The Fire at Aracoma Alma Mine #1

Transcription

The Fire at Aracoma
Alma Mine #1
A preliminary report to Governor Joe Manchin III
J. Davitt McAteer
and associates
November • 2006
The Fire at Aracoma
Alma Mine #1
A preliminary report to Governor Joe Manchin III
J. Davitt McAteer
and associates:
Thomas N. Bethell
Celeste Monforton
Joseph W. Pavlovich
Deborah Roberts
Beth Spence
November • 2006
This report, as well as additional related information, is available at:
www.wvgov.org and www.wju.edu
Front Cover:
Aracoma Alma Mine #1 map
Box Cut Entrance of the Mine
Back cover:
Aracoma Alma Mine #1 map
Graphic Design by Beth Spence
Contents
Letter of Transmittal...........................................................................................2
Dedication..........................................................................................................4
Executive Summary...........................................................................................5
Introduction........................................................................................................7
The Fire at Aracoma Alma Mine #1 ................................................................10
Escape from the #2 Section............................................................................17
On the Surface................................................................................................26
The Attempt at Rescue....................................................................................33
Why did it happen?..........................................................................................43
Recommendations...........................................................................................57
Mine rescue teams..........................................................................................61
Acknowledgments............................................................................................62
Map of Aracoma Alma Mine #1
1
Letter of transmittal
Governor Joe Manchin III
State of West Virginia
1900 Kanawha Boulevard East
Charleston, WV 25305
Dear Governor Manchin:
It is my honor to submit to you this report of the fire at the Aracoma Alma Mine #1 on January
19, 2006, in which miners Ellery “Elvis” Hatfield and Don Bragg perished. In the days following that
fire, you asked me to conduct an investigation into the accident and to report to you as to causes as
well as actions that can be taken to prevent other fires and deaths in West Virginia coal mines.
This is the second of the investigations which you requested; the first was the Sago Mine
Disaster in which twelve men died on January 2-4, 2006.
This report looks at the causes of the Alma Mine #1 accident, the rescue and recovery efforts and
sets out steps I believe are needed to improve mine safety in West Virginia coal mines.
Mine fires are frightening events. Over the nearly 120 years mining has been conducted in West
Virginia, fires have resulted in hundreds of deaths. They are preventable, and the steps to prevent them
are well known. Tragically, those steps were not followed here.
Even if the fire had occurred, the loss of life could have been prevented if the proper remedial
precautions were taken, if the water supply system had not been compromised, if the miners had been
directed to a protected escapeway, if the smoke had not compromised the escapeway they did take, if
the order to evacuate had been given promptly.
Here, as at Sago, the mine rescue volunteers proved heroic in their willingness to come quickly
to attempt to rescue trapped fellow miners. The 26 teams and roughly 150 volunteers acted with
courage and professionalism. We owe them a debt of gratitude. They truly are the “Minute Men” of
American industry.
Sadly, despite their efforts, two families have sacrificed loved ones. We offer our sympathy and
condolence, knowing the gesture is inadequate, but with the hope our efforts will make a difference
for other coal miners. As one of the surviving miners put it, “I hope what I told you can be used for
some good and that another one of our brothers doesn’t have to perish so that another law can be
made. Let’s start it here.”
In the months following these accidents, other miners have died in West Virginia coal mines.
2
As of this day 23 miners have lost their lives in the state’s mines, making this year the worst year in
mining fatalities in many years.
Thus far in the year 2006, there have been 66 mine deaths in the United States. This represents
a 41% increase over 2005 and the worst fatality rate in the last five years. This is a disturbing trend
and calls for action. The mining community, including the owners, operators, miners, union, state and
federal agencies must not hesitate to change the way mining is being done.
On numerous occasions, you have stated your intention to work toward making West Virginia
mines the safest and most productive in the United States. It is our hope that this report and its
recommendations will help in achieving that goal.
Thank you for asking me to assist in working to improve West Virginia’s mine accident record
and in working to make the state’s mines the safest in the nation.
Sincerely,
J. Davitt McAteer
Shepherdstown, West Virginia
November 10, 2006
After two men died in a fire at the Aracoma Alma Mine # 1 on January 19, 2006, West
Virginia Senate President Earl Ray Tomblin (D-Logan) and House Speaker Bob Kiss
(D-Raleigh) amended the charge of the two committees they had created to inquire into
the Sago Mine disaster to include an investigation of the fire at Aracoma Alma. These
Committees have worked diligently with us to seek answers to these West Virginia
tragedies.
West Virginia Senate
Committee Members
West Virginia House
Committee Members
Don Caruth (R-Mercer)
Jeff Kessler (D-Marshall)
Shirley Love (D-Fayette)
Mike Caputo (D-Marion)
Eustice Frederick (D-Mercer)
Bill Hamilton (R-Upshur)
3
We dedicate this report
to the memories of the good men who
lost their lives in the Aracoma Alma Mine #1
January 19, 2006 ...
Don Bragg
A roofbolt operator on the #2
Section, Don Israel Bragg, 33,
had been employed at the Alma
Mine #1 since Jan. 5, 2004.
He resided at Accoville, Logan
County, and is survived by his
wife, Delorice.
Ellery “Elvis” Hatfield
A roofbolt operator, Ellery Hatfield, 46, had been employed at
the Alma Mine #1 since August
31, 2001. He resided near Simon in Wyoming County and is
survived by his wife, Freda.
... and to the families who love and miss them.
4
1
EXECUTIVE
SUMMARY
A fire occurred along a conveyor belt at the
Aracoma Alma Mine #1 in the late afternoon of
January 19, 2006. The fire appears to have been
the result of a malfunction along the belt and the
ignition of flammable materials – most likely,
coal fines.
Mine fires are not uncommon along
conveyor belts in coal mines. The combination
of friction caused by high speed belts and
flammable material can and has resulted in
heatings and/or ignitions.
Means to prevent such fires are also well
known: removal of accumulations of coal dust
from around the belt, the installation of carbon
monoxide detectors to warn if there is a fire, plus
frequent examinations by supervisors during
pre-shift, on-shift, and weekly examinations.
These examinations are mandated by both state
and federal law and by common sense. These
redundant measures are intended to prevent,
detect and extinguish fires along conveyor belts
in coal mines. They did not work in this case.
Efforts to fight the fire were unsuccessful
because there was no water available and the fire
extinguishers that were used were not adequate
to douse the flames. After some time, a crew of
12 miners working inby the fire was ordered to
evacuate; they took the mantrip along the main
line until they encountered dense smoke. They
climbed out of the mantrip, donned their SCSRs
and started toward the secondary escapeway.
Two of the men – Ellery “Elvis” Hatfield
and Don Bragg – became separated from the
crew. The two miners apparently became
disoriented in the dense smoke, moved toward
the fire and vanished. The remainder made it into
the secondary escapeway and came out of the
mine physically unharmed.
The examination system, which is the
responsibility of the mine operators, failed to
detect the malfunction, failed to identify the
existence of combustible material present in
sufficient amounts to ignite, and failed to cause it
to be removed.
Rescue efforts were hampered by the
absence of water and the lack of an accurate
mine map. The bodies of Elvis Hatfield and Don
Bragg were found on January 21, 2006.
A response to the detectors that were in
alarm was not sufficient to cause intervention in
time to put out the fire before it got out of control.
Firefighting efforts were hampered by the
5
safety and health and inspecting the mines,
though inspections and enforcement actions did
not result in preventing this accident.
absence of water in the water line. Supervisorsʼ
efforts focused on putting out the fire and orders
to evacuate were given only after the passage of
time.
The responsibility for preventing conditions
that have the potential to develop into mine fires
rests with the coal mine operator under both
West Virginia and federal law. Conditions existed
which caused the fire to burn, creating dangerous
smoke and heat which resulted in the deaths of
two men and the endangerment of others. These
conditions should have been detected and steps
taken to remove the risks, but they were not. This
fire was preventable, but it was not prevented.
The primary escapeway had filled with
smoke because a stopping had been removed,
which compromised the integrity of the primary
escapeway. By riding the mantrip as far as
possible, the crew traveled toward the fire, which
was between them and the mine opening or
portal. They encountered smoke, but after some
difficulty, successfully donned their SCSRs.
During this time, the two men became separated
from the others and were lost. The remaining
crew made it into the secondary escapeway and
safety.
The mine rescue efforts were hampered
because the mine maps provided by the operator
were neither accurate nor up-to-date. The mine
rescue teams were also hampered because water
was not available to fight the fire.
This report does not address the
questions of whether violations of the
law occurred. Those are matters for the
West Virginia Office of Miners’ Health,
Safety and Training (WVOMHST), the
state agency charged with inspection
and enforcement of the WV Code,
Chapter 22 mining law, and the Mine
Safety & Health Administration (MSHA),
which is the federal agency charged
with the enforcement of the federal Mine
Safety & Health Act of 1977. (30 CFR
800, et seq.)
The West Virginia Office of Minersʼ Health
Safety & Training is charged with inspecting coal
mines in West Virginia and enforcing the legal
requirements including provisions which are
involved in this matter. Those inspections did not
result in the prevention of the mine fire.
The federal Mine Safety & Health
Administration is charged with enforcing the
6
2
Introduction
In the late afternoon of Thursday, January
19, 2006 – just 17 days after 12 men died in the
Sago Mine – fire broke out near the longwall
conveyor belt drive of Massey Energy’s Aracoma
Alma Mine #1, located off West Virginia Route
17 along Bandmill Hollow near Melville and
Stollings in southern West Virginia.
Twenty-nine miners were inside the
mine when the fire started. Nine members
of the longwall crew were able to evacuate
without incident. A crew of 12 miners from the
#2 section, the development section furthest in
the mine from the belt drive and inby the fire,
encountered heavy smoke as they attempted
to escape. Putting on their self-contained selfrescuers (SCSRs) — emergency oxygen packs
— and grabbing hold of each other, 10 of the
miners successfully made their way through the
smoke and around the fire.
Alma Mine #1 (which takes its name from
a coal seam) is a large underground drift mine
composed of a maze of passages spread over
about six square miles. The primary entry is a
deep, narrow hole called a box cut. The mine
is operated by the Aracoma Coal Company, a
subsidiary of Richmond, Virginia-based Massey
Energy Company. The company uses continuous
mining machines for development and a longwall
mining machine for production. In 2004, the
mine produced 2.2 million tons of coal and
employed 190 workers, according to MSHA
records. At the time of the fatal fire, the company
was producing coal from one longwall section
and one construction section (the #2 section).
The roof-bolting team of Ellery “Elvis”
Hatfield, 46, and Don Israel Bragg, 33, somehow
became separated from the rest. Tragically, in an
echo of Sago, efforts to locate and rescue Hatfield
and Bragg were not successful, and they died
of carbon monoxide asphyxiation. Their bodies
were found and recovered on Saturday, January
21.
The story of what occurred at Alma Mine
#1 can be reconstructed in great detail from the
7
memories of those who were present that day.
Evidence points to a number of factors that
contributed to the cause and severity of the
fire, including misalignment of the longwall
conveyor belt, removal of ventilation controls,
high accumulations of combustible materials and
the failure of the warning and water systems.
An investigation of Alma also must examine the
recent history of the mine, unsuccessful early
efforts to extinguish the fire, how decisions were
made once it was obvious the blaze could not
be contained, and, most significantly, whether
appropriate action was taken to immediately
evacuate the mine before the fire raged out of
control.
Then he was asked where he had worked
before Alma.
“Sago,” he said softly.2
Sago. The entire country was swept up
in the tragedy that had occurred at the Sago
Mine less than three weeks earlier. Indeed, had
12 miners not died during and following the
explosion at Sago, scant attention might have
been paid to the fire at Alma Mine #1. Generally
speaking, if fewer than five miners die in what
the industry refers to as an incident, coal mine
fatalities are not considered disasters — and
seldom generate public concern. In fact, five
lives must be lost for an accident to be identified
as a disaster.
As federal and state investigators began
conducting interviews to try to learn how
Ellery Hatfield and Don Bragg lost their lives,
they requested, and, for the most part (with the
exception of high-ranking company officials),
received voluntary testimony from men and
women who had knowledge of the mine, the fire
and the events leading up to it.
But coming on the heels of Sago, while
the nation’s attention was still focused on coal
mining and the images of those who had lost
loved ones, Alma became closely linked with
Sago in the public consciousness.
The two situations are, of course,
different. Both were tragedies and both might
have been avoided had adequate safety measures
Shuttle car operator Gary Baisden,
however, was a reluctant witness. Baisden, a
been in place. But the Sago explosion may have
been triggered by a force of nature — lightning
— while evidence suggests the Alma fire erupted
at the lethal intersection of human error and
negligent mining practices.
member of the #2 section crew who had found
work at another mine after the disaster, testified
only after he was issued a subpoena.
The interview appeared to be very
difficult for him. As the interviewers were
wrapping up, one of them asked Baisden why he
had left Alma to work at a surface mine.
There were other differences. The
management of International Coal Group, which
owned Sago, voluntarily participated in the
public inquiry into the disaster. Management
of Aracoma Coal Company and its parent
corporation, Massey Energy, declined repeatedly
“The sky won’t fall on me,” he replied.1
8
to cooperate with federal and state
investigators. Company officials
above the foreman level refused
to testify. Through counsel, they
submitted letters stating that if they
were subpoenaed, they would exercise
their Constitutional right against selfincrimination. No subpoenas were
sought for those officials.
Federal Mine Safety and
Health Administration (MSHA)
officials ultimately were forced to
obtain a court order in the United
States District Court to acquire documents
needed for their investigation.
The road into the Aracoma Alma Mine #1
The evidence presented in the aftermath
of Alma graphically demonstrates problems with
the mine operator’s safety program, problems
with the regulatory system and the need to take
a closer look at how coal mine safety laws are
enforced. A report about what went so terribly
wrong at Alma #1 offers an opportunity to
examine the inevitable price that is paid when
ineffective safety measures and lax enforcement
collide and put at risk the well-being of the men
and women who mine coal.
In accordance with standard procedures,
MSHA, as the federal enforcement agency,
initiates an investigation following any mine
fatality. If, during the course of that investigation,
information is uncovered which potentially could
be of a criminal nature, a second and entirely
separate criminal inquiry is initiated and the
matter may be referred to the appropriate United
States Attorney. Such a referral has been made
in this case. As a result of this action, years may
pass before all the facts surrounding the fire are
As miner Randall Crouse said to state
and federal investigators, “I hope what I told
you can be used for some good and that another
one of our brothers doesn’t have to perish so that
another law can be made. Let’s start it here.”3
made public and the case is laid to rest.
But it is appropriate to include Alma in
a public examination of mine safety at this time.
Understanding how and why this fire occurred
may provide an opportunity to contribute to
the public debate on mine safety and to initiate
changes that may save lives before the various
federal and state inquiries are completed.
SOURCES
1
0223 Gary Baisden TR. P. 127, L. 01-02
2
0223 Gary Baisden TR. P. 127, L. 11
0208 Randall Crouse TR. P. 89, L. 24-25;
TR. P. 90, L. 1-4.
3
9
3
The fire at the
Alma Mine #1
“The smoke – the smoke basically
overwhelmed me. I panicked, you know. It’s a
bad situation. You could hear stuff falling and
cracking and popping. It sounded like thunder
coming through there.”1
longwall belt mother drive (the end of the
longwall belt that takes coal out of the mine),
Hensley, who was driving the mantrip, jumped
off and opened the airlock doors. The crew
drove under the longwall belt, and dayshift belt
– Miner Jonah “Joe” Rose examiner Carl White opened the second set of
airlock doors so the mantrip could pass into the
Northeast Mains and continue on its way deep
It was about 2:30 in the afternoon of January
into the mine to the section.2
19, 2006, when the 12 members of the #2 section
White later said he had been concerned about
evening crew entered Aracoma Coal Company’s
the longwall conveyor belt because it had shut
Alma Mine #1 on a 14-man rubber-tired diesel
down several times during his shift. He said he
mantrip.
had noticed a hazy mist around the mother drive
The crew, led by section foreman Michael
and the storage unit that houses extra belt, but he
Plumley, included roof bolt operators Elmer
couldn’t locate the cause, even though he checked
Mayhorn, Ellery “Elvis” Hatfield, Don Bragg,
the drive motors and bearing temperatures with
and Randall Crouse; continuous miner operators
a head temperature gun, a device that can be
Steve Hensley and Billy Mayhorn; electrician
pointed at a belt or roller to determine the internal
Michael Shull; shuttle car operators Joe Hunt,
temperature.3
Gary Baisden and Pat Kinser; and scoop operator
White said he had discussed the problem with
Duane Vanover.
mine foreman Dusty Dotson, who went to take
When the crew arrived at the No. 9 headgate
a look at the belt starter box. Whatever Dotson
10
did got the belt running again, White said, and it
continued to run for the remainder of his shift.4
CONVEYOR BELTS
Even so, White was so concerned that, before
he left for the day, he called Bryan Cabell, the
evening shift belt examiner, to tell him about the
conditions he had witnessed.5
Conveyor belts are used extensively
in mines to transport the coal from
underground to the surface. Thousands
of feet of belts are located in coal mines in
the United States. The belts themselves
are large, thick, heavy duty and made of
rubber-coated material. The belts travel
at high speeds and carry multiple tons of
coal each day, traveling over steel rollers
attached to a steel frame.
Meanwhile, the #2 section crew arrived
at their section, where they met up with their
counterparts from the dayshift and held a brief
meeting to discuss a proposed work schedule. As
the day shift crew exited the mine, Carl White
joined them on the mantrip. As he left, White
walked by the storage unit and “it was perfect …
there was no smoke, no haze, nothing. That’s how
clear it was at 3:30.”6 None of the day shift crew
members recall seeing smoke, haze or any hint
of the fire that was to come. They arrived on the
surface at approximately 4:00 p.m.
The Coal Mine Safety and Health Act of
1969 required that all conveyor belts meet
fire resistance requirements.
Given the speed and movement, it is not
uncommon for heating and/or sparks to
cause ignition along belts.
