Commission's Report - Volume 1
This overview is in three parts. First there is a snapshot of the report, identifying some main points. The second part, which is essentially factual, sets out the commission’s views on what happened at Pike River and why. The third part takes a broader view, identifying the lessons learnt from the tragedy and the significant changes required to avoid future tragedies. Recommendations are then made.
Readers requiring more detail should consult the main report (Volume 2).
The Pike River underground coal mine lies high in the rugged Paparoa Range on the West Coast of the South Island. Access to the mine workings was through a single 2.3km stone drift, or tunnel, which ran upwards through complex geological faulting to intersect the Brunner coal seam.
On Friday 19 November 2010, at 3:45pm, the mine exploded. Twenty-nine men underground died immediately, or shortly afterwards, from the blast or from the toxic atmosphere. Two men in the stone drift, some distance from the mine workings, managed to escape.
Over the next nine days the mine exploded three more times before it was sealed. There is currently no access to the mine.
The commission is satisfied that the immediate cause of the first explosion was the ignition of a substantial volume of methane gas. The commission’s report identifies a number of possible explanations for the source of that accumulation of methane, and the circumstances in which it was ignited.
Methane gas, which is found naturally in coal, is explosive when it comprises 5 to 15% in volume of air. In that range it is easily ignited. Methane control is therefore a crucial requirement in all underground coal mines. Control is maintained by effective ventilation, draining methane from the coal seam before mining if necessary, and by constant monitoring of the mine’s atmosphere.
The mine was new and the owner, Pike River Coal Ltd (Pike), had not completed the systems and infrastructure necessary to safely produce coal. Its health and safety systems were inadequate. Pike’s ventilation and methane drainage systems could not cope with everything the company was trying to do: driving roadways through coal, drilling ahead into the coal seam and extracting coal by hydro mining, a method known to produce large quantities of methane.
There were numerous warnings of a potential catastrophe at Pike River. One source of these was the reports made by the underground deputies and workers. For months they had reported incidents of excess methane (and many other health and safety problems). In the last 48 days before the explosion there were 21 reports of methane levels reaching explosive volumes, and 27 reports of lesser, but potentially dangerous, volumes. The reports of excess methane continued up to the very morning of the tragedy. The warnings were not heeded.
The drive for coal production before the mine was ready created the circumstances within which the tragedy occurred.
A drive for production is a normal feature of coal mining but Pike was in a particularly difficult situation. It had only one mine, which was its sole source of revenue. The company was continuing to borrow to keep operations going. Development of the mine had been difficult from the start and the company’s original prediction that it would produce more than a million tonnes of coal a year by 2008 had proved illusory. The company had shipped only 42,000 tonnes of coal in total. It was having some success in extracting coal as it drove roadways but it was pinning its hopes on hydro mining as the main production method and revenue earner. Hydro mining started in September 2010 but was proving difficult to manage and output was poor.
It is the commission’s view that even though the company was operating in a known high-hazard industry, the board of directors did not ensure that health and safety was being properly managed and the executive managers did not properly assess the health and safety risks that the workers were facing. In the drive towards coal production the directors and executive managers paid insufficient attention to health and safety and exposed the company’s workers to unacceptable risks. Mining should have stopped until the risks could be properly managed.
The Department of Labour did not have the focus, capacity or strategies to ensure that Pike was meeting its legal responsibilities under health and safety laws. The department assumed that Pike was complying with the law, even though there was ample evidence to the contrary. The department should have prohibited Pike from operating the mine until its health and safety systems were adequate.
After the explosion a major search and rescue effort was launched. There was no predictable window of opportunity within which the Mines Rescue Service (MRS) could have safely entered the mine. Pike had no system for sampling the mine atmosphere after an explosion and without that information it was impossible to assess the risks of entry. The placement of the main fan underground and the damage caused to the back-up fan on the surface meant that the mine could not be reventilated quickly.
The New Zealand Police led the emergency response and made the major decisions in Wellington. There had been no combined testing of an emergency response of this nature involving Pike, mining specialists, the MRS, the police and emergency services.
For the first few days the families were given an over optimistic view of their men’s chances of survival, but this was inadvertent. When the second explosion occurred five days later any remaining hope disappeared.
The new owner of the mine, Solid Energy New Zealand Ltd, has agreed that it will take all reasonable steps to recover the bodies provided this ‘can be achieved safely, is technically feasible and is financially credible’.  Any recovery will hinge on a resumption of commercial mining operations.
The mine is sealed and its atmosphere is inert. Solid Energy is ensuring the safety of the mine, including physical security, monitoring of the underground atmosphere, checking of seals and contingency planning.
New Zealand has a poor health and safety record compared with other advanced countries. The government has set up an independent ministerial task force to determine if New Zealand’s health and safety system is fit for purpose. The task force will no doubt examine on a broader scale some of the matters that the commission has considered.
To reduce the risks of future tragedies, the commission makes 16 principal recommendations, set out at the end of this volume. Some recommendations have implications beyond the underground coal mining industry.
The commission recommends that there should be a new regulator with a sole focus on health and safety. The new regulator should be a Crown entity with an expert board accountable to the minister and working closely with the Ministry of Business, Innovation and Employment, employers and workers.
Based on the commission’s inquiries, the Health and Safety in Employment Act 1992 is generally fit for purpose but many changes are required to update the mining regulations. The commission recommends that the changes be progressed by an expert mining task force separate from the ministerial task force. The Queensland and New South Wales regulations provide good precedents.
More worker participation in managing health and safety is needed and will require legislative change and guidance from the regulator.
Major improvements to emergency management are required. The first step should be a joint review by the organisations that responded at Pike River, then amendments to the co-ordinated incident management system and finally a programme of testing and simulation of emergencies to iron out any problems.
The statutory responsibilities of directors for health and safety should be reviewed to reflect their governance responsibilities, including their responsibility to hold management to account.
Leaving aside regulatory change, the commission recommends that directors should rigorously review their organisation’s compliance with health and safety laws and assure themselves that risks are being properly managed. Managers should access the best practice guidance available on leading health and safety in the workplace.
The changes recommended by the commission rest firmly on the principle that health and safety in New Zealand can be improved only by the combined efforts of government, employers and workers.
 Deed relating to body recovery at the Pike River Coal Mine, 17 July 2012, SOL0503445.001/2.