The lawyer representing the families of the Pike River victims, Nicholas Davidson QC, says the Royal Commission's report - released today - gives an "unrelenting picture of failure at virtually every level''.
The Royal Commission has found the Pike River Coal mine disaster was a preventable tragedy, but it cannot pinpoint the actual cause of a series of explosions that killed 29 miners at the West Coast mine in November 2010.
It slammed Pike River's management for not properly assessing health and safety risks its workforce was facing.
And it has slammed the Department of Labour's record as the former regulators of health and safety in New Zealand.
In the wake of the report's release, Mr Davidson said it was a failure in the way the legislation has been applied and a failure of the Department of Labour in its inspectorate role.
"Virtually nothing is a surprise here, except the emphatic nature of the conclusions reached.
"It seems to the families that this company was running on empty, financially, where safety was seconded to production. It seems to be the central conclusion contained here.''
He said one of the most telling features of the report is when it talks about an underviewer in April 2010 dealing with the amount of gas venting in the mine and writing an email to the board saying "methane showed no mercy''.
He advised a full reengineering of the entire gas drainage system but nothing was done, Mr Davidson said.
"The truly appalling factual thing - and we kind of knew it before but here it is in black and white - is that in the period before the explosion only one sensor was working to record underground gas.
"It was a faulty gas sensor in the ventilation shaft.
"Anything could have blown it up on previous days. How that could happen, the families simply do not understand.
"It is inconcievable that such a shocking error took place.''
He said it was "extraordinary'' that the explosion didn't happen sooner.
Mr Davidson said the Department of Labour's performance was woeful, but "everyone cops it here''.
He said the report makes New Zealand's health and safety performance rate "third world''.
The board of the firm is severely criticised, he said and the recommendations are "very powerful''
He said Minister Gerry Brownlee and Chris Finlayson gave the families a commitment today that the Government will move "very, very fast'' on the recommendations.
Bernie Monk, spokesman for some of the families, said: "To see it come out in this degree, and be this hard hitting, is really beneficial for the families.''
Mr Finlayson told the families he would get back to them within 14 days to "help us do the reclaimation of the drift''.
"I was really rapt with that. We've got someone to work with. They've taken us seriously. There are answers down that drift.
"They know how many blunders have been made here and they want to make amends.
"We've had to do this ourselves and we have now got that commitment, at long last.''
He said there were not many questions afterwards because the report was well summarised by the ministers.
"These families have gone through the commission - some went every day - and this was summarised in a very strong way.''
He said corporate manslaughter was not discussed today.
Mr Davidson said the report gives recognition that the Government must step in and look at recovery of the bodies.
"We're feeling relieved about that,'' Mr Davidson said.
The report says Mr Whittall inadvertently gave the families false hope, but Mr Monk refused to comment on that.
"I'm over Mr Whittall,'' he said.
A stark reminder
The Royal Commission Inquiry report opened with a stark reminder of those who died, with the photographs of the 29 men whose bodies remain inside they coalmine near Greymouth.
On Friday November 19 the Pike River mine exploded, leaving the men trapped underground - it is unknown if they died immediately or shortly afterwards, from the blast or from the toxic atmosphere.
Eight men were located in the bottom pit area of the mine, while the other 21 men were mostly likely at various workplaces, including the hydro panel and four other work areas.
They were due to leave the mine and would have been getting ready to leave at the end of their shift at 4pm.
Two men managed to escape from the stone drift, some distance from the mine workings.
Over the next nine days there were three more explosions before it was sealed.
The report was inconclusive about what caused the explosion. However they found the immediate cause of the explosion was a large methane explosion.
The area most likely to contain the a large volume of methane was a void formed during the first coal extraction panel in the mind. It found a roof fall in the goaf could have expelled sufficient methane into the mine roadways to fuel a major explosion.
"It is not possible to be definitive , but potential ignition sources included arcing in the mine electrical system, a diesel engine overheating, contraband taken into the mine, electrical motors in the non-restricted part of the mine and frictional sparking caused by work activities,'' the report found.
The report found Pike River mines had insufficient ventilation and drainage systems and could not cope with everything the company was trying to do - driving roadways through coal, drilling ahead into the coal seam and extracting coal by hydro mining.
There was no one at the mine responsible for ventilation management, but ventilation consultants advised Pike on a regular basis.
During the first explosion the main fan failed - a back-up fan was damaged was damaged during the explosion and did not start automatically and the ventilation system shut down.
Corporate systemic failures
The report found the mines board of directors ignored health and safety risks and should have closed the mine until they were properly managed.
When Pike River Coal Ltd began construction of the mine, it was problematic from the outset.
"History demonstrates that problems of this kind may be the precursors to a major process safety accident. Whether an accident occurs depends on how the company responds to the challenges and the quality of its health and safety management,'' it said.
The commission described the Department of Labour performance in relation to health and safety in the mining industry as being ''so poor both at the strategic and operational levels , that the department lost industry and worker confidence.''
The work of the department has been transferred to the new Ministry of Business, Innovation and Employment.
And the Government has already taken some reforms such as establishing a dedicated inspectorate for high-hazard industries, mining and petroleum.
But the commission recommends a new regulatory crown agency be established with a chief executive and board that would reflect that health and safety was a responsibility of employers, workers and government.
It also recommends that the Government should establish an expert taskforce to establish a regulatory framework for underground coal mining and that is should consult Queensland and New South Wales frameworks as best practice.
Other recommendations include
- Collaboration between regulators to ensure health and safety is considered before permits are issued
- Crown Minerals regime changed to ensure that health and safety is an integral part of permit allocation and monitoring
- Statutory responsibility of company directors for health and safety in the workplace should be reviewed to better reflect their governance responsibilities
- An urgent review of emergency management in underground coalmines
- Activities of the Mines Rescue Service needs to be supported by law
- Require underground coal mines to to have modern equipment for emergencies.
The original exploration of the geology of the area had provided insufficient information. It had been surveyed using a 14-borehole exploration programme. "This led to adverse unexpected ground conditions hindering mine development, '' the report found.
During the construction of the mine the bottom section of the ventilation shaft collapsed and a bypass had to be built to reconnect the upper part of the shaft.