Pike River mine disaster
Sobering. That is the word Prime Minister John Key used to describe the Royal Commission report into the Pike River mining tragedy.
OPINION: How about chilling and incomprehensible? The catalogue of failure detailed in the royal commission inquiry is staggering and unprecedented in its breadth.
Permits were given without any scrutiny of health and safety requirements, numerous warnings of a potential catastrophe were not heeded, the company was driven by a culture of production before safety, the mine design and systems were unsafe, yet Labour Department inspectors did nothing to address known safety failures, relying on the company's word instead.
The commission notes that when at the hearings they were shown examples of safety information obtained from Pike records, Labour Department inspectors were "visibly dismayed".
It is a damning indictment on a regulatory regime in New Zealand that has seen layers of prescriptive regulations peeled back to balance safety considerations against productivity. In the wake of the leaky buildings fiasco, and equally damning evidence from the royal commission into the Canterbury earthquakes, our confidence in our public institutions and the rules they work under must now be seriously shaken.
Ultimately, the company is to blame. But Key's admission that had Labour Department inspectors done their job properly the 29 men killed at Pike River might still be alive is a watershed moment. It is an acknowledgement that successive governments and the bureaucracy have failed workers in the worst possible way.
It marks a turning point away from the orthodoxy of the last 20 years.
Labour Minister Kate Wilkinson was the first to fall on her sword. It was not the easy option, even if she still gets to keep her ministerial salary and other portfolios.
Her legacy forever more will be as the minister who resigned over the deaths of 29 miners. Given the scale of failure, her's should not be the only sacrifice.