated with operating coal mines in a reckless manner. We also hope that it causes all mine operators to examine their own dedication to safe mining practices and their attitudes toward safety regulations and regulators. If this type of introspection provides a path for industry and regulators to recommit themselves to safe mining practices each and every day in each and every one of this nation’s coal mines, then we will have honored the lives of the 29 men lost in the Upper Big Branch mine disaster.