Final Report: Royal Commission on the Pike River Coal Mine Tragedy
The explosion at the Pike River mine on 19 November 2010 brought home to New Zealanders once again the risks of
underground coal mining. The 29 men who died follow a long line of other people who have perished in New Zealand mines
over the previous 130 years. This, sadly, is the 12th commission of inquiry into coal mining disasters in New Zealand.
This suggests that as a country we fail to learn from the past.
The commission was established in December 2010 to report on what happened and what should be done to prevent future
tragedies. The terms of reference are on pages 6–9.
In making our inquiries we have gathered voluminous evidence, both written and oral. We have necessarily had to be
selective in determining how much can be included in our report. The commission has aimed to be fair to all concerned in
the tragedy and has avoided criticising individuals, unless it was necessary to do so to properly explore what happened.
The commission is not a court of law and its views and conclusions should not be interpreted as determining, or
suggesting the determination of, criminal or civil liability of any person.
The commission has tried to uncover the systemic problems lying behind the tragedy so that recommendations can be made
for the future.
One difficulty the commission faced in making its inquiries was that, at the same time, criminal investigations into the
tragedy were being conducted by the New Zealand Police and the Department of Labour (DOL). The commission arranged its
public hearings in four phases for efficiency and in an endeavour to minimise any conflict with the criminal
investigations. The commission used the DOL investigation report and associated material, where it was appropriate to do
so, to gain an understanding of what had happened.
The commission’s report is organised into two volumes:
Volume 1 is an overview of what happened at Pike River and what should be done for the future to avoid such tragedies.
Sixteen primary recommendations then follow.
Volume 2 is a more detailed and technical analysis of the tragedy, together with the reasoning that led to our
recommendations. Volume 2 also contains appendices that further explain the conduct of the commission.
We wish to acknowledge and thank the many people who have assisted us with our inquiries, and our counsel, executive
director and staff who have worked so hard. We wish to acknowledge the families of the deceased men. Many attended the
commission’s hearings and provided evidence. We were impressed with their fortitude and courage. The commission would
also like to acknowledge John Haigh QC, who died during the course of the commission.
The lessons from the Pike River tragedy must not be forgotten. New Zealand needs to make urgent legislative, structural
and attitudinal changes if future tragedies are to be avoided. Government, industry and workers need to work together.
That would be the best way to show respect for the 29 men who never returned home on 19 November 2010, and for their
loved ones who continue to suffer.
Hon. Justice Graham Panckhurst
Stewart Bell PSM
David Henry CNZM
There are 16 primary recommendations, supported, where necessary, with more detailed recommendations. Not every view
expressed or conclusion reached by the commission has resulted in a recommendation. The commission trusts that those
charged with responding to this report will also attach weight to the views and conclusions in the text of the report.
Those recommendations, couched directly in terms of the underground coal mining industry, may have wider relevance to
other industries. The detailed reasoning behind the recommendations is in the relevant chapters of Volume 2, Part 2,
‘Proposals for Reform’.
Recommendation 1: To improve New Zealand’s poor record in health and safety, a new Crown agent focusing solely on health
and safety should be established.
• The Crown agent should have an executive board accountable to a minister.
• The chief executive of the Crown agent should be employed by and be accountable to the board.
• The Crown agent should be responsible for administering health and safety in line with strategies agreed with
the responsible minister, and should provide policy advice to the minister in consultation with the Ministry of
Business, Innovation and Employment.
• The ministry should monitor the Crown agency on behalf of the minister.
• The Crown agency should be funded by the current levies but the basis of the levies should be reviewed for
Recommendation 2: An effective regulatory framework for underground coal mining should be established urgently.
• The government should establish an expert task force to carry out the work. Its members should include health
and safety experts and industry, regulator and worker health and safety representatives, supported by specialist
• The expert task force should be separate from the ministerial task force that is reviewing whether New Zealand’s
entire health and safety system is fit for purpose.
• The expert task force should consult the Queensland and New South Wales frameworks as best practice.
• In the interests of time, the expert task force should consider the immediate development of approved codes of
practice, to be replaced by regulation where appropriate.
• The expert task force should consider addressing urgently the specific issues identified by the commission
o the removal of the ‘all practicable steps’ qualification from the mandatory provisions of the regulations,
including those relating to ingress and egress;
o the provision of better health and safety information by the employer to the regulator, including notification
of all high-potential incidents;
o requiring employers to have a comprehensive and auditable health and safety management system;
o mandating the statutory positions necessary to ensure healthy and safe mining (including a statutory mine
manager and ventilation officer), and identifying their key functions and the relevant qualifications, competencies and
o defining standards for ventilation control devices, such as stoppings;
o defining the requirements of underground gas monitoring systems;
o prohibiting the placement of main fans underground and requiring them to be protected against explosions and
other hazards, in accordance with the most appropriate international standards;
o clarifying the restricted zone within which electrical equipment requires protection; and
o updating electrical safety requirements in the light of new technology.
