Evidence at the New Zealand Pike River Royal Commission investigating a mining disaster that killed 29 people, prove that some employers and some inspectors are not motivated by safety.
It is a year since the Pike River mining disaster and I continue to pray that people and organisations would learn from industrial history. I am increasingly disheartened by what I see and hear.
The horrific loss of life in one event is difficult to absorb. It is when you hear the same things being identified that we have all heard before, that you really want to shake the living daylights out of someone and scream in their ears.
It has been said that the development costs of the mine had exploded (a poor, yet appropriate, choice of words) from Australian $30 million (1995) to over Australian $350 million (2010).
Loans against the operation were enormous, the production was significantly below projections, and there was constant pressure to increase production – at the expense of workplace safety.
The operation also confronted geological challenges. Pike River was commonly known as a ‘gassy’ mine. There are pockets of methane gas all over the place. It is this gas which is highly volatile and at high risk of leading to explosive events.
There is absolute certainty that methane was the gas that led to the unnecessary deaths of 29 fathers, grandfathers, brothers and sons.
Pike River was using a specialised form of extraction known as hydro mining. They removed rock by way of high pressure water streams. One person who has given highly regarded evidence is Masaoki Nishioka, a globally recognised hydro mining expert.
Ventilation fans incorrectly placed
His evidence stated that he had warned the senior management of Pike River that their entire design layout was dangerous, ventilation fans had been incorrectly placed, along with several other problems.
Whenever methane levels went above safe levels, fans would fail. The key engineering control to mitigate high methane levels failed at precisely the point at which they were critically required.
Allowed to continue while unsafe
Senior management at Pike River deny they had been warned by Nishioka. It is not my place to judge the truth, or otherwise, of the allegation. What cannot be denied though is the fact that the fans failed when they were required, and that this system fault was known – and the operations were allowed to continue.
Add to that the fact that records show that there were higher than normal – and normal was pretty high – methane spikes during October, the month prior to the explosion), and we see a highly toxic combination of circumstances.
Cigarette butts were found in the mine – they even found a cigarette lighter as well. Even I find that difficult to comprehend. We have a “gassy” mine, and there are known to be workers smoking in the mine.
Pike River gas monitoring equipment had been deliberately tampered with. Can you believe it? In days gone by underground miners would carry canaries into the mine and this was a key method of being protected from gas.
If the canary was ill or on the bottom of the cage, you got out of there pretty damn quick. I personally recall having colleagues jump over me to get out of a Stove Cabin at a Blast Furnace, BHP Steelworks, N’cle.
It was standard practice to enter the room, glance left, say g’day to the canary, and get on with the job. Till one morning when the canary was laying, legs in the air, on the bottom of the cage. The thing probably died of old age – but nobody took any chances and we were out of there.
In days gone by I do not believe a mine manager would provide to the workforce a dead canary to take into the mine as their gas monitoring device – it sound ridiculous even suggesting it.
Mining with a ‘dead canary’
I cannot imagine a worker walking into any mine with a dead canary under their arm. Yet at Pike River that is precisely what appears to have happened. In my view that sort of action is equivalent to murder.
When I consider the behaviour in question (sabotaging a safety device) I am left with a couple of possibilities, but most likely, gas monitoring equipment was deliberately “adjusted” so as not to interfere with the production requirements that were being so powerfully promoted.
Raising risk tolerance
Someone may have thought they were doing the ‘right’ thing by raising risk tolerance. Over time unsafe behaviours do not result in a system failure – so there develops a sense of “invulnerability” and the unsafe behaviours become the “norm”. Even smoking inside a known gassy mine.
What about the regulatory environment? Much of the above comments relate to failure of systems and toxic behaviours in the Pike River workplace community itself. We should not let the New Zealand Department of Labour off lightly.
They have a statutory responsibility to monitor and regulate exactly these sorts of operations, and they failed miserably. In two and a half years the Pike River site had been inspected only seven times.
Inspectors claimed they had not been shown log books and other safety related records. On other occasions they did not even look at what they did have. It needs to be said, they do not appear to have “asked” much either.
Looks more like turning up for “tea and biscuits” and taking a bit of a “walk”. In the case of one Inspector, he acknowledged that he was “not good at taking notes”. Sorry! A key requirement of any regulatory process is maintaining an audit trail back to process!
