Upper Big Branch Report

TABLE OF CONTENTS

Cover Page
Title Page
Dedication
Letter of Transmittal
Foreword
In Memory of
Synopsis of Key Events

PART I: The Explosion at the Upper Big Branch Mine

Introduction
Chapter 1: Events leading up to the explosion
Chapter 2: When the world came to an end
Chapter 3: The aftermath of a disaster
Chapter 4: Confusion in the Command Center
Chapter 5: The long days of rescue and recovery

PART II: The Systems Failures at Upper Big Branch

Chapter 6: Coal dust and rock dust
Chapter 7: Bring the air with you
Chapter 8: The footprint of a disaster

PART III: The Role of Federal and State Regulators

Chapter 9: How could this happen (the federal role)?
Chapter 10: How could this happen in West Virginia?

PART IV: The Culture of the Operator

Chapter 11: The Massey way
Chapter 12: The normalization of deviance

PART V: Epilogue, Conclusions and Recommendations

Epilogue
In Conclusion
Recommendations

Appendices

List of officials who declined to be interviewed
Glossary
McAteer and Associates

Acknowledgements
Back Cover