Yesterday’s release of the West Virginia Office of Miners’ Health, Safety and Training report on the November 2012 death of CONSOL Energy miner Markel Koon in a coal-slurry impoundment offered some frightening details of what happened — and also raised some serious questions about how well one of the nation’s largest coal producers managed a particularly dangerous sort of operation.

First, the report’s description of those moments just before and just after the collapse is really something else, providing a sobering picture of what these mine workers went through. As we explained in today’s Gazette:

At about 11:30 a.m., CONSOL engineer Paul Stuart Carter arrived at the site “after receiving numerous emails from Mr. [Michael] Friedline, [a CONSOL supervisor], in the past weeks concerning the high readings being obtained” on the embankment’s pressure monitor.

Carter and Friedline went to the location of the monitor, where they “observed excessive bubbling of water in the impoundment along the eastern toe/slope and east of the [monitor],” the report said.

“Mr. Carter asked Mr. Friedline if he had noticed the bubbling earlier in the day,” the report said. “Mr. Friedline said, ‘yes, but not as bad.’ Mr. Carter then stated, ‘we need to get off the fill.'”

Friedline radioed Koon, who was operating a dozer on the outer slope of the dump, telling him to leave the area.

The report itself continued:

Mr. Koon was pushing refuse up the slope to install berms and to seal and track loose material of the outer slope. Mr. Koon immediately trammed the dozer to the top of the slope when a large crack began to develop across the refuse fill area.

After the large crack developed, a large section of the fill immediately became unstable. Water/slurry shot through the developing cracks, causing large sections of refuse to break off, sinking into the impoundment.

Mr Koon was heard on the radio saying “what’s going on” as the refuse fill began to fail. The dozer was located on top of the outer slope with the blade toward the dam, when the material under the dozer became unstable. As the section of the refuse began to slide, it caused the dozer that Mr. Koon was operating to turn, going blade first into the water of the impoundment. The cab of the dozer was visible for a few seconds then sank into the water.

The report continued:

Mr. Friedline and Mr. Carter attemped to run toward stable ground, in the direction of the P-7 piezometer. Mr. Friedline and Mr. Carter were both submerged in the water/slurry of the impoundment, along with the pickup trucks they had drive to the site. The conditions of the impoundment deteriorated quickly, causing large sections of refuse to break off, falling into the water of the impoundment. This collapse of material caused an approximately 5-foot high wave of slurry to travel west to east then return to the collapsed area of the saddle dike. Mr. Friedline was able to swim back toward the southern end of the saddle dike where he was rescued from the cold water by several employees. Mr. Carter was swept out toward the center of the impoundment, unable to reach safety. A boat that had been brought to the site was used to rescue Mr. Carter from a slurry island surrounded by water.

It’s hard to imagine what those men went through … but equally hard to imagine Mr. Koon’s family waiting two weeks for his body, still inside his dozer, to be recovered from that impoundment. But it’s also important to take a look back at some of the other things mentioned in there — stuff like this:

CONSOL engineer Paul Stuart Carter arrived at the site “after receiving numerous emails from Mr. [Michael] Friedline, [a CONSOL supervisor], in the past weeks concerning the high readings being obtained” on the embankment’s pressure monitor.

For more on this, check out the “Findings of Fact” section of the state’s report, under the subheading “Correspondence/E-mails”, on page 6.   CONSOL had installed a piezometer to measure the water pressure inside the embankment, and they were getting readings that indicated elevated pressures, a potential sign of instability. That prompted an e-mail exchange the state report described this way:

But then, about an hour before the embankment collapsed, there was another email exchange, described by state investigators this way:

What does that all mean? Well, the state’s report doesn’t really try to explain or put these discussions in any sort of context.  So I asked state mine safety officials about the issue. One thing that were saying is that the pressure monitor had only been installed two weeks before the collapse, and it may have needed time to settle into an accurate reading. In other words, they suggested that maybe the pressures inside the structure weren’t really elevated — and the readings were wrong and would settle into a more accurate level given some time.

Given what happened at about noon on Nov. 30, is that a reasonable explanation now? Or is it more likely that the elevated readings were correct? And more importantly, should CONSOL have had a dozer operator out on the edge of the embankment working while the readings indicated elevated pressures?

This morning, I asked Bill Tucker, administrator of the state mine safety office, about all of this, and he said:

Those are valid questions. It was an elevated reading and they were still working on it. That’s really and truly the million-dollar question all of us had. It’s obvious.

And John Meadows, an assistant inspector in large in the mine safety agency’s regional office, told me this morning:

They were still getting an elevated reading at that time. I would think they would have had concerns about that reading, because it never changed.

I also showed the state’s report to longtime mine safety expert Davitt McAteer, and he remarked:

The dangers involved here are well known. it is a phenomenon that everyone is aware of and yet they’re unable to come to grips with because of the drive to continue to mine coal.

We’ve written before about CONSOL’s very public goal of eliminating all deaths at its coal-mining operations. But so far, the company hasn’t really had anything to say about the state’s report on this fatality. A spokeswoman said this in an e-mail message to me yesterday evening:

We are reviewing and will respond once that process has been completed.