Safety Culture Communicator

Case Study 4 March 2012

April 2010 Upper Big Branch Mine Explosion—29 Lives Lost 

Purpos

This case study provides a useful tool for the U.S. Nuclear Regulatory Commission (NRC) staff as it 

interacts with its stakeholders. It provides the regulated community with the findings of West Virginia 

Governor Manchin’s appointed independent investigation panel and the results of an investigation 

conducted by the U.S. Department of Labor’s Mine Safety and Health Administration (MSHA). Many 

of these findings contrast starkly with the positive safety culture traits that the NRC has incorporated 

into its safety culture policy statement.

What Happen

On April 5, 2010, a series of explosions occurred inside the Upper Big Branch (UBB) mine in southern 

West Virginia. Twenty nine coal miners working for Performance Coal Company (a subsidiary of 

Massey Energy Company and hereinafter referred to as PCC/Massey) lost their lives in the “largest 

coal mine disaster in the United States in 40 years.”1

 The company had a thoroughly documented, 

preexisting history of poor safety performance. “PCC/Massey failed to report accident data 

accurately. MSHA’s post-accident audit revealed that, in 2009, UBB had twice as many accidents as 

the operator reported to MSHA.”2

Probable Cause

Existing government reports suggest that PCC/Massey “promoted and enforced a workplace culture that valued production over safety including 

practices calculated to allow it to conduct mining operations in violation of the law.”3

 Consistently poor environmental conditions were permitted 

to exist inside the mine. “Upper Big Branch was cited every month during 2009 – 64 citations in all (57 from MSHA, seven from the state) – for failure 

to ventilate the mine according to the approved ventilation plan.”4

 Poor ventilation was likely a 

contributor to the accumulation of methane gas. Government investigators believe malfunctioning 

water sprayers on the machine used to cut coal from the rock may have permitted the ignition 

source for igniting the methane gas. Additionally, an abundance of coal dust (from inconsistent 

rock dusting) served as a catalyst to a resulting series of massive explosions. An MSHA followup investigation “revealed multiple examples of systematic, intentional and aggressive efforts by 

PCC/Massey to avoid compliance with safety and health standards, and to thwart detection of that 

non-compliance by federal and state regulators.”5

 “While violations of particular safety standards 

led to the conditions that caused the explosion, the unlawful policies and practices implemented 

by PCC/Massey were the root cause of this tragedy.”6

1. MSHA, Coal Mine Safety and Health, “Report of Investigation—

Fatal Underground Mine Explosion, April 5, 2010,” December 6, 2011, p. 1.

2. Ibid., p. 4.

3. Ibid., p. 2.

4. J. Davitt McAteer and Associates, “Upper Big Branch—The April 5, 

2010, Explosion: A Failure of Basic Coal Mine Safety Practices,” Report 

to the Governor, the Governor’s Independent Investigation Panel, May 

2011, p. 60.

5. MSHA, Coal Mine Safety and Health, “Report of Investigation—

Fatal Underground Mine Explosion, April 5, 2010,” December 6, 2011, p. 2.

6. Ibid., p. 2.

Photo Kayana Szymczak © Getty Images

NRC Positive Safety Culture Traits

Leadership Safety Values and Actions in which 

leaders demonstrate a commitment to safety in 

their decisions and behaviors.

Problem Identification and Resolution in which 

issues potentially affecting safety are promptly 

identified, fully evaluated, and promptly addressed 

and corrected commensurate with their 

significance.

Personal Accountability in which all individuals 

take personal responsibility for safety.

Work Processes in which the process of planning 

and controlling work activities is implemented to 

maintain safety.

Evidence of Weak Safety Culture Traits

One specific work process that the PCC/Massey leadership had in place was to illegally 

provide advance notice to miners of MSHA inspections. This was a flagrant violation of 

Section 103(a) of the Federal Mine Safety and Health Act of 1977, as amended.7

“...when a worker told [the] foreman about the air reversal, [air moving the opposite 

direction of where it should have been in order to properly vent the mine] ‘He didn’t say 

nothing, he just walked away.’”8

The preshift, onshift examination system—devised to identify problems and address them 

before they became disasters—was a “failure.”9

In the weeks preceding the disaster, investigators found that one UBB foreman’s hand held 

methane detector had not been turned on, even though he filled in examiner’s books as if he 

had taken gas readings. “This data [integrity issue] raises doubt about the daily and weekly 

air readings and other data recorded by the crew foreman in the weeks leading up to the 

disaster.”10

“In instances in which a section boss did halt production because of a dangerous condition, 

such as wholly inadequate ventilation, he was instructed to write only ‘downtime.’ He was 

not to create a record acknowledging a potentially deadly situation.”11
NRC Positive Safety Culture Traits

Continuous Learning in which opportunities to 

learn about ways to ensure safety are sought out 

and implemented.

