Independent Review of MSHA's Actions at Crandall Canyon Mine

anybody sit down with the MSHA people that came out and debrief them as a unit to find out
exactly what happened that shift?” he answered, “No.”
This failure is discussed at length in the Communications section of Command Center.
Failure to Have Breathing Apparatus Underground
During each shift of the underground rescue operation, two to four members of MSHA’s MEU
were underground. They were assigned duties such as taking air quality and quantity
readings and observing the work being performed in the No. 1 entry. They were also to be
prepared to don their apparatus to provide assistance in the event of exposure to low oxygen.
However, breathing apparatus were not kept underground. One of the trainers thought that
MEU members were always taking their apparatus underground, but all the team members
stated they were not.
IG 7 discusses “barefaced” exploration. The term "barefaced" refers to the act of rescue team
members exploring without donning their breathing apparatus. This is done when the mine
atmosphere is such that it is safe for them to do so. However, the manual states, “A backup
crew with apparatus should be stationed outside the area [being explored], ready to go in
immediately to rescue the others if necessary.” On August 10 th , a barefaced exploration was
conducted in the No. 1 entry ahead of where the continuous mining machine was loading
material from the bounce. An MSHA inspector and a mine manager attempted to crawl over
the material to find out if they could reach the trapped miners this way. (This is discussed in
greater detail in the Explorations section of this report.) While this barefaced exploration was
occurring, there should have been breathing apparatus underground in case these two persons
needed to be rescued.
It was well known that there were low oxygen levels in advance of the rescue operation.
There were times when ground failures inby forced low oxygen out to the rescue workers'
location. Oxygen levels as low as 14% to 16% were detected in the rescue area on the days
preceding August 16 th . Oxygen levels on these days were controlled with air directed to the
rescue area by curtains.
On August 16 th , oxygen levels of 16% or lower were recorded for at least ten minutes in the
area where workers were trying to recover the victims of the second accident. The
underground rescue workers called on the mine phone for oxygen, including BG-4 breathing
apparatus. MSHA personnel stated that the apparatus had to be retrieved from the surface,
taking at least 45 minutes. Quick action by one of MSHA’s MEU members in restoring
ventilation to the rescue area on August 16 th probably prevented low oxygen levels from
affecting the rescue workers and the injured workers.
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