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Summary C oal mine disasters in the United States are relatively rare events; many of the roughly 50,000 miners underground will never have to evacuate a mine in an emergency during their careers. However, for those that do, the consequences have the potential to be devastating. U.S. mine safety practices have received increased attention in recent years because of the highly publicized coal mine disasters in 2006 and 2010. Investigations have centered on understanding both how to prevent or miti- gate emergencies and what capabilities are needed by miners to self-escape to a place of safety successfully. This report focuses on the latter—the preparations for self-escape. In the wake of the 2006 disasters, the U.S. Congress passed the Mine Improvement and New Emergency Response Act of 2006 (MINER Act), which was designed to strengthen existing mine safety regulations and set forth new measures aimed at improving accident preparedness and emer- gency response in underground coal mines. Since that time, the efforts of the National Institute for Occupational Safety and Health (NIOSH) and the Mine Safety and Health Administration (MSHA) have contributed to safety improvements in the mining industry. However, the Upper Big Branch mine explosion in 2010 served as a reminder to remain ever vigilant on improv- ing the prevention of mine disasters and preparations to help miners survive in the event of emergencies. Concerned with further advancing the safety of miners, the Office of Mine Safety and Health Research at the National Institute for Occupational Safety and Health asked the Board on Human-Systems Integration at the National Research Council to appoint a committee to examine the essen- 1

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2 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES tial components of self-escape. The Committee on Mine Safety: Essential Components of Self-Escape was asked to focus on underground coal mines and define self-escape in the context of mining emergencies. We were to consider environmental and human-systems factors as well as technologies to understand the system in which the miners work and then to propose ways to improve self-escape preparations and training for mining personnel and identify knowledge gaps where further research is needed. Mine emergencies, as the term is used in this report, are unplanned events that have the potential to cause serious injuries or loss of life; they disrupt mining operations and require that underground miners get to a safe place outside the mine. Although this report does not address pre- vention strategies directly, we acknowledge that actions taken to prevent emergencies in the first place have an important role in the preparation for successful escape. These actions extend well beyond the individual miner and rest with the system of mine operators, the regulatory agencies, and other industry stakeholders. This study was set in the context of human-systems integration, a sys- tems approach that examines the interaction of people, tasks, and equip- ment and technology in the pursuit of a goal. It recognizes this interaction occurs within, and is influenced by, the broader environmental context. A key premise of human-systems integration is that much important informa- tion is lost when the various tasks within a system are considered individu- ally or in isolation rather than in interaction with the whole system. In this study, the task of self-escape is part of the mine safety system. Self-escape from adverse events in underground mines is inherently not a solo effort, even in the case of a single individual escaping alone. It is a broader effort of multiple teams and personnel acting in concert. Rec- ognizing this complexity, it is still necessary to begin with a definition of self-escape that must embrace the concept of individual escape. This permits appropriate focus on identifying the needs of individuals in any effort to resolve the emergency, or if it cannot be resolved, on removing themselves from harm. In general, however, the circumstances that require self-escape occur in a setting where a group, or team, of coal miners is together. Being in groups and having leaders, therefore, can be advantageous but cannot replace attention to the needs of each individual. We define self-escape in the event of a mine emergency as the ability of an individual or group of miners to remove themselves from the mine using available resources. While the definition of self-escape references only actions taken after an event is under way, safety management before, during, and after an event is important. Self-escape begins well before any emergency occurs. Keys

