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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 hindsight".
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 governments.
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.