Joseph Dunbar was 17 years old when he set out for work on November 19, 2010. He was so excited about the prospect of a career in the mining industry, he'd begged to start a day early. He never came home.
OPINION: Joseph's is one of 29 faces looking out from the pages of the royal commission report on the Pike River mining tragedy. Young, old, bearded, beardless, they are the faces of husbands, fathers, sons and brothers who put their trust in lawmakers and bureaucrats, and the owners and managers of a new project touted as pioneering a less invasive form of ''keyhole'' mining on the South Island's West Coast.
That trust was wholly misplaced.
Without being able to gain access to the now-sealed mine, the commission has not been able to identify what triggered the methane explosion that claimed the men's lives. It could have been an electrical fault, friction or gas coming into contact with a hot surface.
But the commission, chaired by West Coast-born High Court judge Justice Graham Panckhurst, makes one thing depressingly clear. The explosion was not an unlucky happenstance.
Poorly designed, under-capitalised and inadequately regulated, the mine was a disaster waiting to happen.
The commission finds fault with lawmakers, the Labour Department, Pike River's directors and executives and, it has to be said, the miners themselves.
Kate Wilkinson's resignation as labour minister yesterday is a recognition of ministerial responsibility. Ms Wilkinson was not advised of the dangers inherent at Pike River ahead of the explosion, but was the last in a string of ministers who failed to appreciate the need to complement the ''high trust'' regulatory health and safety model introduced in 1992 with adequate oversight.
The department, now part of the new Business, Innovation and Employment Ministry, is faulted for running down the capability of the mining inspectorate and failing to act decisively when it became aware Pike River was taking unacceptable risks.
Pike River's directors are criticised for neglecting their obligations to worker safety and company executives are faulted for putting production ahead of safety. In the 48 days leading up to the explosion there were 21 reports of methane levels reaching explosive levels and 27 reports of levels reaching lesser, but still dangerous, levels. None were acted upon.
For their part, mine staff are criticised for recklessly bypassing safety devices and taking prohibited items such as smoking materials and battery-powered wristwatches and cameras into the mine.
Individually, the failings put the lives of all who entered the mine at risk. Collectively they signed the death warrants of 29 men.
The inquiry is the 12th commission of inquiry into a mining disaster in this country in the past 130 years.
This time the lessons must be learnt for the sake of future Josephs. Safety is non-negotiable. The Pike River tragedy happened because too many people who could have acted, and should have, failed to do their jobs.
- The Dominion Post