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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Page 34
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 35
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 36
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 37
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 38
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 39
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 40
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
×
Page 41
Suggested Citation:"UNDERGROUND MINE DISASTERS OF THE PAST DECADE." National Research Council. 1981. Underground Mine Disaster Survival and Rescue: An Evaluation of Research Accomplishments and Needs. Washington, DC: The National Academies Press. doi: 10.17226/18461.
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Page 42

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

CHAPTER 2. UNDERGROUND MINE DISASTERS OF THE PAST DECADE During the decade from 1970 through 1979 nine underground mine disasters occurred in the United States (See Table 2.1.) Six were in coal mines and three were in metal and non-metal mines. Four were caused by explosions,* two by fires, and two by inundations; one involved poisoning by hydrogen sulfide gas. A total of 195 lives were lost in these disasters. During the same period, 1438 lives were lost in lesser accidents in underground mines. Investigative reports on two of the decade's disasters, Scotia and Porter Tunnel, have not yet been publicly released because of pending litigation. Reports of the investigations into the other seven disasters were examined by the committee to identify aspects of disaster management that have been affected by the Bureau of Mines post-disaster research program or that could be addressed by that program. The committee sought to determine which survival and rescue procedures have been particularly effective and which have presented problems. The committee also sought to determine what the potential lifesaving impact might have been of techniques and equipment that were not available at the time but that are available today. In addition to these disasters, the committee looked into 56 accidents—47 in coal mines and 9 in metal and non-metal mines—that had disaster potential and were thus relevant to its examination of post-disaster survival and rescue. In this chapter coal mine disasters and metal-nonmetal mine disasters are discussed separately. Although it might appear more logical to group disasters by cause (e.g., fire, explosion, inunda- tion) than by commodity, there are significant differences between coal and metal and nonmetal mines. These differences are reflected in the organization of the mining industry and the federal agency responsible for mine safety and health, and also in the relevant federal laws and regulations, which treat coal and metal-nonmetal mines differently. *The Scotia disaster involved two separate explosions two days apart. -29-

2.1 DISASTER INVESTIGATION REPORTS Disaster investigation reports can help determine legal liability and can provide information that will help avoid future disasters through enactment of new laws and regulations, changes in inspection or enforcement procedures, modifications in equipment design, develop- ment of new training procedures, institution of improved emergency plans, and conduct of new research. Prior to May 1973, all mine disasters were investigated by the Bureau of Mines. The Bureau's reports had a reputation for being com- plete and comprehensive, and were often published as Information Cir- culars and widely circulated. When MESA was created in 1973, all mine safety inspection and investigation responsibilities were transferred to that agency. With that change, greater emphasis was placed on findings related to non- compliance with federal health and safety regulations. This new emphasis continued when, after enactment of the Federal Mine Safety and Health Amendments Act of 1977, responsibility for disaster investiga- tion reports passed to the newly created MSHA in the Department of Labor. This appears to be associated with a growing tendency toward litigation after disasters, and a concern within mining companies, unions, and government agencies about the possible legal implications of statements made during disaster investigations. One consequence is that reports are often delayed for legal review, and important findings that could be applied in other mines are not as quickly and widely available as they should be. 2.2 COAL MINE DISASTERS The number of coal mining disasters and associated fatalities decreased from 13 disasters with 239 victims during 1960-1969 to 7 disasters with 92 victims during 1970-1979. This extended a trend that had begun some years prior to 1960. Similar favorable trends were noted in the number of accidents having disaster potential. Much of this progress may be attributed to o Improvements in mine design o Improved escapeways and other mine egress facilities o Improved disaster prevention techniques and equipment o Improved training programs for miners o Better mine emergency plans and evacuation drill programs o More effective coordination between mine operators and miners' safety committees o Improved mine rescue apparatus o Better geographical distribution of trained mine rescue teams These improvements notwithstanding, the committee's review indicates that further efforts are needed, both in disaster prevention and disaster response. Brief descriptions of the decade's disasters, drawn from the official investigation reports, follow. -31-

