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Chapter 4

Confusion in the Command Center

Early on the morning of April 5, 2010, Wayne Wingrove, an underground inspector with the West Virginia Office of Miners’ Health Safety and Training(WVMHST), began a general quarterly inspection of the Upper Big Branch mine. He had just been assigned to UBB at the beginning of April.

Wingrove left UBB property at about 2:00 p.m. and arrived at his home approximately an hour later. At 3:39 p.m., Jonah Bowles made his calls to the West Virginia Mine Industrial Rapid Response line.1

At 4:23 p.m., the Response line received a call from an operator with Raleigh County 911 who reported receiving a call at 4:22 p.m. The operator said, “We do have a mine accident. We have ten people they think are still underground. I don’t have any details. They just say they had a major accident. It’s Performance Coal Company.”2

Minutes later, at about 4:30 p.m., Wingrove received a call from the WVMHST office telling him to get back to the mine, that a call had come into the state hotline reporting “something bad had happened.”3

At 5:14 p.m., a staff member for the Response line called Massey Energy’s office and spoke with Jeff Gillenwater, the company’s vice president for human resources. Gillenwater told the official, “I did just put out a press release [at 4:57 p.m.] saying we did have an explosion and injuries are unknown at this time. I’m trying to get that information as well right now myself, butI don’t have any numbers yet.”4

By the time Wingrove arrived back at UBB, he could see bodies lined up outside the mine, across from the opening of the track entry, covered with plastic, their boots sticking out.5 The inspector said it “felt like somebody had their hand on my heart and was squeezingthe heck out of it.”6

When he went to the UBB offices to check records, Wingrove found that federal officials were already on site. At 6:00 p.m., he issued a control order pursuant to Chapter 22A-2-68 of West Virginia Code.7,8

Robert G. Hardman, district manager for the Mount Hope District 4 office of the U.S. Department of Labor’s Mine Safety and Health Administration (MSHA),had arrived at the mine shortly after 5:00 p.m., accompanied by his staff assistant, Mike Dickerson.9 MSHA’s national call center records indicate the federal agencywas notified at 3:30 p.m. of an event that had occurredat 3:27 p.m. The district office received notification at 3:42 p.m. of a call from Performance Coal Company to the national call center reporting an inundation of gas resulting in an evacuation of the mine.10 While en route to the mine, Hardman received a call at 4:30 p.m. from Elizabeth Chamberlin, Massey Energy’s vice president for safety, during which she told him one “disoriente dman says men are down” and there were signs that an explosion had occurred.11

By the time Hardman and Dickerson had driventhe approximately 35 miles to UBB, nine miners hadbeen brought to the surface; six of them had beenconfirmed dead. Even before he arrived at the minesite, Hardman had issued a 103 (j) order by telephoneat 4:00 p.m.12 Section 103 (j) of the Federal Mine Safetyand Health Act of 1977 allows MSHA – even if federalofficials are not on site – to take any steps necessary toprotect lives, including supervising and directing rescueand recovery missions, and to ensure the protection ofproperty needed for accident investigations.

At 5:20 p.m. Hardman amended the order to a written 103 (k) order. Section 103(k) of the Federal Mine Act gives the MSHA representative who is on site the authority to take steps necessary to ensure the safety of persons in the mine and to protect evidence. With the issuance of a (k) order, the mine is effectively under the control of the Mine Safety and Health Administration. The company remains in charge of rescue efforts, but all plans must be submitted to state and federalauthorities for approval before they are executed.13

Shortly before 4:30 p.m., the man who would become the face of MSHA during the long days of rescue and recovery arrived in West Virginia on a flight from Washington, D.C. Kevin Stricklin, MSHA’s top administratorfor coal mine health and safety, had flown into Charleston’s Yeager Airport that evening with the intention of driving to Pikeville, Kentucky, where he hada meeting scheduled the following day with Kentucky mining officials. Stricklin also had on his agenda an April 8 meeting with Massey Energy officials to discuss hazard complaints MSHA had received concerning other Massey mines in the area.14

