Sago Death Toll Rises to 14

This headline is not an attempt to be clever. The story is heartbreaking.

Ken Ward of the Charleston Gazette reports:

Two key figures in January’s disaster at the Sago Mine in Upshur County have taken their own lives in the last three weeks, police and other officials have confirmed.

Their deaths have family and friends of surviving Sago miners and mine rescuers — along with mine safety advocates — concerned about the emotional toll of the Jan. 2 mine tragedy....

Mine dispatcher William Chisolm and John Nelson Boni, a fireboss, shot themselves in separate incidents, authorities said.

Chisolm, 47, of Belington, died on Aug. 29, and Boni, 63, of Volga, died Saturday evening.

Chisolm was the dispatcher on duty the morning of the explosion and Boni had discovered a buildup of methane five days earlier in the sealed part of the mine where the blast occurred.

Assuming these miners suffered from depression in the wake of the accident, and depression led to their deaths, then they also were casualties of the explosion.

It is not the first time something like this has happened in a protracted mine accident investigation. Efforts to catch warning signs and prevent future tragedies of the same kind deserve serious attention.

Looking At Old Practices With A Fresh Eye

Two professors and 21 students at West Virginia Wesleyan University recently conducted an exercise in “content analysis” on 10 years’ worth of MSHA fatal accident investigation reports.

Content analysis is a method of looking closely at the vocabulary, concepts, specific facts and world view in a body of writing. It uses a coding system and computers. Content analysis – in its more precise way -- can get at some of the same issues as good old-fashioned “critical thinking.” Marketers, political analysts and historians, among others, have found it useful.

The West Virginia Wesleyan group came to its task with no special expertise in mining, but willing to spend time and develop their understanding. Their thoughts deserve consideration.

Some of the group’s ideas have been raised before in the mining industry. In other cases, their fresh eye may have given them an advantage. It must be said that on a few points, their conclusions went beyond their evidence. That, however, does not invalidate all that they have to say.

“The accident reports do not have a consistent format nor do they contain consistent information,” the group reported. MSHA might respond that the format was evolving but is now consistent, which would be true of the overall outline. But lack of consistency in specific information is glaring to anyone who regularly uses these documents.

One small example: most reports mention the victims’ training, at a minimum to say if it met federal requirements. Yet the report on a roof bolter’s death at the Long Branch Energy #18 Tunnel mine this February (as covered in this issue) was silent on the subject. Did the investigators obtain this information? If not, why not? Did they omit the information as unimportant? Or could there have been another reason to withhold it? Did MSHA do its investigative job thoroughly? The reader can’t tell. And anyone trying to study training in relation to fatalities is doomed to frustration.

The group recommends a “template” to ensure consistent information. This excellent idea might best be carried out by a standard form in an appendix to the report. Narrative sections could cover what is essential to understand the particular accident – potentially a different fact set in each case. More details would be there for those who need or want them. As the study group recommended, information that could not be collected should be noted.

This approach also could advance another recommendation: to increase the educational usefulness of the reports.

One challenge to report writers is the many functions a fatality report will serve. The report must document the basis for enforcement actions, identify root causes, demonstrate the thoroughness of the investigation process, help prevent similar accidents through education, provide some closure for families, assist in identifying more general safety needs, and finally serve as a historical record.

All these purposes are important. The core of the report needs to be a clear, precise and thoughtful narrative of the accident, its background, and the critical findings of the investigation. With comprehensive details included in a separate form-style appendix, all these functions can be served even better than at present.

As the study group noted, some categories used to classify accidents need revision. “Powered haulage” is a case in point. What can we learn from lumping together accidents involving haul trucks, conveyor belts, mantrips and surface railroads? While carefully separating these from accidents involving bulldozers and loaders (“machinery”)? And who remembers when the “powered” part of the term was necessary? “Non-powered haulage” – the mine mule – is long gone.

The study group also crunched the data in an effort to find “specific patterns and go beyond hunches and anecdotes that are part of the mining industry.” While some of their findings were no surprise, a few were.

For instance, who would have predicted that the highest peak in fatal accidents would occur about 2 hours into a shift? And while the students felt that almost 40 percent of all fatal accidents resulted from “action of individual miner,” they counted even more as attributable to management: “action of supervisor,” “action of miner and supervisor,” or “operator/management malfeasance.”

With Kentucky and West Virginia at the top of the count and identical in the number of fatal accidents, the students also pointed out that West Virginia had a much worse problem with roof falls and Kentucky with haulage accidents.

The MSHA reports contain much useful information that, in some cases, has been underutilized. This study is a start, and -- it’s to be hoped – can lead to more.

In tabulating deaths according to the victim’s age, the group noted that their data would mean more if they knew how many working miners there are in each age group. The last demographic survey of the mining industry was in 1986. NIOSH reportedly is working on such a survey now. Results cannot come too soon.

The group made a few unwarranted inferences. For instance, to conclude that “Equipment operator is the most dangerous mining operation,” you would strictly speaking have to compare the percentage of miners who are equipment operators with the percentage of fatalities involving them. But even without that, if equipment operators are the most frequent job category among fatal accident victims, it certainly makes sense to give special emphasis to that occupation.

