Coal Tattoo

Right now down in Beckley, special investigator Davitt McAteer and his team are briefing the families of the 29 men who died at Massey Energy’s Upper Big Branch Mine on the findings of their year-long investigation of the worst U.S. coal-mining disaster in nearly 40 years.

The bottom line in McAteer’s report:

The explosion was the result of failures of basic safety systems identified and codified to protect the lives of miners.

The disaster at Upper Big Branch was man-made and could have been prevented.

We’ve got a news story online here that summarizes the 122-page report, and the report itself is posted here.

A news conference is scheduled for about 12:30 p.m., and we expect reactions to begin flowing in from Massey, federal and state agencies, and political leaders as soon as those folks have time to digest some of the McAteer team’s findings. The Gazette’s Gary Harki, Kathryn Gregory and Larry Pierce will be bringing readers reactions from some of the families.

The report confirms some previous evidence and theories about how the explosion occurred (see here, here and here), describing its conclusion about the actual blast this way:

… The ignition point for the blast was the tail of the longwall. As the shearer cut into the sandstone mine roof, the resulting sparks ignited a pocket of methane, creating a fireball. The fireball in turn ignited the methane that had accumulated in the gob during the Easter weekend and leaked onto the longwall face. The fireball traveled into the tailgate area, where accumulations of coal dust provided fuel for a second, more deadly, force. This dust-fueled blast ricocheted in multiple directions, traveling across the longwall face, into the tailgate entry, and through more than two miles of the mine.

McAteer’s team also offers some key new information, though:  Key pumps meant to keep water from collecting in mine tunnels near the longwall section had broke over the weekend. This, they say, allowed water to build up and at least partially block the flow of fresh air pulled through those tunnels by the mine’s main ventilation fan at Bandytown. And, miners working the morning and early afternoon prior to the disaster reported in sworn testimony that the flow of fresh air through the mine was reversed that day. Air headed in the wrong direction would have greatly diminished the ability to sweep explosive methane and coal dust out of the working sections.

As MSHA coal administrator Kevin Stricklin said in a media briefing the day after the explosion, this sort of thing can only happen if a series of well-understood and longstanding safety precautions are ignored. McAteer’s team reported:

The company’s ventilation plan 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 principle 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 as a result, a small ignition could not be quickly extinguished.

McAteer’s team, calling themselves the Governor’s Independent Investigation Panel, emphasized the point again, in a chapter called, “The Normalization of Deviance””

Many safety systems created to safeguard miners had to break down in order for an explosion of this magnitude to occur. The ventilation system had to be inadequate; there had to be a huge buildup of coal dust to carry the explosion; there had to be inadequate rock dusting so that the explosiveness of the coal dust would not be diluted; there had to be a breakdown in the fireboss system through which unsafe conditions are identified and corrected. Any of these failures would have been problematic. Together, they created a perfect storm within the Upper Big Branch Mine, an accident waiting to happen.


Such total and catastrophic systemic failures can only be explained in the context of a culture in which wrongdoing became acceptable, where deviation became the norm. In such a culture it was acceptable to mine coal with insufficient air; with buildups of coal dust; with inadequate rock dust. The same culture allowed Massey Energy to use its resources to create a false public image to mislead the public, community leaders and investors — the perception that the company exceeded industry safety standards. And it became acceptable to cast agencies designed to protect miners as enemies and to make life difficult for miners who tried to address safety. It is only in the context of a culture bent on production at the expense of safety that these obvious deviations from decades of known safety practices makes sense.

McAteer’s panel is the first investigative team to complete its probe at Upper Big Branch. MSHA has what it says will be a major public briefing scheduled for June 29, but its complete report is not expected for months after that. No firm timeline has been provided for the release of an MSHA internal review. The state mine safety office likewise isn’t scheduled to issue a report until perhaps very late this year. Two criminal cases have been brought as a result of the disaster — both of low-level Massey employees (see here and here) — and it’s anyone’s guess when or even if more such cases will be filed.

But the McAteer report makes clear that his team of mining experts, lawyers and public health experts believes serious reforms are needed within industry, regulatory agencies and our region’s political structure if more disasters like Upper Big Branch are to be prevented:

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.

… This tells us we can mine coal safely in this country. Disasters are not and 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.