The Sago Mine
Disaster
A preliminary report to Governor Joe Manchin III
J. Davitt McAteer
and associates
July • 2006

 The Sago Mine Disaster
A preliminary report to Governor Joe Manchin III

J. Davitt McAteer
and associates:
Thomas N. Bethell
Celeste Monforton
Joseph W. Pavlovich
Deborah Roberts
Beth Spence
JULY • 2006
Buckhannon, West Virginia

 On January 12, 2006, West Virginia Senate President Earl Ray
Tomblin (D-Chapmanville) and House Speaker Bob Kiss (D-Raleigh)
appointed Senators Don Caruth (R-Mercer), Jeff Kessler
(D-Marshall) and Shirley Love (D-Fayette) and Delegates Mike
Caputo (D-Marion), Eustace Frederick (D-Mercer) and Bill Hamilton
(R-Upshur) to conduct an inquiry into the Sago disaster. At the
request of Governor Joe Manchin III, their inquiry was conducted
jointly with our investigation. These legislators have worked
diligently with us in seeking answers to this West Virginia tragedy.

This report, as well as additional related information, is available at:
www.wvgov.org and www.wju.edu

Front cover photo:
Memorial ribbons on the Sago Mine security fence, January 2006
Jeff Swensen / Getty Images

Back cover photo:
Mourners praying at the funeral of Jerry Groves, January 2006
Haraz Ghanbari / AP Images

 Contents
Letter of transmittal .......................................................... 2

Dedication ........................................................................ 4

1. Executive Summary ....................................................... 7

2. Recommendations ....................................................... 17

3. Synopsis .................................................................... 23

4. What caused the disaster? ............................................ 35

5. Why did the seals fail? ................................................. 41

6. Did the miners’ SCSRs fail? .......................................... 49

7. Why did the mine rescue effort take so long? .................. 57

8. What happened to the three shots? ............................... 83

Appendix ....................................................................... 92

Acknowledgements ......................................................... 96

1

 Letter of transmittal
Governor Joe Manchin III
State of West Virginia
1900 Kanawha Boulevard East
Charleston, WV 25305
Dear Governor Manchin:
I have the honor to submit to you this preliminary report on the Sago Mine disaster of
January 2-4, 2006.
On January 9, 2006, when you appointed me as your special advisor on the disaster,
you directed me to investigate and report on the causes; the rescue and recovery
operation, including the miscommunication that caused the Sago miners’ families such
needless heartache; and the steps needed to improve mine safety and mine communications in West Virginia and across the nation.
This report seeks to address these concerns. My hope is that it honors the pledge you
made to the victims’ families when you stated: “These twelve lives will not be lost in
vain. It is my goal to see that West Virginia is home to the safest mining operations in
the nation.”
I believe we can fulfill this pledge and accomplish this goal. But the task will require
dedication, innovation, and vigilance on the part of all in the mining community.
For me, and for my associates in this investigation, it has been an inspiration to meet
and work with the families of the lost miners. In their grief they have become tireless
advocates for change. They have our deep respect and support.
The miners’ families insisted that their loved ones be honored and remembered. They
demanded that the disaster be investigated thoroughly and in the clear light of day.
They were your strongest allies as you and the legislature moved with unprecedented
speed to enact new mine safety legislation on January 23; they were full partners in
the public hearings we conducted on May 2-4; and they became a vital presence in
Washington, working with West Virginia’s congressional delegation to pass the new
federal legislation enacted by Congress in June. As we look to the future, miners’
families have the most at stake and are the main reason why I can feel confident that
real change is coming to the coal industry.
This is a preliminary report primarily because we do not yet have all the answers
about the disaster’s proximate cause. But in your initial charge to me you directed that
if, during the course of the investigation, we were able to reach conclusions about
improvements to mine safety and health which could be implemented along the way,
we should make those conclusions available. We are doing so in this report, which
includes numerous recommendations to improve mine safety and mine rescue.

2

 We offer these recommendations in full awareness that more remains to be done. But
that should not be a rationale for delay. There are technologies and equipment available today that could be making our coal mines significantly safer tomorrow — for
example by improving communication and the ability to locate miners, and, when
escape is not possible, improving miners’ chances of surviving an explosion or fire by
providing refuge chambers.
It has been suggested that some of this equipment is “unreliable,” by which is meant
that it may not work in all locations at all times. That criticism is misplaced.
Underground coal mines are both similar and unique. The roughly 150 currently active
underground coal mines in West Virginia are similar in purpose and function. They are
different, even unique, in the geological, engineering, and other challenges that they
represent. The similarities suggest that innovative technologies should be broadly
applicable. The differences suggest that some technologies will need to be tweaked or
modified in order to be made reliable in specific situations.
If we insist on waiting for perfect technological answers to the challenges facing us,
we will wait forever. The unmistakable message of the Sago Mine disaster is that we
cannot afford to wait. In this report we discuss technologies and techniques which are
currently available, tested in underground mines in the United States and other mining
countries, and which would immediately improve underground miners’ chances to
escape or be rescued in an emergency. Incremental improvements should be adopted
immediately while the search for better technologies goes forward.
Because of your leadership, the leadership of the state legislature, and, at the national
level, the leadership of Senator Robert C. Byrd and the entire West Virginia congressional delegation, West Virginia is poised to lead the coal mining industry of the United
States in creating a far safer workplace, one worthy of the 21st century and the miners who do so much to power the nation’s economy. My hope is that this report will
help spur the kind of progress that miners have been waiting for.
The work of fulfilling our pledge to the Sago miners and their families is ongoing, and
I expect to supplement this report as necessary.
Thank you for asking me to assist you in striving to make West Virginia the nation’s
leader in coal mine health and safety. I submit this report in the hope and belief that
the Sago Mine disaster will be remembered as a turning point as well as a tragedy.

J. Davitt McAteer
Shepherdstown, West Virginia
July 19, 2006

3

 We dedicate this report
to the families of the twelve good men
who lost their lives in the Sago Mine
January 2-4, 2006
Jerry Lee Groves was a
roof bolter, with nearly 30
years of mining experience. He
lived in Cleveland, Webster
County. Married to Deborah A.
Groves, he was the father of a
daughter, Shelly Rose. He was 56.

Tom Anderson was a
shuttle car operator on the
Two Left section of the Sago
Mine, moving coal from the
area of the working face to the
conveyor belt. He had 10 years
in the mines. He lived in Rock Cave, Upshur
County. Married to Lynda Hyre Anderson,
he was the father of four sons, Caleb (deceased), Randy, Mitchell, and Thomas Isaac.
He was 39.

George Junior Hamner
was a shuttle car operator,
with 28 years of mining
experience. He grew up on a
farm near the site of the Sago
Mine and owned a small cattle
farm in Glady Fork, Upshur County. Married
to Deborah Hamner, he was the father of a
daughter, Sara Bailey. He was 54.

James Bennett was a
shuttle car operator with more
than 25 years of mining
experience. He lived in Volga,
Barbour County. Married to
Lily Foster Bennett, he was the
father of a daughter, Ann Merideth, and a
son, John. The eldest of the Two Left crew,
he had been planning to retire in 2006. He
was 61.

Terry Helms was a fireboss
and beltman. He had 29 years
of mining experience. He lived
in Newburg, Preston County.
The father of a daughter,
Amber, and a son, Nick, from
his previous marriage, he was engaged to be
married to Virginia Moore. He was 50.

Marty Bennett was a
continuous-miner operator,
running the machine that cut
coal from the face. He had
29 years of mining experience.
He lived in Buckhannon,
Upshur County. Married to Judy Ann Lantz
Bennett, he was the father of a son, Russell,
who also worked at the Sago Mine. He
was 51.

4

 Fred G. Ware, Jr. was a
continuous-miner operator,
with 37 years of mining experience. He lived in Tallmansville,
Upshur County, just across the
river from the Sago Mine. He
was the father of a daughter, Peggy Cohen,
and a son, Darrell. He was 59.

Jesse L. Jones was a roof
bolter, with 16 years of mining
experience. He lived in
Pickens, Randolph County. He
was the father of two daughters, Sarah and Katelyn. His
brother, Owen, was the foreman of the One
Left crew on the morning of January 2, and
tried to reach Jesse after the explosion. He
was 44.

Jackie Weaver was the
section electrician on Two Left,
with 26 years of mining experience. He lived in Philippi,
Barbour County. Married to
Charlotte Poe Weaver, he was
the father of a daughter, Rebecca, and a son,
Justin. He was 51.

David Lewis was a roof
bolter, with about two years of
mining experience. He lived in
Thornton, Taylor County.
Trained as a diesel mechanic,
he went to work at Sago so
that his wife, Samantha, could stay home
with their three daughters, Kayla, Shelby, and
Kelsie, while she completed a master’s degree
in health care administration. He was 28.

Marshall Winans was
a utility man and scoop
operator, with 10 years of
mining experience. He lived
in Belington, the Talbott
Community, Barbour County.
Married to Pamela Pharis Winans, he was the
father of three daughters, Tiffany, Mandy, and
Holly. He was 50.

Martin Toler, Jr. was the
section foreman on Two Left,
with 32 years of mining experience. He lived in Flatwoods,
Braxton County. Married to
Mary Lou Toler, he was the
father of a daughter, Courtney, and a son,
Chris, who had worked with his father in
another mine. He was 51.

5

 We also dedicate this report to
the sole survivor of the Two Left crew,
Randal McCloy, Jr.

with best wishes for his continuing recovery
and
to the miners
who escaped the Sago Mine
on the morning of January 2, 2006:
Denver Anderson*
Paul Avington*
John Boni
Pat Boni
Gary Carpenter*
Ron Grall
Randy Helmick*
Eric Hess*
Fred Jamison
Owen Jones*
Hoy Keith*
Roger Perry*
Gary Rowan*
Joe Ryan*
Chris Tenney*
Alton Wamsley*
*One Left crew

and
to the miners
who courageously attempted to rescue the Two Left crew:
Jeff Toler
Vernon Hofer
Owen Jones
Al Schoonover
Dick Wilfong

6

 1

Executive
Summary
disaster has taught us and what we must do
with what we have learned.

OVERVIEW
Twenty-nine coal miners went underground
at International Coal Group’s Sago Mine near
Buckhannon in Upshur County, West Virginia, on the morning of January 2, 2006. At
6:26 a.m., a methane ignition in a recently
sealed area of the mine triggered an explosion
that blew out the seals and propelled smoke,
dust, debris and lethal carbon monoxide into
the working sections of the mine. One miner
was killed by the blast. Sixteen escaped.
Twelve were unable to escape and retreated to
await rescue behind a curtain at the face of the
Two Left section. Mine rescuers found the
trapped miners approximately 41 hours later.
By that time all but one had succumbed from
carbon monoxide asphyxiation.

The staggering tragedy of the Sago Mine
disaster — first the loss of the miners, then the
appalling miscommunication to their families
— shocked West Virginia and the nation.
Governor Joe Manchin III pledged to the
families that their loved ones would not die in
vain. To make good on that pledge, he vowed
to bring West Virginia to a position of national
and international leadership in coal mine
safety and health.
Action followed. As official investigations by
the West Virginia Office of Miners’ Health,
Safety & Training (WVOMHST) and the
federal Mine Safety and Health Administration (MSHA) got under way, the governor
appointed a West Virginian and former
MSHA chief, Davitt McAteer, as his special
advisor. Then, on January 23, the governor
introduced and the state legislature enacted
— within the unprecedented span of a single
day — legislation requiring rapid notification
of and response to mine emergencies, storage
of additional self-contained self-rescuers
(SCSRs) underground, and installation of
improved mine communication and tracking
systems in order to be able to locate and
maintain contact with miners in emergency
situations.

This is a report about what happened to the
miners and why. It is also a report about why
the explosion was not contained; why the
Two Left crew was unable to escape; why the
mine rescue effort took so long; why the
trapped miners were sent no signal to tell
them that help was coming; and why, after
they were finally found, their waiting families
were informed that all were alive — and
celebrated that miraculous news for nearly
three hours before being told the awful truth.
This is also a report about what the Sago

7

 Federal Mine Safety & Health Act of 1977,
require improvements in mine safety equipment and technologies, and improve mine
rescue response strategies and management.

Just four days previously, on January 19, the
urgent need for action had been underscored
by a fire that left two miners dead at Massey
Energy’s Aracoma Alma Mine in Logan
County. Since that time, five more West
Virginians have lost their lives in mine accidents, bringing to 19 the number of coal
miners killed on the job in the state in the first
six months of 2006 — compared to three in all
of 2005. Nationwide, 34 coal miners have
been killed on the job thus far this year,
compared to 22 in all of 2005.

The public hearings promised by Governor
Manchin, originally scheduled for March,
were postponed at the request of the miners’
families to allow more time for state and
federal investigators to compile additional
information on the causes and consequences
of the Sago explosion. The international
symposium on mine health and safety technologies went forward as scheduled and,
among other accomplishments, demonstrated
that technologies available today, in areas
such as communications, tracking, and
refuges, can be put into the mines of West
Virginia on an accelerated basis to improve
miners’ chances of escaping or otherwise
surviving an emergency.1

Governor Manchin pledged further action,
announcing that public hearings would be
held on the Sago Mine disaster and that
Wheeling Jesuit University would host the
first International Mining Health and Safety
Symposium in April, to help spur adoption of
improved technologies and equipment in
West Virginia mines. WVOMHST issued an
emergency rule on SCSRs, communication,
and other mine safety improvements, and the
governor appointed a six-person labormanagement task force to assess the availability of the technologies covered by the new
WVOMHST rule.

Public hearings were convened at West
Virginia Wesleyan College in Buckhannon on
May 2, 2006. Over the course of the next three
days, miners’ family members, miners’
representatives, West Virginia legislators and
state and federal investigators heard detailed
presentations and statements about the
disaster. They closely questioned company,
state, and federal officials about conditions at
the mine prior to the disaster, the events of
January 2-4, 2006, and the actions of the mine
rescue command center where company,
state, and federal officials shared decisionmaking responsibilities throughout the mine
rescue operation.

Meanwhile, at the national level, Senators
Robert C. Byrd and John D. Rockefeller IV
and Representatives Nick Rahall, Alan
Mollohan, and Shelley Moore Capito introduced bills to enhance coal mine safety.
Hearings were held in both the Senate and the
House, and Representative George Miller of
California convened a forum to hear testimony from the Sago miners’ families as well
as from family members of the 13 miners
killed in an explosion at the Jim Walter
Resources No. 1 Mine in Brookwood, Alabama, in 2001. Witnesses urged lawmakers to
strengthen oversight and enforcement of the

For the first time in the history of coal mine
disaster investigations in the United States,
family members participated in a public
hearing on an equal basis with state and

8

 Sago Mine, January 2, 2006

Recently
sealed
area

▲

▲

Two Left Working Section

▲

▲

One Left Working Section

Omega
seals

58 block
▲

▲

Older Sealed
Areas

2

Mi

le

s

▲
Portal

▲

▲
Track

9

 federal investigators. The 1,263-page hearing
transcript reflects both their grief and their
determination to honor the memory of their
loved ones. 2
As John Groves, brother of disaster victim
Jerry Groves, stated at the opening of the
hearing: “Even though he’s gone now, he’s
going to be helping people, because we’re
going to be, through him, working to make
sure that a disaster like this never happens
again.”3
Other actions followed. On May 5, 2006, the
West Virginia Board of Coal Mine Health and
Safety filed a rule to establish two state-run
mine rescue teams to enhance the largely
company-based system currently and traditionally in effect. On May 12, 2006,
WVOMHST Acting Director James M. Dean
announced a statewide moratorium on the
use of Omega blocks — the materials used to
construct the seals at Sago — as alternative
explosion-proof seals.
On May 22, 2006 — two days after an explosion at a Kentucky mine blew out seals
constructed of Omega blocks and killed five
miners — MSHA announced a nationwide
moratorium on the use of alternative seals
pending a reassessment of their ability to
withstand explosions. On May 29, 2006, the
West Virginia Mine Safety Technology Task
Force issued its report. Among its other
recommendations, the task force called for
additional provision of SCSRs and improved
training; emergency refuge shelters; and an
August 2007 deadline for mine operators to
submit plans for improved communication
and tracking of miners underground.
On June 15, 2006, at a White House ceremony

attended by several of the Sago victims’
families as well as Governor Manchin and
West Virginia’s congressional delegation,
President George W. Bush signed into law the
Mine Improvement and New Emergency
Response (MINER) Act. Among other provisions, the new federal law requires underground miners to be supplied with two hours
of emergency oxygen at their work sites, as
well as additional oxygen cached in
escapeways; requires mine rescue plans to be
regularly updated and mine rescue teams to
be within an hour’s travel time from the
mine; and allows MSHA to seek injunctions
to halt production at mines whose owners
ignore outstanding fines.
Meanwhile, investigative work on the Sago
Mine disaster continued, and a long-awaited
interview with the sole survivor, Randal
McCloy, Jr., eventually made possible by his
remarkable recovery, was held on June 19,
2006.4 The release of this report, originally
scheduled for July 1, 2006, was briefly postponed in order to allow more time to attempt
to determine the proximate cause or causes of
the Sago explosion and to follow up on
concerns raised in the interview with Mr.
McCloy, primarily about the failure of four of
the SCSRs relied upon by the trapped miners
and the failure of the command center to send
signals to them to let them know that rescuers
were on the way.
This report is being released now with the
proximate cause of the Sago explosion still
unsettled. There appears to be little doubt that
an explosive mixture of methane and air
ignited in the recently sealed area of the mine
inby the Two Left section at 6:26 a.m. on
January 2, and the belief is widespread that a
powerful lightning strike was involved. As of

10

 this writing, however, the means by which
lightning may have entered the sealed area at
that moment has not been determined.
Although various theories have been offered
by International Coal Group consultants and
others, definitive evidence has not yet been
found or confirmed by state or federal investigators. Consequently this report does not
purport to identify the proximate cause of the
methane ignition — and, therefore, until
definitive evidence becomes available, this
report must be considered preliminary. Once
the proximate cause has been identified,
further work will be required in order to be
able to make specific recommendations about
the steps necessary to reliably protect underground mines and miners against a repetition
of the Sago Mine disaster.

THE DISASTER: CAUSES
AND CONSEQUENCES
It is important to make a clear distinction
between what caused the explosion and what
caused the disaster.
There would have been no disaster if the
explosion had been contained by the supposedly explosion-proof seals. If that had happened, it is possible that all of the miners in
the Sago Mine at the time of the explosion
could have escaped safely and successfully.
There might have been no disaster if the
miners on Two Left had been able to make all
of their SCSRs work. Randal McCloy says
that they could not. That left them little choice
but to await rescue, which then came too late
for all but one of them.
There would have been no disaster if it had
been possible for rescuers to communicate

with the miners on Two Left. They could have
been told that there was respirable air at the
mouth of the section, not far from where they
were. But the mine’s phone system — an
outmoded, vulnerable system typical of
underground mines — was knocked out by
the explosion.
There would have been no disaster if mine
rescue teams had been sent into the mine
sooner and allowed to advance to Two Left
without being required to systematically
assess post-explosion conditions throughout
the mine on the way in. But there were delays
in organizing the rescue, and the absence of a
gas chromatograph for much of the first day
meant that gases indicative of the presence or
absence of a fire could not be accurately
measured. The command center chose a
cautious, time-consuming approach geared to
protecting rather than risking the lives of the
mine rescue team members. But that approach, whatever its merits, greatly diminished the chances of winning the race against
deadly carbon monoxide.
There might have been no disaster if it had
been possible to rapidly pinpoint the location
of the trapped miners and drill a borehole
down to them. But the seismic equipment
theoretically capable of hearing their response
to a prearranged signal was not brought to
the mine. Even if it had been brought there,
it would have taken too long to set up and
operate to be of any value — but the trapped
miners had never been told that. Consequently they had reason to hope that barricading themselves would work. Had they
known the truth, they might have tried to
make their way out of the mine, even though
there was no certainty that they would have
succeeded.

11

 There might have been no disaster if there
had been even a single stroke of good luck
at Sago.
Because time is always the enemy, no mine
rescue can succeed without a large measure of
luck. Everything needs to go just right. At
Sago, everything that could go wrong did go
wrong. The explosion occurred on a federal
holiday. Time was wasted trying to reach
responsible officials, determining what had
happened, organizing a response and calling
in the most experienced mine rescue teams in
West Virginia. Time was spent making educated guesses about whether there was a fire
in the mine and whether it might trigger a
second explosion. Time was spent trying to
protect mine rescue teams against an undefined risk. All of that was time that the miners
on Two Left did not have.
We do not find fault in this report with
anyone who responded to the Sago Mine
emergency. The failures we describe above
and throughout this report were, in almost
every instance, failures not of individual
human beings but of systems: mine safety
systems, mine emergency management
systems, and mine rescue systems that are in
desperate need of immediate help. One of the
inescapable lessons of the Sago Mine disaster
is that it could happen again tomorrow —
and if it were to happen, the outcome next
time might not be much different, regardless
of who happens to be in the command center.
Next time, possibly, the seals would withstand the explosion. Possibly the SCSRs
would work as expected. Possibly there
would be no failure of communications. If
miners did find escape to be impossible,
possibly a rescue command center would be

rapidly operational and ready to deploy mine
rescue teams within two or three hours after
the explosion instead of six or seven. Possibly
the command center would have better data
to work with and might be inclined to take
more risks. Possibly the miners would be
brought out alive.
But, as we know, none of these hopeful
possibilities came true at Sago, and they
might not come true next time. It thus becomes a matter of great urgency to understand the reasons and to take corrective action
as rapidly as possible.
Accordingly, the thrust of this report is
directed toward what can be done now to get
better safety technology, equipment, and
strategies into the mines of West Virginia
without further delay. We know that better
technologies are on the horizon (they always
are), but we do not consider it acceptable to
wait for the perfection of technologies or
equipment before improving the protection
available to miners.

FINDINGS AND
RECOMMENDATIONS
Based on the evidence available to us thus far,
we do not believe that the Sago Mine disaster
can be attributed to any specific actions on the
part of International Coal Group (ICG), the
federal Mine Safety and Health Administration (MSHA), or the West Virginia Office of
Miners’ Health, Safety and Training
(WVOMHST). This does not rule out the
possibility of further review — for example, if
it is determined (as it has not been yet) that
ICG’s apparent failure to fully protect the
mine’s electrical and conductive infrastruc-

12

 ture with the grounding and lightning arrestors required by regulations played a direct
role in providing a path for lightning to enter
the sealed area of the mine and trigger a
methane ignition.
Similarly, it can be argued that a thorough
review of the process by which MSHA and
the National Institute of Occupational Safety
and Health (NIOSH) tested and approved
Omega blocks as “explosion-proof” seals
within the meaning of federal regulations
(discussed in section 5 of this report) may
find that the testing protocols and the criteria
upon which those protocols were based were
inherently flawed and inadequate. If so,
serious questions might be raised about the
possibility of failure at the federal level.
Pending such a review, however, it is
premature to make any such charges or
assumptions.
By the same token, the apparent failure of
some of the SCSRs relied upon by the trapped
Sago miners (discussed in section 6) raises
questions about whether this particular unit
can be counted upon to work in a crisis — or,
alternatively, whether miners are being given
sufficient training on what they should expect
to experience while using any rebreathing
device. Pending a nationwide audit of SCSRs,
these questions and their potential implications cannot be addressed to anyone’s satisfaction. (On July 10, WVOMHST instructed
all operators of underground mines in West
Virginia to begin inventorying the estimated
10,000 SCSRs currently in use in the state, in
order to facilitate a quarterly functional-status
audit,5 and as this report goes to press a
nationwide SCSR audit is expected.)

Although issues such as these are discussed
throughout this report and cannot be ignored,
we believe that it will be more productive and
protective of miners’ safety to focus on what
should be done immediately to address the
largely systemic failures that unquestionably
contributed to the tragic loss of life at the
mine. While not ruling out the possible need
for additional state or federal legislation at
some point, this report does not call for more
laws now. We find, rather, that West Virginia’s
leaders and the state’s mining community
have it within their power to implement all of
the recommendations that we offer below.
The keys to immediate progress, in our view,
are commitment, cooperation, and a willingness to pursue what we call ‘default options’
— that is, common-sense changes that can
improve safety while we await the arrival of
better technologies, equipment, and strategies. We have faith in miners’ ingenuity, and
many of our recommendations are grounded
in this approach. Four examples follow:
1. Strengthening underground
communications We do not necessarily
need new laws or more research in order to
improve the odds that a mine phone system
will survive an explosion. One possible
‘default option,’ at least in some mines, is to
bury a phone cable under the floor or track
and harden the phone handsets by placing
them in military-grade housings and/or
recessing them in the ribs of the mine. Few if
any mine explosions have disrupted the mine
floor at any significant distance from the
source, and a recessed phone would stand at
least a reasonable chance of surviving the
pressures of an explosion wave traveling
through an entry.

13

 2. Improving SCSR reliability Pending the outcome of a national audit of SCSRs
currently in service, we can improve the odds
that a miner’s SCSR will work when needed
by making sure that miners receive thorough
training in the actual use of an SCSR as
opposed to the current regulatory requirement, which simply calls for being able to
demonstrate the ability to open and activate
an SCSR while going through the motions of
donning it but not actually doing so. This
gives the miner no sense at all of what it feels
like to breathe through an SCSR. Without that
experience, a miner trying to use an SCSR for
the first time, in a frightening post-explosion
or fire-threatened mine environment, may
feel that breathing through the device feels
constricted or even impossible. It is true that
the SCSRs in use today need to be replaced by
next-generation designs capable of supplying
respirable air for longer than an hour, able to
dock with replacement units without requiring removal from the user’s face, and
equipped with a comfortable half-face or fullface mask that also facilitates communication
rather than the awkward, uncomfortable and
speech-inhibiting mouthpiece, nose clips, and
goggles currently supplied. But until the nextgeneration unit arrives in the marketplace —
and unless a national audit finds serious and
widespread failures among the many thousands of SCSRs now in service — the ‘default
option’ should be to provide miners with the
real-world training they need. SCSRs that are
still functional but withdrawn from service
because of being past their expiration dates
represent an ideal and immediately available
resource for training. As another part of the
‘default option,’ we must require random
testing of SCSRs currently in service by
asking miners to voluntarily don them and
travel all or part way out of the mine while
wearing them.

