When MSHA issued its 190-page report last week on the January 2006 Sago Mine disaster, most of theÂ press focused on the agency's conclusion that a lightning strike was the "most likely ignition source" for the explosion.Â Readers should not forget however, thatÂ 29 coal miners were underground at the time of the explosion.Â Only oneÂ (Mr. Terry Helms) was immediatelyÂ and seriously injured from the powerful blast (an estimated 93 psi) whichÂ destroyed, and in some cases pulverized, the seals built to partition an abandoned section of the mine from the active area.Â The other 28 miners tried to escape the mine, and 12 men eventually perished from carbon monoxide poisoning.
"Lightning didn't kill our guys,"Â said Geraldine Bruso (sister of deceased Sago miner Jerry Groves) "it was the rescue, the equipment, the whole breakdown of the system."Â
A breakdown of the system indeed,Â and the problems persist.Â How so?Â Here's just one example: MSHA only issued a $60 penalty to the mine operator for all theÂ documented problems relatedÂ to the miners'Â self-contained self-rescuers (SCSRs).Â Â Â If that isn't an example of a brokenÂ enforcement system, I don't know what is.Â
The operator of the Sago Mine (Wolf Run Mining of International Coal Group) did not receive a singleÂ "contributory citation" from MSHA for the disaster.Â A contributory citation isÂ one related to a "condition that leads to the causes and effects of the severity of the accident."Â
As part of the investigation report, theÂ agency noted that 149 non-contributory citations had beenÂ issued over the course of their investigation (between January 2006 and April 2007.)Â Â The monetary penalties assessed by MSHA forÂ 116 of the citations totalled about $100,630 (penalties for the remaining 32 have not yet been calculated.)Â Wolf Run Mining is contesting 34 of the citations (assessed value = $44,992.)
MSHA's SagoÂ Report includes 24 pages (pp. 75-99) specifically addressing the miners' SCSRs.*Â The investigators note:
- Despite an MSHA regulation requiring mine operators to conduct a special examination every 90 daysÂ of each SCSR, unitsÂ carried by some of theÂ miners working on January 2 hadÂ not been inspected.
- Despite an MSHA regulation requiring miners to receive training from an approved trainer, at least one of the trainers used at the Sago mine was not approved.
- Despite an MSHA regulation requiring training to be conducted at prescribe intervals, some of the miners did not receive their safety and health training on time.
- Despite an MSHA regulation requiring mine operators to keep accurate records on their SCSRs (e.g., purchase date to ensure they are not expired; dates of 90 inspections, etc.,) the Sago mine's records had numerous errors.Â
- Despite an MSHA regulation requiring miners to receive safety training on SCSRs, the quality of the safety training should have been investigated thoroughly.Â A number of the miners who escaped the blast either did not don their SCSRs or had difficulty deploying them, suggesting the training employed at the mine was not effective.Â [As we recommended in our report to WV Governor Manchin, MSHA should "require random in-mine testing of SCSRs currently in service by asking miners to voluntarily don them and travel all or part way out of the mine while wearing them."]
- Despite an MSHA regulation requiring the proper maintenance of SCSRs, the mine operator stored many if not all of the SCSRs in the mine's bathhouse, a practice that violates the manufacturer's storage instructions.Â [Only after viewing a training video produced jointly by NIOSH and the SCSR manufacturer, did we learn that the Sago mine typically stored their SCSRs in the bathhouse.Â Miners who worked at the mine watched the video with us and reported this to be true.]
Based on MSHA's own narrative about the Sago Mine's practices with respect to the SCSRs, I am dumbfounded by the assessment of a $60 penalty.Â
12 workers dead. SCSR program deficiencies.Â $60? Â $60??
*MSHA's lengthy investigation report includes 38 appendices.Â I expected one of themÂ to be NIOSH's related report of their post-disaster assessment of the recovered SCSRs.Â Typically, this document would be part of MSHA's official document.Â Â There is no NIOSH attachment to MSHA's report.
Celeste Monforton, MPH was a member of theÂ small team assembled by Davitt McAteer toÂ conduct a special investigation for WV Governor Joe Manchin of the Sago and Aracoma/Alma disasters.Â Their investigation reports appear here and here.Â