Last Updated May 20, 2011 3:53 PM EDT
In short, over a 13-month investigation the team found Massey could have prevented the worst mining accident in 40 years. Instead, the company knowingly broke law and disregarded safety practices to produce more coal and make more money.
The report itself is a riveting read with characters like Gary "Spanky" Quarles, a six-foot, nearly 300-pound man who was scared and dreaded going to work in the mornings. Or Howard "Boone" Payne, a roof bolter with flaming red hair who confronted management about the lack of air in the underground mine.
The violations and discoveries are too numerous to list. Here are five that stand out as especially tragic.
Miners didn't have air, and the bosses didn't care
The McAteer report dedicates an entire chapter to the "lack of air: issue. The team discovered that poor -- even absent -- ventilation was a chronic problem. Management didn't respond respond to complaints, and sometimes did worse.
For example, section foreman Dean Jones came home practically every day complaining there wasn't enough air, his wife said. He told his bosses about the problem, but action was never taken. When Dean finally took matters in his own hands and shut down the section for lack of air, this is how his boss responded.
Chris Blanchard called the dispatcher and told him to tell Dean if he didn't get the section running in so many minutes he would be fired. Being fired was a scary prospect for a man whose 14-year-old son had a serious illness. "Chris Blanchard knows that my son has cystic fibrosis, he knew my husband needed the insurance and would have to work," [Dean's wife] said.Most of the miners killed in the explosion had black lung disease
This surprising detail got little media play, although Ken Ward over at Coal Tattoo made special note of it. The McAteer investigating team had a expert in occupational diseases examine the autopsy reports to determine the prevalence of coal workers' pneumoconiosis (CWP), also known as black lung disease. Here's what it found (note the examiner was unable to make a determination on five of the victims):
Seventeen of the 24 victims' autopsies (or 71 percent) had CWP. This compares with the national prevalence rate for CWP among active underground miners in the U.S. is 3.2 percent, and the rate in West Virginia is 7.6 percent. the ages of the UBB victms with CWP ranged from 25 to 61 years.Mining regulators failed at their job
The McAteer team found numerous problems with the Mining Safety and Health Administration, which it accused of overlooking potentially deadly ventilation problems and ignoring other risks. One troubling discovery was the agency's decision to not use enforcement tools that could have pushed Massey to comply with safety standards.
Mining safety laws allowed regulators to issue flagrant violations with fines up to $220,000 against companies that repeatedly failed to meet safety standards. Massey was an ideal candidate. Inspectors spent 1,854 hours at the UBB mine and wrote 515 citations in 2009 alone.
Even though MSHA had used this authority more than 125 times at coal mines over the past five years, issuing fines of $19.5 million, the agency never issued Massey a flagrant violation. As the McAteer team put it, "the disaster at Upper Big Branch mine is proof positive that the agency failed its duty as the watchdog for coal miners." What's more disturbing is that the agency was falling short of its responsibilities and its highest-ranking officials were aware of the problem.
On March 25, 2010 â€" less than two weeks before the disaster â€" MSHA chief Joe Main submitted a required report to the U.S. Senate Appropriations Committee, which outlined widespread lapses in enforcement.A 'window dressing' safety program
Former CEO Don Blankenship has defended Massey's safety record with gusto and asserted that the company never placed profits over safety. The investigating team found quite the opposite.
For example, section foreman were required to fill out six reports at the beginning, during and end of every shift. Those reports tracked the continuous miner load rate, shuttle car haul rate, feeder dump rate, roof bolt per row rate, average cut depth and linear foot per continuous miner.
There is nothing on the daily forms that reflects measures of safety, such as pounds of rock dust applied by machine or linear feet of accumulated float coal dust removed.Methane detectors weren't used
The McAteer team downloaded data from the methane detectors used by foreman Jeremy Burghduff between September 2009 and April 23, 2010. In the six weeks before the disaster -- a time when he was supposed to be checking for hazardous conditions -- the device wasn't turned on during at least 25 of his work shifts. The problem extended beyond Burghduff.
Data downloaded from methane detectors indicated that devices used by other foremen also had not been turned on at times when the foremen were underground and responsible for identifying hazardous conditions.This wasn't a case of forgetfulness. Testimony suggested the methane detectors on equipment had been disabled so that production could continue without taking time to make repairs.
Photo from Flickr user fakeelvis, CC 2.0