From 1983 to 1992 thirty-four conveyor
belt fires were reported. While that
number decreased to ten from 1993 to
2000, conveyor fires remain a serious
risk. That risk is compounded by the fact
that coal dust and coal fines accumulate
on and around the rollers, the steel frame
and the belt itself. Thus when a belt roller
becomes damaged or broken, heating can
occur in close proximity to the fuel source
– the coal dust accumulations. Such fires
are considered especially dangerous
because they can ignite the coal on the
walls of the mine itself.
By this time the evening shift longwall
crew also had arrived in the mine with foreman
David Runyon. Longwall headgate operator
Gary Richardson said the second shift started
producing coal at 4:25 p.m. and the belt ran until
about 5:05 p.m. Richardson said Cabell called
to say he had shut the belt down because of
smoke but would get it running again as soon as
possible.7
MSHA last inspected the Aracoma Mine
between October and December, 2005.
Twenty-five violations were cited, seven
concerning the mine’s ventilation plan
and three concerning accumulation of
combustible materials. (MSHA Records)
By all accounts, Cabell was the first to
become aware of a possible fire. “I looked back
towards the storage unit, and it looked more
dustier than usual,” he testified. “It didn’t look
like smoke, and I didn’t smell nothing.”8
11
He said he found a “carriage wrecked in the
mother drive storage unit”9 that was causing a
misalignment of the belt. Cabell explained that
the carriage sits on a rail. Because it was latched
on one side and not the other, it had turned
sideways. He could see the belt starting to rub a
bearing and when he tried to train the belt off the
bearing, the belt “would rock back and forth and
get right back over on the bearing again.”10
Cabell said he turned the belts off at that time
not because he saw signs of a fire, but because he
saw smoke. “It was not black in color or nothing
like that, but it was – I was just afraid I was going
to tear my belt up, and I didn’t want to spend all
night making splices, so I turned the belt off,” he
said.11
Conveyor belt company photo of a storage unit system
– there was a pretty good bit of smoke, black
smoke, coming up and going around going
– well, going into the [#2] section, actually.”16
(Since belt air was being used to ventilate the
mine, the smoke would have been expected
to go to the longwall section, but, because a
stopping had been removed, the air direction in
the longwall belt entry was reversed, causing the
smoke to travel toward the #2 section.)
Then Cabell said he saw the smoke getting
worse, “not a flame but some red, like cinders,
underneath one of the bearings,”12 and he called
second shift foreman Fred Horton to tell him
about the situation and to request a chain hoist to
try to address the alignment problem.13
“He said, ‘Pat, I need your fire
extinguisher,’”17 Callaway recalled Cabell saying
to him. “And I just flipped it loose and handed
it to him, and he said, ‘Fred said for you not to
leave until we get this put out.’”18
Cabell said Horton told him that foreman
Pat Callaway was coming that way, and that he
should ask Callaway for help.14 While Cabell
was on the phone with Horton, Callaway showed
up in a five-man diesel mantrip, accompanied
by contract miner Jonah “Joe” Rose. Rose’s
recollection is that the pair got there between
5:00 and 5:15 p.m., and both agreed that when
they arrived, the belt was smoking.15
Callaway’s vehicle was mired in mud and
he was afraid of getting stuck, so he told Rose
to stay with Cabell while he moved the mantrip.
After he got it out of the mud, he jumped off and
went to help them.19
The smoke, said Rose, was running along
the bottom of the belt, but it didn’t seem extreme
at that time.20 Cabell discharged Callaway’s fire
extinguisher on what Callaway said was “maybe
a two-foot flame.”21
Rose said, “Well, we came up to the four
doors where the belt was – well, where the belt
goes over at the mother drive, and Bryan Cabell
was there on the mine phone. And there was
12
just – I basically just throwed the fire hose down
and opened the valve, hoping I could direct it
towards the fire, but there was no water in it.”26
As soon as Cabell “stopped extinguishing
it, as soon as he expelled his extinguisher and
stopped spraying, it lit right back up,” Callaway
said.22
Cabell shut the valve off and told Callaway
to try to find out where the water was shut off.
While Callaway went in the direction Cabell sent
him, Cabell said he checked the water line in the
area where he was.27
Callaway told Rose to go to any belt head,
any power center, any oil storage station and
grab every fire extinguisher he could find.23 “And
about the time I was telling him all this, I saw an
oil storage place up toward the mother drive, and
I said, ‘Right there’s one where that oil’s at, go
ahead and get it and get it to Bryan.’”24
Callaway said he went through a man door
to 7 head gate, where he located a four-inch
waterline with fire taps on it.28 “The [water] valve
Rose said he grabbed the fire extinguisher
and followed Cabell down to the mother drive.
“And on the one side of the mother drive, the
flame coming up under the roller was probably
three feet on the one side and touching the top on
the other, on the off side,” Rose said.25
was cocked, you know, it wasn’t completely off
or it wasn’t completely on, it was like it was
– looked halfway open. And I just tried to jerk it,
and it wouldn’t move, so I immediately pulled
my hammer out and knocked it to where I knew it
was completely on.”29
Cabell said he tried to hook up a fire hose that
was lying beside a water line by the storage unit.
“I could not get it to hook up onto the fire tap,”
he said. “And when I couldn’t get it to hook up, I
Callaway ran back through the double doors
and yelled at Cabell. “I asked him . . . did that
help your water, have you got plenty of water
down there?”30
Callaway said Cabell responded that “it
smoked us out before I could get … everything
hooked up.”31
Water System
The water system at the Aracoma Alma Mine #1
is supplied from a holding tank above the box cut
portals and runs through a 12-inch steel line to the
portal. An 8-inch supply line extends underground
and follows the 72-inch conveyor belt for 4800 feet,
then branches off into a 4-inch line that extends
to the 48-inch conveyor belts. Two pumps are
required to boost water pressure to the required
flow because of extreme elevations in the mine.
Water for the fire hose outlets along the mother
drive belt conveyor is supplied by a 2-inch water
line that branches off from an 8-inch supply line.
The supply lines to each working section have one
and a half-inch standard thread fire hose outlets,
which are called the “Fire Tap.”
Cabell said he called the dispatcher and told
him to shut the section belts off and “tell the
[section] boss he had smoke coming up his intake
and to evacuate.”32 Cabell said he made that call
as soon as he saw smoke, before he actually saw
flames.33
While Callaway and Cabell were trying to
locate a working source of water, Rose ran to
the power center and retrieved two more fire
extinguishers. “We had to run like four or five
13
Callaway said he told Cabell, “Well, we need
to fight this from the bottom. We need to go
down lower because smoke’s coming up the belt
entry.”47
breaks down through the overcast man door and
then two breaks down to the power center,” he
said.34 “By the time I got back to the mother drive
where the fire was, basically the electricity from
the lights and all that was off and I would say
there was probably 15 foot of belt . . . on fire.”35
Before they could move in that direction,
Horton arrived with electrician Billy Ray Hall,
according to Callaway. “And he [Horton] told
me to stay there. He said, ‘I want you to stay
here,’ he said, ‘I’ll go down and do that. I want
you to keep a head count. As these guys come off
the section, you keep a head count. And once you
write their name down on your tablet, don’t let
them leave you.’”48
Rose said altogether he discharged three fire
extinguishers,36 and Cabell said he sprayed two or
three on the blaze.37
At that point the fire was clearly out of
control, and Rose, Callaway and Cabell had no
way to put it out. The fire extinguishers weren’t
effective, and the men hadn’t been able to find a
water line in working condition.
“You know, time goes by fast in a situation
like that,” Callaway said. “But it didn’t seem
like we fought the fire maybe 15 minutes until it
smoked Bryan and Joe out.”49
Rose said he panicked and grabbed the mine
phone. “I yelled on the mine phone that we
needed help up here, that we couldn’t get the
fire out.38 I believe the foreman, dispatcher and
everybody heard me that we couldn’t get the fire
out,” he said.39 “And I believe it was Mr. Horton
– it was Mr. Horton that come back across and
said, ‘We know, we’re on our way.’”40
Once they had to retreat from the smoke,
Callaway said he stationed Rose at the most
outby door of the airlock doors on the roadway
up to the #2 section to watch for evacuating
miners.50 Rose said the doors were closed to keep
the smoke confined to the belt entry, but there
was a hole over the doors.51
“The visibility was bad. It was bad in that
area,” Rose said.41 The belt was burning so
rapidly and the smoke becoming so heavy, “it
“And I told Joe to watch through that hole,”
Callaway said, “and I said, ‘If you see lights over
there or you hear voices over there, you tell those
guys the good air is over here, that they could
crawl under that smoke.’ I had crawled under it,
you know, trying to figure a way to get to fight
the fire.”52
was getting completely out of hand.”42 Even the
coal rib itself was on fire, Rose said.43
Rose said he believes officials were calling
for an evacuation because he could hear
them yelling.44 He asked Callaway about the
#2 section, and Callaway told him they had
been notified that there was a fire.45 Assistant
Superintendent and longwall manager Rod
Morrison later said Horton told him Cabell had
notified the #2 section and the longwall section
about the fire.46 Horton himself did not testify.
Horton repeated the instructions. As Rose
recalled, “Mr. Horton and Billy said to look for
men coming down through that entry, to yell for
them or help them or try to get in there and help
them.”53
14
Callaway said he told Rose if the smoke got
too thick for him, it would be too thick for the
men on the other side of the doors, so to come on
out of there.54
was stationed, according to Rose.
“They told us they had two guys missing,”
Callaway said. “They said as soon as they came
through the man door on the four-foot belt,
they realized they weren’t with them. And they
jumped back through and yelled their names and
nobody replied and they came on out. So we, in
turn, started doing what we could do, you know,
with what we had to find them and get the fire put
out.”58
“He had his rescuer on,” Callaway said of
Rose. “If he had looked, he could have saw me
from where he was at, you know, but he said he
panicked and he hollered and told me the smoke
was getting too thick for him, and I said, well,
come on out, you know. If it’s too thick for you
over here, it’s definitely too thick for them over
there.”55
Callaway said Fred Horton returned from his
attempt to get below the fire, saying he couldn’t
get to it, the smoke was rolling back. “He said
he got close enough to see it, but he couldn’t get
close enough to fight it,” Callaway recalled.59
Rose said he put on his SCSR because he
became engulfed by smoke while standing by the
door. “At the beginning, I mean, you could take
your shirt and pull it up and put it over your face,
you know,” he said. “And then it just basically
all come in at once, it was like somebody had lit
eight or nine tires in an enclosed area all at once.
I was just engulfed. The fire was close – probably
right on the other side of the doors, because you
could hear it cracking and popping. I don’t know
whether it was the structure falling or the top
falling. But it got bad, real bad.”56
By that time mine foreman Dusty Dotson,
section superintendent Terry Shadd and longwall
chief electrician Bob Massey had arrived at the
fire.
“The officials outside had started coming
in, and I said, well, if we can’t get to it to fight
it, we need to get below it and try to find some
block and build stoppings or block the air off, and
maybe it’ll smother itself out,” Callaway said.
“And we couldn’t find block and we ran down
“I couldn’t withstand it anymore. The
smoke – the smoke basically overwhelmed me.
I panicked, you know. It’s a bad situation. You
could hear stuff falling and cracking and popping.
It sounded like thunder coming through there.
The vibration and that of it. Not being able to see
your hand in front of your face. I mean, it was
bad.”57
on the longwall and we got some rolls of curtain
[material used to create a temporary ventilation
control] and come up and hung curtain in every
entry to smother the air down to it.”60
After that, Horton told Callaway to take
section foreman Michael Plumley and what was
left of his crew and get them outside. “At that
point we already had rescue teams on the way
and, you know, we knew that it was beyond their
control,” Callaway said.61
About the time he told Rose to leave the
doors, Callaway saw the #2 section crew
emerging from the smoke. They had exited from
a man door five or six breaks from where Rose
15
Callaway said he had picked up extra SCSRs
and some fire extinguishers from the longwall. “I
laid the extinguishers and the rescuers with the
curtain and yelled up and told them where they
were at in the event they needed them. And then
we went to the rides, and I took a head count as
everybody got on the ride.”62
0210 Cabell TR. P. 33, L. 05-10
0210 Cabell TR. P. 34, L. 13-15
13
0210 Cabell TR. P. 35-36
14
0210 Cabell TR. P. 42
15
0224 Jonah Rose TR. P. 32-33
16
0224 Jonah Rose TR. P. 31, L. 18-25; TR. P. 32, L. 01
17
0216 Callaway TR. P. 47, L. 16-17
18
0216 Callaway TR. P. 47, L. 17-21
19
0216 Callaway TR. P. 47-48
20
0224 Jonah Rose TR. P. 34
21
0216 Callaway TR. P. 99, L. 23
22
0216 Callaway TR. P. 100, L. 01-04
23
0216 Callaway TR. P. 48
24
0216 Callaway TR. P. 48, L. 14-19
25
0224 Jonah Rose TR. P. 34, L. 13-19
26
0210 Cabell Tr. P. 44, L. 14-19
27
0210 Cabell Tr. P. 44
28
0216 Callaway TR. P. 48-49
29
0216 Callaway TR. P. 49, L. 04-12
30
0216 Callaway TR. P. 49; TR. P. 50, L. 06-09
31
0216 Callaway TR. P. 50, L. 09-11
32
0210 Cabell TR. P. 48, L. 10-12
33
0210 Cabell TR. P. 34
34
0224 Jonah Rose TR. P. 116, L. 16-19
35
0224 Jonah Rose TR. P. 45, L. 11-16
36
0224 Jonah Rose TR. P. 40, L. 25
37
0210 Cabell TR. P. 43, L. 25
38
0224 Jonah Rose Tr. P. 56, L. 13-15
39
0224 Jonah Rose TR. P. 45, L. 17-20
40
0224 Jonah Rose TR. P. 45, L. 16-19
41
0224 Jonah Rose TR. P. 47, L. 06-07
42
0224 Jonah Rose TR. P. 47, L. 09-10
43
0224 Jonah Rose TR. P. 49, L. 22-24
44
0224 Jonah Rose TR. P. 47, L. 14-16
45
0224 Jonah Rose TR. P. 47, L. 23-25
46
0314 Rodney Morrison TR. P. 32, L. 15-17
47
0216 Callaway TR. P. 50, L. 12-15
48
0216 Callaway TR. P. 50, L. 21-25; TR. P. 51, L. 01-04
49
0216 Callaway TR. P. 54, L. 24-25; TR. P. 55, L. 01-03
50
0216 Callaway TR. P. 55, L. 11-19
51
52
0216 Callaway TR. P. 55, L. 11-19
53
0224 Jonah Rose TR. P. 71, L. 05-09
54
55
0216 Callaway TR. P. 56, L. 02-12
56
0224 Jonah Rose TR. P. 75, L. 18-25; P. 76, L-01-06
57
0224 Jonah Rose TR. P. 185, L. 14-24
58
0216 Callaway TR. P. 51, L. 06-16
59
0216 Callaway TR. P. 51, L. 19-21
60
0216 Callaway TR. P. 51, L. 25; P. 52, L. 1-11
61
0216 Callaway TR. P. 52, L. 17-20
62
0216 Callaway TR. P. 53, L. 06-12
63
0216 Callaway TR. P. 53, L. 14-23
64
0216 Callaway TR. P. 54. L. 08-17
65
0216 Callaway TR. P. 54. L. 18-23
11
12
Callaway said Massey told him the fire had
already burned the water lines in two going to
the #2 section and instructed him to stop and deenergize the pumps going to the #2 section but
to leave the water on to the longwall. “That way,
if they needed water to fight the fire, they could
get water off the longwall because it was on two
separate circuits,” he said.63
So Callaway took a head count and stopped
to de-energize the pump. He discovered that
electrician Billy Ray Hall had already done it,
but he got off and made sure the pump wasn’t
running.64
When he got outside, Callaway took another
head count and was told to stay around. He said
it seemed like just a few minutes when rescue
teams started arriving.65
SOURCES
0224 Jonah Rose TR. P. 185, L. 15-21
0208 Pat Kinser Testimony
3
0306 Carl White TR. P. 44, 45, 60, 61, 334
4
0306 Carl White TR. P. 179, 180-181, 253-254
5
0306 Carl White TR. P. 42-43
6
0306 Carl White TR. P. 47, L. 21-24; TR. P. 48, L. 16
7
0223 Gary Richardson, TR. P. 24, L. 21-25; TR. P. 25,
L. 01-07
8
0210 Cabell TR. P. 30, L. 21-25
9
0210 Cabell TR. P. 31, L. 06-08
10
0210 Cabell TR. P. 32, L. 23-25
1
2
16
4
Escape from
the #2 Section
“He was just gone.”1
While the dust cleared, the two crews had an
impromptu meeting. Roof bolter Randall Crouse
said the two crews normally have what they call a
“hot seat change” – one crew remaining until the
other crew arrives so that there are always miners
on the section.4
– Electrician Mike Shull, speaking of Don Bragg
Continuous miner operator Steve Hensley
remembers the evening shift of January 19, 2006,
starting just like any other for the #2 section
crew.
“We stood and talked, you know,” shuttle car
operator Pat Kinser recalled. “We was talking
about schedule changes. We waited – sat there
until – the dust cleared up, you know, with the
other crew and then I proceeded on to my shuttle
car.”5
The men went to the box cut together and
boarded their diesel manbus “… like always, and
started in the rim, drove all the way up to Number
One full right,” Hensley said.2 As Hensley drove
up under the overcast and down toward the
mother drive, he got off the mantrip, opened the
first set of airlock doors and went through them
and under the longwall belt.
Kinser and Joe Hunt, another shuttle car
operator (or buggyman), greased their cars and
got them ready for the day’s work, then drove
to the face where Hensley would be cutting coal
with the continuous miner.
Beltman Carl White was standing at the
second set of airlock doors at the mother drive.
White opened them and the crew went through
and traveled on to the section, where they met up
with their counterparts from the day shift who
had just finished rock dusting, Hensley said.3
Hunt and Hensley went to the number one
entry face and finished a cut the day shift had
started.
