DAVITT MCATEER.com: On April 13, 2010, Davitt McAteer was asked by former WV Governor Joe Manchin, III to form an independent investigation panel to investigate the cause of the Upper Big Branch Mine explosion

Upper Big Branch Report

On April 13, 2010, Davitt McAteer was asked by former WV Governor Joe Manchin, III to form an independent investigation panel to investigate the cause of the Upper Big Branch Mine explosion and to offer recommendations to prevent futu

On the afternoon of April 5, as Clay sat at his desk waiting for "At the 3:00 p.m. production report, he wasn’t paying too much attention to the North Portal fan until he heard a loud noise, which he described as a “bam.”²

Joshua Williams, a young miner who was on a mantrip exiting the mine, described the moment as “when the world came to an end.”³re explosions. The panel has issued its final report to the Governor, and the report can be viewed here.
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Upper Big Branch Report

FOREWORD

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).