The accident that killed 29 Massey Energy Co employees in a coal-mine explosion could have been prevented, according to a 13-month independent investigation. The report concluded the accident was primarily the result of the company's failed safety systems, which federal and state regulators failed to correct.
The 120-page report by J. Davitt McAteer, the top mine regulator during the Clinton administration, is the first comprehensive account of the worst U.S. coalmining disaster in 40 years, which occurred at Massey's Upper Big Branch mine in Montcoal, W.Va., on April 5, 2010.
Mr. McAteer concluded that the company could have prevented the accident by providing adequate ventilation and limiting explosive coal dust throughout the mine, standard mine-safety practices. "The company broke faith with its workers by frequently and knowingly violating the law and blatantly disregarding known safety practices while creating a public perception that its operations exceeded industry safety standards," wrote Mr. McAteer, a vice president at Wheeling Jesuit University in Wheeling, W.Va. Former Gov. Joe Manchin asked Mr. McAteer to conduct the investigation.
Mr. McAteer also faulted federal and state regulators for not perceiving a high level of risk at the mine, which had previous methane releases. The report asaid officials failed to enforce regulations, including the use of steeper fines, stringently enough to ensure that Massey's ventilation practices met federal standards.
The report describes hazards that miners testified existed just before the powerful explosion, including waist-deep water, large accumulations of coal dust and a lack of air flowing to distant parts of the mine where men were working.
It also chronicles the aftermath of the blast, including the failed attempts to save the lives of seven men overcome by carbon monoxide. Amid the chaos, it took Massey and government safety officials nine hours to determine the names of all the miners who had been working underground when the explosion occurred.
Much of the report relies on testimony from Massey employees and evidence that hasn't previously been made public.
Mr. McAteer's findings directly contradict Massey's version of the accident. A Massey spokesman said the company would comment after it reviewed the report Thursday.
In January, Massey, of Richmond, Va., agreed to be acquired by Alpha Natural Resources Inc., based in Abingdon, Va., for $7.1 billion. Shareholders of both companies are set to vote on the deal June 1.
In a recent interview with The Wall Street Journal, Massey Chairman Bobby R. Inman called the accident "a natural disaster." He reiterated the company's belief that an unforeseeable inundation of natural gas came through the mine floor and overcame ventilation and monitors that both met federal standards.
The company also doesn't believe coal dust played a role in spreading the blast through the mine. Shane Harvey, Massey's general counsel, has said the company will challenge government dust samples taken after the explosion, saying the explosion affected the dust composition and made sampling inaccurate.
Massey officials have also defended the company's safety culture. "We have not found anything in our look that would point to failings," Mr. Inman said about a board review of the company's practices after the accident.
Massey said the government required the company to use an inferior ventilation plan, while federal officials say the company itself failed to ventilate the mine properly.
According to Mr. McAteer, the common understanding of the accident was wrong in that the blast was actually a series of explosions that occurred within milliseconds and rocketed through the mine.
The initial spark occurred at a piece of equipment called a longwall shearer, which weighs more than 90 tons and grinds across a 1,000-foot-wide wall of coal, the report says. The shearer struck the sandstone roof of the mine, and a spark ignited a pocket of methane that had either risen from the floor of the mine or come from the previously mined area behind the machine.
A crew of workers was unable to control the fireball, and missing and clogged water sprays on the shearer failed to extinguish it, the report says. The flame began to speed up and grew larger. Compressed air at the leading edge lifted loose coal dust and became "like a line of gunpowder" sending the explosion in multiple directions.
Witnesses outside the mine testified that dust and debris blew out of the portals for more than three minutes and sounded like jet engines.
Ten miners were killed by injuries from the explosion, while 19 died of carbon-monoxide intoxication, according to the report.
The report said a foreman failed to test for methane before the Monday, April 5, morning shift and that the ventilation system was compromised in part by high levels of water in the mine caused by pumps that broke over Easter weekend. The report also said highly explosive coal dust had been permitted to accumulate throughout the mine.
In the month before the accident, mine personnel requested 561 times that conveyor belts, a potential source of fires, be dusted with inert crushed limestone, but that was carried out only 65 times, according to mine records cited by Mr. McAteer. Equipment to spread the rock dust often broke down, according to miners' testimony.
Mr. McAteer's report concludes that "rock dusting was a haphazard and poorly managed operation at UBB." It adds that if coal dust hadn't been a factor, the explosion "might well have been contained to the longwall area" and not killed some miners more than a mile away.
Relying on sworn testimony of miners who worked the day's first shift before the blast, Mr. McAteer's report describes ventilation problems.
Two miners waded into chest-deep water to repair pumps in one area and weren't given methane monitors by a foreman who had regularly failed to record methane readings, as required by federal law. High water can choke off airflow through mine tunnels.
Mines are typically cool from the ventilation system pumping a constant breeze through them, but on this day the mine was "miserably hot" and there was little air movement, according to another miner.
In another part of the mine, several workers noticed that the airflow was going in the opposite direction from the previous day they had worked in the mine. They believed the ventilation system had been altered, which can't be done legally without approval by regulators.
In the three months before the accident, Mine Safety and Health Administration inspectors cited the mine on multiple occasions for ventilation violations, including one case in which air had been reversed in part of the mine for three weeks.
Mr. McAteer faulted the MSHA for not issuing "flagrant" violations over repeated ventilation problems, which carry as much as $220,000 in penalties per violation. He said the agency's "ultimate failure" was its "inability to connect the dots of the many potentially catastrophic failures taking place at the mine," involving ventilation, methane and coal dust.
The MSHA and the West Virginia Office of Miners' Health Safety and Training are conducting separate investigations.
A separate investigation by the Justice Department has so far resulted in criminal charges against two Massey employees, including the mine's chief of security, for attempting to destroy evidence and lying to investigators about the mine's practice of alerting miners to the presence of federal inspectors on mine property, a violation of the Mine Act.
Mr. Inman, Massey's chairman, has said he expects more criminal indictments, based on how prosecutors have handled several past mine accidents involving multiple deaths.
Miners on several crews headed out of the mine survived the explosion. A roof bolter named Timothy Blake, who worked deep inside the mine, was in a railcar with eight other men about a mile from the portal when a hurricane-like wind carrying debris swept over him. Mr. Blake put on a self-rescuer oxygen unit.
Then in the darkness he went to each man and felt for a pulse and put their self-rescuers over their faces, except for one whose unit had blown away.
It took nearly an hour to move the unresponsive men, and by then Mr. Blake's own oxygen was about to run out. He checked again, and all but the one man without a rescuer still had a pulse.
Mr. Blake decided he had to leave to save himself. "That was the hardest thing I ever done," he told investigators.
A railcar carrying Chris Blanchard, president of the Massey subsidiary that operated the mine, reached Mr. Blake and went on to the eight men. All but one of them died by the time they were brought outside the mine after attempts to administer CPR failed. The other man sustained life-threatening injuries and hasn't been able to testify.
Mr. McAteer's report also faults Massey for not having an adequate system to track miners, which complicated efforts to locate and identify them over the next four days. He blamed Massey and the MSHA for a chaotic initial rescue effort that violated mine-rescue practices and put the lives of rescuers at risk. Mr. Blanchard and another manager were inside the mine unsupervised for four hours after the explosion.