Finley Coal Company Explosion (Hyden, Kentucky; December 30, 1970) ; A coal dust explosion was caused by improper use of explosives, and exacerbated by inadequate application of rock dust. Thirty-nine miners were in the mine. Thirty- three were killed instantly; five who appeared to have moved a short distance after the explosion presumably died of asphyxiation or carbon monoxide poisoning. Mine employees did not carry self-rescuers, although filter self-rescuers were available and stored in set loca- tions. It is unlikely that the miners who survived the explosion could have donned self-rescuers in time to save their lives had they been on their persons, or if oxygen self-rescuers would have been effective had they been available. Consolidation Coal Company Fire (Blacksville, West Virginia; July 22, 1972) ; , Th« fire broke out during a Saturday operation that was not for production but was for the purpose of relocating equipment within the mine. The fire apparently was caused by an electrical short circuit when a continuous mining machine being hauled along a track contacted the energized trolley wires. Forty-three miners were in the mine at the time. Thirty-four evacuated safely. Nine miners were trapped in the mine and ultimately died. They were wearing filter self-rescuers when overcome. Delay in communicating with these miners and evacuating them proved critical. More timely evacuation would probably have enabled them to survive. Delay nothwithstanding, availability of oxygen self-rescuers would probably have enabled them to make their way out of the mine. Itmann Coal Company Explosion (Itmann, West Virginia; December 15, 1972): Methane was ignited by an electric arc that occurred when the trolley pole of a portal bus lost contact with the trolley wire. The explosion occurred during a regular change of shifts on a scheduled production day. Five miners were killed outright and three severely burned miners were rescued by a mine rescue team. Scotia Coal Company Explosions (Ovenfork, Kentucky; March 9 and ll, 1976); Two methane explosions, two days apart, claimed a total of 26 victims. No official report on this disaster has yet been released because of pending litigation. -32-

Seven of the 15 victims of the first explosion survived the initial explosion. It was found during the recovery operation that they had started to evacuate, donned filter self- rescuers, and then decided to return to the working place and barricade, where they ultimately died. The ll victims of the second explosion were killed instantly. Two survivors donned filter self-rescuers and guided themselves out of the mine by following a telephone cable. Porter Tunnel, Kocher and Leon Coal Company Water Inundation (Wilkes-Barre, Pennsylvania; March 1, 1977): This was an inundation of water from earlier abandoned workings. Nine miners were killed instantly. Eight miners escaped unaided, one was carried out, and one was rescued by search parties the next day. No official report has yet been released because of pending litigation. Clinchfield Coal Company Blackdamp Inundation (Duty, Virginia; April 4, 1978): An entry being advanced by a continuous mining machine cut into a mined-out and abandoned area of the same mine, and was inundated by a rapid inrush of blackdamp (air defi- cient in oxygen and high in carbon dioxide). Five miners died and four escaped by their own efforts or with the aid of others. The five victims all lacked life-support equip- ment. Two of them might have survived had they withdrawn immediately; the other three died while attempting to rescue the affected miners without appropriate equipment. In its review the committee also examined a number of accidents that had disaster potential. The committee concentrated on ignitions and mine fires inasmuch as the great majority of recent coal mining disasters have stemmed from such incidents. The committee did not confine its study to domestic occurrences. It also reviewed disaster reports and follow-up studies of several foreign mine fires and explosions. These studies confirmed the conclusions drawn from the review of domestic disasters, listed below. Conclusions Review of coal mine disasters of the past decade suggests that the most significant gains in post-disaster survival and rescue would result from o Providing miners with an oxygen-supplying escape breathing apparatus ("oxygen self-rescuer") to be carried on their persons. Such a device would be for the purpose of keeping miners alive while they escape through regions of oxygen- deficient or toxic atmosphere. It would not need to support the level of respiration needed for rescue work. Nor would it need to be as rugged as a rescue apparatus. -33-

