"I said, 'Well, yeah. We need to get that fixed.' He said, 'Well, I'll look into it.'" Jeter said. "So they had a write-up for it, all the parts and everything, but it never left the mines."

Rock-dusting is the industry term for spreading large amounts of crushed limestone on mine floors, walls and other surfaces. For more than a century, it's been understood that proper rock dusting in underground mines can prevent coal-dust explosions.

McAteer's report explains, "Mines the size of Upper Big Branch typically use track-mounted tank or pod dusters -- like the one Jeter operated -- to rock dust the track haulage, belt lines, airways, working sections and construction sites.

"Efficient use of a track duster in a mine the size of Upper Big Branch would have required drilling a borehole midway in the mine and not far from the working sections," the report said. "This would have allowed a speedy delivery of bulk rock dust to refill the tank dusters."

Upper Big Branch had no such borehole. The mine had just one crew assigned to rock-dusting duties. And the equipment they had never seemed to work properly.

"Sometimes it would clog up, so we would have to spend 30 minutes trying to unclog the hoses to get dusted," Jeter said, describing the orange rock-dusting machine. "Then it would clog up again."

Records uncovered by investigators indicated the orange duster was at least 25 years old, and had not been reconditioned for at lest seven years.

After the explosion, when Massey employees tried to start up the duster for MSHA-required tests, the motor burned up.

Investigators found another duster parked in the mine shop. It was tagged "out of service," and had been stripped down to its frame for parts.

Federal and state investigators have argued for nearly a year that it was clear to them that coal-dust played a major role in the explosion. Massey disputes this view.

McAteer's report provides new evidence to support the coal-dust theory, including testimony from numerous miners who complained about inadequate rock-dusting.

The McAteer team also analyzed dozens of safety examination reports completed by Massey's own employees.

Between January and March 2010, those reports show, Massey miners identified 1,834 instances were parts of the mine needed to be rock-dusted. The work was completed in only 302 of those instances, or about 16 percent of the time.

"If their coal production was as bad as their rock dusting, they would be out of business," McAteer said last week.

'Kicked in the teeth'

A month after the disaster, Massey CEO Don Blankenship told a congressional committee that Massey was a safe company.

"Massey does not place profits over safety," Blankenship testified. "We never have and we never will."

The McAteer report disagrees.

"The company is acknowledged for the number of jobs it provides and for such contributions as bringing doctors to coalfield communities; providing financial assistance to coalfield schools and scholarships for students; supporting volunteer fire departments and sports events; and staging an annual Christmas gift-giving program for needy children," the report says.

"But Massey is equally well known for causing incalculable damage to mountains, streams and air in the coalfields, creating health risks for coalfield residents by polluting streams, injecting slurry into the ground and for failing to control coal waste dams and dust emissions from processing plants; using vast amounts of money to influence the political system; and battling government regulation regarding safety in the coal mines and environmental safeguards for communities."

The McAteer team quotes numerous Massey miners who criticize the company's safety program, called, "S-1" for "Safety is Job 1."

"That's just slogans," testified Denver Lambert, a miner with 34 years experience who worked at Upper Big Branch since 2001.

Purchasing agent Gregory Clay told investigators he was familiar with the terms "S-1" and "P-2."

"Safety first, production second," Clay said. "It should be the other way around. They want production."

Michael Ferrell, who worked at Upper Big Branch for 13 years until he left in February 2010, told investigators those who "tried to do the right thing" in terms of safety were "usually the people that [got] kicked in the teeth for it."

McAteer's report concluded, "There is an obvious disconnect between the lofty standards extolled by Blankenship and the reality of conditions inspectors and investigators found in the Upper Big Branch Mine.

"Requiring reflective clothing, metatarsal boots and seat belts are good practices," the report says. "But they do not address the basics of mine safety -- proper ventilation, adequate rock-dusting, well-maintained equipment, and fire suppression.

"In those basic areas of worker safety, Massey Energy has fallen woefully short."

'What the hell have they done now?'

By early afternoon on April 5, 2010, Jason Stanley and David Farley had managed to get four of the six water pumps up and running. They didn't have the clamps or couplings to fix the other two.

It was nearly 2 p.m., about time for them to begin the long trek back out of the mine at the end of their shift.

They went looking for their boss, foreman Jeremy Burghduff. They found him lying down on the job -- literally.

"Whenever we went through the mandoor ... he kind of bounced up," Farley recalled.

Farley told investigators Burghduff didn't perform his required safety examinations that day. And investigators found that, during 25 shifts between September 2009 and April 2010, Burghduff's methane detector wasn't turned on when he was supposedly checking for hazardous conditions.

Across the mine on April 5, other workers were noticing changes in the flow of air underground.

Mike Kiblinger, a construction foreman, had a crew underground the previous Thursday to cut a new channel for a conveyor belt. He noticed dust from their work was blowing out of the mine.