Electrician troubleshooter Mike Shull,
17
making adjustments on the dust suppression
system on the belt head, was going back and
forth for parts. He had stopped to talk with
section foreman Michael Plumley when the
belts stopped running. (West Virginia Office of
Miners’ Health, Safety and Training investigators’
records indicate the belt stoppage occurred at
approximately 5:39 p.m.)
“I think that they had shut the belts off to get
a hold of us,” Shull said afterwards. “And it’s
usually routine for the belts to go off because we
load so much rock. So he [Plumley] – he kind of
looked at me and he said, well, he says, let’s go
find out what’s wrong with the belts.”6
fire on the belts.”10 Vanover said he relayed the
information to Kinser and Hunt.
Hensley had backed his miner around the
corner and was preparing to cut the face of the
number two entry when Hunt told him they had
to leave “because there was a fire at the mother
drive. You know they didn’t say how bad or – just
fire at the mother drive,” Hensley said.11
Crouse said he and his partner, Elmer “Blue”
Mayhorn, were bolting the number one entry on
the extreme left side of the section when Kinser
came and told them to get their gear. “He just
said we had a belt fire. So we gathered our stuff
and went to the mantrip.”12
Scoop man Duane Vanover, who had gone to
get hydraulic oil for the continuous miner, said he
started to get back on his scoop when he saw the
red light flashing on the mine phone. (Some mine
phones have two indicators – a bell and a flashing
red light. The multiple indicators are necessary
because of the noise generated by mining
equipment). The light is simply a visual signal
used to get miners’ attention when equipment is
running.7
“Joe Hunt went to the right roof bolters,
which was Bragg and Elvis, and told them,”
Vanover said. “While I was walking towards the
manbus, I still heard the right roof bolter bolting
the top. So I went over and told them that we
needed to get outside, we had a fire on the belts.
And then we all proceeded to the manbus.”13
As they prepared to board the mantrip,
Hensley said he asked Plumley if he wanted him
to get some rock dust “because I thought we was
going to maybe go fight a fire, try to re-ventilate
it, or whatever. And he said no, you know, so we
“It usually means somebody’s family’s
called, they need them home for whatever
reason, or they just need to talk to the boss for
something,” Vanover said.8 This time the call
was for the boss.
just go ahead and go.”14
When they got to the manbus, Shull said the
crew realized continuous miner operator Billy
Mayhorn and shuttle car operator Gary Baisden
weren’t with them.15 The two had taken a scoop
and gone to “crib up” bad roof, according to Billy
Mayhorn.16
Plumley picked up the phone, and Shull
overheard his end of the conversation. “I just
heard him say, ‘What, slow down for a minute
here. Where is the fire?’ He said, ‘I can’t drive
into a fire. Where’s the fire at?’”9
Plumley yelled at Vanover: “Get everybody
to the mantrip, we got to get outside. We have a
18
Mayhorn said as they loaded crib blocks
onto the scoop, he asked Baisden if he smelled
anything and Baisden said he didn’t. “I said, well,
A map of Aracoma Alma Mine #1
19
I swear I smell something,” Mayhorn said. “Then
the belts went off. We heard them come around
with the manbus.”17
through a door to the secondary escapeway.
Unfortunately, the crew ran into thick smoke
before they reached the door.
Shull said Hensley, who was driving the
manbus, stopped and picked up Mayhorn and
Baisden.18 Blue Mayhorn said the crew then
headed down Number Five entry, or intake. He
said Plumley told them that they would go down
to the cribs because there was a door there.19
In hindsight, Kinser said if the crew had
known the extent of the fire when they left the
section, “we could have got over on the 48-inch
belt [the secondary escapeway] before we even
hit the smoke. All of us could have been seeing.
And if we could have done that, we wouldn’t
have even had to don our rescuers.”
As the crew left the section, the air was clear.
Vanover said the men were almost light-hearted
as they exited. No one, he said, thought there was
a serious problem.20 Kinser said they assumed a
bearing on a belt roller had gotten hot and was
sparking or smoking.21
Billy Mayhorn said the smoke became visible
after the crew passed the Ten headgate section
turnout. “It was thin at that time, you know, you
could still see and we was still talking and wasn’t
having no problems with it,” he said.26
As the smoke rolled over them, it “just
choked you a little bit, just a cough,” Vanover
said. “We actually put our shirts over our
mouths.”27
“Everybody was really just joking, carrying
on,” Vanover said. “We thought we was going
to go down and put the fire out and just come on
back to work.”22
But when Hensley made a sharp turn from the
Crouse said Plumley told the crew they would
leave by the primary escapeway. “We was going Number Five entry into the Number Four entry,
to go as far as we could … if we couldn’t get out the crew hit heavy smoke “head on,” as Shull put
it.28
that way, we would go to our secondary, which
would be the [48”] beltline,” Crouse said.23
Kinser concurred: “We made a right-hand
turn on the manbus, and when we made the
Baisden said Plumley told the crew they
would try to go back out the intake like they had
come in. “And we couldn’t make it,” he said.24
right-hand turn, it was just like a cloud of smoke
covered you completely up.”29
Kinser said the crew drove about 15 or 20
breaks before encountering smoke. “And then a
light dusting of smoke started coming over us,”
he said.25
Vanover described the smoke as black and
thick. “It started out as a light gray and just got
darker, and when we made that turn, it was real
black. I’d say you was lucky if you could see a
foot in front of you,” he added. “Once you made
that turn, it was just like a blanket was thrown
overtop of you.”30
In all likelihood, Plumley chose or was told
to drive out of the mine rather than walk out
because it was quicker and easier to ride, and
the foreman knew where he could cross over
Shull said Hensley knew that “from right
20
there it was only going to be two breaks to a man
door that we was going to have to go through. So
he tried to get us as close to it as he could until
he couldn’t breathe anymore. And at that time, he
shut the mantrip off and hollered back and told
them, ‘I can’t go any further.’”31
“It was like hitting a black wall of smoke,”
Baisden said. “You couldn’t see your hand in
front of your face. And Steve couldn’t see to
drive the mantrip no more.”32
“We all got off the bus, and I think it was
Mike Plumley, I can’t say – it sounded like his
voice, said that we need to put our rescuers on,”
Vanover said.33 Blue Mayhorn added, “So we was
all hollering, everybody stick together and stuff,
which we did the best we could.”34
Crouse said Plumley had told them to head
for the man door below the cribs. That door
would take the crew to the 48-inch belt line.35
Kinser said, “He [Plumley] said we’ll go through
that door and go down the belt line to get out
because the belt line’s isolated.”36
The miners got off the bus and started
donning their SCSRs, Kinser said. “As far as I
know, you know, at that time, all 12 of us was
still there, putting our rescuers on,” he said.
37
With the smoke so thick and visibility
almost zero, crew members described a scene of
confusion and growing panic as they struggled to
don their SCSRs and make them work.
Kinser said he started putting his on as soon
as he got off the mantrip, and he didn’t have an
easy time with it. “As I was standing up, when I
popped the cap, the goggles fell out the bottom,
and I wasn’t going to spend time looking for
them,” he said.38 “And at that time it [the smoke]
was so heavy, we was getting ready to suffocate.
Me personally, I vomited two or three times
trying to put mine on. When I did get it on, it was
just like a thousand pounds had been lifted off my
shoulders because I had oxygen.”39
Hunt said he, too, lost his goggles. “When I
pulled the latch off the rescuer, them lids, they
went everywhere. I couldn’t find them.”40 Crouse
said he was “shaking so bad I couldn’t grab the
blow lead [a small cord hanging down from the
SCSR that must be pulled to initiate the flow of
oxygen].”41 He said he ended up having to jerk it
up with channel locks.42
Vanover said he didn’t have any trouble
getting his SCSR on. “I heard [Blue Mayhorn]
saying his wouldn’t work, and I think Mike Shull
told him to blow in it. And he did, and he said it
was working.”43
Hensley said Blue Mayhorn was to his
left, Billy Mayhorn was in front of him and
Elvis Hatfield was to his right. “We donned our
rescuers. I thought Mr. Hatfield got his on. I don’t
– I still to this day don’t know if he got his on,
because I never heard nothing else out of him.”44
Billy Mayhorn said he had problems getting
his rescuer on because he panicked. “They have
it stuffed in a pouch and you had problems trying
to get it out of there,” he said. 45 “I had problems
trying to find that tag where you jerk it. I had a
little bit of problems trying to get a hold of that
and jerk it to pop the tags off of it. Then I lost my
goggles, couldn’t find them.”46
He said Hatfield also had problems with his
SCSR, and he doesn’t know if he ever got it on.
“I assumed that he did because of what he had
said, and I was against him. Me and him was
21
dead against each other and he went from, you
know, cussing there a little bit to he shut up, and
I knowed he was still with me so that’s why I
assumed that he had it on.”47
As he eased his way down the rib, Shull
almost tripped over one of the crew members
who was looking for the goggles he had dropped.
Blue Mayhorn had dropped his goggles and
was feeling around for them “when somebody
grabbed me and said, let’s go.”53 Mayhorn
thought it was Plumley, but Shull said, “I finally
grabbed him [Mayhorn] and threw him in line.
And as I started feeling my way down the rib,
somebody grabbed onto my back. I guess that
was what Plumley was doing, putting them in
line, and they were grabbing onto each other.”54
By the time they began putting their SCSRs
on, Billy Mayhorn could no longer see Elvis
Hatfield, but he thinks he was still with the crew
between the mantrip and the door.
Kinser recalls hearing Hatfield hollering that
they had to get the rescuers on. “But other than
that, I don’t know if he got it on. I don’t know
what happened.”48
Hunt said he couldn’t see anything. “I heard
people coughing and stuff,” he said. “I couldn’t
see them. I started walking out. When I was
walking, I thought I was by myself. I lost my
goggles and my eyes was watered up. And I just
reached up and grabbed Shull’s jacket and just
followed him out.”55
Shull said as he got off the mantrip, he put
his hand on Bragg’s back because Bragg was in
the awkward middle position of the ride. Shull
helped him out and told Bragg to put on his
rescuer, but doesn’t recall getting a response. He
never saw Bragg after that. “I mean,” he said, “he
was just gone.”49
Crouse said he had hold of Mike Plumley
from the back, and “tried to keep my hand in his
back and my hand on the rib. That way I know I
was going the right direction.”56
Shull said he made it from where he got off
to the front of the mantrip – a distance of perhaps
ten feet – before he donned his rescuer and went
to the upper rib [or the right hand side rib facing
outby, toward the beltline they were trying to
reach] to try to feel his way out of the thick black
Kinser estimated he could only see two
inches. “I had my hand on the rib. I shined my
light on my hand and I could barely see my
hand,” he said.57
smoke.50
“And as I was feeling my way out, I could
hear Plumley tell – it was a muffle, but you could
hear where he had the SCSR on – he was telling
people to get in line, get in front of each other,”
Shull said.51
Kinser said when he finally got his rescuer
on he found the rib and started making his way
down toward the door, adding that he was in the
lead, probably because he was the first to get his
rescuer on.52
Shull found himself face-to-face with Gary
Baisden, a young miner who was new to the
section.
“And I just grabbed him by the back and
spun him around and pushed him toward the man
door because there were a few that were with us
that hadn’t been up on our section a whole lot,
and that would have been Gary Baisden, Duane
Vanover, Pat Kinser…They wouldn’t have known
22
where that man door was unless somebody was
trying to show them where it was at.”58
Gary Baisden said Plumley, Hensley and
Mayhorn “hollered at Don and Elvis, looked
for both of them. I believe Mike may have even
walked up here one break [inby] looking for them
and couldn’t find them. And it got so bad that
they couldn’t do nothing with it. So they turned
around and went one break this way [outby] and
still couldn’t do nothing with it. They come back
to the man door and come back down this belt
line, hollering for them and looking for them and
never did find them.”65
Shull said he knew about the door because he
and a couple of other guys put it in some three
weeks prior so the bosses would have easy access
to seals instead of having to go five or six breaks
down and back to check them. He said the crew
stopped there daily for Plumley to check the
seals.59
Vanover said he started scooting down the
rib line. “And somebody brushed by me, and I
grabbed a hold of him when they went by, and I
think it was Steve Hensley. And then you heard
somebody holler that they found the door. I’m not
sure who it was. But we started going towards the
voice.”60
Billy Mayhorn said the smoke was so thick
they had “no visual.” He said he would “take [the
SCSR] out of my mouth, hollering, put it back in
my mouth, at the same time we listen. Plumley
and Steve, they cut back toward the manbus
doing the same thing.”66
It was only when the crew got into the fresh
air, where they could see as well as breathe, that
they realized two men were missing.
Mayhorn estimates they spent two or three
minutes calling out for Bragg and Hatfield.67
“You could hear them hollering at the top of
their lungs, hollering for them,” Shull recalled.
“And they came back in and said they couldn’t
find them, it was too thick, the smoke was too
thick and nobody would answer.”68
Vanover recalled that Plumley asked if
everyone was with them. “And everybody looked
around, and everybody seemed like at the same
time, they said Bragg and Elvis,” he said.61
Crouse described the scene as “total panic.”62
Kinser said the other crew members stood
on the other side of the door, calling out for
Hatfield and Bragg, “trying to figure out any
Billy Mayhorn said Elvis Hatfield was his first
concern because “… me and him is best friends.
I mean, we’ve been together 12 and a half years,
so that was the first person I looked for. I turned
around, and I said, ‘Where’s Elvis?’”63
way we could to let them know where we was so
they could get to safety. And we just didn’t have
– didn’t have the equipment to go back – go back
in and look for them.”69
Blue Mayhorn said Plumley, Hensley and
Billy Mayhorn traveled back through the door
to search for the missing men. They “hollered
and hollered, and I don’t know how long. It just
seemed like time stood still right there to me, you
know.”64
Hensley said he borrowed Plumley’s carbon
monoxide detector, or spotter, and “stuck it up
in the smoke and hit like 650 parts per million
carbon monoxide” — a lethal level. They
decided they couldn’t go through it, so they went
23
Blue Mayhorn said Plumley and Hensley
went back to take yet another look for Bragg and
Hatfield.77
back and rejoined the rest of the crew.70
No one could say for sure what happened
to Hatfield and Bragg. They simply vanished
into the black smoke and were never heard
from again. Kinser guessed that one may have
followed the other. “I don’t know. I do know
that they was partners on the section and they
did work together every day side by side. I don’t
know if they thought they had another plan that
they could get out and one went with the other. I
don’t know. I just know that they wasn’t with us
when we got to the other side, in the fresh air.”71
“Steve looked at Pat Callaway and he said,
let me see your rescuer. He said, ‘I’ve got to
have one, I’m going back.’ And Pat gave him his
rescuer and Steve went back into the smoke,”
Shull said.78 But when Plumley and Hensley
returned shortly afterwards, Hensley handed
Callaway his rescuer, saying they had not been
able to find the men.79
Then the crew members walked over to the
intake, probably about a break away, and Shull
said they looked down and saw two lights.80
After they got through the man door, the crew
traveled along the 48-inch belt, their secondary
escapeway. Crouse said they didn’t encounter
smoke,72 but Billy Mayhorn remembers light
smoke seeping through as they made their way
around the top of the fire and through another
man door on the other side.73
“And I mean, we thought, you know, this
is our two guys here, this is what we need right
here,” he said. “And Fred [Horton] was on a
diesel ride, a diesel five-man. Him and Billy
[Hall] took off down there to find out. But by the
time they started getting close, we started seeing
more lights come out, so we knew it was the
longwall [crew] coming out.”81
Shull said it was there they ran into beltman
Bryan Cabell, who directed them through
the door, and when they exited, foreman Pat
Callaway was waiting for them.74
Crouse said when the #2 section miners met
up with the longwall crew, “we knew that there
was spare rescuers on the longwall face. Some of
Callaway pulled out a notepad and pen and
wrote down the names of all the miners who were
accounted for “so nobody else would get lost in
the confusion,” Kinser said.75 Joe Rose, Foreman
Fred Horton and Electrician Billy Ray Hall were
with Callaway, and Raymond Grimmett showed
up on a grader a short time later.
us went to retrieve those in case we would have
to have them.”82
Other crew members got rows of curtain with
the thought that they might be able to smother
the fire or redirect the smoke away from the two
missing men, Hensley said.
“So there was actually six guys that we
met up with there at the top of the hill before
we met down with the longwall crew,” Kinser
said, adding that Horton told Callaway to keep
everyone together while he and the electrician
went over to the fire.76
“We went over there … through the crossover
and up to the mother drive belt and cut that belt
and dropped the structure down and hung a
curtain across trying to choke the air off in the
fire area,” Hensley said.83
24
Using rescuers from the longwall crew, the #2
section miners made one more futile attempt to
find Bragg and Hatfield.