3. Emergency shelters Right now
miners who survive an explosion such as the
one at Sago have only two options: to escape
or to retreat and barricade. Getting out,
obviously, is every miner’s first choice, by
training as well as instinct, but it is not always
possible. Debris or a fire may block the way,
or the portal may be far away, or the miner
may be injured and incapable of walking a
great distance. But barricading means entering a race against time, against bad odds.
After an explosion or inby a fire, carbon
monoxide is almost always present in lifethreatening concentrations. Only a completely
impregnable barricade will suffice. Even if
building one is feasible, the supply of respirable air behind it will be finite and will be
drawn down and contaminated as it is
breathed and rebreathed by the miners
relying on it. Yet, as Sago shows so clearly and
tragically, barricaded miners cannot count on
being rescued within the limited time frame
when life is still sustainable. An obvious
solution is to require emergency refuge
chambers or comparable shelters in underground mines. But — some will say — that
could take years, until thorough testing of
designs and structures has been completed
and state and federal regulations have been
promulgated. Possibly so. A viable ‘default
option’ in the meantime, at least in some
mines, may be to use mine engineering and
machinery already in place to carve a rescue
chamber into the coal seam. The next step
would be to double-reinforce access to the
chamber by building two concrete-block
stoppings with offset doors, and then to
supply the chamber with air and a phone line
(through boreholes), water, food such as
military meals-ready-to-eat (MREs), blankets,
cots, first-aid supplies, and a chemical toilet.
Miners should be able to survive in such a

14

 shelter for days, and if no other exit option is
available, a borehole large enough for a rescue
capsule can be drilled down to the shelter. Is
this just someone’s vague notion of something that might or might not work? No. A
refuge chamber of this type and design was
successfully constructed in an Upshur
County, West Virginia underground mine
nearly 30 years ago, as described elsewhere in
this report. Fortunately it never had to be
used. The kind of ‘default option’ that was
available to Upshur Coals then could be
available to other West Virginia mine operators now. This is not to suggest that a onesize-fits-all approach would work, or that
refuges can be constructed without due
consideration of all the engineering and
construction challenges that may be involved,
but only to suggest that miners’ ingenuity can
be brought to bear on this topic as on so many
others.
4. Emergency communications and
tracking It seems likely that in the near
future we will be able to install and rely on
robust, redundant two-way wireless communication systems capable of surviving explosions. But most such systems are now at the
testing stage, and the process of actually
getting them approved and into the mines
could take longer than expected. In the
meantime, there is a need to be able to locate
miners and send messages to them in an
emergency. A hardened mine phone system,
as described above, may be one ‘default
option,’ but it would not be wireless or able to
locate miners missing in an emergency. An
Australian manufacturer currently offers a
wireless system capable of transmitting text
messages to miners via a digital display on
the top of the miner’s cap lamp battery. The
unit flashes the miner’s cap lamp to alert him

or her to an incoming message. The same
manufacturer offers a tracker unit, no bulkier
than a pager or small cellphone, that can be
carried by a miner (or mounted on mobile
equipment) and that will tell the mine dispatcher where the miner (or equipment) is
located. If the underground antenna for either
system is knocked out, it can be replaced by
an emergency antenna laid out on the surface
above the mine. This ‘default option’ is
available now and in widespread daily use as
a productivity-enhancing tool — in Australia.
A few mine operators in the United States are
also using it successfully, and it has saved
lives in this country — notably in the successful evacuation of 45 miners in 45 minutes
during an underground fire at the Willow
Creek mine in Utah in 1998.6 But many mine
operators are reluctant to invest in such a
system, because it may not work flawlessly in
every part of the mine at all times, because it
can only transmit one way, and because
“something better” (wireless two-way voice
communication) is on the horizon. Yes, but
horizons can be deceptively distant. In the
meantime, installing an interim system
should be considered a ‘default option’ for
safety-conscious West Virginia coal operators.
As these examples attest, significant improvements in mine safety may not have to wait for
the perfection of new technologies. They do
require financial outlays, but the costs pale in
comparison to the costs of losing miners in
disasters. In any case, it simply makes good
sense to explore creative ‘default options’
while demand for coal is surging and prices
are near or at all-time highs, as is the case
today.
If cost is not an insurmountable barrier to
adoption of ‘default options’ and the kinds of

15

 safety improvements summarized below,
then what stands in the way? The answer, it
would seem, is inertia.
For a variety of reasons, some in the coal
mining industry have never seen fit to put
safety on a par with production. That must
change — and, we believe, is changing. All
that is needed now is the will to accelerate the
momentum for change that began building in
the dark hours after the outcome of the Sago
disaster, when the governor of West Virginia
pledged that the miners lost in that disaster
would not be forgotten in the way that so
many thousands of miners lost in the past
have been forgotten. We wholeheartedly
support that pledge and seek to help fulfill it.

the grief-stricken families still struggling to
understand how and why such a thing could
have happened, but also among those in the
mining community who know in their hearts
that we can and must do much more to
ensure that every miner who goes to a job in
an underground mine in West Virginia can
count on coming home alive and well at the
end of the shift.
Underground mines are demanding and
unforgiving environments. Mine safety is
about improving the odds that the daily
challenges of mining as well as emergencies
will be met and mastered. We offer the
recommendations that follow — and this
entire report — in that spirit.

The shock waves from the Sago Mine disaster
are still being felt —most profoundly among

SOURCES
A summary of the Symposium is available at www.wju.edu/sago/def.asp
The transcript of the May 2-4, 2006, public hearing may be accessed at
www.wvminesafety.org/PDFs/SAGOHearing-CertifiedDay1.pdf
www.wvminesafety.org/PDFs/SAGOHearing-CertifiedDay2.pdf
www.wvminesafety.org/PDFs/SAGOHearing-CertifiedDay3.pdf
1
2

May 2, 2006, public hearing, transcript, p. 78.

3

A transcript of the June 19, 2006, interview with Randal McCloy, Jr. (as well as all of the interviews
conducted by state and federal investigators in the course of the Sago investigation thus far) may be
accessed at the WVOMHST website: www.wvminesafety.org/sagointerviews.htm
4

More information is available from WVOMHST at:
www.wvminesafety.org/PDFs/SCSRInventoryMemo.pdf
5

For a description of the role of the PED system at the Willow Creek fire, see:
www.msha.gov/minefire/wcreek2000/willowcreekfinal/willowcreekfinalrpt.pdf
6

16

 2

Recommendations

1 Research, develop and adopt
emergency measures to enhance
protection against explosions from lightning
entering underground mines and sealed
areas; review and enhance equipment performance specifications for mine power stations.
2 Permanently ban the use of
Omega blocks as seals, because
the current 20-psi standard is inadequate
and because they may not meet even that
standard.
3 Require mine operators to
strengthen existing alternative
seals by preparing, within 90 days, a plan to
construct solid concrete block or comparable
seal structures in front of (outby) Omega
block seals, or take other appropriate precautions such as ventilating or inerting gases in
sealed abandoned areas, within reasonable
deadlines clearly stated in the operator’s plan
for completing the task.
4 Evaluate the existing seal
standards and consider, at a minimum,
upgrading to the 50 psi standard adopted in
other mining countries.
5 Require refuge chambers: Mine
operators must develop a plan, by January 2,
2007, to purchase or construct refuge

chambers, subject to state and federal approval of the design, numbers, and locations
of such refuges, with the aim of having refuge
chambers installed by January 2, 2008.
6 Conduct a statewide review of
all Self-Contained Self-Rescuers
(SCSRs) currently in use to determine
operability and detect damage, and require
ongoing, in-mine testing of SCSRs by miners
volunteering to don and breathe through
them to assess performance.
7 Develop comprehensive
emergency plans. Every West Virginia
mine must have a comprehensive mine emergency plan integrated with federal, state and
operator roles and tested periodically by the
state for effectiveness.
8 Ensure that miners have
two-way communications: Aggressively accelerate the testing, approval, and
adoption of robust, redundant, wireless twoway communication systems in all underground mines.
9 Require implementation of
tracking systems via the ‘default option’
of installing currently available one-way
electronic personal emergency and tracking
devices.

17

 10 Undertake a comprehensive
review of West Virginia’s mine
rescue systems, including regulations,
training, equipment and coordination with
West Virginia’s Office of Homeland Security
and Emergency Management.
11 Require installation of lifelines
in all primary escapeways in underground
mines, equipped with directional cones to
guide miners to safety.
12 Expand research, development,
and manufacturing opportunities
in West Virginia to ensure that the state leads
the nation in mine safety and health technology and equipment.
In addition to the above recommendations, we offer
the following steps to enhance prevention, improve
electrical safety, improve the safety of sealed areas,
support escape in an emergency, advance mine
emergency preparedness, strengthen the mine
rescue system, and enhance cooperation among
all mine health and safety stakeholders.

STEPS TO ENHANCE
PREVENTION
Make risk assessment the top
priority in planning, developing, and
managing mines. Safety and health protection
must be systematically engineered into all
mining activities.
Adopt a ‘default option’ strategy.
While awaiting availability of new technologies, systematically strengthen the ones we
have now, such as hardening mine phone
systems (by burying or otherwise shielding
cables) to help protect against explosive
forces.

Put safety on a par with production
by expecting every mining company to
employ adequate numbers of safety and
health personnel reporting directly to top
management and authorized to overrule
production demands when inconsistent with
safety practices.
Ask miners. Involve miners in all aspects
of safety and health planning, design, management and enforcement as a basic requirement, not an afterthought.
Reinforce the state’s vital role in
miners’ health and safety by expanding WVOMHST’s responsibilities, capabilities, and funding for risk management,
education, training, and research, and providing competitive salaries for inspectors to
recruit and retain them.
Build safety protection into all
equipment design, from improving
visibility and proximity protection to providing storage compartments for personal safety
equipment, such as deploying safety equipment in longwalls.
Upgrade miners’ personal protective safety and health equipment
and ‘tools of the trade,’ from brass identification tags to helmets, cap lamps, and selfrescuers, to evaluate their adequacy in a 21stcentury-model West Virginia mining industry.
Urge mine operators to offer
handheld gas detectors to every miner
working underground. Miners choosing to
carry them must be provided appropriate
training and must have the right to report
abnormal readings without fear of retaliation.

18

 Maintain all safety equipment in
top condition, from SCSRs to gas detection devices and communication systems.
Reject ‘business as usual’ attitudes.
When a carbon monoxide sensor alarms, the
response should not be simply to ‘have
someone check it out when they have time.’
Safety protection must be the first order of
business every day, not the last.
Modernize recordkeeping of preshift
exam records, equipment serial numbers, and
safety performance checks, using computerbased logs or templates developed by state
and federal agencies.
Develop opportunities to accelerate
safety technologies, evaluating and
transferring technologies used in other
industries and other countries.

STEPS TO IMPROVE
ELECTRICAL SAFETY
Urge every mine operator to examine the mine’s electrical system, to
identify potential safety vulnerabilities.
Publicize lightning hazards:
WVOMHST and MSHA should publish, post
on their websites, and disseminate the latest
available information on protecting mines’
electrical systems and infrastructure against
lightning strikes.
Improve information: Request researchers from within the United States and abroad
to present papers addressing questions of
lightning and protection of sealed areas at the
2nd International Mining Health & Safety
Symposium in Wheeling in April 2007.

STEPS TO IMPROVE THE
SAFETY OF SEALED AREAS
Require mine operators to assess
and address the risk of allowing miners
to work underground, or in certain areas
underground, during the critical time period
when methane in a sealed area is in the
explosive range (5-15%).
Consider a mandatory requirement
for a mining engineer to certify that a permanent seal was constructed according to
specifications.

STEPS TO SUPPORT ESCAPE
IN AN EMERGENCY
Require improved SCSR training for
miners, by training miners to actually don
and use breathable training-model SCSRs in a
dark, smoke-filled environment (using
available training modules and nontoxic
smoke).
Involve miners in field-testing
competing SCSR brands and encourage
operators to be guided by miners’ preferences
when purchasing SCSRs.
Evaluate the existing 10-year shelf
life allowed for SCSRs. Expired SCSRs
should be retained and used for training.
Require mine operators to store
sufficient numbers of SCSRs underground. The ‘default option’ is the state
requirement of 3 hours per miner, increasing
to 24 hours per miner if refuge chambers are
not installed in 2007.

19

 Review current SCSR storage
requirements to ensure that SCSRs are not
stored in environments likely to compromise
the units’ performance; reassess the adequacy
and effectiveness of the currently required
90-day examination.
Conduct an independent evaluation
of the current NIOSH protocol and procedures for examining SCSRs recovered in
mine disasters.
Require SCSR manufacturers to
improve reliability by redesigning SCSR
temperature and moisture indicators to
eliminate possible mis-indications of status.
Accelerate development of nextgeneration SCSRs by establishing an
awards competition for a prototype full-face
or half-face breathing apparatus for miners,
capable of reliably providing respirable air for
more than one hour and of docking with
replacement units in order to facilitate multihour use without interruption or removal of
the facepiece; and urge researchers and
manufacturers to present papers on this topic
at the 2nd International Mining Health &
Safety Symposium in Wheeling in April 2007.

STEPS TO ADVANCE MINE
EMERGENCY PREPAREDNESS
Improve mine-wide emergency
preparedness by requiring much more
rigorous education and realistic training.
Establish company-wide, centralized safety-systems control centers: Urge each mine operator with more
than one operation to establish a centralized

center capable of monitoring safety systems
on an ongoing basis and coordinating
communications and rescue efforts in an
emergency.
Require specialized training, conducted by WVOMHST and MSHA, for any
management personnel who will be expected
to serve in a position of responsibility in a
mine emergency command center, and
modeled on compulsory continuing education training required in other professions.
Provide liaison to families: In any
rescue situation, the highest-ranking federal,
state and company officials on site must be
personally responsible to ensure that miners’
families receive timely updates of accurate
and confirmed information.
Reaffirm and strengthen the
tripartite mine rescue model through
which state, federal, and company officials
share responsibilities under section 103(k) of
the Mine Act, and develop and publicize
information to ensure that all parties understand their authority and responsibility.
Improve WVOMHST’s and MSHA’s
emergency management capabilities by enhancing the importance of mine
rescue and making a mine rescue director
part of top management.
Conduct mock-disaster drills to test
the emergency preparedness of state
and federal officials, mine operators and the
community. Drills should be conducted for a
range of emergency situations, from partial
mine evacuations to full-scale major mine
disasters, to test the effectiveness of communication systems, availability of personal

20

 protective equipment, proficiency of key mine
personnel, and coordination with local
responders and government officials.
Through post-drill evaluations, deficiencies
in the emergency response plan should be
identified and improvements made within
specified deadlines.
Evaluate the inventory of available
mine emergency operations equipment (such as gas chromatographs, robots,
portable seismic) and the ability of such
equipment to facilitate a rapid mine rescue;
report results to the public. Retire unreliable
or obsolescent equipment and replace with
state-of-the-art as necessary.
Continually evaluate and enhance
emergency equipment: At least annually, and under actual mining conditions, test
all mine emergency operations equipment
(such as robots and seismic), and report
results to the public.
Support timely gas chromatography during a mine emergency by
requiring every underground coal mine in
West Virginia to include in its mine emergency preparedness plan a method to have a
gas chromatograph on site within two hours
after the onset of an emergency.

Require post-emergency medical
examinations and treatment as necessary
for any miner or rescuer exposed to toxic
substances or other threats to life and health
in the course of a mine emergency.

STEPS TO STRENGTHEN THE
MINE RESCUE SYSTEM
Establish a West Virginia-based
National Mine Rescue Committee
made up of mine rescue team members and
other experts, to systematically review the
mine rescue system’s structure, equipment,
and response strategies, and to make recommendations to strengthen the system, in a
report to be delivered at the 2nd International
Mining Health & Safety Symposium in 2007.
Develop a skills-ranked or tiered
scale for mine rescue teams, similar to
what is used for other emergency response
organizations.
Enhance mine rescue training to
include in-mine drills. Veteran mine rescue
teams should be canvassed to develop a ‘wish
list’ for training and equipment that should
become the basis for strengthening mine
rescue training and deployment.

CONSOL ENERGY’S COMMUNICATION’S CENTER
Since 1969, CONSOL Energy has operated a communications center to provide comprehensive communications and monitoring services to its mining operations. The center operates on a 24/7 basis, enhancing safety and productivity of CONSOL’s operations by supplementing mine-site monitoring of production, ventilation and fire prevention systems. The current communications center, located near their
McElroy mine complex in Ohio County, West Virginia, plays an important role in preparing for and
responding to emergency situations. Well-established relationships and procedures permit the rapid
marshalling and coordination of emergency services, such as mine rescue teams, EMS, and fire and
police departments.
21

 Issue a mine rescue team member
identification card, renewable annually,
to expedite travel and admission to the mine
property.
Retire the obsolete seismic system,
and recall the hardhat stickers promising
miners that help is on the way. Prompt
implementation of robust two-way communications systems and tracking systems will
make the current seismic system even more
obsolete than it already is. Encourage research
on next-generation seismic technology and
equipment.
Invite the Incorporated Research Institutions for Seismology (IRIS) and other professional entities to participate in the 2nd International Mining Health & Safety Symposium
in 2007 and to present information on the
feasibility of applying seismology techniques
and equipment to mine rescue.

STEPS TO ENHANCE
COOPERATION
Provide updates on a regular basis
to the Sago families and the public on
progress made to improve mine safety and
the mine rescue system in West Virginia.
Continue to host an international
mine safety and health symposium
annually or biennially to promote cooperation
among mining countries and rapid advancement of new technologies and techniques.

Seek participation from the international community for a study group
to evaluate lightning risk to underground miners. Participants would assess the
incidence and travel paths of lightning strikes
near mines and report their findings at the
International Mine Safety & Health Symposium in April 2007.
Call upon International Coal Group
(ICG) to lead the way in mine safety
and health by making its mines and other
resources available as laboratories for testing
and improving technologies and training
techniques in cooperation with state and
federal agencies.
Examine methods to improve
accident investigation protocols and
procedures, such as appointing independent
investigative committees and defining rights
for victims’ families; and design a data
template to accompany or be incorporated
into accident investigation reports to enhance
their value to safety and health trainers and
researchers.
Encourage voluntary cooperation
and commitment as the preferred approach to get new equipment, technology,
and best practices underground with all
possible speed.
Abandon old myths and misinformation about the reliability of safety and
health technologies and replace them with
hard facts and science-based determinations.

22

 3

A synopsis of the
Sago Mine disaster

Note: The information in this synopsis is
derived from numerous sources, primarily
testimony provided to investigators. Transcripts
are available on the website of the West
Virginia Office of Miners’ Health, Safety and
Training at www.wvminesafety.org. The times
shown (other than the time of the explosion)
are in many cases approximate. Times, data,
etc., may be subject to further investigation
and verification.

MONDAY, JANUARY 2, 2006
3:00 am

Shortly after 3:00, firebosses Terry Helms and
Fred Jamison enter the Sago Mine to conduct
preshift examinations of the mine’s two
working sections, One Left and Two Left.
5:30 am

Between about 5:15 and 5:45, miners and
supervisors arrive at the mine, change into
their work clothes, check their lights and
other gear, and chat with each other in and
around the bathhouse and mine office.
Meanwhile, the two firebosses report to Bill
Chisolm, the mine dispatcher, that there are
no major mechanical problems or safety
violations on the two working sections. Terry
Helms delivers his report over the mine’s
phone system; Fred Jamison delivers his
report in person after exiting the mine to recharge the battery on his mine jeep.

6:00 am

Two crews of miners — One Left and Two
Left, each consisting of 11 miners and a
section boss (foreman) — enter the mine in
two mantrips (battery-powered rail-traveling
personnel carriers). The Two Left mantrip
enters first, since it will be traveling inby
(further in) to the Two Left section, past the
point where the One Left crew will turn at a
track switch to enter the One Left section. The
One Left crew is briefly delayed while foreman Owen Jones, realizing that his mantrip is
too small to accommodate his crew plus three
other miners — two pumpers and a belt
maintenance man — who will be traveling
partway into the mine with him, goes back
for a larger mantrip. The One Left crew, plus
the pumpers and beltman, then follows the
Two Left crew into the mine. Fred Jamison
also re-enters the mine to work at a conveyor
belt not far inby the portal. All told, 29 coal
miners are at various locations inside the Sago
Mine by about 6:15 am.
6:05 am

The computer console in mine dispatcher Bill
Chisolm’s office (a trailer separate from the
mine office) indicates that a carbon monoxide
(CO) monitor in the One Left section is either
malfunctioning or detecting elevated CO
levels. Based on the computer display (which
flashes “malfunction” briefly before alarm-

23

 ing), the dispatcher decides that the monitor
is false-alarming and reportedly calls the One
Left crew to ask the crew’s electrician to check
the fuse when he reaches the section.
6:26 am

As a severe, fast-moving thunderstorm
sweeps across Upshur County, lightning bolts
strike in the immediate vicinity of the mine.
The mine dispatcher, who is on the phone
with mine superintendent Jeff Toler at that
moment, hears a loud pop on the phone and
sees on his computer monitor that several
conveyor belts, which he had previously
powered up from the computer, are shutting
down. The computer also alerts him — both
visually and with an audible alarm — that the
belts’ CO monitors are detecting carbon
monoxide. He reports this to Jeff Toler, who
asks him to contact the One Left and Two Left
crews on the mine phone, to tell them to
check the CO monitors. At first, Toler and his
maintenance supervisor, Dick Wilfong,
assume that some fuses have blown, as has
happened in previous storms.
(The time shown on the computer’s clock was
6:31 am. In the course of the post-disaster
investigation, state investigators performed a
time correlation with an atomic clock and
determined that the mine’s clock was fast by 4
minutes 56 seconds. According to Vaisala, a
nationwide lightning-monitoring service, two
lightning strikes, one of which packed unusual power, occurred within a five-mile
radius of the Sago Mine portal at 6:26. The
explosion in the mine appears to have occurred at virtually the exact same moment.)
6:30 am

Dispatcher Chisolm gets no response from
either of the two crews. He calls repeatedly on

the mine phone: “Inside, inside, inside!”
Within an estimated three to five minutes,
One Left foreman Owen Jones calls out to
report that he and his crew have been caught
in “a big rush of air that came from inby,
toward the Two Left panel,” as Jeff Toler
remembers the report. Wilfong remembers
Jones saying that he didn’t know what
happened. Jones recalls saying “We’ve had a
mine explosion in here!” and adding: “Get a
mine rescue team here now.” Toler tells Jones
to shepherd his crew into the escapeway.
In the mine, in the moments immediately
following the explosion, the One Left miners
struggle to see — some later describe the
visibility as less than a foot at first — and to
breathe in the dust-filled atmosphere. Seven
of the miners don their self-contained selfrescuers (SCSRs); three later describe having
had some difficulty using them, and one of
the One Left miners subsequently testifies
that SCSRs should be redesigned, but from
their testimony to MSHA and WVOMHST
investigators it appears that with one possible
exception all of the SCSRs that were used by
the One Left crew functioned properly.
6:45 am

Jeff Toler, safety director Al Schoonover,
maintenance chief Dick Wilfong and assistant
maintenance chief Vern Hofer enter the mine
in a mantrip. On the way in, in the main track
entry, they first encounter fireboss Fred
Jamison and then pumper John Boni, both
unharmed, and instruct them to exit the mine.
They then stop at a mine phone near 25 block
to call out to the dispatcher, to find out
whether the Two Left crew has been heard
from. The dispatcher reports that nothing has
been heard. Meanwhile the One Left crew has
been making its way on foot in the escapeway

24

 toward the mine portal. The miners hear the
sound of Toler’s mantrip in the parallel track
entry, and a crew member, Joe Ryan, sticks his
head through a man door into the entry and
calls to Toler to tell him where they are and
that one of the crew, Hoy Keith, is having
difficulty. Toler tells Ryan to bring the whole
crew to the mantrip and instructs Wilfong
and Hofer to take the crew out.
7:00 am

The One Left crew heads out of the mine on
the mantrip. (In addition, beltman Pat Boni,
after calling out to find out what has happened, has been instructed to exit the mine
and is walking out, unharmed, in the escapeway.) One Left foreman Owen Jones, whose
brother Jesse is on the Two Left crew, remains
in the mine, further inby, at 41 block, trying to
determine whether he can move toward Two
Left. Jeff Toler, whose uncle, Martin Toler, Jr.,
is the foreman of the Two Left crew, asks
Owen Jones to come back and stay by the
mine phone near 30 block. Toler and
Schoonover then explore inby, walking to 42
block, observing damage to ventilation
stoppings, and using the phone at 41 block to
call out to instruct Wilfong and Hofer to come
back with curtains and other supplies to
repair ventilation controls. Toler and
Schoonover then walk back to rejoin Owen
Jones.
Meanwhile, at about 7:00 am, the mine
dispatcher phones ICG assistant safety
director John Stemple at home to tell him that
Sago has a problem — that there has been a
severe lightning storm, power has been lost
underground, and the One Left crew has
called out to report trouble. Stemple, trying to
understand the situation, asks to be patched
through to Jeff Toler underground. They talk

at about 7:15. Toler tells Stemple that Dick
Wilfong recommends contacting a mine
rescue team and getting them started toward
the mine.
7:20 am

The mantrip carrying the One Left crew
arrives at the surface. Wilfong and Hofer load
up supplies and head back underground.
Stemple begins trying to reach company,
state, and federal officials. Initially he has no
success: Phones are not answered, or his calls
go to answering machines. In the case of
WVOMHST inspector at large Brian Mills, he
gets a message that Mills’s phone has been
disconnected.
7:45 am

Stemple leaves a voicemail message for
WVOMHST inspector John Collins, who lives
near the mine in Buckhannon. Collins returns
the call at 7:50, learns of the incident, phones
Brian Mills at 7:55 to notify him (Stemple had
had an old phone number for Mills), and
heads for the mine.
8:00 am

Stemple tries to phone the Barbour County
Mine Rescue Team, which is under contract
with ICG to provide emergency services. He
discovers that the team’s answering machine
is turned off. Meanwhile, at about 8:00, Chuck
Dunbar, general manager of ICG’s
Buckhannon division, arrives at the mine and
discusses the situation with the mine dispatcher.
8:10 am

Wilfong and Hofer, heading back into the
mine on the mantrip with supplies, meet
Toler, Schoonover, and Jones at 32 block. They

25

 repair blown-out stoppings and proceed via
mantrip to 42 block, where their CO monitors
begin alarming. Concerned about fire and the
possibility of a second ignition, they disconnect the batteries on the mantrip and advance
on foot inby, continuing to repair stoppings as
they go. At 49 block, Toler goes into the track
entry, and moves a phone and emergency
first-aid supplies from the track entry to the
intake entry.

8:30 am

About two hours after the explosion, at 8:32
am, MSHA inspector Satterfield issues a
verbal 103(k) order by phone. According to
Stemple, the inspector tells him that no one is
to enter the mine or do any work at the mine.
Section 103(k) of the Federal Mine Safety &
Health Act of 1977 states:
In the event of any accident occurring in
a coal or other mine, an authorized representative of the Secretary [of Labor], when
present, may issue such orders as he
deems appropriate to insure the safety of
any person in the coal or other mine, and
the operator of such mine shall obtain the
approval of such representative, in consultation with appropriate State representatives, when feasible, of any plan to recover
any person in such mine or to recover the
coal or other mine or return affected areas
of such mine to normal.

8:15 am

Meanwhile, WVOMHST inspector John
Collins arrives at the mine. He talks with
members of the One Left crew about what
they experienced. When two other state mine
inspectors arrive, Collins asks them to take air
readings at the return entry at the portal.
They report the presence of carbon monoxide,
although at low levels. Because the presence
of CO is an indication of a possible mine fire
or explosion, Collins decides to issue a control
order under Title 36, series 19, section 7.1 of
the West Virginia Administrative Regulations.
The regulation states:
Unless granted permission by the Office of
Miners’ Health, Safety & Training, no
operator may alter an accident site or an
accident-related area until completion of all
investigations pertaining to that accident,
except to the extent necessary to rescue or
recover an individual, prevent or eliminate
an imminent danger, or prevent destruction
of mining property.

Meanwhile, at about this same time, Stemple
reaches a member of the Barbour County
mine rescue team. He continues trying to
reach MSHA officials but encounters answering machines at the District 3 office and at
various officials’ homes. Finally, at about 8:30,
he reaches MSHA inspector Jim Satterfield
at home.

