Commission's Report - Volume 1

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Letter of Transmittal

Coat of Arms

Royal Commission on the Pike River Coal Mine Tragedy

Te Komihana a te Karauna mō te Parekura Ana Waro o te Awa o Pike

To His Excellency, Lieutenant-General The Right Honourable Sir Jerry Mateparae GNZM, QSO, Governor-General of New Zealand

Your Excellency

In accordance with the Letters Patent dated 14 December 2010, as amended on 7 February and 27 August 2012, we have the honour to present to you the report of the Royal Commission on the Pike River Coal Mine Tragedy.

It has been a privilege to undertake this work. We hope that our report will help to ensure that New Zealand does not see a repetition of the tragedy of 19 November 2010 when 29 men lost their lives in the Pike River mine.

Dated this 30th day of October 2012.

The Honourable Graham Panckhurst

Stewart Bell PSM

David Henry  CNZM


The explosion at the Pike River mine on 19 November 2010 brought home to New Zealanders once again the risks of underground coal mining. The 29 men who died follow a long line of other people who have perished in New Zealand mines over the previous 130 years. This, sadly, is the 12th commission of inquiry into coal mining disasters in New Zealand. This suggests that as a country we fail to learn from the past.

The commission was established in December 2010 to report on what happened and what should be done to prevent future tragedies. The terms of reference are on pages 6–9.

In making our inquiries we have gathered voluminous evidence, both written and oral. We have necessarily had to be selective in determining how much can be included in our report. The commission has aimed to be fair to all concerned in the tragedy and has avoided criticising individuals, unless it was necessary to do so to properly explore what happened. The commission is not a court of law and its views and conclusions should not be interpreted as determining, or suggesting the determination of, criminal or civil liability of any person.

The commission has tried to uncover the systemic problems lying behind the tragedy so that recommendations can be made for the future.

One difficulty the commission faced in making its inquiries was that, at the same time, criminal investigations into the tragedy were being conducted by the New Zealand Police and the Department of Labour (DOL). The commission arranged its public hearings in four phases for efficiency and in an endeavour to minimise any conflict with the criminal investigations. The commission used the DOL investigation report and associated material, where it was appropriate to do so, to gain an understanding of what had happened.

The commission’s report is organised into two volumes:

Volume 1 is an overview of what happened at Pike River and what should be done for the future to avoid such tragedies. Sixteen primary recommendations then follow.

Volume 2 is a more detailed and technical analysis of the tragedy, together with the reasoning that led to our recommendations. Volume 2 also contains appendices that further explain the conduct of the commission.

We wish to acknowledge and thank the many people who have assisted us with our inquiries, and our counsel, executive director and staff who have worked so hard. We wish to acknowledge the families of the deceased men. Many attended the commission’s hearings and provided evidence. We were impressed with their fortitude and courage. The commission would also like to acknowledge John Haigh QC, who died during the course of the commission.

The lessons from the Pike River tragedy must not be forgotten. New Zealand needs to make urgent legislative, structural and attitudinal changes if future tragedies are to be avoided. Government, industry and workers need to work together.

That would be the best way to show respect for the 29 men who never returned home on 19 November 2010, and for their loved ones who continue to suffer. 

Hon. Justice Graham Panckhurst              


Stewart Bell PSM


David Henry CNZM 



Pike River mine memorial

Download a PDF version of the Pike River Mine memorial images below: Pike River Mine, Atarau, Greymouth, New Zealand (.pdf) 900kb

Memorial to the 29 people who died in the Pike River Coal Mine Tragedy - image 1

Memorial to the 29 people who died in the Pike River Coal Mine Tragedy - image 2

Terms of reference

Royal Commission on the Pike River Coal Mine Tragedy

Elizabeth the Second, by the Grace of God Queen of New Zealand and her Other Realms and Territories, Head of the Commonwealth, Defender of the Faith:

To The Honourable GRAHAM KEN PANCKHURST, of Christchurch, Judge of the High Court of New Zealand; DAVID ROBERT HENRY, CNZM, Consultant; and STEWART LYNN BELL, Commissioner for Mine Safety and Health for Queensland:



WHEREAS on 19 November 2010, at the coal mine at Pike River, near Greymouth, operated by Pike River Coal Limited, there occurred a major explosion within the mine while 31 employees of, or contractors to, Pike River Coal Limited were underground. Two men escaped the mine; the rest were missing:

WHEREAS on 24 November 2010, before the mine was declared safe for search and rescue operations, a further explosion occurred that was of such severity that expert assessment was that none of those trapped underground could have survived:

Appointment and order of reference

KNOW YE that We, reposing trust and confidence in your integrity, knowledge, and ability, do, by this Our Commission, nominate, constitute, and appoint you, The Honourable GRAHAM KEN PANCKHURST, DAVID ROBERT HENRY, and STEWART LYNN BELL to be a Commission to inquire into and report upon (making any recommendations that you think fit upon) —

(a)        the cause of the explosions in the Pike River Coal Mine (the mine) on, around, or after 19 November 2010; and

(b)        the cause of the loss of life of the men working in the mine; and

(c)        the practices used or other steps taken at the mine for, or related to, its operations and management, including, without limitation, their effectiveness in achieving —

(i)         compliance with the law or recognised practices; and

(ii)        a healthy and safe place of work; and

(d)        the search, rescue, and recovery operations contemplated or undertaken after the explosion on 19 November 2010, including, without limitation, —

