OPINION: In every turn of the page there is a new horror. But what is most shocking in the Royal Commission's findings is the stark assertion that the Pike River disaster was preventable.
A catalogue of failures is laid out in the two volume report, made public today. And at the heart of all of them is a drive for cost-cutting.
Pike River Coal was not ready to safely produce coal. Adequate health and safety systems and infrastructure were not in place. Its ventilation and drainage could not cope. And yet it pressed ahead with hydro coal mining - an extraction method known to produce large amounts of deadly methane.
The drive to produce coal - to make money and stave off the debt the company was accruing - before the mine was ready "created the circumstance within which the tragedy occurred," the report concludes.
But the coal mining company were not the only organisation cutting corners. The effectiveness of the mining inspectorate had been declining for many years under the Department of Labour, the report notes.
It began with deregulation by National in the 1990s but continued, unchecked, under the Labour administration.
Pike, as a inexperienced new company, was able to obtain a permit to develop the mine with little scrutiny. They were allowed to construct a mine with just one exit - and a unsuitable ventilation shaft accessed only by a punishing climb up a vertical ladder.
By November 19 2010, there were just two mining inspectors, who were stretched thin. Departmental policy meant they did not audit health and safety procedures or analyse trends in data, but relied on physical inspections. Early in 2010 a mining steering group raised the alarm about the inspectorate ineffectiveness - but it was ignored. A request for a third inspector was not approved.
Other warnings were sounded, but went unheeded by the company. In the 48 days before the first explosion there were 21 reports of excess methane - which continued up until the morning of the disaster. In fact the investigation of incident reports was so haphazard that in the month before the tragedy, a backlog was written off. There were no worker check inspectors, which allowed the company to overlook safety concerns. In addition, the report notes that DOL's record in mine safety was so poor it had lost the confidence of the work force. And a lack of information and emergency response management lead to unforgivable delays and chaos in the wake of the explosion: emergency services were not called for 40 minutes. Incredibly there had been no planning for a coal mining emergency.
DOL's failings are so concerning that the Commission proposes a new single-purpose agency to regulate health and safety. Fundamental changes to mining regulations are also required. This includes the removal of the nonsensical provision that an employer must "take all practicable steps" to comply with regulations - until now a get out of jail free card for mining companies.
It comes as no surprise that the Commission recommends more worker participation in health and safety - but the union veto is likely to be an anathema to the industry and the government. Prime Minister John Key has already indicated the government has rejected one of the Commission's recommendations.
The commission is clear initiatives announced last year don't go far enough. But even with its drive to boost revenue from natural resources, National will have to swallow the fallout.
Even accepting the Commission's findings may not be enough for many of the Pike River families, who have demanded the creation of a corporate manslaughter offence.
They also want to see the recovery of remains - something which the report admits is "very uncertain".
New Zealand has suffered an underground coal mining disaster every generation or so - but learnt no lessons in the aftermath. It is years behind Australia and other developed countries in this area. The report suggests the loss of the 29 Pike River miners should be a watershed for changes to legislation, structure and attitude to avoid future tragedies.