Learning is the lifelong process of transforming information and experience into knowledge, skills, behaviors, and attitudes. ~ Jeff Waizkin
While investigators are still trying to get into the Upper Big Branch Mine where an explosion killed 29 miners on April 5, Mine Safety and Health News has been busy looking at the mine's citation history, and what we can learn with the information we have right now. I have spent this last week categorizing every citation issued since January 2008. Could earlier adjudication of contested citations have prevented this? Perhaps. What what is more troubling is the question of what has been learned from past disasters. Disasters where everyone said, "never again."
The Mine Safety and Health Administration (MSHA) has the power to close all or part of a mine and order the withdrawal of miners. Period. We don't need new laws from Congress for MSHA to have this power -- they already have it. It's a very effective enforcement tool. While MSHA did issue withdrawal orders on 56 occasions last year, it appears this enforcement tool could have been used more often.
Massey Energy had a huge fire in its Aracoma Mine in 2006, where 2 miners died of smoke inhalation. The loss of life could have been worse. Ten men managed to crawl and feel their way out of smoke filled passages, but two got lost and died. The fire started because a misaligned conveyor belt caused frictional heating.
MSHA has cited the Massey Upper Big Branch mine for similar violations, including a case where an MSHA inspector found a misaligned area smoking from heat -- the precursor to a fire. Why did an MSHA inspector find this? Why wasn't a misaligned, smoking conveyor belt found by a Massey mine examiner? Were there too few miners walking the belt-line to keep up with the maintenance tasks at hand?
Miners could not fight the fire at the Aracoma Mine because of lack of water pressure, and because fire hoses did not have compatible fittings with fire hose outlets.
MSHA has cited the Upper Big Branch mine for similar violations -- eight times since March 10, 2009 for lack of compatible fittings between fire hoses and outlets.
In 2008 and in 2009, MSHA found two cases at Upper Big Branch where there was no water flowing through branch lines - none. It found similar problems at Aracoma.
In 2009 at Upper Big Branch there were 12 citations where fire extinguishers had been discharged and not replaced, or there were problems with dry chemical fire suppression systems on equipment.
Using just these examples, we find 22 occasions where MSHA failed to issue an order after repeated violations. These are "alleged violations" and the company is contesting many of them, but a mine doesn't need to be under a "Pattern of Violations" status for MSHA to use this tool of withdrawing miners until all of the fire-fighting equipment is fixed and in working order.
I realize that the Upper Big Branch mine exploded, and the Aracoma disaster involved a fire. But wouldn't both MSHA and the company be on "heightened alert" to these sorts of violations given what happened at the Aracoma Mine?
Massey Energy and MSHA have the information gathered from the Aracoma disaster. They have the experience of Aracoma and previous disasters. They have the skills to fix the problems that were found at Aracoma, and to have fixed the alleged problems at Upper Big Branch. They have the knowledge of what went wrong at Aracoma to prevent similar violations in any mine that has the potential to cause an accident or fatality.
But what has not changed, in at least these instances, is the behaviors and attitudes.
I realize that MSHA cannot be at a mine 24 hours a day, and in fact, MSHA's obligation is to inspect an underground mine 4 times each year, and make spot inspections for mines that liberate vast quantities of methane. But MSHA can use it's experience to say "Stop. Withdraw all miners. Fix this now."
Massey can use it's history from different mines to make findings at its current operations. Given what we know from Aracoma, why was the company not on a heightened alert to these fire-fighting equipment problems? Why was it that an MSHA inspector found a smoking, misaligned conveyor belt, and not a company examiner?
Given what we do know, MSHA and Massey need to ask: What was truly learned?