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Royal Commission on the Pike River Coal Mine Tragedy 2012

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Royal Commission on the Pike River Coal Mine Tragedy 2012 H.3 Royal Commission on the Pike River Coal Mine Tragedy Te Komihana a te Karauna mo- te Parekura Ana Waro o te Awa o Pike Volume 2 + Part 1: What happened at Pike River + Part 2: Proposals for reform 2012 Author: Royal Commission on the Pike River Coal Mine Tragedy Date of Publication: October 2012 Place of Publication: Wellington, New Zealand ISBN: 978-0-477-10378-7 Cover image: Western Escarpment, Paparoa Range, West Coast, New Zealand Website: www.pikeriver.royalcommission.govt.nz 2 Volume 2 - Part 1: What happened at Pike River Contents List of figures 8 Board 46 Chief executive 46 Glossary 10 Site general manager 47 Explanatory note on the page numbering Underground mine operations 47 of references 16 Coal preparation plant 48 PART 1: What happened at Pike River Engineering 48 Technical services 48 Context 19 Project and planning 48 CHAPTER 1 Safety and training 49 Friday afternoon, 19 November 2010 20 Environment 49 A tragedy unfolds: Friday afternoon, Human resources 49 19 November 2010 20 CHAPTER 5 A planned maintenance shutdown 21 Governance and management 50 Signs that all was not well 22 Introduction 50 An electrician enters the mine 22 Composition of the board 50 Calls to emergency services 23 Executive management 50 Daniel Rockhouse 24 Legal obligations of directors 50 A rescue 25 Governance by the board 51 Two miners walk out of the portal 25 Pike’s governance documents 51 The emergency response 25 Risk assessment 52 CHAPTER 2 The challenges facing the board and executive Accident analysis – some concepts 27 management 52 Introduction 27 Board meetings 52 The ‘what/why’ distinction 27 Meetings of the board’s health, safety and environment committee 53 Human factors 27 Serious incidents at the mine 55 Personal safety and process safety 28 Challenges facing executive management in 2010 55 The ‘Swiss cheese’ model of causation 29 Conclusions 56 CHAPTER 3 The future 56 The promise of Pike 31 Introduction 31 CHAPTER 6 The workforce 58 Physical characteristics of the coal field 31 Introduction 58 Exploration of the coal field 33 Workforce problems 58 From feasibility to final investment decision 34 Training at Pike 61 Mine development 36 Training of workers 63 Challenges faced in 2010 42 Some training issues 64 Organisational factors 45 Contractor problems 66 Conclusions 67 CHAPTER 4 Organisational structure 46 Royal Commission on the Pike River Coal Mine Tragedy Te Komihana a te Karauna mō te Parekura Ana Waro o te Awa o Pike 3 CHAPTER 7 CHAPTER 10 Health and safety management 70 Gas monitoring 133 Introduction 70 Introduction 133 Health and safety management systems 70 Remote gas monitoring 133 Requirements of the Health and Safety Machine-mounted and hand-held gas monitoring 140 in Employment Act 1992 (HSE Act) 71 Conclusions 143 The elements of a health and safety management CHAPTER 11 system 71 Electrical safety 146 The Pike approach 71 Introduction 146 Implementing the system 73 Electrical systems at Pike River 146 Evaluation and monitoring 76 The restricted and non-restricted zones 147 Management review 77 Proximity of non-restricted zone and electrical Hazard recording 78 equipment to utility services 148 Conclusions 78 The variable speed drives 149 Regular electrical inspections 150 Mine systems 81 Electrical staffing at Pike River 151 CHAPTER 8 Overall management of electrical safety Ventilation 82 at Pike River 152 Introduction 82 Electrical inspections 153 Who designed the Pike River ventilation system? 83 Conclusions 154 Location of the main fan 84 CHAPTER 12 The ventilation management plan 87 Hydro mining 156 The Pike ventilation system as built 89 Introduction 156 The surface fan 90 The hydro-mining technique 156 The main underground fan 92 The development of hydro mining at Pike River 159 Explosion protection of the fans 94 Haste to begin hydro extraction 162 Responsibility for ventilation at Pike 96 Strata control in the hydro panel 166 Sufficiency of ventilation at Pike River 104 Ongoing problems 169 Recorded methane spikes 105 Conclusions 169 Ventilation monitoring 107 Three key decisions 107 How did it happen? 