Before he left the airport, Stricklin received a call from his office advising him that there was “a pretty major issue at the Upper Big Branch mine…. and there may be some people unaccounted for.”15 Rather than continuing south on U.S. 119 to Pikeville, Stricklin instead turned left at Danville onto State Route 3 and followed a convoy of state vehicles to the Upper Big Branch mine. He arrived sometime between 5:30 p.m. and 6:00p.m.16

Stricklin met Hardman outside the mine, where he learned that six people were confirmed dead and at least 20 were unaccounted for underground. Hardman told Stricklin he was heading to the UBB portal to setup a command center.17 Stricklin accompanied him and volunteered to take responsibility for talking to family members and the media, allowing Hardman to concentrate on running the command center.18

The MSHA officials went to an office on the second floor of a metal building, which Massey Vice President Chris Adkins had assigned for use as the command center. After issuing the written (k) order, Hardman said he “started the normal protocol of organizing a commandcenter … and we began the thrust of the rescueeffort.”19

By their very nature, mine rescue efforts are conducted under unimaginable stress and with great uncertainty. Critical decisions must be made with the best available information, which is often incomplete and sometimes inaccurate.

A command center, or incident control center, is established to assess all the available information, direct the mine rescue operation and make decisions concerning the mine rescue teams, including when they enter the mine, their assignments, their methods of exploration, firefighting duties and location of freshair bases (FABs). The command center is comprised ofrepresentatives of the mine operator, MSHA, the state agency and a miners’ representative, if employees have designated one. All steps in the rescue plan must receive written approval from MSHA and the state agency. Ideally, individuals with specialized skills and expertise inmine emergency response man the command center; in Aerial map of UBB mine area, West Virginia Geological Survey reality, personnel in the command center are representatives of the mine operator and the agencies who are available at the time.

Disasters, the media and politics

Beginning with the 1968 Farmington, West Virginia, mine disaster, the news media has played an increasingly larger role at the scene of mine disasters. Those who are old enough to remember Farmington recall images of grieving widows broadcast by local and national television.

In the years since, especially with the advent of cable television, mine disasters have become full-blown media events, with high profile news anchors flying in to set up cameras, interview local residents and provide endless coverage of rescue efforts. When the Sago Mine blew up in 2006, cable news provided minute-by-minute on-air reporting throughout the forty-plus hours of rescue and recovery efforts. In their haste to get the story first, they sometimes got it wrong. The classic example, now used as a teaching tool in college journalism classes, was the erroneous report that the miners, except for one, were alive. In truth, only one was alive. Twelve were dead.

The presence of the cameras also has placed pressure on politicians in mining states, compelling them to be on site at disasters to comfort families and to take their places at the front of news briefings. Especially since the miraculous rescue of nine miners trapped for more than 78 hours after a flood at the Quecreek mine in Pennsylvania in 2002, governors, senators and representatives have played an ever larger and more public role in the aftermath of mining disasters. While it is understandable that political figures feel the need to respond to disasters in their states by expressing genuine concern for families of trapped or deceased miners, their presence, and that of the new, more intrusive, media, has placed a greater strain on those charged with undertaking mine rescue procedures.

Life and death decisions – whether to send rescuers in or pull them back – are questioned, discussed and second-guessed, allowing the emotion of the moment to infringe upon the detached discipline and scientific approach that forms the basis of mine rescue. At its core, mine rescue is best served when decisions are based “on the numbers,” the raw data as to the toxicity of the atmosphere and the potential for secondary explosions or fires. The emotion generated by media reports should not ever be a factor in those decisions.The mining community needs to address the rescue and recovery system in light of the new challenges presented by technology and the now ever-present media.

