An Independent Panel Assessment of an internal review of MSHA enforcement actions at the Upper Big Branch Mine South; requested by the Honorable Hilda L. Solis, Secretary, U.S. Department of Labor
Published Date:March 22, 2012
Corporate Authors:National Institute for Occupational Safety and Health. Independent Assessment Panel,
Coal Mines And Mining
Upper Big Branch Mine-South Disaster, Raleigh County, W. Va., 2010
Accident Investigation/West Virginia
Coal Mines And Mining/West Virginia/Raleigh County
Coal Mining/West Virginia
Mine Explosions/West Virginia/Raleigh County
Occupational Health/West Virginia
Description:Executive summary -- I. Background -- A. Charge from Secretary Solis -- B. Independent Panel membership -- C. Initiation of MSHA Internal Review -- D. Interactions between the Independent Panel and the MSHA Internal Review Team -- E. Criteria used by MSHA Internal Review Team -- F. Independent Panel assessment to Secretary Solis -- -- II. Assessment of MSHA Internal Review process -- A. General findings -- B. MSHA employee interviews -- 1. Transcripts of employee interviews -- 2. Assessment of employee interviews -- a. Findings obtained from employee interviews -- b. Interview techniques by MSHA Internal Review Team -- C. Limitation of Section 1204(b) -- D. IP conclusions about MSHA IR process -- -- III. Assessment of MSHA Internal Review conclusions -- A. Mine operator's responsibility for the UBB explosion -- B. MSHA's enforcement performance deficiencies at UBB -- C. Causal connection between MSHA's enforcement performance deficiencies and its failure to prevent the UBB explosion -- 1. Preventing fictional ignition -- 2. Preventing a fuel source for the initial gas explosion -- 3. Preventing the dust explosion -- 4. Conclusion -- -- IV. Assessment of MSHA Internal Review recommendations -- A. Major categories of MSHA Internal Review recommendations -- B. Independent Panel's overarching concerns with MSHA IR report recommendations -- -- V. Independent Assessment Panel recommendations -- A. Modifying the enforcement paradigm -- B. Improving the scope and value of MSHA's internal reviews. -- 1. Revise Section 1204(b) -- 2. Utilize specially trained, outside interviewers -- C. Independent oversight to ensure successful implementation -- D. Establishing a technical foundation for improved practices -- -- VI. Acknowledgements -- -- Appendix I. Charge from Secretary Solis -- Appendix II. Biographies of Independent Panel members -- Errata sheet: March 23, 2012.
"Following the explosion at the Upper Big Branch Mine South, the Secretary of the U.S. Department of Labor, Hilda L. Solis, requested that the Director of the National Institute for Occupational Safety and Health identify a panel of individuals with relevant experience to conduct an independent assessment of the Mine Safety and Health Administration (MSHA) Internal Review (MSHA IR) of MSHA enforcement actions at the UBB. Four experts in areas relevant to MSHA's UBB enforcement activities were appointed by the Director to serve as members of an Independent Assessment Panel (IP). In June 2010, the IP met with the MSHA IR Team for the first time. Over the ensuing 18 months, seven conference-call meetings between the IR Team and the IP were help. On February 23, 2012, the MSHA IR Team provided its IR Report to the IP and on March 22, 2012, the Independent Assessment was provided to Secretary Solis. After review the MSHA IR Report in detail, the IP does not take exception to the Report's conclusion that the mine operator, not MSHA, caused the explosion. However, the IP believes that the characterization of the facts underlying this conclusion understates the role that MSHA's enforcement could have had in preventing the explosion. Had the MSHA IR Team considered the causation issues from a broader viewpoint, the IP believes that the Team could have posed, and addressed, the question: would a more effective enforcement effort have prevented the UBB explosion? The IP believes that had the Team addressed this question, it would be in a better position to help MSHA define and prioritize its recommendations and succeed in implementing them." - p. i
"The views expressed by the Independent Panel do not necessarily represent the views of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, or the U.S. Department of Health and Human Services."
Supporting Files:No Additional Files
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