The Case Analysis of the Centralia Mine Explosion Introduction The Bell and Zoller-Centralia Coal Company owned

and operated the Centralia Mine Number 5; the mine opened in 1907 and covered nearly 6 square miles underground. The mine employed 250 men and produced 2,000 tons of coal each day. Heavy deposits of coal dust were present along the roadways and on the roof, ribs and timbers in the working places and entries. On March 25, 1947, the Centralia mine exploded killing 111 miners.

Main Problem One of the main problems in the 1947 Centralia Mine Explosion was the lack of timely or no follow up and follow through from the Centralia Mine Company, state government officials, and the federal government based on state and federal inspectors recommendations for workplace and safety improvements. Underlying Causes The first underlying cause that contributed to the Centralia Mine disaster was that several violations had been reported by the state inspector but were ignored by the Centralia mine management. The first instance of no follow up and follow through occurred when State inspector Scanlan repeatedly submitted reports on the #5 mine indicating that rock dusting was imperative, that the coal dust was at unsuitable levels and that conditions were dangerous. His reports began in February 1942 and were completed and submitted to the Department of Mines and Minerals every three months during 1942, 1943, and 1944. The director of the department did not even see Scanlan's first thirteen reports; instead the Assistant Director handled them as routine correspondence, sometimes reading the report, having it corrected by a secretary for errors in grammar and spelling, incorporating into the closing The Department endorses the recommendations made by Inspector Scanlan and requests that you comply with same and please advise the Department upon completion of the recommendations set forth above. However Centralia did not comply with the recommendations made by Scanlan, in fact they did not even bother to answer the first thirteen letters and to add to that neither the Assistant Director nor the Director of the Department of Mines and Minerals did anything. The second underlying cause that contributed to the Centralia Mine disaster was that there was no follow up and follow through that occurred from the state to the federal government whey they submitted a report with over a hundred recommendations. The second instance of no follow up and follow through occurred in 1942 when the federal government made the first

inspection of the Centralia mine, the findings duplicated the state inspectors findings and reports. In all, 106 recommendations including 33 major ones were communicated in a report to the state. Four months passed before a copy of the federal report reached the Illinois Department at Springfield, however nothing was done. Subsequent federal reports in 1943 and 1944 showed that the major recommendations listed in previous reports still had not been complied with by the state or the mining company. Solution A solution that could have been created to solve the problem of untimely follow up and follow through by the Centralia Mine Company, state government officials, and the federal government would be for the federal government to create an enforceable Standard Operating Procedure (SOP) that details the process and timeframe of responding to recommendations made by state and federal inspectors. The SOP should do the following: describe what the main problem is with the work environment, list what the major and minor infractions are and then list clearly what the major and minor recommendations are considered. A deadline should then be suggested to provide guidance as to when the major recommendations should be implemented and when the minor recommendations should be implemented, with deadline modifications being allowed for the minor recommendations and no allowances being made for the major recommendations. The SOP should also describe the consequences for the mining company not making the recommended changes leading up to and including the closing of the mine. The SOP should explain what the process is for the inspectors who are responsible for the follow up and how they should communicate with and discipline the company when no response is given. An advantage of the SOP would be that this would clearly spell out the expectations and consequences for all the involved parties. A disadvantage would be that this process could create a strain on an already suffering budget because new staff may need to be hired in order to cover the increased level of monitoring and follow up for the mines. I do believe that this solution may create another layer of management within the larger government system that would need to trained on policy implementation and the importance of not participating in conflicts of interest and unethical behavior as an important part of monitoring and compliance of the new standard operating procedures and policies. Another factor to take into consideration is the timeframe in which a solution like this could be created, approved and then implemented. In general terms this is a solution that needs to be created and implemented as soon as possible, however one of the problems is that it takes time for new policies and procedures to receive all the approvals that are needed in order for it to become an enforceable policy and the slow turnaround time for this type of process by cause this to take longer than expected for creation and then implementation. Overall, I think this solution does create a checks and balances system that can inform the inspection and post inspection process.

Commentary The Centralia #5 Mine disaster of 1947 was the mine explosion that should have never happened. After the explosion and once an investigation commenced the Director of the Department of Mines and Minerals and the state inspector started the blame game. The director responded that it was the inspectors job, not his, to shut down a mine if he felt that it was in violation of state standards and that the miners who were killed would have lived if the inspector has done his job effectively. This was but another attempt at bureaucrats trying to dodge the bullet of blame. The comment clearly supports some of the main ideas and characteristics stated by Max Weber of bureaucracy, that there is clear division of labor and the existence of a hierarchy and because it was not the director whose job it was to close the mine than he really did not have any real responsibility for what happened even though he did play a part in the disaster because of his level of negligence. Because of the Centralia mine disaster and to show in good faith that the men that did die in that mine did not die in vain, mine safety became a top priority for local, state, and federal mining agencies. Unfortunately as history has a habit of repeating itself this did not prevent other underground explosions from occurring again or needless deaths from occurring. Perhaps however this does allow for opportunities for public administrators to learn for the mistakes of the past and come up with solutions to prevent the disasters from occurring.