The lacksadaisical methods described within this context, when added to the ingredient of a toxic safety culture (with criminal failures at the level of safety leadership) is a recipe for disaster.
In my heart of hearts I sadly believe that Pike River was always going to have an ignition of methane.
The abject failure to even recognise the risk is, in my view, culpably negligent. New Zealand Department of Labour inspector Michael Firmin, who inspected the mine a number of times between 2005 and 2008, said there was no formal auditing of the Pike River health and safety management systems during his time as an inspector. By the Company or the Regulator.
“I did inspections underground and at times you may identify a problem with the health and safety management system but no, I certainly didn’t do any formal auditing,” Firmin said. In other words all that happened was the odd safety walk, and we have seen by the time frame, these were very ‘odd’ or infrequent indeed.
When asked if the Department had provided Firmin with any training in auditing a mine system he revealed it had not, while a discussion prior to the disaster about the Department getting an audit tool or system had been dismissed.
“…we had brought that up at a mining steering group meeting that we would like to do some audits, but nothing ever came of it,” Firmin said.
During more vigorous questioning Firmin revealed he didn’t know if Pike River had a formal system for identifying hazards (I consider this ‘criminal ignorance” for a safety inspector to admit to this), and he had never been involved in an underground coal mining incident prior to Pike River. He further alleged the Department had never given him any training in assessing complex issues such as methane drainage and ventilation systems.
He also said the New Zealand Department of Labour never oversaw the inspectors, and the Department had never reviewed his assessment processes at the mine, adding they had “quite a lot of flexibility in a sense of the approach that we would take”. In other words what we see described is an “almost anything goes” culture being described.
Firmin confirmed that the Department had never considered engaging expert advice in relation to any aspect of the Pike River mine prior to the tragedy.
Firmin was questioned about whether or not his inspections at Pike River complied with the rules set out in the Health and Safety in Employment Act.
“I take it, fair to say at this stage that the inspections that you conducted at Pike River and the enquiries you made weren’t sufficient for you to be able to form a view as to whether or not Pike River and its contractors were complying with the Health and Safety in Employment Act and Regulations?,” he was asked.
“Well, true, we weren’t … when I look back once every three months was obviously not enough and we should have been auditing,” Firmin responded.
Inspector Kevin Poynter said he was given a log book detailing incidents at Pike River but he was too busy to spend any time with them. As it turns out, from previous evidence, he may well not have understood the implications of what was contained within anyway.
“There were several occasions where I was asked to do non-mining work in non-mining workplaces such as first response to an accident that occurred on a farm, first response to an incident in a factory and a fish-filleting icebox,” Poynter said.
“So in addition we were really busy and we just didn’t have the time to be able to sit down and go through these documents.
“We were two inspectors, we were dysfunctional in that we reported to separate managers, and we had one adviser with no coal background.”
During his evidence, Poynter took the time out to describe his personal thoughts towards the issues that were being raised throughout the day, reminding the inquiry that he was just “one person”.
“It’s really difficult for me as one individual to be able to be responsible for the follow-up of every action that is sitting in front of us,” he said.
“I can’t do the job or be expected to do a job at a mine, when it’s got a whole raft of management structure. They’ve got ventilation engineers, they’ve got geotech, they’ve got designers, they’ve got consultants – and I’m there on my own, trying to do the whole lot and it’s really a difficult job. “We can’t be everything, sorry.”
Low skilled inspectors raise risks
Some beaurocrats hide in a maze of structures that often exist within governmental oversight mechanisms. To place inexperienced, underqualified pople as lead inspectors within a mining operatrion, that was known to be “risky”, is in itself a position that requires a clear response.
It is well and good to charge the mine manager – and I agree with that decision. To allow the New Zealand Department of Labour to scurry away into a dark corner and wait for the lights to be turned down is an opportunity lost. Twenty nine people lost their lives.
They lost their lives for no defensable reason. The deaths at Pike River were no accident. There were no ‘Acts of God’ here. These people died at the hands of men.
* This blog is an extract from the author’s circular on Transformationalsafety.com, where photographs and short biographies of the 29 Pike River victims are included.
• David G Broadbent is a safety psychologist based in Australia, founder of Transformationalsafety.com, and consults a number of corp0rate clients in India and Africa.