The Pike River Mine tragedy will go down as a lesson in "what can go wrong when everything's wrong", according to one of the Pike royal commissioners.
Stewart Bell spoke on workplace safety in Westport yesterday along with Mark Parcell of the Mine Safety Institute of Australia.
About 30 staff from Solid Energy, Bathurst Resources, Holcim New Zealand and NZ Mines Rescue attended.
They watched an Al Jazeera video, which said investigators found 21 warnings of excess methane gas at the mine went either unnoticed or ignored in the weeks before the explosion that killed 29 men.
Investigators said the mine had a 'production before safety culture', an unsuitable ventilation shaft, only one exit and no planning for a coal mining emergency.
Although the mining company was young and inexperienced, the Department of Labour allowed it to operate without adequate monitoring.
Mr Bell said things went wrong from the start. The Paparoa Ranges were a difficult mining environment. Workers couldn't drill enough holes, so didn't know what was going on underground.
He said most Australian mines were shallow with easy access and reasonable weather conditions.
Pike would go down as a lesson in "what can go wrong when everything's wrong".
"Pike had all this stuff going against it right from the word go.
"Pike needed the best of everything. It needed the best management, the best equipment, the best knowledge, the best data. It had none of that. Arguably it had the worst of everything."
Pike created fictional risk assessments and fictional mitigation, he said. It created documentation about ventilation controls that didn't exist.
Mr Bell said the risk-based process had to be done properly by the right people and reflect what was going on at the mine, rather than just being used to get a green light.
He said the mine was always under financial stress and never delivered on time.
It introduced a bonus to encourage production. To get the bonus, miners kept working in high methane atmospheres.
Pike River Mine was tiny and only produced 60,000 tonnes of coal in its entire life.
"It must be the most expensive coal in the world when you add the cost of 29 lives."
Mr Bell said Mines Rescue had been under a lot of pressure to enter the mine, but really didn't have the opportunity to do so.
Nobody knew when the second explosion was going to occur until after it happened.
"We didn't have the data to say it was safe to go. They were kitted up, they were ready to go, but we didn't want them to do it because this window of opportunity is only a window of opportunity in hindsight."
He said experienced mining people knew after the first explosion that nobody would have survived. The mine should have been sealed up, which would probably have prevented other explosions.
Trying to be positive, mine management had suggested mineworkers were on the end of compressed air lines waiting to be rescued.
"They said a lot of things that, in hindsight, if they'd really been using experienced mining people to talk to, they wouldn't have said. Because one of the worst things you can do is give people false hope."
That happened a few times, including when management told families about the second explosion. Management started by saying there was good news and the mines rescue team was going to go ahead then they mentioned the second explosion.
"There was no deliberate attempt to be difficult but they just made a horrible botch of it," said Mr Bell.
He added that politicians always wanted to get involved after mine disasters and he didn't know why.
"They should just stay a hundred miles away from them. They shouldn't get involved at all, they just slow things down. They say things they shouldn't say. They make promises they shouldn't make. And it all comes back to haunt them."
The best thing they could do was to provide the resources to make sure the people who knew what they were doing could do it.
Mr Parcell told The Westport News that although it was almost four years since the Pike River explosion, it was never too late to improve workplace safety.
There were almost two million workers in New Zealand. All of them, not just miners, deserved a safe workplace.