Pike River “accident waiting to happen”

Evidence from the Royal Commission of Inquiry into the Pike River tragedy shows there were signs everywhere that the organisation was unsafe.

Photo David White

Were warnings of impending disaster at Pike River Coal lost in translation, or were they ignored by a company that couldn’t afford to listen?

As Pike spiralled towards catastrophe in the months leading up to November 19, 2010, the company’s credibility and financial security were reliant on getting its long-overdue hydraulic mining operation up and running. By then, the ambitious assumptions underpinning the mine project had caught up with it. It had told its many investors the Brunner coal seam, where the Pike field is located, produced only low to moderate volumes of methane gas and could therefore be mined safely; in fact, locals knew Pike to be a very gassy mine, and testimony last week from Japanese mining expert Masaoki Nishioka suggested it was one of the gassiest in the world.

Pike’s promise that by 2009 it would be extracting around a million tonnes a year of coking coal had become a distant memory. By late 2010 it had managed to scratch out a couple of shipments totalling just 42,000 tonnes, and it desperately needed to get another one away by the end of the year.

The happy, safe and growing workforce pictured in corporate publications was instead a largely inexperienced and sometimes inadequately trained crew. Some, according to evidence filed with the commission, didn’t even know their way out of the mine.

While Pike’s then-general manager, Peter Whittall, was off founding a new business organisation targeting “zero harm” workplaces, his own staff were recording a litany of safety breaches and concerns that should have alerted a diligent organisation that all was not well.

Health and safety expert Kathleen Callaghan, who has inspected a sample of Pike’s incident reports from October and November last year, told the commission the documents highlight “significant and recurring risks to safety”. Among them, inadequate ventila­tion, ignitions, contraband found underground (including a cigarette lighter), phones that didn’t work, slack housekeeping, misplaced explosives, poor follow-up of incidents and a lack of formal procedures for critical tasks such as degassing the mine.

There was shortage of qualified staff, turnover was high and there was concern about the quality of supervision underground.

Dave Stewart, a mining consultant and chairman of the Mines Rescue Trust, who did a series of audits in March and April 2010, described the place as “dysfunctional”, with a high level of mistrust.

It was into this environment that in July 2010 Pike threw a juicy carrot for its workers: they could earn a bonus of up to $10,000 if the com­pany’s new hydraulic mining system was up and running by September 24 and certain production targets were met.

The system, which carves coal from the face with a high-pressure water jet, is a complex operation that releases large and unpredictable volumes of methane and requires skilled miners to work it. Yet Pike hired George Mason, an Australian miner with no experience in the method, as the co-ordinator of the hydraulic operation. Indeed, Mason didn’t even have current mining certification, having ­relinquished it following the 1994 Moura mine disaster in Queensland, where he had held an underground management role.

Mason’s key source of instruction when he arrived at Pike in August last year was Nishioka, a world expert in hydraulic mining, whom the company had engaged the previous month to commission the system. Nishioka was deeply troubled by what he saw at Pike – in particular, inadequate ventilation, no emergency escape-way, very high gas levels and flawed mine design.

Slightly built, deferential, and with excellent but heavily accented English, Nishioka says he spoke “strongly” to mine manager Doug White and Whittall about his ventilation concerns, the lack of a second exit and his view that hydraulic mining should not start until both issues were fixed. Whether he was ignored or simply misunderstood is in dispute – both White and Whittall deny his warnings. Nishioka told the commission Whittall could have had no doubt as to his meaning, however: as a miner with more than 20 years’ experience, Whittall would know the significance of high gas levels and ventilation problems without having to be told “over and over”.

Nishioka says he also expressed his concerns – including the risk of explosion – with Mason, who didn’t discuss it with anyone. Mason told the commission he sometimes found Nishioka difficult to understand, and thought the installation of a big new underground fan, which was started in early October, would fix the problem.

Nishioka left Pike at the end of his three-month contract on October 20, fearing an explosion could occur any time. While at the mine he kept a detailed daily account of developments underground. The notes reveal that virtually every time the hydraulic mining machine was used, methane levels rose into the explosive range. The notes ­indicate that on many occasions when this happened, the men were not withdrawn from the mine, as is required by the underground mining regulations.

They also reflect his ongoing anxiety that the hydraulic mining system was being pressed into action before the new ventilation fan was installed, and reveal that when the fan was introduced in early October it frequently tripped out. He also thought Pike’s gas detectors were inadequate, but when he suggested a type that would give more detailed information, the idea was rejected because of cost.

Masaoki Nishioka, photo Deidre Mussen/The Press

Nishioka was also acutely aware of the workers’ desire to see the hydraulic mining system operational so they would get their bonus. Every week of delay meant it would be reduced by $2500. At the commission, he spoke of his “agony” at Pike’s poorly engineered system, and feeling powerless to stop men working underground.

He wasn’t alone in seeing problems with the hydraulic mining system. On November 3 – just over two weeks before the first explosion – a team of hydraulic mining staff from Solid Energy were invited to Pike to advise on ways to improve the system’s poor productivity. They concluded Pike didn’t understand the conditions it was working in, and hadn’t invested in the necessary development and infrastructure, Solid Energy’s underground mine manager, Craig Smith, told the commission.

They noted the inexperience of the Pike team, and that the set-up was “materially different” from Solid Energy’s Spring Creek hydraulic system. They suggested various changes to Pike. The following day Whittall – by then Pike’s chief executive – mentioned the visit in an email to his board. “[Solid Energy] concluded that our systems and cutting techniques were consistent with their own and had no significant advice to offer at this stage.”

Callaghan, a doctor specialising in occupational medicine, warned in her evidence that Pike River should not be seen as just a mining ­disaster, but that it carried lessons for health and safety throughout New Zealand that must not be ignored. She classed Pike as an “organisational accident”, alongside Three Mile Island, Chernobyl, Erebus and the Deep Water Horizon. Because it was a start-up operating in harsh and complex conditions and using an unfamiliar method, there should have been vigilant internal and external oversight of safety.

Using the “Swiss cheese” model of organisational accidents made famous by Manchester University’s Professor James Reason, she said each hazard – safety ­violations, inexperience, financial pressure, high turnover, lack of follow-up and so on – was like a hole in a layer of cheese. A company’s safety system should eliminate or reduce the size of the holes, because the more holes and the larger they are, the more likely they will line up and allow a catastrophe to occur. At Pike River, holes were “opening up all through the cheese”.

“In crude terms, the evidence I have seen indicates that Pike River mine was an ­accident waiting to happen.”

Click here for all of Rebecca Macfie’s coverage of the Royal Commission of Inquiry into the Pike River tragedy.