Read the report here. 

A four-person panel appointed by the National Institute for Occupational Safety and Health reported that the disaster was not likely to have occurred if MSHA had not missed ventilation problems and a build-up of explosive coal dust.

The NIOSH panel found that even MSHA inspectors did not understand important mine safety rules and that top agency officials were unaware that MSHA missed inspections and overlooked violations as safety problems worsened at Upper Big Branch prior to the disaster.

"If MSHA had engaged in timely enforcement of the Mine Act and applicable standards and regulations, it would have lessened the chances -- and possibly could have prevented -- the UBB explosion," the NIOSH panel said in its 26-page report.

Twenty-nine miners died in the April 5, 2010, explosion at the Massey Energy mine in Raleigh County, ranking the incident as the worst U.S. coal-mining disaster in nearly 40 years.

The NIOSH panel report was provided to MSHA officials Thursday. The Gazette-Mail obtained a copy and posted it online Friday afternoon. By early Friday evening, MSHA had posted a copy of it on its website, and issued a statement from MSHA chief Joe Main.

"MSHA is committed to rooting out and addressing critical issues within the agency head-on, and agrees more needs to be done to ensure full and effective enforcement of the Mine Act," Main said in the statement. "Under the Mine Act, Congress gave mine operators responsibility for running safe mines. Four investigations into the explosion all show that Massey Energy did not live up to that charge.

"Recent testimony confirmed that mine management routinely used illegal tactics to conceal violations from inspectors," the statement said. "MSHA cannot keep miners safe alone -- mine operators must commit themselves to safety and health."

House Education and the Workforce Chairman John Kline, R-Minn., said he intends to question Main about the NIOSH panel report during a committee hearing Tuesday in Washington.

"NIOSH presents yet another disturbing picture of MSHA's failure to enforce the law at Upper Big Branch," Kline said Friday evening. "Inspectors missed opportunities to address violations of the law and may have been able to prevent the disaster before it happened."

Just two weeks after the disaster, Labor Secretary Hilda Solis asked NIOSH Director John Howard to appoint a panel of experts to examine MSHA's internal review of agency enforcement actions at Upper Big Branch prior to the disaster. Solis said at the time that her goal was to ensure the "transparency and accountability" of MSHA's review of itself.

Howard appointed Jeffrey Koehler, director of NIOSH's mine-safety research programs, to lead the panel. Other members included retired NIOSH staffers Lewis Wade and Michael Sapko, and Stanford Law School professor Alison Morantz.

In its report, the MSHA internal review group repeated the agency's accident investigation team's conclusion that serious, repeated and widespread safety violations by Massey's Performance Coal Co. subsidiary led to the disaster.

A four-person panel appointed by the National Institute for Occupational Safety and Health reported that the disaster was not likely to have occurred if MSHA had not missed ventilation problems and a build-up of explosive coal dust.

The NIOSH panel found that even MSHA inspectors did not understand important mine safety rules and that top agency officials were unaware that MSHA missed inspections and overlooked violations as safety problems worsened at Upper Big Branch prior to the disaster.

"If MSHA had engaged in timely enforcement of the Mine Act and applicable standards and regulations, it would have lessened the chances -- and possibly could have prevented -- the UBB explosion," the NIOSH panel said in its 26-page report.

Twenty-nine miners died in the April 5, 2010, explosion at the Massey Energy mine in Raleigh County, ranking the incident as the worst U.S. coal-mining disaster in nearly 40 years.

The NIOSH panel report was provided to MSHA officials Thursday. The Gazette-Mail obtained a copy and posted it online Friday afternoon. By early Friday evening, MSHA had posted a copy of it on its website, and issued a statement from MSHA chief Joe Main.

"MSHA is committed to rooting out and addressing critical issues within the agency head-on, and agrees more needs to be done to ensure full and effective enforcement of the Mine Act," Main said in the statement. "Under the Mine Act, Congress gave mine operators responsibility for running safe mines. Four investigations into the explosion all show that Massey Energy did not live up to that charge.

