Pike River Royal Commission

Royal Commission on the Pike River Coal Mine Tragedy

pikeriver.royalcommission.govt.nz

 

Commission's Report - Volume 2

< Return to Final Report I Volume 2 - Part 2 >

PART 1: What happened at Pike River

Note: This part of the report has been divided into sections for your convenience. *These documents are in PDF format. If you are unable to open the files you can download and install Acrobat Reader for free from the Adobe website

Download a PDF of Volume 2 - Part 1: What happened at Pike River, 4.3mb*

Section homepage - Context

Context

  • CHAPTER 1 - Friday afternoon, 19 November 2010  (878k)*

    • A tragedy unfolds: Friday afternoon, 19 November 2010
    • A planned maintenance shutdown
    • Signs that all was not well
    • An electrician enters the mine
    • Calls to emergency services
    • Daniel Rockhouse
    • A rescue
    • Two miners walk out of the portal
    • The emergency response

  • CHAPTER 2 - Accident analysis – some concepts  (862k)*

    • Introduction
    • The ‘what/why’ distinction
    • Human factors
    • Personal safety and process safety
    • The ‘Swiss cheese’ model of causation

  • CHAPTER 3 - The promise of Pike  (1.1mb)*

    • Introduction
    • Physical characteristics of the coal field
    • Exploration of the coal field
    • From feasibility to final investment decision
    • Mine development
    • Challenges faced in 2010

Section homepage - Organisational factors

Organisational factors

  • CHAPTER 4 - Organisational structure   (835k)*

    • Board
    • Chief executive
    • Site general manager
    • Underground mine operations
    • Coal preparation plant
    • Engineering
    • Technical services
    • Project and planning
    • Safety and training
    • Environment
    • Human resources

  • CHAPTER 5 - Governance and management  (856k)*

    • Introduction
    • Composition of the board
    • Executive management
    • Legal obligations of directors
    • Governance by the board
    • Pike’s governance documents
    • Risk assessment
    • The challenges facing the board and executive management
    • Board meetings
    • Meetings of the board’s health, safety and environment committee
    • Serious incidents at the mine
    • Challenges facing executive management in 2010
    • Conclusions
    • The future

  • CHAPTER 6 - The workforce   (905k)*

    • Introduction
    • Workforce problems
    • Training at Pike
    • Training of workers
    • Some training issues
    • Contractor problems
    • Conclusions

  • CHAPTER 7 - Health and safety management  (913k)*

    • Introduction
    • Health and safety management systems
    • Requirements of the Health and Safety in Employment Act 1992 (HSE Act)
    • The elements of a health and safety management system
    • The Pike approach
    • Implementing the system
    • Evaluation and monitoring
    • Management review
    • Hazard recording
    • Conclusions

Section homepage - Mine systems

Mine systems

  • CHAPTER 8 - Ventilation  (1.5mb)*

    • Introduction
    • Who designed the Pike River ventilation system?
    • Location of the main fan
    • The ventilation management plan
    • The Pike ventilation system as built
    • The surface fan
    • The main underground fan
    • Explosion protection of the fans
    • Responsibility for ventilation at Pike
    • Sufficiency of ventilation at Pike River
    • Recorded methane spikes
    • Ventilation monitoring
    • Three key decisions
    • Conclusions

  • CHAPTER 9 - Methane drainage  (1.2mb)*

    • Introduction
    • Overview of best practice approach to methane drainage
    • The need for pre-drainage at Pike River
    • In-seam drilling at Pike River
    • Problems with Pike River’s gas drainage system
    • Expert advice on gas drainage
    • Pike’s approach to methane management
    • Conclusions

  • CHAPTER 11 - Electrical safety (1.7mb)*

    • Introduction
    • Electrical systems at Pike River
    • The restricted and non-restricted zones
    • Proximity of non-restricted zone and electrical equipment to utility services
    • The variable speed drives
    • Regular electrical inspections
    • Electrical staffing at Pike River
    • Overall management of electrical safety at Pike River
    • Electrical inspections
    • Conclusions

  • CHAPTER 12 - Hydro mining (1.2mb)*

    • Introduction
    • The hydro-mining technique
    • The development of hydro mining at Pike River
    • Haste to begin hydro extraction
    • Strata control in the hydro panel
    • Ongoing problems
    • Conclusions

 

Section homepage - How did it happen?

How did it happen?

  • CHAPTER 14 - The likely cause of the explosions (994k)*

    • Introduction
    • The cause of the first explosion
    • The ABM20
    • The fuel consumed in the first explosion
    • Possible sources of the methane
    • Difficulties concerning the possible sources of the methane
    • The source of ignition
    • The site of the ignition
    • Conclusions concerning the first explosion
    • The subsequent explosions

  • CHAPTER 15 - Regulator oversight at Pike River (875k)* 

    • Introduction
    • The statutory background
    • The mining inspectorate personnel
    • The operational methods of the mines inspectors
    • Three representative interactions
    • Use of the inspectorate’s powers at Pike River
    • The inspection of mine records
    • Conclusions

Section homepage - After the explosion

After the explosion

  • CHAPTER 16 - Search, rescue and recovery (1mb)*

    • Deployment of Pike’s emergency response management plan (ERMP)
    • Police control of the emergency
    • So much for the principles. How were they applied in practice?
    • Role of the Department of Labour (DOL)
    • The risk assessment process
    • Assessment of survivability
    • Sealing the mine
    • The availability of information on 19 November 2010
    • Was there a ‘window of opportunity’?
    • Self-rescue
    • The deaths of the men
    • The recovery operation

  • CHAPTER 17 - The families of the men (855k)*

    • Introduction
    • Initial contact with family members
    • Communications with family during the rescue phase
    • Communications during the recovery phase
    • Responsibility for recovery
    • Welfare support provided to the families
    • Conclusions

< Return to Final Report I Volume 2 - Part 2 >