This week has seen a series of disturbing revelations about the Pike River mine disaster. Rebecca Macfie, author of Tragedy at Pike River Mine: How and Why 29 Men Died, explains what it means
On day two of the latest round of breaking news about the suppurating wound that is the Pike River disaster, the health and safety regulator WorkSafe put out a strangely emphatic statement in response to media inquiries.
It followed Sunday night’s story by John Campbell revealing that an important piece of evidence from the mine was missing. The item had been identified as the cover from the control panel of the mine’s main ventilation fan. In the explosion it had been blasted up the 111-metre ventilation shaft, ending up on the Paparoa tops.
The fan itself was a vital part of the mine’s underground infrastructure. For several reasons it has long been a focus of scrutiny and controversy.
Firstly, it was located underground, within the workings of the very gassy coal mine, rather than outside the mine in fresh air. Its positioning underground was probably unique in the world – the Royal Commission on the Pike River Tragedy found no evidence of any other underground coal mine with its main ventilation fan located underground. When a Department of Labour inspector questioned the company’s intention to place the fan underground, Pike’s general manager and the key driver of the project’s development, Peter Whittall, told him that in the absence of any specific regulations on the matter, “there was nothing that would stop Pike River doing this”.
Second, despite being located underground, the fan was neither intrinsically safe (that is, incapable of igniting methane) nor flame-proof (securely enclosed, so that any ignition can’t escape). It was designed to shut down automatically if methane levels rose. In other words, it would stop precisely when it was required to the very job that it was needed for – to keep gas levels down and the mine ventilated with clean air. Theoretically, this wasn’t supposed to be a problem, because it was in a so-called “non-restricted” area of the mine, where gas levels were supposed to be negligible. But it was only a few metres away from where gassy air was being ventilated away from the coal face, and protected only by a temporary seal. Any proper risk assessment would have exposed the location of the fan as reckless folly, but no such risk assessment was ever done.
Third, commissioning of the fan – which was completed only nine days before the explosion of November 19, 2010 – did not go well. It produced sparks when it was put through its first test run. To resolve the problem, Pike removed a brass bush (washer) which formed a seal between the drive shaft and the stopping (seal), leaving a gap through which gassy air could leak if the fan was not operating.
None of these details is new or controversial –all are in the Royal Commission report.
So it was surprising on Monday night this week when WorkSafe put out its very assertive response to the story of the missing fan control panel cover. In Campbell’s story on One News the night before, former chief mines inspector Tony Forster had expressed concern that such an important item was missing, and said that a proper forensic examination would reveal whether or not the control panel had been the source of ignition that sparked the massive explosion in which 29 people died.
The WorkSafe statement said that modelling done by experts for the Department of Labour (its predecessor organisation) “showed it was not possible for methane gas to have reached the position of this panel in the mine. It is saying that based on computer modelling by internationally renowned fire and explosion and ventilation experts, with the fan operating, gas could not have reached this site, so the modelling indicates it was not likely to be the ignition source”.
We don’t know yet whether this statement is an accurate summary of what those experts said – their report is not in the public domain (I have now requested it under the OIA). However, the experts’ report did feed into the key Department of Labour investigation report, which was released after charges against Whittall were dropped as part of an unlawful deal in late 2013.
It turns out that the Department of Labour investigation report did not dismiss the possibility that the fan could have been the source of ignition. The report said: “There are a number of significant potential ignition sources within the mine. None of these can be conclusively discounted or confirmed as the likely source for the explosion on 19 November.”
Among those potential sources, it listed electrical arcing of equipment such as auxiliary fans or continuous mining machines; electrical arcing at the gas sensor near the top of the ventilation shaft; diesel engines; and (my emphasis) “electrical arcing at the main fan between the shaft and bearings due to electrical discharge machining”. The possibility of the fan as the site of ignition was considered “less likely” – but it was not ruled out.
The Royal Commission also included the main fan among its list of key suspects. It noted that the ignition source for the explosion “remains contentious” and listed a number of possible sources, including “sparks from the non-flameproofed underground fan”.
So, back to that statement from Worksafe on Monday evening, which was quoted briefly on Checkpoint. Why would the agency be so emphatic and confident in stating that the fan – the centrepiece of a new round of stories on account of the missing fan panel cover – was “not likely to be the ignition source”? It makes no sense. Were they trying to shut the story down?
Or did they know that they were about to be dragged under a bus by the release of a bunch of police documents to Dean Dunbar, the father of Joseph Dunbar, the 17-year-old boy who was killed in the mine? Those documents were last night provided to media by the Family Reference Group, which has been working with the Pike River Recovery Agency on the drift re-entry project.
As reported earlier on Morning Report, the documents reveal that the handling of evidence, particularly in the early weeks of the operation, was a shambles.
