Lessons from Pike River

Lessons from Pike River

On Friday 19 November 2010 at 3:45pm there was an underground explosion at the NZ Pike River Coal Mine. Twenty-nine men lost their lives, and their bodies have not been recovered.

This 5 minute video case study is from a recent Business Leaders’ Health & Safety Forum, presents some of the key findings from the Royal Commission into the incident and well worth taking the time to view it.

Read the full details of the Royal Commission Findings here – again well worth a read!

Key learning’s highlighted in the video and some valuable lessons for Leaders:

1. Leaders relied on form rather than substance.
2. Board Members had no experience with Coal Mining and had no idea of what questions to ask of their Managers who carried, in the Boards eyes, full responsibility for safety.
3. The site had world class safety management systems – they just weren’t being used
4. Management expected workers to come to them with problems rather than go and hunt them out for themselves.
5. The main focus was on trying to ensure that workers didn’t make errors and preventing them making mistakes rather than setting up systems that are error tolerant (“allow for stuff ups”).
6. The investigation of incident reports was haphazard, with the result that in October 2010 a backlog of outstanding investigations was written off
7. There were considerable management changes – 6 Mine Mangers in 2 years.

Read the full details of the Royal Commission Findings here