Two Pike River Mine deputies were fired for serious safety breaches before the deadly November blast, a Department of Labour report released this week reveals.
The Government has made public a review of the Department of Labour's interactions with Pike River, which includes a detailed, independent assessment of four incidents at the mine. One concerned ongoing ventilation problems underground.
The report suggests there might have been grounds for prosecuting Pike River Coal Ltd long before the November 19 explosion. It also contains a suggestion workers were not reporting all incidents to managers.
On one occasion, the "dead man" switch (a failsafe device) was found to be taped open with a cable tie - "a serious safety breach".
Because the deputy responsible was dismissed, the inspector felt he had paid the price and should not be prosecuted.
The report also reveals coal miner Alan Daly climbed up a bolting rig - "a clearly unsafe act" - in order to make some adjustments, catching and injuring his foot in the process.
A report at the time found "there appear to be a number of possible breaches by the company, the injured person and the mine official".
It also found that deputy was "focused on production and extra metres".
However, mines inspectors decided not to take any further action because the deputy in charge was dismissed, and the company was willing to rectify the breach.
This week's report found: "The inspectors used advice, persuasion and negotiation to good effect and, in almost all circumstances, achieved their safety objectives without recourse to either administrative notices or enforcement action".
The report also details just some of the many ignitions underground, focusing on when the tunnel was passing through the Hawea fault, before reaching the coal seam.
The shift log report for November 11, 2008, records four ignitions. It was determined ventilation had been inadequate.
On December 24, 2008, mines inspector Kevin Poynter noted he had "only received advice of two ignitions".
"I have been told by a number of people now that there were at least 10."
A company representative responded: "Don't know who fed you the information but there was a few ignitions on four shifts that I know of ... If there is more tha[t] the supervisors chose not to report then I don't know of them and it is not being investigated."
The report was written by Prof Neil Gunningham, co-director of the National Research Centre for Occupational Health and Safety Regulation at the Australian National University, and senior counsel David Neal, who was involved in the Beaconsfield gold mine case.
