To see a map detailing the investigation's findings, click here.
CHARLESTON, W.Va. -- When Jason Stanley and David Farley got to Massey Energy's Upper Big Branch Mine at about 6 a.m. on April 5, 2010, they realized right away it was going to be a tough day. Both noticed there wasn't much air flowing underground.
"That day, it was almost like there was nothing," Farley later told investigators.
Over the Easter weekend, pumps had broken down deep inside the Raleigh County mine. As the "pump crew," Stanley and Farley would spend the day wading through waist-deep water to try to get those pumps working again. If water built up in the long tunnels between the mine's working section and its main ventilation fan, the crucial flow of fresh air could be greatly reduced, threatening the safety of everyone underground.
At 3:01 p.m., the mine blew up. Twenty-nine workers died.
Investigators believe that high water was among the triggers for a devastating chain of events that sent a monstrous explosion rocketing through two miles of tunnels, creating the worst U.S. coal-mining disaster in a generation.
Airflow changes allowed explosive methane gas to creep into the longwall mining section. Worn bits on the longwall machine's cutting tool hit sandstone, causing a spark. Clogged or missing water sprays on the longwall weren't able to extinguish the flames. And coal dust that had been allowed to build up underground fueled the blast, sending it ripping through the mine in all directions.
Last week, an independent investigation team placed the blame squarely on Massey Energy. The team, led by longtime safety advocate Davitt McAteer, concluded that a corporate culture that put coal production before safety allowed serious violations of basic safety practices to become common and accepted at Upper Big Branch.
"These things lined up over a long period of time, they got worse over a long period of time, and they were ignored over a long period of time," McAteer said in an interview.
Some of the basic conclusions in McAteer's report confirmed what government officials and safety experts already suspected. But his team's 126-page report is the most complete account to date of the disaster. This story is based on that report.
Drawing on an underground inspection, physical evidence and interviews with more than 200 witnesses, the McAteer report paints a picture of a mine that was a disaster waiting to happen. It also details missteps by federal and state agencies that didn't take adequate steps to prevent the deaths, despite knowing that the company operating Upper Big Branch had routinely cut corners on safety and health protections.
"Many systems created to safeguard miners had to break down in order for an explosion of this magnitude to occur," the McAteer report concluded. "Any of these failures would have been problematic. Together, they created a perfect storm within the Upper Big Branch Mine, an accident waiting to happen."
Massey Energy issued a brief statement in response to McAteer's report, repeating its earlier claims that the disaster was caused by a sudden, unexpected and uncontrollable inundation of natural gas into the mine. The company has yet to issue its own detailed report explaining the evidence for its theory.
'Bring the air with you'
Bobbie Pauley, the only woman working underground at Upper Big Branch, remembers longtime miners like her fiancé Boone Payne talking about ventilation problems at the vast underground operation.
"They used to say, if you go to Headgate 22, bring the air with you 'cause there ain't none up here,'" Pauley told investigators.
Headgate 22 was a "development section," where a continuous mining machine removed coal and dug tunnels to make way for Upper Big Branch's much more efficient longwall mining machine.
Boone Payne wasn't the only Massey miner to complain about airflow problems in Headgate 22.
"We all knew we didn't have enough air," said Dennis Sims, who previously worked as a roof-bolter on Headgate 22.
Joshua Massey, another Headgate 22 roof-bolter, told investigators, "There wasn't no air. It's hard to ventilate a place when you ain't got nothing to ventilate it with."
In all underground mines, operators are supposed to design detailed systems to pump fresh air through mine tunnels. Proper ventilation, with huge fans and walls to control the direction air flows, is the key to keeping down explosive methane and dust.
But at Upper Big Branch, McAteer's team found missing or damaged ventilation controls, along with airflow restricted by high water and by roof collapses.
Upper Big Branch's ventilation system also suffered from a more basic design flaw: Fans blew air in a straight line through the mine, even though miners worked in a maze of areas that branched off that horizontal path.
"As a result, air had to be diverted away from its natural flow pattern into the working sections," the McAteer report said. "Because these sections were located on different sides of the natural flow pattern, multiple diversionary controls had to be constructed, and frequently were in competition with one another."
In essence, to properly ventilate one working section, miners had to steal air from the others.