At around 8:30, Ty Coleman, ICG safety
manager for its West Virginia and Maryland
operations, arrives at the mine.
A few minutes later, at 8:37, inspector John
Collins briefs WVOMHST director Doug
Conaway by phone.
Meanwhile, in the mine, Toler, Schoonover,
Wilfong, Hofer and Jones continue to walk
inby toward the Two Left turnoff, repairing
damaged ventilation controls as they go, and
pausing to let fresh air dissipate the carbon
monoxide. As they proceed they notice that it
is taking longer for the CO levels to drop and
that the velocity of the fresh air coming in
behind them seems to be diminishing. Because this could mean that the air is shortcircuiting through damaged controls behind
them, Toler asks Jones and Hofer to go outby,
retrieve curtain, and check for damaged

26

 controls. Then he, Schoonover, and Wilfong
proceed inby to about 57 block, where they
find the stopping damaged and hang a
curtain. They then proceed to 58 block and
find that the stopping there too is damaged.
They also encounter dense, swirling smoke
that does not appear to be dissipating. They
discuss what to do, concerned that if there is a
fire inby they should not be directing more air
to it and possibly triggering another explosion. They decide, reluctantly, that the safest
course — for the Two Left crew and for
themselves — is to withdraw from the mine
and let mine rescue professionals take over.
9:30 am

Toler phones the dispatcher from 58 block,
reporting that the smoke is bad and that he,
Wilfong, and Schoonover are walking out of
the mine. They walk out in the intake escapeway. There, making their way out, they find
Owen Jones and Hofer waiting for them, and
the five men make their way toward the
surface together.
10:30 am

Four hours after the explosion, MSHA personnel begin to arrive at the mine. The first to
arrive are inspectors Jim Satterfield, Pat
Vanover, and Ron Postalwait.

to ICG — arrive on site and begin preparing
to travel underground by noon. Meanwhile,
MSHA has contacted Consol Energy, which
has several experienced mine rescue teams,
and requested that they be mobilized and
sent to the mine. ICG, meanwhile, has chartered a plane to bring the rescue team from its
Viper mine in Illinois.
ICG’s John Stemple arrives at the Sago Mine
at about 11:30. Sam Kitts, ICG’s vice president
for West Virginia and Maryland, arrives at the
mine at about 11:45. Shortly before noon,
according to Ty Coleman’s recollection,
Coleman has a command center set up and in
operation at the mine offices; he is in charge
of the rescue effort for ICG. Tim Martin, ICG’s
corporate safety director, arrives shortly after
noon.
Late in the morning, ICG’s Chuck Dunbar
contacts Mike Ross, a local oil-and-gas developer, to locate a drilling rig in order to drill a
borehole into the mine. Ross, in turn, contacts
three drilling companies, one of which, Hyre
Water in Buckhannon, is requested by ICG to
bring a drill to the mine site.
12:00 noon

Toler, Schoonover, Wilfong, Jones and Hofer
exit the mine. Collins and other state and
federal personnel debrief them. They also
describe the situation underground to ICG’s
Ty Coleman.

CO levels being measured at the return entry
increase to 2,300 ppm. Elevated CO levels are
also detected in the mine offices; MSHA
issues an imminent danger order, requiring
the offices to be temporarily evacuated.
(However, as the evacuation is starting, CO
levels decline, and the command center
remains in operation.)

11:00 am

1:00 pm

At about 11:00 am, more than 4 hours after
the explosion, the first two mine rescue teams
— the Barbour County teams under contract

ICG submits a plan, approved by MSHA and
WVOMHST, to continue monitoring gases at
the pit mouth. At 1:15 pm, personnel measur-

10:35 am

27

 ing at the return record 500 ppm CO; 1.1%
methane (CH4); and 19.2% oxygen.
At about this time, the command center
adopts a plan to drill a borehole from the
surface into the Two Left section, based on the
assumption that the Two Left crew, if alive,
are most likely inby the mouth of the section.
The borehole will help determine conditions
on the section and presumably can be used to
communicate with the miners if they are
found alive. Surveying crews equipped with
GPS instruments are sent out to determine a
suitable location, but are hampered by unfavorable weather conditions, which cause
difficulty and delays in getting accurate
readings from GPS geosynchronous satellites
orbiting the earth.

3:00 pm

A gas chromatograph from Consol arrives
and is set up, facilitating bottle sampling of a
wide range of gases.

3:07 pm

Trapped miner James Bennett writes: “The air is
bad. I don’t know how long we can last.”

4:15 pm

Gas concentrations trend down.

4:22 pm

James Bennett writes: “Time is running out for us.
We have not heard anything from the outside yet.”

1:45 pm

4:25 pm

The mine rescue team from Consol’s
Robinson Run mine arrives.

James Bennett tries to write another note: “I love
you...” He does not finish; it is his last note.

2:30 pm

At some point, possibly later than this, Martin
Toler, Jr., writes a note: “Tell all — I see them on
the other side. Jr.” On the right side of the sheet, he
writes: “It wasn’t bad I just went to sleep.” Along
the bottom, he writes: “I love you.”

The mine rescue team from ICG’s Viper mine
arrives. Several other mine rescue teams
arrive in the course of the afternoon.

2:40 pm

Trapped miner Junior Hamner writes a note: “I’m
still OK at 2:40 p.m. I don’t know what is going
on between here and outside. We don’t hear any
attempts at drilling or rescue. The section is full of
smoke and fumes so we can’t escape. We are all
alive at this time.”
2:45 pm

Trapped miner Jackie Weaver writes: “It’s 2:45 pm
— the fumes are getting terrible — everybody is
still partially OK”

4:45 pm

More than 10 hours after the explosion,
MSHA approves a plan to send mine rescue
teams into the mine for initial exploration: TriState Team A is to explore the first 1,000 feet,
stopping every 500 feet to cross three entries
taking air readings. To eliminate conductivity
hazards, the rail and belt structure will be
broken and separated by the rescuers one
break inby the pit mouth.

28

 5:00 pm

A bulldozer is delivered to the mine site and
begins to construct a 1,600-foot-long road
down a hillside to the borehole drilling site.
The bulldozer then excavates a pad 200 feet
long and 90 feet wide to accommodate the
drill. The process of surveying, road-building,
excavation, and subsequent modification of
the drill pad to facilitate precise borehole
drilling takes about 13 hours. (Under normal
circumstances, surveying, siting and drilling a
borehole would take about two days.)

restore power to a dewatering pump so that
the return airway can be kept open. At 7:30,
permission is given to start the pump.
8:10 pm

The pump is started.
8:20 pm

MSHA approves a plan to send two mantrips
operated by mine rescue personnel to the 17
block on No. 3 belt. One mantrip will be
brought back to the surface by the exiting
mine rescue team.

5:10 pm

At about 5:10, MSHA modifies the mine
exploration plan to provide for the more
experienced Consol Robinson Run team to
enter instead of the Tri-State team.

8:30 pm

Batteries are disconnected from a scoop and
mantrip located at 17 block.
8:50 pm

5:25 pm

The Robinson Run team enters the mine in
the intake entry through the fan housing. At
5:45, the team is given permission to stay in
the track entry and move inby. At 5:50, the
team is given permission not to break the
track near the portal as originally planned, so
that the track can be used for mantrip transportation if needed (the track is to be broken
further inby).
6:00 pm

Between 6:00 and 7:00 pm — about 12 hours
after the explosion — the Robinson Run team
moves as far as 8 block, taking readings that
indicate low levels of CO and no measurable
methane. The team is told to hold at 9 block
until the next team arrives. At 6:57, an accumulation of water is reported in the return
entry at 21 block.
7:10 pm

Teams advance to the 32 block of No. 3 belt,
where the mains reduce from 8 to 5 entries.
10:45 pm

The track is cut.
11:30 pm

On the surface, about 10 hours after surveying began for a suitable location to facilitate
drilling a borehole into the Two Left section,
the final coordinates are determined. Work
begins to modify the drill pad to allow the
drill to set up precisely on the coordinates so
that it will drill into a mine entry and not into
a coal pillar.

TUESDAY, JANUARY 3, 2006
12:25 am

Consol’s Robinson Run B team is to advance,
with Consol’s Blacksville team underground

ICG submits a plan, approved by MSHA, to

29

 for backup and the Barbour County team on
the surface for backup.
2:45 am

The mine rescue teams have advanced to 34
block, about 9,400 feet from the portal, when
they report seeing a red light and are given
permission to approach it. They identify the
light as a CO monitoring station, previously
thought to have been de-energized. Because
the monitoring station is a potential ignition
source, they are instructed to withdraw from
the mine until the system can be de-energized.

Two Left section about 300 feet from the face.
Air samples from the borehole indicate CO at
1300 ppm (more than three times the maximum safe level for a one-hour exposure),
negligible methane (.04%), and 20.7% oxygen.
5:50 am

The drilling equipment is shut down and a
10-minute quiet period is observed, in hopes
of hearing a signal from the trapped miners.
There is no signal. The drill steel is struck, to
make noise underground; there is no response.
6:30 am

2:45 am

On the surface, the drill begins drilling the
borehole toward Two Left.
3:40 am

The mine rescue teams reach the surface. In
the command center, a decision is made to
keep them outside until the borehole penetrates the mine.

About 24 hours after the explosion, mine
rescue teams are sent underground again, and
a camera is lowered into the borehole. It
shows no blast damage in the immediate
vicinity, indicating that the explosion did not
originate inby on Two Left and suggesting
that it must have occurred in the sealed area
beyond the mouth of Two Left.
7:00 am

The borehole is drilled to a depth of 220 feet,
about 38 feet above the roof of the mine.

Between 7:00 and 8:00, mine rescue teams
travel to 31 block, No. 4 belt; the robot is
transported into the mine at about 7:35;
drilling of a second borehole into One Left
gets under way; and the robot reaches 32
block, recording low CO levels (27 ppm).

5:00 am

8:50 am

MSHA approves a plan to load its V2 mine
robot and operator and transport them to 31
block. The plan is for the robot to explore
inby, followed by mine rescue personnel.

The mine robot, encountering difficult terrain,
is disabled.

4:00 am

The CO monitoring system’s backup power
source is successfully de-energized.

5:30 am

About 23 hours after the explosion, the
borehole drill punches through into the mine,
258 feet below the surface, at a point in the

10:20 am

About 28 hours after the explosion, the
command center adopts a plan for the mine
rescue teams to proceed to 48 block of One
Left and examine the common return inby for
six breaks. The teams are then to proceed inby

30

 to the Two Left section via the intake entries.
The teams will then examine the Omega
block seals. Exploration will then proceed to
60 block, advancing intake air into the Two
Left section, and will then proceed into the
Two Left section.
1:30 pm

Mine rescue teams change places: Bailey and
Loveridge advance, Tri-State going outside,
Barbour County providing backup on the
surface.

7:15 pm

Mine rescue teams begin exploring the Two
Left section.
7:45 pm

Mine rescue teams find the Two Left mantrip
at 10 block. Moving inby in the track entry,
the teams find widespread damage to
stoppings.
8:00 pm

Mine rescue teams are at 48 block in the track
entry, near the One Left section return entry.

Shortly after 8:00 pm, mine rescue teams
exploring the Two Left intake escapeway find
evidence of 12 SCSRs having been opened,
and see footprints heading outby toward the
seals.

2:15 pm

9:00 pm

Mine rescue teams find the mantrip abandoned by the One Left crew at 50 block,
heading inby with its headlights still on.

Mine rescue teams continue to advance into
the Two Left section.

2:00 pm

11:45 pm
4:30 pm

Mine rescue teams, using curtains to restore
ventilation in damaged areas, establish a fresh
air base at 57 block, No. 4 entry.
5:15 pm

MSHA mine rescuer Ron Hixson finds a
miner’s body in the track entry between 57
and 58 block. The victim is later identified as
Terry Helms.
6:30 pm

36 hours after the explosion, mine rescue
teams find that the Omega block seals beyond
Two Left have been almost completely destroyed, with the pulverized seals blown in an
outby direction, indicating that the explosion
occurred in the sealed area. (The destruction
is so complete that mine rescue team members at first walk past the entry into what had
been the sealed area without realizing it.)

Mine rescue teams have advanced 1,900 feet
into the Two Left section. As rescuers advance
to the face of the No. 3 entry, Jim Klug, captain of Consol’s McElroy team, reports hearing sounds, and moments later he and other
rescuers find the 12 trapped miners behind a
curtain. The first report back to the command
center, relayed by voice, walkie-talkie, mine
rescue lifeline and mine phone, is that all 12
miners are alive. The command center erupts
in celebration and then organizes to send in
stretchers, blankets, water, SCSRs, first aid
supplies and medical personnel. Word
quickly reaches the miners’ families waiting
nearby in the Sago Baptist Church, and they
celebrate the miraculous news: 41 hours after
the explosion, their loved ones have been
found alive.

31

 WEDNESDAY, JANUARY 4, 2006
Midnight

Mine rescue team members, several of whom
are certified emergency medical technicians
(EMTs), determine that there is only one
survivor. They place him on a stretcher, begin
using a succession of SCSRs to give him air,
and prepare to carry him back to their fresh
air base and then to the nearest mantrip —
nearly 3,000 feet in all, through difficult
terrain. One of the mine rescuers, aware of the
miscommunication, uses a walkie-talkie to try
to radio back to the fresh air base, but cannot
get through.
12:15 am

At 12:18 am, the command center receives a
message from the mine rescue teams that they
are leaving the Two Left section, and that they
have one coming out on a stretcher and 11
“items.” The command center, concerned
about communication leaks to the media, had
earlier adopted a code by which the mine
rescue teams would refer to bodies as
“items,” and the teams were supplied an
identification sheet with a number for each
missing miner, to be used instead of names in
radio and phone communications. ICG
corporate safety director Tim Martin, remembering the code, asks for confirmation. The
same answer comes back from underground.
There is disagreement within the command
center about its meaning. Martin tells the
command center to drop the code and ask
about survivors. At about 12:23 am the
rescuers are asked: “Do you have 11 survivors
and one on a stretcher?” The answer comes
back: “No, it’s the other way around.” The
command center is staggered by the news.

12:30 am

Mine rescue teams continue bringing the sole
survivor out of the mine, reaching the surface
at about 1:00 am. With his identity not yet
determined, the survivor is rushed by ambulance to St. Joseph Hospital in Buckhannon.
Meanwhile, all mine rescue teams have been
ordered out of the mine.
1:45 am

At about 1:45 am, with the identity of the
survivor still not yet known, ICG officials
attempt to send a message to the families at
the church via the state police, asking an
officer to relay word to the clergy to the effect
that the command center has conflicting
reports on survivors and that the initial
reports may have been too optimistic. The
message is reportedly relayed but does not
reach the families.
2:00 am

Shortly before 2:00 am, ICG’s Viper mine
rescue team, which has 5 EMTs equipped
with stethoscopes, is rushed back into the
mine to confirm that the remaining Two Left
miners are deceased.
2:30 am

Mine rescuers reach the face of No. 3 entry, reassess the victims, and report back that all 11
are deceased. Meanwhile, the command
center hears from the hospital that the sole
survivor is Randal McCloy, Jr.
A few minutes later, ICG president and CEO
Bennett Hatfield, vice president Sam Kitts,
and others make their way to the church and
break the news to the families. Facing an
outpouring of confusion, disbelief, grief, and
outrage, the ICG officials are escorted out of

32

 the church by state troopers and return to the
command center.

process of bringing the victims out of the
mine continues for another 5 hours.

5:00 am

10:00 am

At around 5:00 am, nearly 48 hours after the
explosion, mine rescue teams carry out the
task of identifying the victims, placing them
in body bags, and using mine equipment (a
scoop) to bring them out because of the
difficulty of carrying them all out on stretchers and the risk that to do so could exhaust
or otherwise endanger the rescuers. The

All victims are removed from the mine by
about 10:00 am — nearly 52 hours after the
explosion.
After the victims have been taken away in
ambulances, the rescuers gather in a circle at
the portal and say a prayer for the lost miners.

33

 34

4

What caused
the disaster?

Shortly before dawn on the morning of
Monday, January 2, 2006, a severe thunderstorm swept across Upshur County, West
Virginia. At 6:26 a.m., multiple lightning
strikes, including one of much greater than
normal power, were recorded within a fivemile radius of the portal of the Sago Mine,
located about five miles south of
Buckhannon, the county seat. At virtually the
exact same instant, methane ignited in a
recently sealed area of the mine just beyond
the Two Left working section, blowing out the
seals and filling the mouth of the section with
smoke, debris, fumes, and lethal levels of
carbon monoxide.
Twenty-nine miners were underground at
Sago when the explosion occurred. Thirteen
were in close proximity to the blast. As was
subsequently learned, one miner was killed
by the force of the explosion itself. Twelve
others, after attempting to make their way out
of the Two Left section, turned back and
retreated behind a curtain hung diagonally
across the No. 3 entry at the working face of
the section in an attempt to barricade themselves against the smoke and carbon monoxide created by the explosion. There they
awaited rescue — which, tragically, would
come too late for all but one of them.

Meanwhile the other 16 miners, who were
more distant from the ignition point and not
seriously harmed by the explosion, were able
to exit the mine safely with the aid of other
miners, including the mine superintendent,
who rushed into the mine and who then
made a courageous but unsuccessful effort to
reach the miners trapped in the Two Left
section.
At this writing, the proximate cause of the
methane ignition has not been determined
with finality. Among the Sago miners who
escaped (as reflected in their testimony to
investigators), the belief is widespread that
lightning somehow triggered the methane
ignition. But the question of precisely how
lightning may have entered the recently
sealed area of the mine has not yet been
resolved.
Multiple lightning strikes — at least two and
perhaps three — are known to have occurred
in the vicinity of the mine. The most powerful
of the strikes registered at 101 kilo amps (kA),
roughly three times the average peak current
of lightning, and occurred at 6:26:35 a.m. at
coordinate N.38.926 – W.80.233, approximately two miles from the sealed area of the
mine but quite close to the 12 KV power lines
owned by International Coal Group and

35

 leading from the Allegheny Power substation
at French Creek to the mine preparation plant,
then branching off with a separate split to the
mine offices and portal, where it supplied
power underground.

portal, then traveling through the electric
system, phone system, track, belt structure,
and/or roof mesh, and thereby finding some
way to and past the seals and into the sealed
area to the point of the explosion.5

Two other lightning strikes were recorded at
6:26:35 a.m., closer to the mine power line,
preparation plant and portal but of normal
lightning strength of 35 kA and 38 kA. These
may actually have been a single strike, subject
to differing interpretations as to location.1

Since the sealed area had been abandoned in
part because of a history of roof falls, there
was some speculation early in the course of
the investigation that a roof fall might have
provided a frictional ignition source. Subsequent identification of the apparent ignition
point and the forces emanating from that
point suggested, however, that a roof fall
probably was not the triggering mechanism,
leaving lightning or spontaneous combustion
as the alternative causes.

At the same instant — 6:26:35 a.m.2 — the
carbon monoxide (CO) monitor alongside the
mine conveyor belt at block 57 spiked at 51
parts per million (ppm).3
These simultaneous events would seem to
point to lightning as the probable cause of the
methane ignition and subsequent explosion.
However, investigators are still attempting to
determine how lightning may have entered
the sealed area.
One possibility is that lightning followed a
path (still undetermined) from the surface
downward into the sealed area, possibly
involving a submerged pump, partially
submerged pump cable, and wire roof mesh
in finding its way to the site of the ignition. A
de-energized and submerged pump was left
in the area when the area was sealed, reportedly because crews were unable to remove it.
The pump was reportedly connected to a
length of cable which reached to near the
ignition point.4 At this writing, the pump has
been removed from the mine for further
examination.
Another possibility is that lightning followed
a path (also still undetermined) to the mine

Since spontaneous combustion has been
deemed unlikely by most investigators, they
have focused on attempting to determine
how lightning found its way into the sealed
area. Although various theories have been
advanced, the facts must drive the theory
rather than the other way around, and some
key facts have yet to emerge. Therefore, until
the issue of the proximate cause has been
definitively resolved, speculating is pointless.
That said, however, three questions clearly
relevant to both the cause and the consequences of the explosion must be addressed:
• Prevention: Did the Sago Mine’s owner,
International Coal Group (ICG), do everything required by law and regulations to
protect the mine against lightning strikes?
• Containment: Was the sealed area properly
sealed, and were the seals used strong enough
to contain a substantial explosion?

36

 • Propagation: Was propagation of the
explosion minimized by effective rockdusting
outby the sealed area?
From testimony provided to investigators and
at the public hearing in Buckhannon on May
2-4, 2006, it is clear that ICG failed to properly
ground the mine’s electrical power infrastructure in its entirety, and failed to install lightning arrestors at some key locations as required by federal regulations. Pending further
investigation, the question of whether these
failures directly contributed to the explosion
and subsequent loss of life remains to be
resolved, but there is no question that they
represent serious failures of mine management.
As to the seals themselves, in the early stages
of the investigation much attention was paid
to the question of whether they were properly
constructed. That question has not been
entirely resolved and may never be, since
most of the seals were pulverized. But to
some extent the focus on this question had the
effect of distracting attention from the larger
and more relevant question, which is whether
the Omega blocks that were used to construct
the seals were, in fact, capable of withstanding a severe explosion originating inby the
seals. Although this question is explored in
more detail in section 5 of this report, it is
important to note here that this question does
not go to the adequacy of ICG’s management
of the Sago Mine. The mine operator installed,
and relied upon, a type of seal approved for
the purpose by the federal government.
Thus the crucial question with regard to the
seals at Sago is whether the criteria used to
determine the acceptability of Omega blocks
as explosion-proof bulkheads were appropri-

ate and adequate. The evidence available at
this point suggests that the test criteria were
insufficiently comprehensive and failed to test
the ability of Omega blocks to withstand and
survive dynamic pressure from an explosion
originating inby the seals. This leads to the
conclusion that Omega blocks should never
have been approved as explosion-proof seals,
because it appears highly unlikely that, no
matter how they were constructed, they could
have contained an explosion such as the one
that occurred in the Sago Mine on January 2.
Addressing the last of the three cause-related
questions raised above, however — the
question of whether propagation of the blast
was effectively contained by adequate
rockdusting outby the sealed area — it needs
to be said that the explosion on January 2
might well have resulted in even greater loss
of life but for the fact that investigators found
the mine to have been well rockdusted prior
to that date. Some investigators, in fact,
consider Sago to have been exceptionally well
rockdusted, apparently reflecting the efforts
of mine managers to improve safety conditions at the mine in the wake of meetings held
in late 2005 with MSHA representatives.
Rockdusting — the systematic application of
powdered limestone to mine surfaces —
suppresses coal dust, a substance even more
explosive than methane. Deprived of coal
dust as a mechanism to propagate the forces
generated by the initial ignition, the explosion
of January 2 had lost much (although certainly not all) of its power before it reached
the One Left crew at their location further
outby the sealed area. They experienced the
blast mainly as a powerful rush of air and
debris. A coal dust explosion, in contrast,
might have engulfed the entire mine, killing

37

 that the question of what caused the Sago
Mine disaster has a three-part answer:

everyone or nearly everyone inby the portal.
Moreover, deprived of coal dust, the explosion did not ignite a mine fire, which if it had
spread could have made escape for the One
Left crew problematic or impossible.

• Lightning probably caused the explosion.
More remains to be learned, however, about
how lightning made its way into the sealed
area where the methane ignition took place,
and, depending on how that question is

Accordingly, subject to development of
additional and definitive evidence, we believe

LIGHTNING RELATED EXPLOSIONS IN COAL MINES (1993-2006)
An examination of the 9 known or suspected lightning strikes in 5 U.S. coal mines, since 1993, is an unsettling
exercise. In contrast to other MSHA investigation reports which provide a measure of engineering certainty, these
are more speculative, containing phrases like “probable cause was lightning” or ‘it is reasonable to conclude that
lightning may have ignited methane.” We need prompt research on the role lightning plays in underground mine
explosions and ways to prevent it.
Mine Name/ Operator &
MSHA ID #
Location

Coal Seam
& Depth

Date & Time
of Explosion

Description of Seal

➔

1

Mary Lee
No. 1
01-00515

Drummond
Company, Inc.
Goodsprings, AL

Mary Lee
Seam
600/700

8/22/93
4:30 P.M.

Cementitious foam

➔

2

Oak Grove
01-00851

U.S. Steel Mining
Company, Inc.
Adger, AL

Blue Creek
Coal Seam;
1100’

4/5/94
10:50 P.M.

5 solid block concrete,
mortared; 33
cementitious foam seals

➔

3

Gary No. 50
46-01816

U.S. Steel Mining
Company, Inc.,
Pineville, WV

Pocahontas
No. 3;
600/700’

6/9-6/16/95

TEK foam, 4 ft. thick seals

➔

4

Oak Grove
01-00851

U.S. Steel Mining
Company, Inc.
Adger, AL

Blue Creek
Coal Seam;
1100’

1/29/96

5 seals, 6 ft. thick; 38
cementitious foam by
Celtite Div./Fosroc, Inc.

➔

5

Mine No. 1
46-07273

Oasis Contracting,
Inc. Quinlan, WV

Cedar Grove
Seam;390’

5/15/96
4:00 A.M.

Micon 550, 6” solid
concrete blocks as framing
walls for 16” polymer grout
and aggregate inner core

➔

6

Mine No. 1
46-07273

Oasis Contracting,
Inc. Quinlan, WV

Cedar Grove
Seam;375’

6/22/96
8:00 P.M.

Micon 550, 6” solid
concrete blocks as framing
walls for 16” polymer grout
and aggregate inner core

➔

7

Oak Grove
01-00851

U.S. Steel Mining
Company, Inc.
Adger, AL

Blue Creek
Coal Seam;
1100’

7/9/97
8:15 P.M.

Cementitious foam seals
by Celtite Div./Fosroc Inc.

➔

8

Gary No. 50
46-01816

U.S. Steel Mining
Company, Inc.
Pineville, WV

Pocahontas
No. 3;
600/700’

5/18/01
5:09 P.M.

Micon 550

➔

9

Sago
46-08791

International Coal
Group, Inc.,
Tallmansville, WV

Middle
Kittanning
Seam;300’

1/2/06
6:26 A.M.

40” thick Omega block
seal

➔

38

 answered, specific steps must then be taken
to protect other underground mines and
miners against the risk of lightning-related
methane ignitions.
• The seals that should have helped contain
the explosion were not sufficiently explosion-proof and never should have been
approved for that purpose. The catastrophic
failure of the Omega block seals clearly made
the explosion far more lethal than would
otherwise have been the case.

• Effective rockdusting of the mine prior to
January 2, 2006, helped contain the explosion and saved lives. It is important to
underscore this point, both to give credit
where credit is due and to highlight the
importance, on an industrywide basis, of
guarding against mine emergencies by taking
the kinds of basic preventive measures
required both by law and by experiencebased risk assessment and best practices.

(chart continues...)