o More effective training of miners in the immediate actions to be taken when a fire or other emergency is detected or sus- pected . o More effective training of managers, supervisors, and dispachers in the development and implementation of disaster plans, so that in the event of an emergency proper instruc- tions are given in timely fashion and are promptly and properly carried out. There has also been some indication* that rescue teams could work more effectively in conditions of high temperature and humidity if they were provided with liquid-oxygen rescue breathing apparatus. This is of particular importance in deep, hot, humid mines such as are found in the western United States. Two of the decade's disasters, the Blacksville fire and the Clinchfield inundation, occurred during periods of irregular operation rather than during regular production shifts. Experience in other industries suggests that often weekends and other non-regular periods are times when the usual chain of top management personnel are not on duty, and when subordinates may hesitate to make prompt decisions that are likely to cause major disruptions in the mine. The committee could not determine whether this has been a problem in mines. If it has, management should take steps to ensure that appropriate decisions are made quickly if an emergency arises at such a time. Other measures that might have considerable impact include: improvements in mine design to permit rapid isolation of areas affected by fire; improvements in mine communication systems for emergency use; prompt dissemination, throughout the industry, of investigative reports of disasters and accidents having disaster potential; emphasis in disaster reports on technological and operational remedies in addition to the present emphasis on noncompliance with regulations; and better understanding of human reactions and behavior in emergency situations as a basis for more realistic disaster plans and disaster training. 2.3 METAL AND NON-METAL MINE DISASTERS There were three disasters in metal and non-metal mines during the 1970-1979 decade (see Table 2.2). The Sunshine Mine fire in 1972, with 91 fatalities, caused the industry and government agencies to re- examine all elements of mine rescue and disaster response. Even as enhanced disaster prevention and rescue capabilities were put in place, the industry continued to experience serious accidents that could have resulted in greater loss of life than was actually experienced. During the decade there were three fatal fires in underground metal and non-metal mines. In addition to the 1972 Sunshine Mine fire, fires at the Star Mine in 1971 and the Lakeshore Mine in 1973 claimed two lives each. There were also two methane explosions that resulted in fatalities. Both were in salt mines. The Sterling Shaft explosion in 1975 took four lives. The Belle Isle explosion in 1979 *See "Recovery; Somerset Mine," U.S. Steel Corporation, Western District-Coal, undated. -34-

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resulted in five deaths. A hydrogen sulfide gas invasion at the Barnett Complex mine in 1971 took seven lives. The Belle Isle explosion and the Star, Sunshine, and Lakeshore fires all resulted in entrapment of miners. In the Belle Isle disaster, the 17 trapped miners were successfully rescued. In the Sunshine fire, only two of the 93 trapped miners were rescued, and in both the Star and Lakeshore fires, the trapped miners, two in each case, perished. The Lakeshore fire was also characterized by materials entrapment. There were two other incidents of entrapment by materials: Mars Hill in 1974 and Long Dave Lode in 1979, in which one and three miners respectively were trapped; all were rescued. Fires at the Homestake Mine in 1975 and at the Crescent and Logan Wash Mines in 1978 had disaster potential but did not result in entrapment, injury, or death, either because no miners were in the affected area or because all were evacuated safely. The same is true of the inundation of water and mud at the American Tunnel Mine in 1978. The three disasters of the decade (Barnett Complex, Sunshine, and Belle Isle) involved about 216 of the industry's approximately 36,000 employed personnel; 103 of these were killed. In two of these disasters, all miners underground were involved in life-threatening circumstances. The nine potential disasters that the committee looked into involved more than 1,000 additional underground employees in possible life-threatening circumstances, and resulted in nine deaths. Seven of these incidents affected the total mine area and required evacuation of all underground personnel. (See Table 2.2.) Underground fires, liberation of toxic formation gases, and inundation continue to be major causes of metal and non-metal mine disasters and potential disasters. Frequently these occurrences are associated with a non-routine activity, which complicates control of the situation and makes evacuation and rescue difficult. Although it is evident that new practices developed over the decade are contributing to an improved emergency response, shortcomings are still present, as discussed below. Fires In addition to the three fires that resulted in loss of life to miners, there were 105 other reportable fires (i.e., fires of more than 30 minutes duration) during the decade. Most of these fires were handled with pre-planned procedures providing for prompt evacuation of personnel from the mine followed by appropriate fire fighting actions. A normally small fire, compounded by other unusual circumstances, can rapidly grow to disaster dimensions. The Sunshine Mine fire in 1972 is a case in point. A small fire in the exhaust airway of the mine complex breached the separating bulkheads to contaminate the fresh air intake. The fire increased in intensity more rapidly, spread more quickly, and produced more toxic gas than is considered normal for underground mine fires. Knowledge of mine fire chemistry was not sufficiently understood at that time to have predicted the concentra- tions of combustion products that did in fact occur. Moreover, a systematic study of the Sunshine Mine design would have revealed that rescue efforts in response to a fire of this nature would be difficult. An underground mine fire at the Star Mine in 1971, resulting in two deaths, was also unusual in that the fuel was a new product made -36-

