By November 18, 2010, there was just enough progress at Pike to reassure some workers that the operation could yet be a success, but not enough to ease the dark fears held by others.
The ABM20 continuous mining machine was on the job and cutting efficiently. The new fan was running more smoothly and generating a welcome increase in the volume of air flowing through the working places of the mine - indeed, it created a breeze in the hydro panel "cold enough to freeze your snot", as one man put it. Doug White was still respected as a manager who cared about the men, and was seen to have the competence to turn Pike into a success.
But Queensland miner Willie Joynson was among those who wanted out. He had been at Pike for 15 months. Nicknamed Digger, he was 49 and had first worked in a mine as a 17-year-old. He was sought after by mining companies because of his long experience and capacity for hard work. He had shifted with his wife Kim and their children to the West Coast because it offered a better life than northern Queensland - he could go to work underground and be home for tea each night, rather than having to be away at distant mines for days on end.
He also liked the idea of working in a small mine.
When he first got to Pike he had some reservations about the place: he thought the company's expectations were too high for the size of the mine, and there was a need for better training and more experienced workers. However, he thought it had the potential to grow and develop.
But from July 2010, Joynson started expressing concerns to Kim and to friends. He thought Pike was a time bomb just waiting to happen. He talked about problems with gas, about the fan that kept tripping off, machinery that wasn't fixed correctly or quickly, and the frustrations caused by previous crews who didn't set things up properly for the follow-on crew (mainly because of machinery breaking down). He spoke of the number of people who were leaving, and others who just didn't turn up for their shifts.
He and Kim decided he should leave, and he found another job in Australia in August. Then his fears were calmed after talking to Pike managers. The couple decided to stay a bit longer.
In September Joynson again started expressing anxiety about gas, machinery and ventilation. He worried about the number of contractors underground who, while good at their trades, had no experience of working in coal mines. "He would say, 'There are so many more factors to deal with working underground than working in a house, and that safety should not be taken for granted. You cannot get experience on paper, you can only learn from doing the job in the correct conditions and from listening to those who have been doing it a long time'," Kim would later recall.
The tradesmen were keen to learn and wanted more on-the-job training, but Joynson felt managers weren't listening to their concerns.
In late October he told Kim things were not very good. "In particular, he said that if something happened he would not be coming home. I said he should go to Australia, whatever the response from future employers might be to him just walking out."
The couple decided they would move back to Australia in time for the children to start new schools in February 2011, the beginning of the academic year.
In November he told Kim there had been a near miss at work. She had never seen him look so worried. "When Willie [was] stressed he sleepwalked. "In our marriage this only occurred about five times, twice on family issues and three times in New Zealand. In July 2010 he was doing it. This is why I booked his flight home. I felt he needed to get away - I felt Pike was the cause of his stress.'
Then in November he sleepwalked again. "One time I woke up and he was in the wardrobe talking about the mine. His concerns were so strong he told me that if anything happened they would not get out alive. He felt there was no clear way out: the emergency exit was no good, some could not fit up the ladder, and it was too far by foot."
On the weekend of November 13 he spoke of another near miss. Kim again told him to quit and walk away. "Willie said he could not leave the guys at that point, that I did not understand, and that the inspectors were coming to look into things."
Over the following week there was not much time to talk as both Kim and Willie were working shifts. When they did find time, Kim would become angry and tell him to "just leave Pike", which didn't ease his stress. "Maybe if I had taken more notice, the signs that something was really wrong were all there."
Pike river mine was awash with information foretelling catastrophe, but all those who had the power to act on the warning signs were deaf and blind to them. Vital information lay fallow on desks and in files, and pleas from men at the coalface for action and improvements went unheard and unanswered. Even Doug White, Queensland's former deputy chief inspector of coal mines and a man admired by his staff for his efforts to improve safety at Pike, couldn't see the dangers that were keeping Willie Joynson awake at night.
After Peter Whittall moved to Wellington in early 2010, White was the most senior manager at the mine site. As operations manager he had overall responsibility for production, engineering, health and safety, and coal processing. He also absorbed the position of statutory mine manager in June 2010, a role that carried the legal duty to personally supervise the health and safety aspects of the operation.
Yet White had an incomplete picture of what was really going on. He didn't know the fixed sensors in the mine's return roadways that were supposed to transmit accurate and continuous methane readings to the control room were either not working, had been disconnected from the control room, or were inaccurate. He assumed the sensors were being regularly calibrated and maintained, but they were not.
After Steve Ellis arrived at Pike to take up the job of production manager at the start of October 2010, White effectively handed over his duties as mine manager to the new man, even though Ellis did not have the right qualifications to hold the job. Until that time White had been seeing regular updates on methane trends in the mine because Greg Borichevsky, the technical services co-ordinator, brought the information to daily production meetings. White assumed that this flow of information carried on when Ellis took command of those meetings, but it did not.
White was conscious of the need for better training at Pike, and engaged former chief inspector of coal mines Harry Bell to provide refresher courses on self-rescue techniques.
The first course was held on a Friday afternoon in early October 2010, but the following week only three men could be spared from production to attend. After that the sessions were put on hold.
