"It is the operator's responsibility to comply with the laws," McAteer, a former director of the federal Mine Safety and Health Administration, said at a news conference Friday.Last week, the West Virginia Office of Miners’ Health, Safety and Training, released a report finding that the fire and deaths were caused by missing walls that control air flow and water lines for fire hoses and sprinklers that had been shut off and fire hoses that couldn't be connected because of incompatible fittings.
Don. I. Bragg, 33, and Ellery Elvis Hatfield, 47, got separated from their crew in the smoke-filled Aracoma Alma No. 1 Mine in Logan County and were unable to escape the Jan. 19 fire.
McAteer wrote in a report released Friday that Massey couldn't alert miners about the fire and the need to evacuate. The mine's system for detecting fires and telling miners to evacuate was flawed, and water to the sprinkler system and fire hoses was shut off, he wrote.
He also noted that the state did not conduct a required annual electrical inspection for two years before the fire.
"The two victims' lives could have been saved with early intervention and a fire suppression system that worked," McAteer wrote.
Lack of training and instructions to shortcut safety by Massey's owner also may have contributed to the deaths, according to McAteer's report:
According to the report, dispatcher Mike Brown -- the person in charge of monitoring mine alarms and the computer that regulates equipment underground -- was new in the job and had not been adequately trained on what to do when the fire alarm went off. He reset the alarm several times without understanding that the carbon monoxide alert was an indicator of a fire breaking out.McAteer also noted that severe understaffing at West Virginia's mine safety agency may have led to inspectors overlooking many of the safety violations at the mine.
"He didn't think he had the authority to order the mine evacuated, and he certainly lacked the experience and knowledge to take it upon himself to do so," the report states.
Mr. Hagy, the foreman, also mentioned an Oct. 19, 2005, memorandum from [Massey CEO Don] Blankenship to ignore requests by anyone to do anything other than "run coal." The requests to be ignored, according to Mr. Blankenship's memo, included to "build overcasts (overhead conduits needed to carry fresh air), do construction jobs, or whatever."
Mr. McAteer's report makes clear that, instead of immediately evacuating the mine after a fire broke out along a defective conveyor belt line, igniting coal and coal dust, mine officials tried to fight the fire.
In the 63-page report, McAteer said a "severe manpower shortage" prevented state inspectors from properly enforcing safety rules at the mine. At the time of the fire, two inspectors at the state agency’s district office were off work because of illness and injuries, the report said.But understaffing doesn't explain all of the problems with oversight, according to McAteer:
However, even when the office is fully staffed, just 12 inspectors are responsible for completing quarterly inspections of 83 underground mines and 40 preparation plants.
Also, four electrical inspectors are required to conduct annual examinations. In order to do so, each would have to make 123 inspections every three months, the report said.
"This is a tremendous workload — the math would suggest an almost impossible task," McAteer said in the report.
"The bottom line, however, is that while manpower shortages may have been a contributory factor, they do not provide an adequate explanation for the breakdown in regulatory oversight on the part of both federal and state officials," the McAteer report said.The full report can be found here.
McAteer recommended a joint study of how state and federal inspectors could do a better job.
"Some of the most urgent and troubling questions about accountability that the fatal fire raised will inevitably remain unanswered until and unless such a review is conducted, either by the agencies involved or by an independent entity," McAteer wrote.