0209 Duane Vanover TR. P. 48, L. 09-12
0208 Mike Shull Tr. P. 26, L. 18-21
29
0208 Pat Kinser TR. P. 25, L. 22-25; TR. P. 26, L. 01
30
0209 Duane Vanover TR. P. 44, L. 16-18, L. 06-09
31
0208 Mike Shull TR. P. 26, L. 25-25; TR. P. 27, L. 01-04
32
0223 Gary Baisden TR. P. 48, L. 19-23
33
34
0210 Mayhorn E. TR. P. 30, L. 24-25; TR. P. 31, L. 01-02
35
0208 Randall Crouse TR. P. 38, L. 13-21
36
0208 Pat Kinser TR. P. 37, L. 09-11
37
0208 Pat Kinser TR. P. 26, L. 06-08
38
0208 Pat Kinser TR. P. 43, L. 04-08
39
0208 Pat Kinser TR. P. 42, L. 10-17
40
0209 Joe Hunt TR. P. 83, L. 15-19
41
42
43
44
0208 Steve Hensley TR. P. 30, L. 15-19
45
0210 B. Mayhorn TR. P. 92, L. 21-23
46
0210 B. Mayhorn TR. P. 93, L. 01-06
47
0210 B. Mayhorn TR. P. 94, L. 11-19
48
0208 Pat Kinser TR. P. 44, L. 16-18
49
0208 Mike Shull TR. P. 76, L. 04-18
50
0208 Mike Shull TR. P. 27, L. 04-12
51
0208 Mike Shull TR. P. 27, L. 13-18
52
0208 Pat Kinser TR. P. 26
53
0210 Mayhorn E. TR. P. 72, L. 06-08
54
55
0209 Joe Hunt TR. P. 51, L. 14-25
56
0208 Randall Crouse TR. P. 83, L. 25; TR. P. 84, L. 01-03
57
0208 Pat Kinser TR. P. 42, L. 20-22
58
0208 Mike Shull TR. P. 28, L. 17-24; TR. P. 29 L. 01-04
59
0208 Mike Shull TR. P. 29
60
61
62
0208 Randall Crouse TR. P. 48, L. 08
63
0210 B. Mayhorn TR. P. 98, L. 16-20
64
0210 Mayhorn E. TR. P. 31, L. 13-16
65
0223 Gary Baisden TR. P. 57, L. 21-25; TR. P. 58, L. 01-08
66
0210 B. Mayhorn TR. P. 99, L. 15-25; TR. P. 100, L. 01
67
0210 B. Mayhorn TR. P. 100, L. 07-08
68
0208 Mike Shull TR. P. 31, L. 12-17
69
0208 Pat Kinser TR. P. 27, L. 17-22
70
0208 Steve Hensley TR. P. 31, L. 24-25; TR. P. 32, L. 01-05
71
0208 Pat Kinser TR. P. 44, L. 22-25; TR. P. 45, L. 01-10
72
73
0210 B. Mayhorn TR. P. 87, L. 09
74
0208 Mike Shull TR. P. 32, L. 20-24
75
0208 Pat Kinser TR. P. 69, L. 09-13
76
0208 Pat Kinser TR. P. 72, L. 19-23; TR. P. 73, L. 21-25;
TR. P. 74, L. 01-05
77
0210 Mayhorn E. TR. P. 31, L. 09-10
78
0208 Mike Shull TR. P. 32, L. 15-20
79
0208 Mike Shull TR. P. 32, L. 22-25
80
0208 Mike Shull TR. P. 34, L. 06-07
81
0208 Mike Shull TR. P. 34, L. 07-16
82
0208 Randall Crouse TR. P. 58, L. 25; TR. P. 59, L. 01-04
83
84
0208 Pat Kinser Tr. P. 76, L. 21-25; TR. P. 77, L. 01
85
0208 Pat Kinser TR. P. 84, L. 06-08
86
0208 Pat Kinser TR. P. 84, L. 09-15
87
27
28
Kinser said while this was going on, he sat
with one of his buddies who was having a hard
time catching his breath, and then he took the
man back over to the main intake and waited for
everyone else.84
“I pulled a Gatorade out of my bucket, got me
something to drink because my mouth was real
dry,” he recalled.85 Then Mine Superintendent
Peppy Lester told him to relay a message to Fred
Horton to get every man out of the mine except
for a few of the bosses.86
Hensley said Horton told the crew hanging
curtain that conditions were too bad, that they
needed to get outside.87 The crews loaded up on
two diesel mantrips and exited the mine. They
arrived at the surface at approximately 8:00 p.m.
SOURCES
0208 Mike Shull TR. P. 76, L. 17-18
3
0208 Steve Hensley TR. P. 27
4
0208 Steve Hensley TR. P. 28, 29
5
0208 Pat Kinser Tr. P. 23, L. 18-25; TR. P. 24, L. 01-02
6
7
8
9
0208 Mike Shull TR. P. 25, L. 13-17
10
11
12
13
0209 Duane Vanover TR. P. 30, L. 24-25; TR. P. 31, L. 01-07
14
0208 Steve Hensley TR. P. 28, L. 24-25; TR. P. 29, L. 01-03
15
0208 Mike Shull TR. P. 25, L. 25; TR. P. 26, L. 01-02
16
0210 B. Mayhorn Tr. P. 30, L. 18
17
0210 B. Mayhorn TR. P. 48, L. 18-21
18
0208 Mike Shull TR. P. 26, L. 05-06
19
0210 Mayhorn E. TR. P. 29, L. 18-19
20
21
0208 Pat Kinser TR. P. 36, L. 09-12
22
23
24
0223 Gary Baisden Tr. P. 38, L. 19-20
25
0208 Pat Kinser Tr. P. 25, L. 14-18
26
0210 B. Mayhorn TR. P. 87, L. 19-22
1
2
25
5
On the
Surface
to the dispatcher’s office. As a dispatcher, his
duties included handing out cap lamps to miners
heading underground, distributing supplies,
monitoring the operation of the belts, monitoring
– Dispatcher Mike Brown
the CO system and directing mine traffic.2
“And when they came up to me and asked me
… if I had prayed for the men, and I told them
yes. And we all stopped and we prayed.”1
Up in his office in the box cut, dispatcher
Mike Brown wasn’t particularly concerned when
a sensor that measures carbon monoxide in the
mine went off in the immediate vicinity of the
conveyor belt. Such systems are required when
mines use belt air for ventilation, as is the case
at Alma Mine #1, and both visual and audible
alarms are triggered when carbon monoxide
concentrations in the atmosphere reach five parts
per million.
Brown had just started working at Alma
on August 28, 2005. It was his first mining
job, and he was assigned to work with the
beltman. Less than three months later, during
the week of Thanksgiving, he was moved up
Although neither West Virginia nor the
federal government has specific experience or
training requirements for dispatchers, in many
mines the position is assigned to experienced
miners who have a good working knowledge of
the mine and know what to do in the event of an
emergency.
By his own admission, Mike Brown did not
fit that description. A contract miner with less
than a year of total mining experience – a red
cap,3 in mining parlance – Brown’s only training
had been provided by the day shift dispatcher,4
who had told him what to do if the CO alarm
sounded, but not how to handle a full-blown
emergency. He didn’t think he had the authority
26
alarms, Horton picked up a mine phone at the #3
section.11
to order the mine evacuated, and he certainly
lacked the experience and knowledge to take it
upon himself to do so.5
Brown listened in as Cabell told Horton
that the entryway was filled with smoke and he
“couldnʼt get to where the smoke was.”12
“I was told that when an alarm would go off,
I was to acknowledge the alarm [by hitting a reset
key on a computer] and then contact someone in
the vicinity of that alarm, of that CO monitor,”
Brown testified.6 That description of his training,
such as it was, suggested that when an alarm
was triggered, his first reaction should be to
assume that whatever was wrong could be fixed
by re-setting the alarm and then having someone
working near the monitor check it out to make
sure that it was only malfunctioning rather than
indicating a real problem. So when the system
began alarming, he did as he had been trained.7
“And Fred asked him what was wrong, and
he said that one of the … dollies were cocked
sideways,” Brown said.13 “I don’t know what all
that stuff is. But, anyways, he told him that, and
he said he would need a chain hoist. And he said
he couldn’t, at that time, see where the smoke
was coming from but he was … he’d get back to
Fred, he’d find out.”14
Diesel mechanic/electrician Tim Dingess
was putting traction chains on a tractor in the
shop adjacent to the dispatcherʼs office when he
overheard Cabell say on the mine phone that he
had smoke at the mother drive “and then it was
like the next thing I knew, it was chaos.”15
When he had time during his shift, Brown
would rewrite his log sheet – to make it more
legible, he said. Thatʼs what he says he was doing
on January 19 when the alarm went off on sensor
82 at the longwall belt head at 5:36 p.m. Twentyone seconds later, the warning became an alarm.8
Dingess said although it had been reported
that the monitor went off at 5:36 p.m., he
believed it was shortly after 5:00 p.m.16 The
difference could have been accounted for by the
fact that clocks were showing different times,
according to Brownʼs testimony.17 (During the
investigation, State and Federal officials analyzed
the clocks and found that they were not correct.
State officials estimated the computer clock was
23 minutes fast. When time adjustments were
made, the first sensor at the storage unit was
found to have alarmed at 5:13 p.m., followed by
a second sensor at 5:16 p.m. The #2 section belts
were shut down at 5:39 p.m.)
“So I got up and I went over and I
acknowledged the alarm, and … I walked back
to the desk and sat down,” Brown said.9 At about
the same time beltman Bryan Cabell called,
frantically trying to locate foreman Fred Horton,
Brown recalled.10
Brown said Cabell told him he really needed
to talk with Horton. At some point during their
conversation, and about two minutes after the
first sensor, sensor 81 alarmed near the tailpiece
for the 72-inch belt. Brown said that as he
prepared to tell Cabell about the CO system
27
When Dingess heard Cabell tell Horton about
the dolly that was stuck, or cocked, he went into
the warehouse, retrieved a chain ratchet and gave
it to Raymond Grimmett to take to Horton.18
Dingess estimated it would take Grimmett, who
was driving a road grader, about 20 minutes
to get from the box cut to the mother drive.19
Grimmett testified he knew nothing about a fire
when he entered the mine with the ratchet.20
him he had overheard a conversation between
Brown and someone – he thought it was Bryan
Cabell – concerning a fire at the mother drive.25
Morrison said he grabbed a phone and asked
Brown who he had been talking with and if there
was, in fact, a fire at the mother drive. Brown told
him he had just spoken with Cabell and that “they
had been trying to extinguish a fire at the mother
drive area.”26
Morrison then called Horton, who told him
he was on his way to the mother drive area.27
Morrison believes it was at least 6:00 p.m. when
he went to the dispatcherʼs office,28 accompanied
A short time after his initial call, Cabell called
back. “He said, ‘There’s too much smoke. I can’t
get to it. I’ve wasted two fire extinguishers, and I
can’t get to it,’” Brown said Cabell told Horton.21
“And Fred said, ‘Well, what do you need, Bryan?
Just tell me what you need.’ He said, ‘I need more
fire extinguishers.’ And he said, ‘I see flames.’
And he [Horton] said, ‘Do what, Bryan?’”22
Mine Evacuations
Neither state nor federal regulations set out
precisely when a mine should be evacuated,
partially or in its entirety. However, the statutory
provision of the law [30CFR75.1501] states that
“for each shift that miners work underground,
there shall be in attendance a responsible
person designated by the mine operator to take
charge during mine emergencies involving a
fire, explosion or gas or water inundations. The
responsible person shall have current knowledge
of the assigned location and expected movements
of miners underground, the operation of the
mine ventilation system, the location of mine
escapeways, the mine communications system,
any mine monitoring system, if used, and the mine
emergency evacuation and firefighting program of
instruction.” That designated responsible person
“shall initiate and conduct an immediate mine
evacuation when there is a mine emergency
which presents an imminent danger to miners due
to fire or explosion or gas or water inundation.”
75.1501(b) infers that miners not needed to
fight the fire should be evacuated to the outside.
As it states in part that… “Only properly trained
and equipped persons essential to respond to
the mine emergency may remain underground.”
75.352(c)(2) states that miners must be withdrawn
promptly to a safe location identified in the mine
emergency evacuation and fire fighting program of
instruction, which is typically one sensor outby the
sensor in the alarm mode.
Brown said Cabell repeated that he saw
flames and Horton told him to “get to it.” Cabell
responded that he couldn’t get to it, and “that’s
when Fred told him he was headed his way,”
according to Brown. He said he never heard
Horton say anything about evacuating personnel,
just to “get to it.”23
Brown said he then knew the situation was
serious: “I hung up the phone because I knew it
was bad.” Brown’s written log shows: “fire at
storage unit at mother drive.”
Dingess said by this time CO alarms around
the mother drive were “all going off.”24
Assistant longwall superintendent Rod
Morrison had his dinner bucket in his hand and
was getting ready to get in his truck and go home
when longwall chief electrician Bob Massey told
28
down the belt in the #2 section, he assumed the
longwall belts were off. He said he did not have
the capability to shut those belts off.38 [According
to longwall headgate operator Gary Richardson,
the longwall crew made the decision to leave the
longwall section on their own after the power was
knocked off and communications failed.]
by Massey, day shift mine foreman Dusty
Dotson, section superintendent Terry Shadd and
assistant longwall coordinator Ed Ellis.29
“I never even put coveralls or anything of
that nature on,” Morrison said. “I just grabbed
my hat and my light and my belt …”30 He said
he again called Horton, who confirmed that there
was a fire and that Bryan Cabell had notified the
longwall and the #2 section crews.31
“… I assume they were because the
communications on those two CO monitors went
dead. I’m thinking that there – because they’ve
already said there’s a fire. So I assumed that the
fire destroyed the CO monitors and it surely
stopped the belt,” Brown said.39
Just before he entered the mine, Morrison
said he instructed Brown to contact Aracoma
superintendent Lawrence “Peppy” Lester, general
manager Gary Goff, the top on-site official at
Alma, and Aracoma Coal president Dwayne
Francisco, also director of underground mining
for Massey Coal Services.32 Brown recalled
also being asked to contact Eddie Lester, vice
president of operations for Aracoma Coal.33
Brown said Morrison told him to shut off the
belt to the #2 section and to let the crew know
smoke was coming their way and to evacuate.34
Morrison said Horton told him the evacuation
order had been given and that Bryan Cabell had
called the longwall and the #2 section.35
Dingess came into the dispatcher’s office,
and Brown asked him to man the phones while
he used the restroom. Dingess said he didn’t
consider that he had taken over for Brown. “Mike
was pretty shook up,” he said. “I was just there
to more like help him. I didn’t take control of the
situation, but I was just there for like protective
supports or something.”40
As he went upstairs to the restroom, Brown
met Peppy Lester.
When Brown shut off the belt, the #2 section
foreman Mike Plumley called to ask him what
was wrong. “And I told him I turned them off,
that smoke was headed in his direction,” Brown
said.36 “I started to tell him more, and Fred
Horton told him, ‘Mike, listen to the dispatcher
and evacuate off the section.’”37
“He asked me what was going on, and I
told him what I could,” Brown said.41 By the
time Brown got back to the box cut, Lester had
changed out of his street clothes and was on his
way into the mine.
MSHA inspector Vicki Mullins had left the
Logan field office and was at home when she
received a call at approximately 7:50 p.m. from
Sharon Cook, a training specialist in MSHA’s
Madison field office, telling Mullins there was
a mine fire at Aracoma Alma Mine #1 and that
Brown said he attempted to contact the
longwall section, but was not successful. He
later learned that the longwall crew had already
begun to leave the mine, and, by the time he shut
29
safety of any person in the coal or other mine,
and the operator of such mine shall obtain the
approval of such representative, in consultation
with appropriate State representatives, when
feasible, of any plan to recover any person in
such mine or to recover the coal or other mine or
return affected areas of such mine to normal.”
two men were missing. Cook learned of the fire
because her cousin, inspector Eugene White, had
been placed on standby by the WVOMHST.42
Astonishingly, the federal agency charged
with oversight of the nationʼs coal mines first
learned about a major mine fire only because of
the coincidence that an employee in an office a
county away happened to be related to a West
Virginia inspector.
Before she left for the mine, Mullins also
called Minness Justice, an electrical inspector
who was assigned to the Alma mine, and asked
him to bring her computer equipment with him
when he came to the mine.46 On her way, Mullins
said she continued to try to reach her superiors,
including district manager Jesse Cole and
assistant district manager Luther Marrs. It wasn’t
that her cell service was bad, Mullins said; she
simply couldn’t reach any of them by phone.47
Mullins, who lives near the Alma mine, said
she tried to call MSHAʼs Logan office, but her
call was routed to voicemail and she was unable
to reach either of her supervisors at home because
both had moved and had new phone numbers.43
“So I called Tim Justice, who was our
ventilation specialist and regular mine inspector
and told him what was going on,” Mullins said.44
She said Justice told her that since she was
closest to the mine, she should go there and issue
a 103(k) order.45
Mullins estimates she was at the mine by
8:15 or 8:20 p.m.48, the first federal safety
official to arrive on site. She met Masseyʼs safety
coordinator, Frank Foster, who told her they had
a mine fire and two people unaccounted for. The
mine management team was still underground
when Mullins verbally issued the (K) order to
Foster at 8:30 p.m.49
In the aftermath of Sago, it was a common
misconception that the issuance of a so-called
(K) order puts the federal government in charge
of a mine rescue. In fact, the order is intended to
create an orderly mechanism for decision-making
with the mine operator remaining responsible
for the mine. However, the operator’s rescue and
recovery plans are to be submitted in writing to
MSHA and the WVOMHST for approval.
“And I asked him – he’s the first person
I asked – why nobody from MSHA had been
contacted,” she said. “And he said that he had
been trying to for several hours, you know, with
no success.”50
Specifically, section 103(k) of the Federal
Mine Safety and Health Act of 1977 states: “In
the event of any accident occurring in a coal or
other mine, an authorized representative of the
Secretary [of Labor], when present, may issue
such orders as he deems appropriate to insure the
Mullins said Foster said, “ʻI couldnʼt even get
nobodyʼs number at your office,ʼ”51 Mullins had
experienced the same problem. When she had
called her office, the phone wasnʼt answered with
the name of the agency and didnʼt offer a means
30
for reporting an accident. It simply went to voice
mail.52
He said they also carried fire hose down the
four-foot belt and hooked it to a fire valve, but
couldnʼt get water because the power had been
cut off.58
By this time, Brown said Goff told him not to
provide information to anyone who called from
outside the mine and to turn calls over to Goff in
the mine office. Brown said Safety Tech Randy
Boggs directed electrician Chad Neal to come
down and take over the phones.53
At about 9:00 p.m. Vicki Mullins conducted
a roll call of Alma employees. By this time the
#2 section miners and the longwall crew had
evacuated the mine, and family members had
begun to gather at the mouth of the hollow from
where the mine is located. The situation, Mullins
said, was “kind of chaotic.”59
“It was getting real stressful to me because
they were asking questions, and they wanted
answers, and I couldn’t give any,” Brown said.
“So I gave up my position.”54
Some of the miners asked if they could go
speak to their families and come right back.
“And I really didnʼt see a problem with that,
to keep down the, you know, confusion and
family worry and everything, and they said they
would come right back,” Mullins said. “I thought
it would take a while for them to come back up
there, but they came back quite fast.”60
Inside the mine, Rod Morrison and Ed Ellis
got off the mantrip and walked to Four Right,
where they opened two airlock equipment doors
at the bottom of nine tailgate to try, in Morrisonʼs
words, “to actually short-circuit everything that
I could”55 and try to draw the smoke off an area
where he thought miners might try to escape.