That Monday, though, Kiblinger felt the air going the opposite direction. He thought someone must have made a major ventilation change over the weekend.

"I mean, it'd pick up and it would die, then pick up and die," said Scott Halstead, describing air fluctuations at the longwall face that afternoon.

Roof bolter Joshua Williams also noticed the air reversal. He told foreman Bobby Baker about it.

"He didn't say nothing," Williams recalled. "He just walked away."

When his shift was ending at about 2:45 p.m., Williams said the dust was light, and the air "foggy looking." When the crew left the mine, the air was still going the wrong way.

In the longwall section, the miners had been having a frustrating shift. The longwall machine had been down several times, and the crew spent much of their time scrambling to fix mechanical problems.

At about 2:42 p.m., operator Rex Mullins called out to the surface, reporting that coal production had resumed.

Shortly before 3 p.m., workers on the longwall manually engaged a two-part shut-off system, powering down their equipment. Later, bodies of four of the miners who died were found about two-thirds of the way down the longwall face from their normal work positions. Nobody knows exactly what happened, but the McAteer report concludes, "These men must have seen something ominous and out of the ordinary" -- perhaps the fireball of the initial methane ignition.

Day-shift crews were busy trying to make their way out of the mine, and home to their families.

At about 3 p.m., dispatcher Adams Jenkins got a call from James Woods from the Tailgate 22 crew. Woods was driving a mantrip and asked Jenkins to confirm he had a clear road to the surface.

A couple of minutes later, "that's when it happened," Jenkins told investigators.

"All the dust started, just a white smoke pouring out of the portals, and it sounded like thunder," he said. "It was constant, and I didn't know what happened. And [mine superintendent] Gary May, he said, 'Oh, Lord ... something bad's happened.'"

Greg Clay, a purchasing agent and sometimes dispatcher, jumped from his chair and looked out the window. He could see rock and debris blowing out of the mine portal and said, "it just sounded like jet engines."

Mine superintendent Everett Hager was overheard saying, "What the hell have they done now?"

Joshua Williams, a younger miner who was on a mantrip exiting Upper Big Branch, described the moment as "when the world came to an end."

Brent Racer, a shuttle car operator, stopped at a mine phone, listening for some answer from the mine inside.

"It's like dead silence," Racer recalled. "No one was answering."

In Monday's Charleston Gazette: The rescue effort.

Reach Ken Ward Jr. at kw...@wvgazette.com or 304-348-1702.

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.

Broken-down equipment

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.'

"I said, 'Well, yeah. We need to get that fixed.' He said, 'Well, I'll look into it.'" Jeter said. "So they had a write-up for it, all the parts and everything, but it never left the mines."

Rock-dusting is the industry term for spreading large amounts of crushed limestone on mine floors, walls and other surfaces. For more than a century, it's been understood that proper rock dusting in underground mines can prevent coal-dust explosions.

McAteer's report explains, "Mines the size of Upper Big Branch typically use track-mounted tank or pod dusters -- like the one Jeter operated -- to rock dust the track haulage, belt lines, airways, working sections and construction sites.

"Efficient use of a track duster in a mine the size of Upper Big Branch would have required drilling a borehole midway in the mine and not far from the working sections," the report said. "This would have allowed a speedy delivery of bulk rock dust to refill the tank dusters."

Upper Big Branch had no such borehole. The mine had just one crew assigned to rock-dusting duties. And the equipment they had never seemed to work properly.

"Sometimes it would clog up, so we would have to spend 30 minutes trying to unclog the hoses to get dusted," Jeter said, describing the orange rock-dusting machine. "Then it would clog up again."

Records uncovered by investigators indicated the orange duster was at least 25 years old, and had not been reconditioned for at lest seven years.

After the explosion, when Massey employees tried to start up the duster for MSHA-required tests, the motor burned up.

Investigators found another duster parked in the mine shop. It was tagged "out of service," and had been stripped down to its frame for parts.

Federal and state investigators have argued for nearly a year that it was clear to them that coal-dust played a major role in the explosion. Massey disputes this view.

McAteer's report provides new evidence to support the coal-dust theory, including testimony from numerous miners who complained about inadequate rock-dusting.

The McAteer team also analyzed dozens of safety examination reports completed by Massey's own employees.

Between January and March 2010, those reports show, Massey miners identified 1,834 instances were parts of the mine needed to be rock-dusted. The work was completed in only 302 of those instances, or about 16 percent of the time.

"If their coal production was as bad as their rock dusting, they would be out of business," McAteer said last week.

'Kicked in the teeth'

A month after the disaster, Massey CEO Don Blankenship told a congressional committee that Massey was a safe company.

"Massey does not place profits over safety," Blankenship testified. "We never have and we never will."

The McAteer report disagrees.

"The company is acknowledged for the number of jobs it provides and for such contributions as bringing doctors to coalfield communities; providing financial assistance to coalfield schools and scholarships for students; supporting volunteer fire departments and sports events; and staging an annual Christmas gift-giving program for needy children," the report says.

