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Upper Big Branch Upper Big Branch The April 5, 2010, explosion: a failure of basic coal mine safety practices Report to the Governor Governor’s Independent Investigation Panel Cover photo credit, Jeff Gentner, The Associated Press: State Police control traffic at the entrance to the Upper Big Branch mine on April 5, 2010. They are standing beneath elevated conveyor belts used to carry coal from the mine. Back cover photo credit, Beth Spence: Miners Memorial on the grounds of the state capitol in Charleston, West Virginia, during a memorial service for the UBB miners, April 12, 2010. Upper Big Branch The April 5, 2010, explosion: a failure of basic coal mine safety practices Report to the Governor Governor’s Independent Investigation Panel J. Davitt McAteer and associates Katie Beall James A. Beck, Jr. Patrick C. McGinley Celeste Monforton Deborah C. Roberts Beth Spence Suzanne Weise May 2011 This preliminary report sets out the findings of our investigation and recommendations to date. The report is available electronically at http://www.nttc.edu/ubb. We will update this site with additional information should it become available. The report also is available at http://www.wju.edu DEDICATION This report is dedicated to the men who lost their lives in the Upper Big Branch mine: Carl Calvin Acord Ronald Lee Maynor Jason Atkins Nicolas Darrell McCroskey Christopher Bell James E. “Eddie” Mooney Gregory Steven Brock Adam Keith Morgan Kenneth Allan Chapman Rex L. Mullins Robert E. Clark Joshua Scott Napper Cory Thomas Davis Howard D. Payne Charles Timothy Davis Dillard Earl Persinger Michael Lee Elswick Joel R. Price William Ildon Griffith Gary Wayne Quarles Steven Harrah Deward Allan Scott Edward Dean Jones Grover Dale Skeens Richard K. Lane Benny Ray Willingham William Roosevelt Lynch Ricky Workman Joe Marcum And to the man who was seriously injured in the explosion: James Woods 1 TABLE OF CONTENTS Letter of Transmittal ........................................................................................................................................2 Foreward ...............................................................................................................................................................4 Memorials .............................................................................................................................................................6 SynopsisPART I: The of Key Explosion Events at..................................................................................................................................10 the Upper Big Branch Mine Introduction ........................................................................................................................................14 Chapter 1: Events leading up to the explosion .....................................................................17 Chapter 2: When the world came to an end ..........................................................................23 Chapter 3: The aftermath of a disaster ....................................................................................27 Chapter 4: Confusion in the Command Center .....................................................................33 PART II:Chapter The Systems 5: The Failureslong days at of Upper rescue Big and Branch recovery ................................................................41 Chapter 6: Coal dust and rock dust ...........................................................................................50 Chapter 7: Bring the air with you ...............................................................................................59 PART III:Chapter The Role 8: The of Federal footprint and of aState disaster Regulators ......................................................................................67 Chapter 9: How could this happen (the federal role)? ......................................................76 PART IV:Chapter The Culture 10: How of couldthe Operator this happen in West Virginia? ......................................................85 Chapter 11: The Massey way.........................................................................................................92 PART V: Epilogue, Conclusions and Recommendations Chapter 12: The normalization of deviance ..........................................................................97 Epilogue ..............................................................................................................................................104 In Conclusion ....................................................................................................................................107 AppendicesRecommendations .........................................................................................................................109 List of officials who declined to be interviewed.................................................................114 Glossary ...............................................................................................................................................115 McAteer and Associates ................................................................................................................119 2 LETTER OF TRANSMITTAL Governor Earl Ray Tomblin State of West Virginia 1900 Kanawha Boulevard East Charleston, West Virginia 25305 Dear Governor Tomblin: It is with sadness and honor that I submit this report of the Upper Big Branch mine disas- ter to you. Sadness because events occurred which made this investigation necessary; honor be- cause the loss of these lives compel us to make these losses meaningful by improving mine safety. On April 13, 2010, I was asked by then Governor Manchin to conduct an independent in- vestigation of the Upper Big Branch Mine disaster where 29 miners were killed. As part of that effort, I and seven associates formed the Independent Investigation Panel (GIIP) which undertook an analysis of the events leading up to the disaster, the disaster itself, as well as, its aftermath. We have attempted, through impartial analysis, to determine not only the causes of the di- saster, but also to learn how to prevent further such events from occurring and to develop reforms to make mining safer. We have followed the facts to wherever they have led; have attempted to learn the essen- tial causes of the explosion and also have examined the existing regulatory system to determine how this could have happened; and finally how government and industry responded to this emer- gency. Here, as so often before, the mine rescue volunteers proved heroic in their willingness to quickly assemble and attempt to rescue – then recover – the trapped miners. The team members all receive our praise and profound thanks. They truly are the “Minute Men” of American industry. Further, we wish to thank the many Upper Big Branch miners and supervisors who gave candid and honest testimony. Their concern with finding the facts in order to prevent other simi- lar disasters speaks volumes about their regard for the victims and their families and is in sharp contrast to others who declined to testify. Sadly, despite all efforts, 29 miners died and one was severely injured. Their families have an immeasurable burden to carry the rest of their lives. To each of them we offer our sympathy, condolence and prayers knowing of its inadequacy, but offering this undertaking in an effort to make improvements which will protect the men and women who are at work today. 3 During the course of this investigation, I was asked by a sister of one of the vic- tims “Please, just tell us what happened.” We have endeavored to do just that. We have also attempted to learn why it happened and explain to the families, friends and general public what went wrong. Our investigation, while thorough, could not be exhaustive. There are still ques- tions which remain, in part, because the force of the explosion destroyed much evidence. Regrettably, some may never be answered. More than a year has passed since the disas- ter, and we believe it best to submit now to you what we’ve learned and offer concrete suggestions on how to prevent other disasters, rather than extend our inquiry indefinite- ly. The findings and recommendations offered here are in a constructive spirit of transforming the U.S. mining industry into a global leader for safe and healthy mining, today and tomorrow. Our recommendations are of no value unless adopted by industry and govern- ments for it is only then that miners will have a better chance to return home safe and sound to their families each day. Our nation’s reliance on coal is likely to continue for sometime – all of us reap the benefits that result from the efforts of men and women working in coal mines. We owe it to them to ensure a safe and healthful work place; we as a nation and the mining indus- try have shown that we know how to mine safely. We are obliged to do that. The efforts of my associates, Beth Spence, Jim Beck, Celeste Monforton, Debbie Roberts, Katie Beall, Pat McGinley and Suzanne Weise, have been truly remarkable. For more than a year, this group has attended interviews, conducted a full underground investigation, reviewed thousands of documents, transcripts, data, information and cor- respondence. They have worked tirelessly to determine the cause of the explosion and how to prevent it from happening again. Following such a disaster, there is but one choice: to promptly and thoroughly investigate and to set out a course of action which will ensure,
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