Better charts were nearby in government office
By Dennis B. Roddy
Pittsburgh Post-Gazette (Pennsylvania)
Copyright 2007 P.G. Publishing Co.
CHARLESTON, W.Va. — Rescue teams sent into a burning mine to save two missing men and extinguish the spreading blaze were handed inaccurate maps that put them in greater danger while an updated map sat in a government office in another town, according to the federal inspector in charge of overseeing safety at that mine.
Minness Justice, who inspected the Aracoma Coal Co.'s Alma No. 1 Mine for the federal Mine Safety and Health Administration, had cited the Logan County mine a month earlier when he discovered that its working map was incorrect, showed air flowing in the wrong direction, and listed underground doors and walls where there were none.
E-mails and notes by Mr. Justice show repeated telephone calls to MSHA’s District 4 headquarters in the days leading up to the fire that killed two miners at Aracoma Alma. Those notes suggest that Mr. Justice was pressing the district headquarters to complete and approve a new map of the mine.
Federal investigation transcripts also show that MSHA officials were meeting in District 4 headquarters in Mount Hope, 75 miles to the east, to discuss the map revisions the day the fatal fire erupted, but apparently did not send for the updated map as rescue teams went underground to fight the blaze and search for the missing men.
Mr. Justice later was placed under investigation by both an internal review team from MSHA and the Office of the Inspector General.
The internal review investigators sought to determine whether he and another MSHA inspector, Edward Paynter, had overlooked dangerous conditions at Aracoma Alma when they examined the mine. Sources indicated that both men have been cleared of wrongdoing by the internal review team.
Assigned to Aracoma Alma near the end of 2005, Mr. Justice repeatedly cited the mine for unsafe conditions ranging from bad ventilation to accumulations of coal debris on several of its conveyor belt lines.
Mr. Justice, in e-mails to MSHA investigators this year, demanded to know why they apparently had not interviewed officials at the Mount Hope district office who would have known about the revised map that he said could have been given to rescue team members.
Several rescue workers complained they were sent into a burning mine with faulty maps.
“While this more accurate map was lying in the office at Mount Hope, mine rescue teams were risking their lives with inaccurate maps provided to them,” Mr. Justice wrote to Kenneth Murray, who is heading the official MSHA investigation into the Aracoma Alma fire.
That e-mail, dated Feb. 20 of this year, follows a year in which Mr. Justice has remained largely silent on the mine fire while awaiting the outcome of several investigations, including a criminal probe opened last year by the U.S. attorney in Charleston.
Contacted yesterday at MSHA’s mining academy, where he has been posted pending completion of the multiple investigations, Mr. Justice declined to comment on the documents obtained by the Pittsburgh Post-Gazette.
Federal investigators are looking into allegations that key “stoppings” -- walls designed to direct and separate airways inside mines -- were missing, allowing smoke to wash into an escape route being used by miners as they fled the fire. Two of those men, Don I. Bragg and Ellery Hatfield, became lost in the dense smoke that poured into the escape route and later died of smoke inhalation.
Within hours of the fire, Mr. Justice also discovered that the mine’s carbon monoxide detection system, which serves as a fire alert system, had registered alarms both at 9:30 a.m. and 2:30 p.m. the day of the fire, but that those reports were not entered into the logbook kept in the mine office and that the system was reset and work was not interrupted.
Both the mine logbook and the mine’s official working map later could not be located, but Mr. Justice kept notes -- later turned over to investigators and which have been examined by the Post-Gazette -- showing the earlier alarms that were ignored. When MSHA investigators attempted to examine the electronic records kept in the mine’s computer system, they discovered that someone had attempted to erase the hard drive.
Federal prosecutors are expected to make a decision on whether to issue indictments in the case within three months. The separate MSHA investigation into the fatalities is expected to be made public by the end of March.
Mr. Justice, in his e-mail to Mr. Murray, complained that the MSHA probe into the tragedy failed to zero in on why the more accurate map was not retrieved in time for officials to give it to rescue teams, and also questioned why the MSHA panel failed to interview three men from the district headquarters.
Naming ventilation specialists at MSHA’s District 4 headquarters who he says would have seen the new map, Mr. Justice asked why they were not summoned for questioning.