The officials rely on data from atmospheric monitoring systems, values provided by technicians taking air readings at the mine portals, and observations from miners who witnessed the event or who have specialized knowledge about the mine. Key information also comes from mine rescue teams, who, when they are deployed underground, become the eyes and ears inside the mine for the command center. It is the command center’s task to evaluate the information received, make decisions based on it and provide direction to the mine rescue teams.

Mine rescue team members are trained to respond to mine emergencies such as fires, explosions, roof falls and water inundations, in which the environment is both dangerous and unstable. They volunteer hundreds of hours each year to hone their skills through training exercises and mine rescue contests.

Team members practice using specialized monitoring equipment to take gas readings and learn to interpret the results. They practice fighting fires, assessing air velocities, building ventilation controls to divert airflow, administering first aid, establishing and maintaining communication lines. Their training activities follow established mine rescue protocols again and again, so that in an actual emergency, their response will be second nature. During mine rescue contests – the most robust of the training activities used in the United States – teams are expected to obey established protocols with precision. In fact, they are penalized for failing to adhere to procedural rules. As experienced mine rescuers will explain, when the adrenaline is pumping, individuals might do something crazy – but that’s where the training kicks in, to stop them from doing something stupid that places them or other team members at risk.20

The mine rescue teams also rely on the command center to watch their backs. The first priority and duty of officials in the command center must be the safety of mine rescuers.

The manner in which a command center operates depends on the experience, knowledge and expertise of those who come together in the hours after a tragedy – how well they function as a group, how well they respond in a stressful environment and how well they are able to withstand the pressures of outside influences.

At Upper Big Branch, many things did not work well. For example, note taking was spotty, and, as a result, command center officials failed to create an adequate written record to indicate how events transpired. Interviews with officials who were present have led the Governor’s Independent Panel to conclude that phone calls to the command center from underground either were not recorded or were recorded haphazardly. Communication from the media and families of the missing miners filtered into the command center and decisions were influenced by these events.21

Stricklin said he didn’t know who had been in charge of the evacuation, but that Chris Adkins was in charge of rescue and recovery for the company.22 Early in the command center operation, Adkins constantly had the phone to his ear in order to provide instructions and make inquiries to the mine rescuers underground. Other officials in the command center were at a disadvantage because they heard only Adkins’ side of conversations or what he said the speaker on the other end of the line had said. At approximately 7:30 p.m. WVMHST mine rescue coordinator Danny Spratt took a special phone adapter from his state truck and hooked it to the phone in the command center.23

The adapter was something WVMHST had had specially made following the 2006 Aracoma disaster after officials witnessed Adkins and other Massey officials using a single phone for nine hours straight in the command center. At Aracoma, the phone system was set up so that only one person could hear communications from rescuers underground.24 The adapter allowed six headsets to be connected to the phone line so that multiple individuals could hear communications from teams underground. One of the headsets had a boom microphone for the person who served as primary communicator to the underground teams. When Spratt set up the device in the UBB Command Center, he suggested that one of the outlets be used for a digital recorder. Spratt knew an audio recording would assist with evaluating the emergency response. It was something WVMHST had used during its emergency response drills. His suggestion was rejected.25 Any decision about recording would have been made jointly by Chris Adkins and Bob Hardman, the company and MSHA leaders in the Command Center.

Not surprisingly, there was a great deal of chaos as state, federal and company officials tried to determine who was underground, where they were and what condition they were in.

While mine rescue protocol envisions an orderly process, even well trained rescuers often respond to disasters with an adrenalin-fueled instinct to rush underground. At times people who are not trained in mine rescue enter the mine unsupervised, without a clear plan of action and without the proper apparatus, as was the case with Massey officials at Upper Big Branch.

