Editors Note: The following is the text from Sen. Ted Kennedy's report on the Crandall Canyon mine disaster. This report will be printed in a continuing series about the mine disaster. It is to be noted this report is from the Senate and not from the investigative team from the Mine, Health and Safety Administration. Senators Bennett and Hatch issued a word of caution at taking the whole report as fact and will draw their final conclusions after all the investigations have been completed.
MSHA did not rigorously or thoroughly review and test the proposed plan and Agapito's technical analyses supporting it. In the one instance where an MSHA employee did thoroughly evaluate Agapito's work, his conclusions were rejected by MSHA supervisors after conversations with Murray Energy officials. This record demonstrates the need for (1) the use of more cautious and conservative engineering assumptions in safety analyses of deep cover mining, and (2) more rigorous and thorough review by regulators of technical analyses submitted by mine operators.
The Plan Should Not Have Been Pursued As Conditions Worsened.
The company ignored multiple warning signs during mining - including heightened seismic activity and a major mine bounce - that should have raised red flags about safety conditions.
During mining of the North barrier pillar in early 2007 - just 900 feet from where the Aug. 6 tragedy occurred - there were multiple signs of instability: A Feb. 7 report describes "unpredictable rolling out rib conditionsÃ¯Â¿Â½in Main West:"
Exhibit 6: During the retreat mining, a March 7 report by a shift foreman states that the mine was "bouncing real hard on occasion. Smacked little Carlos up aside of the haid [sic] with a pretty good chunk."
Exhibit 7: A March 10, 2007 internal memo conclusively establishes that company management, including CEO Robert Murray, was aware of the instability in the North barrier pillar. The memo to Murray stated that "The mine is experiencing heavy bouncing and rib sloughage." Beside this description, Murray wrote "noted."
Exhibit 2: On March 11, a large bounce occurred in the North barrier and damaged nearly 800 feet of the mine, leading Murray Energy to abandon the area and seal it. The record strongly suggests that the law required the company to formally report the incident, but the company failed to do so.
NIOSH and MSHA classify "deep cover" mines as those in which more than 750 feet of rock (in mining terminology, "overburden") lie above the mining face. Crandall Canyon Mine falls within this category since, at its deepest point, the mine lies below 2,200 feet of rock.
Ribs are the walls of tunnels in underground coal mines. More technically, ribs are the side of a pillar or the wall of an entry.
Ribs or pillars "slough" coal when coal falls off or slides down the wall onto the floor of the entry. Mine experts recognize sloughage as a sign that the pillar or rib is being subjected to stress or pressure from the rock overlaying the tunnel (known as "overburden" or "cover"). Improving Safety At Small Underground Mines, Robert H. Peters, Bureau of Mines, 1994, found at http://www.cdc.gov/niosh/mining/pubs/pdfs/sp18-94.pdf ("Normally stable pillar line conditions often deteriorate if the pillar line moves slowly or remains idle for an extended amount of time. This deterioration can manifest itself in the form of excessive sloughage, heave, and squeezesÃ¯Â¿Â½.When the pillar line moved slowly or remained idle over the weekend or during a miner's vacation, normally stable pillars began to take weight, as evidenced by sloughageÃ¯Â¿Â½").
BLM Inspector Falk reported serious concerns about retreat mining after visiting the mine in December 2006 and February 2007, but these concerns apparently were not shared with MSHA.
Exhibit 8. A June 5, 2007 memo reported "constant bumping and sloughing of the ribs."
Exhibit 9. An Aug. 3 update memo to Mr. Murray verifies that the company expected instability as they retreated under deep cover and that "significant sloughage is occurring" during pillaring, a sign of stresses on the pillars.
Exhibit 10. Miner Dale Black (who perished in the Aug. 16 tragedy) told MSHA inspector Donald Durrant that, prior to the Aug. 6 collapse, "there was heavy bumping and there were days he had some concerns."
MSHA also failed to heed warning signs of instability and poor safety conditions during mining of the barrier pillars. After the major collapse in March, MSHA should have visited the mine immediately to (1) determine whether the bounce was reportable (and thus whether the company should be cited for its failure to officially report it), and (2) assess the safety of continued mining in the South barrier pillar. MSHA officials justified their failure to investigate on the grounds that the incident did not seem reportable or significant, given the company's account.
