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The first investigative report about last year's coal mine disaster in West Virginia blames a corporate "culture in which wrongdoing became acceptable, where deviation became the norm" for the deaths of 29 Massey Energy mine workers.
The report was produced by an independent team of investigators appointed by former West Virginia Gov. Joe Manchin and led by Davitt McAteer, a former federal mine safety chief who has investigated other mine disasters in the state.
"Massey exhibited a corporate mentality that placed the drive to produce coal above worker safety" at the company's Upper Big Branch mine, the report concludes. "Many systems created to safeguard miners had to break down in order for an explosion to occur."
The McAteer team, which is formally known as the Governor's Independent Investigation Panel (GIIP), also assessed the role of state and federal regulators in the April 5, 2010, tragedy.
"The disaster at the Upper Big Branch mine is proof positive that the [federal Mine Safety and Health Administration, or MSHA] failed its duty as the watchdog for coal miners," the panel's report says.
As for West Virginia's Office of Miners' Health Safety and Training (WV MHST), the investigators say enforcement was weak due to inadequate staffing and funding, and a political failure "to nurture and support strict safety standards."
In a written statement, Massey Energy did not respond to most of the harsh criticism contained in the report.
"We have just received Davitt McAteer's report and are carefully reviewing it," writes Shane Harvey, Massey's general counsel
But Harvey did make "some initial observations," including a complete rejection of the report's claim that coal dust fueled and accentuated the explosion. Harvey repeated Massey's earlier position on coal dust.
"Our experts feel confident that coal dust did not play an important role," Harvey said. "Our experts continue to study the UBB explosion and our goal is to find answers and technologies that ultimately make mining safer."
Harvey also repeated Massey's contention that the blast was fueled by "a massive inundation of methane-rich natural gas." The McAteer report acknowledges that an inundation of natural or methane gas could have triggered the initial ignition but notes that inundations were a known phenomenon at the mine and that neither Massey nor MSHA appeared to do anything to prevent or neutralize them.
The West Virginia Office of Miners' Health, Safety and Training also did not respond to the report's criticism of state mine safety efforts. Spokeswoman Leslie Fitzwater says the agency "look(s) forward to reviewing Mr. McAteer's report and evaluating his recommendations."
In an interview with NPR, assistant Labor Secretary Joe Main tried to shift attention to the report's focus on Massey Energy but acknowledged, "we could have done more. The report identifies areas that we're taking a hard look at. We've already taken some self-examination, as well."
Main added that the report supports the need for tougher mine safety legislation from Congress. And he said his agency has already targeted "catch me if you can" mine operators and applied tough enforcement tools the agency had never used before.
Family members of the victims were also presented with the findings of the report Thursday morning.
"America needs coal, we need it. But there's a right way to do it and a wrong way to do it. And at this mine, they done everything wrong," said Clay Mullins, who once worked in the mines and is the brother of Rex Mullins, who died in the disaster.
"They don't want to listen to nobody. They want to do it their way," said Gary Quarles whose son was killed in the explosion. "What I want to see from Massey — they've got to step up and say we are responsible. They've got to do this."
McAteer's panel confirmed earlier preliminary findings and news reports about the cause of the disaster, some of which resulted from a yearlong NPR News investigation. The independent team also provides some new details.
A 'Perfect Storm' Of Conditions
A combination of ineffective ventilation in the mine, faulty safety equipment, excessive coal dust and ignored internal safety checks "created a perfect storm within the Upper Big Branch mine, an accident waiting to happen," according to the report.
Effective ventilation sweeps away explosive methane gas, which occurs naturally in Appalachian coal mines. But at Upper Big Branch, mine managers struggled for months to get enough air to the sections being mined, "stealing it from one mining section to ventilate another." Miners interviewed by investigators complained about excessive heat and little airflow, which are markers of inadequate ventilation. But they testified that mine managers did not fix the ventilation system.
"[UBB miners] had to deal with ineffective upper management on a daily basis," the report says.
Miner Bobbie Pauley told investigators, "You don't ruffle a lot of feathers when you work for Massey. If we didn't have enough air we ran coal."
The weekend before the blast, which was Easter, pumps failed in underground tunnels, causing flooding waist- and neck-deep in some areas. That water hampered the airflow throughout the day of the explosion.
Uncontrolled Coal Dust
Investigators also documented Massey Energy's failure to properly control coal dust underground, which is highly explosive and acts as an accelerant when ignited. Coal mines are required to neutralize coal dust with crushed limestone or rock dust, but records contained in the report show that Massey failed to apply rock dust in more than 1,500 locations underground in the three months before the disaster.
The company's own foremen noted that 1,834 "entries" or tunnels needed dusting from January to April 2010. But the foremen's notes also indicate that rock dusting was only applied in 302 entries.
"Rock dusting was not a priority at Upper Big Branch in the early days of 2010," the report says.
"The amount of rock dust applied in UBB was insufficient to stop the propagation of an explosion."
Only two mine workers were assigned to rock dusting and only on a part-time basis, according to investigative interviews. The equipment they used was poorly maintained and often failed, and there were days when they didn't have enough rock dust, couldn't get transportation underground and were assigned other work.
Two weeks before the explosion, one rock duster wrote in his notes, "NO RIDE, NO help. NO spotter ... I'm set up to fail here."