By the time the Command Center was set up, Hardman was staging mine rescue teams to go underground, Stricklin recalled. Stricklin said it was then he learned that Performance Coal officials Chris Blanchard and Jason Whitehead were in the mine.26 Also by this time, three members of Massey’s Southern West Virginia Mine Rescue Team – Jim Aurednik, Rob Asbury and Mark Bolen – were underground, beginning to repair phone lines to establish communications; they said they also were searching for Blanchard and Whitehead.27

At 5:30 p.m., Hardman modified the (k) order to allow two Massey mine rescue teams to enter the mine to 35 Crosscut. When the teams reached that point, it was determined that the air quality would allow further exploration. At 6:15 p.m., Hardman modified the (k) order to allow the teams to advance to 78 Crosscut.28

Stricklin estimated that the Command Center was set up and officials on the surface were in contact with Blanchard and Whitehead underground “somewhere in the vicinity of 6:15 to 6:30.”29 Stricklin said Massey’s Southern West Virginia team went underground at 6:45 p.m., the first team into the mine.30 Hardman said that by 7:05 p.m., two state teams were in the mine and a total of nine teams were available outside the mine.31

Although the rescue efforts were underway, Hardman acknowledged that he “never did get a handle initially … on how many we had underground. But there were bare-faced people employed by Massey underground in the mine.” Hardman was unable to locate records indicating who the individuals were or what time they entered the mine.32

Stricklin said he expressed concern to both Hardman and Adkins about people being underground who “weren’t mine rescue trained” and “were on their own,” saying, “We need to get these people out of here.”33

Since the disaster, a number of family members have expressed concern that the company officials who rushed into the mine after the explosion may have been attempting to locate and cover up evidence of corporate wrongdoing. While it is problematic for persons with an inherent interest in the outcome of an investigation to be alone in a mine following a disaster, Massey Energy has maintained that Blanchard and Whitehead were motivated only by a desire to rescue those trapped in the mine.34

Unfortunately, the situation was further complicated by the fact that these company officials did not, according to rescue team members, provide adequate information about where they had gone or what they had discovered. Nor were they adequately debriefed.

Officials in the Command Center should have been made aware of what Blanchard and Whitehead had witnessed because it would serve to inform mine rescue teams as to conditions they might encounter in the mine. Mine rescue protocol emphasizes that mines should be evacuated and that mine rescue team members who explore a mine must be briefed so that they have the critical information they need about conditions underground. That protocol calls for one team member to serve as a “briefing officer” at the fresh air base to record and track the activities of rescuers as they explore the mine.35 At a minimum, the standard operating protocols for briefing and debriefing were not consistently practiced by those in charge of the rescue operations at UBB.

As the evening wore on, Stricklin also became more and more frustrated as a result of the operator’s failure to provide accurate information about the number of people who had not been accounted for.

There is no safety precaution more fundamental than maintaining a system that tells operators who is in a coal mine at a given time. Throughout the 19th and 20th centuries, operators used a “tag-in” system. Each miner was assigned a number with a corresponding metal check tag that was moved to an “in” position hook by the miner as he entered the mine. When he left the mine after his shift, the miner moved the tag to an “out” position. This method didn’t tell the operator where in the mine the miner was, but it did provide a record of who was in the mine.

After the 2006 Sago disaster and Aracoma fire, mine operators were required to install electronic tracking systems that would enable them to approximate each miner’s whereabouts in the mine. Such a tracking system was being installed at Upper Big Branch. Derrick Kiblinger, a UBB miner who was in charge of the installation, said, “It’s still in the process … the tracking system was really far behind … maybe 20 percent of it would have been done” on April 5.36

Kiblinger described having difficulty getting parts fast enough to keep the installation on schedule and said he needed a larger crew to get the job done.37 “When I started in October, somebody should have been working on every shift to even be close,” he said. “Had this system been in place, you would have known a lot quicker where these men were. You would have known within 2,000 foot, probably a little better, where they were.”38

UBB miners appeared to be confused about the status of the tracking system. Some testified that they believed the tracking system was functioning because they had been assigned tag readers and were wearing them when they went underground. Several reported receiving training about the system at an annual refresher class conducted early in 2010. Their testimony suggests they had not been told that the system was not completely installed. More importantly, they were not aware that management had informed MSHA it was going to use a manual check-in/check-out system until the electronic system was “installed and functional.”39

After the Sago disaster, operators were required to submit an Emergency Response Plan (ERP) that outlined how the company would respond in the event of an emergency. In the ERP, the company designated a “responsible person,” a person in charge for every shift. In their ERP submitted to MSHA on October 9, 2009, Performance/UBB officials indicated they had a back-up system for keeping track of the miners who were underground.