This reliance on representations of the mine operator does not satisfy MSHA's regulatory and monitoring obligations. In addition, when Agapito Associates revised its assumptions after the March collapse, MSHA failed to rigorously review Agapito's revised findings. The agency did not submit the plan to MSHA's Technical Support Center for review because it would take too much time. The agency was also under pressure from the company to approve the plan quickly - which it did. The investigation has also uncovered disturbing information showing that, in May 2006, MSHA officials entered into an improper agreement with Murray Energy in which MSHA relaxed the reporting requirements of the law - excusing the company from reporting seismic events as the law requires.
Evidence Indicates that Murray Energy Violated the Mine Plan, Making a Bad Situation Worse.
It is impossible be certain what happened in the moments before the Aug. 6 collapse. However, the investigation has uncovered evidence indicating that, at the time of the collapse, the company was mining in a manner specifically prohibited by MSHA.
Interview with Donald Durrant, Oct. 10, 2007. Durrant said that generally, during his Main West inspections, there were "some roof issues." But as a rule, he said, the mine roof and floor were very strong. However, Durrant said he had concerns about mining the barrier pillars in Main West. Specifically, he was "concerned about additional tunneling because of the weight the barriers would be supporting." Recommendations
The investigation demonstrates that the Department of Justice must get involved and that there is a need for significant reforms in the process of formulating, reviewing and approving mine plans: 1. The Secretary of Labor Should Refer the Case to the Department of Justice for Prosecution. The record shows that Murray Energy failed to exercise care and caution in formulating the mine plan, disregarded increasing signs of danger in the mine, failed to tell MSHA about these dangers, and violated the mine plan in a way that put miners in danger. Murray Energy's actions must be fully investigated and those who broke the law must be prosecuted to the fullest extent of the law.
2. Additional Requirements For Roof Control Plan Review Process
The failure of the review process at Crandall Canyon Mine highlights the urgent need for reform and strengthening of the review process for mining plans- particularly for deep cover mines. Such reform must (1) codify the required steps in the roof control process more explicitly, (2) require in-depth review and analysis, by both mine operators and MSHA, of proposed mining plans and supporting engineering studies, and (3) insulate the process from inappropriate industry pressure or influence.
Such reform should require the following:
When proposing mining plans or revisions in mining plans, the mine operator should create a detailed historical record of safety conditions at the mine. This record should include a review of the mine's safety record and history of seismic disturbances or instability. MSHA should review and analyze this record for accuracy through site visits and a review of mine safety documents, MSHA citations and standards violated, and any other relevant materials.
MSHA should review all technical and engineering analyses submitted by mine operators in support of roof control plans or amendments. At a minimum, the technical review should include checking the results of computer analyses by: 1) verifying the validity of all input data; 2) ensuring the use of a modeling program approved by NIOSH for mine design; 3) validating all dimensions, geologic information and material strength properties; and executing multiple computer runs by varying model input parameters to provide a parameter-sensitive risk assessment of the proposed mine design.
In addition, for plans involving retreat mining, all plans and technical and engineering analyses should be submitted to the Roof Control Division of MSHA's Safety and Health Technology Center, which will generate a risk assessment of the plan and make a recommendation of approval or disapproval.
The mine operator should create a formal, comprehensive risk assessment of the proposed roof control plan or amendments. This risk assessment should assess the level of risk to miners in each component of the plan or planamendment in light of (a) the detailed record of safety conditions discussed above, (b) all technical and engineering analyses submitted, (c) potential safety hazards posed by the mining plans, and (d) any other factors deemed relevant by the Secretary or the District Manager. MSHA should review and analyze this record for accuracy through site visits and a review of mine safety documents, MSHA citations and standards violated, and any other relevant materials. Each of the documents described above should be submitted as part of the Uniform Mine File and posted on the MSHA website. The Secretary should also revise MSHA's Program Policy Manual and any other MSHA internal guidance to incorporate these new requirements.