➔

Effect on Seals

Magnitude
of Strike

Suspected Cause

Effect on
Miners

➔

2 seals blown out
and fan shaft cap
damaged

(-)21.7 ka

Explosion was a result of a lighting
(electrification) strike at the vent pipe
pipe on the cap of 70 North fan shaft

No personnel
injured

➔

2 seals blown out
and 1 damaged

(+)84.8 ka

Lightning strike close to abandoned
cased bore hole ignited methane

No personnel
injured

➔

No seals blown out

(-)90.2 ka;
7 strikes

Lighting strike could have caused
explosion; no direct path identified

No persons
in mine

➔

5 seals destroyed
with pieces blown
80’ to 100’

(+)55.8 ka

Lightning strike near any wells could
No personnel
couple energy onto any of the metallic injured
casings, travel down to an entry
in the sealed areas

➔

3 seals blown out,
(+)59 ka
1 partially blown
out. (Non-producing
mine;seals leaked)

Probable cause was either lightning
strike or friction/ignition from a
roof fall

No persons
in mine

➔

Not reported

(-)50 ka

Probable cause was either lightning
strike or friction/ignition from a
roof fall

No persons
in mine

➔

3 seals destroyed
and 1 severely
damaged

(-)142.2 ka

Path into the sealed areas undefined

No personnel
injured

➔

Seals intact

Unknown

Lightning strike confirmed at time
and vicinity of explosion; reasonable
to conclude that methane ignition
resulted when an explosive mixture
was ignited by lightening

Force confined
by seals;
no loss of life

➔

All 10 seals pulverized; no seal
material attached
to roof, rib or floor

(-)101ka

Lightning strike may have caused
explosion; no path identified
or confirmed

1 killed initially;
16 escaped; 12
trapped,eventually
only one survivor.

Source: MSHA investigation reports, with the exception of the Sago entry.
39

 SOURCES
1

Monte Hieb, memorandum, 7/5/06.

This event was originally thought to have occurred at 6:31 a.m. However, state investigators determined that the computer clock at the mine was 4 minutes 56 seconds fast. Adjusting the clock to
Universal Time (atomic clock time), they found that the CO monitor alarmed at 6:26:35, precisely the
same time that the lightning strikes were recorded by Global Positioning System (GPS) clocks, which
are also set to Universal Time.
2

This reading appears to have actually exceeded the monitor’s maximum level (50ppm). When it pegs
at that level the monitor is designed to shut itself down and must be reset.
3

4

Monte Hieb, memorandum, 7/5/06.

5

Monte Hieb, memorandum, 7/5/06.

40

 5

Why did the
seals fail?

‘The current seal construction regulations… assume that an explosion
occurring in [a mined-out and abandoned area] will not be stronger than
20-psi pressure. However, if a large flammable gas volume exists in the
[sealed area], the resulting explosion pressure can be >20 psi.’
— National Institute for Occupational
Safety and Health, 20011

The explosion in the Sago Mine originated in
a recently abandoned and sealed area. In
theory, the seals constructed to isolate the
abandoned area from the adjacent working
sections of the mine should have withstood
the blast — unless the ignition of methane
inby the seals generated forces so powerful
that no barrier, regardless of the materials
used and the method of construction, could
have contained the explosion.
That does not appear to have been the case.
Instead, what appears to have happened is
that the supposedly “explosion-proof” seals
failed because they were constructed of a
material — Omega blocks — that should
never have been approved for the purpose of
containing an explosion originating in a
sealed area.
On May 12, 2006, Acting Director James M.
Dean of the West Virginia Office of Miners’
Health, Safety and Training imposed a statewide moratorium on the use of Omega blocks
as explosion-proof seals in underground

mines. Eight days later, on May 20, 2006, an
explosion in the Kentucky Darby No. 1 Mine
in Harlan County, Kentucky, blew out a seal
constructed of Omega blocks, killing five
miners in the explosion and its aftermath. On
May 22, 2006, the federal Mine Safety and
Health Administration imposed a temporary
nationwide moratorium on the construction
of alternative seals such as Omega blocks,
requiring mine operators wishing to seal
worked-out areas to revert to the practice of
using solid concrete-block bulkheads, pending a reassessment of the structural integrity
of alternative seals.2
West Virginia’s decision to bar the use of
Omega blocks as seals was appropriate and
should be made permanent. Moreover, the
state should join with the United Mine
Workers of America, which has opposed the
use of Omega blocks as seals for many years,
and with other concerned parties to spur the
appropriate agencies to conduct a comprehensive review of the entire history of the
development of explosion-proof criteria for

41

 seals used in the mines of the United States.
These criteria appear to be severely inadequate and in urgent need of revision. In the
meantime, Omega blocks should not be
considered explosion-proof regardless of
how they are constructed, and the current
temporary nationwide moratorium on their
use in underground mines for purposes other
than as ventilation stoppings should be
made permanent.
Although a comprehensive assessment of the
development of the criteria currently governing the construction of explosion-proof
bulkheads in U.S. mines is beyond the scope
of this report, a brief discussion is warranted
in order to explain the need for further
investigation and action.3
The worst mine disaster in the nation’s
history occurred in 1907, when an explosion
in a coal mine at Monongah, West Virginia,
claimed 362 victims. In the wake of that
catastrophe and several others that occurred
over the next two years, Congress established
the federal Bureau of Mines in 1910. Although
the Bureau was initially given no enforcement
authority (strong federal mine legislation was
not enacted until 1969), the Bureau did have
a mandate to investigate the causes of fatal
accidents and to make recommendations for
improvements in safety and health protection
(which mine operators were free to adopt
or ignore).
The Bureau’s research on sealing abandoned
mine areas dates back to 1914, when the
agency began conducting explosion tests in its
new experimental mine. Over the years,
sometimes in cooperation with similar agencies in other mining countries such as Germany and the United Kingdom, the Bureau

undertook numerous studies of explosions
and developed strategies to prevent and
contain them.
Early on, experts were able to arrive at a
consensus view regarding the basic standards
needed to contain explosions. In 1921, for
example, the U. S. government, in adopting
criteria for explosion-proof bulkheads between coal mines on government-owned
lands (the only sphere where the government
had the power to regulate at the time), required that such stoppings be able to withstand an explosion generating a pressure of 50
pounds per square inch (psi).
Similarly, commissions investigating disasters
in the United Kingdom in the 1930s and in
1960 concluded that mine explosions are
likely to develop pressures ranging from 20 to
50 psi, and determined that a 50-psi standard
would provide a reasonable margin of safety.
Later studies of explosions in Poland and
Germany led researchers there to conclude
that bulkheads should be designed to withstand higher pressures, and that a 72-psi
standard would be advisable.
Despite these findings, however — and
despite subsequent adoption of 50 psi and in
some cases more rigorous standards in
mining countries such as Canada, Australia,
and South Africa — the Bureau of Mines
adopted a much lower standard for the
United States.
The Federal Coal Mine Health and Safety Act
of 1969 — enacted in the wake of the explosion that killed 78 miners at a Consolidation
Coal Company mine near Fairmont, West
Virginia, in November 1968 —required
bulkheads to be “explosion-proof.” The

42

 Bureau of Mines was then charged with
developing appropriate standards to give that
term meaning. Notwithstanding the increasing adoption of the 50-psi (or higher) standard elsewhere, the Bureau published a single
report in 1971 that made the case for a 20-psi
requirement — a standard subsequently
adopted in federal regulations [30 CFR
75.335] that remain in effect today.
That 1971 report (Explosion-Proof Bulkheads:
Present Practices, U.S. Bureau of Mines Report
of Investigations 7581) makes for deeply
disturbing reading in the wake of the Sago
Mine disaster. The author of the report, the
late Donald W. Mitchell, then Acting Supervisor of the Bureau’s Pittsburgh Mining and
Safety Research Center, briefly reviewed U.S.
and foreign experience with mine explosions
and noted that in test explosions in the
Bureau’s experimental mine, pressures had
registered as high as 127 psi. He then stated,
however, that pressures 200 feet or more from
the origin of an explosion seldom exceed 20
psi. That statement, while not documented
anywhere in the report, appears to be the
rationale for his conclusion that bulkheads
may be considered “explosion-proof” if they
can withstand a static load of 20 psi.4
Mitchell’s report makes no clear distinction
between static and dynamic pressures, even
though the differences can be important.
Picture an explosion taking place at one
end of a relatively long, narrow room. The
explosion, propagating outward into the
confined space, exerts static pressure on the
walls parallel to the direction of travel, and
dynamic pressure on the opposite wall. In this
example, the opposite wall takes the greater
hit. But from the evidence available it appears
that Mitchell, in arguing for a 20-psi standard,
gave little consideration to dynamic pressures.

The Bureau in its experiments appears to
have tested materials for static pressure
resistance only — that is, installing them as
ventilation stoppings would be installed,
typically in crosscuts parallel to the likely
source of a blast, rather than as barriers built
in the entry directly across its path. Consequently, the tests conducted over the years by
the Bureau of Mines and its successor agencies — the Mine Health and Safety Administration and the National Institute for Occupational Safety and Health — to determine
whether a given material and structure is
“explosion- proof” as required by federal law
do not seem to address the kind of explosion
experienced at Sago.
It should be noted, and emphasized, that we
have not yet had an opportunity to review the
apparent limitations in the methodology of
Mitchell’s report with experts at MSHA or
NIOSH, and we need to be open to the
possibility of having missed something.
However, unless that is the case, it is difficult
to escape the conclusion that the 20-psi
standard — adopted entirely as a result of
that one 1971 report — provides none of the
margin of safety that government explosion
experts were sensibly advocating as far back
as 1921, when they proposed 50 psi as a
standard for seals survivability.
Why is this important now? It is important
because Mitchell’s 1971 report became, for the
Bureau of Mines and then for MSHA and
NIOSH, the standard reference which for the
past 35 years has apparently guided the
parameters for the testing and certification of
allegedly “explosion-proof” seal designs and
materials — including Omega blocks.
The Omega 384 block, manufactured by
Burrell Mining Products, is a lightweight
43

 fiber-reinforced block consisting of a mixture
of cement, foam, and fly ash. Because a
standard Omega block (16 inches by 24 inches
by 8 inches) is three times the size of a single
solid concrete block but weighs far less, the
product has become popular in the mining
industry, where it is widely used to construct
ventilation stoppings. Omega blocks can be
easily stored and transported into the mine on
pallets, and stoppings made of the blocks can
be built more easily and with considerably
less risk of musculoskeletal injuries than
when working with solid concrete blocks.
Omega blocks can also be cut with a hand
saw and are incombustible as well as moisture-resistant.

ment — were probably aware of the tests’
limitations. To most of us, the knowledge that
the government will not sign off on something as “explosion-proof” unless it withstands an explosive force of 20 pounds per
square inch has been good enough. What
more would we need to know? And, prior to
this year’s disasters at Sago and Darby, what
we knew, essentially, was that MSHA had
approved Omega blocks in 1992 as alternative
seals, and that they were considered explosion-proof as long as the construction of the
seals was done in accordance with the way
they had been tested as well as in accordance
with the specific, MSHA-approved ventilation plan for the mine installing them.

In 1990, MSHA was asked to approve Omega
blocks as explosion-proof seals. Explosion
tests were conducted in October 1990 at the
Lake Lynn Experimental Mine. Burrell employees constructed four seals, each of which
survived a pressure pulse of approximately
20 psi. However, as with previous “explosionproof” tests, the testing was done with the
seals constructed in crosscuts, as though they
were ventilation stoppings, rather than built
directly in front of and across the source of the
blast. Thus the seals demonstrated only their
ability to survive a powerful but glancing
blow, rather than a full-force, head-on blow.
In short, they were not subjected to the kind
of test to which Omega blocks would be
subjected at Sago nearly 16 years later. By
way of analogy, think of an automobile being
termed “collision-proof” on the basis of
surviving a glancing blow at an intersection
rather than a head-on crash at highway
speeds.

But in reality that was not good enough,
because, as we now know, the tests themselves were not good enough. They did not
test the ability of seals built of Omega blocks
to survive a direct hit — a force of 20-psi or
higher — from inby the seals.

Few in the mining industry — or, for that
matter, in the ranks of mine safety enforce-

In hindsight, it is difficult to understand why
such tests were never conducted — never,
that is, until mid-June 2006, six months after
the Sago disaster. (In the latest tests, the
Omega-block seals failed.) If the assumption
was that explosions would not originate in
abandoned and sealed areas because there
would be no ignition sources in such areas,
that is contradicted by long experience. For
example, a roof fall in a sealed area could
trigger a frictional methane ignition if it
occurs while a methane buildup in the sealed
area is in the explosive range (5 to 15 percent
of the mine atmosphere). Moreover, evidence
has been accumulating for several years that
lightning can ignite methane in an abandoned
and sealed area, triggering an explosion.

44

 Between 1993 and 1997, seven explosions in
abandoned areas of underground mines in
Alabama and West Virginia were found to
have been caused by lightning. MSHA investigators found that, in most cases, seals
constructed of various materials had been
partially blown out by the blasts. Fortunately,
in all of these cases the lightning strikes
occurred in remote areas of the mines; the
explosions were not severe; and no miners
were working directly in their path or in
affected areas.
In the wake of these incidents, NIOSH issued
a bulletin in 2001 to alert the mining industry
to the apparent hazard of lightning-triggered
ignitions, noting that in at least one case the
force of the explosion clearly exceeded 20 psi.
The bulletin further noted:
“The current seal construction regulations,
which relate to all suitable underground seal
designs, assume that an explosion occurring
in the gob [mined-out and abandoned area]
will not be stronger
than 20-psi pressure.
However, if a large flammable gas volume
exists in the gob, the resulting explosion
pressure can be >20 psi.”5
Unfortunately, NIOSH concluded that if
lightning as a potential source of ignition
could not be eliminated, the only alternative
would be to eliminate flammable concentrations or reduce the volume of the flammable
mixture present in the sealed area (by taking
steps such as minimizing pressure differentials across seals to reduce air leakage). Other
steps, such as eliminating wires or other
conductors and removing potential ignition
sources such as old batteries from sealed
areas, were also recommended. But neither
NIOSH nor MSHA, despite their acknowl-

edged awareness that sealed-area explosions
could generate more than 20 psi, recommended reconsidering the 20-psi standard for
“explosion-proof” bulkheads in the light of
accumulating experience.
The decision by MSHA and WVOMHST in
May 2006 to impose a moratorium on the use
of Omega blocks as seals comes too late for
the victims of the Sago Mine disaster. But it
would seem to indicate a recognition, even if
not explicitly acknowledged, that both the 20psi standard and the explosion-proof testing
regime are long overdue for reassessment.
State and federal authorities must now work
together — and must be willing to draw upon
the experience of other mining countries and
the more stringent standards they have long
since adopted — to ensure that this urgent
priority is addressed without further delay.
In the wake of the Sago Mine disaster, much
attention was paid to the question of whether
the Omega block seals at Sago were properly
constructed. That would seem to be a largely
irrelevant question, even something of a
distraction, since the evidence strongly
suggests that they would have been destroyed regardless of how they were constructed. The more basic problem is with a
standard for “explosion-proof” that is clearly
inadequate, both in terms of the standard
itself — 20 psi — and the tests traditionally
used to determine whether a given material
can meet that standard.
Standards for explosion-proof bulkheads in
West Virginia and throughout the United
States must now be brought into line with
global standards, which suggests setting the
bar at pressures significantly higher than 20
psi, and remedial steps must be taken to

45

 ensure that all seals now in use are strengthened, if necessary, within a specific and
enforceable timeframe.6 Where appropriate,
on a case-by-case basis, boreholes should be
drilled into abandoned areas to ventilate
them. Other steps such as inerting sealed

areas by injecting nitrogen may also be
warranted and should be explored with all
deliberate speed.
For now, only seals constructed of solid
concrete blocks (also known as Mitchell-

An explosion-proof seal
Pilaster center
Transverse pattern
of laying block

Staggered block array
to strengthen pilaster

The diagram above shows a solid concrete block seal (also known as a Mitchell-Barrett seal). For
extra strength the blocks are staggered — laid both lengthwise and crosswise — and all joints
are mortared. To provide strength at the edges of the seal, the seal is hitched into the coal rib.
When a seal is to be constructed above a specified height, it must be further strengthened by
including a pilaster — an extra row of staggered blocks in the center as shown. Construction of
such a seal is time-consuming, labor-intensive, requires masonry skills, and can involve risks
such as musculoskeletal injuries while handling the heavy blocks and the possibility of being
injured by a rib roll while hitching the rib. Consequently, alternative seals were developed and
have become popular. Some, such as cementitious materials poured or pumped into frames
filling the entire void between floor and roof, may have bulk and strength sufficient to withstand
severe explosions. But Mitchell-Barretts should be thought of as the gold standard.

46

 Barrett seals) or seals of demonstrated equivalent strength should be used for construction
of seals in West Virginia and throughout the
country. Mitchell-Barrett seals (see diagram)
have successfully withstood explosions
generating pressures far greater than 20 psi
and offer a much higher level of protection
than afforded by Omega blocks and other
alternative seals.
In a related matter, research needs to be
conducted to better understand the impact
that variations in mining height and abrupt
changes in the cross-sectional area of mine
entries in a sealed area may have on the
velocity of an explosion. At Sago, for example,
bottom mining had been done in the area
where the explosion occurred. We need to
know the impact that bottom mining may
have had on the strength, velocity, and
direction of the explosive forces resulting
from the methane ignition. As is well known,
the velocity of water increases when it moves
from a large pipe to a smaller pipe (an action
known as the Venturi Effect). Because air acts
in the same way as water, an explosive force
which is initiated in a large space is then
forced into a smaller space can be expected to
result in a similar increase in velocity. In
addition, turbulence that is created when a
blast wave passes across entry obstructions or
sudden mining-height changes increases

mixing of stratified mine gases and can
enhance propagation effects.7
Computer modeling systems are available
through institutions such as Sandia National
Labs, Naval Surface Warfare Center, Army
Corps of Engineers facilities, and others. Such
tests should be funded and undertaken
immediately in order to better understand
the explosive forces which could be potentially created in coal mines by large and
numerous changes in entry height due to
bottom mining.
In addition to maintaining the current moratorium on the use of Omega blocks as seals, a
comprehensive survey of the numbers and
locations of Omega-block type seals currently
in use should be completed, and plans to
retrofit or otherwise accomplish the construction of explosion-proof seals within a specific
timetable should be pursued, with each West
Virginia mine operator responsible for developing plans subject to approval by the West
Virginia Office of Miners’ Health, Safety and
Training.
Until measures such as these have been taken,
every sealed area in every underground coal
mine in West Virginia and throughout the
United States should be considered a potential time bomb — and treated accordingly.

SOURCES
NIOSH Technology News 489, Reducing the Danger of Explosions in Sealed Areas (Gobs) in Mines, May
2001.

1

2

For more information, see: www.msha.gov/regs/complian/PIB/2006/pib06-14.asp

A review of the statutory and regulatory history of the present standard is available at www.wju.edu/
sago/def.asp. See Memorandum for the File, MSHA 20 psi Seal Standard.
3

47

 Mitchell, Donald W., Explosion-Proof Bulkheads: Present Practices, Report of Investigations 7581, U.S.
Dept. of the Interior, Bureau of Mines, 1971.

4

NIOSH Technology News 489, Reducing the Danger of Explosions in Sealed Areas (Gobs) in Mines, May
2001.
5

6

Monte Hieb, memorandum, 7/11/06.

7

Monte Hieb, memorandum, 7/5/06.

48

 6

Did the miners’
SCSRs fail?

‘… The mine filled quickly with fumes and thick smoke… The first
thing we did was activate our rescuers, as we had been trained. At least
four of the rescuers did not function. I shared my rescuer with Jerry
Groves, while Junior Toler, Jesse Jones and Tom Anderson sought help
from others. There were not enough rescuers to go around.’
— Randal McCloy, Jr.1

When Randal McCloy, Jr., the only survivor
among the miners trapped in the Two Left
section of the Sago Mine on January 2, recovered to the point of being able to release a
statement to the families of his co-workers on
April 26, he delivered terrible news. The crew
had survived the explosion, only to discover
that their first line of defense — the selfcontained self-rescuers (SCSRs) they carried
into the mine with them every single working
day — had failed them. They could not make
all of their SCSRs work. Without enough fully
functioning SCSRs to go around, there was no
way, as they understood the situation, for all
of them to make it safely out of the section
and back to where there might possibly be
respirable air.
When Mr. McCloy in his continuing recovery
was able to be interviewed by state and
federal investigators on June 19, he amplified
on his earlier statement, explaining how he
struggled with the non-functioning SCSRs
and could not make them work. He described
sharing his own SCSR with his roof-bolting

buddy, Jerry Groves, and how he struggled
with Mr. Groves’s SCSR: “I fought with it for
I don’t know how long, trying to mess with
that valve, blow air through it or anything
I could do, but nothing would work.”2
The apparent failure of some of their SCSRs to
generate oxygen may have doomed the
miners trapped on Two Left. Without enough
functioning SCSRs to go around, they could
not have tried to walk out of the mine, knowing that they would making their way
through lethal concentrations of carbon
monoxide and that any miner without a
working SCSR would rapidly succumb.
And it is impossible to imagine any of them,
in that situation, simply walking away from
their fellow miners.
Instead, according to Mr. McCloy, they tried
to make their way together to where they had
left their mantrip — yelling to keep track of
each other in the blinding smoke — but had
to abort that escape attempt when they
encountered thick dust and swirling smoke

49

 and what they believed was impassable
debris. “We couldn’t escape the smoke,” Mr.
McCloy recalled. “There was nowhere to go
because it just lingered everywhere, you
know, just everywhere you went.”3
So the miners returned together to the section
face, where they hung a curtain as a barricade, began trying to signal their location to
the surface by beating on roof bolts with a
sledgehammer, and shared the limited number of SCSRs that did seem to be working.
Meanwhile the miners on the One Left crew,
further outby the explosion, were making
their way into the escapeway and out of the
mine after being engulfed in a rush of air,
dust, and debris. Seven of them donned their
SCSRs. From their subsequent testimony to
investigators it appears that, with one possible exception, all of their SCSRs worked,
although at least two miners had some
difficulty using them.
Mine Safety and Health Administration
(MSHA) investigators subsequently recovered all of the SCSRs from the Sago Mine,
including the Two Left section, had them
tested by the National Institute for Occupational Safety and Health (NIOSH), and
reported that all were in working order. This
seems to raise the question: Who is right?
The miners who believed that their SCSRs
failed, or the laboratory technicians who
examined those same units and found them
to be operational?
That is the wrong question. The right question is not whether SCSRs work well under
ideal conditions in a NIOSH laboratory.
The question is whether they work in the
mine, in an emergency, when they’re desperately needed.

To address that question, we must look first at
how an SCSR is typically used, and then at
the quality of the training provided to the
miners who must rely on them.
The situation on Two Left in the moments
immediately after the explosion tells us all we
need to know about the kinds of conditions in
which an SCSR is likely to be used. The mine
suddenly fills with noise, smoke, and fumes.
It’s pitch-black. The smoke and dust are dense
and swirling. A miner’s cap lamp — much
more powerful than an ordinary flashlight —
cannot penetrate the murk. The mine atmosphere becomes terrifyingly foul and stays
that way. Breathing immediately becomes
difficult. Miners quickly lose contact with
each other and can easily become disoriented.
They know, instantly, that they are in a
desperate life-and-death situation in which
seconds count, and that the SCSRs they carry
are their first and possibly last line of defense.
So their first priority is to activate their SCSRs
— under just about the worst kind of stress
imaginable.
The Sago miners were equipped with the SR100, an MSHA-approved SCSR manufactured
by CSE Corporation in Monroeville, Pennsylvania. Like other SCSRs approved by MSHA,
the SR-100 is rated to provide a minimum of
one hour of breathable air while the user
breathes under exertion, such as while escaping a mine, and in laboratory tests has provided approximately four hours of air at rest.
The belt-wearable SR-100, which weighs
about six pounds and costs about $680 per
unit, is currently the most widely used SCSR
in U.S. mines.
Problems have been experienced with the SR100 over the years. In 1998, for example,

50

 MSHA issued an alert to the mining community after finding that some SR-100s emitted
higher than normal levels of carbon dioxide
in the air supplied to the user. Although the
SCSRs still functioned, MSHA warned that
miners using them might find themselves
breathing uncomfortably fast and more
deeply than expected, possibly causing them
to become frustrated with the SCSR and
discarding it. CSE suggested that the devices
most likely to produce higher than normal
carbon dioxide levels were those that had
been exposed to excessive shock and vibration over an extended time.
Similarly, MSHA issued an alert in 1999 after
finding that a small number of SR-100s
manufactured from 1991 to 1993 had deteriorated hoses. CSE pledged to replace any such
units, and subsequently modified the SR100’s hose design. MSHA urged mine operators to perform regular, thorough inspections
of their SCSRs, remove from service any units
with detectable damage, and replace older
units. MSHA also advised placing extra
SCSRs on each mining section.

Activating and donning the SR-100 requires
practice and clear thinking. The miner removes the SCSR from its pouch. Holding it in
his hand, he kneels on the ground and removes his hard hat so that he can shine his
cap lamp on the area immediately in front of
him. He opens the SCSR by lifting the latch
on top, which supposedly allows him to
remove both the top and bottom protective
covers. In practice, removing the covers can
be difficult, as the manufacturer acknowledges in its instructional materials. The miner
then removes the safety goggles packed in the
unit, looping them over his wrist so he won’t
lose them in the murk and mud. He takes the
neck strap out and puts it over his head,
taking care not to put the unit on backwards,
which would make it difficult to use the
mouthpiece and nose clips properly. He pulls
an orange actuator tab downward to activate
oxygen (the unit contains a small oxygen

Given the widespread use of the SR-100,
however, problems have been relatively rare,
and it has generally been considered a reliable
unit. But general reliability is no comfort to a
miner suddenly facing a life-threatening
emergency. At that instant, the miner’s only
question is: “Can I get this thing on in a hurry
and will it work?”
The answer to that vital question is not as
simple as we would like. A number of variables are involved, the most important of
which is the quality and frequency of the
training that the miner may have received
prior to needing the SCSR in an actual
emergency.

Donning an SCSR is awkward and uncomfortable
under the best of circumstances — let alone in a
smoke-filled mine.

