CHARLESTON, W.Va. -- Federal and state regulators failed to conduct proper inspections, take strong enough enforcement actions or "connect the dots" to prevent the Upper Big Branch Mine Disaster, an independent investigation team found.

The team led by longtime mine safety advocate Davitt McAteer focused most of the criticism in a 126-page report on Massey Energy, which operated the Raleigh County mine.

But the team also had harsh words for the U.S. Mine Safety and Health Administration, which is charged with protecting miners and enforcing federal safety rules.

"The disaster at the Upper Big Branch Mine is proof positive that the agency failed its duty as the watchdog for coal miners," McAteer's team concluded in a report released Thursday.

The report noted Gazette reports that MSHA did not use new tools -- such as tougher safety fines for particular egregious violations -- given to it by Congress after a series of mine disasters in 2006.

It also said MSHA neglected to push for better coal-dust monitoring, overlooked the "deadly potential" of the Upper Big Branch mine's troubled ventilation system, and allowed the nation's mine safety system to "atrophy."

"The ultimate failure of MSHA at UBB, however, was the agency's inability to see the entire picture, the inability to connect the dots of the many potentially catastrophic failures taking place at the mine -- especially the operator's failure to properly ventilate the mine, to control methane, to apply sufficient amounts of rock dust," the McAteer report said. "The ability to stand back and take a long look -- to see the red flags, to connect the dots -- and the ability and willingness to take quick action when necessary distinguishes a regulatory agency which can prevent disaster from one which only reacts."

In its prepared statement responding to the McAteer report, MSHA did not address the report's criticisms of the federal agency.

The team led by longtime mine safety advocate Davitt McAteer focused most of the criticism in a 126-page report on Massey Energy, which operated the Raleigh County mine.

But the team also had harsh words for the U.S. Mine Safety and Health Administration, which is charged with protecting miners and enforcing federal safety rules.

"The disaster at the Upper Big Branch Mine is proof positive that the agency failed its duty as the watchdog for coal miners," McAteer's team concluded in a report released Thursday.

The report noted Gazette reports that MSHA did not use new tools -- such as tougher safety fines for particular egregious violations -- given to it by Congress after a series of mine disasters in 2006.

It also said MSHA neglected to push for better coal-dust monitoring, overlooked the "deadly potential" of the Upper Big Branch mine's troubled ventilation system, and allowed the nation's mine safety system to "atrophy."

"The ultimate failure of MSHA at UBB, however, was the agency's inability to see the entire picture, the inability to connect the dots of the many potentially catastrophic failures taking place at the mine -- especially the operator's failure to properly ventilate the mine, to control methane, to apply sufficient amounts of rock dust," the McAteer report said. "The ability to stand back and take a long look -- to see the red flags, to connect the dots -- and the ability and willingness to take quick action when necessary distinguishes a regulatory agency which can prevent disaster from one which only reacts."

In its prepared statement responding to the McAteer report, MSHA did not address the report's criticisms of the federal agency.

Later, in an interview, MSHA chief Joe Main said, "Could we have done more? The answer is yes. And have we done more? The answer is yes. We're using tools that weren't in use on April 5."

On the state level, the McAteer report said that understaffed and overworked inspectors at the Office of Miners Health, Safety and Training often do not complete required quarterly inspections and lack expert staff to address more complicated issues such as mine ventilation.

At the time of the explosion, the state inspector assigned to Upper Big Branch had not examined the mine's longwall section since mid-December 2009. The inspector, Gerald Pauley, admitted he did not examine parts of the mine because he "ran into water up to my knees."

McAteer blamed the state agency's inactions on the coal industry's political influence in West Virginia.

"There are within the WVMHST many dedicated, committed and safety-conscious inspectors and supervisors who are not afraid to issue citations or provide tough enforcement," the report said. "However, the overwhelming scope of the job, the economic circumstances of a booming coal industry, the pressure to get along, the recognition of the importance of mining jobs within the state are factors that place immense pressures on state inspectors, pressures which make the regulatory enforcement process difficult to carry out."

In his statement responding to the McAteer report, Senate President Earl Ray Tomblin, acting as governor, said, "With the information presented in the report, we are steps closer to identifying the cause of this horrific incident and also to identifying potential reforms to improve mine safety."

Federal and state lawmakers have both declined to pass any new mine safety protections in the year since the Upper Big Branch mine blew up, killing 29 workers.