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SUMMARY 3 to preparing for self-escape include planning and training. Mine operators must ensure that everything to support escape is in place and available. There should be no impediments to escape that are within the control of planning. First and foremost, mine operators must be compliant with mine safety regulations. Next, they need to work with miners to master the abil- ity to recognize and/or respond to warning signals and harness the knowl- edge of the specific hazards, exits, and resources of their particular mines. CONCLUSION: Efforts on the part of mine operators and other in- dustry stakeholders to empower self-escape in a mine emergency—to include, but not be limited to, training, technology, equipment, and emergency response plans—need to be fully integrated and coordinated, using a human-systems integration approach, to establish unified, effi- cient, and effective protocols. Among the key issues to be considered in pursuit of this goal are robust data collection, careful and constructive assessment of emergency response plans, feedback mechanisms from miners and mine operators to identify residual challenges and remedies, and active engagement with technology suppliers. With modest effort and investment, the mining industry can derive great benefit by learning from its own efforts to plan for emergencies as well as from what is currently known in areas such as technology development, decision-science, safety culture, and training. The committee offers seven recommendations below (and with more details in the chapters) on how existing knowledge can be used and how more can be learned to improve the capability of miners to self-escape. ASSESSMENT OF EMERGENCY RESPONSE Coal mines vary in size and coal production, but each mine operator has the responsibility to mitigate hazards in the coal mine environment and keep miners safe. This vast variability across the industry leads to difficulty in describing a single, best approach to manage mine safety. Regulations have been created to ensure mine safety that can be equitably applied to all mines, regardless of the mining method, production capacity, number of employees, geography of the mine, and other factors. Consequently, regula- tions, generically written, tend to enforce only least-common denominator factors. Regulatory compliance may serve the basic needs of some mines; however, mines can benefit further by employing a safety management ap- proach that extends beyond focusing only on regulatory compliance. An important component of such an approach requires having an understand- ing of how well one’s emergency plans can be executed and an awareness of what improvements can be made.

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4 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES The mining industry has made many significant strides forward to mitigate hazards, train miners, and advance mine safety. Improvements in regulations, procedures, and technologies have positively altered the mine environment and consequently reduced the frequency and severity of emer- gencies. Yet the committee is concerned that improvements in mine safety, especially in regulation, have historically followed major mine disasters. This approach often draws the attention of legislators to apply what was learned from disaster investigations and enact rules meant to mitigate the specific causes of particular incidents. What has been missing is the consid- eration of safety improvements in advance of incidents, using the available knowledge from research, and consideration of larger systemic issues. To promote a more systemic assessment, one needed element is a public database populated with pertinent information across a wide range of mine incidents or emergency scenarios to support development of self- escape training and research. Such a database could possibly be populated with data from information already collected, but data relevant to escape from mines are very limited and currently insufficient for analytic and information-sharing purposes. Another possibility is to include data from interviews with select miners to gather knowledge from their experience about emergency situations and how to deal with them. Overall, systematic efforts are needed to collect and analyze regularly information from escape situations and make outcomes and lessons learned available to stakeholders for future improvements. The currently required quarterly escapeway drills provide an avenue for collecting such informa- tion with minimum additional impact on mines and miners. Under the regu- lations, escapeway drills are intended to use different emergency scenarios quarterly to test emergency preparations (e.g., miners’ knowledge of the mine, conditions and locations of emergency equipment, use of breathing apparatus, and plans for diverting smoke and fighting fires). RECOMMENDATION 1: At least annually, and in conjunction with one of the required quarterly escapeway drills, mine operators should conduct a comprehensive self-escape scenario exercise at every un- derground mine. These exercises should be an integrative practice incorporating the roles of miners, the responsible person as defined in 30 Code of Federal Regulations § 75.1501, the mine communications center, and any other stakeholders that the operator deems pertinent to a successful self-escape, including representatives of the miners where applicable. The scenario should test all aspects of the mine’s emergency response plan and mine emergency evacuation and firefighting program to assure that these are effective and up to date. Information gathered from the proposed annual exercises will speak to the effectiveness of

