MSHA has released the results of the agency's actions prior to the April 5, 2010, explosion that killed 29 miners at the Upper Big Branch Mine. The team, made up of MSHA employees outside UBB’s district (District 4) focused on the agency’s enforcement and plan approval activities, as well as the effectiveness of MSHA standards, regulations, policies and procedures. "While there was no evidence linking the actions of MSHA employees to this tragedy, we found instances where enforcement efforts at UBB were compromised because MSHA and District 4 did not follow established agency policies and procedures," says internal review team leader George Fesak. Shortcomings in the inspection and plan approval process include insufficient training, inadequate managerial oversight and deficiencies in the directives system, which disseminates written policies and procedures. In addition, inspectors did not consistently identify flaws in the mine operator's program for cleaning up loose coal and float coal dust, nor did they use the operator examination book’s records effectively when determining the operator's negligence. Inspectors also did not identify the extent of noncompliance with rock dust standards along belt conveyors or identify deficiencies in the roof control panels. District 4 personnel did not intervene because the then-owner, Massey Energy, manipulated procedures to avoid complying with reduced standards for respirable coal mine dust and allowed the operator to significantly delay corrective action to reduce miners' exposures to unhealthy respirable dust concentrations after overexposures were identified. "MSHA is responsible for its actions and will address each of the problems the team has specifically identified," says Joseph A. Main, MSHA’s assistant secretary of labor. Corrective actions such as impact investigations, mandatory training and upgraded computer systems have been in place since April 2010. To view the entire report, click here.