51

 reserve to help inflate its breathing bag). He
extends the breathing hose, removes a plug
from the mouthpiece, and inserts the mouthpiece in his mouth, biting down hard on it to
hold it in place. He pulls the two nose pads
apart and affixes them to his nose, completely
closing both nostrils. Although it is
counterintuitive, he then exhales into the unit
to get its rebreathing mechanism going. He
puts on the safety goggles. He adjusts the
neck strap so that the SCSR rests on his chest.
He then fastens the waist strap tightly to keep
the SCSR from swinging loose as he moves.
He puts his hard hat back on his head, stands
up, and starts planning his escape. (He can’t
voice-communicate with other miners while
using his SCSR, so he must try to maintain
physical or visual contact.) If everything goes
perfectly, he gets his SCSR up and running in
about 30 seconds.
It isn’t easy, even if you’ve been thoroughly
trained and are young and in great shape. If
you’re older, and not in such great condition,
it’s harder. If your training has been superficial, and if you haven’t been retrained recently, it’s harder still. If you wear eyeglasses
and they’ve been blown away and you’re
blinded by smoke and grit, and you’re choking, gasping, and at the brink of panic, it’s
harder yet. Several of the One Left miners
discovered that they just about could not do it
without help from other miners.
Moreover, the challenge doesn’t end with
donning the SR-100. It is possible to
“overbreathe” the unit — in which case it will
feel to the miner as though he is trying to suck
air through a crimped drinking-straw instead
of breathing through a hose. As ICG’s assistant safety director, Johnny Stemple, ex-

plained while demonstrating an SR-100 at the
May 2-4 public hearings in Buckhannon:
“The [SR-100] will provide oxygen at a certain
rate. And you can overbreathe those rescuers.
You can breathe faster than they can provide
oxygen. If you’re in a mode where you’re
moving very fast, very quickly, you can
overbreathe those units. You have to slow
your breathing rate down or slow your pace
down to allow those units to produce oxygen
at — or to allow your body to take in the
oxygen as fast as [the] unit is producing the
oxygen. It’s not a unit that provides pressure,
so when you activate the unit, there’s not
oxygen coming out of it. You have to breathe
into it and breathe out of it, or suck out of it,
to get oxygen. And you can outbreathe
those units.”4
Stemple’s description, while accurate, does
not mention another complication that can
arise if a miner has not been thoroughly
trained on the SR-100. In fact, the unit does
generate oxygen very briefly when it is first
activated — “a few puffs,” as some trainers
say — so it is possible to get the impression
that it is working comfortably at first but then,
after a couple of breaths, breathing may seem
to become much more laborious. Someone
thoroughly familiar with the unit would
understand that it is still functioning, just
differently — because, after those first few
puffs, the unit needs to have the user actively
exhaling into the rebreathing mechanism in
order to be able to convert exhaled carbon
dioxide into oxygen. However, someone who
has never had to use the unit could easily get
the impression that it has suddenly stopped
working, or that breathing through it has
suddenly become unnervingly difficult.
Instead of making escape from a smoke-filled

52

 mine easier, the SCSR is making it even
harder — or so it may seem. At that point
even a veteran miner might be tempted to
make the potentially fatal decision to give up
on using the SCSR, hoping somehow to get
along without it.
We do not know whether this is exactly what
happened to the miners on Two Left. But we
do know what matters — that some of them
were convinced that their SCSRs were not
working. We do not for a moment believe that
the miners trapped on Two Left were incompetent. We are sure, however, that they had
not been adequately trained in the use of their
SCSRs — and there is also the possibility that
some of the SCSRs they relied on had been
badly battered from long exposure to the
rigors of daily transportation into and out of
the mine.
From testimony provided to MSHA and state
investigators and at the May 2-4 public
hearing, we can be reasonably certain that
those Sago miners who received SCSR training after International Coal Group acquired
the mine were, in most instances, required
only to demonstrate to an instructor that they
knew how to don the unit, while in other
cases they may have simply been shown how
to do it. (And in at least one case a Sago miner
testified that he was asked to sign a slip
certifying that he had been retrained on the
SCSR when in fact he had been absent that
day.)5 It should be said, however, that the
training provided by ICG was probably
typical for the mining industry at this point in
time.
The Sago miners did not actually breathe into
a unit, because that is not part of the required
training. And there can be no doubt that they

did not experience in training the kinds of
challenges, including overbreathing, that they
would face in a real crisis.
The reason why there can be no doubt about
that is that ICG has not purchased the SR-T, a
$220 training unit marketed by CSE designed
to “give the user a chance to experience the
sensations that are common with the SR-100
[including] breathing resistance and temperature sensations.”6 As CSE notes in its marketing literature, a miner wearing the SR-T in a
workplace setting can get a sense of what it is
like to use the SR-100 under stress: “Higher
work rates will increase breathing resistance
and inspired temperature.”7 That would be
valuable experience to store in memory.
Again, it should be noted that ICG is by no
means alone in opting not to purchase this
CSE training model. As far as we have been
able to determine, CSE has sold few if any of
these units to U.S. coal producers, who
understandably prefer the less expensive
approach of using old SR-100s as training
models. (The SR-100 has a storage life of 10
years, after which units must be discarded or
used for training.) The manufacturer reports,
however, that the SR-T is in widespread use
in Australia, not by government regulation
but by a “duty of care” agreement within the
mining industry that views thoroughly
realistic SCSR training as a basic safety
imperative.
We need that attitude in West Virginia and
throughout the coal industry in the United
States. Whether it would have saved the lives
lost on Two Left is something we cannot
know for sure. What we can say is that more
thorough and realistic SCSR training — and
at more frequent intervals than the annual

53

 retraining required by the regulations that
were in effect on January 2, 2006 — would
improve the odds that a miner can count on
his or her SCSR in a crisis. And improving
the odds is a large part of what survival is
all about.
The fact that four of the SCSRs relied on by
the Two Left miners did not work for them —
leaving them with not enough SCSRs to go
around — is tragic. The fact that NIOSH’s
subsequent tests found all of the SCSRs from
Two Left to be in working order compounds
the tragedy, because if those tests were accurate they can only mean one thing: that the
Two Left miners, even though most of them
were veterans, had not been sufficiently
familiarized with the challenges of using an
SCSR in an emergency setting.
Going forward, it will be necessary, at minimum, to do on an industrywide basis what a
few companies already do: train miners in
realistic settings, including special rooms or
trailers that can be filled with (harmless)
Hollywood smoke. Every miner needs and
should have that level of SCSR training,
repeated frequently enough to retain it in
memory. As Joe Ryan, a veteran member of
the One Left crew, described the experience of
struggling with his SCSR on January 2:
“We’ve heard it so many times, we could do it
in our sleep. But then, when you have to do it,
it’s a different — it’s really, really....”8 He
didn’t finish the sentence; he didn’t have to.
In addition to immediately improving training, we need to address the urgent question of
whether the SCSRs currently in service can be
counted on to work in practice. The West
Virginia Office of Miners’ Health, Safety and
Training is attempting to address that ques-

tion by requiring mine operators to inventory
SCSRs and report problems on a quarterly
basis, effective August 15, 2006.9 This should
be a useful development. However, SCSRs
should also be field-tested. The best way to do
that would be to give federal and state inspectors the authority to ask individual miners on
working sections — at random, without
forewarning, and on a voluntary basis — to
don their SCSRs and walk out of the mine, or
at least far enough to get a good feel for
breathing through the unit. Since the unit will
then have to be replaced, and because this
safety exercise will also be seen as downtime
and lost productivity, many coal operators
can be expected to vigorously oppose this
proposal. But some will surely recognize that
as we absorb the lessons of the Sago Mine
disaster — in which the initial explosion
seems to have been followed by one tragedy
after another — this is the very least we can
do to prevent a recurrence. For those opting
to invest in and use training-model SCSRs,
the random testing requirement could be
waived.
Another necessary step is to reduce the 10year life expectancy currently permitted for
SCSRs. That time period, we believe, is
arbitrary and not based on any laboratory
determinations. To create a greater margin of
safety — including guarding against the risk
of malfunction from the repeated wear and
tear that SCSRs experience as they are transported in and out of mines daily — SCSRs
should be withdrawn from use after a shorter
period of service.
Moving beyond these interim measures, we
must immediately take steps to accelerate
development of the next-generation SCSR.
The SR-100 and similar units produced by

54

 other manufacturers represent technologies
that are more than two decades old. Despite
their obvious performance limitations and
increasing obsolescence, there has been no
serious effort to fast-track the research,
development, and deployment of the next
generation. MSHA and NIOSH have not gone
much beyond workshop conceptual discussions, and no one has stepped forward to
assist researchers, inventors and manufacturers interested in getting a 21st-century product into the hands of 21st-century miners.

voice transmitter that allows communication
while breathing. This represents an obvious
advance that is worthy of further support.
While there is a clear need to push ahead with
development and testing of next-generation
SCSRs, there has been a vacuum of leadership
at the national level. This, too, must change,
but West Virginia does not need to wait for
that to happen. The state has ample technology-transfer resources and its congressional
delegation has often been able to channel
federal R&D funds to projects of demonstrable importance. No R&D project could be
of greater potential value to the state’s most
basic industry than the development of
enhanced safety technologies such as nextgeneration SCSRs. Without some such stimulus, it could be many years — even another
generation — before a next-generation SCSR
is developed, tested for performance and
reliability, approved by MSHA, and purchased by coal operators.

This must change. Several next-generation
concepts are worthy of support, including a
hybrid SCSR which in less toxic environments
can convert to functioning as an air-purifying
respirator, and a dockable SCSR that would
permit supplementary units to be docked to
the main unit while in use, eliminating the
need for the wearer to switch units. In addition, a prototype two-hour SCSR unit developed by OX-GEN Flexible Life Systems, Inc.,
and displayed at the International Mining
Health and Safety Symposium in Wheeling,
West Virginia, on April 20-21, 2006, shows
promise and merits further support and
testing. The unit can be stored in portable 48unit caches kept within 50 feet of miners on
working sections, and has a comfortable halfface mask, rather than a mouthpiece, with a

Miners working today do not have the luxury
of waiting that long for the safety protection
they need now. It should be a high priority for
West Virginia, working with manufacturers,
to take the lead in fast-tracking R&D and
deployment of the next generation of SCSRs.

SOURCES
Randal McCloy, Jr., “To the Families and Loved Ones of My Co-Workers, Victims of the Sago Mine
Disaster,” April 26, 2006, p. 1.
1

2

Randal McCloy, Jr., testimony, June 19, 2006, p. 33.

3

Randal McCloy, Jr., testimony, June 19, 2006, p. 47.

55

 4

Public hearing, Buckhannon, WV, May 2-4, 2006, transcript, p. 297.

5

John Nelson Boni, testimony, January 19, 2006, p. 60.

6

CSE Corporation, Instruction Manual for the SR-T Self-Contained Self-Rescuer Live Training Unit, p. 1.

CSE Corporation, Instruction Manual for the SR-T Self-Contained Self-Rescuer Live Training Unit,
p. 12.
7

Harley Joe Ryan, testimony, January 26, 2006, p. 52.

8

West Virginia Office of Miners’ Health, Safety & Training, “Memorandum to All West Virginia Underground Coal Mine Operators and Independent Contractors Who Perform Work in WV Underground
Coal Mines,” July 10, 2006.
9

56

 7

Why did the mine rescue
effort take so long?

There is no end to the heartbreak.
Think about James Bennett, writing a message on a scrap of paper as he and eleven
other miners awaited rescue behind a curtain
serving as a makeshift barricade at the face of
the Two Left section of the Sago Mine. It was
4:25 on Monday afternoon, January 2, and
they had been trapped and waiting for help
for almost exactly ten hours. The air was foul
with carbon monoxide. Three minutes earlier,
at 4:22 p.m., carefully noting the time, he had
written: “Time is running out for us. We have
not heard anything from the outside yet.”
Now he started another note: “I love you...”
That was as far as he got.
4:25 p.m. At that hour, mine rescue teams
were still waiting outside the mine, still
waiting for permission to go in. It would be
another hour, in fact, before the first teams
were allowed to begin exploring the mine —
exploring from the portal, more than two and
a half miles from where the Two Left crew
waited. And it would be more than another
30 hours before rescuers reached the face of
Two Left, No. 3 entry; heard the sound of a
miner gasping for breath; tore back the
curtain being used as a barricade; and found
the trapped miners. By that time — 41 hours
after the explosion — all but Randal McCloy,

Jr., had succumbed to the carbon monoxide
that permeated the mine atmosphere.
For the miners’ families, and for the miners of
the One Left crew who survived the blast,
and for the mine superintendent and the
other men who tried so courageously to go to
the rescue of the Two Left crew in the first
chaotic hours after the explosion — for all of
them, the unending nightmare of the Sago
Mine disaster swirls around one central
question about the rescue effort: Why did it
have to take so long?
There is no satisfactory answer. The best we
can do in this report is to look at what happened and try to understand, without unfairly second-guessing anyone after the fact,
what the thinking was in the rescue command center. At this point in time, still awaiting the outcome of MSHA’s internal investigation, we have incomplete information
about exactly how those decisions were
made. Based on what we know thus far,
however, we need to consider why the rescue
effort largely failed and what must be done to
improve the odds that the next mine rescue
operation will be more successful.
The explosion occurred at 6:26 a.m. on January 2. As soon as he became aware that the

57

 Two Left crew had not been heard from and
was not responding to calls from mine dispatcher Bill Chisolm, mine superintendent
Jeff Toler gathered maintenance chief Dick
Wilfong, safety director Al Schoonover, and
assistant maintenance chief Vern Hofer and
headed into the mine. They were in such
haste that they did not think to bring a twoway radio or gas monitor with them. They
encountered some miners not far inby the
portal and told them to exit the mine. Then,
pausing near a phone to check in with the
dispatcher, they were heard by the escaping
One Left crew, who were making their way
out of the mine in the parallel escapeway
entry. When a One Left crew member poked
his head through a man door, hollering to
make the crew’s location known, Toler instructed Wilfong and Hofer to take the men
out of the mine on Toler’s mantrip.
The One Left foreman, Owen Jones, whose
brother Jesse was on the missing Two Left
crew, refused to leave the mine. Jeff Toler,
whose uncle, Martin Toler, Jr., was the foreman of the Two Left crew, asked Owen Jones
to stay by a mine phone while he and
Schoonover advanced inby on foot. About
half an hour later, around 8:00 a.m., Wilfong
and Hofer returned from the surface with
radios, gas monitors, self-contained selfrescuers (SCSRs), and supplies to restore
blown-out ventilation. The five men then
advanced further into the mine on the
mantrip. At 32 block they observed a blownout ventilation stopping between the track
and the intake escapeway and hung curtain
material to keep the air flowing inby past
them. They continued to advance in the track,
hanging more curtain as they encountered
more blown-out ventilation controls between
32 block and 42 block.

At 42 block, their handheld gas monitors
alerted them to the presence of carbon monoxide (CO). They knew nothing about the
condition of the mine atmosphere ahead of
them. Worried about triggering another
methane ignition, they de-energized the
mantrip, disconnecting its batteries, and then
proceeded on foot in the intake air entries. As
they advanced, they encountered thickening
smoke and higher CO levels, and found
multiple ventilation stoppings blown out.
Stopping to continue hanging curtain to
advance the air flow, they had to wait for the
CO levels to drop before moving ahead to
hang the next curtain.
As they approached the outby end of the
mouth of the Two Left section, continuing to
hang curtain, they realized that the CO levels
were taking longer to drop, and they found
themselves getting into dense, swirling
smoke. Thinking that the air flow must be
short-circuiting somewhere behind them,
Toler asked Jones and Hofer to go outby,
retrieve curtain, and look for ventilation
controls in need of repair. Then he,
Schoonover, and Wilfong made their way to
58 block, at the mouth of the Two Left section.
They could see nothing of the section from
their position near the intake escapeway: the
smoke was too thick.
Somewhere in there, they knew, the Two Left
miners were likely to be trapped — if they
were alive. A few times the three men heard
sounds, and they yelled toward the sound,
hoping it was someone coming toward them.
But no one called back: most likely they were
hearing distant falls of pieces of roof, jarred
loose by the blast.

58

 Toler, Schoonover, and Wilfong stood there
for awhile at 58 block, hesitating, trying to
decide what to do next. They thought that if
they tried to restore ventilation into the
section, they might be feeding fuel to a fire, or
creating an explosive mixture of methane and
air. If they donned their SCSRs, which would
give them an hour of respirable air, they
might make it to somewhere near the face of
the section, roughly half a mile from where
they were standing, only to run out of air on
the way back.
Jeff Toler wanted to go in anyway. Dick
Wilfong, who had been a mine rescue team
captain and was a veteran of fires and other
mine emergencies, worried about the risks.
“I didn’t think we could go any further,”
Wilfong later testified. “One of us would go
down... I knew we was going to have to put
our self-contained self-rescuers on. And we
didn’t have but a couple extras with us. And
there was three of us there at that time... If we
all put our rescuers on and tried to go in there
with no line or no ways to communicate other
than hollering at each other, that we would —
somebody would — maybe all of us would
perish... And even if we went in there and
found somebody, what was we going to do
then? Say if we would have found six men
or five men or four men. Then you’ve got
two rescuers and you’ve got one on yourself,
you know. Who do you give them to, you
know, if you’ve got more people than you’ve
got rescuers? What do you do in a case
like that?”1
It was an agonizing decision. At about 9:30
a.m., roughly three hours after the explosion,
Jeff Toler picked up the mine phone at 58
block and reported to the dispatcher that they

were abandoning their attempt to reach the
Two Left crew and were coming out —
walking, because they did not want to take
chances by re-energizing their mantrip. Toler,
Schoonover, and Wilfong made their way
back into the intake escapeway, where,
further outby, Jones and Hofer were waiting
for them. The five men would emerge from
the mine at around 10:30 a.m.
By that time the mine had been placed under
a so-called (K) order. And because there has
been controversy about what that meant, and
how the imposition of the (K) order influenced the subsequent mine rescue effort, we
should pause here to look at that question.
As described in the synopsis of events elsewhere in this report, International Coal
Group’s assistant safety director, Johnny
Stemple, began trying to reach federal and
state authorities at about 7:30 a.m., roughly
one hour after the explosion. It was a holiday
and he initially had no success, encountering
nothing but unanswered phones and
voicemail recordings.
At about 7:50 a.m., Stemple reached John
Collins, an inspector for the West Virginia
Office of Miners’ Health, Safety & Training
(WVOMHST). Collins, who lives nearby in
Buckhannon, arrived at the mine at about 8:15
a.m. and issued a control order, which had the
effect of barring entry to the mine except for
mine rescue purposes (see the synopsis of
events for the text of the order). He also
issued instructions to begin monitoring
carbon monoxide, methane, and oxygen
levels in the air-return entry at the portal.
(The mine had a blowing ventilation system,
meaning that the mine fan forced air into the
intake entry and that it then circulated

59

 through the mine by means of an extensive
network of aircourses and ventilation controls
before exiting at the return entry.)
Then, at about 8:28 a.m., Stemple got through
to Jim Satterfield, an MSHA inspection
supervisor, and described what he knew
about the situation at the mine: a possible
explosion, two crews underground, one of the
crews unaccounted for, five men trying to
make their way toward Two Left. Satterfield
reportedly told Stemple he would contact
other MSHA officials. At 8:32 a.m., he issued a
103(k) order over the phone, instructing
Stemple (as Stemple recalls the conversation)
that no one was to enter the mine or do any
work at the mine pending the arrival of
MSHA personnel and approval of a mine
rescue plan.2
Section 103(k) of the Federal Mine Safety &
Health Act of 1977 reads as follows:
In the event of any accident occurring in a
coal or other mine, an authorized representative of the Secretary [of Labor], when
present, may issue such orders as he
deems appropriate to insure the safety of
any person in the coal or other mine, and
the operator of such mine shall obtain the
approval of such representative, in consultation with appropriate State representatives, when feasible, of any plan to recover
any person in such mine or to recover the
coal or other mine or return affected areas
of such mine to normal.

A (K) order does not actually close a mine,
nor does it mean that MSHA takes total
control of the mine. The thinking behind
Section 103(k) is that mine management
knows the mine better than anyone else and
should have the primary responsibility for
putting a rescue plan into operation, but that
MSHA and state mine safety agencies such as
WVOMHST have a statutory responsibility to

ensure that the operator’s plan is sound —
and therefore, for the protection of miners,
must have the authority to approve, disapprove, or require modifications of the plan. In
theory, the imposition of a (K) order creates an
orderly mechanism for shared decisionmaking — a way to expedite a well-planned
mine rescue operation while sharing responsibility for managing the risks involved. Over
the years it has often worked well.
In the aftermath of the Sago Mine disaster,
however, there have been lingering concerns
about how the (K) order was implemented
and whether it had the effect of impeding the
rescue operation. Satterfield was not physically present when he issued the order, as the
Act requires. Pending completion of MSHA’s
internal investigation, it is not clear whether
he was fully informed of conditions at the
mine, including the fact that Toler’s initial
rescue effort had gotten to within less than
3,000 feet of where the trapped Two Left
miners were thought to be — and that the
rescuers had been able to proceed to that
point barefaced (that is, without having to use
their SCSRs), an indication that much of the
mine atmosphere had not been severely
impacted by the explosion and that the
ventilating system was largely functional and
could be quickly and easily repaired, at least
as far as 58 block.
This has given rise to the view, widely held
among the victims’ families and by some of
the other Sago miners, that MSHA, by issuing
a (K) order, put the brakes on what otherwise
might have become an aggressive and perhaps successful rescue mission — and one
that could have saved precious hours by
starting in the vicinity of 58 block rather than
at the portal.

60

 Given the long duration of the Sago Mine
rescue operation and its outcome, this view is
totally understandable. But there are several
problems with it.
First, the imposition of a (K) order does not
absolve anyone on the scene — MSHA,
WVOMHST, or ICG — from responsibility for
developing, agreeing upon, and implementing the most aggressive rescue operation that
is deemed feasible under the circumstances.
Second, it is clear that the ICG personnel who
went underground in hopes of finding the
Two Left crew made their painful decision to
withdraw based in part on their concern
about triggering a second methane ignition
and in part because neither they nor anyone
else at the Sago Mine were equipped to
explore the potentially lethal mine atmosphere inby 58 block.
ICG had no one on-site who was trained and
properly equipped for such a mission. Although members of the One Left crew courageously volunteered to go back underground
later that morning to search for the Two Left
crew, a strong case can be made that it would
have been criminally irresponsible to send
them into a toxic, smoke-filled mine atmosphere equipped only with their SCSRs,
unable to communicate to the surface from
inby 58 block (because the mine phones inby
had been knocked out by the explosion and
their two-way radios had limited range),
facing the possibility of encountering a fire
and running the risk of triggering a second
methane ignition.
Third, the evidence available to us thus far
suggests that at no time during the rescue
operation did ICG go to MSHA and

WVOMHST with a firm plan for a more
aggressive rescue strategy than the one that
appears to have evolved by some sort of
consensus among those in the command
center. Had ICG done so, and had MSHA and
WVOMHST refused to consider such a plan,
there might be more of a basis for criticism
than now exists. While it may be reasonable
to question whether the rescue strategy
adopted by the command center was overcautious, it is not correct to state that the
imposition of the (K) order in and of itself
thwarted the rescue effort, either at 8:32 a.m.,
when Satterfield imposed the order, or
thereafter.
Like many mining companies, ICG had no
trained mine rescue teams of its own at any of
its operations in West Virginia, Kentucky, and
Maryland. The nearest ICG team was at its
Viper mine in Williamsville, Illinois, more
than 600 miles away. Federal regulations in
effect on January 2 required every mine to be
provided emergency services by mine rescue
teams located not more than two hours from
the portal. For the Sago Mine, ICG had a
contract with the Barbour County Mine
Rescue Team, a volunteer association serving
numerous mines in the area.
Stemple tried to phone the Barbour County
team at about 8:00 a.m., only to discover,
according to his subsequent testimony, that
the team’s 24-hour answering machine had
been switched off.3 About 15 minutes later he
succeeded in reaching one of the members of
the team, who then notified the team’s trainer,
who called the others. After assembling their
gear, the first of two Barbour County teams
arrived between 10:40 and 11:00 a.m. (recollections and logs differ about the exact time),
well over two hours after first being notified

61

 and more than four hours after the explosion.
About an hour later, around noon, the first
team reported that it was ready to go into the
mine. But mine rescue protocol requires
having a backup team available, and the
second Barbour County team did not arrive
until about 12:30 p.m.
Meanwhile, MSHA and state inspectors,
assisted by some of the Sago miners, had
been taking gas readings at the return entry.
The first readings, taken at around 8:30 a.m.,
were not highly elevated: carbon monoxide
was recorded at 500 parts per million (ppm)
and methane was measured at 1.1 percent of
the mine atmosphere, well below the explosive range of 5 to 15 percent.

Toward noon, however, carbon monoxide
levels at the portal suddenly spiked upward
to 2,300 ppm, a development that increased
concerns about the possibility of a fire in the
mine. The spike also created confusion in the
mine offices, where a rescue command center
had just been set up, because the CO was
making its way from the mine pit into the
mine buildings. An MSHA inspector ordered
the buildings evacuated. Some of the miners’
family members had gathered at the mine
offices, and they were escorted off the property (to the Sago Baptist Church, a few hundred yards away, where many of them would
remain for most of the next two days). Then,
as the evacuation proceeded, CO levels
dropped and the command center was

EFFECT OF CARBON MONOXIDE POISONING
AND COGNITION
Carbon monoxide (CO) poisoning and its relationship to adverse neurological symptoms is well established in the medical literature, and has been understood for decades by the public health and safety
community. When a person is overexposed to CO, their carboxyhemoglobin (COHb) level rises. The
higher the CO level, the more severe the neurological symptoms will be, including headache, dizziness,
weakness, nausea, vomiting, confusion, disorientation, and visual disturbances.1 This impairment to the
neurological system can compromise a person’s judgment, and make it difficult process information and
make critical decisions. Because the brain is quite sensitive to the effects of CO,2 these symptoms can
emerge quite rapidly after exposure, especially at high levels occurring after a coal mine explosion when
air flow is disrupted. It is reasonable to suspect that the miners trapped in the Sago mine had some
degree of CO-induced neurological impairment which may have affected their judgment with respect to
successfully finding an escape routes.3, 4 — Robert A. C. Cohen, MD

Raub JA, Mathieu-Nolf M, Hampson NB, Thom SR. Carbon monoxide poisoning:
a public health perspective. Toxicology. 2000; 145: 1-4.

1

2

Kao LW, Nanagas KA. Carbon Monoxide Poisoning. Med Clin N Am. 2005; 89: 1161-1194.

Henz S, Maeder M. Prospective study of accidental carbon monoxide poisoning in 38 Swiss soldiers.
Swiss Med Wkly. 2005; 135: 398-406.

