As a long list of safety failures at the Pike River mine were read out, the sound of muffled weeping could be heard from the public gallery at the Greymouth District Court.

It was one of many moments when the Royal Commission of Inquiry into the Pike River disaster left family of those who died distressed, angry or incredulous.

Mountains of evidence - much of it disturbing - have been presented to the inquiry since it began its mammoth effort to uncover the reasons for the deaths of 29 miners in July.

Historical problems with the mine development and setout and a flawed rescue and recovery operation were analysed in early phases of the hearings.


But the inquiry ended 2011 by delving into the possible root causes behind the second worst mine disaster ever to strike New Zealand, with the focus on four main areas:

1. The managers

An allegedly toxic, out-of-touch and rudderless Pike River management team have been the focus of criticism throughout the inquiry.

The claims culminated with accusations of workplace bullying on its dramatic final day for 2011.

Former mine safety manager Neville Rockhouse, who lost his son Ben in the disaster, said his boss Peter Whittall was intimidating and autocratic.

He said Whittall openly mocked him, yelled and slapped a wall with his hand as he made a presentation. That was followed by a "meltdown" in front of other managers.

The incident sparked the first of Mr Rockhouse's two attempts to resign.

Counsel asked Rockhouse whether, on reflection, he felt he had been the victim of workplace bullying.

He conceded he had.


Meanwhile, former Pike River chief executive Gordon Ward came under fire for refusing to contribute to the inquiry.

Company chair John Dow said Pike River was always Ward's "baby".

But he said Ward had a baffling tendency to estimate production at the "optimistic" end and was guilty of over-promising and under delivering to investors.

The inquiry also heard about a disconnect between management and mining teams.
Minserv mining consultant David Stewart painted a picture of a "dysfunctional" Pike River mine beset by low morale and a lack of trust in senior management.

Masaoki Nishioka, a former Pike River hydro mining operator, said there was no strong leadership or management underground and many miners were cynical about cashflow problems plaguing the company.

He left the company fearing the mine could explode at any moment.

2. The mine inspections

Former mines inspector Kevin Poynter wept as he described the "impossible" workload he faced in the lead up to the Pike River disaster.

He was one of two inspectors responsible for investigating safety in all of New Zealand's coal mines.

His responsibilities meant he could rarely get to Pike River for inspections, only gaining a "snapshot" of the environment inside the mine.

Under questioning, it was revealed he had not seen or taken action on records showing a long list of safety failures at Pike River.

He admitted enforcement action should have been used to improve safety inside the mine.

But he angrily rejected suggestions from counsel for the Pike River Coal managers that he had been lax on safety.

"There were other things I was doing all through that period including... dealing with the loss of a grandson.

"So I find it a little bit rich... to suggest that I wasn't following up because I wasn't concerned about it."

Mr Poynter's bosses at the Department of Labour also came under fire during the inquiry.

Auckland University human factors expert Kathleen Callaghan said the department did not equip its inspectors to investigate complex matters of safety culture or give them easy access to legal advice.

"There is an expression which says the fish rots from its head."

3. The workforce

Shocking safety failures took hold inside the Pike River mine before an explosion ripped through it on November 19, the inquiry heard.

One of the two blast survivors, Daniel Rockhouse, told his father Neville Rockhouse of plastic bags placed over gas sensors and explosives used to spread stone dust on the mine walls.

Those allegations came alongside a stream of testimony about the disproportionate amount of inexperienced miners employed at Pike River.

Albert Houlden, a former lead hand at mine contractors McConnell Dowell, said young men at the mine were getting paid "a lot of money for doing very little" while the mine was lagging behind its production targets.

When production bonuses were introduced, their work rate increased beyond what they could handle, he said.

Meanwhile, it was revealed the man in charge of a risky coal extraction method at Pike River received no formal training and was left searching the internet for advice.

Hydraulic mining manager George Mason said the extraction process, described as a "prime suspect'' in the fatal explosion, as "very high tech".

He struggled to find training resources on the internet and ended up learning on the job.

Mr Rockhouse said had he known what was going on before the explosion, he would have "camped" inside the mine.

"The rules of mining are written in blood."

4. The money

All the evidence presented has been set against the background of cost blowouts and cashflow problems plaguing Pike River mine.

On the inquiry's opening day in July, counsel detailed blowouts in mine construction costs from $29.3 million in 1997 to $207 million in 2007.

Those escalating costs were coupled with a production delays caused by machinery failure, recruitment problems and difficult geology.

Management introduced bonuses for teams who reached coal extraction targets in an effort to speed up lagging production, the inquiry heard.

After those targets were introduced, unsafe practices started taking hold in the mine as workers strained to increase extraction speeds, it heard.

Nishioka said all the miners were aware of the crushing financial problems facing Pike River.

His calculations were that the mine would run out of money in November or December last year.

Dow acknowledged Ward had been overly optimistic with his predictions for how much coal the mine would produce.

That excessive optimism was cited as a reason for him leaving the company in October 2010.