More puzzling is a claim that “…the fact that only sixteen percent of the fatal coal mine accidents had no violations indicates there is a problem with safety enforcement and follow through in America’s coal mines. Prevention of accidents through code enforcement does not appear to be a priority of either MSHA or the coal industry.”

It would be surprising if many fatal accidents occurred without any safety violations to cause them. And while lax enforcement does sometimes exist, a broad-brush conclusion about MSHA and the whole industry – from these data -- does not follow.

One comment to add the students', based on personal experience in summarizing these reports for the last couple of years for Mine Safety and Health News. The “root cause analysis” in the reports is often too general to be informative. It may simply say that management didn’t conduct a hazard analysis, had no process in place to address a particular hazard or failed to enforce its own process. A deeper inquiry into the whys and wherefores of these omissions would be more meaningful.

The West Virginia Wesleyan project also has created a database available for others’ analysis while giving the students experience with a practical project for an important goal. Credit goes as well to West Virginia Governor Joe Manchin and state Sago investigation director Davitt McAteer, who instigated the project.

It’s to be hoped that someone may undertake a similar project for fatalities involving metal and nonmetal miners, who – unknown to most – accounted for even more on-the-job deaths in the past 10 years than the coal mining industry.

Bush to Senate: Stick It To You

Latest from Washington is that the Bush Administration has re-nominated Richard Stickler to head MSHA. He has been a controversial choice since he was first named as the prospective appointee in September 2005.

Senator Robert C. Byrd (D-WV) put a hold on the nomination after a public hearing. Also, it came out that despite the controversy, Stickler was quietly added to the Labor Department payroll as an independent contractor, which raised more hackles. At the recent formal signing of the new MINER Act, while showing respect, a Sago Mine family member actually spoke directly to the President about her disapproval of Stickler.

Senators who objected to the nomination obtained a pledge from Republicans in Congress that Mr. Stickler would not be installed in recess appointment. The Senate sent back his nomination, asking the White House to try again.

In line with this Administration's usual stance towards Congress, the White House has simply sent back the same nomination. Yup, a uniter, not a divider.

Labor Department sources say Stickler remains stationed at Department of Labor HQ across the Potomac, where he is receiving extensive briefings on MSHA issues.

The White House has done the same thing with the returned nomination of John R. Correll, who was deputy assistant secretary at MSHA from 2002 to 2005, and was picked to head the Interior Department's Office of Surface Mining and Reclamation.

The Interior Department's news release praising the nomination this May said Correll "has served since 2002 as Deputy Assistant Secretary for Operations in the U.S. Department of Labor’s Mine Safety and Health Administration."

Actually, it's my understanding that John Correll left MSHA's offices in 2005 for a special assistant post at Labor Department HQ, at the same time then-MSHA Chief of Staff Loretta M. Herrington transferred to the Office of Disability Employment Policy. Assistant Secretary Dave D. Lauriski had departed MSHA earlier in the year and his other deputy even earlier, so that kind of made it a clean sweep.

Or did Correll remain a secret Assistant Secretary? :)

Dave Lauriski hired Correll in 2002 into what was nominally a career position. He arrived just after the Quecreek rescue and had been out of the picture for a while by the time of the Sago explosion.

Government Executive has a good summary of the back-and-forth on these and other nominations.

Personal opinion: The "my way or the highway" stance sure isn't doing anything for miners. There are solid mine safety professionals and managers out there who also could be acceptable to most. Among other possibilities, long-term MSHA career professionals and managers have been retiring in substantial numbers for a few years now. Many worked under numerous Administrations of both parties without problems. MSHA should not be a political volleyball.

Labor Day Musing: In Memoriam, [Lance] Corporal Ayron Christopher Kull

I never met the young man named Ayron Kull, but a routine assignment for Mine Safety and Health News created a haunting memory of him.

The facts on public record and online are sketchy, but enough to create a picture.

He was born in 1983, or maybe late 1982. [It was 1982 -- see below.] He attended Howard Elementary School in Niles, Mich. After graduating from Niles High School in 2001, he joined the Marines. He became a lance corporal with the 15th Marine Expeditionary Unit, 2nd Battalion 1st Marines (2/1) Fox Company, stationed at Camp Pendleton in California. His picture, in dress uniform, shows a young, serious-looking fellow.

His unit went to Iraq.

His mother, Jenny Kull, is clearly one of those special people who go beyond the norm to help others.

Mrs. Kull, who "saw online how soldiers were asking for things from home," such as eye drops, moist towlettes, sunscreen, and assorted other personal hygiene items, had already been shipping packages on her own when she shared the idea of adopting her son's unit with other staff members at school.

"Then it snowballed from there," says Mrs. Krull, who has another son in the Air Force. Students and staff at both Howard and Ellis Elementary Schools jumped on the bandwagon, and the Howard-Ellis PTO stepped forward to cover the cost of shipping the packages.

Mrs. Krull's Adopt-a-Marine project offered a list of suggested items along with a resealable plastic bag to people who wanted to participate.

"There are specific guidelines in sending out the packages," Mrs.Krull says. "I told people at school to have fun with it and add something unique."

