Just recently I was completing a case study on the Pike River Mining Tragedy and its relevance to safety in general and governance in particular.
The tragedy took place on 19th November 2010 in New Zealand’s South Island and resulted in the death of 29 miners and only two survivors; sadly one of those killed was only 17 years old and on his first day on the job (he elected to start one day early).
The exact ignition source of the methane explosion is not known but the failings of management prior to the explosion are now well documented and in the public domain thanks to the Royal Commission of Inquiry led by Justice Graham Panckhurst and the two volumes of report running to hundreds of pages.
The failings began with the directors and senior managers of the company who failed to exercise safety governance of the developing mine and abdicated their safety responsibilities to people much further down the line and, further, failed either to seek advice, or to heed the advice of the subject experts who were called in prior to the disaster.
Other failings included lack of adequate safety support, no appointed Ventilation Manager, Lack of Competence / Experience among underground workers, a lack of adequate planning, differing standards for employees and contractors, evidence of tampering with safety devices, poorly planned and executed ventilation, use of contraband underground, poor government regulations, failure to take action on serious safety issues raised by workers… the list just goes on and on.
What is most striking for me though was the rush to get production coal out of the mine… The mine’s development had been held up because of difficult rock conditions in reaching the coal mining areas and the location of the mine in a conservation area: Due to this management were anxious to begin coal production and this, together with a myriad of other acts and omissions was the final episode leading up to the tragedy.
This space here is far too small to go into a lot of detail on this tragedy (you need to see my case study for that) but one detail is clear, if you shirk from your responsibilities on Safety Governance the road from there-on is slippery one and nothing good can come of it… If you are in a senior management position you need to know your Safety Governance Roles and enforce them diligently.
(See my blog on MTR Safety Governance for a good example of how Safety Governance should be run).
Finally as damming a statement as you will find in any report, here is an extract from that Royal Commission:
“The (River Pike) company did not have a clear strategy from the board that set out its vision, objectives and targets for health and safety management. It did not treat health and safety as a key corporate risk and prioritise the development of an integrated health and safety management system”
Don’t let that legacy be your legacy…