"But Massey is equally well known for causing incalculable damage to mountains, streams and air in the coalfields, creating health risks for coalfield residents by polluting streams, injecting slurry into the ground and for failing to control coal waste dams and dust emissions from processing plants; using vast amounts of money to influence the political system; and battling government regulation regarding safety in the coal mines and environmental safeguards for communities."

The McAteer team quotes numerous Massey miners who criticize the company's safety program, called, "S-1" for "Safety is Job 1."

"That's just slogans," testified Denver Lambert, a miner with 34 years experience who worked at Upper Big Branch since 2001.

Purchasing agent Gregory Clay told investigators he was familiar with the terms "S-1" and "P-2."

"Safety first, production second," Clay said. "It should be the other way around. They want production."

Michael Ferrell, who worked at Upper Big Branch for 13 years until he left in February 2010, told investigators those who "tried to do the right thing" in terms of safety were "usually the people that [got] kicked in the teeth for it."

McAteer's report concluded, "There is an obvious disconnect between the lofty standards extolled by Blankenship and the reality of conditions inspectors and investigators found in the Upper Big Branch Mine.

"Requiring reflective clothing, metatarsal boots and seat belts are good practices," the report says. "But they do not address the basics of mine safety -- proper ventilation, adequate rock-dusting, well-maintained equipment, and fire suppression.

"In those basic areas of worker safety, Massey Energy has fallen woefully short."

'What the hell have they done now?'

By early afternoon on April 5, 2010, Jason Stanley and David Farley had managed to get four of the six water pumps up and running. They didn't have the clamps or couplings to fix the other two.

It was nearly 2 p.m., about time for them to begin the long trek back out of the mine at the end of their shift.

They went looking for their boss, foreman Jeremy Burghduff. They found him lying down on the job -- literally.

"Whenever we went through the mandoor ... he kind of bounced up," Farley recalled.

Farley told investigators Burghduff didn't perform his required safety examinations that day. And investigators found that, during 25 shifts between September 2009 and April 2010, Burghduff's methane detector wasn't turned on when he was supposedly checking for hazardous conditions.

Across the mine on April 5, other workers were noticing changes in the flow of air underground.

Mike Kiblinger, a construction foreman, had a crew underground the previous Thursday to cut a new channel for a conveyor belt. He noticed dust from their work was blowing out of the mine.

That Monday, though, Kiblinger felt the air going the opposite direction. He thought someone must have made a major ventilation change over the weekend.

"I mean, it'd pick up and it would die, then pick up and die," said Scott Halstead, describing air fluctuations at the longwall face that afternoon.

Roof bolter Joshua Williams also noticed the air reversal. He told foreman Bobby Baker about it.

"He didn't say nothing," Williams recalled. "He just walked away."

When his shift was ending at about 2:45 p.m., Williams said the dust was light, and the air "foggy looking." When the crew left the mine, the air was still going the wrong way.

In the longwall section, the miners had been having a frustrating shift. The longwall machine had been down several times, and the crew spent much of their time scrambling to fix mechanical problems.

At about 2:42 p.m., operator Rex Mullins called out to the surface, reporting that coal production had resumed.

Shortly before 3 p.m., workers on the longwall manually engaged a two-part shut-off system, powering down their equipment. Later, bodies of four of the miners who died were found about two-thirds of the way down the longwall face from their normal work positions. Nobody knows exactly what happened, but the McAteer report concludes, "These men must have seen something ominous and out of the ordinary" -- perhaps the fireball of the initial methane ignition.

Day-shift crews were busy trying to make their way out of the mine, and home to their families.

At about 3 p.m., dispatcher Adams Jenkins got a call from James Woods from the Tailgate 22 crew. Woods was driving a mantrip and asked Jenkins to confirm he had a clear road to the surface.

A couple of minutes later, "that's when it happened," Jenkins told investigators.

"All the dust started, just a white smoke pouring out of the portals, and it sounded like thunder," he said. "It was constant, and I didn't know what happened. And [mine superintendent] Gary May, he said, 'Oh, Lord ... something bad's happened.'"

Greg Clay, a purchasing agent and sometimes dispatcher, jumped from his chair and looked out the window. He could see rock and debris blowing out of the mine portal and said, "it just sounded like jet engines."

Mine superintendent Everett Hager was overheard saying, "What the hell have they done now?"

Joshua Williams, a younger miner who was on a mantrip exiting Upper Big Branch, described the moment as "when the world came to an end."

Brent Racer, a shuttle car operator, stopped at a mine phone, listening for some answer from the mine inside.

"It's like dead silence," Racer recalled. "No one was answering."

In Monday's Charleston Gazette: The rescue effort.

Reach Ken Ward Jr. at kw...@wvgazette.com or 304-348-1702.