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The aim of this study was to characterize workplace practices and respiratory health among coal miners with large opacities consistent with progressive massive fibrosis (PMF) who received care at a federally funded black lung clinic network in Virginia.Participants were interviewed about their workplace practices and respiratory health. Medical records were reviewed.Nineteen former coal miners were included. Miners reported cutting rock, working downwind of dust-generating equipment, nonadherence to mine ventilation plans (including dust controls), improper sampling of respirable coal mine dust exposures, working after developing respiratory illness, and suffering from debilitating respiratory symptoms.Consistent themes of suboptimal workplace practices contributing to development of PMF emerged during the interviews. Some of the practices reported were unsafe and unacceptable. Further research is needed to determine the prevalence of these factors and how best to address them.