Missed inspections and unused enforcement tools got most of the attention earlier this week when the U.S. Mine Safety and Health Administration released its long-awaited “internal review” report on the Upper Big Branch Mine Disaster. But as I read and re-read MSHA’s internal review, two absolutely remarkable things stand out that the anyone who cares about the safety and health of our nation’s coal miners should know about.
First, turn to page 132, a little ways into a section headlined Longwall 050-0 MMU Plan – Specific Issues. Here, MSHA reminds us that Massey Energy back in 2008 moved the longwall mining machine from Upper Big Branch to another Massey operation temporarily. Company officials brought it back in late 2008, and MSHA approved a new longwall mining plan — MSHA’s equivalent of a permit — in June 2009. But according to the internal review team:
The initial MMU plan proposed by the operator and subsequently approved by District 4 for longwall 050-0 was significantly less stringent than the final MMU plan for the previous longwall 031-0. The approved MMU plan for longwall 050-0 required an intake air quantity of 40,000 [cubic feet per minute] and many of the previously required methane and dust control parameters were either released or omitted.
Wow. Now, we had heard a little bit about this before, when some information about the longwall plan leaked out of one of the private meetings MSHA officials held with families of the miners who died at Upper Big Branch.
But that information had the previous longwall plan at Upper Big Branch requiring 60,000 cfm, compared to the 40,000 in the 2009 longwall mining plan. But according to this comparison done by the internal review team, that previous plan required 104,000 cfm, compared to the 40,000 that MSHA approved for the 2009 longwall plan. And that comparison outlines at least 20 other areas in which the new plan approved by MSHA — for the longwall mining area where the explosion occurred — were weaker than the previous longwall mining plan at Upper Big Branch. We’re talking about requirements for the number of water sprays and when and how those sprays were operated … and remember that MSHA’s accident investigation team found that the lack proper ventilation and adequate water sprays were major contributing factors in the deaths of 29 miners in the April 5, 2010, explosion.
Now, the internal review team says that MSHA personnel tried to explain this:
District 4 personnel indicated approval of the reduced ventilation parameters on the new longwall were justified due to a significant difference in the mining conditions from previous panels.
But the internal review team responded:
… Each longwall MMU utilitized the same manufacturer and model shearer to extract coal from the face; a significant amount of roof and floor strata were mine during each pass; and each MMU (continuous miner or longwall panel) in the mine eventually ended up on a reduced respirable dust standard …
The internal review team concluded:
… A minimum air quantity of 40,000 cfm was not sufficient to control respirable dust and mitigate methane outbursts at the mine. In addition, many of the enhanced dust parameters included in the MMU plan for longwall 031-0 should have been considered for inclusion in the longwall 050-0 plan.
… District 4 did not ensure that the plans recommended for approval by the technical departments were consistent and reflected previously approved plans, mine accidents, methane liberation, and respirable dust compliance history.
How could this happen? How could MSHA go with a much-weakened ventilation plan at Upper Big Branch, especially given the mine’s history of methane problems?
In its report, the internal review team blames this — as it does so many things — on the lack of experience among new MSHA employees and turnover among agency supervisors, especially in Southern West Virginia:
When a new base ventilation plan was submitted by the Operator in 2009, plan reviewers were not aware of the potential for methane inundations. The issue was not addressed in the ventilation plan in 2004; thus there were no provisions that could be carried over into the Operator’s plan in effect at the time of the explosion. In addition, the Acting District Manager and Ventilation Department supervisor, who had knowledge of the earlier methane inundations, changed employment in the interim. This left the new District Manager and the new Ventilation Department supervisor without institutional knowledge of the 2004 event. Finally, the 2004 Technical Support reports documenting the inundation potential were not maintained, nor were they required to be maintained, in Ventilation Department files used as a reference by UBB ventilation plan reviewers.
Elsewhere in the report, though, the MSHA internal review team adds this detail:
As discussed in the “Management Issues” section of this report, the ADM-Technical was in his position during the time the methane outbursts occurred; received a copy of the memorandum addressing the MSHA Technical Support investigation; and received and initialed the memorandum regarding the UBB request for assistance in determining the proper location for drilling degasification holes. After review by the District, if provisions of a mine plan are identified as unsuitable to the particular conditions at the mine, the PPM directs the District Manager to initiate changes are needed. However, neither the ADM-Technical nor the District manager initiated modifications to the ventilation plan in 2004 to mitigate the hazards associated with methane floor outbursts.
