A report commissioned by the governor of West Virginia lays the blame for the Upper Big Branch mine disaster squarely on Massey Energy, owner and operator of the facility – although regulatory agencies come in for scathing criticism as well.

The April 5, 2010 explosion which killed 29 miners was preventable and even predictable, according to the findings of an independent team appointed by the former West Virginia governor, Joe Manchin III, and led by former federal mine safety chief Davitt McAteer.

Massey “broke faith with its work­ers by frequently and knowingly violating the law and blatantly disregarding known safety practices while cre­ating a public perception that its operations exceeded industry safety standards,” according to the report, which was subtitled, “a failure of basic coal mine safety practices.”

In its push to produce coal and save time that would be needed to make repairs, Massey engaged in a “normalization of deviance,” that lead to conditions like chronically low airflow and high water, illegal ventilation changes, the lack of a cohesive engineering plan, and fraudulent reporting systems to be commonplace.

“Most objective observers would find it unaccept­able for workers to slog through neck-deep water or be subjected to constant tinkering with the ventilation sys­tem – their very lifeline in an underground mine. Prac­tices such as these can only exist in a workplace where the deviant has become normal, and evidence suggests that a great number of deviant practices became nor­malized at the Upper Big Branch mine,” said the report’s authors.

Instead of having an overall engineering plan to guide the mining,the Upper Big Branch mine was engineered as opera­tions advanced. “To the outsider, this would seem like a backwards way of operating.” Testimony gathered indicated that engineers had very little actual involvement with the mine; one had never been in it.

Miners routinely lacked safety equipmentand were sent into remote parts of the mine with no communication devices, vehicles or gas detectors. They were further endangered by the inadequate rock dusting performed by Massey, despite its being recognized as a major factor in preventing flare-ups from turning into major explosions.

Faulty and inadequate equipment “was the norm” at the mine. The report listed a poorly maintained top of the line shearer, broken rock dusters, and damaged and defective airlock doors. Many airlock doors – cheaper and easier to install than overcasts – were used at the mine, despite their being vulnerable to damage and impossible to be made truly airtight – further compromising the safety of the workers.

Manysafety mechanisms in the mine were disabled,such as methane detectors that had been “bridged out,” or disabled, so that production could continue without taking time to make repairs.

In a summary of the causes of the explosion, the report said; “The company’s ventilation system did not adequately ventilate the mine. As a result, explosive gases were allowed to build up. The company failed to meet federal and state safe principal standards for the application of rock dust. Therefore, coal dust provided the fuel that allowed the explosion to propagate through the mine. Third, water sprays on equipment were not properly maintained and failed to function as they should have. As a result, a small ignition could not be quickly extinguished.”

Both the U.S. Mine Safety and Health Administration (MSHA) and the West Virginia Office of Miners’ Health, Safety and Training (WVHST) were criticized for failing to ensure that Massey was compliant with laws and regulations.

"Laws and regulations are effective only if they are respected by companies and enforced with diligence by regulators."

Massey Energy’s chief of security, Hughie Elbert Stover, has been indicted for lying to the FBI and obstructing the criminal investigation. Stover is alleged to have directed and trained security guards to give advance notice of MSHA inspections and to dispose of documents related to the investigation.

Additional Massey personnel are expected to face criminal and civil penalties.

“The story of Upper Big Branch is a cautionary tale of hubris,” said the report. “A company that was a towering presence in the Appalachian coalfields operated its mines in a profoundly reckless manner, and 29 coal miners paid with their lives for the corporate risk-taking. The April 5, 2010, explosion was not something that happened out of the blue, an event that could not have been an­ticipated or prevented. It was, to the contrary, a com­pletely predictable result for a company that ignored basic safety standards and put too much faith in its own mythology.” Manchin said the report would help in identifying potential reforms to improve mine safety.

In January 2011, Massey offi­cials announced that the company would be sold to coal giant Alpha Natural Resources, effectively dissolving Massey Energy as a business entity. Plans are underway to seal the Upper Big Branch mine.