Human factors expert Dr Kathleen Callaghan will give evidence at the Pike River Royal Commission of Inquiry today.
As Greymouth prepares for tomorrow’s one year anniversary of the tragedy that killed 29 men, the Royal Commission will hear about patterns of behaviour that may have had a role in the disaster.
Scroll down for live updates
This week the Department of Labour came under intense scrutiny as the commission heard of a stream of problems at Pike River that were never picked up by mines inspectors.
A lack of resources, and inadequate processes at the department meant repeated complaints about the inspectors’ heavy workload and lack of technical back-up were never addressed.
3 News online reporter Emma Mackie is following the inquiry with live updates throughout the day.
Click here for the live stream
LIVE UPDATES
12:49pm – Inquiry adjourned until Monday 21 November at 11:30am.
12:47pm – Hon Justice Panckhurst makes a statement about the distress of the families of the 29 men killed at the tragedy. He says the commission was mindful of the close proximity of the inquiry to the one-year anniversary of the disaster which is tomorrow. He explains he felt to continue with the inquiry would be the most appropriate testament to the men and their families.
12:45pm – Hon Justice Panckhurst asks if counsel assisting can contact Dr Callaghan regarding what her input will be to phase four of the inquiry. The witness agrees and confirms that process is already underway.
12:40pm – The commission asks the witness about the effects of stress on the inspectors.
Dr Callaghan says stress can significantly affect a person’s decision making.
12:37pm – The commission asks Dr Callaghan about the involvement of the Department of Labour in her work. She says she sees representation from the department at professional conferences on human factors.
She says there are some in the department that are more aware of human factors than others.
12:36pm – Ms Shortall concludes her cross-examination.
12:35pm – Dr Callaghan has acknowledged she has seen only a snapshot of information from Pike River, and the commission confirms it understands that.
12:31pm – Dr Callaghan says she has seen “well in excess of 508” incidents from Pike River.
Dr Callaghan says she welcomes more information about Pike River for her analysis.
She confirms she has not looked at all of the company’s standard operating procedures or management plans.
“I am more than happy to examine any other information that anybody would like me to have a look at in order to see if I would change my mind,” says Dr Callaghan.
12:26pm – Counsel suggests there was no “review filter” applied to Dr Callaghan’s study.
Ms Shortall refers to the limitations of a Queensland study where the largest limitation of the study was that adhoc data was used of incidents and accidents.
Dr Callaghan confirms her analysis suffers from the same limitation, but she says every incident she looked at told a recurring story.
12:21pm – Dr Callaghan confirms she has not made any visits to coal mines in relation to her human factors analysis of Pike River mine.
“I’m not saying I’m an expert in mining safety in any way,” she says.
She says human factors is generically useful and applicable and you do not need to be a technical expert in every industry.
12:18pm – Counsel suggests the application of human factors to coal mining accidents is “relatively limited”. Dr Callaghan disagrees and says there is widespread international understanding of human factors in coal mining.
12:14pm – Counsel for Pike River directors, managers and officers Stacey Shortall, cross-examines Dr Callaghan.
Counsel highlights that Dr Callaghan has no expertise in underground coal mining health and safety, and has not provided consultancy in respect to underground coal mining health and safety.
Dr Callaghan has never visited a west coast mine.
Counsel continues to question Dr Callaghan’s professional background with regards to underground coal mining.
12:10pm – Dr Callaghan says in an environment that is constantly changing, inspectors need significant time.
12:06pm – The witness says inspectors should have leadership skills, and a high level of interpersonal skills.
She says inspectors should be communicating with people from all levels of an organisation.
Inspectors need to be able to deal with stress, and they need a high level of analytical skill.
Inspectors need access to legal advice.
12:04pm – Dr Callaghan tells the commission the department needs an expert in human factors to contribute to their work.
11:57am – Nigel Hampton QC, counsel for the union, asks Dr Callaghan about the role of employee representation in health and safety. She confirms it is very important.
She says there is indication that employee representation at Pike River was inadequate.
11:53am – Dr Callaghan will participate in the fourth phase of the inquiry.
11:51am – “The error producing conditions at Pike River mine are not dissimilar to the ones identified at the Department of Labour,” says Dr Callaghan.
11:48am – Dr Callaghan says the evidence suggests New Zealand has learnt nothing from the Erebus disaster.
11:41am – Counsel refers to a minor soft tissue incident where a worker was hit by a falling rock.
Dr Callaghan says because the incident did not cause serious harm to the worker, it did not appear to be followed-up with respect to the reasons why it happened.
One of the reasons for the incident was identified as inadequate installation of ground support. She says this is a significant issue.
11:35pm – Dr Callaghan refers to former inspector Kevin Poynter’s evidence regarding reported ignition incidents at the mine. There was uncertainty around how many ignition incidents there were, whether they were reported by supervisors and followed-up.