ADM-Technical stands for Assistant District Manager for Technical Programs. At the time. this was Rich Kline, a 15-year veteran of MSHA and that position. Interestingly, the 2009 longwall plan was also signed off on by Lincoln Selfe, a 20-year MSHA veteran. The MSHA ventilation department supervisor at the time the 2006 longwall plan for Upper Big Branch was approved? That was Bill Ross, who left MSHA in 2008 to become a ventilation staffer for Massey. Readers of Coal Tattoo and of the McAteer team’ s independent report will recall that the man who took over for Ross at MSHA, Joe Mackowiak, later strongly urged Massey corporate vice president Chris Adkins to send Ross over to Upper Big Branch to help with ongoing ventilation problems. That was less than three weeks before the mine blew up.
Adkins and Ross both asserted their Fifth Amendment rights and refused to answer questions from Upper Big Branch investigators. MSHA lawyer Derek Baxter blocked Pat McGinley, a member of McAteer’s independent team, from delving into more detail about the previous methane incidents at Upper Big Branch. And the earlier methane incidents aside, doesn’t it seem a little surprising that, when reviewing a plan to resume longwall operations at Upper Big Branch, the MSHA personnel responsible for that review wouldn’t go back and take a glance at the previous plan first?
The other thing that just screams out from the internal review at this point was actually summarized by the internal review team in its executive summary, but didn’t get a lot of media attention from me or anybody else so far:
The Operator took advantage of MSHA procedures to avoid being subject to respirable dust standards reduced to concentrations below 2.0 milligrams per cubic meter due to the silica content of the Mine dust. District 4 permitted reduced standards for respirable coal mine dust to be reestablished at 2.0 milligrams per cubic meter when the Operator simply changed Mechanized Mining Unit (MMU) designations by replacing the continuous mining machine. District 4 personnel also allowed the Operator to significantly delay corrective actions to reduce miners’ exposures to unhealthful respirable dust concentrations after overexposures were identified.
Later in its report, on page 155, under the heading Respirable Dust at Upper Big Branch Mine-South, the internal review team put it this way:
By replacing MMUs and manipulating the operating status of existing MMUs, the Operator exploited “loopholes” in MSHA policy and procedures in order to avoid complying with reduced respirable dust standards.
For more details, you have to go to Appendix O of the internal review report. There, MSHA explains that respirable dust limits in underground mines are tightened below the general standard of 2.0 milligrams per cubic meter when certain amounts of quartz are present in the mine, because quartz exposure can lead to silicosis. These tighter standards are supposed to stay with continuous mining units (MMUs), even when those units move to other locations. But at Upper Big Branch, here’s what happened:
District 4 allowed sets of mining equipment on working sections to be assigned new MMU identification numbers even though the Operator replaced only one piece of equipment, the continuous mining machine. By deactivating an existing MMU and replacing it with another MMU in this manner, the Operator was able to: (1) avoid complying with a reduced respirable dust standard and resume mining at the same location under a respirable dust standard of 2.0 mg/m3 and (2) terminate an outstanding citation for excessive respirable dust concentrations without verification that dust control parameters effectively controlled respirable dust. At UBB, MMUs generally were deactivated, and replacement MMUs activated, on the same day. In some cases, MMUs were deactivated after the replacement MMUs were already activated.
By replacing MMUs in this manner, the Operator potentially exposed miners to harmful levels of respirable dust for extended periods of time.
Given this, is it surprising that so many of the miners who died at Upper Big Branch were found to have contracted black lung disease? Why didn’t MSHA officials stop this charade? Here’s all the internal review team had to say about that:
During his interview, the Chief of the Coal Health Division stated that when a new MMU number is assigned by using MSHA Form 2000-142 and Item 7C of the form is left blank, the MSHA computer system automatically sets the respirable dust standard to 2.0 mg/m3, even when the new MMU starts mining in an area of the mine where a reduced standard was in effect.
Although Item 7C on the form states: “Headquarters Only,” the instructions for the form explain that the district can enter a lower value to retain the reduced standard. The Health Division Chief also stated the issue had not been brought to headquarters’ attention, and he expected information about entering a reduced standard had been conveyed to new employees in the District Health Departments.
In interviews, District 4 managers, supervisors, and specialists indicated that they were not aware that, when appropriate, the District could maintain a reduced dust standard associated with the former MMU when a new MMU replaces it on the same working section. Rather, they believed only MSHA headquarters could override the pre-programmed designation.
George Fesak, the head of MSHA’s internal review, told reporters earlier this week:
… Those violations were not caused by MSHA or MSHA’s inspectors. They were caused by Massey Energy…I don’t really see where we caused that explosion.
And asked if MSHA failed the Upper Big Branch miners, agency chief Joe Main said:
I don’t think there’s any question that MSHA could have done better.