Independent Review of MSHA's Actions at Crandall Canyon Mine

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GENERAL CONCLUSION Internal Reviews conducted by MSHA since 1989 indicate that many deficiencies were repeatedly identified. The “Corrective Actions” taken by the Agency to address the identified deficiencies in many cases were to increase documentation requirements for enforcement personnel. Increased documentation did not eliminate these problems. Rather, it appears that the corrective actions resulted in additional paperwork that was detrimental to the Agency’s performance. Many inspection personnel stated that the increased documentation distracted them from their primary goal of conducting inspections, lowered morale, and has not enhanced the safety of miners. In July 2007, a 2-day meeting was held for Coal Mine Safety and Health managers, supervisors, and conference/litigation representatives to discuss the 150+ deficiencies that were identified by the Sago, Aracoma Alma, and Darby Internal Review teams. Most of the meeting focused on the deficiencies, recommendations, and corrective actions that were identified by the reviews. The Crandall Canyon Independent Review Team identified some of the deficiencies discussed at the meeting also occurred during the rescue operation at the Crandall Canyon Mine, which was less than a month after the meeting. Some of the repeated deficiencies were related to command center security, briefing, debriefing, and § 103(k) order issues. The deficiencies and recommendations identified in this report are intended to enhance MSHA’s performance in protecting the health and safety of the Nation’s miners. The Independent Review Team hopes that the recommendations will result in significant changes that will improve MSHA’s roles in administering the Mine Act and its implementing regulations. MSHA’s corrective actions should result in positive steps being taken to eliminate the deficiencies, and not simply by increased documentation requirements or inadequate training. 146
Signature Page This report is submitted in response to your request that an independent review be conducted of MSHA's actions at the Genwal Resources, Inc. Crandall Canyon Mine. Respectfully submitted, Earnest C. Teaster, Jr. Co-Chairman Crandall Canyon Independent Review Team Dated July 21, 2008 Joseph W. Pavlovich Co-Chairman Crandall Canyon Independent Review Team
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Independent Review of MSHA’s Acti
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Protective Ground Support Used Duri
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Location of March Bounce Last Known
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EXECUTIVE SUMMARY The Federal Mine
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• Persons who could have contribu
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There was no lack of hard work and
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BLM INSPECTIONS OF CRANDALL CANYON
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oxygen and dust into the fresh air
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MSHA’S ACTIONS PRIOR TO AUGUST 6,
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that the proposed retreat sequence
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On February 23, 2007, District 9 re
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technical guidance from someone exp
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District management’s oversight w
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elieved that a higher stability fac
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questions were asked in an attempt
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offset between crosscuts 139 and 14
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To determine the validity of the in
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disapproval to the District Manager
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amendments for the South Barrier re
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The following table contains certai
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The Price Field Office did not inve
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The inspector stated that this even
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conducted every seven days. However
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Recommendation: MSHA should establi
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DIRECTION AND ACTIVITIES DURING THE
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111-8, which was in effect at the t
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MSHA Person-In-Charge of Mine Rescu
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Davis stated that when Stickler and
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There was also no verification that
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employee stated, “Everybody got f
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Underground Phone Communication Sys
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PROTECTIVE GROUND SUPPORT USED DURI
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equipment to tram in and out of the
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Top of Rockprop Bottom of Rockprop
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Canyon the inby end of the ropes wa
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educed to writing and served to the
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planned to film the underground res
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Stickler stated that family members
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Conclusion: MSHA failed to enforce
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Later on August 6 th , a mine rescu
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anybody sit down with the MSHA peop
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EXPLORATIONS During the underground
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since the ribs could not further ex
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DRILLING OF BOREHOLES Boreholes pla
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pump for a period of time, the meas
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After this hole was drilled, MSHA
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The borehole showed there was no vo
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RISK VERSUS VALUE In all rescue and
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stoppings to crosscut 95 would also
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section were equipped with Self-Con
Page 104 and 105: data, the idea was not pursued any
Page 106 and 107: for an hour and one-half and then w
Page 108 and 109: sampling equipment to their truck a
Page 110 and 111: Agency. The handbook consisted of 9
Page 112 and 113: updates and briefings on the rescue
Page 114 and 115: Utah Governor Jon Huntsman, Jr., MS
Page 116 and 117: Stickler contradicting or correctin
Page 118 and 119: trapped miners should, to the exten
Page 120 and 121: Conclusion: The MSHA person-in-char
Page 122 and 123: An attachment to the policy sets fo
Page 124 and 125: air and water waiting for us to com
Page 126 and 127: Davis did clarify that there was no
Page 128 and 129: the family and press briefings, and
Page 130 and 131: emergency with role-playing by all
Page 132 and 133: MINER ACT AND MINE EMERGENCY EVACUA
Page 134 and 135: Post-Accident Communications The MI
Page 136 and 137: Recommendation: The Agency should d
Page 138 and 139: At the time of the accident, the ER
Page 140 and 141: locations, and along normal travel
Page 142 and 143: CMS&H STAFFING AND RESOURCE UTILIZA
Page 144 and 145: CMS&H STAFFING LEVELS District staf
Page 146 and 147: In addition to the decreased levels
Page 148 and 149: completion rate decreased dramatica
Page 150 and 151: Other specialists had limited inspe
Page 152 and 153: ALLEGATIONS OF INFLUENCE BY THE MIN
Page 157: APPENDIX A LIST OF PERSONS INTERVIE
Page 160 and 161: Moore, III, Clarence W. ...........
Page 163: List of Ground Control Panel Member
Page 167: Event Number Activity Code Genwal R
Page 171 and 172: Borehole #3 Location: #4 Entry, X-c
Page 174 and 175: Oxygen Content of Air: Sign and Sym
Page 177 and 178: EFFECTIVE DATE: 12/22/2006 EXPIRATI
Page 179 and 180: Act, Pub. L. No. 109-236, June 15,
Page 183: APPENDIX G PROGRAM POLICY LETTER NO
Page 186 and 187: 2006. The MINER Act requires that t
Page 188 and 189: The above table is based on the 199
Page 190 and 191: 2. Inflatable shelters or equivalen
Page 193: APPENDIX H PROGRAM INSTRUCTION BULL
Page 196 and 197: I. Quantity of Breathable Air. In d
Page 198 and 199: What is MSHA's authority for this P
Page 201: NORTH BARRIER Last Known Location o
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Independent Review of MSHA's Actions at Crandall Canyon Mine

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