The royal commission report on the Pike River disaster leaves the reader struggling to comprehend how safety was so badly mismanaged at the mine.
It also leaves one wondering where the whistleblowers were.
The commission report identified some signal moments when management did not respond adequately to safety warnings about ventilation and the gas drainage systems in the mine. But the commission also found that workers and consultants at Pike River knew there were serious dangers.
So why did nobody blow the whistle?
In its September report, first reported in Sunday Star-Times, the Health and Safety Taskforce reported that it is four times as dangerous to work in New Zealand as in Britain. The task force, charged with making New Zealand a safer place to work, suggested something in our "she'll be right" culture was responsible for that extremely poor record of workplace safety.
Perhaps there is something in our culture that prevents whistleblowing too.
Our culture emphasises stoicism, loyalty and staunchness. We have a tradition of not breaking ranks. We do not take to moaners.
Even in countries such as the US, where movies are made celebrating whistleblowers and there are foundations and not-for-profit centres to assist them, many still suffer dire career consequences.
The risks for whistleblowers are encapsulated nicely in a pamphlet from the Open Democracy Advice Centre in the US.
"The fear of being labelled a sneak or a troublemaker, or of breaking rank and appearing disloyal to colleagues, and the fear of being required to provide irrefutable evidence, are powerful disincentives to speaking up. For generations, playground culture has dictated that we do not tell tales. The distinction is not always drawn between those who wantonly betray trust and those who act - often irrespective of their own immediate interests - to protect others and the interests of their employers."
The risks are real, especially in a small community with few employment options. Imagine being held to blame for having done something that ended up costing local jobs.
New Zealand has the Protected Disclosure Act to protect certain kinds of whistleblower, including (probably) keeping them anonymous. It is practically unknown to most people.
A survey of 562 Sunday Star- Times readers this week found 81 per cent did not know what legal protections whistleblowers have.
The act is also far too hedged with qualifications and requirements. Section 9 requires an employee to be reasonably convinced that one of three conditions must be satisfied before they can talk to an appropriate authority.
That is legalistic nonsense, as is the name of the act, which is hardly intelligible to the common person. A sane country does not put limits on people's ability to raise concerns with regulators.
Any would-be whistleblower would need legal advice, and good advice at that.
And, of course, there's the fear of the witch hunt, which government departments and private companies engage in with gusto when damaging information is leaked.
Most people work for smaller companies - Pike River wasn't huge. Staying anonymous may be hard, and even if it is never proved to be you, this is a small country - and in an even smaller industries, the career risk is enormous.
It may also be that people don't know who to blow the whistle to, or lack faith that the regulators will act.
The Labour Department's standards in mine regulation were hopeless. It has admitted it.
Why take a risk for nothing?
When it makes its report to Government, the Health and Safety Taskforce, will be making some points about whistleblowing.
Among them, Sunday Star-Times understands, it is likely to point to the success of the British Health & Safety Executive which is widely known to welcome, and guarantees anonymity to, whistleblowers.
We've yet to send those signals on workplace health and safety.
But the task force is also likely to make strong recommendations that the concept that "mates look out for mates" gets enshrined more solidly in law.
Blame for the board and the management are lavishly apportioned in the royal commission report. But it also makes it clear it was not just the management and board who were not doing enough to make sure people were safe.
Those who died paid for the silence with their lives. Those who did not report safety failures to the authorities will have to live the rest of their lives wondering if they could have prevented the tragedy.
- Sunday Star Times
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