At that point, Morrison said he had no idea
that anyone was missing, but “I did take that
into consideration before them doors were ever
opened.”56
As the evacuating miners had arrived on the
surface, Brown said they talked about what they
were experiencing, what each had done.
“They all know that I go to church,” said
Brown, who is known as “Preacher” to some
of the miners. “And when they came up to me
and asked me … if I had prayed for the men,
and I told them yes. And we all stopped and we
prayed.”61
After he opened the doors, Morrison called
Fred Horton to see if it had any effect on the
smoke. It was then he learned that Don Bragg
and Ellery Hatfield were missing. He and Ellis
then went back and checked every route the men
might have taken, he said.57
SOURCES
Ellis said he and Morrison went toward the
mother drive and helped curtain off the intake
travelway going to the longwall before they were
ordered to evacuate the mine by MSHA officials.
0224 Gary Brown TR. P. 190, L. 22-25; TR. P. 191,
L. 01-03
2
0224 Gary Brown TR. P. 25-27
1
31
0224 Gary Brown TR. P. 51
5
6
0224 Gary Brown TR. P. 37, L. 07-11
7
0224 Gary Brown TR. P. 37, L. 01-24
8
9
0224 Gary Brown TR. P. 192, L. 13-16
10
11
12
0224 Gary Brown TR. P. 193, L. 07-08
13
0224 Gary Brown TR. P. 95, L. 14-20
14
0224 Gary Brown TR. P. 95, L. 21-25; TR. P. 96, L. 01-02
15
0228 Timothy Dingess TR. P. 60, L. 17-18
16
0228 Timothy Dingess TR. P. 61, L. 23-25;
TR. P. 62, L. 01-02
17
18
19
20
0316 Raymond Grimmett TR. P. 31, L. 12-22
21
0224 Gary Brown TR. P. 96, L. 16-21
22
0224 Gary Brown TR. P. 96, L. 21-25
23
0224 Gary Brown TR. P. 97, L. 01-05
24
25
26
27
28
0314 Rodney Morrison TR. P. 41
29
30
31
0314 Rodney Morrison TR. P. 31, L. 19-25;
TR. P. 32, L. 01-17
32
0314 Rodney Morrison TR. P. 34
33
0224 Gary Brown TR. P. 130 and 194
3
0224 Gary Brown TR. P. 107, L. 22-25;
TR. P. 108, L. 01-04
35
36
0224 Gary Brown TR. P. 107, L. 23-25
37
0224 Gary Brown TR. P. 117, L. 20-23
38
39
0224 Gary Brown TR. P. 119, L. 07-16
40
41
0224 Gary Brown TR. P. 131, L. 23-24
42
0323 Vicki Mullins, TR. P. 23-24
43
0323 Vicki Mullins TR. P. 24, L. 12-25;
TR. P. 22, L. 09-12
44
0323 Vicki Mullins TR. P. 22, L. 17-20
45
46
47
48
0323 Vicki Mullins TR. P. 23, L. 11
49
0323 Vicki Mullins TR. P. 27-28
50
51
52
0323 Vicki Mullins TR. P. 27
53
0224 Gary Brown TR. P. 130, L. 16-18; 132,
L. 12-14; TR. P. 133, L. 01-12
54
0224 Gary Brown TR. P. 130, L. 12-16
55
56
0314 Rodney Morrison TR. P. 46 L. 02-24
57
0314 Rodney Morrison TR. P. 48-53
58
0316 Edward Ellis TR. P. 161 L. 18-24
59
0323 Vicki Mullins TR. P. 35, L. 03
60
61
0224 Gary Brown TR. P. 190, L. 19-25;
TR. P. 191, L. 01-03
34
4
The conveyor belt that burned near the fire area
32
6
The Attempt
at Rescue
“…once the first man was found, of course,
the whole area was secured by the state police,
completely locked down. Cell phones were
confiscated. No calls made ...”1
Cole indicated he would go to Alma and sent
Kline to the district office in Mount Hope.
Gillenwater said he tried without success to
call inspector Vicki Mullins, unaware that she
– MSHA official Rich Kline already was at the mine.4 He then called inspector
Curtis Vance, Jr., and the two met at the Logan
office. It was 9:30 p.m. or a little later when
Gillenwater and Vance arrived at the mine.5 As he
Bill Gillenwater, supervisory inspector at
entered the command center, Gillenwater said he
the Logan MSHA field office, had just finished
remembers seeing Mullins, Tim Justice and Cass
eating dinner and was watching TV at about 8:30
Trent from his office; state inspectors Richard
p.m. when he received a call from his assistant
Boggess and Eugene White; and Massey Energy
district manager, Luther Marrs, telling him he
officials Frank Foster and Chris Adkins.6
needed to get to the Alma mine, that there was a
Mullins already had issued a 103 (k) order,
fire and two men unaccounted for.2 Gillenwater
said Marrs instructed him to “set up the command but she told Gillenwater that management
personnel were still underground exploring for
center and get things started.”3
the missing miners, and that she had urged they
Eddie Lester, vice president of operations for
be withdrawn because “we didn’t need people in
Aracoma Coal Company, notified MSHA District
the mine who weren’t fire fighters.”7
Four assistant district manager Rich Kline, who
The (K) order, in effect, gives the operators
had called Marrs and district manager Jesse Cole.
33
the right to protect personnel and property,
which they were attempting to do by trying to
extinguish the fire. Legally, Vicki Mullins could
have ordered the officials out of the mine, but she
may have been hesitant to do so for three reasons:
the fire was still burning; the two missing miners
may have been alive; and the absence of methane
made the risk of an explosion unlikely.
West Virginia and East Kentucky teams – had
arrived at Alma Mine #1.
Aracoma Coal safety director Charles Conn,
who also is captain of Masseyʼs East Kentucky
Mine Rescue Team, said he got there at about
8:00 p.m., before MSHA or state officials were on
the scene. The rest of his team arrived between
8:30 and 9:00 p.m., he said. Robert Asbury,
Meanwhile, Eddie Lester also had located
captain of the Southern West Virginia mine
West Virginia state inspector Richard Boggess in rescue team, arrived with his entire team some
Madison at about 7:33 p.m. Boggess left for the
time later, although he could not recall the exact
mine immediately and was there within the hour, time. Eddie Lawson, who led Arch Coalʼs Mingothe first state safety official on the scene. Other
Logan team, said he got to the mine at about 9:10
state officials arrived within minutes. Inspector
p.m., when most of the company officials were
Eugene White said by the time he arrived at about still underground. His entire team arrived, fully
8:30 p.m., Doug Conaway, then director of the
equipped, at 10:55 p.m.
West Virginia Office of Miners’ Health Safety
The tragic experience of Sago was fresh,
and Training (WVOMHST) was already on the
and some of the rescuers rushing to Alma had
scene. WVOMHST deputy director C.A. Phillips
participated in the largely failed rescue attempt
arrived shortly thereafter. White said Conaway
in Upshur County less than three weeks before.
assigned him to the command center. Boggess,
While no one faulted the mine rescue teams, the
the regular state inspector for Alma and the state
slow response at Sago had been widely criticized
official who knew the mine best, was assigned to
and may have spurred those making decisions at
take notes in the command center.
Alma to act with greater urgency.
Boggess said Conaway told him to order all
“We had in mind about Sago,” White said. “A
management personnel out of the mine at 8:40
lot of people felt they sat at Sago too long. We
p.m., and all the company employees had exited
held the teams until we had backup, but as soon
by around 10:30 p.m., Boggess said. Although
as we got backup, they went under.”
Gillenwater had established the command center
Since the situation at Alma involved a fire
earlier in the evening, the situation was pretty
chaotic until the company officials arrived on the rather than an explosion and since the location
surface, White said. “For a period of time, it was of the fire was known, teams were able to
travel directly to the fire area without having to
mass confusion,” Boggess agreed.8
establish fresh air bases along the way as they did
By the time the mine was evacuated, the first
at Sago, where conditions were unknown. This
two mine rescue teams – A.T. Massey’s Southern
allowed teams to move rapidly once inside the
34
mine, White said. “We knew we had a fire, not an
explosion. Our view was, use caution, but go,” he
said.
Mine Rescue Teams – Order of Work
The rescue teams that advanced inby the fire
in search of the missing miners did establish and
advance the fresh air bases.
It also should be acknowledged that the two
situations presented vastly different problems.
The Alma fire was not the result of an explosion
and, because there was virtually no methane
present, the risk of the fire triggering an
explosion was minimal or nonexistent. (Results
of the analyses of air samples indicated the total
methane liberation from the mine was less than
0.5 million cubic feet per day.) Moreover, the belt
fire had not spread to the extent that the travel
routes of the teams were blocked, and the fire was
being controlled from spreading to those areas by
the teams fighting it.
As at Sago, the mine rescue teams exploring
inby in search of the missing miners were
equipped with full mine rescue apparatus, which
protected them in the smoke and high levels of
carbon monoxide. Although any time mine rescue
teams are sent into bad air wearing apparatus,
they assume a higher than normal level of risk,
officials determined the risk assumed in this case
was consistent with the value of the operation.
Since it had been reported by some of the
survivors that they thought the men went back
toward the #2 section, there was a chance the
rescue teams would find survivors in an isolated
area that was smoke-free. All of these factors
allowed a more expedited rescue action plan.
About 15 minutes after his arrival,
35
When an event occurs at a mine requiring the use
of mine rescue teams, many teams will respond
to the situation. Some of these responding teams
will be those of the coal company itself. Others
include teams the company contracts with to
provide coverage, teams from other companies or
private contract teams, along with the state and
federal mine rescuers. It is a well-known fact that,
although all teams that respond to an event will have
the minimum required training and qualifications
specified in Part 49 of the regulations, not all teams
will have the same level of training, experience,
knowledge, and actual working time in adverse
conditions. It is imperative that persons in the
Command Center, or those directing the participation
of the mine rescue teams, are familiar with the teams
and have a good understanding of their knowledge,
experience working in low coal, fighting fires, or
building temporary seals in adverse conditions.
Teams with this knowledge and expertise should be
preferred to complete certain tasks, as opposed to
teams with lesser experience in these areas. Mine
rescue team assignments should never be a “first
come, first served” exercise, and teams should be
utilized accordingly.
Lawson said, the #2 section foreman Mike
Plumley gave a briefing in which he described the
path the escaping miners had taken, where they
abandoned the diesel mantrip, the point at which
they had donned their SCSRs and the route the
crew took to reach fresh air.9
By approximately 11:00 p.m., four rescue
teams had assembled at the mine: Masseyʼs East
Kentucky and Southern West Virginia teams,
Arch Coalʼs Mingo-Logan team and Foundation
Coalʼs Riverton team. Lawson said the rescue
teams didnʼt get what he would term a real
briefing, just a “game plan” involving those first
four teams to arrive at the mine.10
While the teams were getting unloaded and,
in Lawson’s words, getting “everything
However, White said to his knowledge no
written plan was signed off on until after the
bodies of the two missing miners had been
recovered on Saturday, January 21. The state, he
said, never requested written proposals.20
staged up so that we could get inside,”11 Vicki
Mullins began to interview the members of the
#2 section, who told her they had abandoned
their mantrip near a borehole around Nine
headgate. Knowledge of the borehole offered
an opportunity for rescuers to monitor carbon
monoxide levels above the site where the miners
went missing.12
“There was a map the company officials
marked on, and that tells what was done,” he
said. “We let the company run the command
center. We put our opinions in, but they ran the
command center.”21
Alma employee John McNeely was the only
one present who knew precisely where the hole
was located, and gaining access to it required
making a lengthy trip several miles north of
Logan and up a remote mountain. Mullins
sent Cass Trent, a new MSHA employee, with
McNeely.13 She asked Minness Justice to check
the CO system since he was most familiar with it.
By then, Gillenwater had arrived at the mine and
taken up his position in the command center.14
Chris Adkins and Dwayne Francisco joined
Foster in representing the company, and the
officials set up a communications system
between the command center and those searching
underground. With memories of the terrible
miscommunication at Sago still fresh, everyone
involved at Alma was extremely conscious of the
need to limit access to information. The phone
was set up so only Foster could communicate
directly with rescuers, Gillenwater said, while
Adkins and Francisco switched off the duty of
directing the underground operations.22
Gillenwater said he also sent Tim Justice to
monitor the borehole15 and stationed Vance at a
bleeder fan,16 which also had registered high CO
levels. Gillenwater remained in the command
center.
MSHA’s District Four Manager Jesse Cole
and Assistant Managers Luther Marrs and
Lincoln Selfe arrived at Alma around 11:30 p.m.
Cole and Selfe went into the command center,
and Marrs said he assumed responsibility for
monitoring conversations between the rescuers
below ground and officials above ground in a
room adjacent to the command center.23
Mullins noted that when management people
came out of the mine, they began to take control
of the command center.17 Massey Energyʼs safety
coordinator Frank Foster gave the initial briefing
on the situation, according to Gillenwater.18
“Frank kind of led the company efforts,”
Gillenwater said. “He was the – Iʼd say the
leader in the group in terms of the companyʼs
control of direction, where to go. He would make
recommendations; everybody would just give
comments on what that was. Frank was more or
less leading the charge, if you will.”19
The Southern West Virginia and East
Kentucky rescue teams entered the mine at
around 11:37 p.m., approximately six hours after
the first CO monitor went off in the dispatcherʼs
office and while the belt fire was still burning.
36
Structure of Mine Rescue Teams
A typical mine rescue team in the US is comprised of 6 to 8 team members. A description of team
positions and functions is as follows:
●
●
●
●
●
●
Team Captain — the leader of the team, responsible for guiding the team in the proper route
and direction and ensuring the safety of team members. While traveling, the captain will
make continuous examinations, both visually and with instruments, to ensure that the team
is not led into an unsafe area or exposed to an unsafe condition. The captain also will be the
final decision-maker on what functions and duties the team will, or will not, perform.
Map Man — Usually travels directly behind the captain, maintains an accurate and detailed
map of the area the team explores, and assists the captain in determining the direction and
route of travel during exploration.
Gas Men — Usually travel in the 3 and 4 positions, carry equipment for detecting mine and
fire gases to assist the captain in determining gas concentrations and team safety. Also, the
gas men usually carry a stretcher for rescue of a live person, which will be loaded with extra
equipment the team may need, including an extra breathing apparatus, SCSRs, first aid kit,
fire extinguisher, and assorted hand tools.
Tail Captain — Travels at the rear of the 5-man team and assists in ensuring the safety of
the team members in front. The tail captain maintains constant communication to the mine
surface or fresh air base to report findings, conditions and information concerning the team
exploration and leads the team out of the newly explored areas back to the surface or fresh
air base.
Briefing Officer — Stationed at the surface or fresh air base to stay in constant
communication with the team. The briefing officer reports and relays information from the
team to the command center and helps direct the team travel. He will always have wireless
or hard-wired radios to stay in contact with the tail captain while the team is exploring.
Alternates — Usually a team will include some alternate team members who are fully
trained in wearing the breathing apparatus and can be substituted into any of the working
positions.
The foremost function of a mine rescue team is to ensure the safety of the team members, and to
avoid making changes to the mine environment that may endanger themselves, miners, or other working
teams. Teams must also follow the directions of the command center explicitly, and not free-lance or
perform duties without first consulting the command center and receiving permission. Teams must report
conditions and findings accurately and in great detail. Teams must work as a well-functioning unit. This
knowledge and experience is gained through intensive and repetitive training in the classroom, on the
practice field, in underground training situations, and through participation in mine rescue contests.
Prior to entering an unexplored area of a mine, a team must receive a detailed briefing by a
representative of the command center, concerning the event, the circumstances and conditions that are
known and unknown, and be given specific directions and tasks to be performed. The team must receive
an accurate map of the area so that they can explore and evaluate conditions accurately and document
findings. After performing their duties and returning to the surface, teams must be debriefed by a
representative of the command center, on the conditions they encountered, and on general information
they discovered during their exploration. This debriefing should be thorough and detailed, and the
information used by the members of the command center to evaluate and plan future excursions into the
mine.
Typically, in current rescue operations, the five-person team will be accompanied on their
exploration or assignment by a federal and/or state mine inspector, who is a rescue team member of their
respective agency, and who is fully trained in the use, care, and maintenance of the breathing apparatus,
and in mine rescue procedures.
37
They went into the mine on a diesel mantrip
and traveled to the 4 Right Panel, where one team
remained at the mouth of the panel to establish a
fresh air base while the other advanced across the
Northeast Mains to the 9 tailgate or 10 headgate
entry. (Charles Conn was among those Aracoma
officials who believed the missing men would
come to the old 3 section, or 4 Right, in an
attempt to escape.)24
Firefighters did not have water at the mother
drive until about 10:45 a.m. Friday, the morning
after the fire, and foam was not applied to the fire
until about 11 a.m. Friday morning.
The East Kentucky team was unable to locate
the mantrip because of dense smoke and intense
heat in the area. Conn said he later learned they
had missed it by about 10 feet.26
Lawson said the two Massey teams encircled
a coal pillar surrounding a gas well and worked
their way toward a set of double doors at the
mother drive. The rescuers told him “there was
intense smoke, very visible flames when they
opened the airlock doors.”27
The two teams were followed approximately
ten minutes later by the Mingo-Logan team and
the Riverton team.
By the time Lawson arrived underground,
the team exploring the mains had opened a set
of airlock doors, encountered thick, black smoke
and retreated back to the fresh air base. All four
teams then advanced toward the longwall belt
mother drive area where they assessed the fire.
The Southern West Virginia team was assigned to
fight the fire, with the Riverton team serving as
backup. The East Kentucky team, backed up by
Mingo-Logan, was sent to explore the North East
Mains area to try to locate where the #2 section
crew had abandoned its mantrip.25
For 42 hours after the first teams went
underground, rescue teams rotated in to fight
the fire, to search for the missing miners and
to provide backup. There was no shortage of
teams – in all, 26 came to Alma Mine #1 — but
questions were subsequently raised about whether
they were used in the most efficient and effective
manner.
