On 5 November 2012, the New Zealand Royal Commission on the Pike River Coal Mine Tragedy handed down its final report into the explosion at the Pike River Coal Mine which killed 29 men nearly two years ago.

A failure to learn from the result of comprehensive investigations into safety disasters means that the risk of such disasters in the future is increased. Even though not every workplace contains the hazards and risks of a coal mine, there are lessons for every workplace in Australia from the failure of systems and processes at the Pike River Coal Mine.

Work safety is a board issue

For Australian boards which have been slow to engage with the obligations of due diligence, the report of the Royal Commission should sound the clearest possible call to action. The report makes it clear that directors have to consider work safety risks as being their concern, rather than simply a matter for management.

Even though New Zealand does not currently have an equivalent to the obligations of due diligence which arise for officers of Australian corporations operating in jurisdictions in which the Model Work Health and Safety Act 2011 has been enacted, the Royal Commission emphasised the importance of work safety as a key element of corporate governance and concluded:

“Regardless of legislative change, it is essential that directors and those in equivalent positions rigorously review and monitor their organisation’s compliance with health and safety law and best practice”.

The Royal Commission severely criticised the board of Pike River Coal Limited, finding that “the board did not provide effective health and safety leadership to protect the workforce from harm” and that the failings of the board included a failure to consider safety in relation to the design of the mine, a failure to hold management to account, and a failure to ensure that the board was made aware of relevant safety information.

Every Australian corporate officer ought to be responding to the Royal Commission’s report by asking, “If there was an incident at my company, how would I be able to show that I had taken safety into account?” – and if the answer to that is “I don’t know”, or, “It’s OK, the managers are looking after that”, then those officers need to find a better answer as a matter of urgency.

Work safety starts with design

Health and safety considerations should be built into the design. They are not “add-ons”.

The Royal Commission referred to a number of design aspects of the Pike River Coal Mine which were deficient, including the fact that the main fan which was designed to vent methane from the mine was located underground. This meant that the fan was badly damaged in the explosion. The placement of the fan underground was a world first but the Royal Commission described it as “a major error”.

The report also underscores the importance of updating risk assessments as designs change, which did not occur as geological conditions discovered during the construction of the mine changes the initial plans.

In Australia, the Model Work Health and Safety Act 2011 deals expressly with the obligations of designers of plant or structures which are to be used at workplaces, and it is important that both designers, and their clients, understand how those obligations work.

Safety is everyone’s job, everyday

Safety systems have to be appropriate for the workforce – training needs to be presented in a way which the workforce can understand, and where there is not safety leadership from senior employees, the system is almost set up to fail.

In the case of the Pike River Coal Mine Tragedy, the Royal Commission report found that safety issues were not taken seriously at various levels of the workforce. At the executive level there was “a culture of production before safety”. At the workforce level, “there was clearly an attitude of recklessness in at least some quarters of the workforce” as evidenced by incidents of bypassing safety systems and of contraband taken underground. The Royal Commission also found a high level of inexperience in the workforce resulted in overconfidence and a failure on the part of some workers to understand how their actions could affect the safety of others, and that this was compounded by failures in relation to training and induction.

Another key lesson from Pike River Coal Mine Tragedy is that it is important that other aspects of the way that work is performed don’t cut across the safety objectives. The Royal Commission noted that inexperienced workers were offered bonuses of up to $13,000 to achieve particular production targets and that, in the pursuit of these targets, high levels of methane in the mine were ignored.

Safety information needs to include lead as well as lag indicators

Australian corporate officers need to ensure that they are being provided with the right safety information and ultimately, their organisations need to ensure that process of learning from near misses, as well as from disasters, remains constant.

In October of this year, Professor James Reason CBE, whose work was cited by the Royal Commission, travelled to Australia with Norton Rose to present seminars to our clients. In those seminars, Professor Reason made the point that “the road to disaster is paved with falling or low lost time injury frequency rates”. Essentially, a focus on the minutiae or a simple indicator means an organisation completely ignores, and does not prepare for, the possibility of low frequency, high consequence events.

The Pike River Coal Mine Tragedy illustrates the point. The safety information which was reported to the board comprised mainly personal injury rates and time lost through accidents, that is, “lag indicators” pointing to past events. The Royal Commission said that this “gave the board some insight but was not much help in assessing the risks of a catastrophic event faced by high-hazard industries”. In particular, the company did not have any systems in place for reporting on “lead indicators”, such as near misses which could have caused catastrophic harm.

The most obvious lead indicator was the number of recorded methane spikes (which indicated an explosive concentration of methane which had not resulted in an explosion). The Royal Commission found that there was no evidence that the board understood the difference between lag and lead indicators and said that “a focus on personal injury rates alone is not adequate to identify the ultimate workplace hazards” of low frequency, high consequence events.


The capacity to learn from serious safety incidents is a vital attribute for safety professionals. One of the chapters in the Royal Commission’s report is entitled “A failure to learn”. Acknowledging that safety is everyone’s job, everyday – including those in the boardroom, and ensuring due diligence is taken to ensure adequate safety systems and processes in your organisation is crucial.