3

4

Cohen RAC. Letter to J. Davitt McAteer, July 2006. Available at: www.wju.edu/sago/def.asp

62

 reoccupied — only to be temporarily vacated
again when the CO rose again, briefly, a few
minutes later.
By 1:00 p.m., CO levels at the mine mouth
were back down to 500 ppm, and methane
was measured at 1.1 percent. But the command center considered the situation too
volatile to let the Barbour County mine rescue
team go in. Even after a more experienced
team from Consol Energy’s Robinson Run
Mine arrived on site at around 1:45 p.m., the
prevailing view in the command center seems
to have been that there was a strong possibility of fire somewhere in the mine, and that to
send any mine rescue teams in without
knowing more about constituent trends —
that is, what was happening over time to the
mix of carbon monoxide, methane, other
gases and oxygen in the mine atmosphere —
would be irresponsible.
“We have a rich history of secondary explosions,” Ray McKinney, MSHA’s Administrator for Coal Mine Safety and Health, often
points out, and he is right. One of the examples that still haunts veteran mine rescue
coordinators is the Scotia Mine in Letcher
County, Kentucky, where an explosion on
March 9, 1976, killed 15 miners — nine
instantly, and six from carbon monoxide
asphyxiation while awaiting rescue. Rescue
teams recovered all of the victims within
about 18 hours. Then, on March 11, while the
roof was being rebolted to facilitate further
exploration of the mine, a second and even
more violent explosion occurred, killing 10
miners and three federal inspectors. Rescue
teams had to be withdrawn because of the
fear of still another ignition, and the mine was
sealed. The victims of the second blast could

not be recovered until the mine was reopened
about a year later.
A more recent disaster served to underscore
McKinney’s concern. On September 23, 2001,
an explosion at the Jim Walter Resources No.
5 Mine in Brookwood, Alabama, injured four
miners, including one who was too gravely
hurt to move. The other three injured miners
went to get help. The explosion had impaired
the mine’s ventilation system and methane
was rapidly accumulating, but 12 miners
bravely tried to rush to the aid of the injured
miner. Fifty-five minutes after the first explosion, a second and more violent one occurred,
killing 13 miners — the miner who had been
injured in the first blast and those who had
tried to come to his rescue (one of whom
survived the second blast but later died of
burns).
Because of nightmare scenarios such as Scotia
and Brookwood (and there have been others),
McKinney and other senior MSHA officials
are understandably reluctant to send mine
rescue teams into harm’s way without knowing as much as possible about the conditions
they are likely to encounter. And on the
afternoon of January 2, MSHA was at a
double disadvantage on that score.
MSHA owns two gas chromatographs —
sophisticated instruments capable of measuring and analyzing multiple gases, including
those most indicative of the presence of a fire.
One is kept in Denver and the other in Pittsburgh. Hampered by the holiday, MSHA was
slow in making arrangements to bring its
Pittsburgh chromatograph to Upshur County,
and it did not arrive at the mine until around
5:00 p.m., about two hours after a chromatograph owned by Consol arrived.4

63

 Meanwhile MSHA was hindered in its ability
to interpret the gas readings at the mine
portal not just by the absence of a chromatograph but also because one of the agency’s
key people, the man probably most able to
interpret gas chromatograph readings with
assurance, was not at the mine — although
through no fault of his own.
John Urosek, chief of the ventilation division
of MSHA’s technical support group, was in
Colorado on January 2, monitoring a mine
fire that had been burning for weeks (fortunately without loss of life) in an Arch Coal
mine. After learning of the situation at Sago,
he was in the process of trying to obtain an
airline ticket when Tim Martin, ICG’s corporate safety director, happened to call Arch
Coal, hoping to track down a firefighting
consultant, Ian Houlison. When Martin
learned that both Houlison and Urosek were
at the Colorado mine, he chartered a private
plane to bring them both to Buckhannon. But
it was close to 8:00 p.m. on January 2 —
nearly 12 hours after the explosion — before a
state police escort delivered them from the
Clarksburg airport to the mine site. It was
only after that point that Urosek could begin
contributing his interpretive expertise to the
mine rescue planning process.
Meanwhile, in late afternoon, Consol’s
chromatograph had begun augmenting the
readings from handheld gas monitors. At 5:25
p.m., with CO readings at the portal declining, Consol’s Robinson Run mine rescue team
was finally authorized by the command
center to enter the mine, through the fan
housing, with instructions to explore the first
1,000 feet inby the portal. Mine rescue teams
had been arriving at Sago throughout the
afternoon, and the command center’s first

plan had called for one of them, Tri-State, to
make the initial exploration. But the Robinson
Run team was given the task because
Consol’s mine rescue teams were the most
experienced at the site.
At about the same time, a bulldozer went to
work at the surface, building a rough road to
permit drilling equipment to be moved to a
site directly over Two Left. The command
center’s plan was to put a borehole down to
assess the mine atmosphere in the area where
the miners seemed most likely to be trapped
if they had survived the initial blast.
Both projects — exploration of the mine and
construction of the borehole — proceeded
slowly as the evening wore on. On the surface, there were delays while surveyors using
high-grade Global Positioning System receivers tried to determine precisely where to site
the drill rig. Because of unfavorable weather
conditions they were having trouble getting
accurate readings from orbiting GPS satellites.
Exploration underground, meanwhile, was
slowed by the command center’s instructions
to the mine rescue teams to work systematically back and forth across the multiple
entries of the mine as they advanced, taking
multiple gas readings and thoroughly checking conditions before proceeding further.
That cautious and deliberate approach seems
to have been intended primarily to ensure
that the rescuers would not inadvertently
proceed past a possible ignition source, and it
made sense in the context of MSHA’s fear of
secondary ignitions. There is little doubt that
the “rich history” was much on the minds of
the MSHA officials in the command center,
some of whom had been involved in the
agency’s investigation of the Brookwood

64

 disaster. No one had to tell them to worry
about the safety of the mine rescue teams
exploring the Sago Mine.
On the other hand, there had to have been
some concerns that the operation was proceeding too slowly. Everyone involved in
mine rescue knows that time is the enemy
when coal miners are missing after an explosion or in a fire. With every passing hour, the
odds of finding anyone alive rapidly diminished. The command center must have been
acutely aware of that, just as the mine rescue
team members certainly were.
The dilemma, to be understood, must be seen
as something like war. It is a maxim that
generals tend to want to fight the last war,
rather than the one in front of them, because
the last war is the one they know. So they may
be reluctant to try new strategies, even when
the situation calls for fresh thinking. Mine
emergencies pose a similar kind of challenge.
Senior MSHA officials know all about Scotia,
Brookwood, and other cases where things
have gone terribly wrong. That awareness is
drilled into their training and inevitably
colors their thinking. Nobody wants to be
remembered for having lost a mine rescue
team. But history teaches some harsh lessons.
Lincoln had to replace his cautious generals
with men like Grant and Sherman, who are
remembered today not for the losses they
took but for getting the job done. The last-war
analogy should not be pushed too far, but it
should not be ignored.
As Mark Chewning, one of the captains of the
Barbour County Mine Rescue Team, later told
investigators: “You know, I’ve been doing this
for, I think, 21 years now, and they should let
the mine rescue people have a little more

leeway in what to do and what not to do... I
mean, since we’re the ones being trained to
do this, we should have a say in it somewhere
— you know, say ‘Hey, you know, we’ll try it.’
We know the danger to begin with or we
wouldn’t be in it... Like, these 12 guys in there
— if we was willing to take the chance, to go
try, I think we should have had the option to
go try, if we sign a waiver or however you
want to do it.”5
That view did not prevail in the command
center. One result was that problems, as they
arose, tended to have the effect of slowing the
rescue operation or stopping it cold. For
example, when water was encountered in the
return entry, considerable time was spent
restoring power to a pump, starting it, and
waiting to let rescuers advance until the
pump brought the water level down. Similarly, when rescuers spotted a red light near
34 block, and determined that it was a CO
monitoring station that should have been deenergized when power was cut to the mine
after the explosion, all of the rescue teams
were pulled out of the mine while the problem (a battery backup power source that had
to be disabled from the dispatcher’s computer) was dealt with. While actions such as
these were definitely prudent, they also
added time to the rescue operation when time
was already at a premium.
On the surface, meanwhile, the drilling of the
borehole got under way at about 2:45 a.m. on
January 3, approximately 20 hours after the
explosion. The command center, after pulling
the rescue teams out of the mine, decided to
keep them outside until the borehole had
punched through into the Two Left section,
because of concern that the drill might ignite
methane. The drill punched through at about

65

 5:30 a.m. Work stopped and the drilling
equipment was shut down a few minutes
later in order to listen for sounds from the
mine. There were none. The drill steel was
then struck in the hope that someone in the
mine would hear the sound and send a signal
back to the surface. No signal came. At about
6:30 a.m., while a video camera was being
lowered into the borehole, rescue teams were
sent back underground. The camera showed
no signs of physical damage from an explosion, but it also showed no signs of the Two
Left crew.
More than 24 hours had now passed since the
explosion. The story of the second day is
essentially one of continuing slow movement,
punctuated by setbacks. For example, MSHA
had brought a robot to the mine, and sent it in
at around 7:30 a.m. on January 3 with the
hope that it could accelerate the rescue
operation by monitoring the mine atmosphere ahead of the teams. The robot was also
equipped with a camera, and theoretically
could travel up to 4,000 feet by remote control
— meaning that it would be able to reach the
mouth of the Two Left section from its starting point at 31 block. Instead, the robot
functioned for only about an hour before
getting stuck and becoming disabled on a
muddy and uneven patch of the mine floor,
where it stayed for the duration of the rescue
and recovery operation.
Frustration — with the robot, with the pace of
the rescue — seems to have been building in
and around the command center. Later, ICG
corporate safety director Tim Martin described it to investigators: “There was some
high emotion there, obviously, that we have....
13 men unaccounted for and we need to get
to those folks... [yet] they were actually using

a method almost like a mine rescue contest to
tunnel across and back and just being extremely methodical about exploring and
measuring the constituents.”6
According to Martin, who was near but not in
the command center, he huddled with
MSHA’s John Urosek and firefighting consultant Ian Houlison to talk about accelerating the
mine exploration. They agreed, Martin said,
that it would be feasible to advance more
quickly by limiting readings to fewer entries
closer to the intake. They discussed who
should present this idea to the command
center, and agreed that Urosek should do it,
Martin recalled: “And it took about ten
minutes but they finally accepted the idea,
and that’s when the teams kind of picked up
pace and started moving.”7
At about 2:00 p.m., rescue teams reached the
mouth of the One Left section. At the command center, meanwhile, a decision was
made to bypass exploration of One Left, other
than the openings at the mouth of the section,
since it was reasonably certain that there was
no one there (the One Left crew had come
out, and the assumption was that fireboss
Terry Helms had left the section, on his way
to Two Left, before the explosion occurred,
because it was known that his lunch bucket
had been left for him at the Two Left switch).
About 15 minutes later, at 50 block, the teams
found the One Left mantrip where the crew
had abandoned it, with its headlights still on.
At about 4:20 p.m., the command center
decided to have the rescue teams move their
fresh air base up to 57 block. While some of
the team members were hanging curtain
outby the base site, to direct the air flow over
it, others explored the entries between 57 and

66

 58 block. At about 5:15 p.m., MSHA rescue
team member Ron Hixson, working his way
forward alone in the track entry on his way to
join a Consol team as a backup man, came
upon the soot-covered body of Terry Helms,
lying across a rail near the coal rib. (A subsequent examination indicated that Mr. Helms
had probably died instantly, after being
caught in the direct path of the explosion.)
Shortly after 5:45 p.m., with the new fresh air
base established, rescuers advanced toward
the sealed area to check the mine atmosphere
there. Not knowing that the seals had been
almost completely destroyed, they actually
walked through the pulverized rubble without realizing they had done so until they
reported their location — and some very high
CO readings — to the command center. They
then retreated, working their way across the
entire set of seals and confirming that the
seals had been blown out by an explosion
originating in the sealed area.
At this point — some 35 hours after the
explosion — the command center finally had
a clear sense of what had happened on the
morning of January 2. Until this point, or at
least until the borehole camera revealed the
absence of damage on the Two Left section,
there had been lingering speculation that the
explosion might have originated near the face
of the section, perhaps triggered by the Two
Left crew, arriving and energizing equipment
in the presence of an explosive methane-air
mix that they had not detected. Now, with the
realization that the crew most likely had not
been killed outright by the explosion, there
was a heightened sense of urgency about
finding them.

Advancing into the Two Left section, rescue
teams found all of the ventilation controls in
the primary escapeway damaged from the
mouth of the section to crosscut 12, more than
a third of the way toward the face. Then, at
around 7:30 p.m., rescuers spotted the Two
Left mantrip in the track entry at crosscut 10.
Searching the area, rescuers found no one but
reported to the command center that it
appeared as though the crew had tried to use
the mantrip to escape and had been forced to
abandon the vehicle after encountering debris
from the explosion across the tracks. Rescue
team members found footprints in the intake
escapeway, indicating that the Two Left crew
had walked there from the abandoned
mantrip, but the footprints disappeared —
possibly lost in the mud and water — so there
was no indication of how far the crew might
have gone before turning back. (The command center was also concerned about the
possibility that they had not turned back —
that they had gotten disoriented in the smoke
and stumbled past the destroyed seals into
the abandoned area — but the rescue teams
reported having seen no footprints there.)
Just after 8:00 p.m., rescuers exploring the
intake escapeway found the top and bottom
covers of 12 SCSRs at crosscut 11. That in itself
did not indicate where the men were, but
logic suggested that if they had been unable
to make their way out of the mine in the
mantrip, they most likely would have retreated in the other direction, toward the face.
But it was also possible that they could have
barricaded themselves somewhere else in the
nearly half-mile-long section. The rescue
teams, switching out according to protocol so
that no team would become exhausted,
needed nearly three hours to explore the
entries from the mouth of the section to
crosscut 15, just over halfway to the face.
67

 At some point between 11:00 and 11:30 p.m.
(the exact time is not shown in the command
center’s logs), the rescue teams were given
permission to break with protocol and make a
push to the face of the section. Normal mine
rescue protocol would have required them to
advance no more than 1,000 feet before
establishing another fresh air base and hanging curtain to direct air to the new base. That
process could have added another two hours
or more to the exploration of Two Left. As
Ron Hixson later testified: “Yes, we were

going to go further than 1,000 feet. The air
quality was bad, but it wasn’t a situation
where you would die or anything if your
apparatus failed or if you had a major problem. We felt the risk was worth taking and we
had the radios to communicate back and
forth, and we went for the face.”8
But to push straight for the face meant that
communication would be difficult. The mine
phone system could be used to communicate
between the command center and the fresh

ne

Le

ft

Location
of miners

Tw

o

Le

ft

O

Handheld at
power center

Handheld
at 9 block
Handheld and hardline
at 59 block

Se

a

Ar
led

ea

Hardline phone at 58 block
communication with
command center

Communications were stretched to the limit at the moment when mine rescuers found the
trapped miners in the No. 3 entry of Two Left. A rescuer under apparatus equipped with a
handheld two-way radio in the track entry near the power center had to relay messages to
another rescuer under apparatus with a handheld near crosscut 9. He then relayed messages
to rescuers in respirable air at 59 block. They communicated by cable to rescuers at the fresh
air base at 58 block, who communicated by mine phone to the command center at the
surface. (Light grid at upper right shows coal blocks not yet mined.)

68

 air base at 58 block. Moving inby from the
fresh air base, a couple of hundred feet into
the neck of the Two Left section, rescuers
equipped with a cable reel strung a cable that
allowed them to stay in touch via headset
with the rescuers manning the fresh air base.
Because all of these mine rescue team members were working in respirable air, they were
not wearing breathing apparatus, and so their
hardline communications were reasonably
clear and reliable.

federal and one state inspector — MSHA’s
Ron Hixson and WVOMHST’s Bill Tucker.
The rescuers were grateful for the order to
break with protocol. (As McElroy team
captain Jimmy Klug said later: “By the way,
whoever made that decision was a good
person to do that.”9) They advanced rapidly
in the track entry, knowing that the odds of
finding anyone alive after so many hours
were very slim — but carrying a dozen extra
SCSRs with them, just in case.

But further into the section, where the CO
levels were elevated, rescuers had to be under
apparatus, communicating to each other
through voice diaphragms in their face
masks. Some also had handheld two-way
radios, which when fully charged had an
effective range of about 500 feet — as long as
they were in direct line-of-sight with each
other. That was feasible if two men stayed
within 500 feet of each other in the same
entry, but if one of the men was moving back
and forth between entries, the other man was
unlikely to be able to hear him clearly, if at all.

At about 11:40 p.m., they reached the face,
and split off, with Klug and Tucker exploring
the entries to the left, Hixson and McElroy
team members Mike Clark and Jim Smith
exploring to the right. Making their way into
the last open crosscut just outby the No. 3
entry, Klug and Tucker suddenly heard a
deep gasping sound at about the same moment that they caught sight of a curtain hung
diagonally across the entry.

To help deal with the problem of stretchedout communications, one of the rescuers
equipped with a two-way radio stayed in the
track entry at crosscut 9, roaming a few yards
inby or outby as necessary to pick up transmissions. He was theoretically able to relay
messages from inby to the rescuers at the
cable reel, who could then relay them by cable
to the rescuers at the fresh air base, who could
then relay them by mine phone to the command center. But this four-step communication linkup was inherently fragile, as would
soon be demonstrated.
The push to the face was led by a team from
Consol’s McElroy Mine, accompanied by one

As Klug pushed past the curtain, the beam of
his cap lamp showed him that he had found
the missing miners. Some were sitting against
the coal rib. Some were lying down. All were
silent and motionless, except for the miner
who was the furthest inby, closest to the face.
Klug heard him gasp again and ran straight
to him.
The miner was in a sitting position. Another
miner sitting next to him, a bigger man, had
toppled across him. Klug struggled to pull the
gasping miner free. Bill Tucker, hurrying into
the entry just a step or two behind Klug,
turned back into the crosscut momentarily to
yell for help.
As Tucker later testified to investigators: “I
was screaming, ‘We need help! We need help!’

69

 And I mean, when you first looked in, in my
mind at that point, you know, I thought that
most of them were dead. But I was hollering
back for help and I said, ‘They’re over here!
They’re over here and they’re alive!’”10
No one should ever blame Bill Tucker for
miscommunicating the situation. At least one
miner was alive, and in the instant of discovery there had not been time yet to check all of
the others. However, as Hixson, Smith, and
Clark responded to Tucker’s call and rushed
into the entry, it became obvious to them that
the other miners were not alive. Klug later
testified: “We all knew. I mean, I don’t want
to — we knew.”11
But they checked anyway. While Klug and
some of the others moved the gasping miner
onto his back, fearful that he was about to
expire and hollering at him in a desperate
effort to bring him back to consciousness,
rescuers went from miner to miner, shaking
them, calling out to them, feeling for pulses.
The other miners were gone, all of them. For
the rescuers there was absolutely no doubt
about it.12
But that was not the message that made its
way through the four strained links of the
communication chain to the command center.
It is still not clear how the word reached the
rescuer with the two-way radio in the track
entry at crosscut 9, but what he remembers is
that someone transmitted from the face area:
“We need help, we’ve found them, we found
all the men, we need help... We need medical
help. We’ve got two people we’ve got down,
we’ve got to have stretchers, we need help.”13

rescuers rushed forward to the face, responding to the first call for help, they too checked
the lifeless miners, shaking them and calling
out to them. One of the rescuers pulled one of
the victims away from the rib, and when he
did, as Hixson recalls, “I think it was just air
trapped in his lungs, but he let out a load
moan, and we thought we had a second man
alive.”14 It was only a matter of moments
before the rescuers realized their error, but the
message went back before they could cancel
it.
Chris Lilly, captain of the Tri-State Mine
Rescue Team, was at the fresh air base, communicating with the command center via the
hardline mine phone, when word came from
the next inby link of the communication chain
— the rescuer at the cable reel, who in turn
was relaying messages from the rescuer with
the two-way radio at crosscut 9. Lilly remembers the message: “It may have been, ‘We
need supplies, oxygen, stretchers, 12 alive.’ Or
it was ‘Twelve alive, we need oxygen and
stretchers.’... It was either supplies first or
what they found first.”15 Whichever it was,
Lilly remembers asking for confirmation:
“They confirmed it. And then we reported it
outside to the control center.”16
(Memories conflict on the question of confirmation. MSHA rescuer Frank Thomas was
also at the fresh air base when the message
came from the rescuer at the cable reel. He
later testified: “The guy on the hard line
[cable], the words came out of his mouth,
‘Twelve alive.’ The guy on the mine phone
called out [to the command center], ‘Twelve
alive.’ Nothing was confirmed before he
called outside.”17)

Hixson remembers how the confusion arose
about a possible second survivor. As more

70

 Although the situation at the face was chaotic,
the evidence suggests that very little time
elapsed before the rescuers got on their radios
again to report what they all quickly understood — that there was just one survivor.
Hixson, realizing they were going to need
more people to help carry the survivor, got on
his radio and called out: “Hey, we have all 12
guys accounted for. We have one alive, and
we need help, and we need help now.”18
The rescuer with the relay radio at crosscut 9,
running back and forth as he tried to maintain
reception from inby, heard that message. In
order to transmit it, he had to run a few yards
outby in the entry. He remembers transmitting: “They’ve only got one person alive.”19
Ordinarily he would have waited for a
response, but this time he didn’t — because
he saw lights coming, realized it was the
rescuers carrying the survivor, and “I just ran
up to meet them, to help any way I could
help.”20
They needed help. Carrying anyone on a
stretcher in a coal mine, stumbling over
terrain illuminated only by cap lamps, is
tough work. Carrying the sole survivor of the
disaster was made even tougher by the fact
that he was unconscious, perilously close to
death, and in desperate need of oxygen. And
the stretcher-bearers had to make their way
through the rubble from the explosion in
addition to stumbling through mud and
water that was sometimes up to their knees.
In the entry, upon finding the survivor, Klug
had broken open an SCSR and forced the
mouthpiece between the survivor’s lips, but it
was hard to keep the mouthpiece in place and
even harder to get him to breathe through it.
And once the survivor was on a stretcher and

being carried back toward the fresh air base,
making the SCSR work for him became a
major challenge. It meant running alongside
the stretcher, holding the mouthpiece in the
survivor’s mouth, holding the SCSR alongside him, peering at him constantly to see if
he was breathing, avoiding falling toward
him or away from him, and trying not to go
faster or slower than the stretcher bearers —
who were still under apparatus, their face
masks fogging over with sweat, tiring rapidly
as they stumbled and slipped. It was a nightmarish carry. If a man felt about to collapse,
he would yell out and another rescuer would
slide in to take his place, taking care not to
let the stretcher drop, struggling to maintain
the pace.
It was at about 12:15 that the rescuers bearing
Randal McCloy, Jr. — they didn’t know his
identity yet — reached fresh air at the neck of
the Two Left section. By that point they had
used three SCSRs in order to keep giving him
the initial oxygen shot supplied by the small
bottle within each CSE SR-100.21 Now, with
the rescuers able to proceed barefaced in
respirable air, they borrowed a rescuer’s
Draeger BG-4 breathing apparatus and fitted
it to McCloy’s face. The BG-4 is a positive
pressure device, meaning that it supplies
oxygen whether the user works at breathing
or not. Soon the rescuers noticed that McCloy
seemed to be breathing better — not normally
by any means, but no longer taking a breath
only every five seconds or so. Encouraged,
they managed to keep moving rapidly as they
carried him back to a mantrip at the mouth of
the One Left section, and then, in the mantrip,
headed out of the mine.
On their way out, they encountered an
unexpected sight, coming toward them —

71

 a motor pulling a supply car crowded with
people. There was confusion as the rescuers
hollered to clear the track so they could keep
going with the survivor.22 The incoming
miners — including mine superintendent Jeff
Toler — wanted to know where the other
survivors were. As Frank Thomas remembers
the moment: “Someone gets out of the
mantrip that was coming in and asked,
‘Where’s the rest of them?’ And in our bunch:
‘The rest of who?’ ‘The rest of the men, the
other miners.’ ‘They’re all dead.’ Complete
silence.”23
The confusion had ramped up at 11:45, when
the command center got the message from the
fresh air base that all 12 miners were alive. Ty
Coleman, International Coal Group’s safety
manager for West Virginia and Maryland,
was ICG’s man in charge in the command
center throughout the rescue operation. As he
later testified: “I was just basically listening to
the mine phone and it came over the
[speaker] phone… ‘We found 12 alive.’ And
this was late in the hour. And I thought, you
know, maybe I didn’t hear right. And the
room got loud and I [can’t] remember who
was next to me, and I said, ‘What did he say?
Did you hear what I [heard]?’ He said, ‘Yeah,
12 alive.’…It was absolutely euphoric, the
feeling there… But unfortunately I said, ‘You
know, we got to confirm, you know, let’s
clarify it.’ And the room erupted, but we were
still doing business. And I had never seen so
many old hairy guys cry in my life.”24
There have been many accounts of the room
erupting in celebration. And after all those
anxious hours, it was only natural to celebrate. There is no evidence, however, that
Coleman or anyone else in the room thought
to request confirmation, despite their aware-

ness of the tenuous communication chain
inside the mine and what has to have been
their acute awareness of the odds against all
of the miners surviving in bad air for such a
long time. They did not follow basic emergency protocol requiring verification of all
communications. Instead, reports of the
miraculous discovery — “twelve alive!” —
almost instantly reached the miners’ families
waiting at the Sago Baptist Church.
Worse yet, it appears that one or more ICG
employees may have taken it upon themselves to provide details to the families that
simply could not have originated with the
rescuers underground. For example, several
family members vividly remember a company official telling them that as soon as the
miners emerged from the mine they were
going to come over to the church before going
to get medical treatment.25
That struck some of the family members as
wildly implausible. As Amber Helms, daughter of Terry Helms, said: “Any man who is
trapped underground for that long a time is
not going to have a choice of whether they
want to walk to a church. They’re going to be
put in an ambulance and they’re going to take
them immediately [to a hospital].”26 But
whatever doubts the families may have had
were pushed aside by the apparent certainty
of the reports from the mine and the sheer joy
of hearing that their loved ones were alive.
No one cautioned them to wait for verification or further bulletins. Moreover, it
appears that no one from MSHA or
WVOMHST briefed the families at any
time during the entire rescue operation —
an appalling failure.

72

 Meanwhile, at the command center, preparations got under way to send medical supplies
into the mine and to summon ambulances to
take the miners to the hospital. It was not
until almost three-quarters of an hour later, at
12:25 a.m., that clarification came — to the
command center, not the families — and even
then the command center failed to understand at first.
When the rescuers carrying Randal McCloy
reached the neck of the Two Left section, near
their fresh air base, they had been met by
other rescuers hurrying inby on the assumption that all 12 miners were alive. Realizing
that the original miscommunication had
taken on a life of its own, Jimmy Klug went to
the mine phone at the fresh air base and
called outside to the command center.
Earlier, before going underground, Klug and
some of the other rescuers had been told to
use a code to communicate with the command center in the event that they found
anyone, because some of the people in the
command center had become concerned that
the news media were somehow eavesdropping on their communications. The code for
“body” was “item,” and each of the missing
miners was to be identified by a number. The
rescuers had used the code when they found
Terry Helms, reporting to the command
center that they had found one “item” in the
track entry. Now Klug used the code again,
after realizing that the command center
apparently did not know that all but one of
the miners were dead. He recalls saying over
the mine phone: “We have 11 items.”27
The message didn’t seem to sink in, according
to Tim Martin, ICG’s corporate safety director,
who heard what Klug was saying. Martin had

had a role in coming up with the code. He
remembers that the command center at that
moment was “kind of full and the emotions
were very high that they thought they had 12
miners alive. The word came across from
[Klug] on the phone that ‘We have one on a
stretcher and 11 items.’ And it just hit me like
a ton of bricks that I knew what that meant.
And I kind of stepped back for a minute — I
just, you know, was in shock. But then I could
see the rest of the room didn’t understand.”28
Klug, as captain of a Consol team, was speaking with a Consol safety director, Rick
Marlow. Martin remembers saying to Marlow
and the others in the command center: “I
think we got bad news here... You need to
confirm that. And they argued with me for a
short period of time that, ‘No, no, no... we got
12 people coming out’... And I had to kind of
raise my voice pretty loud to get them to
listen to me. I said, ‘Listen, he... just said we
got 11 items.’ I said, ‘Have him repeat what
we have as far as survivors.’... And the
answer came back, ‘We have one on a
stretcher and 11 items.’ And they turned to
me and said, ‘See, we’re okay,’ or something
to that effect. I said, ‘Listen, are you all forgetting about the code?’ I said, ‘Tell them to drop
the code and just tell us what they’ve got as
far as survivors.’ So they called back in and
said, ‘Do you have 11 survivors and one on a
stretcher?’ And they said, ‘No, it’s the other
way around.’”29
That message staggered the command center.
Klug recalls Marlow telling him: “‘Forget the
code. What do you mean?’ I said, ‘There’s 11
deceased people.’ And he just — he was
speechless.”30 Klug remembers that Marlow
then told him: “Just bring everybody outside,
we’re going to regroup and go back in.”31

73

 The rest of the night’s tragedy can be quickly
told, in part because it dominated the next
day’s news stories and in part because it does
not directly bear on this narrative of the mine
rescue operation, which in reality came to an
end at 11:45 on Tuesday night, January 3, with
the discovery of the trapped miners and the
realization that all but one were deceased.
Randal McCloy’s rescuers brought him out of
the mine at about 1:00 a.m. on Wednesday
morning, January 4, after being briefly delayed when they encountered the incoming
personnel, including a doctor — who, since
they had no communication with the command center, were still under the impression,
up to that moment, that they would be
finding 12 miners alive. Mr. McCloy’s removal from the mine marked the conclusion
of the rescue effort — approximately 41 hours
and 15 minutes after the Two Left miners first
found themselves trapped by the smoke and
debris from the explosion in the sealed area of
the mine.
There are three lingering questions about the
rescue operation that must be addressed:
• Why did the command center, after learning about the miscommunication from within
the mine, take so long to communicate the
truth to the miners’ waiting families?
• Why did the command center have so
much difficulty determining the facts in the
first place?
• And, finally, what can be done to improve
the odds that the next mine rescue operation
— always a race against time — will not
require nearly two full days to complete?