(i)         the practices used, other steps taken, and the equipment and the other resources available; and

(ii)        preparedness for those operations; and

(e)        the requirements of the Acts, regulations, or other laws, or of any recognised practices, that govern each of the following:

(i)         underground coal mining and related operations;

(ii)        health and safety in underground coal mining and related operations; and

(f)         how the requirements in paragraph (e) interact with other requirements that apply to the mine or to the land in which it is situated, including, without limitation, those for conservation or environmental purposes; and

(g)        resourcing for, and all other aspects of, the administration and implementation of the laws or recognised practices that apply to the mine or to the land in which it is situated; and

(h)        how the matters referred to in paragraphs (e) to (g) compare with any similar matters in other countries; and

(i)         any other matters arising out of, or relating to, the foregoing that come to the Commission’s notice in the course of its inquiries and that it considers it should investigate: 

Matters upon or for which recommendations required

And, without limiting the order of reference set out above, We declare and direct that this Our Commission also requires you to make recommendations upon or for —

(a)        the prevention, as far as possible, of similar disasters, and the safe working in future of the mine and other mines; and

(b)        what ought to be done, if the mine is not reopened, to ensure the safety of the mine and the surrounding area; and

(c)        practices or other steps for the purposes of search, rescue, and recovery operations in similar disasters; and

(d)        whether any changes or additions should be made to relevant laws and practices:

Exclusions from inquiry and scope of recommendations

But, We declare that you are not, under this Our Commission, to inquire into and report upon the wider social, economic, or environmental issues, such as the following:

(a)        the social consequences, for Greymouth and the West Coast, of the tragedy; and

(b)        the economic impact, on Greymouth and the West Coast, of the tragedy and of coal mining, or any other mining, and related operations; and

(c)        the merits of coal mining, or any other mining, and related operations in New Zealand (including, without limitation, in respect of land, or an interest in land, held under, or held under an Act or Acts listed in Schedule 1 of, the Conservation Act 1987):

“Practices” defined

And We declare that, in this Our Commission, unless the context otherwise requires, practices includes, without limitation, each of the following (however described):

(a)        decision making:

(b)        procedures:

(c)        processes:

(d)        services:

(e)        systems:

Appointment of chairperson

And We appoint you, The Honourable GRAHAM KEN PANCKHURST, to be the chairperson of the Commission: 

Power to adjourn

And for better enabling you to carry this Our Commission into effect, you are authorised and empowered, subject to the provisions of this Our Commission, to make and conduct any inquiry or investigation under this Our Commission in the manner and at any time and place that you think expedient, with power to adjourn from time to time and from place to place as you think fit, and so that this Our Commission will continue in force and that inquiry may at any time and place be resumed although not regularly adjourned from time to time or from place to place:

Information and views, relevant expertise, and research

And you are directed, in carrying this Our Commission into effect, to consider whether to do, and to do if you think fit, the following:

(a)        adopt procedures that facilitate the provision of information or views related to any of the matters referred to in the order of reference above; and

(b)        use relevant expertise, including consultancy services and secretarial services; and

(c)        conduct, where appropriate, your own research: 

General provisions

And, without limiting any of your other powers to hear proceedings in private or to exclude any person from any of your proceedings, you are empowered to exclude any person from any hearing, including a hearing at which evidence is being taken, if you think it proper to do so:

And you are strictly charged and directed that you may not at any time publish or otherwise disclose, except to His Excellency the Governor-General of New Zealand in pursuance of this Our Commission or by His Excellency’s direction, the contents or purport of any report so made or to be made by you:

And it is declared that the powers conferred by this Our Commission are exercisable despite the absence at any time of any one member appointed by this Our Commission, so long as the Chairperson, or a member deputed by the Chairperson to act in the place of the Chairperson, and at least one other member, are present and concur in the exercise of the powers:

And We do further declare that you have liberty to report your proceedings and interim findings under this Our Commission from time to time if you judge it expedient to do so:

Reporting date

And, you are required to report to His Excellency the Governor-General of New Zealand in writing under your hands, as soon as is reasonably practicable but in any event not later than 31 March 2012,[1] your findings and opinions under this Our Commission, together with the recommendations, required and otherwise, that you think fit to make in respect of them: 

And, lastly, it is declared that these presents are issued under the authority of the Letters Patent of Her Majesty Queen Elizabeth the Second Constituting the Office of Governor-General of New Zealand, dated 28 October 1983,* and under the authority of and subject to the provisions of the Commissions of Inquiry Act 1908, and with the advice and consent of the Executive Council of New Zealand.

In witness whereof We have caused this Our Commission to be issued and the Seal of New Zealand to be hereunto affixed at Wellington this 14th day of December 2010. 

Witness Our Trusty and Well-beloved The Right Honourable Sir Anand Satyanand, Chancellor and Principal Knight Grand Companion of Our New Zealand Order of Merit, Principal Companion of Our Service Order, Governor-General and Commander-in-Chief in and over Our Realm of New Zealand.


By His Excellency’s Command —

Prime Minister.

Approved in Council — 

Clerk of the Executive Council.

* SR 1983/225


 Pike River coal mine plan, 2010

Download a PDF version of the map below: Pike River Coal Mine Plan, 2010 (.PDF) 108kb


[1] Extended to 28 September 2012 on 7 February 2012 (CAB Min (12) 3/1); further extended to 30 November 2012 on 27 August (CAB Min (12) 30/7).

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