At approximately 3:02 p.m. on Easter Monday, April 5, 2010, a powerful explosion tore through the Upper Big Branch mine, owned by Massey Energy and operated by its subsidiary, Performance Coal Company, at the convergence of Boone and Raleigh counties in southern West Virginia.
Twenty-nine miners died and one was seriously injured as the enormously powerful blast rocketed through two and one-half miles of underground workings nearly 1,000 feet beneath the surface of the rugged mountains along the Coal River. The disaster has had grave consequences for a mining company, for a community and, most importantly, for the family members who lost men dear to them.
On April 13, 2010, then West Virginia Governor Joe Manchin III asked J. Davitt McAteer, former Assistant Secretary of Labor in charge of the federal Mine Safety and Health Administration, to conduct an independent investigation into the disaster. The Governor said, “We owe it to the families of the 29 miners we lost last week to find out what caused this. We owe it to them and every coal miner working today to do everything humanly possible to prevent this from happening again… I fully expect that we will learn ... from this and make dramatic changes to protect our miners.”1
As a result of an inquiry that continued for more than a year, the Governor’s Independent Investigation Panel has reached the following conclusions:
- The explosion at the Upper Big Branch mine could have been prevented.
- The explosion was the result of failures of basic safety systems identified and codified to protect the lives of miners. The company’s ventilation system did not adequately ventilate the mine. As a result, explosive gases were allowed to build up. The company failed to meet federal and state safe principal standards for the application of rock dust. Therefore, coal dust provided the fuel that allowed the explosion to propagate through the mine. Third, water sprays on equipment were not properly maintained and failed to function as they should have. As a result, a small ignition could not be quickly extinguished.
- Three layers of protection designed to safeguard the lives of miners failed at Upper Big Branch. First, the company’s pre-shift/on-shift examination system broke down so that safety hazards either were not recorded, or, if recorded, were not corrected. Second, the U.S. Mine Safety and Health Administration (MSHA) failed to use all the tools at its disposal to ensure that the company was compliant with federal laws. Third, the West Virginia Office of Miners’ Health Safety and Training (WVHST) failed in its role of enforcing state laws and serving as a watchdog for coal miners.
- Regulatory agencies alone cannot ensure a safe workplace for miners. It is incumbent upon the coal industry to lead the way toward a better, safer industry and toward a culture in which safety of workers truly is paramount. A genuine commitment to safety means not just examining miners’ work practices and behaviors. It means evaluating management decisions up the chain of command – all the way to the boardroom – about how miners’ work is organized and performed.
- The politics of coal must be addressed at both a state and national level. Coal is a vital component in our nation’s energy strategy. The men and women who mine it also are a national resource whose lives, safety and health must be safeguarded.
THE GOVERNOR’S INDEPENDENT INVESTIGATION PANEL
In forming the Governor’s Independent Investigation Panel (GIIP), Davitt McAteer enlisted a group of colleagues with expertise in coal mining, mining law, mining communities, occupational safety and public health. GIIP members participated in a joint federal and state investigation conducted both underground at Upper Big Branch and through witness interviews conducted primarily at the federal Mine Health and Safety Academy in Beckley, West Virginia.
On June 2, 2010, mine rescue personnel from the federal Mine Safety and Health Administration (MSHA) and the West Virginia Office of Miners’ Health, Safety and Training (WVMHST) re-entered the Upper Big Branch mine to assess conditions. It took several weeks before the mine was made safe for investigation teams. Final pre-investigative walk-throughs of the mine were conducted on June 25 and June 28.
The underground investigation officially began on June 29. The investigation teams, each with assigned duties (e.g., photography, mapping, physical evidence collection), included representatives from MSHA, WVMHST, Massey Energy and the UMWA. The GIIP, with its small numbers, selected teams with which to travel. The majority of the underground investigation was completed by January 14, 2011.
The GIIP also participated in nearly all of the witness interviews, which began May 10, 2010. Individuals interviewed included current and former employees of Performance Coal Company and Massey Coal Services; contractors employed at UBB; and UBB, MSHA and WMHST staff. Some family members also were interviewed privately, at their request.
More than 300 interviews were conducted, with the majority (221) taking place between May and August 2010. Eighteen corporate officials, including Don Blankenship, chairman and Chief Executive Officer of Massey Energy at the time of the explosion; Performance Coal president Chris Blanchard and Vice President Jamie Ferguson, and Massey Vice President of Safety Elizabeth Chamberlin, invoked their Fifth Amendment privilege against self-incrimination and refused to cooperate with investigators. (See Appendix)
The independent team also reviewed inspection records, mine plans and other documents. WVMHST made their UBB mine file available. MSHA provided violation data, citations, inspector notes and other records publicly available on its website but with certain fields of information redacted. Our request for un-redacted copies of some records (e.g., inspector notes) was denied; MSHA staff indicated that the Solicitor’s Office considered the information exempt pursuant to the Freedom of Information Act (FOIA).
THE GIIP REPORT
The Governor’s Independent Investigation report is divided into sections. The first section outlines the events that led up to the April 5, 2010, disaster; reconstructs the disaster itself; and describes the response to the tragedy and the rescue and recovery efforts.
The second section describes in detail the systemic failures that allowed the disaster to occur – the faulty ventilation system, the inadequate application of rock dust and the equipment failures.
The third section analyzes government oversight agencies – both state and federal – and asks the painful question posed by family members: how did you let this happen?
The fourth section examines the culture of the mine’s operator, Massey Energy, its prominence in the Appalachian coalfields and its particular influence over the industry in West Virginia. It explores how that culture created a climate in which a disaster such as that at Upper Big Branch could occur.
The fifth section offers summaries, conclusions and recommendations for going forward.
We recognize that this report cannot bring back those who died in the Upper Big Branch mine. However, it is our hope that this frank and unvarnished presentation of what transpired on April 5, 2010, offers a clear picture of the real and constant risks associated with operating coal mines in a reckless manner. We also hope that it causes all mine operators to examine their own dedication to safe mining practices and their attitudes toward safety regulations and regulators. If this type of introspection provides a path for industry and regulators to recommit themselves to safe mining practices each and every day in each and every one of this nation’s coal mines, then we will have honored the lives of the 29 men lost in the Upper Big Branch mine disaster.
1 Office of the Governor, “Governor Appoints J. Davitt McAteer to Head Upper Big Branch Mine Independent Investigation Panel,” April 13, 2010.