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One year ago tonight, mine rescuers discovered the remains of the last four missing coal miners deep inside Massey Energy's Upper Big Branch mine in West Virginia.
There had been hope that the four had made it to refuge chambers and were still alive. Optimistic rescuers carried four sets of breathing apparatus with them, hoping they would be used to bring the miners safely to the surface. The bodies of 25 other miners were found four days earlier.
A year later, the nation's worst coal mine accident in 40 years is still not fully explained. And the scope of the disaster still alarms mine safety experts.
"I've been in MSHA for 31 years and I've never seen 29 fatalities," says Kevin Stricklin, administrator for coal mine safety and health at the Mine Safety and Health Administration. "This takes us back to the '60s or '70s, this explosion."
"It continues to be extremely difficult to believe that we're operating mines in this country that can conceivably cause the death of 30 individuals in one blow," adds Davitt McAteer, a former assistant secretary of labor who is conducting an independent investigation of the Upper Big Branch explosion.
Echoes Of An Earlier Disaster
McAteer's book Monongah details the nation's worst coal mining accident ever, which killed nearly 500 immigrant and African-American men and boys in West Virginia in 1907. But McAteer and others say there are echoes of Monongah at Upper Big Branch.
"If you look at what happened in this mine and what happened at Monongah, the difference is a period of 100 years and the fact we don't use mules in coal mining anymore," says Mark Moreland, whose law firm represents the interests of coal miners in the disaster investigation. Moreland and his wife, Rachel, also represent the families of some Upper Big Branch victims in wrongful death suits against Massey Energy.
"The extent of coal dust here is like it was a hundred years ago," Moreland adds. "That's frightful. That's sad."
MSHA has mapped miles of excessive coal dust on the roof, floors, walls and conveyor belts in the Upper Big Branch mine based on sampling after the explosion. Coal dust is highly explosive and turns small ignitions of methane gas into massive firestorms.
MSHA investigators theorize that sparks from the cutting tools on a poorly maintained longwall mining machine ignited methane gas. They found worn bits on the tool, called a shearer, and malfunctioning water sprayers. The mine also has a history of poor ventilation, which needs to be robust enough to sweep away methane gas and coal dust.
In combination, proper ventilation and working water sprayers neutralize small methane ignitions and keep coal dust particles from becoming suspended in the air, their most explosive state.
If these safety systems were working as designed, McAteer says, "you would have limited the explosion into a single area and you would have limited its spread. The fact that it spread through the mine says to you that the systems didn't work."
Massey Exec: A 'Natural Disaster'
Massey Energy rejects the notion that failed safety systems and excessive coal dust played roles in the explosion. Massey board Chairman Bobby Inman told The Wall Street Journal this week that this was a "natural disaster." The company contends that a natural and unexpected infusion of methane or natural gas fueled the blast.
"It's not our conclusion that it was a natural disaster in my understanding of that term," McAteer responds, "but was a disaster which was preventable and which had human causes."
McAteer says he'll elaborate in his final report, which could be out in a matter of weeks. He had the same response to another lingering question: Did Massey Energy put production over safety? "Yes," says Judy Jones Petersen, whose brother Dean Jones was a Massey foreman when he died at Upper Big Branch.
"There was an incident in which my brother had his section shut down by one of the federal MSHA people," Petersen recalls. "And as soon as that federal investigator left, there was a call to my brother saying, 'Put it in the coal, Deano.' Get the production going again."
A Focus On Maximizing Production
Massey Energy was keenly focused on production, according to company production records obtained by NPR. They chart every foot of coal mined and every minute of time lost every hour of every shift every day. And every two hours, production reports from every mine went to former CEO Don Blankenship, according to his own deposition in 2008.
Three years earlier, Blankenship sent a memo to the superintendents at Massey's underground mines, including Upper Big Branch.
"If any of you have been asked by your group presidents, your supervisors, engineers or anyone else to do anything other than run coal (i.e. - build overcasts, do construction jobs, or whatever) you need to ignore them and run coal," the memo says. "This memo is necessary only because we seem not to understand that coal pays the bills."
Building overcasts is a safety function designed to improve ventilation in mines.
Blankenship followed up with another memo later saying safety is first at Massey. But some say the expectations were clear.
Miner Cites Pressure: 'You Can't Slow Down'
The production pressure affected Ricky Lee Campbell, who drove coal-carrying "buggies" underground at two Massey mines, including Upper Big Branch.
"It makes you want to go nonstop," Campbell recalls. "You can't slow down. It's like you're always rushing things."
Campbell has a whistle-blower complaint pending against Massey. He claims he was fired because he complained about safety problems.
Campbell remembers his every move at work being timed by a company official with a stopwatch. He says the pressure kept miners from hanging ventilation curtains, which help maintain the robust airflow that helps control methane gas and coal dust.
"That takes up that one minute. That's another minute of you getting two buggies," Campbell explains. "So you can hang that curtain or get two extra loads or three extra loads. They want them loads."
Ex-CEO: Equal Emphasis On Productivity, Safety
Last fall, before he retired as CEO, Blankenship defended his laser focus on production.
"I don't think that timing your productive processes means that you're putting pressure on people to be unsafe because actually you're also timing how long it's taking them to do it safely," Blankenship said. "And that observation by that time-study guy, if you will, will include comments about things that he sees that are unsafe."
Blankenship also said he tracked safety as close as production.
But in the months before the explosion, federal mine inspectors forced more safety shutdowns at Upper Big Branch than at any other mine in the country.
Still, even the regulators missed or failed to address the multiple safety systems failures McAteer describes. MSHA has also been cited for lax enforcement in reports of earlier disasters and in internal audits.
"It stands to reason that if a mine blows up and 29 men die, the safety net for those workers that the federal government was supposed to have in place didn't work," says Ken Ward, the veteran coal industry reporter at the Charleston Gazette. "For anybody from MSHA to say, 'We were doing our job at this mine,' doesn't make much sense because their job is to keep this from happening."
Regulators' Role Also Questioned
MSHA officials have said their inspectors can't be underground in coal mines all the time so mining companies bear responsibility for safety failures.
But Assistant Labor Secretary Joe Main acknowledges some shared blame for Upper Big Branch.
"There are fundamental problems that we've got in this industry that are more serious than all of us have been taking them," Main told NPR.
Main responded to Upper Big Branch with wave after wave of surprise inspections targeting problem mines. The agency also began to use enforcement tools it had never used before, including the authority to seek a federal court injunction against mines with habitual and persistent safety violations. A Massey mine in Kentucky was targeted for that action.
But even with tougher enforcement, agency officials are unwilling to say that another major disaster could not happen now.
"On April 4th of last year, I'd say there's probably very little chance of something occurring. And after April 5th, it humbled me a lot," says MSHA's Stricklin.
"I'd like to think that we won't have another Upper Big Branch," Stricklin adds. "But if the company's not on their guard, the miners aren't on their guard and MSHA's not on their guard, a disaster is always a possibility."
MSHA investigators say they'll have a preliminary report on the explosion at the end of June.