By Anna Miller
Every day on their drive to work, the employees of Upper Big Branch coal mine in Raleigh County, W.Va. passed a road sign that read, “Accidents are caused. They don’t just happen.”
On April 5, 2010, the mine, which was operated by Massey Energy Company, was the site of the country’s deadliest mining disaster in 40 years when an explosion killed 29 men.
For the past year, it’s been up to Celeste Monforton, professorial lecturer in School of Public Health and Health Services’ Department of Environmental and Occupational Health, to help dissect its cause.
Dr. Monforton, who has worked at the U.S. Department of Labor’s Occupational Safety and Health Administration and its Mine Safety and Health Administration, was selected to serve on an independent investigation team appointed by West Virginia’s then-Gov. Joe Manchin. Dr. Monforton’s expertise as a public health professional was a valuable commodity among the four engineers and lawyers with whom she worked.
As is common in disaster situations, the team was asked to analyze the causes of the explosion and develop recommendations for improving mine safety. Working alongside similarly tasked state and federally appointed teams, Dr. Monforton and her associates examined the physical evidence of the mine, reviewed extensive company and regulatory documents and helped conduct interviews with 270 witnesses.
“We weren’t just interested in the mechanics of what went wrong, but also what it was about the way this mine and this company operated that led to a disaster of this magnitude,” Dr. Monforton said.
The team’s findings, which are detailed in a recently released report called “Upper Big Branch: a failure of basic coal mine safety practices,” expose a slew of mechanical, chemical and organizational shortcomings that contributed to the tragedy. “It takes a lot more than one guy not doing his job to provoke a disaster of this proportion,” said Dr. Monforton.
The team found a severe and persistent lack of both air and rock dust in the mine.
“Old-time miners will tell you two things about coal mining: you need air, and you need rock dust,” she said. “But time and time again, the Upper Big Branch miners told us that there was rarely enough of either.”
Air flow is necessary to blow away coal dust and methane gas. Rock dust, a substance made from limestone, helps snuff imminent explosions.
According to the investigation, Massey Energy only employed two part-time “rock dusters”— nowhere near enough manpower to coat the walls of a mine nearly three miles long. Less than two weeks before the explosion, one of these men wrote in a record book, “No ride. No help. No spotter…I’m set up to fail here.”
Unfortunately, his entry was not uncommon, said Dr. Monforton.
Also cause for alarm, the team found, was that the machine that extracts coal, known as the long wall machine (or, as Dr. Monforton calls it, “the money maker”), was not correctly dispensing the mist of water needed to clear away coal dust and prevent sparks from becoming flames. The issue was a chronic problem because the mine operator failed to filter the river water used, allowing sediment to clog the misters, Dr. Monforton said. In reaction, the workers removed the sprays altogether, prompting the machine to produce sharp streams of water rather than light mists.
The day the explosion occurred, the mine was particularly hazardous. Having been closed the day before, water had built up underground and impeded the air flow further. According to one worker, the mine,which under normal conditions is cool and damp,felt so stagnant with heat that day that he stripped down to his boxers while working.
Ultimately, the investigation determined that the explosion was caused when a spark from the long wall machine’s shearers ignited a pocket of methane. The reaction triggered lingering coal dust to act like lines of gunpowder, fueling a series of more powerful explosions to surge through more than two miles of the mine’s tunnels.
“A perfect storm was brewing inside the Upper Big Branch mine – insufficient air, a build-up of methane and enough coal dust to carry an explosion long distances through the mine,” the report stated. “All that was needed was a spark.”
What concerns Dr. Monforton most is why these problems existed in the first place. Why did complaints about insufficient air and rock dust go unaddressed? Why weren’t the long wall machine’s misters repaired appropriately?
Most of the answers were found when examining the company’s culture: one that appeared to value profit over people.
“When we think about worker safety, we often think about mining equipment and personal safety equipment, but we have to think about the work environment and how people are treated,” said Dr. Monforton.
At Upper Big Branch, employees were discouraged from reporting — and correcting — problems, the investigation found. If problems were recorded, they were usually ignored. If solutions were pursued, employees could be punished for “wasting” time. One employee was even laid off for a few days after he took the initiative to correct the dangerously low flow of air. Solving problems takes time, and, when each minute of operation can potentially earn thousands of dollars in profit, time is valuable.
While Dr. Monforton’s team conceded that “there are still questions which remain…[and] regrettably, some [that] may never be answered,” their report was finalized and submitted to West Virginia’s current governor, Earl Ray Tomblin, shortly after the disaster’s one-year anniversary. It outlines more than 50 recommendations for improving mine safety, including ways to strengthen enforcement of mining practice laws, install more rigorous certification and training programs for workers and their supervisors, maintain modern technologies and use appropriate and efficient techniques to report problems.
“The findings and recommendations offered…are in a constructive spirit of transforming the U.S. mining industry into a global leader for safe and healthy mining, today and tomorrow,” wrote J. Davitt McAteer, the team leader and assistant vice president of Wheeling Jesuit University in Wheeling, W.Va.. It is the team’s hope that the report “will ensure, as far as is humanly possible, that the lives of the 29 men were not lost in vain.”