Kiwi ingenuity killed the 29 Pike River miners. But we console ourselves, saying the disaster was an anomaly. Just a whole bunch of stuff went wrong. We promise it will never happen again.
OPINION: It wasn't an anomaly. It will happen again. Deep in our psyche we believe improvisation is innovation. We believe cutting corners copes with complexities.
We believe that if we work hard enough, long enough, she'll be right.
For more than 25 years the Pike River story was so beguiling, sucking in promoters, investors, workers and regulators: millions of tonnes of some of the "best coking coal in the world"; big revenues, high profits; precision underground mining; minimal impact on the pristine environment; high-paying jobs for locals; big rewards for investors; smart, minimal regulation . . . all made possible by Kiwi ingenuity.
The truth was radically different.
The mining industry always knew Pike River's very complex geology made it one of the most challenging mining prospects in the world.
"The geology, geography and climate of the West Coast [made] all the processes around coal mining, not just the mining extraction process itself, as hard or harder than most other locations in New Zealand and the world," Don Elder, Solid Energy's chief executive, told the royal commission of inquiry into the disaster.
Yet the mine was promoted by New Zealand Oil & Gas, which had no experience in mining. It floated Pike River Coal, a one-mine start-up, on the NZX in 2007 with a board with no experience of underground coal mining.
Wider than that, though, investors, advisers, regulators and workers all ended up failing the most basic tests of responsibility.
As a result, the whole Pike enterprise was utterly inept and doomed to fail tragically, as the royal commission's report lays bare in chilling detail.
Anybody who cares about their own safety at work, let alone the safety of others, should read the report. It describes a deeply dysfunctional culture that inevitably killed people.
Please don't dismiss this as irrelevant to your low-risk work.
Each year, we kill twice as many people per 100,000 workers as Australia and Norway, and eight times as many as Britain.
Pike River, though, tells us a lot more about ourselves than just woeful workplace practices. It tells us we revel in risk but we prepare ourselves poorly to mitigate it. Too often we bash on, ill-informed and insufficiently skilled, believing ingenuity will win the day.
This was the Pike culture right from the start. It sought a mining licence based on only 14 bores drilled from the surface. Yet to get the detailed information it needed to plan and operate the mine in such complex geology, it would have had to drill at 100-metre intervals across the plateau, a mining expert told the commission.
Pike was mining blind.
Promoting the mine, it boasted it would produce a million tonnes of coal a year by 2008. But it produced only 42,000 tonnes in the two years from its opening to the disaster in November 2010.
As the commission lays bare, the company made scores of disastrous decisions. The most reckless of many was to notch up a world first.
It located the ventilation fan at the heart of the underground workings rather than on the surface. This bit of Kiwi ingenuity was fraught with dangers, particularly the high risk of an electrical spark triggering a methane explosion and destroying the ventilation system. But the Department of Labour inspector decided nothing in the regulations prevented such a setup.
Few of the safety devices proposed were implemented.
When coal mining began in November 2008, the mine was classed as "gassy" because of the large volumes of methane seeping through it. The company never got on top of this danger, by far the biggest in coal mining.
Gas drainage, monitoring and ventilation were woefully inadequate. Pike relied on free venting of the gas. Yet this was "no longer recognised as normal practice in modern underground coal mines", the commission reports. The greater the financial pressure on the company in 2010, the harder it pushed to produce coal and the quicker the dangers compounded. In the 48 days before the explosion killed 29 miners, there were 21 reports of explosive levels of methane gas in the mine and 27 of lesser but still potentially explosive levels.
The company couldn't cope because its structure and culture was so abysmal. In the two years it produced a bit of coal, it had six mine managers, two technical senior managers and three engineering managers.
It seems nobody was in charge of designing the ventilation system.
In 2010 alone it had two production managers.
It had a high proportion of workers with no underground mining experience. Although it was able to recruit some very experienced people, they apparently could not apply their knowledge and skills.
Doug White, for example, joined the company in early 2010 and was site general manager at the time of the explosion.
He had been deputy chief inspector of mines in Australia.
Pike never had an internal or external audit of its health and safety practices. It did have other reports. Of two in 2010, its insurer initiated one and the company initiated a compliance check.
Both were full of dire warnings and urgent recommendations but the company failed to act.
The commission this week made a raft of deep and detailed proposals, particularly on a rigorous new regulatory structure.
The Government said it accepted them in broad terms.
The prime minister, however, was quick to blame the company rather than the existing regulatory regime or the Government's lackadaisical effort to improve it.
Those who ran the company certainly have plenty to answer for.
But so does corporate New Zealand. Why didn't leaders and experts in the mining industry, investors, bankers, analysts and insurers ring alarm bells when it was obvious the company was floundering? Why didn't regulators and politicians? Why didn't the miners' own community?
Why was the Pike River company a dreadful, widely known secret nobody wished to share until it killed 29 men?
- Sunday Star Times