of chemical resin-based materials. Two employees accidently ignited a fiberglass ventilation duct pipe. The combination of resin-based fuels and moving air in the duct created a chemical fire with dense and toxic combustion products. Both workers were overcome while attempting to retreat from the fire location. Neither of the two exposed employees had filter self-rescuers. The follow-up investigation did not deter- mine whether protection from the fumes and smoke would have been possible had filter self-rescuers been available. This accident resulted from the use of a new product in mine operations without fully testing it for combustion qualities. The product is now manufactured with a flame retardant to prevent a reoccurrence of the Star Mine fire. A large variety of diesel-powered loaders, transporters, concrete pumps, and other machinery is used in modern mining, and several mine fires have involved this mobile diesel-powered equipment. Of these, only the Lakeshore Mine fire in 1973 resulted in fatalities. In this unusual circumstance, a large diesel loader was covered by drill cut- tings flowing uncontrolled out of a large diameter borehole. The sudden slide of drill cuttings trapped two miners in a dead-end tunnel and covered the loader with its motor running. The buried loader overheated and started burning. If not for the fire, the trapped personnel probably would have been freed. Many of the 108 metal and non-metal mine fires resulted in orderly evacuation of mine personnel without incident or injury. The use of the filter self-rescuer in these evacuations is not always detailed in the reports of these incidents. However, enough cases describe the use of the filter self-rescuer to demonstrate its value while evacuating through smoke-contaminated mine entries. Entrapment Entrapment of personnel, either by toxic smoke or by material runs that blocked exits, characterized six accidents in which a total of 118 people were trapped or prevented from making a normal exit from the mine. Ninety-three of these were the 91 victims and two survivors of the Sunshine Mine fire. Including the latter two, 23 people were rescued from entrapment by mine rescue personnel. Both the Belle Isle Mine and Sunshine Mine evacuations were complicated by inoperative shaft facilities, in the first case due to damaged equipment and in the latter due to the operator of an underground hoist being overcome by the fire combustion products. These rescue efforts are notable for the organization and achievement by mine rescue personnel under difficult and unfamiliar conditions. Methane explosions Methane ignitions and explosions in non-metallic mines resulted in nine deaths during the decade. The Sterling Shaft explosion in 1975 involved ignition of gas in an abandoned salt mine shaft which was being backfilled. The explosion resulted in the deaths of three miners at the shaft collar, with another missing, having probably fallen down the shaft. This is an example of a non-routine activity resulting in a disaster. The Belle Isle Mine methane explosion and high pressure gas blow- out in 1979 illustrates how the normal evacuation of personnel not -37-

