A self-contained self-rescuer unit after it has been opened up. MORE COVERAGE Another W.Va. miner dies in accident Many questions surround use of breathing equipment Oxygen training questioned Senate passes bill to improve safety at coal mines

Federal mining officials were so concerned about coal miners' inability to use emergency oxygen packs that in 1999 they proposed increasing the annual training to four times a year.

"There is ample data indicating that more frequent training would improve the miners' ability to properly don the device," states a 130-page draft of the proposed safety standard obtained by the Post-Gazette.

Yet, less than two years later, that proposed rule for enhanced training was dropped -- until the death of 12 miners at West Virginia's Sago Mine No. 1 earlier this year prompted the U.S. Mine Safety and Health Administration to issue an emergency temporary standard calling, once again, for quarterly training.

The 1999 document describes multiple mine disasters and near-disasters where a lack of training rendered the oxygen packs nearly useless to miners. It also cites a study that found that, three months after receiving training, 90 percent of the 77 miners tested on their proficiency at donning the packs "performed so poorly that they were regarded as having almost completely forgotten how to put on the device."

The device used in that test was the CSE SR-100, the same self-contained self-rescuer model used by miners at Sago and Darby Mine No. 1 in Kentucky, where five miners perished last weekend.

Three of the Kentucky deaths were from carbon monoxide poisoning, and family members of the lone survivor say he told them that his device gave out after five minutes.

That followed Sago Mine survivor Randal McCloy Jr.'s account that four of the crew's 12 SR-100 oxygen packs failed after the Jan. 2 explosion. MSHA officials have said preliminary tests showed that all 12 SCSR's worked but each pack had oxygen left, raising questions about whether the devices malfunctioned, or the miners had trouble using them.

SCSR's have been credited with saving lives during emergencies over the years, including at the 1988 fire in Washington County's Marianna Mine No. 58 where 27 miners escaped, and 18 miners in the 1990 fire at the Mathies Mine, also in Washington County.

But their 25-year history is also marked with incidents where lack of training put lives in danger, or worse. Among them:

In November 1998, two miners trying to escape during the Willow Creek Mine fire in Utah said they had trouble starting the oxygen flow on their SCSR and took out their mouthpieces. "This was determined to be related to a training problem," the document states.

While 18 miners escaped the 1988 Mathies Mine fire, seven of the 18 miners removed their SCSR mouthpieces to talk "or get more comfortable during the escape." Another took off his nose clip, and another later said he could not get enough oxygen from his SCSR. "If any of these persons had encountered a toxic atmosphere at the point where they removed their protection, MSHA believes that they could have died," according to the MSHA document.

In a 1984 fire at Greenwich Colliers No. 1 Mine in Indiana County, a miner was unable to put on his SCSR, but managed to escape anyway. "Had he encountered a toxic atmosphere, MSHA believes that he might have died," the document said.

The most oft-cited example, though, is the December 1984 fire at the Wilberg Mine in Orangeville, Utah, in which 27 miners died.

The MSHA investigation report on Wilberg determined that four miners died after incorrectly donning their SCSRs. Another miner tried three different SCSRs and died after he took the last one off too soon.

According to the report, "Many [of the miners] were not sufficiently instructed to be considered adequately trained in the use of the self-rescue devices."

Based on these events, as well as research dating back to 1991 that recommended quarterly training, "we now believe ... that additional inspection and training in donning and use of self-rescue devices is needed to adequately protect miners" wrote then-MSHA head J. Davitt McAteer in 1999.

Mr. McAteer left MSHA in January 2001 following the presidential election that brought wholesale change in the agency's administration. Nine months later, the proposed standard was withdrawn because of "resource constraints and changing safety and health regulatory priorities."

"I thought it was unfortunate," said Mr. McAteer last week of the withdrawal five years ago.

Mr. McAteer, now a special adviser to West Virginia Gov. Joe Manchin III, is heading up the state's investigations into the Sago disaster and the Jan. 19 mine fire at Aracoma Alma Mine No. 1 in Logan County.

Since 1981, every coal miner working underground must carry or have easy access to a self-contained self-rescuer. In the aftermath of the Wilberg deaths, MSHA began requiring annual training with the devices in 1987.

Even then, "the training was not as frequent as it should have been" said Jack Spadaro, who was head of the National Mine Health and Safety Academy in Beckley, W.Va. until 2004.

Miners he spoke to at the academy told him the requirement for yearly training "simply wasn't being enforced. It wasn't happening," said Mr. Spadaro.

"Miners would go years without training with SCSR's."