White also knew that the lack of a proper emergency exit from the mine was a matter of ongoing anxiety for the men underground, and that the issue came up repeatedly at meetings of the company's health and safety committee. The committee - a poorly attended group where there were sometimes more managers than workers in attendance - had escalated its concern about the lack of a proper second egress in September 2010, writing a formal letter to Pike management. Yet White told the board on November 15 that the ventilation shaft provided an escapeway until a second egress could be built the following year.
White was justly proud of the improvements he had made at Pike - in particular bringing in the ABM20, which had begun to turn around the mine's chronic inability to produce coal. He considered the establishment of a second exit to be a priority. But despite his determination that Pike should be run according to the stringent mining standards applicable in Queensland - where two exits in fresh air are mandatory - he oversaw the push into hydro mining instead of suspending operations until a second escape route for the workers had been built. He knew that a mine of Pike's design "would not have existed in Queensland".
By November 19, 2010, the absence of an emergency exit from the mine was, on its own, sufficient cause to shut down production and address the safety deficit. Doug White did not take that step.
The union representing mine workers, Engineering, Printing and Manufacturing Union (EPMU), could have brought the mine to a halt, at least temporarily, by encouraging strikes, pickets or bans over safety. But it caused no disruption to Pike's path to calamity. It had a limp presence at the mine, in part because it wasn't welcome.
There was only ever one walk-out over safety, when mine deputy Dan Herk threw down the gauntlet about the lack of mine vehicles available to quickly evacuate workers in the event of an emergency. Herk called the local EPMU representative, Matt Winter, and said he was concerned for the men's safety; Winter advised he should, therefore, walk out. Herk led the men out of the mine. Shortly afterwards Winter received an angry call from Pike's human resources manager, Dick Knapp, advising him to tell the men to go back to work. When Winter refused, Knapp threatened to sue the union. The issue the men were protesting about was attended to within a matter of hours, with the prompt repair of a broken-down vehicle that had been out of action for three weeks.
Winter was aware of workers' concerns about the lack of a proper emergency exit, and he had heard about the series of methane ignitions in late 2008. He was also worried about the high number of cleanskins - workers new to mining - at Pike. He understood that it was desirable in underground coal mining to have a ratio of experienced to inexperienced workers of about four to one. Pike had a much larger proportion of inexperienced men than other sites he looked after.
It wasn't easy to enlist Pike workers into the union. Some told Winter they didn't want to upset management by signing up. And he got the impression Pike management wasn't interested in forming any sort of relationship with EPMU. Pike had an internal health and safety committee but the union had no representation on it. Winter found Pike management "arrogant and unwilling to listen. They were prepared to tolerate the presence of the union in line with their legislative obligations, but they were not at all interested in developing a good relationship." He left his job in early 2010 and handed over to a new man, Garth Elliot.
Others at the site also had the impression that the company preferred not to have a strong union presence. In 2009, when health and safety manager Neville Rockhouse sought to have the union involved in a training exercise, Peter Whittall told him in an email: "Please do not use the union in the same sentence as anything at Pike. Our relationship and the way we communicate is between us and our employees." And so men like Willie Joynson, who went underground every day to earn a living, and who were entitled to the protection of robust safety systems and equipment that left a fat margin for error, were working on the edge. Pike River mine, which needed to have the best of everything to succeed in its tough environment - the best geological knowledge, the best equipment, the most rigorous safety regime - had the worst of everything. Joynson and his workmates were exposed on all sides by those whose job it was to protect them: a regulator that was submissive and unwilling to use the powers at its disposal; a board that was incurious, bereft of knowledge and experience of underground coal mining, and unable to see the symptoms of failure; management that was unstable, ill-equipped for the environment and incapable of pulling together all the pieces of its own frightening picture; and a union that was marginalised and irrelevant.
Road to disaster
2000: Plans for the mine are drawn up based on geological studies dismissed by one expert as "cartoons". The exploratory boreholes, 500m to 1km apart, fail to discover the coal seam is unevenly distributed and the access tunnel must pass through wet, crumbly rock.
2006-2008: The tunnel takes twice as long to build and costs twice as much as expected. Pressure builds on the company to produce coal and start making money.
2007: The ventilation fan is placed underground, contrary to normal mining safety procedures.
2008-2010: Untested mining machines bought from Australia break down constantly. The company ignores advice to get rid of them. Mine deputies (team leaders) complain of repeated safety breaches and management inaction.
November 2008: Ten gas ignitions terrify workers. The Department of Labour takes no action.
February 2009: The ventilation shaft collapses and is filled in with concrete. The replacement shaft proves impossible to climb up during a safety drill in October.
August 2009: Four deputies reveal deep concerns about safety during a professional examination. Their concerns are passed on to Pike management but no action is taken.
February 2010: The first coal is produced, almost four years after the date first predicted.
July-October 2010: Pike offers workers a $13,000 bonus to start hydro-mining by September 3. The bonus declines for every week the target is missed. Meanwhile an invited hydro-mining expert, Masaoki Nishioka, tells Pike its equipment is poor, its plans are faulty and he would not send men underground without better ventilation and a second exit.
September-October: The methane gas sensors break down. The only remaining sensor is inaccurate and not connected to the control room.
Early October-November 19: Miners make almost daily reports of 21 cases of methane at explosive levels and 27 at levels that are lower but still potentially dangerous.
• Tragedy at Pike River Mine: How and Why 29 men died by Rebecca Macfie (Awa Press $40)