The Pike River mining disaster which killed 29 men was a "metaphor for human failure on many levels", barrister Nicholas Davidson has told a mining conference in Nelson.
New Zealand had an inferior record of health and safety, he told delegates in a session on insights into Pike River at the New Zealand branch of the Australasian Institute of Mining and Metallurgy annual conference.
Davidson, of Christchurch, who represented some of the families during the royal commission of inquiry into the 2010 Pike River tragedy, said yesterday that "time consigns victims and families to the shelf of history". He continued to speak publicly on the matter in deference to those families.
"There's still a dearth of recognition of human elements [in disasters].
"Lessons have not been retained, we forget, we move on - there are periods of grace before something rises again to strike us," Davidson said.
Senior human factors consultant with Z Energy, Kathleen Callaghan, said Pike River was an accident waiting to happen.
"To be blunt, there's nothing new to be learned. It constitutes another failure to learn.
"Accidents like Pike River are not out of the blue. Impending disaster sticks out like dogs' balls."
She used the "swiss cheese" model used in the aviation industry as a template to show how accidents happened when the holes in the slices of cheese lined up.
"From day one, Pike River had significant holes in the slices," Callaghan said.
She said the risk of the holes aligning was ever-present throughout the work force.
"We are often one slice away from catastrophe," she said.
Davidson said what struck him during the inquiry was the lack of awareness of the consequence of workplace accidents.
A snapshot of interviews with the families about what the men thought of Pike River ranged from them hating the conditions, the general disorder, and there being no communication from people at the top.
Others had said it was the worst mine they had ever worked in, where "everything was broken down", to conditions leading to such fatigue that the "boss was sleeping standing up while working underground".
Davidson said Pike River and other disasters were sometimes the result of an inability by the people in charge to recognise and accept fault.
Journalist Rebecca Macfie, who has had a close media involvement in the tragedy, congratulated the conference organisers for having the courage to include it on the conference agenda.
She said Pike River was partially the result of a culture of arrogance and hubris, and a pattern of denial and self-delusion.
Macfie said the mine was "built on exaggeration" and began with the idea it could pursue its grand passion on the cheap, and with the use of other people's money.
She said morale in the company was terrible, and staff turnover was high.
"The death of 29 men underground was an extraordinary tragedy and remains the cause of ongoing torment, but it was the outcome of a succession of very ordinary misjudgments and mistakes," Macfie said.
Leading Safety consultancy director Hillary Bennett said "imperfect people and imperfect organisations" were part of reality.
It was important to look thoroughly into non-compliant behaviour because the issue was often around leadership and culture, she said.
"When things go wrong the default position is to blame someone. Humans are very often villains in the piece but that's not very helpful, and it doesn't stop us doing it again.
"It would be more helpful to ask, ‘did it make sense to do what they did at the time?'.
"You can't stay in your shoes and try and understand what happened."
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