Phase Two Hearings Questions
Cause of loss of life: (Issues 2.1 - 2.5)
1. Where within the mine were the men most likely located at the time of the explosion and what activities were being undertaken?
2. Is there any evidence (including video and laser images) that indicates the Coroner’s finding as to the likely cause and timing of the deaths should be re-visited?
Search and Rescue: (Issue 2.5)
3. Were there suitable and sufficient outlets providing means of entry and exit for employees in the mine on 19 November?
4. Were the equipment and facilities for self-rescue adequate, properly maintained and situated in the right places within the mine?
5. Were the self-rescue policies and procedures of the Company clear and were the workers adequately trained?
Emergency Response Planning: (Issues 2.6 - 2.8)
6. Was the Company’s emergency response plan (ERP) adequate for the eventuality of an explosion and had it been tested for this eventuality?
7. Had the Company’s ERP been integrated and tested with those of other agencies including the New Zealand Fire Service and New Zealand Mines Rescue Service (MRS)?
8. Was the Company able to provide fundamental information required for the Search Rescue & Recovery (SR & R) operation?
9. Had the Company planned how testing of the mine atmosphere would occur following an explosion?
The SR & R Operation: (Issues 2.9 - 2.11)
10. Did the organisational structure, communications, information systems and decision-making processes established by the Police enable decisions to be made in a clear and timely manner?
11. Were the multiple levels of the organisational structure and their physical separation a hindrance to effective decision-making?
12. Were the roles of the Company, the Statutory Mine Manager and the other supporting agencies defined and understood by all participants?
13. Were the services of the technical experts used to best advantage?
14. What were the components of the risk assessment structure and did it operate effectively?
15. What was the role of DOL and MRS during the SR & R operation and what contributions did they make to the Incident Management Team?
The decisions reached: (Issue 2.12)
16. Is there an evidentiary basis for the proposition that a “window of opportunity” existed following the first explosion?
17. Were the decisions concerning:
- the survival of the men;
- the transition from rescue to recovery; and
- controlling ventilation, sealing the mine and utilisation of the GAG machine
appropriate and timely?
18.Did the timing of these decisions have any adverse consequences in relation to the number of explosions and the conditions within the mine?
Resources: (Issue 2.13)
19. Were there deficiencies in the availability and level of logistical support for the SR & R operation?
Communications with the families: (Issue 2.20)
20. Were appropriate steps taken to contact the families immediately after the first explosion?
21. Subsequently, when briefings occurred:
- were “false hopes” raised?
- was material information withheld or its release unduly delayed?
If so, was this by design or as a result of the exigencies of the situation?