As previously noted, it was at about 12:30
a.m. on Wednesday when McElroy team
captain Jimmy Klug succeeded in communicating to the command center that the rescuers were bringing out just one survivor on a
stretcher and that the rest of the Two Left
miners had died. The command center’s
response to that was to order everyone out of
the mine — even though the mine rescue
team from ICG’s Viper Mine was underground at the time, assisting in the removal of
Randal McCloy. Several members of the Viper
team were certified emergency medical
technicians (EMTs), fully capable of reassessing the condition of the other Two Left miners. But they were ordered out of the mine
along with everyone else.32
ICG president and CEO Bennett Hatfield,
who was in the command center at the time,
subsequently testified that the command
center was informed that there “appeared” to
be only one survivor and the other miners
“appeared” to be deceased33 — a statement
not supported by the testimony of Klug and
other rescuers, who do not appear to have
had, or communicated, any ambivalence
about the status of the miners. Nevertheless,
Hatfield also testified: “The immediate
reaction in the command center was that this
report of only one survivor may be erroneous.
Many participants in the command center
clung to the fervent hope that the other 11
miners may be in some sort of comatose
state.”34 If indeed they were clinging to such
a hope, it is all the more difficult to understand why they ordered everybody out of the
mine rather than immediately sending a team
back to the face of Two Left.
The command center seems to have been in a
state of general confusion at that point —

74

 understandable given the level of fatigue and
roiled emotions that everyone there must
have been struggling with, but it continued to
experience problems. For example, when
rescuers brought the survivor to the surface at
about 1:00 a.m., no one managed to determine
his identity before sending him in an ambulance to St. Joseph Hospital in Buckhannon.
It was not until more than an hour later that
the command center learned which miner
had survived, and in the meantime there was
no information that could be transmitted to
the families about his identity.
ICG’s Viper team, exiting the mine with the
other rescuers shortly after 1:00 a.m. on
Wednesday, January 4, walked up from the
pit to the command center. Team captain Pete
Bryant later testified that no one debriefed
them about what they and the other rescuers
had seen in the mine.35 However, when they
encountered ICG corporate safety director
Tim Martin, he told them, according to
Bryant, to “get back in there and see if there
were any folks still alive.”36 Someone then
supplied the team with five stethoscopes and
some first aid equipment, and they headed
back into the mine — perhaps 20 minutes
after exiting it, as Bryant recalls.37
There is some confusion on that point. According to MSHA’s log, all rescue personnel
were out of the mine at 1:20 a.m. The log also
shows that the command center, after deciding to send the Viper team back underground
to reassess the condition of the Two Left
miners and remove them from the mine,
supplied the team with body bags as well as
stethoscopes. The rescuers then re-entered the
mine at 1:55 a.m, according to MSHA’s log.
At 2:35 a.m., they reported to the command
center that they had reassessed the miners
and that all were indeed deceased.38

At that point — nearly three hours after
rescuers had first determined, beyond any
doubt in any of their minds, that only one of
the miners in Two Left was alive, and more
than two hours after the initial miscommunication had been cleared up — Hatfield and
other ICG officials went to the Sago Baptist
Church to deliver the horrific facts to the
miners’ families.
Hatfield subsequently testified that an attempt had been made at about 1:45 a.m. to
send a message to the church that there were
“conflicting reports” on survivors and that
the initial reports might have been “too
optimistic.”39 But by 1:45 a.m. there were no
“conflicting reports” — none at all.
Subsequent interviews with the rescuers by
federal and state investigators confirm that
none of them, as they exited the mine, had
any doubt whatsoever about the condition of
the miners they had left behind — nor is it
remotely imaginable that any of them would
have been willing to leave the Two Left
section if they had believed that any of the
miners there were still alive. The only confusion on this point seems to have been in the
command center. In any case, the message
sent at 1:45 a.m., although reportedly relayed
to the church by state police officers, never
reached the families.40
ICG officials have offered various explanations for the confusion in the command
center, the failure to confirm information
coming from underground, and the failure to
hold that information within the confines of
the command center. “Those of us involved in
the rescue effort suffered from the same
fatigue and range of emotions that everyone
in the church did,” Hatfield later testified.41

75

 Ty Coleman, in charge of the rescue operation
for ICG, testified that he was in the command
center for the entire 40-plus hours of the
rescue operation and “did not relinquish
command responsibility” at any time from
the morning of January 2 until the bodies of
the miners were brought out of the mine on
the morning of January 4.42

That is a long stretch of time. Fatigue may
well have played a part in the command
center’s confusion, and it should be noted
that — as MSHA is well aware — emergency
management experts routinely caution
against letting managers stay on station too
long, to the point where sleeplessness and
exhaustion can impair judgment and deci-

76

 sion-making. No one should question the
dedication of anyone in the command center,
but if we are to learn anything from the Sago
disaster it should be fair to point out that
fatigue must be managed just like every other
facet of an emergency.
As to the question of why the command
center failed to control dissemination of the
initial misinformation about finding 12
miners alive, Hatfield blamed the lapse on
“cellphone communications,”43 and ICG vice
president Charles Snavely testified: “With all
the people coming in and out of the command center, evidently people overheard this
communication and reported that to the
families at the church.”44
Cellphones unquestionably played a role in
the miscommunication to the families, and it
should be noted that Sago was the first mine
emergency to occur in this age of ubiquitous
cellphones. Their omnipresence strengthens
the case for ensuring that firm control of
communications, preferably through predesignated spokespersons, becomes part of
any emergency management plan in the
future.
On the other hand, throughout the rescue
operation at Sago there appears to have been
little if any control over who came and went
at the command center, and little effort seems
to have been made to keep critical information within its walls. At the moment when the
command center heard that all 12 miners in
Two Left were alive, ICG’s Tim Martin was
outside, on his way back to the command
center from the mine’s bathhouse, where he
had been helping a mine rescue team stage its
equipment in preparation for going into the
mine. As he later testified, he heard “several

people” out in the open commenting on the
“great news.”45 Someone’s cellphone may
have been used to get the news to the families, but that could not have happened if the
news had been kept confidential until it was
confirmed. The information could not have
been “overheard” because no attempt was
being made to guard it against being overheard. MSHA, the state, and the company
share the responsibility for that failure.
MSHA rescuer Ron Hixson probably spoke
for all of the rescuers when, while being
interviewed later by federal and state investigators, he was asked if he had anything he
wanted to add.
“The only thing I’d like to say is that... I know
there was a lot of press and there was a lot
went on with the communications,” Hixson
said. “And as far as the guys underground,
speaking for myself on down the line, I’m not
blaming anybody... but we were in a very
difficult situation. If that communications
would have stayed where it was supposed to,
at the command center, and not got out, none
of that would have happened. And I feel as
bad for those families — I mean, that was a
terrible thing that they had to go through. I
just think as far as mine rescue, you know,
any time I’ve ever been involved in it, when
we’re calling outside, that information is
checked and double-checked and triplechecked before it’s ever written down, before
it’s ever — you know, it’s verified. And it
never had a chance to be verified this time.”46
MSHA’s internal investigation, not yet completed as of this writing, may address some of
the not yet answered questions about how the
command center functioned. In the meantime, it is not our purpose here to question the

77

 commitment of any of the individuals —
federal, state, or corporate — who had the
demanding and ultimately heartbreaking
task of trying to organize a race against time.
But there are questions, of course, about the
initial delays in getting the mine rescue effort
launched. And there is a larger question that
will always hang over the Sago rescue
operation:
Could precious time have been saved by
starting the rescue at — or at least close to —
58 block, given that the mine outby that point
had been at least partially explored, the air to
that point was respirable, and gas measure-

ments were not showing exceptionally high
or explosive elevations?
That is a hard question to answer with any
certainty. Those conditions were known as of
9:30 a.m. on the morning of the explosion,
when Jeff Toler, Dick Wilfong, and Al
Schoonover were still at 58 block. But then,
rightly apprehensive about a possible second
explosion and further loss of life, they exited
the mine. Once they were outside, however,
no eyewitness accounts of conditions inby the
portal were available to the command center.
What if they had stayed at 58 block instead of
exiting the mine? If they had been able to

SAGO AND ALMA
On Thursday, January 19, 2006, just 17 days after the Sago Mine disaster, a fire broke out in Massey
Energy’s Aracoma Alma No. 1 Mine in Melville, Logan County, West Virginia. Twenty-one miners
were inside the mine when a carbon monoxide detector alongside a conveyor belt began sounding an
alarm at about 5:35 p.m. Nineteen miners made it out of the mine safely. Two miners — Don Bragg and
Elvis Hatfield — became separated from a crew of 10 others and did not escape.
Mine rescue teams entered the Alma mine at around 11:30 p.m., about six hours after the belt fire was
discovered and while it was still burning. Rescue teams using water and foam suppressed the fire
sufficiently to allow them to continue searching the mine. On Saturday, January 21, they found the
bodies of the missing miners.
Today, more than six months after these tragedies, a question still haunts many of the Sago miners’
families:
Why was it possible to send mine rescue teams into the Alma Mine, within just a few hours after the
emergency began, and past a burning fire — when the command center at Sago had refused to let rescue
teams go in for nearly 10 hours after the explosion, at a mine where there was no fire, and then kept them
on a tight leash instead of letting them head straight for the Two Left section?
Part of the answer is that there are some important differences between the two emergencies. There was
no explosion at Alma, and the mine liberated virtually no methane at all, so there was minimal risk of an
explosion occurring while rescuers were in the mine.49 The fire at the belt was not spreading out of
control and therefore was not endangering either access or escape. Other than having to cope with smoke,

78

 continue reporting conditions from the mine
phone at 58 block, would it have been possible to rush properly equipped rescuers in
to that point, taking the chance that the
possibility of fire and/or a second explosion
was low enough to justify the risk ?
It would have been asking a lot to expect the
three men to stay in the mine for many hours.
Mine rescue teams were not on site in sufficient strength to launch an adequate rescue
effort until about eight hours after the explosion. And with no gas chromatograph on site,
accurately assessing the fire risk would have

been difficult if not impossible until fairly late
in the day on January 2.
As for the risk of a second methane ignition,
whoever was calling the shots in the command center would certainly have wanted to
know as much as possible about how much
methane the mine liberated. This was not as
difficult as assessing the risk of fire. From
each quarterly inspection, MSHA had a
history of the mine’s methane liberation. Sago
liberated very little methane — so little, in fact
(approximately 100,000 cubic feet per 24
hours47), that when MSHA District 3 Manager

heat, and carbon monoxide, for which they were trained and equipped, the rescue teams were not imperiled by conditions in the mine. There was no reason to hold them back.
At Sago, in contrast, there was concern about what was not known. The gas readings obtained at the
portal were subject to varying interpretations and the possibility that they might not reflect conditions
further inby. After about 9:30 a.m. on January 2, there was no one inside the mine to provide first-hand
reports on conditions. There was at least the possibility of a fire, and there was concern that the ventilation changes made in the first rescue attempt by mine superintendent Jeff Toler and others might have
been pushing methane over such a fire, increasing the risk of a second explosion. Jeff Toler himself
testified to his anxiety about that possibility.50
So the two situations were not comparable. The rapid response at Alma does not necessarily mean that
the more cautious response at Sago was fatally flawed.
But the Sago miners’ families are still right to raise these questions, because there are reasons to be
concerned about the differing responses.
What we know about human nature suggests that those in command at Alma (some of whom had also
been at Sago), as they confronted another emergency less than three weeks after the tragic outcome of the
year’s first disaster, had to have been aware of the need to organize the most aggressive response that
could be justified under the circumstances — and they appear to have done that.
Their actions did not save the lives of the two missing miners. But they did demonstrate the value of
taking risks within reason. And that, in the end, is a large part of what mine rescue is all about.

79

 completing the mission before a methane
buildup could imperil it.

Kevin Stricklin got the phone call telling him
that the Sago Mine had had an explosion, he
thought the caller must have misidentified
the mine.48

It is possible — just possible — that such a
scenario would have worked (even without
eyewitness reports on conditions at the
mouth of Two Left), and if everything had
gone just right, mine rescuers might —
might — have reached the Two Left crew at
some point late in the afternoon on January 2,
when some and perhaps all of the miners
were still conscious, as we can tell from their
notes and from Randal McCloy’s recollection.
But a mine rescue launched in such a way
would have put the rescue teams at high risk,
no question about it. Although it seems
certain that they would have been willing to

Knowing that the mine was not a big methane-producer, the command center might
have figured that the initial explosion would
have burned out most of the methane and
that it would take a long time to build back
up into the explosive range, even with the
mine’s ventilation impaired. So the risk of
sending mine rescuers in would have to be
weighed against the advantage of sending
them in as soon as possible — mainly to
improve the odds of finding men alive, of
course, but also to improve the odds of

REFUGES: A NECESSITY, NOT AN OPTION
Although escape should always be a miner’s first choice in a mine emergency, miners should not have to
choose between escape and barricading. They should have the option of safe refuge in a chamber capable
of sustaining life for days if necessary.
Refuge chambers in coal mines are not a new or untried idea. In the 1970s, coal operators Frank and
Dusty Williams operated a mine in Upshur County, not far from where the Sago Mine is today, and
voluntarily built a rescue chamber in the mine. As the diagram shows, the chamber was excavated off the
intake air escapeway. It was 18 feet wide and
roughly 90 feet deep. Two concrete-filled 12-inch
UPSHUR COALS CORPORATION
block stoppings with offset doors provided blast
EMERGENCY SHELTER HOLD
protection. The doors were far enough apart so that
NO SCALE
a stretcher could be passed between them. The
chamber was connected to the surface by two cased
boreholes, one 6 inches in diameter and the other 8
inches, which could be used to supply air, food, and
a phone line. Dusty Williams remembers that the
chamber was a break-even cost proposition “because the coal paid for the work.”
6” CASED BOREHOLE

8” CASED BOREHOLE

CONCRETE FILLED 12” BLOCK
STOPPINGS

TO 2ND RIGHT MAINS

TO 1ST RIGHT MAINS

(INTAKE AIR ESCAPEWAY)

One size does not fit all, in coal mining as elsewhere, so the refuge built by Upshur Coals should
80

 take that kind of risk, it is unclear whether
anyone in the command center seriously
considered such an option or would have
been willing to shoulder the personal and
professional responsibility for its failure.
It is not easy to consider this question, even
from a safe distance. Those who were in the
command center on January 2 had to make
life-and-death decisions based on limited
information. Some might reject the idea that
an accelerated rescue operation could have
had any merit at all, recalling the rich history
of secondary explosions in coal mine disasters
and believing that no responsible mine
emergency manager should ever willingly
subject mine rescue teams to that kind of risk.

That view is understandable. But there is
another possible response, one that will haunt
anyone closely involved with the Sago
disaster:
When a building is on fire and people are
trapped inside, a fire chief must sooner or
later make the gut-wrenching decision about
whether to send in his firefighters — knowing
that they have trained for the job and are
willing to accept the risks, and knowing full
well that delays will almost certainly cost
lives. It is fair to ask why a coal mine should
be any different.

not be thought of as anybody’s ideal solution. It’s just a good example of miners’ ingenuity at work. There
are other approaches. MineARC, an Australian manufacturer, custom-builds transportable steel refuge
chambers capable of accommodating up to 20 miners and supporting life for up to 36 hours. At a Solid
Energy underground coal mine in New Zealand, a transportable chamber is placed 300-600 feet from the
face and is moved as coal is mined. Three other permanent chambers are installed in the mine, spaced
about 3,000 feet apart, connected by lifelines with directional cones. If miners are unable to escape the
mine, they can seek refuge in the chamber, communicate with the surface, replace their SCSRs if necessary, and then proceed to the next outby chamber using the lifelines. They can repeat the process, going to
the next “changeover station,” as the refuges are called, until they can safely exit the mine, or wait in one
of the chambers for instructions from mine rescuers.
There are numerous other refuge chamber designs, including one manufactured by Mine Safehouse,
LLC, that was shown at the International Mining Safety and Health Symposium at Wheeling Jesuit
University in April. The Safehouse structure is said to be capable of resisting fire at temperatures
exceeding 2000 degrees Fahrenheit and explosive forces up to 75 psi without conducting appreciable heat
to the interior.
Obviously, careful consideration must be given to how and where a refuge chamber will be placed and
how to ensure that it will truly provide a safe shelter when needed. Exhaustive testing and design
refinements are a necessary part of getting refuge chambers into the underground mines of West Virginia. But after Sago there can no longer be any excuse for postponing the day when every miner can
count on having a safe place to go to in an emergency if escape appears not to be an option.
81

 SOURCES
1

Wilfong, 2/17/06 testimony, p. 59.

27

Klug, 3/26/06 testimony, p. 27.

2

Stemple, 2/22/06 testimony, p. 14.

28

Martin, 3/23/06 testimony, p. 27.

3

Stemple, 2/22/06 testimony, p. 13.

29

Martin, 3/23/06 testimony, p. 28.

4

Urosek, 5/3/06 public hearing, p. 571.

30

Klug, 3/26/06 testimony, p. 14.

5

Chewning, 3/28/06 testimony, pp. 17-18.

31

Klug, 3/26/06 testimony, p. 14.

6

Martin, 3/23/06 testimony, p. 23.

32

7

Martin, 3/23/06 testimony, p. 24.

8

Hixson, 3/27/06 testimony, p. 25.

9

Klug, 3/24/06 testimony, p. 12.

Bryant, 3/24/06 testimony, p. 20; federal and
state logs.
33

Hatfield, 5/2/06 public hearing, p. 224.

34

Hatfield, 5/2/06 public hearing, p. 224.

35

Bryant, 3/24/06 testimony, p. 21.

36

Bryant, 3/24/06 testimony, p. 22.

37

Bryant, 3/24/06 testimony, p. 22.

38

MSHA log 1/4/06.

39

Hatfield, 5/2/06 public hearing, p. 225.

40

Hatfield, 5/2/06 public hearing, p. 225.

41

Hatfield, 5/2/06 public hearing, p. 226.

42

Coleman, 2/21/06 testimony, p. 37.

43

Hatfield, 5/2/06 public hearing, p. 226.

44

Snavely, 5/2/06 public hearing, p. 229.

45

Martin, 3/23/06 testimony, p. 25.

46

Hixson, 3/27/06 testimony, p. 27.

47

Collins, 5/2/06 public hearing, pp. 160-161.

10

Tucker, 3/28/06 testimony, p. 12.

11

Klug, 3/24/06 testimony, p. 24.

12

Lilly, 3/23/06 testimony, p. 26.

13

Jolly, 3/26/06 testimony, p. 12.

14

Hixson, 3/27/06 testimony, p. 14.

15

Lilly, 3/23/06 testimony, p. 23.

16

Lilly, 3/23/06 testimony, p. 13.

17

Thomas, 3/27/06 testimony, p. 10.

18

Hixson, 3/27/06 testimony, p. 14.

19

Jolly, 3/26/06 testimony, p. 14.

20

Jolly, 3/26/06 testimony, p. 14.

21

Lilly, 3/23/06 testimony, p. 27.

22

White, 3/28/06 testimony, p. 13.

23

Thomas, 3/27/06 testimony, p. 12.

MSHA presentation to miners’ families,
Buckhannon WV 3/9/06.

24

Coleman, 2/21/06 testimony, p. 32.

49

25

Mine Safety and Health News, 4/3/06.

26

Mine Safety and Health News, 4/3/06.

48

Joseph W. Pavlovich, memorandum to Thomas
N. Bethell, 7/4/06.

50

82

Toler, 1/18/06 testimony, p. 15.

 8

What happened to the
three shots?

‘I figured that they would bring that machine down and would have found us,
would have drilled the hole in the right spot and would have took us out of
there. That’s what I expected. I was expecting to hear shots fired... on top,
above, and didn’t hear nothing. We banged and banged and banged, everyone
did.... but we never did know that I guess they... just didn’t have that machine
to do that task.’
— Randal McCloy, Jr.1

Approximately three and a half years prior to
the Sago Mine disaster, at about 8:45 p.m. on
July 24, 2002, miners working in the Quecreek
Mine, a small underground coal mine in
southwestern Pennsylvania, accidentally
broke through into an adjacent abandoned
mine. Torrents of water rapidly flooded the
Quecreek Mine, trapping nine miners. Three
days later they were all brought out alive,
after rescuers drilled 240 feet down to within
a few feet of the miners’ location and then
lifted them out of the mine, through the
enlarged borehole, in a rescue capsule. Because of nonstop television coverage, the
miraculous rescue was seen by millions of
Americans — including at least some of the
12 miners who became trapped in the Sago
Mine on January 2, 2006.2
Tragically, the Quecreek rescue may help
explain why there was such loss of life at
Sago. If the trapped Sago miners had known
that no one was going to save them in the
way the Quecreek miners were saved, would
they have abandoned their initial attempt to
break out of the Two Left section on their

mantrip, after encountering debris from the
explosion blocking the tracks? They were in
smoke, probably disoriented, and four of their
self-contained self-rescuers (SCSRs) would
not work for them. Randal McCloy, the sole
survivor of the crew, remembers their foreman, Martin Toler, Jr., saying, “We’re going to
have to hit the section”3 — head back toward
the face, where they could hang curtain as a
barricade and wait for the rescuers to listen
for them and then drill down to them.
If they had known that no one would be
listening, would they have scrapped that
plan? We cannot know. What we do know,
however, is that if they had been able to
remove the debris from the ventilation overcast which had fallen and was blocking the
tracks, the way out of the Two Left section
would have been reasonably clear. It is true
that without enough functioning SCSRs to go
around, they might not have been able to
remove the obstacles and then bull their way
out in their mantrip through the smoke and
carbon monoxide without some of them
losing consciousness along the way —
83

 but they might have tried, if they had not
thought, perhaps unconsciously, that a
Quecreek rescue scenario was possible.
But why shouldn’t they have thought such a
rescue was coming? No one had told them
not to. The miners on Two Left did exactly
what they had been told to do.
As every miner knows, miners are trained to
respond to a mine fire, explosion, or other
emergency by first trying to get out of the
mine. If that fails, they are supposed to
barricade themselves against smoke and toxic
carbon monoxide and await rescue. As we
know from the testimony of Randal McCloy,
the miners on Two Left went by the book.
Led by their foreman, who was driving their
mantrip, they first tried to escape, and when
they concluded that escape was not an option,
they retreated to the safest place on the
section — the face, as far removed as possible
from the source of the smoke and fumes —
to barricade themselves and await rescue.
The federal Mine Safety and Health Administration (MSHA) says it has distributed to
every miner in the United States a three-inchsquare adhesive sticker, to be placed inside
the miner’s hard hat. The instructions printed
on the sticker are very clear:
WHEN ESCAPE IS CUT OFF
1. BARRICADE
2. LISTEN for
3 shots, then …
3. SIGNAL by
pounding hard
10 times
4. REST 15 minutes,
then REPEAT signal until…
5. YOU HEAR 5 shots, which
means you are located
and help is on the way.

