The catastrophe at Pike River mine was avoidable, and would not have happened if not for a push for production at the expense of safety, and dangerous assumptions made by everyone from the Department of Labour to the company’s board of directors and senior management that all was well.
The 400-page report of the Royal Commission of Inquiry holds few surprises: for those who sat through the weeks of damning evidence last year and early this year, the three commissioners have arrived at the only conclusions possible: “The drive for coal production before the mine was ready created the circumstances within which the tragedy occurred.”
The board of directors failed to ensure health and safety was being properly managed, management failed to properly assess the risks workers were facing, and the Department of Labour lacked the focus, capacity or strategies to manage its legal responsibilities.
Directors and senior management should have put a stop to mining until the risks could be managed, but they did not.
The Department of Labour should have prohibited Pike from operating until its health and safety systems were adequate, but instead it assumed the company was compliant with the law and did nothing about its inadequacies.
Yet there were signs of trouble on multiple fronts, if anyone had bothered to look or listen. An insurance risk survey three months before the explosion raised serious concerns about the hazards posed by the hydro-mining method adopted by Pike. The board of directors, however, didn’t see the report.
There were warnings contained in the reports of underground deputies and workers who had, for months, been reporting incidents of excess methane and other health and safety problems. In the 48 days before the explosion, there were 21 reports of methane reaching explosive concentrations (between 5 and 15% in volume of air), and another 27 reports of lesser but still potentially dangerous volumes. “The reports of excess methane continued up to the very morning of the tragedy. The warnings were not heeded,” the report says.
There was evidence of reckless behaviour by workers incentivised to push for production targets, who were bypassing safety devices to allow work to continue regardless of the presence of methane.
And there were warnings such as that from experienced miner Brian Wishart, who knew the mine’s methane drainage system was inadequate and emailed management saying: “History has shown us in the mining industry that methane when given the [right] environment will show us no mercy. It is my opinion that it is time we took our methane drainage … more seriously and redesigned our entire system.
Despite the fact that monitoring and measuring of methane is one of the most fundamental aspects of risk management in underground coal mining, Pike had few methane sensors, they were poorly sited, and by the time of the explosion only one was working. Despite the inadequacy of the system, there was enough information to show that methane had reached dangerous concentrations most days after hydro-mining began. “This information was not properly assessed and the response to warning signs of an explosion risk was inadequate.”
As Nick Davidson, lawyer for the Pike families, put it, the commission’s report paints and “unrelenting picture of failure” in a system that was “flawed from the top to the bottom”.
Pike was a new company with no underground coal mining experience, yet it was able to obtain permits to develop the mine with no scrutiny of its health and safety system. It went ahead on the basis of inadequate geological information, employed an inexperienced workforce, encountered endless production delays, was burning through cash, and pushed on aggressively with mining before it had put adequate risk management and safety infrastructure in place.
The explosion of November 19 2010 was a preventable tragedy, but with a mines inspectorate that had been in decline for years, and a board and management who were focused on production, there was no-one to call a halt before the inevitable catastrophe struck.
The commission has recommended sweeping regulatory changes, including the establishment of a new Crown agent focused solely on health and safety, and calls urgently for an effective framework for underground coal mining. Safety needs to be considered from before mining permits are issued, and the statutory responsibilities of directors for health and safety should be reviewed. It says directors should “rigorously review and monitor their organisation’s compliance with health and safety law and best practice.
Worker participation is essential, with trained health and safety reps and union-appointed check inspectors empowered to call a halt to dangerous practices.
The NZ Listener’s Rebecca Macfie was recently awarded the Bruce Jesson prize for journalism to write a book on the Pike River disaster.
For more of her writing on the subject see here.