Mine safety oversight report finds 'disturbing' lapses
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An internal review of safety oversight at three mines that accounted for 40 percent of last year's deadly toll underground found "deeply disturbing" enforcement deficiencies, especially at the West Virginia mine where two men died in a fire.
The U.S. Mine Safety and Health Administration reports released yesterday conclude that MSHA enforcement personnel are not to blame for coal mining disasters last year that claimed 12 lives at the Sago Mine in West Virginia and five at Darby Mine No. 1 in Kentucky.
But, at Aracoma Coal Co.'s Alma No. 1 Mine, investigators say a combination of indifference to safety standards by mine operator Massey Energy and a failure by MSHA personnel to use the agency's enforcement authority set the stage for two miners' deaths.
As it was releasing its report yesterday, MSHA fired the two inspectors who examined Aracoma in the year leading up to the fatal fire, and a spokesman said additional actions are pending against other MSHA employees.
Richard Stickler, assistant secretary of labor for mine safety and health, also announced yesterday the creation of an Office of Accountability that will increase oversight and enforcement within the agency.
The agency already has an accountability program, but one of the reviews concluded it is fundamentally flawed because it fails to identify root causes of enforcement problems.
Following the Sago explosion, for example, MSHA knew there were problems with its standards and proper construction of mine seals, yet those same problems occurred four months later at Darby.
The new Office of Accountability will have a director and two compliance specialists in the field to make sure inspection procedures are followed.
Phil Smith, spokesman for the United Mine Workers of America, voiced skepticism about the new office, given the acknowledged inadequacy of MSHA's existing accountability program.
"Now they're going to establish a new accountability office? It's still going to be their people reporting on their people."
What's needed, said Mr. Smith, is an external review of mining accidents and MSHA enforcement. "When you look at these reports, they found deficiencies in three different MSHA districts. To us, that indicates a pattern."
The voluminous reports reprise descriptions of problems identified previously -- uneven enforcement, inadequate standards for and poor construction of mine seals and insufficient training in the use of emergency oxygen devices.
Kevin Stricklin, who is now head of MSHA's coal program, was district manager for northern West Virginia at the time of the Sago explosion. Mr. Stricklin and his staff of inspectors had stepped up enforcement at Sago but "their evaluations of gravity and negligence were adversely influenced" by conference officers who would reduce the severity of the violations, the review found.
At Darby, district personnel should have stepped up enforcement and reviewers found that "inspectors did not identify and cite several violations" prior to the explosion. But, ultimately, those deficiencies did not cause or contribute to the deaths of the five miners, the report concluded.
The most troubling findings center on the Aracoma fire, which, because of an ongoing federal criminal investigation, has not been as publicly detailed as Sago and Kentucky Darby.
The agency's internal report on its handling of Aracoma draws a picture of alarming disarray in the District 4 office in Logan County. Routine inspections were not performed, obvious safety hazards went unaddressed, and MSHA inspectors lacked technical support to examine some equipment, and supervisors neglected their duties to oversee employees, the review found.
Two MSHA employees directly responsible for inspecting the mine, Minness Justice and Edward Paynter, were served with dismissal notices yesterday as the report was being made public.
A MSHA spokesman last night said the agency is pursuing personnel actions against others in District 4 as well.
"This is an attempt by MSHA to cover up their mistakes by putting the blame on the lowest-ranking person in the field," Mr. Justice said last night. He said the agency, in part, used faulty data in an attempt to argue that he had not inspected some sections of the mine and vowed to fight the firing, which he called retaliation for his speaking out about failures in the District 4 office.
The report also says that some District 4 inspectors interpreted MSHA's sometimes controversial "compliance assistance" policy, a Bush administration initiative designed to focus on bringing mines into compliance with laws, as essentially a go-slow order on enforcement.
Some inspectors, the report said, "stated that they were confused by the new compliance assistance language and believed that while they were still supposed to issue citations, they should be more cooperative with companies."
The cause of the fire and subsequent deaths was documented last year by investigators who discovered that friction on a misaligned conveyor belt ignited the belt and surrounding coal, and that neither the fire suppression sprinklers nor a nearby water line functioned. Smoke from that fire washed into the escape route being used by miners because required walls -- called stoppings -- intended to keep the air flow separate between work and escape areas, were missing.
The smoke washed directly into the fleeing miners and two of them, Ellery Hatfield, 47, and Don I. Bragg, 33, became lost and died of smoke inhalation.
In the year preceding the accident, Aracoma's injury rate was twice that of other coal mines nationwide.
Yesterday's internal report declared that MSHA inspectors in the Logan Field Office "did not document that the mine was inspected in its entirety during any of the four regular inspections conducted in 2005," the year leading up to the fire.
Aracoma and its owner, Massey Energy, were hit with $1.5 million in fines, and the state of West Virginia revoked or suspended the mining licenses of seven employees at the mine, most of them supervisors.
MSHA's review found that District 3 managers "appropriately elevated the level of enforcement" at Sago before the Jan. 2 explosion, due to increased injuries and roof falls, and mine operator Wolf Run Mining's "indifference to compliance."
But those efforts were hurt when citations were reduced on appeal. "Inspectors were aware of the modifications and therefore began to evaluate negligence and gravity in a manner to get citations through" the appeals process, the report said.
The explosion, which MSHA has attributed to lightning, and subsequent entrapment killed 12 miners.
With rescuers unable to reach the crew for 41 hours, Sago became international news. The tragedy was compounded by initial reports that the miners had survived, setting off a celebration by families and friends that turned to anger and despair when the truth was learned.
MSHA's internal review describes a chaotic command center at Sago, open to anyone walking by or listening in.
Investigators later found that the methane explosion had obliterated the mine seals.
UMW spokesman Mr. Smith said he thinks MSHA officials "let themselves off the hook" in the internal review by saying the agency saw no need for stronger seals before Sago. At the time, seals had to withstand a force of 20 pounds per square inch -- even though many other industrialized countries had standards of 50 psi or higher.
"We opposed that standard when it was implemented, we opposed that standard every step of the way," said Mr. Smith. "It shouldn't take people dying for MSHA to realize its mistake."
According to MSHA's review, district personnel should have stepped up enforcement at Darby before the fatal May 20 explosion because of the mine operator's history of repeat violations.
Mine operator Kentucky Darby LLC "did not observe basic mine safety practices and critical safety standards were violated," according to the report.
Those failures included improper construction of a seal, not following safe work procedures to correct it and inadequate training in the use of breathing devices called SCSRs and escapeways. A required annual refresher training session with SCSRs in December 2005 "was significantly deficient," investigators found.
The review did find problems with MSHA inspections and enforcement at Darby and "inspectors did not identify and cite several violations" prior to the explosion.
Among other problems, inspectors did not make sure seals had been constructed properly, and they did not check to see if methane detectors were properly calibrated or if the people using them were properly trained.
In the end, though, the internal review team "did not find any evidence that these deficiencies caused or contributed to the fatal explosion."
Five miners perished of carbon monoxide poisoning in the May 20 explosion at the Kentucky Darby mine in Harlan County.
Tony Oppegard, a mine safety expert and attorney representing four of the Darby widows, said he found the Darby report hypocritical. "They issue a 200-page report where they hammer their own inspectors and supervisors, then conclude they didn't contribute to the accident. It's illogical."
He also thinks mine safety enforcement has been hurt by MSHA's "compliance assistance" approach of working with mine operators to bring them into compliance with health and safety regulations.
On the web
Go to post-gazette.com for an audio report on MSHA's internal review of the mine accidents.
First Published June 28, 2007 11:22 pm