directly involved in the explosion can be hampered by damaged man-hoisting facilities. Disaster Response and Rescue Operations Metal and non-metal mine disasters and rescue operations differ from those in coal mines primarily in the wide variety of situations the metal and non-metal rescue team is confronted with. Nearly all the disaster situations differ in mine design and operating methods. The shaft access is about the only facility common to most metal and non- metal mines. Metal and non-metal mines of all sizes have been involved in disaster recovery and rescue operations. More than half of the decade's disasters and potential disasters involved the exposure of fewer than 50 people working underground at the time of occurrence. The other half of the incidents occurred in large metal mines. Disasters do not usually directly involve the total mine complex of the larger mines; the Sunshine Mine fire was an exception. Usually all personnel except those directly affected by the disaster are evacuated successfully. This has been particularly true in recent years follow- ing implementation of new safety standards for evacuation and emergency exit provisions. Entrapment or isolation from fresh air exits is an important concern in metal and non-metal mine disasters. During the past decade twenty-seven miners, not including the victims of the Sunshine Mine fire, have been trapped. All but five were rescued through the efforts of mine rescue teams. The two survivors of the Sunshine Mine fire had been trapped in a branch of the fresh air ventilation circuit that had not been invaded by contamined air, with no exit except through an unlined 48-inch diameter vertical borehole. They were rescued through the efforts of Bureau of Mines personnel supported by various other government agencies. Prior to the present practice of having trained mine rescue per- sonnel readily available at the mine site, a number of rescue opera- tions were frustrated by late arrival of mine rescue personnel. Some of the seven lives lost in the 1971 Barnett Complex disaster might have been saved if mine rescue teams and support equipment had been available on a timely basis. Recent experience indicates that to a large extent, mining companies have established mine rescue teams capable of responding on short notice. Most deep metal and non-metal mines are accessed through a hoist- ing facility which is often the rock hoist and material and man-hoist combined. A major concern in most metal and non-metal mine disasters is whether or not the vertical shaft entrance is affected or damaged. At the very least, the shaft presents a difficult path for mine rescue teams striving to gain access to deep mine levels. Seventeen miners were rescued after the Belle Isle explosion in 1979 by heroic efforts of mine rescue personnel who entered the mine through a damaged hoist facility. No safe and expedient method of entering a damaged shaft has been developed. In deep mines, drilled boreholes are not reasonable alter- natives to a damaged shaft. -38-

Other Aspects of Survival and Rescue Many metal mines are vertically oriented and are relatively deep, compared to horizontally oriented, relatively shallow coal mines. For these reasons, presently available trapped-miner location devices and borehole-drilling rescue techniques have not been used in metal mine rescue operations. Filter self-rescuers have been used in evacuation of personnel through smoke in mine fires since the Sunshine Mine fire in 1972. Except in the case of a fuel-rich fire or other chemical-fueled fire, where large quantities of combustion products are produced, the filter self-rescuer appears to have provided adequate protection to personnel traveling through smoke. Several large diesel loaders have caught fire, but either have been allowed to burn out or were so situated that workers and fire fighters were not in the heavy smoke produced by the fire. With the wider use of chemically formulated materials and diesel equipment with rubber tires, the potential for fires consuming diesel fuel, rubber, and other materials and producing dense smoke and high concentrations of carbon monoxide and other toxic combustion products will increase. The filter self-rescuer, which only protects against carbon monoxide, is probably not adequate in such an atmosphere of smoke and chemical combustion products. Rescue operations in the Sunshine Mine fire and at the Lakeshore Mine demonstrated the extreme difficulty facing a mine rescue team in advancing their fresh air base in deep, hot underground mines. Single- heading advance of the fresh air base is difficult and requires con- siderable ingenuity by the mine rescue team. If the mine is hot, the work involved in building bulkheads is extremely fatiguing and time consuming. Conclusions Greatest loss of life in underground metal and non-metal mine disasters has been associated with those instances in which the fire or explosion affects all or most of the underground mine complex. This further complicates rescue and recovery operations and adds to the time required for mine rescue teams to reach and help survivors. In many cases, a systematic evaluation of mine design for hazards could have revealed the possibility of a disaster. Appropriate pre- ventive measures might then have been taken, and appropriate disaster response plans provided. Such plans, carefully developed and installed, and supported by proper training, would substantially enhance the survival prospects of miners. Existing technology can provide a great deal of support to these plans. Oxygen self-rescuers, or even filter self-rescuers had they been available and used, might have saved some of the Sunshine fire victims. With the increasing likelihood of toxic combustion products in mine fires, oxygen self-rescuers will assume greater importance in disaster survival. Because of the variety of mine conditions, an evaluation of each mine may be necessary to determine whether oxygen self-rescuers should be carried on the miners' persons or whether they can be cached. The present capability of mine rescue teams for advancing quickly in the mine and for working in hot environments has not been adequate to assure timely rescue. -39-