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SUMMARY 5 current practices and processes specifically with regard to effective de- cision making and action(s) at both the individual and systems levels. Appropriate staff from the National Institute for Occupational Safety and Health (NIOSH) should attend as many exercises as necessary to collect and interpret pertinent outcomes and lessons learned us- ing a standard process. The NIOSH assessment of performance at individual mines of all key personnel, both internal and external, and the effectiveness of emergency response systems should be shared with the personnel involved in each exercise. In addition, a report that has been scrubbed of identifying markers, detailing the outcomes and les- sons learned should be prepared and entered into a public database for use by any interested parties to develop better self-escape capabilities (overall practices, policies, technologies, and training). New resources for NIOSH to accomplish this responsibility should be identified so as not to draw resources from critical program elements. TECHNOLOGY The mining industry has spent nearly $1 billion on emergency prepara- tions since 2006 and continues to look for better technologies. Several areas have been identified as needing upgrades, and cooperative efforts are under way that involve miner representatives, operators, technology providers, and the government. Given the challenges that face the miner under emer- gency situations, it is imperative that the human-technology interface be as efficient and effortless as possible and that attention be given to technology survivability during an emergency. Operational requirements for emergency supplies of breathable air need to be revised to ensure a supply of breathable air for self-escape that will function in atmospheres of various compositions, that is they need to ensure performance against all harmful gases and an adequate supply of breathable air in oxygen deficient atmospheres. Additionally, filtered devices (used in a small number of mines) that only protect against carbon monoxide and do not supply breathable air should be removed entirely unless specifically justified. RECOMMENDATION 2: The National Institute for Occupational Safety and Health (NIOSH) and the Mine Safety and Health Admin- istration should review their operational requirements for emergency supplies of breathable air. Furthermore, NIOSH should allocate funds for research and development to improve the functionality of emer- gency supplies of breathable air, with special focus devoted to resolving a wide range of issues including

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6 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES • verbal communication, • positive pressure, • facial hair, • device weight and size minimization, • device changeover or air replenishment in toxic environments, • fit testing where applicable, and • adequate vision through clearing or removal of condensation. RECOMMENDATION 3: The National Institute for Occupational Safety and Health, the Mine Safety and Health Administration, and technology companies should accelerate efforts to develop technologies that enhance self-escape. These technologies should use human-centered design principles with specific attention to facilitating improved situ- ational awareness and decision making. The technologies should in- clude, but are not limited to: • communications, both miner to miner and miner to surface; • real-time gas monitors that are appropriate for all miners; • fail-safe tracking that is hardened and survivable; and • multifunction devices that combine technology to reduce physical burden and excessive demands on attention. The current technology regulatory and approval process in the United States appears to be a deterrent to rapid technological innovation and access to global markets, which hampers the commercial viability of innovation. RECOMMENDATION 4: The National Institute for Occupational Safety and Health and the Mine Safety and Health Administration should reexamine their technology approval and certification processes to ensure they are not deterring innovation in relation to self-escape technologies that are used in other industrial sectors and global mar- kets. They should collaborate in convening a joint industry, labor, and government working group to identify a range of mechanisms to reduce or eliminate any barriers to technology approval and certification, which should include exploring opportunities to cooperate with other international approval organizations to harmonize U.S. and interna- tional standards without compromising safety. DECISION SCIENCE A miner’s regular job is to produce coal or to perform support work to maintain the mine, making it a safe work environment. Miners appropri- ately absorbed in their daily work assignment routine may be susceptible

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SUMMARY 7 to missing or misinterpreting emergency warning cues. It is important to make miners aware of the warning signals most likely to occur in their mine environment so appropriate early decisions can be made. Mine emergen- cies are stressful and complex events, often characterized by unanticipated conditions and the need for decision making and complicated by hazards that vary widely from mine to mine. The findings from research in the field of decision science, broadly defined as the investigation of decision processes and communication strate- gies by individuals and in groups, have much to offer planning for mine self-escape. Decision science research has identified thinking and reasoning patterns that can commonly occur in stressful situations such as optimism (or false alarm) bias, backup avoidance, or compromised reasoning. Under stress, one’s ability to think systematically is often compromised. Research has shown that just knowing about this possibility and related biases can aid decision making in stressful situations. In addition, if life-saving be- haviors that have been defined in emergency plans are trained so they are automatic (without much thought) then cognitive capacity can be preserved so that adequate attention can be directed at the unexpected events and conditions. To effectively remove themselves to a place of safety, miners need to have working knowledge of their surroundings and self-escape equipment and technologies; they also need to have the psychological tools to make effective decisions and communicate effectively. RECOMMENDATION 5: The National Institute for Occupational Safety and Health should use current decision science research to in- form development of self-escape training, protocols, and materials for training for effective decision making during a mine emergency. Miners and mine operators should be knowledgeable of typical warning sig- nals and able to determine if a true emergency exists and decide how to respond appropriately. All miners should be trained using standard protocols developed for predictable components of self-escape. This will allow miners to devote adequate attention to unexpected events and enhance situational awareness. SAFETY CULTURE Safety culture forms the organizational context in which all safety- related actions take place. It is defined by the safety-related behaviors that are expected, the resources available to support safety, and the steps taken to identify, eliminate, or control hazards. Safety cultures develop over time as a function of leadership and as organizations operate and adapt to local conditions or respond to events. It is understood that mine operators have

