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CHARLESTON, W.Va. -- Federal safety inspectors failed to identify dangerous accumulations of explosive coal dust at the Upper Big Branch Mine, curtailed harsher enforcement actions against mine operator Massey Energy, and did not conduct legally mandated complete mine examinations before the April 2010 explosion that killed 29 miners, the Obama administration disclosed in a report issued Tuesday.
U.S. Mine Safety and Health Administration officials did not forward potential criminal violations for proper investigation, allowed uncertified trainees to inspect key parts of the mine, and did not monitor Massey safety reports to ensure obvious hazards were corrected, according to a long-awaited MSHA "internal review" report.
MSHA enforcement efforts at the Raleigh County mine were severely compromised because agency officials -- from rank-and-file inspectors to top managers -- did not follow established government policies and procedures, according to the more than 300-page report.
The report said an internal team of MSHA officials found no evidence that missteps by agency employees caused the worst U.S. coal-mining disaster in nearly 40 years, but a retired MSHA manager who led the internal review until last fall said there was no good excuse for the kinds of problems uncovered.
"I wouldn't think we would have these kinds of issues in this day and age," said longtime MSHA official Jack Kuzar. "Oversight wasn't very good. We just didn't take care of business."
House Education and the Workforce Chairman Rep. John Kline, R-Minn., said the internal review "documents a disturbing failure of enforcement by MSHA.
"A mine operator recklessly endangered the lives of its workers and federal enforcement officials failed to hold the operator accountable," Kline said in a prepared statement. "While the responsibility for this tragedy lies with Massey, any effort to enhance mine safety will not succeed if enforcement officials do not effectively do their jobs."
MSHA officials posted the report on the Internet just after a private briefing for families of the miners who died at Upper Big Branch, and then held a news conference that emphasized agency efforts to improve.
"I don't think there's any question that MSHA could have done better," said agency chief Joe Main. "I don't think there's any question that we surely plan to do better."
Main said his agency has already instituted a variety of reforms, would continue examining the internal review to come up with other advances, and plans to keep seeking additional enforcement authorities from Congress.
"MSHA is responsible for its actions and will address each of the problems the team has specifically identified," Main said.
Among the most serious areas in which the internal review team said MSHA fell short of its mandate to protect the coal miners at Upper Big Branch:
Inspectors did not examine portions of the mine during each of the six quarterly inspections prior to the explosion, despite a congressional mandate that MSHA inspect each underground mine "in its entirety" at least four times per year. Areas not inspected included portions of the mine where the explosion occurred. MSHA managers signed off on the quarterly inspections without notifying they were not properly done.
MSHA managers did not review whether eight major violations should be assessed "flagrant" penalties of up to $220,000 each, even though the incidents met the criteria for a mandatory review.
Agency officials, citing "resource limitations," did not follow MSHA procedures that required six different incidents at Upper Big Branch -- including poor ventilation and coal-dust accumulations -- to be considered for potential criminal prosecution.
MSHA inspectors did not identify major deficiencies in Massey's own program for monitoring and cleaning up accumulations of coal dust, and federal officials seldom took their own samples to ensure proper amounts of crushed stone or "rock dust" had been applied to control prevent ignitions and explosions. Top agency officials required only that inspectors eyeball the amount of rock dust applied, a procedure they knew was not accurate.
Agency officials did not "effectively review" mine examination books where Massey was required by law to record hazardous conditions and outline steps taken to remedy those problems. Inspectors did not cite the company for not including obvious hazards in the record books or for not repairing problems the company did note in the books.
The new report said that MSHA's internal accountability programs have been successful at identifying agency deficiencies, but that top agency officials have not done enough to eliminate those deficiencies.
At Upper Big Branch, the internal review team blamed MSHA deficiencies mostly on a continued lack of money and staff, a lack of experience among a large body of newly hired inspectors, and turnover among MSHA management in the agency's Southern West Virginia district office.
For example, the internal review report said MSHA did not properly follow up on earlier methane accidents at Upper Big Branch -- in 1997, 2003 and 2004 -- because of a series of changes in district management at the agency's local offices.
And, a trainee inspector who was not yet authorized to do such work alone performed one of the last two inspections of the longwall-mining section where the Upper Big Branch explosion occurred, the internal review report said.
The general types of breakdowns outlined in the report mirror those from nearly a dozen other "internal review" reports published after major coal-mining disasters over the last 20 years, as well as numerous other self-audits by MSHA and outside evaluations by the Department of Labor's Inspector General and the U.S. Government Accountability Office, the auditing arm of Congress.
The 2010 disaster came just four years after a series of coal-mine disasters in 2006 and 2007 that prompted a new federal law, increased funding and staffing for MSHA, and renewed attention to coal-mine safety and health problems. After taking office in January 2009, President Obama put Main -- a longtime United Mine Workers safety director -- in charge of MSHA, but did not ask Congress to continue beefing up mine safety resources, and kept numerous MSHA managers whose tenure included the recent disasters.
Longtime mine safety advocate Davitt McAteer, who ran MSHA during the Clinton administration, led an independent team that investigated Upper Big Branch and concluded that the disaster itself was "proof positive that [MSHA] failed its duty ad the watchdog for coal miners." McAteer said the response so far from regulatory agencies, lawmakers and the industry has not been anywhere near strong enough, considering the "profound failures" that led to the disaster.
"The reports all point to a failure on the part of the company and a failure on the part of federal and state agencies, and yet we can see no remedy out of this failure to enforce the most basic safety standards in the mine," McAteer said. "It's a sad day."
Reach Ken Ward Jr. at firstname.lastname@example.org or 304-348-1702.