Judy Bybee's sixth-grade class, who had been writing letters to soldiers, began filling the gallon size bags to send to Lance Cpl. Kull's unit.

Ayron Kull served two tours in Iraq. While there, he made the acquaintance of a reporter for the North County Times, who was writing a series called "Postcards From Fallujah." Darrin Mortenson's stories mentioned him three times.

On April 17, 2004:

Lance Cpl. Ayron Kull, 21, of Nyles, Mich., managed to catch one of the dozens of chickens that run wild in the streets of this lawless and deserted section of Fallujah within the cordon.

April 30:

"I still think we should push forward," said Lance Cpl. Ayron Kull, 20, of Niles, Mich., who was just coming off a shift monitoring the late-afternoon firefight in the city Friday. "But maybe it's good. Let's give the Iraqis a chance. Maybe they can do it and we won't have to come back here and start all over again."

And most poignantly in light of later events, on May 5:

Lance Cpl. Ayron Kull, 21, of Niles, Mich., was a radioman who could make light of even the worst days by poking and jabbing at friends and talking endlessly about what it was going to be like "when we get back."

There's a picture of him with his buddies in Fallujah here, if you click on the forward arrow to the second picture.

Ayron Kull's active duty ended in 2005. He returned to Niles, Mich. At some point around this time, his father passed away. [His final rank was Cpl. His fathers actually passed away between his two tours. See update below.]

He got a job in a local sand and gravel operation, the Aggregate Industries, Inc., Milliken Plant. (Interestingly -- but not really unusual in this industry -- although the plant employed only seven workers, the company was ultimately controlled by a global giant, Holcim Group, which is based in Switzerland and says it has some 80,000 employees worldwide.)

Four weeks and two days after starting his new job, Ayron Kull was dead.

Assigned to shovel spilled material from around a conveyor belt, he approached the moving belt from underneath a crusher that stood above the end of it. There was no machine guard on that side. He somehow contacted the moving machinery.

Two co-workers noticed the conveyor had stopped. At first they didn't realize what had happened, investigators later reported. They thought that maybe the belt was overloaded. They shut off the power. A supervisor arrived to check into the problem. Then someone saw Ayron Kull's safety glasses sitting on a horizontal beam at the back of the plant. He found the missing man caught in the machinery.

Fellow workers sliced throught the heavy conveyor belting and cut off Ayron Kull's reflective vest and coveralls to free him. By then, emergency services had arrived, but efforts to revive the injured man were in vain. He was pronounced dead at the scene.

Ayron Kull's family and friends said goodbye to him on Saturday, April 8. Buddies from the Marines flew in to attend the service, and a group of Iraq veterans who are also motorcyclists, calling themselves the Patriot Guard, sent representatives.

The Patriot Guard advised its members that memorial contributions could be made to the Wounded Warriors Memorial Fund, c/o Great Western Bank, Building 147, Offutt Air Force Base, Bellevue, NB 68113.

Ayron Kull's supervisors at work who knew him, surely, must grieve over his death also.

The federal Mine Safety and Health Administration investigated the accident. On April 14, MSHA cited Aggregate Industries for a single alleged violation in that Ayron Kull was working around the unguarded machinery without its being de-energized and blocked against motion. The investigators also reported that the plant management had not established safe procedures for employees to clear away spillage near moving conveors and that Ayron Kull did not recognize the hazard of what he was doing.

Sometime -- it may not be for several more months -- the company will be assessed a proposed civil penalty of up to $60,000. The company will have the right to contest the citation and penalty. That could lead to months or even years of litigation. The fine will not, of couse, undo the tragedy. It may not even be enough to convince upper-level management -- who never knew Ayron Kull -- to invest more time and resources in accident prevention.

More than 5,000 Americans die on the job annually. Ayron Kull's story is especially poignant in that he survived a war only to lose his life in earning a livelihood.

On this Labor Day, after the hot dogs and apple pie and the 1938 recording of Kate Smith singing "The Star Spangled Banner" so clear and true and straight from the heart, it seems right to take a moment to remember Corporal Kull and the others like him.

We can do better by America's working families. If we and our leaders keep in mind the Ayron Kulls of this country, and if in remembering, we have the will.

Update with corrections: January 19, 2007. I've learned from someone who was close to Ayron Kull that I had a few details wrong and there is even more to his story.

New information: He was born June 16, 1982. His final rank was Corporal. His father actually passed away between his two tours in Iraq. His safety vest caught in the conveyor and as a result he was suffocated. The machinery did not do the damage directly.

More: "I think it's important for people to know that on his first tour he couldn't even tell his mom he was going because his battaltion was one of the first over the line -- and his second tour wasn't much prettier being that Ayron and FOX company were stuck in Fallujah for a month."

"Ayron was one of the only people I've ever known that EVERYONE loved. He was always there to make you smile, or to help you out."

He had a life still at its beginning, a family, and a woman who was very dear to him -- who has posted a touching memorial essay at http://profile.myspace.com/index.cfm?fuseaction=user.viewprofile&friendid=40396731

So many human connections -- and the loss of such a person is really a loss to us all.