Coal Tattoo

We reported in the Gazette back in November that investigators had found problems with the water spray systems meant to control dust and potential fires and ignitions in the longwall section of Massey Energy’s Upper Big Branch Mine.

Today, we followed up with another story with a few more details discovered during testing just before Christmas of the longwall machine’s cutting tool:

West Virginia and federal investigators have discovered more problems with a water-spray system in the longwall unit of Massey Energy’s Upper Big Branch Mine, a finding that could be a key piece of evidence about the April 2010 explosion that killed 29 miners.

More missing and malfunctioning water sprays were confirmed during testing of the longwall machine’s cutting tool in late December, although officials have not released an exact count of the problems that were found.

Massey officials confirmed that at least six sprays were missing from the cutting tool, called a shearer, but said it’s not clear if they were destroyed by or were missing before the deadly explosion.

Other media coverage of this particular issue has focused more on the wrangling between Massey and MSHA over exactly how and when the longwall shearer spray system would be tested. But investigators have been saying all along that the initial findings — the water sprays that could be seen to be missing even before the system was tested — could turn out to be a key piece of evidence in the disaster probe.

So far, we’ve seen that investigators were looking very closely at the results of tests conducted to see how well Massey Energy rock-dusted the Upper Big Branch Mine. And some government investigators remain very interested in finding out how Massey and MSHA responded to early warnings in the form of methane outbursts at the mine in 2003 and 2004. It was also clear from early on that this was a mine with serious ventilation problems, and that federal inspectors didn’t believe the company was taking those issues seriously enough (see here, here and here).

And over the last nine months, we’ve also learned that MSHA was unable to keep track of its own enforcement records well enough to take the appropriate actions at Upper Big Branch, yet didn’t ask Congress for additional needed money to step up its oversight.  In addition, we know that MSHA ignored for years the recommendations of outside safety experts about the need to tighten rock-dusting standards and do something about lesser standards for preventing explosions in “intake” airways.

The string of preventive measures that may have failed at Upper Big Branch reminds me of a major New York Times piece that ran the day after Christmas about the Deepwater Horizon oil disaster:

Nearly 400 feet long, the Horizon had formidable and redundant defenses against even the worst blowout. It was equipped to divert surging oil and gas safely away from the rig. It had devices to quickly seal off a well blowout or to break free from it. It had systems to prevent gas from exploding and sophisticated alarms that would quickly warn the crew at the slightest trace of gas. The crew itself routinely practiced responding to alarms, fires and blowouts, and it was blessed with experienced leaders who clearly cared about safety.

On paper, experts and investigators agree, the Deepwater Horizon should have weathered this blowout.

This is the story of how and why it didn’t.

It is based on interviews with 21 Horizon crew members and on sworn testimony and written statements from nearly all of the other 94 people who escaped the rig. Their accounts, along with thousands of documents obtained by The New York Times describing the rig’s maintenance and operations, make it possible to finally piece together the Horizon’s last hours.

What emerges is a stark and singular fact: crew members died and suffered terrible injuries because every one of the Horizon’s defenses failed on April 20. Some were deployed but did not work. Some were activated too late, after they had almost certainly been damaged by fire or explosions. Some were never deployed at all.

Criminal investigations of the kind going on at Upper Big Branch are important, for they’re part of the way our society holds responsible those who violate the standards we’ve all agreed we should live by. By refusing to have a more open investigation — in the name of protecting the sanctity of that criminal probe — the Obama administration could be saying that punishing people is more important than finding ways to keep it from happening again.

But disasters of any kind are seldom able to be boiled down to one single problem, or the actions of a single individual (or company).

Massey’s Aracoma Mine fire is one example. Sure, by most accounts that mine was a mess, and Massey’s Aracoma Coal Co. subsidiary paid a $2.5 million criminal penalty as a result.  But government inspectors didn’t exactly perform well at Aracoma, either, and their managers higher up in MSHA never stepped in to make sure the law was being properly enforced.

Or consider the Sago Mine Disaster … While MSHA didn’t issue any contributing violations, it’s clear from special investigator Davitt McAteer’s report that Sago could have been prevented if industry and regulators had both used all of the tools at their disposal to see that every miner makes it home safely after every shift.

So what does that mean for Upper Big Branch and the ongoing, behind-closed-doors investigation?

As the press, the public and the politicians grow increasingly impatient with MSHA and the lack of any real public accounting of exactly what happened and why, it’s important to remember that it’s terribly unlikely that any investigation is going to point to a smoking gun.  More likely, we’ll be told by investigators that a string of safety systems — from rock-dusting rules and ventilation plans, from federal inspections to state oversight — all were violated, ignored or just broke down.

Coal mining is a a business that has very little margin for error. It’s easy for a small mistake to get someone hurt or killed. It’s equally easy for a cascading series of mistakes, oversights and failure to lead to a disaster.

Wouldn’t the mining community — and most importantly working coal miners and their families — benefit from getting some of the lessons from Upper Big Branch out right away, where the public and the industry can see them and learn from them?