The report from the Royal Commission on the Pike River
Coal Mine tragedy, released on Monday, is a damning indictment
on the company's management, the Department of Labour and the
emergency response to the series of explosions that killed 29
miners at the West Coast mine in November 2010.
The commission found the disaster was a preventable tragedy
and there were failures at every level. It found the
immediate cause was a large methane explosion but was
inconclusive about the ignition sources that might have
caused it. It slammed Pike River's management and board for
focusing on production over safety, its inadequate systems
and for ignoring warnings over dangerous methane levels. It
said the emergency response was hampered by the company's
lack of information about the mine, the workers underground,
and adequate back-up and operational systems.
It criticised the Department of Labour's record as the former
health and safety regulator, describing its performance in
relation to the mining industry as "Third World" and "so poor
both at the strategic and operational levels, that the
department lost industry and worker confidence".
The work of the department has now been transferred to the
new Ministry of Business, Innovation and Employment.
The commission said the emergency response was "cumbersome",
lacked expertise and might have impeded a rescue had it been
possible. The commissioners were critical of the mine
manager's 40-minute delay in calling emergency services after
the explosion, and the co-ordinated incident management
system, which oversaw the rescue operation from Wellington,
slowing the emergency response and preparations to seal the
mine to reduce further explosions, led by three police
officers who lacked mining expertise. (The commission did
praise the New Zealand Police for "expert management" of the
many logistical demands throughout the response effort.)It
rejected criticism of a "window of opportunity" for a rescue:
"International best practice is to re-enter an underground
coal mine only on the basis of representative and reliable
atmospheric information. This did not exist at Pike River."
Labour Minister Kate Wilkinson resigned her portfolio
immediately after the report's release.
Three Pike River Coal board members disagreed with the
commission's suggestion they did not act appropriately with
regard to health and safety at the time and said much of the
comment had been made "with the convenient benefit of
Pike River Coal and former chief executive Peter Whittall are
facing 21 charges brought by the Department of Labour.
Prime Minister John Key said the Government would broadly
accept the commission's 16 recommendations and work to
implement them as quickly as possible. It would consider the
recommendation to establish a new Crown entity focusing on
health and safety. Mr Key accepted there were systemic
failures in the regulatory regime across successive
Mr Key apologised to the families of the 29 men: "On behalf
of the Government, I apologise to the families, friends and
loved ones of the deceased men for the role this lack of
regulatory effectiveness played in the tragedy."
The report makes clear blame lies at many levels, with
various organisations and individuals.
Safety was ignored at management level and subsequently by
workers themselves in the push for profit and production. And
in that environment the ultimate failure was in an effective
regulator overseeing the operation.
There are clear lessons to be learnt. Ms Wilkinson's
resignation, and Mr Key's acknowledgement and apology, are
welcome and appropriate. But while the Government works to
implement the commission's findings, it is incumbent upon
other mine operators - and all associated employers,
managers, directors and employees - to examine health and
safety procedures and practices to ensure such a preventable
tragedy never occurs again. That much is owed to the Pike
River 29 and their families.