One of the key documents is the report of a debrief from Operation Pike on April 26, 2012. Much of the document is about the difficulties of running such a large operation, where two agencies – the Department of Labour and Police – were running separate investigations. The list of startling revelations is long, but here is a sample of verbatim quotes from the document:
- During the initial set-up phase of the operation, “Exhibits arrived at investigation base with no documentation including videotapes and photographs; did not know when or where they had been taken. Chain of evidence for documentary exhibits including videos and photographs diabolical. There are no job sheets or 268 reports for any of these exhibits.”
- “No procedure for dealing with devices at the mine, for example, a number of pen drives were handed out to download information and no record as to who had what.”
- “Cameras disappeared that were bought solely for recording so the operation and investigation had documentation. Do not know where they went.”
- “DoL [Department of Labour] did not appear to have the structure and planning to manage a file in a logical sequence. Police still missing DoL information because once DoL laid their charges the team was reduced to one or two people.”
- “Correspondence management was put in place too late and had no image or exhibit management system so when it became important in about late January/February , just after Coronial Hearing, had to try and find out who had taken over 600 images and what they were of.”
- “The difficulty was DoL seizing exhibits and us not knowing what they had.”
- “Operational team did not appoint exhibits officer for a number of weeks and therefore no-one managing exhibits.”
- “DoL handled some key exhibits [taking to Australia, sending things away], without recording chain of custody so if tested in court could be difficult.”
Another document, written by Superintendent Peter Read, who ran Operation Pike, refers to the “overwhelming number of documents being created by the operation, which were not being managed and appeared to be going into a big void” during the initial phase. It wasn’t until four weeks into the investigation that someone was appointed to manage the documents, “and by then there were over 1000 documents that needed to be collated and managed.”
Read refers to an apparently serious conflict of interest, in which the Department of Labour’s inspectors were providing the police with training about mining, but those same people had to be interviewed by police. Further, “I am still not completely satisfied that we received everything they [Department of Labour] had done by way of follow-up telephone interviews and the like from formal interviews that had been commenced and started as a parallel investigation.”
Read referred to the “large number of still and video images by people working on the operation” – Police, contractors, and Pike River Coal itself – “which we never found out about until after they had been taken … We were unable to provide an accurate description of who had taken what, when it was taken and the provenance of each one of the still photographs and sometimes the video footage.”
It’s important to note that in the early weeks of the operation, the Police did not regard Pike as a criminal investigation, and therefore couldn’t seize evidence and had to rely on the DoL’s seizure powers. It was only after the Coronial hearing in January 2011 that the police moved to an investigation of possible manslaughter or criminal negligence charges (deciding in mid-2013 not to proceed with either). Also during this period, the foxes were still in charge of the chicken house – key Pike managers, including Whittall, were still in position, working for the receivers after the company went broke about three weeks following the explosion.
Given the chaotic exhibit management revealed in the police debriefing documents, it now seems unsurprising that a piece of kit connected with Pike’s dodgy underground fan, which had been blown over 100 metres up the vent shaft, is lost.
The disclosures also indirectly cast further light on the unlawful 2013 deal in which Worksafe let Whittall walk away from charges under the Health and Safety in Employment Act in exchange for a $3.41 million payment to the families. Throughout that year, Whittall’s lawyer, Stuart Grieve QC, had been challenging the agency’s handling of evidence, and promising a long, aggressive and costly defence of the charges against Whittall.
So where are we at after this week’s revelations? The location of the fan control panel cover remains unknown. Superintendent Read told me that the police have never had it, and they are making inquiries into its whereabouts. WorkSafe said in its statement on Monday night that it doesn’t have it either, didn’t see it at the time, and has no knowledge of what happened to it because “evidence custody was not its responsibility.”
Perhaps the singular theme to emerge from this week is that items of electrical equipment from the mine will yield important forensic clues about the explosion, if they are properly investigated. Most of that equipment is still underground, and much of it is part way up the drift at the area known as pit bottom in stone. Those who question the virtues of the re-entry project, and complain that far too much money is being spent to placate weeping widows, might now have a far better idea of the type of forensic evidence that lies underground, still awaiting expert investigation more than eight years on.
Postscript: It was reported during the week that the families had never seen a photo of the damaged fan control cover until shown it by Tony Forster last week. However, a different photo showing the same item, but from a subtly different angle, was published in Tragedy at Pike River Mine in late 2013. When I included the photo in the book I had no idea that the item shown was part of the controversial fan, nor that the item itself was missing. It was of sufficient interest to publish because it seemed to illustrate the force of the explosion, and also because Mines Rescue Service had suggested the area around where it was found ought to have been grid searched for human remains – which did not occur until several weeks later.
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