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A Systems Failure: How the Cherries Lined up the Pike River Mine Disaster

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A Systems Failure: How the Cherries Lined up the Pike River Mine Disaster A systems failure: how the cherries lined up THE PIKE RIVER MINE DISASTER HFESA Ron Cummings Memorial Lecture 2018 Jim Knowles November 2018 1 Background Friday, 19 November 2010 At 3:45pm, the Pike River Underground Coal Mine, near Greymouth on the west coast of the South Island, New Zealand, exploded 29 men underground died immediately or later, from the blast or from the toxic atmosphere Over the next nine days the mine exploded three more times before it was sealed. November 2018 2 The survivors Two men in the stone drift, some distance from the mine workings escaped with minor injuries. Daniel Rockhouse and Russell Smith November 2018 3 Background November 2018 Pike River Mine is still an unexplored crime scene. There has been no forensic examination of the drift or mine. No-one has been able to explain categorically what happened that day. November 2018 4 Greymouth November 2018 5 The Terrain November 2018 6 The Mine The portal (entrance) Ventilation shaft Mine workings The stone drift – 2.4km Pit bottom in stone November 2018 7 Fire at the ventilation shaft November 2018 8 Smoke from the ventilation shaft November 2018 9 The poker machine analogy “the cherries” November 2018 10 How the cherries lined up Fire Suppression Unit Accident Cherries Legislation changes Loss of specialist knowledge and skills Costs and production pressures Poor mine design and maintenance Management structure and culture Operational issues Human resources November 2018 11 The path to tragedy Changes in legislation Mines came under Health Safety and Employment Act 1992 Coal Mines Act (1st April 1993) repealed Cost cutting within the department lead to reduced inspections and money for investigation November 2018 12 The path to tragedy Loss of specialist knowledge and skills Transfer of specialist mines inspectors from Ministry of Commerce to the Department of Labour (DoL) Decline in numbers of specialist mine inspectors under the DoL Appointment of a poorly qualified hydro-mining engineer with a history of reports critical of his performance November 2018 13 The path to tragedy Cost and production pressures Mine development in difficult geological conditions leading a vent shaft collapse Above ground infrastructure costs overrun leading to short cuts in the actual mine development November 2018 14 The path to tragedy Mine design and maintenance Difficult terrain Inadequate geological information Lack of mine inspectorate oversight particularly in relation to ventilation Gassy mine (high levels of methane) with frictional ignition Inadequate ventilation system and gas monitoring Poorly maintained rescue equipment Inadequate emergency planning November 2018 15 The path to tragedy Mine management structure and culture High turn over of mine managers Micro management and bullying Lack of experience in the particular conditions Reports of serious issues underground were not dealt with Board pressure to increase production Board took a ‘hands off’ approach with no underground coal mining experience November 2018 16 The path to tragedy Operational issues Shifts, maintenance schedules Equipment not Fit-for-Purpose Geographical issues – difficult access and unstable strata Difficult mining conditions – wet, steep, cold, strata control November 2018 17 The path to tragedy Human resources High turnover of staff and employees Lack of experienced mine workers (only 5 with more than 2 years) Inadequate training Poor workplace culture leading to low workforce morale Poor communication and decision making Reliance on individual behaviour rather than safe systems of work November 2018 18 In summary Failures in every aspect of regulatory responsibility and mine management Every category of human error at every level The cherries lined up November 2018 19 The ‘Event’ November 2018 20 The Aftermath Poor decisions after the initial explosion Unco-ordinated mines rescue Withholding of information Broadcasting incorrect information particularly to families of the dead miners A strong push to cover up what went wrong (no political will for a forensic investigation) November 2018 21 Some findings of the Royal Commission 2012 Error is a characteristic of human behaviour and therefore inevitable in any human system It follows that any system relying on error-free human performance is fundamentally flawed Accidents are rarely the result of a single action, failure or factor, but rather of a combination of personal, task- related, environmental and organisational factors, some longstanding. November 2018 22 2017 Change of government - the Labour Party had won government with the promise to investigate what went wrong at Pike