In a transmittal letter from Jonah Bowles, safety director for Marfork Coal Company, to MSHA District 4 Manager Robert Hardman, the company stated,

“Until the new tracking system is installed and functional, an employee will be on duty on the surface when anyone is underground. The Responsible Person on each shift will provide this employee with a roster of all persons underground and the proposed zone in which they will be working. A written log of each miner’s location will be maintained by this employee. It is the responsibility of each worker to notify this employee when they move to another work zone.”40

During interviews with investigators, UBB miners did not seem to be aware of this backup system.41

According to the ERP, the Responsible Person on the day shift was the superintendent and the backup was the chief electrician. On April 5, 2010, the dayshift superintendents were Gary May (UBB side) and Everett Hager (Ellis side), and the chief electrician was Rick Nicolau.

Unfortunately, in addition to having a tracking system that wasn’t functioning, the company also did not maintain the metal/brass “tag” system, and the backup written log system was not maintained. As a result, for hours after the explosion, there was complete confusion as to how many miners were in UBB and who those miners were.

When he arrived at UBB at approximately 7:00 p.m., MSHA mine rescue team member Jerry Cook recalled being told by Hardman that 19 people had not been accounted for and that seven deceased miners had been removed from the mine.42 By this time, officials had learned that another of the initial nine miners brought out of the mine had died.

At 8:32 p.m., Massey Energy CEO Don Blankenship released a statement, which said, “It is with a heavy heart that Massey Energy confirms at this hour seven dead and 19 miners unaccounted for.”43 These figures account for only 26 miners rather than the 29 who actually died in the explosion.

Just before 10:30 p.m. Hardman again asked how many miners had not been accounted for. Massey Vice President Chris Adkins posed the question to Keith Hainer, the company’s vice president for maintenance, saying they “need to know how many unaccounted for.”44 Shortly after 11:00 p.m. Hardman was still trying to confirm the number of missing miners saying there were “22 underground when I got here,” and “we found five, so 17 left.”45

Some time around midnight, Chris Adkins asked Performance Coal longwall coordinator Jack Roles how big the crew was in an apparent effort to pin down the number of miners still missing and unaccounted for.46

Jimmy Gianato, director of the West Virginia Office of Homeland Security and Emergency Management, told investigators with the Governor’s Independent Investigation Panel that he was with Danny Spratt, a WVMHST official, at the mine Command Center when he had a growing concern as to the actual number of persons who were underground. The numbers provided by Massey continued to change. In addition, some miners had been put into ambulances and taken to hospitals and others had been removed by helicopter. When he asked that evening (April 5) for an accounting, Gianato said Massey officials Elizabeth Chamberlin and Chris Adkins (on the phone in the Command Center)47 said they were having difficulty establishing a number.48 Gianato said he advised Chamberlin that they needed to do whatever it took to account for every worker, even if it meant calling each individual miner’s home.49

Command center notes place the time at 12:30 a.m. on April 6 – more than nine hours after the explosion – when state, federal and company officials finally got an accurate number as to the people who were underground when the explosion occurred.50

“They didn’t do a very good job with that for a couple of reasons,” Stricklin said. “I don’t know if they had people coming out of two different portals. They had people that had already started underground when this explosion occurred, and the Pyott-Boone [tracking] system seemed to be pretty useless in my opinion. As the evening went on, it frustrated me more and more, because I wanted to go down and give the families definite information of how many people were unaccounted for, and it seemed like I was having a very hard time getting that from Massey.”51

