NTTC Logo - Return to homepage 


Governor Earl Ray Tomblin
State of West Virginia
1900 Kanawha Boulevard East
Charleston, West Virginia 25305

Dear Governor Tomblin:

It is with sadness and honor that I submit this report of the Upper Big Branch mine disaster to you. Sadness because events occurred which made this investigation necessary; honor because the loss of these lives compel us to make these losses meaningful by improving mine safety.

On April 13, 2010, I was asked by then Governor Manchin to conduct an independent investigation of the Upper Big Branch Mine disaster where 29 miners were killed.

As part of that effort, I and seven associates formed the Independent Investigation Panel (GIIP) which undertook an analysis of the events leading up to the disaster, the disaster itself, as well as, its aftermath.

We have attempted, through impartial analysis, to determine not only the causes of the disaster, but also to learn how to prevent further such events from occurring and to develop reforms to make mining safer.

We have followed the facts to wherever they have led; have attempted to learn the essential causes of the explosion and also have examined the existing regulatory system to determine how this could have happened; and finally how government and industry responded to this emergency.

Here, as so often before, the mine rescue volunteers proved heroic in their willingness to quickly assemble and attempt to rescue – then recover – the trapped miners. The team members all receive our praise and profound thanks. They truly are the “Minute Men” of American industry.

Further, we wish to thank the many Upper Big Branch miners and supervisors who gave candid and honest testimony. Their concern with finding the facts in order to prevent other similar disasters speaks volumes about their regard for the victims and their families and is in sharp contrast to others who declined to testify.

Sadly, despite all efforts, 29 miners died and one was severely injured. Their families have an immeasurable burden to carry the rest of their lives. To each of them we offer our sympathy, condolence and prayers knowing of its inadequacy, but offering this undertaking in an effort to make improvements which will protect the men and women who are at work today.

During the course of this investigation, I was asked by a sister of one of the victims “Please, just tell us what happened.” We have endeavored to do just that. We have also attempted to learn why it happened and explain to the families, friends and general public what went wrong.

Our investigation, while thorough, could not be exhaustive. There are still questions which remain, in part, because the force of the explosion destroyed much evidence. Regrettably, some may never be answered. More than a year has passed since the disaster, and we believe it best to submit now to you what we’ve learned and offer concrete suggestions on how to prevent other disasters, rather than extend our inquiry indefinitely.

The findings and recommendations offered here are in a constructive spirit of transforming the U.S. mining industry into a global leader for safe and healthy mining, today and tomorrow.

Our recommendations are of no value unless adopted by industry and governments for it is only then that miners will have a better chance to return home safe and sound to their families each day.

Our nation’s reliance on coal is likely to continue for sometime – all of us reap the benefits that result from the efforts of men and women working in coal mines. We owe it to them to ensure a safe and healthful work place; we as a nation and the mining industry have shown that we know how to mine safely. We are obliged to do that.

The efforts of my associates, Beth Spence, Jim Beck, Celeste Monforton, Debbie Roberts, Katie Beall, Pat McGinley and Suzanne Weise, have been truly remarkable. For more than a year, this group has attended interviews, conducted a full underground investigation, reviewed thousands of documents, transcripts, data, information and correspondence. They have worked tirelessly to determine the cause of the explosion and how to prevent it from happening again.

Following such a disaster, there is but one choice: to promptly and thoroughly investigate and to set out a course of action which will ensure, as far as is humanly possible, that the lives of the 29 men were not lost in vain.

J. Davitt McAteer
Shepherdstown, West Virginia
May 2011

Back to Table of Conents