River and if possible, re-enter the mine drift A minister was given responsibility to oversee the process of recovery On 20 November 2017 the government announced the formation of the Pike River Recovery Agency (PRRA) November 2018 23 The Families Some of the dead miners families had been actively protesting for seven years to get answers as to why the mine blew up, and to retrieve bodies. They had blockaded the mine to prevent it being permanently sealed and had lobbied politicians and bureaucrats to get some action November 2018 24 The Families Formation of the Families Reference Group The Group was formed to fight for information, justice and accountability It had the support of a number of mining experts, politicians and the wider community November 2018 25 Re-entry and Recovery Concept Development November 2018 26 Pike River Recovery Agency (PRRA) On 31 January 2018, the PRRA formally came into existence with its headquarters in Greymouth and with a budget of over NZ$ 30 million November 2018 27 Senior Appointments Major General David Gawn, CEO, PRRA Rob Fyfe previous CEO Air New Zealand, and advisor to the Minister. November 2018 28 Pike River Recovery Agency • Established as a stand-alone government department by Order in Council on 31 January 2018 • Subject to the development of a detailed operational plan being approved by the Minister • Objectives are to conduct a safe manned recovery of the mine drift in order to: o Gather evidence to better understand what happened in 2010 with an eye to preventing future mining tragedies, and promoting accountability for this mining tragedy o Give the Pike River families and victims overdue closure and peace of mind and o Recover remains where possible. November 2018 29 Phase one – Risk Analysis Three options for re-entry to the stone drift Option A – ‘Small Tunnel’ involves the construction of a small 2 metre by 2 metre tunnel Option B – ‘Single Entry’ (Existing Drift) using the current access tunnel Option C – ‘Single Entry’ (Large Diameter Borehole) involves the drilling of borehole of 600mm diameter or greater. This was discarded as an option during the Peer Review process. November 2018 30 Phase one – Risk Analysis November 2018 31 Options A – New egress Nitrogen pumped into mine inbye of the rock fall Vent shaft Mine workings inbye Re-entry via new egress tunnel Outbye Intake air Rock fall Portal Stone drift (tunnel) New egress tunnel exhaust November 2018 32 Site of operations for Option A Very steep gully both sides Therefore very difficult access for heavy machinery and helicopters Possible portal location November 2018 33 Option A – new egress Possible portal locations Current portal Admin buildings November 2018 34 Option B - Single entry Nitrogen pumped into mine inbye of the rock fall Pit bottom Vent shaft Mine workings inbye Outbye Intake air Portal Return air Rock fall Re-entry via stone drift (tunnel) November 2018 35 Risk analysis tables November 2018 36 Risk Analysis results Very high and high safety risks Option A Total of 135 risks Option B Total of 118 risks Option C Total of 134 risks Safety, Environment, Reputation and Value risks Option A Total of 670 risks Option B Total of 546 risks Option C Total of 689 risks November 2018 37 Risk analysis results Figures supplied by Robin Hughes November 2018 38 Phase Two – Peer review session The Peer Review team met in early October and consisted of: • 12 Technical experts with a diverse amount of expertise in Mining, Strata Management, Ventilation and Environmental controls • 4 Active listeners • Members of the Families Reference Group November 2018 39 Phase Two - Peer Review session The mandate of the Peer Review team was to: • critique and review each of the proposed options for the re-entry • assess the adequacy of the proposed control measures identified in the risk assessments. • re-rank the ‘residual’ risk November 2018 40 Risk analysis November 2018 41 Risk review process November 2018 42 Phase Two - Peer review The Peer Review Group agreed that all of the options considered were feasible and all could be done safely. Option C (large diameter borehole) was discarded by both of the review teams for practical reasons November 2018 43 Recommendation On 14 November the NZ government accepted the PPRA recommendations to attempt a re-entry of the drift, with Option B the preferred method, subject to further scrutiny by WorkSafe NZ It is likely that this will occur in the first quarter of 2019 November 2018 44 Issues with re-entry Forensic evidence is correctly secured, examined, transported and identified Police need to be trained to enter mine and collect forensic evidence If not feasible, capable underground personnel will need to be trained in forensic DVI search procedures and techniques wearing body cameras and being directed and advised by police from the surface.
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