Recommendation 3: Regulators need to collaborate to ensure that health and safety is considered as early as possible and
before permits are issued.
Recommendation 4: The Crown minerals regime should be changed to ensure that health and safety is an integral part of
permit allocation and monitoring.
• The proposals in Review of the Crown Minerals Act 1991 Regime are endorsed.
• Mining permits should have a general condition requiring the need for compliance with the Health and Safety in
Employment Act 1992 and regulations.
• The Ministry of Business, Innovation and Employment should provide information to prospective permit holders on
health and safety laws and regulations.
• The ministry should review the information required from applicants for mining permits and the way it assesses
applications against the criteria in the minerals programme.
Recommendation 5: The statutory responsibilities of directors for health and safety in the workplace should be reviewed
to better reflect their governance responsibilities.
Recommendation 6: The health and safety regulator should issue an approved code of practice to guide directors on how
good governance practices can be used to manage health and safety risks.
Recommendation 7: Directors should rigorously review and monitor their organisation’s compliance with health and safety
law and best practice.
Recommendation 8: Managers in underground coal mines should be appropriately trained in health and safety.
Recommendation 9: The health and safety regulator should issue an approved code of practice to guide managers on health
and safety risks, drawing on both their legal responsibilities and best practice. In the meantime, managers should
consult the best practice guidance available.
Recommendation 10: Current regulations imposing general health and safety duties on the statutory mine manager should be
extended to include detailed responsibilities for overseeing critical features of the company’s health and safety
• The new regulations should have regard to the Queensland legislation applying to the mine’s senior site
• The statutory mine manager should be protected by new procedures requiring disclosure to the regulator when the
employer does not accept the manager’s proposals for improving health and safety.
Recommendation 11: Worker participation in health and safety in underground coal mines should be improved through
legislative and administrative changes.
• Legislative changes should:
o require operators of underground coal mines to have documented worker participation systems;
o ensure all workers, including contractors, are competent to work safely, are supervised and are included in the
mine’s worker participation system;
o empower trained worker health and safety representatives to perform inspections and stop activities where there
is an immediate danger of serious harm;
o require the results of monitoring and investigation of health and safety in the workplace to be automatically
made available to workers; and
o allow unions to appoint check inspectors with the same powers as the worker health and safety representatives.
• The regulator should:
o issue an approved code of practice on employee participation;
o promote workers’ rights and obligations through education and publicity; and
o ensure that inspectors routinely consult workers and health and safety representatives as part of audits and
Recommendation 12: The regulator should supervise the granting of mining qualifications to mining managers and workers.
• The regulator should lead the work to strengthen standards so that they are comparable with those of Australia.
• The regulator should work with Australian counterparts towards developing a joint accreditation process with
Australia and an Australia/New Zealand board of examiners.
• Additional statutory roles and qualifications are required in new regulations, including a statutory ventilation
officer and an agreed level of industry training and supervision for all new or inexperienced workers.
• The regulator should work with the Accident Compensation Corporation and others on raising the standards of
health and safety consultants.
Recommendation 13: Emergency management in underground coal mines needs urgent attention.
• Operators of underground coal mines should be required by legislation to have a current and comprehensive
emergency management plan that is audited and tested regularly.
• The emergency management plan should be developed in consultation with the workers and the Mines Rescue Service.
• The emergency management plan should specify the facilities available within the mine, such as emergency
equipment, refuges and changeover stations, and emergency exits.
• The emergency management plan should contain a strategy for notifying next of kin and ensuring that genuine
enquirers receive appropriate information.
• The mining operator must keep and regularly update a comprehensive list of emergency contact details for all
• The emergency management plan needs to be compatible with CIMS, the co-ordinated incident management system used
by New Zealand’s emergency services and the police.
• The regulator should include the emergency management plan in its audit programme.
Recommendation 14: The implementation of the co-ordinated incident management system (CIMS) in underground coal mine
emergencies should be reviewed urgently.
• The implementation of CIMS should be reviewed to ensure that emergencies in underground coal mines are well
• The review team should include the mining industry, police, emergency services, the Mines Rescue Service and the
• The CIMS framework should be rigorously tested by regular practical exercises at underground coal mines.
• The incident controller at an underground coal mine emergency must have mining expertise and, together with the
incident management team, must be responsible for co-ordinating the emergency effort and approving key decisions. This
does not prevent a government agency such as the police from being the lead agency or from maintaining its command
Recommendation 15: The activities of the New Zealand Mines Rescue Service need to be supported by legislation.
• The Mines Rescue Trust Act 1992 should reflect the functions performed by the Mines Rescue Service.
• The adequacy and fairness of the current levies imposed on mines to fund the service need to be reviewed.
Recommendation 16: To support effective emergency management, operators of underground coal mines should be required to
have modern equipment and facilities.
• Operators should be required to have equipment and facilities suitable for self-rescue by workers during an
• Operators should be required to include, in their emergency management plans, provisions for continued
monitoring of underground atmospheric conditions during an emergency.
• Operators should be required to install facilities that will support emergency mine sealing and inertisation.