BACKGROUND: Miners inhale dust at work and are at a risk for coal workers pneumoconiosis (CWP), a preventable and potentially fatal lung disease. After regulations were implemented in the 1970s, declines were reported in both dust levels and the prevalence of simple and advanced CWP until about 2001, when despite stable reported dust levels, disease levels sharply increased. METHODS: A structured, retrospective chart review was performed to describe the demographics and disease progression for 138 coal miners with progressive massive fibrosis (PMF) whose claims were approved by the West Virginia State Occupational Pneumoconiosis Board between January 2000 and December 2009. RESULTS: PMF, a complication of CWP, developed in 138 West Virginian coal miners at a mean age of 52.6 years after an average of 30 years work tenure. The time of progression averaged 12.2 years from the last normal chest radiograph until PMF was detected. Lung function declined sharply in both smokers and nonsmokers, averaging 87 mL/y for FEV(1) and 74 mL/y for FVC. The board has confirmed 21 deaths in this group. The most common job activities were operating continuous-mining machines (41%) and roof bolting (19%). Virtually all of these miners' dust exposures occurred after the implementation of current federal dust regulations. CONCLUSIONS: Contemporary occupational dust exposures have resulted over the past decade in rapidly progressive pneumoconiosis and massive fibrosis in relatively young West Virginian coal miners, leading to important lung dysfunction and premature death.