“We would like to know why Bill Ross, Raymond Browning and Dave Morris were not interviewed,” Mr. Justice wrote. “It appears that they have a great deal of information concerning MSHA’s involvement with the map Simon Stepp submitted a week prior to the accident.”
In an interview with MSHA investigators, transcripts of which were released last year, Mr. Stepp, who had worked for Massey Energy, the mine’s owner, for only a few months, said he had submitted an updated map of the mine after Mr. Justice cited the company for what he called a seriously flawed map. Among complaints about the map was a finding that it showed air flowing in the wrong direction.
He told investigators he talked with the ventilation department and submitted a new map one week before the accident, but that there were delays in getting it cleared.
“I gave them the map that I had, showed them the ventilation route way, the way it was supposed to be and showed it to them and saying what else is on there and what — basically wanted some help with it, so they could help me out with it and try to get the map right,” Mr. Stepp said. “And it sat there for a week. I gave it to Raymond Browning one week before the accident and the map sat there for a week.”
MSHA officials interviewed by the investigating team said they were unclear about what changes Mr. Stepp wanted to make in the map.
On Jan. 19 of last year — hours before the fire broke out at Aracoma Alma — Mr. Stepp and MSHA officials said they met at the Mount Hope office to discuss the map again.
“And they talked, they said it looked fine, you just need to show exactly what I changed,” Mr. Stepp later testified. “They didn’t want to look at the whole map, so they just wanted to look at that -- those areas that changed. And I showed them, but they wanted something a little more concrete.”
With the updated map still at the Mount Hope office, the men departed for the day. At the same time, an office dispatcher at the Aracoma Alma Mine noticed a spike in carbon monoxide levels along one of the mine’s conveyor belts. A defective set of rollers had caused enough friction to ignite a fire. Fire suppression sprinklers failed to work because a valve had been turned off and a fire alarm failed to sound because it did not have a battery.
According to the Feb. 20 e-mail Mr. Justice sent to investigators, Luther Marrs, the assistant director in charge of the Logan field office of MSHA, which oversees Aracoma Alma, would likely have known about the availability of a revised map.
“Mr. Marrs and Rich Kline [another MSHA official] had a meeting with Bill Ross a few hours prior to the accident,” Mr. Justice wrote. He said the men “had prior knowledge that there was a mapping problem at the mine prior to the accident, but yet none of them came forward to question Massey even after mine rescue were complaining about the maps. Kenny, all of these people were at the mine site during the first 12 hours, why did they not come forward and question [Massey’s] direction for the mine rescue operations.”
Mr. Marrs was interviewed by MSHA accident investigators and confirmed that he had attended a meeting on the revised map the day of the fire. Later that day, he testified, the head of one mine rescue team, while being debriefed by Drexel Short, a Massey official, complained of inaccuracies in the map given to rescuers. Reached yesterday at his office, Mr. Marrs declined to comment.
In another e-mail, this one to Allen Dupree, an MSHA official heading up the internal review inquiry into handling of the Aracoma Alma fire, Mr. Justice said he personally attempted to bring the inaccuracies in the map to the attention of MSHA and company officials in the debriefing room at the mine as the rescue was beginning.
“Again we ask why the two top officials of District 4 did not take action on the information that they had concerning the mapping problems, and why they never ask[ed] me a single question about the inaccurate maps, even though I brought it to the attention of people in the debriefing room the short time I was allowed in there,” Mr. Justice wrote.
His e-mail to Mr. Dupree also reported that families of miners involved in the emergency attempted to point out errors in the map during a meeting with government officials.
Rescue workers who went underground to search for the lost miners and to fight the fire said they were hampered by the erroneous map, which left the wrong impression about which way air was flowing inside the mine.
“Common sense tells you that you fight a fire with the fresh air at your back so you know what you’re doing. We were fighting the fire, the heat and smoke was hitting us in the face,” said Mark Taylor, a rescue worker with the Southern Coal Fields Mine Rescue Team.
Another rescue worker, Charles Bradley Justice -- who is not related to Minness Justice -- told investigators the erroneous map delayed both the rescue and firefighting. Although he did not believe the teams likely could have saved Mr. Bragg and Mr. Hatfield, with an accurate map “we could have possibly gotten to the guys quicker.”
“There’s a lot of areas the ventilation controls were shown to be in place,” he told investigators. “They were not there. And that changed the entire outcome of this event.”