173 Conclusions 107 CHAPTER 13 CHAPTER 9 Pike’s safety culture 174 Methane drainage 112 Workplace culture 174 Introduction 112 A number of cultural influences 175 Overview of best practice approach to methane The risk of an explosion 176 drainage 112 Conclusions 177 The need for pre-drainage at Pike River 115 CHAPTER 14 In-seam drilling at Pike River 116 The likely cause of the explosions 179 Problems with Pike River’s gas drainage system 120 Introduction 179 Expert advice on gas drainage 122 The cause of the first explosion 179 Pike’s approach to methane management 126 The ABM20 179 Conclusions 129 4 Volume 2 - Contents The fuel consumed in the first explosion 181 the rescue phase 237 Possible sources of the methane 183 Communications during the recovery phase 240 Difficulties concerning the possible sources Responsibility for recovery 242 of the methane 185 Welfare support provided to the families 242 The source of ignition 185 Conclusions 244 The site of the ignition 189 Conclusions concerning the first explosion 190 PART 2: Proposals for reform The subsequent explosions 190 CHAPTER 15 History 247 Regulator oversight at Pike River 194 CHAPTER 18 Introduction 194 Major change is required 248 The statutory background 194 Introduction 248 The mining inspectorate personnel 195 New Zealand’s poor health and safety performance 248 The operational methods of the mines inspectors 195 Overseas health and safety regimes 249 Three representative interactions 196 The 1972 Robens committee 250 Use of the inspectorate’s powers at Pike River 200 The Health and Safety in Employment The inspection of mine records 202 Act 1992 (HSE Act) 251 Conclusions 203 Recent government initiatives 252 CHAPTER 19 After the explosion 207 Coal mining in New Zealand 254 CHAPTER 16 Introduction 254 Search, rescue and recovery 208 New Zealand coal fields 254 Deployment of Pike’s emergency response New Zealand coal mining industry 256 management plan (ERMP) 208 Australian coal mining industry 257 Police control of the emergency 210 Conclusions 257 So much for the principles. How were they applied in practice? 211 CHAPTER 20 A failure to learn 258 Role of the Department of Labour (DOL) 216 Introduction 258 The risk assessment process 217 New Zealand coal mine tragedies 258 Assessment of survivability 217 Overseas tragedies 261 Sealing the mine 218 Non-coal mining tragedies 263 The availability of information on 19 November 2010 219 Conclusions 264 Was there a ‘window of opportunity’? 221 Self-rescue 222 The regulators 265 The deaths of the men 228 CHAPTER 21 Collaboration between government agencies 266 The recovery operation 232 Introduction 266 CHAPTER 17 Law reform 266 The families of the men 236 The regulatory framework 267 Introduction 236 Conclusions 268 Initial contact with family members 236 Communications with family during Royal Commission on the Pike River Coal Mine Tragedy Te Komihana a te Karauna mō te Parekura Ana Waro o te Awa o Pike 5 CHAPTER 22 TheT regulatory framework 305 The decline of the mining inspectorate 270 CHAPTERC 26 Introduction 270 AAn effective regulatory framework 306 The inspectorate under the Coal Mines Act 1979 270 IntroductionIn 306 The transition period from the early 1990s to 1998 271 TThe general regulatory framework 306 The mining inspectorate from 1998 273 TheT adequacy of the general supporting framework 307 Conclusions 278 AAn inadequate framework for underground mining 307 CHAPTER 23 TheT mining regulations 307 Management of the mining inspectorate 280 SSafety cases 309 Introduction 280 TThe penalty regime 309 Management and support 280 AAn effective supporting regulatory framework Lack of guidance information 283 forfo underground coal mining 310 Inadequate reviews of inspectors 283 CChanges for the task force to consider urgently 310 Resourcing of the mining inspection function 283 RRecommendation 2 314 Oversight of the mining inspection function 284 CHAPTERC 27 The Gunningham and Neal review 285 SStrengthening the Crown minerals regime 317 2006–09 mining policy review 285 IntroductionIn 317 Risk registers 286 SSummary of law 317 Conclusions 286 ProblemsP with permitting 318 CHAPTER 24 GGood mining practice 319 Effectiveness of the health and safety regulator 288 RRecent developments 320 Introduction 288 RRecommendation 3 321 Changes to the Department of Labour since RRecommendation 4 321 the Pike River tragedy 288 Leadership of health and safety 289 IndustryI and workers 323 The functions and structure of the CHAPTERC 28 Department of Labour 289 ImImproving corporate governance 324 Shared responsibility at governance level 292 IntroductionIn 324 High-level health and safety expertise 292 TThe board of directors 324 The Department of Labour’s 10-year strategy 293 GuidanceG available 326 Focusing on high-risk sectors 294 RRecommendation 5 328 Accountability and review of the department 295 RRecommendation 6 328 Conclusions 296 RRecommendation 7 328 CHAPTER 25 CHAPTERC 29 A new regulator 298 ImImproving management leadership 329 Introduction 298 IntroductionIn 329 Functions 298 LLeading improvements in health and Form of a new regulator 298 ssafety performance 329 Compliance strategy 301 SStrengthening the statutory mine manager’s role 330 Resourcing 302 RRecommendation 8 331 Recommendation 1 303 RRecommendation 9 331 RecommendationR 10 331 6 Volume 2 - Contents CHAPTER 30 AppendicesA 367 Worker participation 332 1:1 Conduct of the inquiry 368 Introduction 332 EstablishmentE of the commission
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