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Coal Mines Act (1st April 1993) repealed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.
November 2018 45 Issues with re-entry
The coroner will ask the Solicitor General to re-open the inquest if new evidence or human remains are discovered
Psychological stresses associated with recovering bodies and re-opening a disaster site after 8 years
November 2018 46 Issues with re-entry
Approving equipment to go underground Transporting large plant and equipment to site with restricted access .
Plant being transported to Team at site of site nitrogen plant
November 2018 47 Summary
‘If you think that safety is expensive, try having an accident’
November 2018 48 A cost of human error 49
November 2018 49 In memory of the Pike River 29
November 2018 50 Acknowledgement
I would like to thank Colin Smith, solicitor of Greymouth, NZ, whose presentation at the University of Otago in 2016 was the source of some of the material presented here today. His nephew, Michael Monk, died in the Pike River Mine explosion. I would also like to thank the PRRA team and the families technical reference group
November 2018 51 THANK YOU
November 2018 52