The chairman of Pike River Coal said yesterday he was "horrified" at a litany of safety incidents at the West Coast mine, but could offer no meaningful explanation as to why they never reached his ears before the tragedy last November.
The Royal Commission of Inquiry, in Greymouth, was told yesterday that former mines inspector Harry Bell rang former mine manager Peter Whittall (later chief executive), in the presence of a secretary, to outline his "extreme" concerns about gas in the mine.
Mr Bell claims that Mr Whittall replied: "Sometimes your officials let you down."
Mr Whittall did not tell company chairman John Dow about the conversation, families' lawyer Nicholas Davidson QC said.
It was just one of a number of incidents that never reached the board.
Mr Davidson also read from a submission from polytechnic trainer Reg Matthews, who alleged a miner found a methane detector, which had been cut off a machine.
Several witnesses also claim that in February last year two men reported feeling nauseous while working underground - five machines were working with no ventilation.
But the person got "into trouble big time" for bringing it up.
Again, neither incident reached Mr Dow, Mr Davidson said.
"I wish I could offer something that was meaningful. I've been reflecting on it," Mr Dow said.
"I'm not sure I could give you much more than speculation [and this is not the] place to do it."
Between 2008 and the mine explosion on November 19 last year, Pike River had six statutory managers; no-one lasted more than six months.
Mr Dow did not know his experienced mine manager Doug White had been about to leave, and was already looking for other employment.
Safety manager Neville Rockhouse, who lost his son Ben in the disaster, was reporting to statutory managers who were "churning over", Mr Davidson said.
Michelle Gillman, who answered to Mr Rockhouse, claims that he continually requested additional funding.
She was so concerned at the stress he was under that she did not try to talk him out of resigning, fearing he would have a heart attack.
Once, he returned from a meeting with 13 safety action points - and his noticeboard was already full. Ms Gillman was so incredulous she photographed the board.
Mr Dow: "I didn't see evidence of him being overworked, and he certainly didn't raise it with me."
Mr Davidson said there was a whole "ream" of serious incident reports, showing the commission a large bundle of documents.
"Take it from me, there are scores. Doesn't that tell you something right now that this board was not armed with the information it should have had?"
Mr Dow said incident reports were to alert management of problems.
"There were people on site who must have been aware of these issues. Why didn't they raise them with the board?" Mr Dow asked.
"They did not raise them in monthly reports or when the board was on site, or tell me."
Mr Dow said had he known men's lives were at risk, he would not have tolerated it.
"There are a lot of things [that have] come out I've been horrified at."
Repeatedly, Mr Dow named managers Gordon Ward, Doug White, Mr Rockhouse and Peter Whittall as those responsible for safety.
Engineering, Printing and Manufacturing Union lawyer Nigel Hampton QC listed the directors' backgrounds in banking, wool, accounting, law - but not underground mining.
He produced an email that revealed the board terminated Mr Ward's contract three months before the mine disaster.
At the end of the cross-examination, Mr Dow accepted things should be done differently in future.
He also revealed he knew Pike River underviewer George Mason had been at the Moura Mine, in Australia, when it exploded, and that manager Steve Ellis did not have a qualification when employed.
