Pike River Independent investigation report released
10 April 2013
Independent investigation report released
Ministry of Business, Innovation and Employment (MBIE) Chief Executive David Smol today released the findings and recommendations of the independent investigation he commissioned following the report of the Royal Commission on the Pike River Coal Mine Tragedy.
The independent investigation report including an executive summary is available at this link along with Questions and Answers.
The following statement can be attributed to David Smol:
“The day after the Royal Commission reported on 5 November 2012, I announced there would be an independent investigation using experienced investigators from outside the Ministry of Business, Innovation and Employment (MBIE) to advise me on any implications for me as an employer from the Commission’s findings. Many individuals with direct management accountability no longer work at MBIE but the independent investigation was to enable me to decide whether to commence any disciplinary action against current staff.
“I would like to thank the independent investigators David Shanks (Deputy Chief Executive of Corporate and Governance at the Ministry of Social Development) and Jane Meares (barrister at Clifton Chambers) for their work.
“The independent investigators followed an exhaustive, robust, and thorough process. Their investigation involved interviews with current and former staff and consideration of documentation, employment and operating procedures at relevant times in the former Department of Labour (DOL) and the former Ministry of Economic Development (MED) which are now part of MBIE.
“The investigation found there were actions or more often inactions on the part of officials in both agencies that may have contributed to the tragedy. But they did not find evidence of carelessness, incompetence or breach of policy on the part of any staff including managers that would merit an employment investigation.
“The investigators concluded instead that systemic failures in the agencies meant that an employment investigation is not warranted. The investigators said DOL’s performance as a health and safety regulator was ‘dysfunctional and ineffectual’.
“In relation to MED’s assessment and monitoring of Pike’s mining permit, the investigators found that such functions were discharged in a ‘light-handed and perfunctory way’.
“Like the Royal Commission report, the report of the independent investigators is sobering as to the breadth of systems failure. The performance of the former departments was not acceptable. These are serious lessons for the public service and other regulators and enforcement agencies.
“As the investigators say, an effective health and safety regulator must have a culture that focuses on doing everything it can to reduce the risk of harm and danger to New Zealanders rather than being focussed on reputational and organisational risk.
“I accept the findings and apologise again to the Pike River families for these failures. More work will be done in response to this investigation, in addition to the extensive work already underway to respond to Pike River Tragedy and the report of the Royal Commission.
“I have moved to implement all the independent investigators’ recommendations. These include putting in place proper systems to enable staff and managers at all levels to escalate serious concerns about risk quickly and transparently so that proper decisions can be made about them.
“As recommended, we will conduct post-implementation reviews across all the work programmes in both New Zealand Petroleum & Minerals and Health and Safety Group including as it transitions to the new crown agency for workplace health and safety.
“We must ensure we have learned from the lessons of the Pike River Coal Mine Tragedy. We owe it to the memories of those who died,” Mr Smol concluded.
to the Tragedy and report of the Royal Commission, the work
already underway or completed includes:
• The Independent Taskforce on Workplace Health and Safety was set up and will make recommendations to Ministers by the end of April.
• The Pike River Implementation Plan outlines how each of the Royal Commission recommendations is being addressed, including the establishment of a new health and safety regulatory regime for the mining sector.
• Ministers have announced the establishment of a new Crown Agent that will be dedicated to health and safety.
• The High Hazards Unit was established with a specific focus on high hazard industries and employers including the mining, petroleum and geothermal areas.
• From 1 July, there will be a new Health and Safety Inspectorate with new specialist roles, new responsibilities and a new way of working. There are currently 139 Health and Safety Inspectors, and under the new Inspectorate, the number will increase to 158.
• The Lifting Our Game Programme is changing the way MBIE delivers health and safety regulation to improve performance. This change focuses on lifting capability at the frontline, and on building the systems, processes and tools to be effective. This programme is expected to provide a strong foundation for the new agency.
• A bill is going through Parliament which will ensure that the health and safety regulator’s view is taken into account before mining permits are issued. An interim process to ensure health and safety issues are considered in the allocation of permits has been set up pending passage of the bill.
• The need to build capability in the management of minerals permitting was recognised in 2010 as the result of a strategic review. New Zealand Petroleum & Minerals, a business unit within MBIE, was established in May 2010 to build on the former Crown Minerals unit. It was set up to take a more strategic approach, with greater sector and industry leadership responsibilities, a strengthened commercial focus and enhanced capability in the form of specialist skill sets and greater staff numbers.