“They kept saying they were working on the Pyott-Boone system to get an exact number, and I’m not sure that number ever came from the Pyott-Boone system,” Stricklin told investigators. Stricklin apparently was not aware that the tracking system was only 20 percent installed. He said he asked mine officials whether they had a traditional tag-in, tag-out system and recalled that they replied that they didn’t know. “That was, I believe, from Elizabeth Chamberlin, who didn’t work at that mine.”52

Even without this vital information, Stricklin, accompanied by state officials and Massey representatives, met for the first time with shocked and grief-stricken family members at approximately 8:30 p.m.53 The families had gathered near the UBB entrance in the Marfork safety building.

By this time, there were seven known fatalities. After consultation with Elizabeth Chamberlin, Stricklin made the decision to meet with the family members of the known dead and then conduct a separate meeting with the families of the missing miners.54

“After a period of time, we left the room where the seven deceased miners’ families were, and we went into a bigger meeting area with the rest of the family and friends of the other miners that were missing,” Stricklin said. “At that time, I still didn’t have a finite number of miners that were missing, and that really bothered me, to go into the room – but we went in, and we basically gave them an update of just preliminary information on what had occurred and that there were already fatalities involved in this.”

Another complication in the rescue efforts was that for several days after the disaster, news reports based on briefings by MSHA officials and West Virginia Governor Joe Manchin raised the possibility that some of the missing miners may have reached a safe shelter one break outby the longwall face.

The next briefing for the families was conducted at 10:30 p.m. Among those participating were Stricklin, Congressman Nick Rahall, WVMHST director Ron Wooten, Jim Gianato and Massey Energy’s Michael Snelling and Jennifer Chandler. The families were informed that the bodies of five more miners had been located, but the identities of the men had not been confirmed and, therefore, would not be provided to them. The family members desperately wanted this information and also asked whether officials had had any communication from missing miners underground, particularly from any who may have deployed safe shelters.55

The company and government officials again met with the families at about 1:30 a.m. on April 6, after rescue workers had been ordered out of the mine. Chris Adkins of Massey Energy told family members that the bodies of 24 deceased miners had been located and that four miners had not been accounted for. According to written notes kept by one of MSHA’s family liaisons, Adkins told the families he did not hold out much hope for the four missing men.

At approximately 3:20 a.m., Governor Joe Manchin and Congressman Nick Rahall, who had continued their vigil with the families, corrected the information previously reported by Adkins, telling family members that the total number of deceased miners was 25 with four not yet located. Notes from the MSHA family liaison indicated that ten of the victims had been positively identified – the seven from the Tailgate 22 crew and three others.

Even though they knew that 25 were dead, the officials meeting with the families didn’t know the names of the deceased because the mine rescue team members weren’t able to easily find identification without moving bodies. The final identification came when they removed the bodies on April 10, 12 and 13. A family member told the Governor’s Independent Investigation Panel that this time was particularly agonizing because each family was holding out hope that their loved one was one of the missing, not one of the dead.

Meetings with the families, followed by media briefings, became a ritual that continued until the last miner was brought out of the mine early in the morning of Tuesday, April 13.