Ron Hixson, a member of MSHA’s mine
rescue team who had worked at Sago, was
packing to return to Sago (to participate in the
post-disaster mine recovery operation) when he
got the call to report to Alma. Upon arrival at the
mine, he got his equipment ready — and then sat
on standby all night.28
As they prepared to fight the fire, members of
the Southern West Virginia team discovered they
had no water supply.
Officials determined that pumps near the fire
area would have to be energized to get water
to the fire, but the electrical configuration in
place meant that powering those pumps would
take power further into the mine, where the fire
was still burning. Mine electricians, assisted
by the Pinnacle Mine Rescue team, were sent
in to separate the power supply at the pumps.
Brad Justice, captain of the Southern
Coalfield Mine Rescue Team, said his team
arrived at the mine at about 10:30 p.m. on the
night of the fire. They were briefed at about 2:00
a.m. and told they were going underground, he
said. But they remained on standby.29
38
“And then at like probably 7 oʼclock [a.m]
we had a briefing, we were supposed to go
underground again – and that changed. I think
we finally went underground at 10:00, 10:00 a.m.
on the morning of the 20th,” he said. “Iʼd say my
team was in the box cut by 10:50 [p.m.] and we
sat there until 10 a.m. the next morning.”30
anything went on, I knew where I was at.”33 In
other words, he and his team had to depend on
themselves to figure out how to exit the mine if
the need arose.
Justice, too, expressed frustration with the
mine maps. He believes his team could have
fought the fire more effectively if they had been
given accurate maps.34
This waiting experience is not unusual, but
it can reduce the effectiveness of the teams. In
fairness to those in the command center, as the
call went out for rescuers, more teams responded
than could be used underground to fight the fire
Since they believed fresh air to be going
through the mine, Justice said, the rescue team
members thought “there was a good possibility
these guys were sitting up here alive. So,
therefore, weʼre not going to tear up stoppings
and send smoke on top of a possible live person.
So we sat here and we tore out a couple blocks
and shot water – we tried to spray water. And the
reality of it is that all we were doing was soaking
the ground. We werenʼt doing anything. We
werenʼt hitting the fire.”35
and to begin establishing advanced fresh air bases
and exploring inby.
A more serious problem encountered by
rescuers was that mine maps that were provided
to them by company officials weren’t accurate.
(Federal Regulation 30 CFR 75.1200 and
75.1202 mandates that each underground coal
mine operator maintain a map that is accurate,
up-to-date and on scale, not less than 100 or more
than 500 feet to the inch.)
“Had we known this area wasnʼt isolated,
we could have tore out the stoppings beside the
belt head and walked over [to the fire],” he said.
“Instead of spraying water 140 feet, we could
have sprayed water three to four feet.”36
Hixson said that once his team was
underground, inaccurate maps “made it difficult
for us to do what the command center was
asking.”31
Although the rescue operation at Alma
appears to have been more orderly than at Sago,
there were difficulties in the command center. To
some extent this may have been inevitable. Mine
rescues are never neat and tidy. As more than one
experienced safety official has observed, there is
a certain amount of chaos because of the tension
involved when workers are missing and no one
can say with absolute certainty what should be
done. Still, Mullins believed that there were too
many people in the command center and that
“We had trouble following stopping lines,”
he said. “We had trouble following – finding
doors to go through when we were told to make
air readings. Sometimes there was no stopping.
Sometimes there was no door. Sometimes
everything was a solid stopping line, again, with
no doors.”32
On his first trip underground, Hixson
tried to map out an area “for myself so that if
39
there was “mass confusion.”37
input and agreement by all parties.40
Complicating matters, Mullins said, was
an apparent lack of clarity about just what a
(K) order meant. Mullins said that when she
suggested to Massey official Chris Adkins that
he should limit access to the command center to
a few MSHA, state, and company officials, he
responded that he couldn’t do that, because she
had written the (K) order.38
“The majority of the people in the command
center were representatives of mine rescue
teams,” he said, adding that after he got up to
speed about what was going on, he began to help
brief and debrief rescue teams.
“They [the rescue team representatives]
werenʼt noisy or causing problems, but it just
made for a very crowded room, which is always
uncomfortable. I just had never seen this before,
as we usually briefed these people when we
briefed the teams before going in. I think it
evolved to this because the briefings were not
being done very well early on.”
Another problem was that the standard
briefing and de-briefing system for rescuers was
not initially put in place. State mine rescue team
member Clarence Dishmon was one of several
rescuers who complained that he was neither
briefed when he went in nor debriefed when he
came out of the mine. “I’ve always been taught,
you know, you brief somebody before they go
underground, and you debrief them when they
come out,” Dishmon said. “And that didn’t
happen on my part.”39
Situations in the mine were changing quickly,
so briefings of teams were detailed to the point
of what had been done and what areas had been
explored so far. Teams were generally told where
they would be going and what their tasks would
involve, but they also were instructed to remain
flexible when they got to their assigned fresh
air base. It was taking about two hours from
the time a team was briefed until they arrived
at one of the forward fresh air bases, because of
the distance and difficulty of travel, so, by the
WVOMHST director Doug Conaway had
asked retired MSHA district manager Joe
Pavlovich to assist in monitoring the command
center for the state because of Pavlovichʼs
experience with previous mine rescue efforts.
Pavlovich said when he got there at about 11:00
a.m. Friday, the command center consisted of
between 25 and 30 people sitting and standing
around a long narrow table. These included
company, MSHA and state officials who were
involved in the decision-making, together with
representatives of most or all of the rescue
teams that were on site. Although the room was
crowded, Pavlovich said he felt the process was
orderly and good decisions were being made with
time they reached their destination, their work
assignment might change. When the teams
arrived at their assigned fresh air base, they
would then be instructed, by phone, as to what
their mission would be.
Pavlovich said he and Charlie Bearse,
president of Massey’s Sidney Coal, worked with
a large map, making plans as to where teams
would go next. Massey Chief Operating Officer
Chris Adkins was on the phone with rescuers,
40
they don’t have them and Massey still has them.”
primarily Johnny Robinson, who was the
company’s point man underground.
By the time he got to the mine, Pavlovich
said rescue teams had established several fresh
air bases, including one near the burning belt.
One team was engaged in fighting the fire with
another serving as backup, and several additional
teams were in advanced fresh air bases exploring,
serving as backup or waiting for instructions.
Each time a team made a push into a previously
unexplored area, the command center was
locked down. State police barricaded the door
and wouldnʼt allow anyone in or out until the
team completed the exploration and reported
their findings to protect against the kind of
misinformation debacle that occurred at Sago.
As the rescue team members called out their
updates to Adkins, he repeated the information to
everyone in the command center. Pavlovich and
Bearse documented the updates on the mine map
and made notations of locations.
“This was more like our own log that we were
using in the decision-making process on what had
been explored, what had been found, what steps
to take next,” Pavlovich said.
Pavlovich said when he, Bearse, Francisco,
Adkins and the state and federal officials in the
command center at the time considered where
they wanted teams to go next, they discussed
it with everyone in the room and got verbal
approval from the state or federal officials who
were present. Then Adkins would relay the orders
to the teams by mine phone. Bearse wrote plans,
and they were kept in a pile, sometimes signed
by state and federal officials, sometimes not. In
response to state officials who said there was no
written plan until after the missing miners were
located, Pavlovich said, “Maybe the written
plans started when I got there, because Bearse
and I had worked on the fire recovery of the Blue
Diamond #77 Mine in Eastern Kentucky, and he
was familiar with the plan system that we used.”
By Saturday morning, the teams fighting the
fire at the longwall belt drive were making great
progress in extinguishing the flames and reducing
the heat inby. This permitted other teams to
explore just inby the fire area, the only area
which had been previously inaccessible.
It was Brad Justiceʼs Southern Coalfield team
that located the body of Don Bragg at 2:40 p.m.
on Saturday, January 21, just four crosscuts, or
496.7 feet, inby the fire. Bragg was still wearing
goggles and had his rescuer in his mouth. He had
a nose clip, hardhat with a hood over it.41
Rich Kline testified that “once the first man
was found, of course, the whole area was secured
by the state police, completely locked down. Cell
phones were confiscated. No calls made and all
that.”42
Pavlovich said he “figured that was something
the state and feds would have established early
and I just assumed it was being done.” He said he
didn’t know what happened to the written plans,
and, after Bearse left early Saturday morning, he
doesn’t remember seeing any more. “I guess if
MSHA and the State weren’t requiring them, that
The lessons of Sago had not been lost. Kline
said officials engaged in an extended discussion
about bringing out the first body, confirming
41
its identity, then double-confirming and tripleconfirming, Kline said. The decision was made
not to make an announcement until the other
body was recovered.43
Forty minutes later the Consol of Kentucky
team located the body of Ellery Hatfield only
82.7 feet from the fire. The bodies were more
than 500 feet apart, one south of the site of the
fire, the other east, suggesting that the two miners
likely did not make a joint decision to leave the
others.
Again, company officials underground
were asked to go back and make yet another
confirmation before they recovered the bodies
and secured the area for investigators.
The victims were transported to the surface
and all the rescue teams left the mine except two
that stayed to monitor the fire area. Although
the fire was extinguished on January 21, rescue
teams continued to monitor and cool the fire area
until January 24, to ensure that the fire did not reignite.
SOURCES
0323 Rich Kline TR. P. 90, L. 23-25; TR. P. 91, L. 01-02
0331 Bill Gillenwater TR. P. 23
3
0331 Bill Gillenwater TR. P. 37, L. 12-14
4
5
1
2
8
Information referring to Eugene White, Richard Boggess,
Doug Conaway, C. A. Phillips was obtained from state
officials who were in the command center.
9
0329 Eddie Lawson TR. P. 21, L. 24-25;
TR. P. 22, L. 01-09
10
0329 Eddie Lawson TR. P. 24, L. 22-24
11
12
0323 Vicki Mullins TR. P. 45-46
13
14
15
16
17
18
0331 Bill Gillenwater TR. P. 38, L. 18
19
0331 Bill Gillenwater TR. P. 40, L. 24-25;
TR. P. 41, L. 01-07
20
Information obtained from state officials
21
Information obtained from state officials
22
23
0324 Luther Marrs TR. P. 30, L. 03-21
24
0321 Charles Conn TR. P. 36, L. 06-19
25
0329 Eddie Lawson TR. P. 38-39
26
0321 Charles Conn TR. P. 97, L. 15-16
27
28
0308 Ronald Hixson, TR. P. 19, L. 10-14
29
0315 Charles Bradley Justice TR. P. 22-26
30
0315 Charles Bradley Justice TR. P. 26, L. 07-13,
L. 24-25; TR. P. 27, L. 01
31
0308 Ronald Hixson TR. P. 21, L. 11-13
32
0308 Ronald Hixson TR. P. 20, L. 16-25;
TR. P. 21, L. 01-02
33
0308 Ronald Hixon TR. P. 29, L. 03-05
34
0315 Charles Bradley Justice TR. P. 32, L. 12-25
35
36
37
38
0323 Vicki Mullins TR. P. 58, L. 18-25;
TR. P. 59, L. 01-03
39
0320 Clarence Dishmon TR. P. 85, L. 23-25;
TR. P. 86, L. 01-02
40
Information obtained from Joe Pavlovich
41
0315 Charles Bradley Justice, TR. P. 74
42
0323 Rich Kline TR. P. 90, L. 23-25; TR. P. 91 L. 01-02
43
0323 Rich Kline TR. P. 91, L. 05-08
6
7
42
7
Why did it
happen?
“Aracoma was a mess. ”1
– MSHA official Rich Kline
The underground mine fire that broke out
near the longwall conveyor belt drive of the Alma
Mine #1 on January 19, 2006, raises two major
questions: what caused the fire and why were two
miners lost as crews evacuated the burning mine?
Testimony delivered during the federal and
state investigation makes it apparent that the
fire was caused by a conveyor belt malfunction,
which created a heating or spark, which, in
turn, ignited combustible materials. The short
explanation is that equipment that was not kept in
good working order provided the heating source
that ignited coal dust and coal spillage which,
when allowed to accumulate along conveyor
belts, creates a combustible mix. When a bearing
overheats, as was suggested by testimony, all the
ingredients are in place for a lethal mine fire.
more effort was expended in fighting the fire
than in evacuating the mine; because the water
hoses were dry; because the carbon monoxide
monitoring system was not properly installed. In
addition, the emergency escapeway evacuation
route taken by the miners was compromised
by the fact that a permanent ventilation control
(stopping) had been removed, allowing smoke
from the fire to flow into the escapeway and meet
them on the way out. In the confusion, the two
men became separated from the crew and were
lost. Attempts to rescue the missing men were
hampered by the absence of an accurate mine
map and because there was no water to fight the
fire.
At Alma Mine #1 the Number 9 headgate
has a storage unit for its conveyor “mother” belt
that is approximately 220 feet long and has a
rail guide on which a main carriage and drop off
carriages ride. A pinch roller unit helps remove
belt from the storage unit.
Miners testified before state and federal
In a nutshell, the two men were lost because
43
The first and most important line of defense
investigators that the drop-off carriage system
was not working properly, and carriages
sometimes had to be manually set in the proper
location and chained in place. At the time of the
fire, a drop-off carriage became misaligned when
it unlatched on one side and remained latched on
the other side. The misalignment of the carriage
caused the belt to run out of alignment and rub
against a bearing.
against hazards in coal mines is the responsibility
of the company, which is required to conduct
pre-shift, on-shift and weekly examinations.
Either these examinations did not take place or
the examiners on every shift failed to detect the
potentially hazardous conditions and have them
corrected before they posed a threat to life and
property.
The West Virginia Office of Miners
Health, Safety and Training is mandated under
West Virginia law to conduct inspections of
underground mines four times each year to
correct conditions such as dust accumulations
before they pose life-threatening risks.
In the aftermath of the fire, investigators
from the Mine Safety and Health Administration
(MSHA) and the West Virginia Office of Miners
Health, Safety and Training (WVOMHST) found
high quantities of combustible accumulations
along belt conveyors, in some places up to the
lower rollers of the belt. These accumulations
should have been identified and reported in
the record books by examiners, and corrective
actions should have been taken and documented,
neither of which was done.2 Miner Wyatt
Robinson testified about waste accumulation
and stated he had spent a great deal of time
“shoveling belt” after the fire. When asked if
his duties changed after January 19, Robinson
testified, “Lord, yeah. I mean, basically all we’re
doing now is shoveling. We don’t do anything,
you know, other than shovel.”3
Likewise, federal inspectors are required to
conduct regular inspections.
The conditions documented during the
investigation of the fire suggest the entire system
of inspections failed at Alma Mine #1. It might
be argued that this was a unique circumstance – a
one-time occurrence. However, state and federal
inspection records indicate this was not the case.
Both the WVOMHST and MSHA had cited
this mine for dust accumulations on numerous
occasions in the 12-month period prior to the fire.
In fact, federal inspections in the quarter
preceding the fire (October-December 2005),
resulted in the mine being cited with 25
violations, including seven concerning the
mine ventilation plan and three concerning
accumulation of combustible materials.4
Three oversight systems mandated by law
– inspections by the company, by the state and
by the federal government – failed to detect the
hazardous conditions (combustible materials) in
a timely manner. Because the inspection system
failed, the necessary steps to prevent a fire were
not taken.
If citations for dust accumulations were
not enough to signal a warning that dangerous
44
conditions existed at this mine, miners testified
that they extinguished two other belt fires in
the two weeks preceding the January 19 fire.
No records exist to show that these fires were
reported to MSHA or state officials.
Robinson discharged a fire extinguisher
on the fire, but was not able to get it out. He
estimated the flames were three and a half feet
wide and three feet high. “It was a decent size
fire, you know what I mean?” he said.12
Beltman Brandon Conley told investigators
that on December 23, 2005, essentially the “same
events happened that happened on January 19.”5
Eventually Robinson and foreman Dave
Meade hooked up water hoses and sprayed the
fire for about 20 minutes before completely
extinguishing it. Robinson said Meade filled out
an accident report on the incident and contacted
safety director Charles Conn. But Robinson
expressed concern that, despite the size of
the fire, the foreman did not order the mine
evacuated, an action Robinson believes should
have been taken.
Conley testified a dolly twisted, causing the
mother drive belt to run to the offside and rub
against a bearing until it caught fire. When he
tried to hook up a hose, he found that the valve
and hose didn’t match, and he couldn’t get much
water pressure on the fire from the one-inch line.
Conley said he fought the fire for at least 30
minutes before bringing it under control.6
“Itʼs a danger,” he said. “I mean, what if I
couldnʼt have put the fire out? Itʼs not a real good
chance to take in the mines. If I would have been
the foreman on shift that night, I would have
evacuated.”13
When the smoke cleared, Conley said he
could see a pile of shavings from the mother
drive belt. He reported the fire to foreman Fred
Horton and said Horton instructed him “not to
say fire over the phone, just to say smoke or
getting hot or something like that so you don’t
scare everybody else.”7
After each fatal accident, MSHA issues a
“fatalgram” describing the deaths. In the Alma
Mine #1 fatalgram, MSHA listed the following
“best practices” that should have been in place:
Conley said he left his job at Aracoma after
the January 19 fire because “[I] just don’t feel
remove all accumulations of combustible
material; maintain equipment in safe operating
condition; conduct thorough conveyor belt
examinations; ensure that hazardous conditions
are immediately corrected; and immediately
investigate any indication of fire and treat an
alarm as if a fire exists until proven otherwise.
safe there anymore.”
8
Another beltman, Wyatt Robinson, Jr.,
testified fire broke out on December 29 at the
tailpiece of the Number 5 belt.9 Robinson said
he and fellow beltman Carl White encountered
smoke when they entered the belt entry from the
intake.10 Robinson said one of the bottom rollers
had “got real hot and spit a little bit of fire on
some belt shavings next to the rib. And it was the
belt shavings and the rib was burning, too.”11
These are not only best practices – they are
requirements of the law, both federal and state.
Tragically, these protections were not sufficient to
prevent this accident.
