Independent Review of MSHA's Actions at Crandall Canyon Mine

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employee stated, “Everybody got fired there at least once.” Another MSHA employee stated that Stickler threatened to “Fire us all. It wasn't just me. It was fire us all and get more players, if we couldn't get it in that book the way he wanted it.” However, Stickler stated that he did not threaten to fire or replace anyone. He stated that he told Davis his concerns and expected them to be addressed. The footage measurements were deemed to be so critical for Stickler that the underground workers were given strict orders on how to take the measurements and the criticality of measuring and reporting them every hour. An MSHA employee stated, “I tried to give any explanation to him as to why they were down or they had a bounce, he said very specifically I don’t want to hear that. I want to know how far they've advanced and what the footage on the props is.” Rescue workers even had to stop or slow the operation at times to obtain the readings, as they could not allow the shuttle cars in the narrow clean-up area while they were there on foot using a tape measure to get the distance advanced. Stickler emphasized to them that estimating the measurement was totally unacceptable and that it had to be exact every hour. This distance was then recorded in the log book in a specific manner, listing the footage to the tail of the miner and also the footage to the last Rocprop installed. Then the entry was outlined and highlighted so that Stickler could look at the book and see the measurements instantly. No other entries in the book had to be so specifically identified, such as safety concerns or bounces that were occurring. A similar issue of briefings and debriefings not being conducted was also identified by the Sago Internal Review report released on June 28, 2007. MSHA’s MEU members were not briefed or debriefed regularly during that rescue operation. The importance of conducting briefings and debriefings was discussed during a MSHA-wide training meeting for supervisors and managers at the National Mine Health and Safety Academy held on July 11- 12, 2007, approximately three weeks before the Crandall Canyon accident. A portion of the training meeting was to discuss all issues identified by internal review reports for the Sago, Aracoma Alma, and the Darby No. 1 mine disasters. Most District 9 supervisors and managers attended this meeting. Stricklin issued CMS&H Memo No. HQ-07-094-A on August 24, 2007, to follow-up and re-emphasize what was discussed in the July meeting. The memo stated in part “Every mine rescue team exiting the mine should be de-briefed by a person/persons designated by the command center. Similarly, no team should be sent underground prior to being thoroughly briefed. The MSHA MEU representatives traveling with the team should be included in all briefings and de-briefings.” Conclusion: There was no protocol established by the persons-in-charge for conducting initial briefings and regular formal briefings. Copies of approved plans were not always provided to or discussed with rescue workers prior to entering the mine. Stickler’s interaction with the MSHA employees on-site during the rescue operation created an environment that hindered the communication process. This may have led to valuable information not being shared with the persons-in-charge. 54
There was no protocol established by the persons-in-charge for conducting regular formal debriefings. The July 11-12, 2007, training provided for managers and supervisors to ensure that briefings and debriefings be conducted was ineffective. Recommendation: MSHA should develop a program to train personnel in charge of rescue and recovery operations. This training should include how to ensure that formal briefings and debriefings are conducted with all personnel involved. Persons-in-charge should be trained on how to create an atmosphere that promotes open communication. Transportation Shortly after MSHA’s initial response to the accident, an 8-hour shift rotation schedule was established to ensure that inspectors and/or MSHA MEU members would be underground with the rescue crews. On each shift, three to four inspectors/MEU members would be on the South Barrier section, observing the work that was occurring, taking measurements of the progress, observing roof and rib conditions, and monitoring air quantities and qualities. These personnel stated that from the beginning of the operation on August 6 th until the underground activities stopped on August 16 th , they were never afforded regular transportation into and out of the mine. Diesel-powered pick-up trucks were used to transport personnel into and out of the mine. Since the miners working on the rescue were working 12-hour shifts, the times of shift change didn’t align. Inspectors had to do what ever they could to get transportation. Inspectors stated that at the start of their shift they would wait at the portal to catch a ride with someone who might be taking a truck into the mine. When they were preparing to leave the rescue area at the end of their shift, they would leave whenever a ride was available. Because of this, there were a few instances early in the operation in which there was no MSHA personnel underground. MSHA’s persons-in-charge where unaware of this problem and stated that they didn’t know the inspectors were having problems getting into or out of the mine. If regular debriefings had been conducted, as discussed above, this information would have been made known to the persons-in-charge. Conclusion: The persons-in-charge did not ensure MSHA personnel working underground had readily-available transportation into and out of the mine. There was a lack of communication that was occurring between the persons-in-charge and the inspectors working underground. Recommendation: Persons-in-charge should ensure that MSHA personnel have transportation to the affected area when a rescue or recovery operation is ongoing. 55