1 WV Mine Industrial Rapid Response Line, audio recording, April 5, 2010
2 WV Mine Industrial Rapid Response Line, audio recording, April 5, 2010
3 Wayne Wingrove testimony, p. 27
4 WV Mine Industrial Rapid Response Line, audio recording, April 5, 2010
5 Wayne Wingrove testimony, p. 30
6 Wayne Wingrove testimony, p. 29
7 Chapter 22A-2-68 of West Virginia Code states “following a mine accident resulting in the death of one or more persons and following any mine disaster, the evidence surrounding such occurrence shall not be disturbed after recovery of bodies or injured persons until an investigation by the Office of Miners’ Health, Safety and Training has been completed.”
8 Wayne Wingrove testimony, p. 30
9 Robert Hardman testimony, June 6, 2010, p. 8
10 Robert Hardman testimony, June 6, 2010, p. 7
11 Mike Dickerson, MSHA Family Liaison, written notes
12 Robert Hardman testimony, p 8
13 Section 103(k) of the federal Mine Safety and Health Act of 1977 states: “In the event of any accident occurring in a coal or other mine, an authorized representative of the Secretary, when present, may issue such orders as he deems appropriate to insure the safety of any person in the coal or other mine, and the operator of such mine shall obtain the approval of such representative, in consultation with appropriate State representatives, when feasible, of any plan to recover any person in such mine or to recover the coal or other mine or return affected areas of such mine to normal.”
14 Kevin Stricklin testimony, p. 34
15 Kevin Stricklin testimony, p. 12
16 Kevin Stricklin testimony, p. 12
17 Kevin Stricklin testimony, p. 13
18 Kevin Stricklin testimony, p. 14
19 Robert Hardman testimony, June 6, 2010, p. 10
20 Paraphrased from conversations with MSHA and WVMHST mine rescue team members, May 2010 through April 2011.
21 GIIP review of Command Center notes and interviews with officials who were present in the Command Center.
22 Kevin Stricklin testimony, p. 15
23 Personal communication with Danny Spratt, April 7, 2011
confirmed by other officials in the Command Center.
24 McAteer and Associates, Aracoma Alma Mine #1 Report, November 2006, p. 36
25 Personal communication with Danny Spratt, April 7, 2011
26 Kevin Stricklin testimony, p 17
27 Based on testimony of Mark Bolen, Jim Aurednik and Shane McPherson.
28 Robert Hardman testimony, June 6, 2010, p. 13
29 Kevin Stricklin testimony, p. 18
30 Kevin Stricklin testimony, p. 43
31 Robert Hardman testimony, June 6, 2010, p. 16
32 Robert Hardman testimony, June 6, 2010, p. 11
33 Kevin Stricklin testimony, p. 19
34 Blanchard and Whitehead invoked their Fifth Amendment right against self-incrimination and have not answered questions about their actions.
35 Mine Safety and Health Administration, “Responding to a Mine Emergency: Training Responsible Persons at Underground Coal Mines,” Instruction Guide Series 110 (1G 110), 2008.
36 Derrick Kiblinger testimony, June 9, 2010, p. 18
37 Derrick Kiblinger testimony, June 9, 2010, p. 77
38 Derrick Kiblinger testimony, June 9, 2010, p. 79
39 Letter from Jonah Bowles, Safety Director, Marfork Coal Company, to Robert Hardman, submitting Emergency Response Plan, October 9, 2009.
40 Letter from Jonah Bowles, Safety Director, Marfork Coal Company, to Robert Hardman, submitting Emergency Response Plan, October 9, 2009.
41 Testimony of Samuel Brewer, p. 41
Terry Claypool, p. 68
Adam Fraley, p. 46
Roger Toney, p. 83.
42 Jerry Cook testimony, p. 20
43 Massey Energy news release, April 5, 2010, 8:32 p.m.
44 MSHA Command Center notes, April 5, 2010
45 MSHA Command Center notes
46 MSHA Command Center notes
47 Elizabeth Chamberlin and Chris Adkins are two of the Massey officials who invoked their Fifth Amendment right against self-incrimination.
48 The tracking system had not been completely installed and the system of using brass tags was not being fully utilized.
49 Personal communication with Jimmy Gianato.
50 Kevin Stricklin testimony, p. 45
51 Kevin Stricklin testimony, p. 16
52 Kevin Stricklin testimony, p. 16
53 Kevin Stricklin testimony, p. 23
54 Kevin Stricklin testimony, p. 22
55 Mike Dickerson, MSHA Family Liaison, written notes

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