Environment for Raising Concerns in which a 

safety-conscious work environment is maintained 

where personnel feel free to raise safety 

concerns without fear of retaliation, intimidation, 

harassment, or discrimination.

Effective Safety Communication in which 

communications maintain a focus on safety.

Respectful Work Environment in which trust and 

respect permeate the organization.

Questioning Attitude in which individuals avoid 

complacency and continuously challenge 

existing conditions and activities in order to 

identify discrepancies that might result in error or 

inappropriate action.

Evidence of Weak Safety Culture Traits

“Testimony indicates that PCC/Massey inadequately trained their examiners, foreman and 

miners in health and safety...especially in hazard recognition, performing new job tasks and 

required annual refresher training. This left miners unequipped to identify and correct hazards.”12

“Witness testimony revealed that miners were intimidated by UBB management and were 

told that raising safety concerns would jeopardize their jobs. As a result, no whistleblower 

disclosures were made in the 4 years preceding the explosion, despite an extensive record of 

PCC/Massey safety and health violations at the UBB mine during this period.”13

“Workers at UBB were treated in a ‘need to know’ manner. They were not apprised of 

conditions in parts of the mine where they did not work. Only a privileged few knew what was 

really going on throughout UBB.”14

“Miners also mentioned disrespectful written messages they received” from [a senior 

manager]. Others, were intimidated by [a manager’s] “nasty notes” and didn’t say anything 

because they were “job-scared.”15

“Testimony revealed that UBB’s miners were intimidated to prevent them from exercising 

their whistleblower rights. Production delays to resolve safety-related issues often were met 

by UBB officials with threats of retaliation and disciplinary actions.”16

What Can Organizations Learn from This Acc

This accident reinforces the need for, and importance of, promoting a positive safety culture by routinely evaluating an organization’s safety culture 

activities and initiatives and by making enhancements and adjustments to ensure that an organization remains proactive and appropriately focused 

on this important area. This case study points to the following key lessons: 

• Senior management dictates the tone for the balance between safety and corporate performance. These two items are not mutually exclusive and 

can and must successfully coexist. However, a strong safety culture demands a safety first approach to business.

• No single event led to this catastrophe. Instead, it resulted from a series of events that were precipitated by a work environment in which workers 

were not encouraged to raise safety concerns and managers may have been discouraged from halting production in order to address an unsafe 

condition. 

• This disaster may have been avoided had there been a more robust, positive safety culture in which workers and managers were encouraged to 

raise concerns.

7. Ibid., p. 9.

8. J. Davitt McAteer and Associates, “Upper Big Branch—The April 5, 2010, Explosion: A Failure of Basic 

Coal Mine Safety Practices,” Report to the Governor, the Governor’s Independent Investigation Panel, 

May 2011, p. 19.

9. Ibid., p. 97.

10. Ibid., p. 19.

11. Ibid., p. 99.

12. MSHA, Coal Mine Safety and Health, “Report of Investigation—

Fatal Underground Mine Explosion, April 5, 2010,” December 6, 2011, p. 5.

13. Ibid., p. 2.

14. J. Davitt McAteer and Associates, “Upper Big Branch—The April 5, 2010, Explosion: A Failure of Basic 

Coal Mine Safety Practices,” Report to the Governor, the Governor’s Independent Investigation Panel, 

May 2011, p. 99.

15. Ibid., p. 100

16. MSHA, Coal Mine Safety and Health, “Report of Investigation—

Fatal Underground Mine Explosion, April 5, 2010,” December 6, 2011, p. 5.

Sources of Information:

1. MSHA, Coal Mine Safety and Health, “Report 

of Investigation—Fatal Underground Mine 

Explosion, April 5, 2010,” December 6, 2011.

2. J. Davitt McAteer and Associates, “Upper Big 

Branch—The April 5, 2010, Explosion: A Failure 

of Basic Coal Mine Safety Practices,” Report 

to the Governor, the Governor’s Independent 

Investigation Panel, May 2011 (http://online.

wsj.com/public/resources/documents/

wvamine0519.pdf).

3. Briefings by the U.S. Department of Labor and 

MSHA on the disaster at PCC/Massey’s UBB 

mine in southern West Virginia at the request of 

President Barrack Obama, April 2010.

Rick Daniel, from the NRC Office of Enforcement, 

developed this safety culture case study. If you 

have any questions, please contact David Solorio, 

Branch Chief, by telephone at 301 415 0149 or by e 

mail at Dave.Solorio@nrc.gov. 

Note that the NRC has not conducted a formal analysis 

of the events discussed herein for, or in conjunction 

with the US Dept. of Labor’s, Mine Safety and Health 

Administration, the Governor’s Independent Investigation 

Panel or any other government or private organization. 

The NRC compiled the information presented and 

discussed herein from government sources that were 

publicly available at the time of publishing, as identified.