Page 1:
Independent Review of MSHA’s Acti
Page 4 and 5:
Protective Ground Support Used Duri
Page 7:
Location of March Bounce Last Known
Page 10 and 11:
EXECUTIVE SUMMARY The Federal Mine
Page 12 and 13: • Persons who could have contribu
Page 14 and 15: There was no lack of hard work and
Page 16 and 17: BLM INSPECTIONS OF CRANDALL CANYON
Page 18 and 19: oxygen and dust into the fresh air
Page 20 and 21: MSHA’S ACTIONS PRIOR TO AUGUST 6,
Page 22 and 23: that the proposed retreat sequence
Page 24 and 25: On February 23, 2007, District 9 re
Page 26 and 27: technical guidance from someone exp
Page 28 and 29: District management’s oversight w
Page 30 and 31: elieved that a higher stability fac
Page 32 and 33: questions were asked in an attempt
Page 34 and 35: offset between crosscuts 139 and 14
Page 36 and 37: To determine the validity of the in
Page 38 and 39: disapproval to the District Manager
Page 40 and 41: amendments for the South Barrier re
Page 42 and 43: The following table contains certai
Page 44 and 45: The Price Field Office did not inve
Page 46 and 47: The inspector stated that this even
Page 48 and 49: conducted every seven days. However
Page 50 and 51: Recommendation: MSHA should establi
Page 52 and 53: DIRECTION AND ACTIVITIES DURING THE
Page 54 and 55: 111-8, which was in effect at the t
Page 56 and 57: MSHA Person-In-Charge of Mine Rescu
Page 58 and 59: Davis stated that when Stickler and
Page 60 and 61: There was also no verification that
Page 64 and 65: Underground Phone Communication Sys
Page 66 and 67: PROTECTIVE GROUND SUPPORT USED DURI
Page 68 and 69: equipment to tram in and out of the
Page 70 and 71: Top of Rockprop Bottom of Rockprop
Page 72 and 73: Canyon the inby end of the ropes wa
Page 74 and 75: educed to writing and served to the
Page 76 and 77: planned to film the underground res
Page 78 and 79: Stickler stated that family members
Page 80 and 81: Conclusion: MSHA failed to enforce
Page 82 and 83: Later on August 6 th , a mine rescu
Page 84 and 85: anybody sit down with the MSHA peop
Page 86 and 87: EXPLORATIONS During the underground
Page 88 and 89: since the ribs could not further ex
Page 90 and 91: DRILLING OF BOREHOLES Boreholes pla
Page 92 and 93: pump for a period of time, the meas
Page 94 and 95: After this hole was drilled, MSHA
Page 96 and 97: The borehole showed there was no vo
Page 98 and 99: RISK VERSUS VALUE In all rescue and
Page 100 and 101: stoppings to crosscut 95 would also
Page 102 and 103: 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
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updates and briefings on the rescue
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Utah Governor Jon Huntsman, Jr., MS
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Stickler contradicting or correctin
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trapped miners should, to the exten
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Conclusion: The MSHA person-in-char
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An attachment to the policy sets fo
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air and water waiting for us to com
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Davis did clarify that there was no
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the family and press briefings, and
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emergency with role-playing by all
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MINER ACT AND MINE EMERGENCY EVACUA
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Post-Accident Communications The MI
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Recommendation: The Agency should d
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At the time of the accident, the ER
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locations, and along normal travel
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CMS&H STAFFING AND RESOURCE UTILIZA
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CMS&H STAFFING LEVELS District staf
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In addition to the decreased levels
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completion rate decreased dramatica
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Other specialists had limited inspe
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ALLEGATIONS OF INFLUENCE BY THE MIN
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GENERAL CONCLUSION Internal Reviews
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APPENDIX A LIST OF PERSONS INTERVIE
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Moore, III, Clarence W. ...........
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List of Ground Control Panel Member
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Event Number Activity Code Genwal R
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Borehole #3 Location: #4 Entry, X-c
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Oxygen Content of Air: Sign and Sym
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EFFECTIVE DATE: 12/22/2006 EXPIRATI
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Act, Pub. L. No. 109-236, June 15,
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APPENDIX G PROGRAM POLICY LETTER NO
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2006. The MINER Act requires that t
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The above table is based on the 199
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2. Inflatable shelters or equivalen
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APPENDIX H PROGRAM INSTRUCTION BULL
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I. Quantity of Breathable Air. In d
Page 198 and 199:
What is MSHA's authority for this P
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NORTH BARRIER Last Known Location o
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Independent Review of MSHA's Actions at Crandall Canyon Mine

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