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8 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES an obligation to comply with the law. However, to enhance self-escape capabilities, mine operators should also pursue efforts that create a strong, positive culture of safety. Safety needs to be recognized as a core value throughout the industry. There exists a repository of information on safety culture from other industries that can be reviewed for guidance relevant to the mining industry. The National Institute for Occupational Safety and Health is to be recognized for recently initiating research on safety culture specific to underground coal mining. RECOMMENDATION 6: A.  he National Institute for Occupational Safety and Health T (NIOSH), in coordination with mining stakeholders, should com- pile the existing research and recommendations on safety culture from other high hazard and process industries and disseminate them to the mining industry. Such information would provide a useful resource that mine stakeholders could use to examine their own safety cultures and identify strengths and weaknesses specific to their organizations. B. NIOSH should expand its safety culture research efforts to include a larger and more generalizable sample of mining organizations as well as to examine linkages between cultural attributes and safety performance, ideally using longitudinal data on safe work practices and accident and injury outcomes. NIOSH’s current data base of qualitative and questionnaire data would appear to provide a strong basis for this expansion. Ultimately, the results from this research effort could be used to produce a set of safety culture tools that could be used by the entire mining community. This compilation of data collected using these tools could then be used for further analyses and benchmarking activities. TRAINING Training is a necessary step in preparing individuals and groups to use available resources appropriately. Regulations relevant to training for self- escape appear to emphasize training duration and frequency rather than training to mastery. To ensure that miners can function effectively in an emergency, a train-to-mastery system with competency standards is needed, not time in class. A detailed systematic task analysis would identify knowl- edge, skills, abilities, and other personal characteristics (KSAOs) critical to a successful self-escape. These KSAOs will provide a general blueprint for self-escape training programs and essential competencies. The definition of

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SUMMARY 9 mastery varies by what level of performance and reliability is acceptable —and increasing levels come with higher price tags of training time and general cost. The committee envisions that after step A. in Recommenda- tion 7 below is completed, and the KSAOs for self-escape are identified, a consensus group of stakeholders will meet to determine what level of per- formance is acceptable and define competency standards for those KSAOs. This meeting would include representatives from NIOSH, mine operators, and miner organizations. RECOMMENDATION 7: To advance self-escape training: A.  he National Institute for Occupational Safety and Health T (NIOSH) should conduct or sponsor a formal task analysis and an analysis of the knowledge, skills, abilities, and other personal attributes (KSAOs) required for miners to self-escape effectively in coordination with the efforts of the responsible person, the com- munication center and mine management. B.  the basis of these analyses and working with interested stake- On holders, NIOSH should undertake the research required to identify the training modalities, techniques, and protocols best suited for those KSAOs as well as the interactions between miners, respon- sible persons, the communication center, and mine management. Thereafter, NIOSH should review current training and identify existing gaps within the mining industry. C.  the basis of the research and review in step B. above, and using On best practices within the training field, the Mine Safety and Health Administration (MSHA) and NIOSH should revise or develop training flows that bring miners, responsible persons, communica- tion centers, and mine management to mastery in those KSAOs, including interactions between those three groups. D. NIOSH should conduct research to verify the effectiveness of train- ing developed in step C. above and miners’ retention of informa- tion learned under simulated emergency conditions. E.  its current review of facilities supporting mine rescue training, In MSHA should also evaluate whether these facilities could support self-escape simulation and scenario training.

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