The trapped Sago miners tried to follow the
rules. Hearing nothing from the surface —
no three shots — they used a sledgehammer
to begin banging on a roof bolt, pounding
hard as instructed, then resting for awhile
before pounding again. It was exhausting
work. They had to take their SCSRs out of
their mouths in order to get enough air to
keep pounding4 — but that also meant they
were breathing carbon monoxide. Even so,
for a long time they took turns pounding. But
they never heard anything from the surface,
let alone the five shots that were supposed to
tell them that help was on the way.
Meanwhile, on the surface, representatives of
International Coal Group were periodically
briefing the miners’ families on the status of
the rescue operation. West Virginia State
Delegate Bill Hamilton of Buckhannon,
whose district includes the Sago Mine and
who was a friend of one of the missing miners
— Junior Hamner — was present for some of
ICG’s briefings. At the close of the public
hearing on the disaster, he recalled that at one
of the briefings “the question was asked,
‘Have you heard the miners pounding on
anything?’ The answer, ‘No.’ The second
question, from the same miner’s family, was,
‘Are you listening for sounds from the miners?’ Question answered, ‘Yes.’ But in testimony… we know that wasn’t true. They
weren’t listening.”5
Nobody was listening. The explanation offered
after the fact was that there was no need to
listen, because the command center had a
good idea of where the miners were. That is
true up to a point, but only up to a point. It
was likely that the trapped miners were
somewhere on the Two Left section. But the
section consists of multiple entries and is

84

 more than half a mile in length from mouth to
face. At the outset of the rescue effort it was
not known that they were barricaded at the
face. All that was known was that they were
not within shouting distance of where mine
superintendent Jeff Toler and other miners
had hollered for them from the mouth of the
section before being forced to abandon the
first rescue attempt in the early morning
hours of January 2. As the command center
discovered many hours later — only after
learning that the seals closing off the abandoned area of the mine had been pulverized
— there was also a possibility that the Two
Left miners, while trying to escape, might
have lost their way and ended up wandering
into the no-longer-sealed section, possibly
barricading themselves a mile or more from
the face of Two Left.
In other words, it would seem to have been a
good idea to rush some seismic gear to Sago,
set off the promised three shots, and listen for
the miners. But MSHA’s mobile Seismic
Location System never left its base near
Pittsburgh. Why?
In print and on its website, MSHA describes
its system in these words: “The seismic
location system is truck-mounted and is
capable of detecting and locating the source of
seismic vibrations produced by trapped
miners. Miners may generate seismic signals
by pounding on mine surfaces such as the
roof, floor, or ribs. These signals are detected
by sensors installed either on the surface or
underground. The system is capable of
detecting signals at a range of 1,500 feet, and
can monitor approximately one square mile
over most mines (depending upon terrain).
Helmet stickers describing how to signal have
been distributed to all miners in the United

States. The system is highly mobile, and can
be airlifted.”6
This description is inaccurate. In reality, as
MSHA personnel know, the seismic system
is old, outmoded, cumbersome and timeconsuming to deploy, and it could not have
been operational at Sago in time to be of any
help to the trapped miners.7
Ty Coleman, the man in charge of the rescue
operation for ICG, testified that he requested
MSHA’s seismic equipment at about 10:30
a.m. on January 2, four hours after the explosion, and was assured by MSHA officials that
“We’ve got the package coming to you,” as he
recalled the conversation.8 If so, they
misspoke. The system stayed where it was.
And the tragic fact is that there were good
reasons for leaving it there.
As MSHA officials know, setting up the
system at Sago would have required extensive surveying above the mine, the construction of a road capable both of accommodating
the seismic truck and allowing it to move
freely from location to location above the
mine, the determination of precise coordinates in order to site the truck, and then the
firing of shots and — if no response was
heard — the relocation of the truck to another
site preparatory to firing off more shots.
The total elapsed time — from turning the
key in the ignition of MSHA’s parked 1970sera truck until the first shots were fired —
could easily have exceeded 15 hours.9 Even if
the truck had left Pittsburgh at, say, 10:30 a.m.
on January 2, when Coleman says he was told
it was on its way — and even if construction
of a road above the mine had started simultaneously — the system probably would not

85

 have been able to be operational until well
after midnight, long after many if not most of
them had lost consciousness because of
carbon monoxide asphyxiation. By that time
they were far past the point of being able to
respond to three shots, let alone listen for the
five that would tell them that the promised
help was on the way.
Much later — in fact not until more than a
month after the May 2-4 public hearing on the
Sago Mine disaster — MSHA acknowledged
that, contrary to the upbeat information about
its seismic system posted on the agency’s
website, “MSHA’s experience has shown
[that] application of the seismic technology is
very limited.”10 That is an understatement. In
fact, the system has been deployed only twice
during the past 20-plus years, and it did not
succeed in locating trapped miners on either
occasion.11 Although the system was transported to the Quecreek mine rescue site, it
was not used even there, because other
surveying and drilling strategies proved to be
faster and more accurate and efficient.
In any case, the miraculous Quecreek rescue
was made possible by a highly atypical
situation. The Quecreek miners, although
trapped, were not breathing carbon monoxide, because they had been trapped by a
flood, not by an explosion or fire. They did
not run out of respirable air while they waited
for three long days to be lifted out of the
mine. In the end they were saved by a good
job of figuring out where they were and then
pinpointing the location of a borehole, but
that work took a long time. The Sago miners
did not have the luxury of time.
MSHA’s seismic system, developed nearly
four decades ago, has been made obsolescent

both by its inherent limitations and by the
development of superior technologies. At
Sago, for example, ICG arranged for the
drilling of a borehole directly over the Two
Left section using survey-grade Global
Positioning System (GPS) instruments keyed
to precise mine maps, with the entire process
guided by cellphone by an engineering
consultant who was in Atlanta at the time. A
bulldozer built a road for a locally based drill
while surveyors using wireless laptop computers in their pickup trucks determined the
drilling coordinates. Nobody had to drive an
old rig from Pittsburgh to Upshur County.
Even so, the process of getting the borehole
drilled into the section was delayed by bad
weather — making it difficult for the surveyors’ computers to pick up signals from multiple earth-orbiting satellites, as GPS surveying requires — and the task needed nearly a
full day to complete. That was record time,
compared to the more than two days normally required to survey and site a borehole,
but it was still much more time than the Two
Left miners had to spare. Moreover, difficult
terrain prevented the surveyors from siting
the drill so that it would penetrate close to the
face of the section, where the trapped miners
(if they had still been conscious and alert)
might have heard or seen it.12 Instead, the
drill penetrated the mine with precision —
punching into the middle of an entry rather
than drilling into a solid block of coal as
would have happened if the coordinates had
been off by even a few feet — but it penetrated about 300 feet from where the miners
were barricaded.
During the May 2-4, 2006, public hearing on
the Sago Mine disaster, coal miner John
Helms, who lost his brother Terry in the

86

 disaster, questioned Kevin Stricklin, manager
of MSHA’s District 3, about the cap stickers
MSHA distributes to all miners. “I’ve worked
in the coal mines for 37 years,” Mr. Helms
said, “and got these little stickers where it
said to barricade, beat on the roof, help will
come. I better throw them away — hadn’t
we? We better come up with some other
plan.”
“I think we need to re-evaluate that, yes, sir,”
Mr. Stricklin said.13
That was an honest answer. We do need to rethink the training given to miners in light of
the time likely to be involved in a mine rescue
operation, even one that is conducted more
aggressively and at greater risk to the rescuers
than was the case at Sago. Perhaps even more
importantly, we need to use the no-show
failure of MSHA’s seismic system to prod us
into some fresh thinking about better ways to
protect miners against a recurrence of what
happened to the waiting Two Left crew.
First and foremost in importance, of course, is
prevention — starting with taking the necessary steps to systematically assess risks and
minimize the chances that an explosion will
occur in the first place. If an area is to be
sealed, the supposedly “explosion-proof”
materials used to seal it must in fact be able to
contain an explosion. It is equally urgent to
ensure that miners will not be failed by the
safety equipment that they carry or otherwise
depend upon. That means, among other
things, equipping them with ample quantities
of SCSRs that work, and equipping mines
with robust two-way communication systems
capable of surviving explosions and fires. As
discussed elsewhere in this report — and as
recognized by new state and federal legisla-

tion — there is no good reason to delay any
longer in getting such technology into the
mines of West Virginia and the rest of the
nation.
That leaves the question of whether to invest
time and money in a next-generation seismic
system with greater capabilities than the one
that failed the Sago miners. It is a difficult
question. We must always keep in mind that
time is the enemy when miners are trapped
and barricaded, and the time likely to be
required to transport any MSHA-style centralized seismic system from a remote location, even in-state, argues against relying
heavily on such a system. (In fact, based on
the evidence, our view is that the present
MSHA system should be mothballed. Inquiries made in the course of our investigation
indicate that similar seismic technology has
not been successfully deployed in South
Africa, Australia, or Canada, reinforcing our
belief that MSHA’s system is unlikely ever to
prove of value except, perhaps, in specific
situations not yet identified.)
On the other hand, researchers should be
encouraged to develop a totally different kind
of seismic system capable of much more rapid
deployment — such as a coiled-cable sensor
system that could be laid out on the surface of
a mine to detect vibrations from someone
pounding underground. Equipment could be
kept in each MSHA district (or, depending on
price, required at every mine) and deployed
quickly. Unless trapped miners can reach a
refuge (discussed below and elsewhere in this
report), pounding is all they can do — and
there seems little doubt that a command
center, hearing proof that trapped miners are
alive, would be more likely to let rescue teams
take some risks to reach them.

87

 Unless better seismic technology becomes
available, an alternative is to take maximum
advantage of 21st-century mine surveying
techniques. Given current GPS capabilities,
for example, mine engineers know, as a mine
advances, exactly what the surface coordinates are for the working sections underground. In an emergency, surveyors need
only to be able to pick up geosynchronous
signals from multiple satellites to be able to
pinpoint the coordinates on the surface where
a borehole should be drilled.
That solves only part of the elapsed-time
problem, however, since a road would still
have to be built to the site and a pad constructed to facilitate drilling. (Because of the
need to construct a pad, airlifting drills by
helicopter has limited applicability.) Therefore, even under the best circumstances,
rescuing miners by borehole, as at Quecreek,
should be thought of as a relatively remote
possibility, not a promise.
This reinforces the case for requiring emergency refuges in mines as the primary alternative to escape — which should always be
the first choice. Suppose, for example, that a
refuge chamber had been available on the
Two Left section — an explosion-hardened
shelter with an air supply, water, rations, and
communication to the surface. Or suppose,
even, that such a shelter had been located at
some distance, such as off of the main entries,
equidistant between the One Left and Two
Left sections.
With either of these scenarios, it is possible to
imagine the miners of the Two Left crew
emerging alive after even two or more days of
awaiting rescue. Even in the second scenario,
knowing what we know of their failed at-

tempt to break out of the section on their
mantrip, it is at least possible to imagine that
they would have struggled to remove the
debris blocking the track, knowing that they
did not have far to go to reach the safety of
the refuge chamber.
Instead, they had no idea what they were
facing — and with no way of communicating
to the surface, they could not find out. For all
they knew, the explosion might have contaminated the emergency escapeways all the way
to the portal, more than two miles from where
they were. There was no way they would all
have made it that far on foot, especially with
four apparently nonfunctional SCSRs. So their
choice was to risk losing some of the crew on
the way out or to stick together and make for
the section, as Junior Toler suggested. They
stayed together.
Randal McCloy honored the memory of his
foreman in these words: “He was, like,
leading everything. He’s not the type of guy
who’s pushy about anything, but he was
concerned for everybody. He wanted to do
the right thing. He didn’t want to, like, get us
stuck out in the woods with no rations,
something like that.”14
Junior Toler did the right thing — but he and
his crew were failed by a mine rescue system
that made promises it did not keep.
Above the mine, on the surface, a winding
road runs directly over the Two Left section,
at about its midpoint. If you park a truck
there, get out, and walk cross-country in a
westerly direction for a few hundred yards,
you will be standing approximately above the
face of the section, where Junior Toler and the
Two Left crew waited for some sign of rescue.

88

 Sago Mine, January 2, 2006
Old Two Left
sealed area

EXPLOSION
ORIGIN (approx)
▲
Road

Tw

O

ne

Le

o

Le

ft

ft

▲

Omega Seals

Portal

It is uneven terrain, and on January 2 it would
have been slick with rain. But a surveyor or
mine engineer could have walked the terrain,
accompanying someone equipped with
explosives. There are a lot of people in West
Virginia — miners, construction workers,
highway engineers — who know how to use
explosives. If anyone in the command center
had directed that three shots be set off above
Two Left to let the miners know that help was
coming, it could have been done.
But it was not done. And it is just not sufficient to say that the command center did not
need to set off shots because the probable
location of the miners was known, or to argue

that setting off three shots would have served
no purpose since there was no system in place
to listen for the miners’ response. That misses
the point.
Someone in the command center must have
known that the miners, if alive, would do
what they had been trained to do — and what
all those cap stickers told them to do. But no
one in the command center seems to have
thought that it would be important to let
them know that help was on the way.
If the command center had a good idea where
the miners were, five shots could have been
fired at the surface within, say, half an hour
89

 after firing off the first three shots. The five
shots would have told the miners they could
stop pounding, preserve energy, and possibly
prolong life by breathing as slowly and lightly
as possible. But no such message was sent
to them.
Is this just a case of 20-20 hindsight, made
possible only by Randal McCloy’s survival
and his subsequent revelations about what
his crew did while awaiting rescue? No.
Those in the command center should have
been thinking about all the what-ifs. They did
not. They failed in this regard, not because
they are uncaring people — we do not believe
that — but because they are part of an outmoded and inadequate mine emergency
management system that is in desperate need

of an overhaul. The system has grown stale
with disuse (and with the departure, partly
through retirement, of some experienced
mine emergency managers). Its immediate
needs include greatly improved training
requirements and rigorous emergencysimulation drills covering, among other
things, how to communicate with trapped
miners until the day comes when they can be
reliably contacted by explosion-resistant twoway wireless communication systems.
The Sago tragedy leaves no doubt that the
mine emergency management system must
change, and fast. If another Sago disaster
were to occur tomorrow, would the outcome
be any different?
Right now, no one can be sure.

SOURCES
Randal McCloy, Jr., 6/19/06 interview with federal and state investigators, transcript, pp. 63-65.

1

Del. William Hamilton, closing statement, May 2-4, 2006, public hearing, transcript, p. 1237.

2

Randal McCloy, Jr., 6/19/06 interview with federal and state investigators, transcript, p. 21.

3

Randal McCloy, Jr., “To the families and loved ones of my co-workers, victims of the Sago Mine
disaster,” 4/26/06 statement, p. 2.
4

Del. William Hamilton, closing statement, May 2-4, 2006, public hearing, transcript, p. 1237.

5

Jeffrey H. Kravitz and Robert G. Peluso, “The Mine Emergency Capabilities of the Mine Safety and
Health Administration,” undated, p. 5.
6

See, for example, the testimony of Kevin Stricklin and John Urosek at the May 2-4, 2006, public
hearing, transcript, p. 599 (Stricklin) and p. 637 (Urosek).
7

90

 Harrison Tyrone Coleman, May 2-4, 2006, public hearing, transcript, p. 456.

8

J. B. Crawford, Letter to J. Davitt McAteer, re: Sago Mine Disaster Public Hearing, Additional MSHA
Information and Documents, June 22, 2006.
9

J. B. Crawford, Letter to J. Davitt McAteer, re: Sago Mine Disaster Public Hearing, Additional MSHA
Information and Documents, June 22, 2006.
10

J. B. Crawford, Letter to J. Davitt McAteer, re: Sago Mine Disaster Public Hearing, Additional MSHA
Information and Documents, June 22, 2006.
11

Gary Hartsog, 3/28/06 testimony, p. 35.

12

May 2-4, 2006, public hearing, transcript, p. 602.

13

Randal McCloy, Jr., 6/19/06 interview with federal and state investigators, transcript, p. 86.

14

91

 APPENDIX I: Synopsis of State of West Virginia
and federal activities following
the Sago Mine disaster
1/4/06

Federal Mine Safety and Health Administration (MSHA) announces its staff to investigate the Sago Mine Disaster.
1/9/06

MSHA announces it will conduct its investigation jointly with the West Virginia Office of
Miners’ Health, Safety and Training
(WVOMHST)

disaster and its pre-accident enforcement at
the mine.
1/19/06

Mine fire at Massey Energy’s Aracoma Alma
No.1 mine kills two: Donald Bragg and Ellery
Hatfield.
1/20/06

U.S. Senators Rockefeller, Kennedy, Enzi, and
Isakson meet with Sago families.

1/9/06

Governor Joe Manchin III appoints J. Davitt
McAteer as his special advisor on the Sago
Mine disaster and promises a public hearing.

1/21/06

1/11/06

1/23/06

McAteer briefs U.S. Senator Robert C. Byrd
on the disaster.

West Virginia Legislature passes mine safety
bill SB-247.

1/12/06

1/23/06

Governor Manchin announces Senators
Caruth, Kessler, Love and Delegates Caputo,
Frederick and Hamilton will serve on the
state’s investigation team to work in
conjunction with McAteer’s efforts.

U.S. Senate Appropriations Committee,
Subcommittee on Labor, Health, and Human
Services, chaired by Senator Arlen Specter
holds hearing on Sago disaster, with Senator
Robert C. Byrd leading the questioning.

1/15/06

1/24/06

Memorial service held for the Sago miners at
West Virginia Wesleyan College.

MSHA seeks federal court order to grant
United Mine Workers of America (UMWA)
access to the investigation.

Investigators enter the Sago Mine to begin
collecting physical evidence.

1/17/06

MSHA and WVOMHST begin voluntary
interviews of witnesses.
1/18/06

MSHA appoints staff to conduct an internal
review of the agency’s response to the Sago

1/25/06

MSHA publishes in the
Federal Register a Request for Information on
emergency equipment and technology (e.g.,
communication, robotics, refuge chambers.)

92

 1/25/06

2/8/06

MSHA announces investigation team for fatal
Aracoma Alma fire.

Governor Manchin announces an International Symposium on Mine Safety and Health
at Wheeling Jesuit University in April.

1/26/06

Federal judge grants MSHA’s request for an
injunction against ICG to allow the UMWA to
participate in the Sago investigation.

2/9/06

1/30/06

2/10/06

Esterhazy, Saskatchewan: 72 trapped Canadian potash miners survive 40 hours underground in a refuge chamber.

WVOMHST asks the National Institute of
Occupational Safety & Health (NIOSH) to
conduct explosion testing on Omega blocks.

1/31/06

2/11/06

Richard Stickler, President Bush’s nominee for
Assistant Secretary of Labor for Mine Safety
and Health, testifies at his Senate confirmation hearing.

MSHA reports it has received about 50
proposals from manufacturers of underground communication and tracking devices;
Consol Energy and Peabody Energy agree to
assist in evaluating the devices.

Governor Manchin appoints Jim Dean as
acting director of WVOMHST.

2/1/06

Governor Manchin asks the state’s coal mines
to temporarily cease operations until emergency safety reviews are conducted, following three separate mining accidents, in which
two miners were killed and another seriously
injured.

2/13/06

Congressman George Miller (D-CA) holds a
forum on mine safety, taking testimony from
family members of miners killed in the 2001
Brookwood and 2006 Sago mine disasters.
2/15/06

2/1/06

Senators Byrd and Rockefeller and Representatives Rahall, Mollohan, and Capito introduce bills in their respective chambers of
Congress to enhance coal mine safety.

MSHA announces plans to increase penalties;
action is subject to formal rulemaking.
2/21/06

An explosion at a coal mine near San Juan de
Sabinas, Mexico traps 65 miners.

2/6/06

MSHA requests mine operators to “Stand
Down for Safety.”

2/24/06

MSHA and WVOMHST conclude initial
interviews with witnesses.

2/7/06

Doug Conaway resigns as director of
WVOMHST.

2/27/06

WVOMHST files with the Secretary of State
its emergency rule on SCSRs, communication
and other mine safety improvements.
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 2/28/06

3/14/06

Governor Manchin appoints a six-person
labor-management task force to assess availability of communication systems and other
technologies contained in new WVOMHST
rule.

ICG meets with family members of the
deceased Sago miners and provides findings
of its on-site investigation, including the
company’s conclusion that “the explosion
was ignited by lightning.”

3/1/06

3/15/06

House Committee on Education and the
Workforce, Subcommittee on Workforce
Protections, chaired by Charles Norwood (RGA), conducts hearing on mine safety.

Sago Mine resumes production.

3/1/06

Governor Manchin announces that McAteer
will chair a public hearing on the Sago disaster (originally scheduled for mid-March) at
West Virginia Wesleyan College on May 2.

3/23/06

MSHA and WVOMHST resume interviews
for the Sago investigation, expanding their
inquiry to include the mine rescue effort.
3/27/06

NIOSH begins external and internal examination of SCSRs recovered from the Sago mine.

3/2/06

3/30/06

Senate Committee on Health, Labor and
Pensions, chaired by Senator Michael Enzi (RWY), holds an oversight hearing on mine
safety.

Randal McCloy, Jr. is released from the
hospital and continues his rehabilitation at
home.
4/11/06

3/8/06

U.S. Senate Committee on Health, Labor and
Pensions approves Richard Sticker’s nomination to be MSHA’s Assistant Secretary.

Family members receive transcripts of witness interviews conducted by MSHA and
WVOMHST.
4/15/06

3/9/06

MSHA publishes an emergency temporary
rule in the Federal Register on mine evacuation
procedures and equipment; provisions are
similar to the rules issued earlier by
WVOMHST.

NIOSH conducts the first in a series of explosion test of Omega block seals in its Lake
Lynn Experimental Mine.
4/18/06

NIOSH and MSHA host a workshop on mine
escape planning and emergency shelters.

3/13/06

MSHA holds a public meeting to receive
information on communication and tracking
technology, related to its January 25 request
for information.

4/20/06

Governor Manchin convenes the first International Symposium on Mining Health and
Safety at Wheeling Jesuit University.

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 4/21/06

5/29/06

MSHA approves two handheld portable
radios for use in underground mines, the first
such devices approved by the agency in 10
years.

West Virginia Mine Safety Technology Task
Force issues its report and recommendations.

4/24/06

MSHA begins public hearings on its emergency temporary standard on mine evacuation procedures and equipment.
4/26/06

Randal McCloy, Jr. gives the Sago families a
confidential letter describing his and his coworkers’ experience while awaiting rescue.
5/2/06

Public hearing on the Sago mine disaster
convenes at West Virginia Wesleyan College
in Buckhannon, WV; provides 3 days of
inquiry from family members, state and
federal officials and miners’ representatives.

6/8/06

MSHA provides an update on its testing and
evaluation of communication and locating
devices for underground miners.
6/9/06

WVOMHST files its emergency rule implementing recommendations of the Mine Safety
Technology Task Force.
6/13/06

West Virginia adopts rule to establish two
state-run mine rescue teams; takes effect July
13, 2006.
6/15/06

President Bush signs Mine Improvement and
New Emergency Response (MINER) Act into
law.

5/5/06

West Virginia Board of Coal Mine Health and
Safety files rule to establish two state-run
mine rescue teams.

6/15/06

NIOSH conducts the second in a series of
tests of Omega block seals in its Lake Lynn
Experimental Mine.

5/12/06

WVOMHST imposes a statewide moratorium
on the installation of Omega block seals and
begins a review of all alternative seals already
in place.

6/19/06

MSHA, WVOMHST and McAteer interview
Randal McCloy, Jr.
6/29/06

5/22/06

MSHA announces a moratorium on alternative seals, a reassessment of the structural
integrity of existing alternative seals, and
requirements to test the atmosphere behind
seals.

Comment period ends on MSHA’s emergency temporary standard on mine evacuation procedures and equipment.
7/10/06

WVOMHST announces statewide SCSR
inventorying and reporting system, effective
August 15, 2006.

95

 Acknowledgements
First, I wish to express my appreciate to our investigative team — Celeste Monforton,
Thomas N. Bethell, Joseph W. Pavlovich, Deborah Carpenter Roberts, Beth Spence,
and Dave Stuart — for their work in preparing this report. Special thanks also to
Patrick McGinley, Professor, West Virginia University School of Law; Suzanne Weise,
Esquire, and Jesse J. Wagner, Sr. whose detailed models of the Sago Mine have been
of immeasurable value in helping everyone involved with this investigation to visualize
the mine environment.
Special thanks to Wheeling Jesuit University and its President, Reverend Joseph R.
Hacala, S.J. Without his understanding, support and compassion, this report would not
have been possible. We offer sincere appreciation also to West Virginia Wesleyan
College for their professionalism and endless hospitality throughout our inquiry.
As I noted in the transmittal letter on the opening pages of this report, we owe a deep
debt of gratitude to the families of the victims of the Sago Mine disaster. They are a
constant and continuing source of inspiration and motivation to press for changes in
mine safety and the mining industry in the hope that other families will not have to
suffer as they are suffering. We also express our thanks to Randal McCloy, Jr., the sole
survivor of the Two Left crew, whose recollection of what he and his fellow miners
experienced has been of great value to our investigation.
We thank the students of Wheeling Jesuit University, West Virginia Wesleyan College,
West Virginia University, University of Charleston and Marshall University, who volunteered immediately following the disaster and in the months which followed. It makes
me proud as a West Virginian that these young people stepped up to help.
We want to express our gratitude to the many individuals — whether in state and
federal agencies, companies, professional or private life — whom we have called upon
for advice, guidance and expertise in the preparation of this report. And we are grateful to the hundreds of individuals who have contacted us with ideas and suggestions
about how to improve mine safety and health in West Virginia and across the nation.
This investigation has been supported by the State of West Virginia and its Governor,
Joe Manchin, III. We thank Governor Manchin and his staff for their support and
assistance during this investigation and preparation of the report.
The list of names that follows encompasses, we hope, most of those who have been
involved in one way or another with our work over the past six months. Inevitably,
however, there are bound to be omissions. We apologize for that, and hope that
anyone whose name should have appeared here will be brought to our attention
for future correction.
J. Davitt McAteer

96

 Aimee Adams • Lynda Anderson and family • Jonathan Andrew • Kent Armstrong • Pamela
Jubin Balch • Simon Barber • Richard D. Begley • Judy Bennett, Russell Bennett and family
• Jason S. Bentley • Jamie Berg • Jodi Besenyei • Jacek Bielawa • Phil Bounds •
Wojciech Bradecki • LeeAnn F. Brown • Melissa A. Brown • Tony Bumbico • U.S. Senator
Robert C. Byrd • Brent Bodine • Premier Lorne Calvert • Pam Campbell • U.S.
Congresswoman Shelley Moore Capito • State Delegate Mike Caputo • State Senator Don
Caruth • Mary Ellen Cassidy • Elizabeth Chamberlin • Skye M. Chernicky • Gene Cilento •
Kevin Cimino • Peggy and Aaron Cohen • Robert Cohen, MD • Doug Conaway • Kimberly
A. Cottrell • Tammy Crites • Sean Daniel • Taylor A. Daugherty • James Dean • Christo
de Klerk • Mary Doane • Jerry Donahue • Earl Dotter • Carol and Doug Duffield • Robert
Edge • Chuck Edwards • Miranda Elkins • Susan Elliott • Yvonne Farley • Alan Fine •
Mike Foletti • Brian France • State Delegate Eustace Frederick • Bruce G. Freedman, MD •
Jimmy Joe Gianto • Richard T. Gillespie • Bobby Godsel • Michael Griffin • Cara J. Group •
Wanda Groves and family • Father Joseph R. Hacala, SJ • State Delegate Bill Hamilton •
Professor Vivian Hamilton • Debbie Hamner and family • Larry Harrah • Bennett K. Hatfield
• William R. Hayden • Monte Hieb • Amber Helms and the Helms family • Jerry Henderson
• F.W. Hermann • Justin Hershberger • David Hinkins • Brenda Hissam • Jessica L. Holley
• Tad Hudkins • Craig Hyre • Justin Jack • Darwin F. Johnson • Yvonne Johnson •
Shenna L. Johnston • Lula Bell Jones and family • Jarrod Jordan • State Senator Jeff
Kessler • State House Speaker Bob Kiss • Sam Kitts • Jill Kriesky • Kimberly N. Leezer •
Samantha Lewis • Pete Lilly • Alisa Lively • Tricia Lollini • Kathleen M. Long • Kathryn G.
Lough • State Senator Shirley Love • Bernard Lown, MD • Joseph P. McAteer • Timothy O.
McAteer • Randal and Anna McCloy • Professor Joyce McConnell • Pastor Ed McDaniels •
Professor Marjorie McDiarmid • Professor Pat McGinley • Darrell V. McGraw, Jr. • Andrew
Meek • Ann and Dan Merideth and family • David Michaels • Mine Safety and Health
Administration • U.S. Congressman Alan B. Mollohan • Virginia Moore • Keith Moran •
Thomas E. Moran • Christina Morgan • Zachery M. Morton • Paul Myles • Kraig R. Naasz •
National Institute for Occupational Safety and Health • National Mining Association • Blaire
Nuzum • James O’Dell • Thomas J. O’Neill • Carolyn Ostand, RN • Brenda Pinnell

•

Jennifer Powell • Andrea Pyles • U.S. Congressman Nick J. Rahall, II • Bill Raney • Paul
and Cindy Rank • Katy Ratai • James Rau • Lawrence H. Roberts, MD • U.S. Senator John
“Jay” Rockefeller • Joseph R. Romano • Shelly and Mike Rose • Chad Rosepappa • Neil
Roth • Robert O Rupp • Allison E. Sharpe • Elizabeth H. Short • Bob Skinner • Malcolm
Smith • Mayor Nicholas Sparachane • Catherine E. Squires • Duwane Squires • Ben Stout
• David Stuart • Catherine E. Swigert • Tony Szwilski • Ryan A. Thorn • Mary Lou Toler
and family • Senate President Earl Ray Tomblin • U.S. Department of Labor • United Mine
Workers of America • Kyla R. Vala • Jesse J. Wagner, Sr. • Charlotte Weaver and family •
Charlotte Weber • Suzanne Weise • Dusty Williams • Frank Williams, Jr. • Kimberly N.
Williams • Ann Wilson • Pam Winans and family • Tom Wingler • WV Office of Miners
Health Safety and Training • WV Board of Coal Mine Health & Safety • WV Coal Association •
WV Department of Homeland Security • Wheeling Jesuit University Board of Directors • Evan
M. Wolfe • Kevin G. Younkin • Gary Zamel • Paul Ziemkiewicz

97