Everywhere you turn in this report, there is another safety procedure that was supposed to be followed that wasn’t or safety equipment that was supposed to be in place that either wasn’t there or didn’t work.

Thats how United Mine Workers of America Cecil E. Roberts characterized a report on the fire at the Aracoma Alma No. 1 Mine that killed miners Don. I. Bragg, 33, and Ellery Elvis Hatfield, 47, last January. Robert says that the mine was “set up to be a death trap in the event of an accident, and that’s what it became.”

According to the report by the West Virginia Office of Miners’ Health, Safety and Training,

State investigators said missing walls that control air flow and faulty firefighting equipment were key factors in the deaths of two miners in a conveyor belt fire at an underground coal mine in January.

Investigators concluded the missing walls allowed smoke to enter the main escape route at the Aracoma Alma No. 1 Mine, the Office of Miners' Health, Safety and Training said in a report released Thursday.

The investigation found that water lines for fire hoses and sprinklers at the scene of the fire were shut off and that fire hoses at the site couldn't be connected because of incompatible fittings, a problem that had been reported to management after a similar fire on Dec. 23.

Investigators said the fire resulted from a misaligned conveyor belt that carries coal. The belt was rubbing a bearing, causing friction. Mine personnel were unable to fix the alignment problem before the evening shift started, but operated the belt anyway, according to the report.

According to the report, the crew was not notified of the danger until about 40 minutes after the fire broke out at 5 p.m. Eddie Lester, vice president of operations for the mine, did not notify the state about the fire and the two missing miners until 7:33 p.m.

Throughout this week I've reported on findings by the Chemical Safety Board and CBS 60 Minutes that BP knew of the unsafe conditions that led to the March 2005 explosion that killed 15 workers, but the company chose not to fix them. I noted then, and I'll repeat now, that if you investigate almost any workplace disaster (or even small accidents) and you'll find that there were plenty of warning signs known to both workers and managers, but there was no existing management system to ensure that such warnings get addressed before disaster strikes.

Massey Energy Company, which owns the mine, isn't taking full blame:

"At Aracoma, it appears that deficiencies were not fully recognized by mine
personnel or by state or federal inspectors," Massey said.

But Roberts understands who's responsible:

“These are Massey management’s responsibilities,” Roberts said. “These are things they’re supposed to be staying on top of. The report clearly shows that this is a tragedy that didn’t have to happen, shouldn’t have happened, and only happened because proper and required safety and maintenance procedures were not followed at that mine.”

***

“This is yet another example of what happens when upper management puts pressure on a mine to ‘run coal’ before doing anything else, ” Roberts said, referring to a memo Massey CEO Don Blankenship sent to Massey mines last fall, before the Aracoma disaster. “Proper maintenance isn’t done, needed and required safety equipment is not put in place, and effective safety procedures in the event of an emergency are not followed. When you put production ahead of safety, tragedies like this are all too often the result.”

Last October, Blankenship warned his mine superintendents,

If any of you have been asked by your group presidents, your supervisors, engineers or anyone else to do anything other than run coal (i.e., build overcasts, do construction jobs, or whatever), you need to ignore them and run coal. This memo is necessary only because we seem not to understand that the coal pays the bills.

But Roberts wasn't letting mine inspectors off the hook either:

“You have to wonder why many of these things were not identified. Ventilation stoppings were out, carbon monoxide monitors were not installed, the water wasn’t turned on to the fire suppression system, and more. Why weren’t these clear violations of the law identified?”