The death notice for Steven Robert Cain said he was a 32-year-old resident of Comfort, in Boone County, W.Va.  He was a member of the Peytona Southern Baptist Church and a former Eagle Scout.  He had a wife, Becky Cain, a six-year-old son, Izek, and a three-year-old daughter, Megan.

How did Cain die? Why did he die?

A report issued by the U.S. Mine Safety and Health Administration concludes Cain was killed because managers of  Massey Energy mine put him to work at a dangerous job, despite his “little mining experience and minimal training.”

But Massey and the contractor that employed Cain, Mountaineer Labor Solution, received just a tiny slap on the wrist from MSHA. Federal regulators did not cite either company. Instead, they issued two safeguard orders, minor actions that require safety improvements but come with no monetary penalties.

Cain died on Oct. 8, 2008, at Massey subsidiary Independence Coal Co.’s Justice No. 1 Mine, an underground operation in Boone County. He was crushed between a railcar and a mine wall sometime between 11 p.m. and midnight.

According to the MSHA report:

The victim was attempting to move a high voltage line out of the way of the loaded rail car as it was being pushed by a diesel locomotive along a side track. The locomotive operator’s visibility was limited due to overhead electrical cables and water line that were hanging from the mine roof, and supplies that were positioned on the locomotive and the supply cars. 

The report added:

The accident occurred because the victim, who had little mining experience, had positioned himself in a hazardous area. Additionally, the visibility of the locomotive operator was limited, and the miners did not adequately communicate their intentions and/or positions to one another.

A couple of interesting things here …

First of all, the two “safeguard orders,” issued to Independence Coal under Section 314(b) of the Mine Act.

The first one said:

On October 8, 2008, a track-mounted supply motor was being used to push a trip of loaded flat cars into a side track. The flat cars had been loaded in a manner that caused inadequate clearance to exist between the loaded materials on the supply car and the mine coal rib (six inches) and mine roof ( zero inches). These conditions were found to be contributing factors to an accident that caught a miner between the load on the flat car and the mine rib, resulting in fatal injuries.

And the other one said:

A track-mounted supply motor was being used to push a trip of loaded flat cars into a side track. The flat cars had been loaded in a manner that inhibited visibility and decreased communication between the motor operator and the helper. The motor operator did not have a clear line of sight, or know where the motor helper was located, as the loaded supply cars were pushed into the side track. These conditions were found to be contributing factors in an accident that caught a miner between the load and the mine rib, resulting in fatal injuries on October 8, 2009.

So, this wasn’t just the case of an inexperienced worker being in the wrong place at the wrong time. These mining cars were loaded in a manner that made an accident much more likely.

Investigators from the West Virginia Office of Miners’ Health, Safety and Training made similar conclusions in their report, released last December.  But state investigators cited Massey for overloading the cars so that they wouldn’t easily fit where they needed to go and so that the driver couldn’t see where he was going.

Now, about the training Cain received. According to the MSHA report:

Steven Cain started his mining career on May 17, 2008, attending a two-week course at Coal River Training, where he received his 80 hour certificate. Cain started to work for Mountaineer Labor Solution on June 1, 2008, as a newly employed inexperienced miner. Mountaineer Labor Solution provided experienced miner training to Cain on this date. Mountaineer Labor Solution is a contractor, providing underground miners to several coal operators in the region. On June 5, 2008, Cain went to work at the Justice No. 1 mine as an experienced miner, having received the required apprenticeship training program from West Virginia Miners’ Health, Safety and Training. Cain’s training was comprised of self-contained self rescuer (SCSR), health (noise), and hazardous material handling (haz-com).

[updated, 3 p.m. — Surely this is a typo in the MSHA report … No way Cain was considered an “experienced miner,” which is defined in the regs as a miner who has completed an MSHA-approved training program and who has at least 12 months of underground mining experience. See the definitions at http://www.msha.gov/30cfr/48.2.htm. According to MSHA records, Cain had just 17 weeks experience at the time of his death]

On June 9, 2008, Cain received hazard training from the Justice No. 1 mine. Cain’s first assignment underground began by working along the coal conveyor haulage system. His duties consisted of shoveling along the belts as well as the maintenance (greasing rollers and replacing worn out rollers) of the system. Cain spent about 8½ weeks performing this activity. Cain was then assigned to work with the supply crew. This assignment consisted of the loading, transportation, and the unloading of mine supplies throughout the mine. 

West Virginia investigators cited Massey, saying that Cain was not “effectively supervised” because he was allowed to work in an unsafe area while the supply cars were being moved.

But MSHA?

The federal agency’s report lists this as one root cause of Cain’s death:

A miner with little mining experience and minimal training was assigned work duties with rail supply cars and locomotives (motors), which required adequate communications between motor operator and helper.

As a corrective action, MSHA lists this:

The operator has developed and implemented a training plan, designed to ensure the safety of persons being trained on new tasks. The operator has provided a qualified person to do the training. The trainer will also provide training on communications between miners operating or working near locomotives and rail cars.

MSHA did not even issue a safeguard order on the training issue.  And not for nothing, but the federal regulations already require mine operators to have comprehensive training plans (approved by MSHA). Under Part 48 of the MSHA rules those plans must contain:

…Programs for training new miners, training experienced miners, training miners for new tasks, annual refresher training, and hazard training for miners.

On its Web site, Massey Energy says:

Safety is the top priority for every Massey member. No coal company can succeed over the long term without a total commitment to safety and a significant investment in the necessary training, equipment and personnel. We strive to remain an industry leader in safety by developing new technologies and employing effective training programs to reduce accidents and improve safety for all of the hard-working men and women of Massey Energy.