"Recent testimony confirmed that mine management routinely used illegal tactics to conceal violations from inspectors," the statement said. "MSHA cannot keep miners safe alone -- mine operators must commit themselves to safety and health."

House Education and the Workforce Chairman John Kline, R-Minn., said he intends to question Main about the NIOSH panel report during a committee hearing Tuesday in Washington.

"NIOSH presents yet another disturbing picture of MSHA's failure to enforce the law at Upper Big Branch," Kline said Friday evening. "Inspectors missed opportunities to address violations of the law and may have been able to prevent the disaster before it happened."

Just two weeks after the disaster, Labor Secretary Hilda Solis asked NIOSH Director John Howard to appoint a panel of experts to examine MSHA's internal review of agency enforcement actions at Upper Big Branch prior to the disaster. Solis said at the time that her goal was to ensure the "transparency and accountability" of MSHA's review of itself.

Howard appointed Jeffrey Koehler, director of NIOSH's mine-safety research programs, to lead the panel. Other members included retired NIOSH staffers Lewis Wade and Michael Sapko, and Stanford Law School professor Alison Morantz.

In its report, the MSHA internal review group repeated the agency's accident investigation team's conclusion that serious, repeated and widespread safety violations by Massey's Performance Coal Co. subsidiary led to the disaster.

The internal review found "several instances where enforcement efforts at UBB were compromised," but said it "did not find evidence that the actions of [MSHA] personnel or inadequacies in MSHA safety and health standards, policies or procedures caused the explosion."

The NIOSH panel, however, said the MSHA internal review team was asking the wrong question.

"This characterization of the facts understates the role that MSHA's enforcement could have had in preventing the explosion," the NIOSH panel reported. "Had the MSHA [internal review] considered the causation issue from a broader point of view, the [NIOSH panel] believes that the [internal review team] might also have posed the following question: Would a more effective enforcement effort have prevented the UBB explosion?"

The NIOSH panel focused on two areas that investigators said were key factors in the disaster:

First, MSHA personnel inspected at least four times between December 2009 and April 2010 an area of the mine where a roof fall had occurred and apparently missed a violation of the operation's roof-control plan that required additional roof supports. The roof fall restricted airflow in the mine, contributing to the explosion.

"If MSHA personnel had completed their required enforcement actions during at least one of the four inspections, it is less likely that a roof fall would have occurred," the NIOSH panel said. "The airflow would not have been restricted as a consequence. With the proper quantity of air, there would not have been an accumulation of methane, thereby eliminating the fuel source for the gas explosion."

Second, regarding the buildup of highly explosive coal-dust underground, the NIOSH team noted that, "inspectors did not identify deficiencies in the mine operator's program for cleaning up loose coal dust and rendering accumulated float coal dust inert by dispersing sufficient quantities of rock dust.

"If MSHA enforcement personnel would have taken appropriate enforcement actions during the inspections in the months prior to the explosion, either dangerous accumulations of explosive coal dust would have been rendered inert, or the mine would have been idled," the NIOSH panel said. "In short, even if there had been a gas explosion, it would have lacked sufficient fuel to trigger a massive dust explosion."

The NIOSH team also took issue with MSHA's conclusion that a contributing factor in the disaster was Massey's efforts -- through advance notice of inspections and other measures -- to hide safety problems from government inspectors.

"Concealment activities by the mine operator would have adversely impacted MSHA's enforcement performance at UBB, however, the mine operator did not, and could not, conceal readily observable violative conditions such as float [coal] dust accumulations throughout the UBB and missing supplemental roof supports," the NIOSH panel said.

The NIOSH panel also said the MSHA internal review team did not do enough to understand the similarities between the findings of agency failings in previous coal-mining disasters, and to ensure those problems are fixed.

"Despite the best intentions of its personnel, the agency has had persistent and substantial difficulty in parlaying insights contained in its internal review reports into a process of continuous quality improvement," the panel report said.

The NIOSH panel recommended that the Labor Department appoint an "independent monitor" to ensure that reforms are put in place.

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