Federal inspectors either missed problems at West Virginia's Upper Big Branch mine or failed to inspect the areas where they existed in the 18 months before a deadly 2010 explosion, but an internal review concludes there's no evidence those failures caused the disaster.
The Mine Safety and Health Administration posted the report online Tuesday after briefing relatives of the 29 miners killed in the nation's worst coal mining disaster in four decades.
The report acknowledges multiple failures by field staff in MSHA's largest region, southern West Virginia's District 4. It also said their effectiveness was compromised by internal communication problems and by federal budget cuts that had created staffing shortages, inexperience and a lack of sufficient training and managerial oversight.
Although MSHA has made significant improvements in the past two years, the report said it's not enough and contains about 20 pages of detailed, technical recommendations for regulatory and administrative changes.
"More must be done to protect the health and safety of the nation's miners," it said.
MSHA director Joe Main said he takes the findings seriously and praised the review team for identifying systemic breakdowns.
"We can't just do internal reviews. We have to fix the problems," he said. "We take responsibility for the agency's actions here. We have an obligation to fix these things, and yes, we're going to do that."
Gary Quarles, whose son Gary Wayne died in the blast, said he would take some satisfaction in hearing Main and other MSHA officials accept responsibility, "as long as they do their part and make sure this don't happen again."
Quarles said many people at the private meeting told regulators they were as much to blame as the former mine operator, Massey Energy.
"And they sat there and took it. They never said they weren't at fault," he said. "More or less, they was taking blame. I don't see how they could have kept from it."
While the report focuses on systemic failures, Main said he will review whether administrative actions should also be taken against individuals. But he said blame for the disaster continues to rest squarely with Massey, bought last summer by Virginia-based Alpha Natural Resources.
Four investigations have concluded the blast was sparked by worn and broken equipment, fueled by a deadly buildup of methane and coal dust, and allowed to spread because of clogged and broken water sprayers.
MSHA investigators found Massey made "systematic, intentional and aggressive efforts" to hide problems and throw off inspectors, even falsifying safety records. Managers also alerted miners when inspectors arrived, allowing time to disguise or temporarily fix dangerous conditions.
The former superintendent has been charged with conspiracy to commit fraud and is cooperating in a Department of Justice investigation. A former security chief, meanwhile, has been sentenced to three years in prison for lying to investigators and attempting to destroy records.
The internal review said MSHA inspectors consistently failed to identify problems with accumulations of explosive coal dust and deviations from ventilation and roof control plans. It also said they failed to use the operator's examination books to determine whether hazards had been corrected.
It noted those inspectors failed to identify 10 safety violations that MSHA's accident investigation team later determined had contributed to the blast. In some cases, they didn't recognize hazards, the report said. In others, they just didn't inspect the areas where they existed.
Although inspectors wrote a total of 684 violations in the 18 months before the blast, the report said they failed to act on eight that could have been deemed "flagrant," the most serious designation. They also failed to conduct special investigations on at least six occasions to determine whether managers knowingly violated safety standards.
The report, conducted by MSHA employees outside District 4, found that "inadequate direction training and supervision" was as much a problem as inexperienced inspectors.
But it tempered the criticism, noting that MSHA's messages were not communicated consistently, resulting in "unclear, redundant and conflicting instructions" to inspectors.
Main, who took over the agency in October 2009, said MSHA had a centralized process for communicating policies until 2002. It is now virtually impossible for field staff to know about the 199 policies the agency has adopted since 2004, he said.
"There was an overload, to a certain extent," Main said. "Depending on when you were hired and where you were trained, you may or may not have received some of those instructions."
MSHA is currently rewriting its inspector manual, consolidating and clarifying the policies. It's also overhauling its training programs.
At more than 200 pages, plus appendices, the internal review is more comprehensive than similar agency appraisals done after five mine disasters since 2001.
As in this one, each review concluded that MSHA employees had done incomplete or inadequate inspections, that inspectors had inadequate supervision and direction, and that inspectors failed to identify the mine operator's deviation from approved mining plans.
"There's a lot of things in this report that goes deep into the weeds to figure out what the problems are and how to fix it, so it looks worse than other internal reviews," Main said. "But this is something we needed to do."
Cecil Roberts, president of the United Mine Workers of America, said he's encouraged that Main has identified what needs to be done and is on the right path.
"There is clearly much work to do in order to bring the agency up to the standards miners have a right to expect," he said. "... The UMWA stands ready to do all we can to help in that effort."
MSHA review: http://1.usa.gov/zf6ocF