45
Other factors beyond the fire itself
violation as “reasonably likely” to cause serious
contributed to the deaths of Don Bragg and Ellery injuries and ranked it as moderately negligent.
Hatfield. Some issues to consider include:
The longwall was shut down for about two hours
until the problem was addressed.14
• Permanent ventilation controls, or
stoppings, were removed and not replaced.
Complex ventilation systems are required to
provide clean air for miners, to remove explosive
methane gas and coal dust and to ensure the
safety of the men and women who work
underground. Making sure the ventilation system
operates precisely according to law is even more
important in mines such as Alma, which run
conveyor belts on the same route through which
fresh air is pumped into the mining sections.
One aspect of controlling/directing air in the
mines is through cinderblock ventilation controls,
which also are called stoppings. The absence
of stoppings in and around the mother drive
belt area of Alma Mine #1 has been cited as a
primary reason that the smoke traveled up the
intake into the working #2 section on January 19.
Because those stoppings, or walls, were not in
place, miners did not have fresh air passageways
through which they could escape a fire or
explosion.
Alma construction foreman Don Hagy
said the ventilation control around the mother
drive was removed at least five weeks before
the fire in order to extend a 72-inch beltline.
Hagy said he never mentioned to his bosses that
the stopping had not been put back.15 During
mandated rudimentary safety inspections, the
operator is required to examine these belt entries
on every operating shift. There is no record of
company inspections that make mention of the
missing stoppings.16
Had the stopping been in place, it would
have prevented any exchange of air between the
conveyor belt and the fresh air intake, which also
serves as the primary escapeway. Because it had
been removed, smoke flooded into the escapeway
and overtook the miners as they attempted to
evacuate the burning mine.
Rescuer Brad Justice said that, barring an
explosion, “If youʼve got isolated escapeways,
your guys are going to get out of the coal mines,
if they make it that far [to the escapeway].17 Had
those stoppings been in place and that beltline
been isolated, this conversation wouldnʼt even be
going on,” he said. “We might have went back
and fought a fire, but we would not locate any
bodies.”18
Aracoma was cited for ventilation
violations three times over a two-day period in
November 2005. On January 18, the day before
Don Bragg and Ellery Hatfield lost their lives,
state inspector Richard Boggess again cited the
mine for what he termed a serious ventilation
violation. Boggess measured airflow of 25,000
cubic feet per minute on the longwall section,
compared with the required flow of 45,000 cubic
feet per minute. The inspector characterized the
• The water supply system was inadequate.
The water system at the Alma Mine #1 mine
is supplied from a holding tank above the box
cut portals and runs through a 12-inch steel line
46
to the portal. From there an 8-inch supply line
carries it underground, where it branches off into
smaller lines.
monoxide (CO) monitoring systems to keep a
constant watch on air quality.
While Aracoma Coal did have in place an
approved Pyott-Boone system, not all of the
systemʼs alarms were functioning at capacity and
the system was not installed in all working areas.
Federal regulations require that CO systems
provide audible and visual alarms that can be
heard and seen by miners in working sections. No
carbon monoxide alarm unit had been installed
on the No. 2 Section to provide automatic
notification of carbon monoxide alarms from
outby sensor locations. The alarm would have
alerted members of the #2 section of the presence
of carbon monoxide and would have expedited
the evacuation on January 19, 2006.
A number of persons who testified spoke
about the absence of water.19 Belt examiner
Bryan Cabell, the first to discover the fire, said
when he wasnʼt able to hook a hose onto a fire
tap, he opened a valve, hoping to direct water
toward the fire, “but there was no water in it.”20
Pat Callaway, the foreman who joined Cabell in
the effort to fight the fire, described striking a
valve with a hammer in a vain attempt to open
the valve completely and start the water flow.21
At the mine, each conveyor belt drive
is equipped with water sprinkler type fire
suppression systems that are designed to activate
in the event of fire or a rise in temperature. The
water sprinkler fire suppression system installed
for the No. 9 headgate longwall belt conveyor
drive did not activate. The water valve was
found in the closed position. In addition, no
water sprinkler system had been installed for the
No. 9 headgate longwall belt takeup storage unit.
Testimony also revealed that miners,
including Dispatcher Mike Brown, were
inadequately trained as to the basic operation
of the system and that not all alarms and
alerts were recorded in the log event book.
The training for the dispatchers who were
charged with monitoring the CO system was
ineffective and did not provide them with any
emergency protocols to follow in the event the
alarm was genuine and not a false alarm or
malfunction that required re-setting. [The witness
interviews revealed that Mike Brown had a basic
understanding of the system. The inadequate
training was found to be with Kirby Puett, a
dispatcher on the day shift. The MSHA accident
investigation team immediately issued a violation
for this inadequate training following Puettʼs
interview. The company trained each dispatcher
to abate the violation.]23
Rescuers didnʼt have water at the fire area
until about 10:45 a.m. on January 20, some 17
hours after the fire was discovered. Jonah Rose,
one of the miners who tried to douse the flames
with fire extinguishers, said if water had been
available at the fire tap, the miners would have
been able to extinguish the fire. “I believe water
would have put it out,” he said.22
• The mineʼs carbon monoxide monitoring
system was ineffective. In order to get MSHA
approval to use belt air in the face ventilation
of mines, companies are required to use carbon
47
we had to have an accurate ʻ1200 mapʼ to give
mine rescue teams.”25
• Inaccurate mine maps posed a danger
to miners and to rescuers. Federal regulations
require operators to maintain accurate and upto-date maps on site showing the entire mining
operation and all active workings (the so-called
1200 map called for in subsections of the 30CFR
75.1200 provisions of the law). The regulations
include a requirement that temporary notations
must be made any time permanent ventilation
controls are constructed or removed, and
revisions and supplements are to be made at
intervals not to exceed six months.
For 16 to 18 hours after the fire, Justiceʼs
primary duty was handing out maps to mine
rescue captains, and he heard plenty of
complaints about the maps.26
Hixson said, “We had trouble following
stopping lines. We had trouble finding doors to go
through when we were told to make air readings.
Sometimes there was no stopping. Sometimes
there was no door. Sometimes everything was a
solid stopping line, again, with no doors.”27 The
maps, as a state official in the command center
put it, “were a piece of crap.”28
According to testimony from Ron Hixson, a
member of MSHAʼs mine rescue team, among
others, the maps at Aracoma Alma Mine #1 were
neither accurate nor up to date. MSHA Inspector
Minness Justice said he had pointed out the
problems to company officials in the weeks prior
to the fire and had secured their promise to revise
the maps. Justice said, for example, the maps
showed air going down the four-foot belt toward
the #2 section when in actuality, the air was
coming up the belt.24
• State and federal agencies failed to
adequately regulate this mine. MSHA is in the
process of conducting an internal review of its
regulatory activities at the mine. It is essential for
this review to be both objective and exhaustive
in determining what went wrong and why, and
its findings and recommendations must be geared
toward taking all necessary steps to ensure that,
at every level of MSHA, the safety of miners is
the agencyʼs top priority.
He said he warned company officials that “in
the event we ever had an explosion or a mine fire,
For their part, state officials have indicated
that a severe manpower shortage prevented
them from providing adequate oversight.
Dennie Ballard, assistant inspector-at-large for
WVOMHSTʼs District 3 office in Danville,
said that at the time of the fire, two inspectors
in the district (WVOMHSTʼs largest) were off
work because of illness and injuries. However,
even when the office is fully manned, just
12 inspectors are responsible for completing
quarterly inspections of 83 underground mines
and 40 preparation plants. Four additional
Typical view of a stopping that has been knocked out
48
electrical inspectors are required to conduct
annual electrical examinations. In order to
complete the required oversight, these inspectors
would have to make 123 inspections every three
months. That is a tremendous workload – the
math would suggest an almost impossible task.29
To illustrate the problem, just one example
of the type of things that went wrong at Alma
was the inability of company officials to produce
any record that they had performed more than
100 required electrical equipment checks in the
two months prior to the fire. State regulators,
however, were unaware of those violations until
after the fire – because they did not perform their
own required annual electrical inspections for the
two years preceding the fire.
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.
• A delay in notifying the section to
evacuate and the failure to let the section crew
know the severity of the fire resulted in the
loss of the two miners. Because clocks were
not consistent and memories are incomplete, it
is difficult to reconstruct the exact time when
the fire was discovered in the Alma Mine #1 and
when the section crews were told to evacuate.
However, we can draw conclusions from
testimony that the crew left the #2 section as
soon as they learned about the fire. They drove
their mantrip into thick, heavy smoke a short
time later, which suggests that the fire had been
burning for a while.
Currently WVOMHST has no mechanism
for conducting an internal review. Such a
review is urgently needed in this case, in part to
help determine the extent to which manpower
shortages contributed to regulatory failures and
to shed light on the changes needed to maximize
the agencyʼs effectiveness. Although the issue of
increasing WVOMHSTʼs investigatory staff has
been addressed in a previous report, the staffing
still falls short of that needed to effectively
regulate the industry. 30
WVOMHST officials have reconstructed
a time line from computer records that shows
the first sensor alarming at 5:13 p.m. and belts
shutting down at 5:39 p.m. Dispatcher Mike
Brown recounted a conversation he overheard
between belt man Bryan Cabell and his foreman,
Fred Horton, in which Cabell told Horton he saw
flames, and Horton responded, “Get to it.” Brown
did not hear the foreman say anything about
evacuating personnel, but to get to the fire and get
it out.31
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. A joint study aimed at making
determinations and recommendations on how
to maximize the coordination and effectiveness
for use of state and federal resources is in order.
Some of the most urgent and troubling questions
We donʼt know first hand what Horton did
or said because he didnʼt offer testimony to state
and federal investigators. When this conversation
allegedly took place, Horton was not at the scene
of the fire. He heard Cabell talk about flames, but
he did not know the size or ferocity of the fire at
49
they were using.
that point. It is understandable that those miners
who were fighting the fire, with their adrenalin
pumping, believed they could extinguish it and
went to work to do just that.
Even if the evacuation had not occurred
any earlier than it did, no one might have been
lost had the crew walked out their smoke-free
secondary escapeway (the entry where the 48”
belt is located, which is the section belt for the
#2 section, and is also the entry designated as
the “secondary escapeway” for the #2 section)
instead of trying to drive out the primary
escapeway, which led to the mother drive belt
area.
We also donʼt know what other company
officials said or did to get the workers out of the
mine. Only two management people testified
– construction foreman Don Hagy, who wasnʼt
in the mine after the fire was discovered, and
Morrison, who was in his truck getting ready
to go home when he learned about the fire.
(Other company officials sent correspondence
through their lawyers stating that, if subpoenaed,
they would refuse to testify and would instead
invoke their Fifth Amendment rights.) During
the interviews, no one from the company was
identified as the official in charge – and testimony
from the miners indicated that they didnʼt know
who that official was.32
The question was later asked by investigators,
but never satisfactorily answered, as to why
Plumley either made the decision or was
directed to take his men out through the primary
escapeway even though the smoke from the
fire on the mother belt was traveling down the
primary escapeway. Although Plumley refused to
answer questions when called by investigators,
some miners indicated they were aware that a
permanent ventilation control, or stopping, had
been removed from the tailpiece of the 72-inch
belt so the belt could be extended. Without the
ventilation control, there was nothing to stop
the smoke from traveling directly toward the #2
section.35
It is speculative to suggest that we know
what went on in Plumleyʼs mind – and we donʼt
know if he received orders from a superior as
to how to exit the mine. Without doubt, it is
easier and quicker to drive out of a mine than to
walk. But, since Plumley and company officials
above ground knew the fire was at the mother
drive, and, if they were aware of the absence of
the stopping, it is difficult to understand why
the #2 section crew was not ordered to walk out
Looking back, Jonah Rose, who helped battle
the blaze, said he felt the section crews should
have been notified to evacuate when he and Pat
Callaway pulled up to the fire on their manbus.33
“If Bryan [Cabell] or one of them, if a mine
foreman would have called for an evacuation
right then, all of the men would have got out
safely, the longwall, the #2 section, everybody,
and nobody would have perished in that,” Rose
said.34
Roseʼs testimony, and that of Callaway,
suggests that they instead spent precious time
trying to bring the fire under control. At the very
least, those miners working inby the fire area
should have been evacuated at the very moment
Cabell, Callaway and Rose determined they could
not put out the fire with the fire extinguishers
50
the secondary escapeway along the 48-inch belt
above and around the fire.
considered:
• Should mines be ventilated by belt
air? The Aracoma Alma Mine #1 employs a
ventilation technique known as “belt entry air,”
meaning the mine uses its coal conveyor tunnel,
which carries coal out of the mine, to draw fresh
air into the working face. This technique is
permitted by both MSHA and the WVOMHST.
The Coal Mine Safety and Health Act of 1969
prohibited the practice, allowing it only under
a special waiver system. But in 2004 the use of
belt air was legalized on a widespread basis in the
mining community. Whether it is safe to use the
belt entry as the means to intake air to ventilate
the mine is something that has been debated
for many years, and itʼs an issue about which
“In my opinion, the thing that could have
been done to prevent the deaths,” said the #2
section shuttle car operator Pat Kinser, “if we had
actually known the extent of the fire when we left
the section heading that way … we could have
got over on the 48-inch belt before we even hit
the smoke. All of us could have been seeing. And
if we could have done that, we wouldnʼt have
even had to don our rescuers.”36
In addition to the two major questions as to
what caused the fire and why the two miners
perished, other overriding issues should be
The mantrip used by the evacuating #2 Section miners
51
ventilation and safety experts still disagree. Those
supporting it argue that it decreases the number of
entries needed and can therefore increase safety.
The concern is, because the risk of conveyor belt
fires is so high, using belt air further increases the
risk to miners working deep in the mine since the
air traversing the belt would help underground
mine fires spread and send smoke into the mines.
In any event, when belt air is used, additional
safety precautions must be taken, such as the
installation of a continuous carbon monoxide
monitoring system. Regardless of the position
taken by safety experts, itʼs almost unanimously
held that when using belt air to ventilate mines,
conditions should be nearly perfect in order to
assure the safety of workers. Testimony indicates
that this mine clearly did not operate perfectly.
• Did the dispatcher’s lack of familiarity
with the mine have an impact on fire response?
The dispatcher on duty at Alma Mine #1 probably
did the best he could, given his experience of just
over seven weeks on the job and the quality of
the training he testified he received. His lack of
familiarity with the mine combined with the fact
that he failed to understand his responsibility as a
first responder undoubtedly had a negative impact
on fire response. An experienced miner, with
an in-depth knowledge of the mine, adequate
training as to the role of a dispatcher and the
ability to decisively step into an emergency
situation because of that experience and training
might have made the difference between life and
death.
• Did Self Contained Self Rescuers (SCSRs)
work properly? The self contained self rescuers
used at Alma Mine #1 appeared to function
properly. The problem is that SCSR technology
has not been significantly improved during the
past 30 years. Miners who escaped from the #2
section described a number of problems as they
tried to get their rescuers working in a smokefilled mine. They spoke of dropping goggles, of
losing nose pieces, of feeling sick and suffocated
as they tried to breathe with the devices. The
testimony suggests that better equipment should
be developed and that training should involve
actually using – breathing into – the SCSRs.
The training provided by the mine operator was
inadequate. The difficulty the miners had donning
the SCSRs is a training issue.37
Aracoma Alma #1 Mine Inundation and Fire History
January 19, 2006
Conveyor Belt fire on Mother Drive Belt
December 29, 2005
Fire at Tailpiece of #5 Belt (Testimony of
Wyatt Robinson Jr., TR. P. 66, L. 01-17)
December 23, 2005
Fire on Mother Drive Belt (Testimony of
Brandon Conley, TR. P. 31-33)
November 15, 2004
Water Inundation (WVOMHST Reports)
52
Finally, and most significantly, the question
of responsibility for the deaths of Ellery Hatfield
and Don Bragg must be addressed.
The failure to recognize the fire’s potential,
not being able to hook up the fire line, and
then not having water in the system, made for
a perfect storm in the Alma Mine #1. The two
victims’ lives could have been saved with early
intervention and a fire suppression system that
worked. The responsibility to maintain and
assume a workable fire suppression system rests
with the mine operator.
The WVOMHST and MSHA could have
and should have done a better regulatory job,
both before and after the incident. However,
responsibility for an employee’s health and safety
rest with the mine operator. Massey Energy.
Since it opened, Alma Mine #1 has had its
share of problems. On Nov. 15, 2004, the mine
was flooded when a continuous miner operator
cut into an adjoining old mine, unleashing 40 to
60 million gallons of water. The inundation was
described as serious by WVOMHST inspector
Richard Boggess, who investigated the incident
with MSHA inspector Roger Richmond.38
Investigators determined that the problem
was inaccurate mine maps. A certified map
erroneously showed the old mine some 700 feet
away from its actual location. Fortunately, no
one was injured and the mine was evacuated
within ten minutes, according to the investigation
report.39
Rich Kline, assistant district manager
of technical programs for the Mount Hope
MSHA office, said he went to the mine after
the inundation “to see what they had done, why
they had cut into it, what went wrong with the
engineering.”40
Kline, too, concluded that the maps were
wrong.
“Aracoma was a mess,”41 he said during
testimony following the January 19 fire. “They’re
getting the coal out and not keeping the mine
system proper.”42
Kline said on another occasion, he issued a
citation for icing on the portal when the box cut
was installed. Kline described the condition as
“overhanging ice with miners underneath so there
was a possibility of grave fatal injuries there.”43
Boggess said at a time when the state required
inspectors to keep a list of mines that presented
the most problems, the Alma Mine #1 was at the
top of his list.44
Bill Gillenwater, the supervisory inspector at
MSHA’s field office in Logan, said it was hard
to get a handle on the management structure
at Aracoma and that made regulation difficult.
“They’re not open about who is responsible for
what,” Gillenwater told investigators.