From a mine issue to a corporate issue
Federal inspector Keith Stone had been working for the U.S. Mine Safety and Health Administration for less than a year when he was assigned to keep tabs on Massey's Upper Big Branch Mine. His first inspection was in January 2010.
Stone was checking the mine's primary escapeway when he noticed the airflow underground wasn't moving in the direction indicated on Massey's maps.
Stone alerted Upper Big Branch foreman Terry Moore about the problem. With the air going backward in the primary escapeway, Stone warned Moore, miners would have to take a longer route out of the mine if there was a fire or other emergency.
Talking with miners in that section, Stone learned they had complained about the problem to top mine officials Chris Blanchard and Jamie Ferguson. Moore told Stone the air had been reversed for about three weeks. Moore said he had alerted mine superintendent Everett Hager and been told, "not to worry about it."
Stone wrote up the company, alleging "reckless disregard" for worker safety.
Later that day, Stone found air in a separate conveyor belt tunnel was going in the wrong direction. He ordered workers evacuated from the area until the problem was fixed.
Stone told investigators ventilation was always his biggest concern at Upper Big Branch.
"I don't know if the first day set the tone for that, you know, issuing the two [orders]," Stone testified. "And then you do it again and ... A couple other inspectors issue it, so it's just a recurring thing, you know, and it's hard to stay on top of."
Stone was so concerned he went to the ventilation specialists at MSHA's district office in Mount Hope.
"He feared that UBB officials might be engaged in a practice not unheard of in the industry -- that of operators manipulating the air during ventilation inspections in order to have plenty of air in the section being inspected at that time," the McAteer report said. "In effect, air is 'stolen' from sections that are not being inspected."
In response, MSHA district ventilation chief Joe Mackowiak sent a team of inspectors to the mine in March. Each would go to a different section, and they would check air across the mine all at once. Again, they found air in part of the mine was going the wrong way.
MSHA officials who dealt with Upper Big Branch on ventilation issues told investigators the company didn't have enough experienced engineers on staff to address such problems.
"They're trying to use duct tape to fix things instead of engineering. They're not taking the time to look ahead at what they have," said Rich Kline, an assistant district manager for MSHA.
Things got so bad that Mackowiak tried in mid-March to get his old boss, Bill Ross, to help. Ross had retired as MSHA's top ventilation person in Mount Hope and taken a job with Massey.
"He'd asked me on several previous occasions that any time there was a problem to give him a call and he would be more than happy to go to that mine and help," Mackowiak said. "So I called Bill Ross ... and I said there is a problem, here's what it is, low operating air volume on Headgate 22. This is the second time that's happened and it's inexcusable."
Mackowiak told investigators that Ross said he'd love to go work on the problems at Upper Big branch, but that Massey's Chris Blanchard, the president of Performance Coal, wouldn't let him.
At Ross' request, Mackowiak emailed a higher-ranking Massey official, corporate Vice President Chris Adkins, to ask for Ross' assistance.
"Low air on the headgate section again, despite last week's shut down," Mackowiak wrote to Adkins on March 16. "I called Bill Ross and he is on another project right now. I think they could use some help."
Asked about his email to Adkins, Mackowiak told investigators, "I wanted to ... elevate this issue from a mine level to a corporate level to where someone would respond to this appropriately, because the second time I have ... low operating air volume on a section is inexcusable."
Mackowiak told investigators he never heard back from Adkins.
Adkins is among at least 17 top Massey officials, including former CEO Don Blankenship, who invoked their 5th Amendment right and refused to answer questions about the disaster.
Mackowiak said Massey officials never undertook an effort to do a holistic repair of the troubled Upper Big Branch ventilation system.
"As an inspector would find issues in the mine, and they would issue ventilations or citations and orders, the company would react to that with generally a plan change, but you would only see a small component of it, whatever was necessary to abate that condition and then move on," Mackowiak testified. "And that was done a myriad of times."
After the disaster, Massey officials blamed MSHA for ventilation problems at the mine, saying federal inspectors forced the company to make changes Massey's engineers disagreed with.
McAteer's report said his team found no records to support Massey's claims.
Two years before the Upper Big Branch Mine blew up, miner Nathaniel Jeter complained to Performance Coal Co. President Chris Blanchard about the condition of the mine's track-mounted rock-dusting machine.
"I said to him, 'Well, when are they going to get that track duster fixed?'" Jeter told investigators. "He said, 'Track duster? I didn't know we had a track duster.'