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Part two of a two-part series.
One year after a West Virginia mine explosion took 29 lives, questions linger about the time it took to find and identify victims, and notify their families.
An NPR News investigation has discovered new details about the search and rescue effort, and problems that plagued mine rescuers.
The new details emerged from an analysis of command center notes and other documents obtained by NPR.
The documents include hand-scrawled lists of miners indicating officials at Massey Energy, the owner of the Upper Big Branch coal mine, had trouble determining who was underground when a fiery explosion roared through the mine on April 5, 2010.
The notes also indicate difficulty identifying which miners were underground and where they were located in the vast mine.
That task was complicated because the explosion occurred during a shift change.
One list suggests miners who died in the explosion were working with miners who weren't even there. Another dated nine hours after the blast names miners believed to be working at the longwall section where the explosion was triggered. Some names are misspelled. Some don't list job assignments, which might indicate the miner's precise location. And one entry has a job assignment but question marks in place of a name.
That prompted Davitt McAteer, who was appointed by former West Virginia Gov. Joe Manchin to lead an independent investigation of the Upper Big Branch explosion, to ask:
"You mean to tell me that in today's age, where computers can tell you within seconds the level of production off a longwall and where that coal is moving along the conveyor belt, we can't keep track of people? That's unacceptable."
A new electronic tracking system was partially installed at the mine but it wasn't helping, says Kevin Stricklin, the administrator for coal mine safety and health at the Mine Safety and Health Administration (MSHA).
"It was a very frustrating time on site for me to know how many people were unaccounted for," Stricklin recalls. "Massey just kept giving me different numbers. I mean, we should know exactly how many people are underground."
McAteer says Massey didn't bother to check the tracking system for names and locations of miners. The company "was still using the, 'Well, we think they were at such and such a section because that's where they usually were,' " method, McAteer says.
Shrouded in respirators, mine rescue teams had to navigate dark, smoky and gassy entryways or tunnels, which had steel tracks twisted like pretzels and mile after mile of debris.
"You're sending them into a void," McAteer says. "And they have to look everywhere. It compounds the problem that they're going to face. It slows them down."
Families Hold Vigil And Await News
The families of the miners were also desperate for information. Seven families learned their loved ones had died that first night after nine miners were found in and close to a mantrip, or shuttle car, about 1.6 miles from the mine entrance.
But it took nearly eight hours to determine that 22 more miners were missing, according to the command center notes. At 10:53 p.m., the notes say, "22 unaccounted for MIA." The explosion occurred at 3:02 p.m., according to MSHA.
The anxious families of those 22 missing miners gathered at a Massey Energy storage building near the mine entrance and began a vigil that would stretch four days.
"I was truly convinced, truly convinced, that my brother was going to come out of there alive," says Judy Jones Petersen, a Charleston physician whose brother Dean Jones was at the end of his shift when the blast hit.
Petersen and Jones' wife, Gina, and her five sisters sat, slept, ate and waited, day and night, in metal folding chairs on a floor stained with tobacco spit. They became known as the "sisters on the wall" because they maintained their vigil against a side wall and near the podium where announcements were made.
"It was what I would describe as hell," Petersen recalls. "Not knowing. Waiting in those terrible conditions. Families suffering side by side."
Nearly 12 hours after the explosion, Massey Energy announced 18 bodies had been found and four miners were still missing. But no names were provided for another four days.
Some families actually engaged in macabre debates, Petersen says, about which miners might have survived.
Massey Exec Identifies Bodies
Mine rescuers were focused on finding the missing miners so they didn't recover or identify those who died. But two Massey executives were also underground for at least nine hours after the explosion, according to the command center notes.
Massey Energy says Chris Blanchard and Jason Whitehead were trying to find survivors. Blanchard is president of Performance Coal, the Massey subsidiary that operates Upper Big Branch. Whitehead was director of underground operations at the time. He has since been promoted and is now a Massey Energy vice president. Neither were certified mine rescuers on the day of the blast.
At 9:58 p.m., the command center notes report the discovery of three bodies in the longwall area. Six minutes later, there's this entry: "The 3 victims were [word unclear] identified By Blancher [sic] In Track."
"[Blanchard] should have been trying to account for his men," Petersen says. "And if his men were dead, he should have told those families, 'I saw your loved one. I laid eyes on your loved one. I know your loved one is gone.' "
That, Petersen says, would "allow that family to leave the hellish nature of what we went through. But it didn't happen."
A spokesman for Massey Energy does not dispute the notion that Blanchard identified victims. But Shane Harvey, the company's vice president and general counsel, says Blanchard's "observations, made in difficult underground conditions, did not meet the standards of the protocol" for positively identifying victims and notifying families.
That protocol, Harvey says, was established by Massey, MSHA and the West Virginia Office of Miners Health, Safety and Training.
"All families were notified," Harvey adds, "once positive identifications were made in accordance with the protocol."
MSHA's Stricklin says positive identifications were critical.
"You have to be absolutely, positively certain, and during this operation we were not," Stricklin says. "In fact, there were no names associated with bodies as we were finding them."
Confusion Inside The Mine
Blanchard and Whitehead traveled nine miles underground, according to Massey Energy. And it appears their movement underground added to the confusion. The pair left footprints and used and discarded emergency breathing devices called self-rescuers or SCSR's.
"The one positive thing that we've seen is that there's a cache of SCSR's that miners would go to if something were to occur," explained Stricklin at a news conference early on the morning of April 6. There are indications, Stricklin added, "that SCSR's were taken from that area."
Used and discarded SCSR's bolstered hope that some miners might have reached refuge chambers underground.
Clarification of these questions is elusive because Blanchard and Whitehead and 16 other Massey managers and executives have refused to testify in the Upper Big Branch investigation.
"It's really the first time on such a large scale that a management team has declined and it's unprecedented, to my knowledge, in this country," says McAteer, who once led MSHA and has investigated two other major mine disasters.
Both Stricklin and McAteer indicate their final investigative reports will include more about the confusion underground.
It wasn't until just after midnight April 10 that the waiting ended for the 22 families crowded into the Massey storage building near the mine entrance.
State troopers and social workers filtered in and families were told an announcement was coming. Petersen and the "sisters on the wall" braced for the news.
"It was solemn" at first, Petersen says. "As soon as [Massey chief operating officer] Chris Adkins said, 'All men accounted for. No survivors,' immediately people started screaming. People were falling down. Chairs and tables were flying. It was absolute, dangerous chaos."
Petersen quickly led Dean Jones' stunned wife, Gina, out the door to safety, with the crying and the wailing fading behind them.
NPR's Nathan Rott contributed to this report.