“And it was hard to find out, who do we
talk to about this. And then you could go at any
given day, and you’d always find a new name or
a new face to talk to. It was hard to work with
this company, to have understanding of who was
responsible for what. They didn’t want to make
that known, I don’t think,” he said.45
During the investigation and interview,
Donald R. Hagy, outby foreman at Alma Mine
#1, identified an October 19, 2005, memorandum
53
from Massey Energy CEO Don Blankenship to
all deep mine superintendents that he read into
the record of the state and federal investigation:
“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 coal pays the bills.”46
Since mining began on a large scale in 1890,
all too frequently West Virginia has led the nation
in both the number and rate of fatal and nonfatal
accidents. Unfortunately, that history continues
into this century.
Within the state, mines in the southern
coalfields area where Aracoma is located are
especially dangerous. A 1996 report from
the Mine Safety and Health Administration
concluded that, during the period from 1991 to
1995, 28 percent of the nation’s mine deaths
occurred in southern West Virginia, where only
13 percent of the national workforce is located.50
What did that mean to him, Hagy was asked.
“Well, it sounds as if they don’t want you to shut
production down to go build an overcast or do
construction jobs,” he said.47 And how would he
feel if, as a section boss, that memo were laid in
front of him. “You would feel that you wasn’t
running enough coal from the way it sounds, “he
said.48
Between 1991 and 2000, 116 of 428 fatalities
nationwide, or 25 percent, occurred in southern
West Virginia, which continued to employ only
13 percent of the nation’s mining force.
That is not to say that there have not been
improvements in miner safety in the past ten
years. During that time, fatal and non-fatal
accidents have declined, both in West Virginia
and the nation, and in 2005 there were only three
fatal accidents in West Virginia mines, an all-time
A second memo from Blankenship was sent a
week after the first to try to clarify the company
position. “Last week I sent each of you a memo
on running coal,” Blankenship wrote. “Some of
you may have interpreted that memo to imply
that safety and S-1 [a Massey Energy safety
program] are secondary. I would question the
record.
Clearly, many mines are addressing mine
safety and health considerations, and many West
Virginia mines operate safely day in and day
out. In addition, many mine companies operate
mines day after day, week after week, month after
month without serious lost time accidents. These
companies spend the time, money and energy
to train and equip their workforce and correct
potentially dangerous conditions before they pose
a threat to their workers. Sadly, not all mines
membership [sic] of anyone who thought that I
consider safety to be a secondary responsibility.
“The point is that each of you is responsible
for coal producing sections, and our goal is to
keep them running coal. If you have construction
jobs at your mine that need to be done to keep it
safe or productive, make every effort to do those
jobs without taking members and equipment from
the coal producing sections that pay the bills.”49
54
0302 Wyatt Robinson TR. P. 92, L. 18-20
0302 Wyatt Robinson TR. P. 106, L. 01-09; L. 17-19
14
Information obtained from state officials.
15
0309 Donald Hagy TR. P. 10, L. 13-15; TR. P. 52-56
16
MSHA and WVOMHST records
17
18
19
See Transcripts of Cabell, Calloway
20
0210 Cabell TR. P. 44, L. 10-19
21
0216 Callaway TR. P. 49, L. 04-12
22
0224 Jonah Rose TR. P. 177, L. 10-11
23
Information supplied by MSHA
24
0330 Minness Justice TR. P. 40, L. 01-17
25
26
27
0308 Ronald Hixson TR. P. 20, L. 14-25;
TR. P. 21, L. 01-02
28
Information provided by State Officials
29
Information from Dennie Ballard was obtained
from state officials in the command center at Alma.
30
McAteer Report to Governor Bob Wise
31
0224 Gary Brown Tr. P. 97, L. 01-05
32
See testimony of Gary Brown, Pat Callaway,
Carl White, Shane Stanley
33
0224 Jonah Rose TR. P. 181
34
0224 Jonah Rose TR. P. 181, L. 20-25; TR. P. 182, L. 01
35
See M. Plumley transcript
36
0208 Pat Kinser TR. P. 88, L. 23-25; TR. P. 89, L. 01-08
37
See Joe Hunt, Pat Kinser, Billy Mahorn TR
38
West Virginia Office of Miners Health Safety & Training
39
Source – Accident Report of the State
40
0323 Rich Kline TR. P. 26, L. 22-24
41
0323 Rich Kline, TR. P. 109, L. 16
42
0323 Rich Kline TR. P. 111, L. 10-12
43
0323 Rich Kline TR. P. 25, L. 16-19
44
Information from Boggess obtained from state officials
45
0331 Bill Gillenwater TR. P. 45, L. 21-25;
TR. P. 46, L. 01-06
46
0309 Donald Hagy – EXHIBIT B – TR. P. 120,
L. 16-25; TR. P. 120, L. 01
47
0309 Donald Hagy TR. P. 121, L. 03-06
48
0309 Donald Hagy TR. P. 125, L. 17-19
49
Appalachian News Express, Pikeville, Ky., 2-24-06
50
McAteer Report to Governor Bob Wise
12
make that necessary commitment – and miners
pay the price.
13
Thus far in 2006, mine deaths in West
Virginia have skyrocketed to 23, a level unseen
since 1981. All in the mining community hope
that this is not a trend but an anomaly. However,
we must act to ensure that it does not continue.
Companies whose fatality rates exceed the
national average must commit to change and
they must do it now. Those that do not must be
held accountable by the West Virginia Office of
Miners’ Health, Safety and Training. Those mines
that experience higher than average accident rates
must be brought into line through education,
compliance assistance and tough enforcement.
The state’s coal miners deserve no less.
SOURCES
0323 Rich Kline TR. P. 109, L.1
MSHA and WVOMHST records
3
4
Source – MSHA Inspection Reports;
Charleston Gazette, Ken Ward, 3/12/06
5
0209 Brandon Conley TR. P. 30, L. 17-20
6
0209 Brandon Conley TR. P. 31-33
7
8
9
10
0302 Wyatt Robinson TR. P. 76-78
11
1
2
55
Map of Northeast Mains and Longwall Panel
of Aracoma Alma Mine #1
56
8
RECOMMENDATIONS
4. Mine electrical systems should be
designed for easy isolation of critical
systems during mine emergencies.
1. The West Virginia Office of Minersʼ
Health, Safety and Training inspection
force must be brought up to full strength
and supplemental hiring undertaken in
light of industry production levels. Salary
levels should be raised to ensure that
qualified personnel are attracted to take
and keep positions.
5. State and federal regulations relating to
the prevention of fires on conveyor belts
must be vigorously enforced.
6. Requirements relating to pre-shift, onshift and weekly examinations by the
mine company must be vigorously
enforced.
2. A joint federal and state study should be
immediately undertaken aimed at making
determinations and recommendations on
how to coordinate and maximize state and
federal resources to ensure the safety of
coal mines.
7. State and federal inspections must ensure
compliance with regulations.
3. Electrical inspectors must be hired so
that the state has a full complement
of inspectors capable of undertaking
mandated electrical inspections.
8. Undertake a statewide comprehensive
study of the use of intake air over belt
entries to determine whether belt air
57
should be used and, if so, under what
conditions.
12. Develop and annually update
comprehensive emergency plans. Each
underground mine operator should be
required to annually conduct a tabletop
mine evacuation exercise. Having a plan
is not sufficient. It needs to be practiced
and to include all employees.
9. Enact new state legislation that requires
every company to conduct a complete
mine-by-mine inspection of each
conveyor belt and maintain on site a
certified statement from the principal
office of each parent company that the
belt is meeting all requirements of the
state provisions and that the emergency
equipment – CO monitors, etc. – is fully
operational.
13. Require implementation of an improved
communication and tracking system at
every underground location.
14. Through emergency rule-making,
manufacturers should be required to
attach SCSR goggles to the SCSR case
by an easily detachable lanyard to prevent
them from being lost when opening the
SCSR in a dark or smoky environment.
10. Adopt a regulation that requires each
mine superintendent and mine engineer
to certify each quarter that the mineʼs
safety equipment, including CO monitors,
SCSRs, water supply, sprinkler systems,
etc., are in proper working order. The
failure of any system or a citation
indicating it is not in working order would
result in the suspension of the engineerʼs
license. Falsification of records would
result in the mine superintendent being
barred from serving in that or any other
senior management capacity and would
result in the revocation of his foremanʼs
certificate if he possesses one. The
certifications are to be filed with the West
Virginia Office of Minersʼ Health, Safety
and Training.
15. Mine maps must be kept updated and
filed electronically with the WVOMHST
and MSHA so they can be monitored to
ensure they are kept up-to-date and so that
they are available to rescue teams when
needed.
16. Coordinate mine rescue efforts with
emergency management at the state and
county levels so that all resources can
be made available. For instance, rescue
teams in waiting at Aracoma could have
had access to fire department facilities to
permit rest during the waiting period.
11. Implement the requirement for refuge
chambers at every underground mine.
58
strengthening the tripartite mine rescue
model through which state, federal and
company officials share responsibilities
under section 103(k) of the Mine Act;
enhancing the importance of mine rescue
and making a mine rescue director part
of top management in WVOMHST and
MSHA; conducting mock disaster drills
to test the emergency preparedness of
state and federal officials, mine operators
and the community; evaluating the
inventory of available mine emergency
operations and equipment and replacing
obsolete equipment with state-of-theart; continually evaluate and enhance
emergency equipment and require post
emergency medical examinations for
any miner or rescuer exposed to toxic
substances or other threats to life and
health in the course of a mine emergency.
17. Contract employees should receive the
same level of training and supervision as
full-time employees.
18. WVOMHST and MSHA should adopt
the National Incident Management
System (NIMS) Incident Command
Model, a nationally recognized
emergency incident management system.
While most emergency situations are
handled locally, a major incident may
require help from other jurisdictions,
the state, and federal government.
NIMS sets out procedures that allow
responders from different jurisdictions
and disciplines to work together to better
respond to emergencies through a unified
approach to incident management.
Such a system improves coordination,
cooperation and communication between
public and private entities.
2. The steps to support escape in an
emergency: training miners to don and
use breathable training model SCSRs in a
dark, smoke-filled environment; involving
miners in field-testing competing SCSR
brands; evaluating the existing 10-year
shelf life allowed for SCSRs; requiring
operators to store sufficient numbers of
SCSRs underground and ensure that they
are not stored in environments likely
to compromise the unitsʼ performance;
conduct an independent evaluation of the
current NIOSH protocol and procedures
for examining SCSRs recovered in mine
A number of recommendations made in
the Sago Mine Disaster report also are
applicable here. They include:
1. The steps to Advance Mine Emergency
Preparedness: requiring more rigorous
education and realistic training; requiring
specialized training for management
personnel expected to serve in a
position of responsibility in a mine
emergency command center; providing
a liaison to families; reaffirming and
59
retire the obsolete seismic system and
encourage research on next-generation
seismic technology and equipment; invite
the Incorporated Research Institutions
for Seismology (IRIS) and other
professional entities to participate in the
2nd International Mining Health & Safety
Symposium.
disasters; require SCSR manufacturers
to improve reliability by redesigning
temperature and moisture indicators;
and accelerate the development of nextgeneration SCSRs by establishing an
awards competition for a prototype fullface or half-face breathing apparatus for
miners.
4. The Steps to Enhance Cooperation:
provide updates to the Alma families and
the public on progress made to improve
mine safety and the mine rescue system
in West Virginia; examine methods to
improve accident investigation protocols;
encourage voluntary cooperation and
commitment to get new equipment,
technology and best practices
underground with all possible speed;
abandon old myths and misinformation
about the reliability of safety and health
technologies and replace them with hard
facts and science-based determinations.
3. The steps to strengthen the mine rescue
system: establish a West Virginia-based
National Mine Rescue Committee to
review the rescue systemʼs structure,
equipment and response strategies and
to make recommendations to strengthen
the system to be delivered at the 2nd
International Mining Health & Safety
Symposium in 2007; develop a skillsranked or tiered scale for mine rescue
teams; enhance mine rescue training
to include in-mine drills; issue a mine
rescue team member identification card;
60
Mine Rescue Teams that responded
at Aracoma Alma Mine #1
ARCH COAL COMPANY
Mingo Logan Mountaineer Team
Lone Mountain Mine Rescue Team
CONSOLIDATED COAL COMPANY
Buckhannon Mine Rescue
VP-8 Mine Rescue
Consol of Kentucky
DICKENSON-RUSSELL COAL COMPANY
Dickenson-Russell Mine Rescue
EASTERN ASSOCIATED COAL CORPORATION
Harris Southern Appalachian Team
Federal No. 2 Team
EXCEL MINING COMPANY
Excel Kentucky
Excel Illinois
FOUNDATION COAL
Riverton Mine Rescue Team
Emerald Mine Rescue Team
Cumberland Mine Rescue Team
JEWELL SMOKELESS COAL CORPORATION
Jewell Smokeless No. 1 (A Team)
Jewell Smokeless No. 2 (B Team)
MASSEY ENERGY
Massey Energy Southern West Virginia Team
Massey Energy East Kentucky Team
MINE SAFETY AND HEALTH ADMINISTRATION MINE EMERGENCY UNIT
MOUNTAINEER NO. 1 (Gold Team) MINE RESCUE ASSOCIATION, INC.
MOUNTAINEER NO. 2 (Blue Team) MINE RESCUE ASSOCIATION, INC.
OFFICE OF MINERSʼ HEALTH SAFETY AND TRAINING MINE EMERGENCY TEAM
PARAMOUNT COAL COMPANY
Paramount (Blue Team) Mine Rescue
PINNACLE MINING COMPANY
Pinnacle Blue Team
Pinnacle Gray Team
POCAHONTAS MINE RESCUE ASSOCIATION, INC.
SOUTHERN COALFIELD MINE RESCUE ASSOCIATION
61
Acknowledgments
I wish to express my appreciation to our investigative team – Beth Spence, Celeste Monforton,
Thomas N. Bethell, Joseph W. Pavlovich, and Deborah Carpenter Roberts – for their work in the
investigation of both Sago and now Aracoma Alma. I am especially indebted, in this instance, to Beth
Spence and Deborah Roberts, whose continuing efforts ensured the completion of this report.
Special thanks go to Wheeling Jesuit University, its board of directors and interim president James
Birge, PhD. I also thank WJU’s past president, Reverend Joseph R. Hacala, S.J. Without his
understanding, support and compassion, this report would not have been possible.
As I noted in the transmittal letter on the opening pages of this report, we owe a deep gratitude to the
families of the victims of the Aracoma Alma Mine disaster.
As with the Sago report, we thank the students of Wheeling Jesuit University, West Virginia Wesleyan
College, West Virginia University, University of Charleston and Marshall University, who volunteered
immediately following the disaster and in the months which followed. It makes me proud as a West
Virginian that these young people stepped up to help.
We want to express our gratitude to the many individuals – whether in state and federal agencies,
companies, professional or private life – whom we have called upon for advice, guidance and
expertise in the preparation of this report. And we are grateful to the hundreds of individuals who
have contacted us with ideas and suggestions about how to improve mine safety and health in West
Virginia and across the nation.
This investigation has been supported by the State of West Virginia and its Governor, Joe Manchin III.
We thank Governor Manchin and his staff for their support and assistance during this investigation
and preparation of the report.
The list of names that follows encompasses, we hope, most of those who have been involved in one
way or another with our work over the past nine months. Inevitably, however, there are bound to
be omissions. We apologize for that, and hope that anyone whose name should have appeared here
will be brought to our attention for future correction. I wish to note an omission in the Sago Report
acknowledgements. We neglected to mention the American Friends Service Committee and W.
Clinton Pettus, the regional director of AFSC’s Middle Atlantic Region. Their help and support in
both investigations has been invaluable.
J. Davitt McAteer
62
American Friends Service Committee ● Jonathan Andrew ● Kent Armstrong ● Dr. James
Birge ● Mrs. Delorice Bragg and Family ● U. S. Senator Robert C. Byrd ● State Delegate
Mike Caputo ● State Senator Don Caruth ● Mary Ellen Cassidy ● Elizabeth Chamberlin ●
Skye M. Chernicky ● Robert Cohen, MD ● Doug Conaway ● Jack Cottle ● Steve Cox ●
James Dean ● Christo de Klerk ● Mary Doane ● Earl Dotter ● Chuck Edwards ● Yvonne
Farley ● Alan Fine ● Mike Foletti ● Brian France ● State Delegate Eustace Frederick
● Bruce G. Freedman, MD ● Autumn D. Furby-Pritt ● Jimmy Joe Gianto ● Richard T.
Gillespie ● Bobby Godsel ● Michael Griffin ● Father Joseph R. Hacala, SJ ● Joan T.
Hairston ● State Delegate Bill Hamilton ● Mrs. Freda Hatfield and Family ● Monte Hieb ●
Yvonne Johnson ● State Senator Jeff Kessler ● State House Speaker Bob Kiss ● Sam Kitts
● Betty Lassiter ● Pete Lilly ● Tricia Lollini ● Ty Lollini ● Kathleen M. Long ● Kathryn
G. Lough ● State Senator Shirley Love ● Joseph P. McAteer ● Timothy O. McAteer ●
Professor Joyce McConnell ● Professor Pat McGinley ● Darrell V. McGraw, Jr. ● David
Michaels ● Mine Safety and Health Administration ● Kenneth A. Murray ● Paul Myles ●
Kraig R. Naasz ● National Institute for Occupational Safety and Health ● National Mining
Association ● Dennis O’Dell ● Dennis Packer ● C. A. Phillips ● U. S. Congressman Nick
J. Rahall ● Bill Raney ● James Rau ● Christopher C. Riley ● Lawrence H. Roberts, MD
● U. S. Senator John “Jay” Rockefeller ● Kathy Sloan ● Dave Stuart ● Ryan A. Thorn ●
Senate President Earl Ray Tomblin ● Bill Tucker ● U.S. Department of Labor ● United
Mine Workers of America ● Suzanne Weise ● West Virginia Office of Miners Health
Safety and Training ● West Virginia Board of Mine Health & Safety ● West Virginia
Coal Association ● West Virginia Department of Homeland Security ● Wheeling Jesuit
University Board of Directors ● Eugene White ● Rick Wilson ● Paul Ziemkiewicz
63

The Fire at Aracoma Alma Mine #1

Transcription

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