Pike River Mine disaster, New Zealand, November 2010

In November 2010, gas explosions in a coal mine in New Zealand led to the loss of 29 men, whose bodies were never recovered. There were two survivors who walked out of the mine with moderate injuries.

The Pike River mine, located on the west coast of the South Island, New Zealand, was operated by Pike River Coal Ltd. The company had only begun coal production at the Pike River mine in 2010.

After operations started, there were several reports of excess methane levels in the mine but they were not followed up. Methane gas is colourless and odourless, and it is formed and released during the coal mining process. Methane gas becomes explosive when it mixes with air as it loses stability.

On 19th November 2010, the first explosion at the mine occurred at around 3.45 pm. It was not known what triggered the explosion. At the time of the incident, 31 workers were inside the mine; two injured miners that were closest to the tunnel’s entrance managed to walk out. The other 29 men were believed to be about 1.5 kilometres from the mine’s entrance (the tunnel was 2.3-kilometre long).

There were three more explosions on 24th, 26th and 28th November, which ended hopes of any rescue or recovery operation to reach the men left inside the mine. The 29 victims, of which 16 were miners and 13 were contractors, were assumed to have died from either the first explosion on 19th November or from the toxic gas build-up.

You are tasked to conduct an accident investigation on what caused these losses using evidence that has already been established. You are not expected to uncover new evidence but should use sources already in existence and discoverable to the public.

Question 1 – Evidence and Timeline

(a) Examine the collected evidence for this incident and present this using the structure of the Swiss Cheese Model.

(b) You should present the layers of Organisational Influence, Unsafe Supervision, Preconditions and Unsafe Acts independently and highlight your reasons for placing each item within the layer. You should also state where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be overcome (if possible).

(c) For all evidence that you use, you should present actual and/or potential scientific verification, and you should formally cite the source(s).

(d) From this evidence, create a timeline of events that led up to the explosion at the Pike River Mine and the loss of lives. Each element in the timeline should identify the evidence and from which layer of the Swiss Cheese Model these come from.

(e) You are free to use other additional tools to support your analysis, but you should state your reason(s) for doing so.

Question 2 – Root Cause Analysis

(a) From the evidence gathered and your timeline, construct a Root Cause Analysis (RCA) using the Swiss Cheese Model created in Question 1.

(b) Identify the root cause(s) of the incident using a Causal Tree.

(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.

(d) Analyse the likelihood of success for each recommendation and provide reasons to justify your answer.

(e) You are free to choose the format of the recommendations. However, the format chosen should support the earlier assessment methodologies that you employed.

Question 3 – Incident Report

(a) Create a detailed report of this incident using the structure studied in this course i.e.
(i) What happened?
(ii) What caused it to happen?
(iii) What do you recommend should happen next?
(b) Your report should be suitable for submission to the Board of a company using the format shown below