Water Sprayers Fail To Suppress Sparks
The report also repeats earlier revelations about malfunctioning water sprayers on the shearer, the cutting tool, on the mine's longwall mining machine.
On April 5, the report says, air underground flowed in the wrong direction, potentially carrying methane gas toward mining machines and the miners working with them. "All that was needed was a spark," the report notes.
The weak ventilation allowed methane gas to accumulate at the longwall machine's shearer, which was cutting into sandstone at the top of a coal seam. Investigators suggest the gas floated above and past methane monitors.
The malfunctioning water sprayers failed to suppress sparks from the shearer, which then ignited a small methane fireball. Weak airflow and water sprays failed to control the fireball, which then ignited coal dust. What followed, the report says, was a series of massive explosions, growing in intensity and force as more and more coal dust ignited.
Some of the most serious damage was 2 miles away, and some of the most traumatic injuries were suffered by miners farthest from the ignition point.
Report Rejects Massey's Claims
Massey Energy has insisted that it put safety first in its mines. The company presented an internal survey in which more than 90 percent of the employees responding said Massey mines were safe.
Last summer, the company theorized that the explosion resulted from a sudden, unpredictable and natural infusion of methane or natural gas from cracks in the mine floor. Massey has also strenuously denied that it failed to properly rock dust UBB and has challenged an MSHA analysis of rock dust in the mine that was conducted after the explosion.
"The thing that is most disturbing in the press is the idea that we as Appalachianers or as coal miners or as company executives don't really value life," said former CEO Don Blankenship at the National Press Club last year. "We certainly would never put profits over safety, and no one would want the experience of informing 29 families that they'd lost their loved ones."
Investigators quote forensic evidence that supports the scenario of an explosion fed by coal dust. The McAteer report also says there is no evidence to support Massey's claim that MSHA officials forced changes in the mine's ventilation plan that made the mine unsafe.
Whatever the cause, the explosion killed 29 people, inflicting fatal carbon monoxide intoxication, traumatic injuries or both, according to autopsy reports reviewed by investigators. Two others who were also hit by the blast managed to survive. One of them, Timothy Blake, was riding in a "mantrip," or shuttle car, heading toward the mine entrance.
"Everything just went black. It was like sitting in the middle of a hurricane," Blake told investigators. "I held my breath, put my [self-rescue breathing device] on. And then it was just — nothing but pure silence and stuff still flying by."
Blake described trying to put self-rescuers on the other mine workers in the mantrip, dragging each out onto the tracks. "They all had a pulse," he testified, "so they was still alive."
Blake's self-rescuer was losing its effectiveness, so he headed out on foot, encountering some miners and mine officials rushing in to help. "That's all my friends," he told foreman Pat Hilbert, who is also an EMT and stayed behind to help Blake as the others headed for the mantrip.
"What can we do?" Blake asked. "All we can do is pray," Hilbert replied, and the two men then prayed.
Failures Of Federal Regulators
"Twenty-nine miners lost their lives in the UBB mine because safety systems failed in a major way," the McAteer team reports, directing some of its strongest criticism at federal regulators.
"There was a disconnect between these ongoing problems and MSHA's enforcement strategy," the report says, noting the agency's failure to apply its toughest enforcement tools at the mine.
"The ultimate failure of MSHA at UBB ... was the agency's inability to see the entire picture, the inability to connect the dots of the many potentially catastrophic failures taking place at the mine," the McAteer team writes.
The report also notes the recent release of internal audits that MSHA kept from the public until they were exposed by The Charleston Gazette. "The results suggest a troubling and widespread pattern of oversight failure," investigators say.
Massey's 'Challenger' Disaster
But the report's harshest words are directed at Massey Energy. Comparisons are drawn to the failed safety culture that contributed to the explosion of the space shuttle Challenger in 1986.
"Massey engaged in a 'normalization of deviance' ... in the push to produce coal," the McAteer team concludes, borrowing a phrase from Diane Vaughan, author of The Challenger Launch Decision. "It is only in the context of a culture bent on production at the expense of safety that these obvious deviations from decades of known safety practices make sense."
Former Massey Energy CEO Don Blankenship promised to release the company's own report on the disaster during a meeting with reporters in November. Blankenship suddenly retired in December, and the company has yet to issue a report.
Eighteen Massey Energy executives and employees declined to be interviewed by investigators. Among them is Chief Operating Officer Chris Adkins.
The McAteer team also takes the unusual step of chiding Alpha Natural Resources, which is in the process of buying Massey Energy, for assigning Adkins the task of running Alpha's safety program after the companies merge June 1, when the shareholders of both companies vote on the takeover.
Adkins' executive supervision of UBB and the company's Aracoma mine, which experienced a deadly disaster in 2006, "makes him a questionable choice to run a safety program," the report says.
Alpha spokesman Ted Pile told NPR last month, "We spent a lot of time ensuring that these people [Adkins and other Massey executives] would be a good match with our ethics."
The federal mine safety agency plans to brief the families of the victims of the tragedy on its preliminary findings on June 28. A public meeting is scheduled a day later. West Virginia mine safety investigators have said they hope to have their own report ready by the end of the year.
A federal criminal investigation continues. Criminal charges have been filed against two lower-level Massey Energy managers so far.
NPR News Investigations editor Anne Hawke contributed to this story.