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LINDA WERTHEIMER, HOST:

It's MORNING EDITION from NPR News. I'm Linda Wertheimer.

For the last 20 months, the federal Mine Safety and Health Administration has repeatedly blamed Massey Energy for the fatal explosion at its Upper Big Branch coal mine in West Virginia. On Tuesday, the agency released a 13-pound final report that came to the same conclusion.

But buried in the report is an indication that the agency itself also has direct responsibility for the explosion that killed 29 mine workers. NPR's Howard Berkes has obtained additional documents that describe the agency's failure.

HOWARD BERKES, BYLINE: The final Upper Big Branch report and additional documents obtained by NPR and the Charleston Gazette all add up to this, says Davitt McAteer, who conducted an independent investigation of the Upper Big Branch explosion.

DAVITT MCATEER: You have a known problem. You go in and take a look at it. You make some recommendations on it. And then they disappear. And five years, six years later, the mine explodes from that known problem.

BERKES: The known problem is inundations of natural methane gas from cracks in the floor of the mine. In 1997, coal miner Stanley Stewart witnessed one of these gas leaks at the Upper Big Branch mine and the fireball of methane that resulted.

STANLEY STEWART: When I saw the glow coming from in behind the wall down on the tail, I took off hard as I could toward the head. I thought I was a dead man.

BERKES: The same thing happened again in 2003 and then a year later. A top executive at Massey Energy and federal regulators from the Mine Safety and Health Administration knew all about it, according to documents obtained by NPR. They met and discussed the problem in 2004 and the agency recommended eight actions Massey should take. Last year, former Massey CEO Don Blankenship couldn't name a single step his company took in response.

DON BLANKENSHIP: I don't know that anyone could foresee that natural gas coming out of the floor at UBB was going to be ignited and cause an explosion.

BERKES: Actually, former Massey chief operating officer, Chris Adkins, was there when the 2004 gas inundation occurred. That's according to a Massey Energy timesheet obtained by NPR and the Charleston Gazette. Independent investigator Davitt McAteer tried to find out whether the mine safety agency responded.

MCATEER: And we don't know whether those recommendations were followed and were followed up on by the agency. What we do know is that there were no special precautions, in place, at the mine in April, when the explosion occurred.

BERKES: And the top federal regulator in the region didn't know a thing about the methane leaks, according to unreleased investigation transcripts obtained by NPR.

Bob Hardman was district manager for four years before the April 2010 explosion. None of his predecessors and no one on his staff reported the problem. In fact, he testified, he first learned about leaks a month after the tragedy, when someone slipped internal memos under his office door. If he'd known, Hardman said, he'd have required more robust airflow or ventilation underground to neutralize methane leaks. Again, Davitt McAteer.

MCATEER: And that failure to render this harmless is a shortcoming that has direct impact on the explosion and on the cause of the explosion.

BERKES: And in its final report, the mine safety agency says Massey Energy's failure to respond to the problem contributed to the explosion. The blast started, the report says, with the same kind of methane leak from the same rock formations beneath the mine. There's nothing in the report about the agency's own failure to respond. That's one focus of an internal review, says Kevin Stricklin of the Mine Safety and Health Administration.

KEVIN STRICKLIN: We're looking into it and see what we did know and why nothing was done with it. If we didn't do anything, then we need to do a better job in the future. I can't say that we blew the mine up, though.

BERKES: Davitt McAteer complains that the mine safety agency declined to provide to his independent investigative team documents and other information about the methane leak problem. So only the agency itself will report on its failure before the disaster.

Howard Berkes, NPR News, Beckley, West Virginia.

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