Improved emergency communications are vital to efficient evacua- tion and rescue operations. Operating communications have often been destroyed or damaged extensively in major fires or explosions, and emergency systems that can withstand such events are needed. Thorough training and continued practice in disaster response procedures would enhance the miner's capability for proper use of emergency procedures and equipment. Seismic techniques for locating trapped miners, rescue drilling capabilities, and refuge chambers have made little or no contribution to the rescue of survivors of underground metal and non-metal mine disasters. There is evidence to suggest that non-routine activities, especially on weekends, are times of high vulnerability to disaster. Better preparation for the eventuality of disaster in such circum- stances could result in saving lives. In the committee's judgment, the improvements that would have been most effective in saving lives in the past decade's underground metal and non-metal mine disasters are o An oxygen-supplying escape breathing device ("oxygen self-rescuer") available to all miners. o More thorough training of miners in emergency response procedures. o Improved capabilities for rescue teams working in deep, hot mines. o Improved communications systems for use in emergency and rescue operations. Other improvements having very limited potential for saving lives are o Refuge chambers suitable for use in metal and non-metal mines. o Procedures for locating trapped miners in deep mines. o A rescue drilling capability for deep mines. 2.4 RECOMMENDATIONS On the basis of a review of the decade's disasters—both in coal and in metal and non-metal mines—the committee believes that the single piece of equipment most likely to reduce loss of life in mine disasters is the oxygen self-rescuer. The next most effective means of reducing the number of fatalities is better training to prepare miners to take appropriate action when a fire or other emergency occurs. Better planning for emergencies is needed to make such training effective. Improved capabilities for rescue work in deep or hot mines is needed to expedite rescue operations in such environments. A careful and systematic assessment of the risks involved in non-routine activities should be undertaken. All such activities should be backed up with well-defined disaster response procedures. All personnel involved in the activity should be familiar with and trained in evacuation and disaster response procedures. Present reporting and investigating procedures should be examined to see if they serve their purpose adequately or whether an alternative approach—such as investigation by an independent body analogous to the National Transportation Safety Board—would be more effective. The -40-

problems associated with self-incrimination should be addressed, as it is of critical importance to be able to conduct a post-audit in a manner that encourages honest evaluation without fear of legal reper- cussions associated with litigation or prosecution. In compiling data on past accidents and disasters, it would be useful to include information on situations that had the potential to develop into disasters but didn't. Such potential disasters are likely to occur more frequently than actual disasters, but may not be reported, either because there is no requirement to report them or out of fear of punitive action. Yet it is as important to know what worked in responding to potential disasters as it is to know what didn't. It would be useful to develop a mechanism for reporting and analyzing such incidents and for disseminating the resulting informa- tion in a form that might assist others in averting disaster. A pro- vision for granting immunity from punitive action to those who report such incidents might increase the effectiveness of the reporting system. -41-

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