11:31am – Dr Callaghan says the Gunningham Neil report shows lots of hazards, incidents and accidents at Pike River that “go way beyond slips, trips and falls”.
The fact those events kept on being repeated indicates there was either no follow-up action or the action taken was inappropriate to prevent the problem arising again.
11:28am – Changing and challenging mining conditions, such as those at Pike River, increase the risk of human error.
11:26am – Dr Callaghan says she does not see how Department of Labour inspectors could have ascertained if Pike River was compliant, without the use of an audit system.
11:24am – The witness says Pike River documentation shows the “burden” of error-causing factors remained unchanged, with the same problems occurring over and over again.
11:20am - “It’s the walk that leads to the prevention of harm, not the talk,” says Dr Callaghan when asked how the report reflects whether Pike River was complying with the act. She says the report does not necessarily demonstrate whether or not they were compliant, it focuses more on what people said.
Dr Callaghan explains theories of cause and intervention.
11:18am – Callaghan comments on issues raised in the Gunningham Neil report compiled after the Pike River tragedy.
11:12am – Dr Callaghan says it would have required a depth and breadth of knowledge for the inspectors to be able to ascertain whether a company was complying with the act across all hazards.
It’s a complex task that cannot be underestimated.
11:09am – Inquiry resumes.
10:48am – Adjourned for 15 minutes.
10:47am – Dr Callaghan says all the information she has seen shows recurring patterns of causal factors, that are well established in the literature to increase the likelihood of a process safety event.
10:46am – Suppression lifted.
10:14am – Information is suppressed.
10:10am - Dr Callaghan says the repetition of low level events is a cause for concern.
10:08am – She says hazard reports at Pike River show significant and recurring risks to safety, in respect to housekeeping, maintenance, and ventilation.
10:04am – Training in safety needs to be tailored to individuals. Dr Callaghan says we need to be mindful of the strengths and weaknesses of individuals. At PRC she says there were a number of experienced and inexperienced workers and a varirty of workers from different places - people from South Africa, Australia, and New Zealand.
The variety of these factors needed to be addressed to work out how best to train the workers in safety.
10:02am - The workforce had a high number of inexperienced people.
9:59am – According to Dr Callaghan It is vital to study the impact of human error on mining accidents.
She says decision making is based on timing, knowledge, and experience, a lack of experience increases the chance of making an error.
9:55am – The witness says she is not an expert in mining and her comments today are not specific to mining.
9:52am – Dr Callaghan says when we have to live with uncertainty, or think things through on the spot, it increases the chance of making an error. She says when a company is in “start-up” phase there is an increased risk of error.
She says right from the start there were “very obvious error producing conditions” at Pike River that needed to be identified and addressed.
9:49am – Counsel moves on from general discussion to talk more specifically about Pike River.
9:45am – In order to prevent tragedies Dr Callaghan says we need to look further back to what leads people to make errors or break the rules. She refers to the work of Professor Jim Reason, international expert in human error.
9:36am – According to Dr Callaghan, the National Accident Agenda in New Zealand has not addressed the major process safety events, but has focussed instead on personal safety events.
9:34am – Dr Callaghan says we must distinguish between person and process safety.
9:28am – The factors being discussed today are generic to health and safety in New Zealand, not isolated to mining says Dr Callaghan.
9:26am – One person could not have had a grasp of the breadth of hazards.
9:22am – Dr Callaghan reads from her evidence statement.
“The Pike River tragedy may have been a process safety event…it reflected the level of the regulator and government decision making.
“Pike River proves that we have failed to learn from previous accidents.
“The evidence I have seen indicates that Pike River mine was an accident waiting to happen.
“Pike River was a workplace accident that occurred in a mine…it has implications for the wider health and safety environment in New Zealand.”
9:18am – Dr Callaghan says disasters need to look at why individual human errors are made, in order to prevent the same mistakes being made again.
9:17am – The witness has worked in the improvement of aviation safety.
9:14am – Dr Callaghan says safety is a multi-disciplinary field that requires human factors expertise as part of that to ensure a safe workplace. She confirms human failure has been at the heart of many tragedies, including the Exxon Valdez oil spill in Alaska in 1989.
9:10am – The null hypothesis is a scientific approach that starts an investigation with the premise “that nothing is going on here”.
The human factors approach considers the person at the centre of everything, it looks at peoples’ interactions with everything and everyone they encounter. They aim to make those interactions as positive as possible.
9:08am – Dr Callaghan is not an expert in risk assessment.
9:05am – Dr Callaghan explains her professional background and how she offered her evidence to the commission as opposed to being approached by the commission as an expert witness. She is director of the human factors group at the University of Auckland’School of Medicine.
9:00am – Inquiry resumes.
3 News