A mining consultant sent to audit the Pike River Mine found the company was dysfunctional, under serious financial pressure, and its own staff were suspicious.
The Royal Commission of Inquiry this morning heard that David Stewart visited the mine repeatedly between February and April 2010.
He intended to return but got involved in another job.
He did not make it back until the night of the explosion, on November 19, accompanied by Mines Rescue.
Mr Stewart was initially approached by Pike River Coal chairman John Dow, who was concerned at the high staff turnover, morale, and difficulties with meeting targets.
Mr Stewart found that staff were under pressure to achieve targets, as everyone knew what the mine had cost to develop. Employees worked hard but there were some negative attitudes to the mine's success, and all were concerned about the future of the project.
The turnover of managers had compromised the mine, Mr Stewart said.
Like many mines, there was an underlying "suspicion and mistrust'' of management, but it seemed worse at Pike River.
Former chief executive, and earlier the mine manager, Peter Whittall, was "clearly in charge'', although his replacement mine manager Doug White had recently been appointed.
Mr White seemed to have a "better grasp'' of the issues than new underground mine manager Mick Lerch.
There were many inexperienced miners, complicated by the mix of New Zealanders, Australians and South Africans, Mr Stewart said.
"It appeared to add to the apparent dysfunctional nature of the organisation and communication, within the mine and between underground, and the surface.''
Unusually, there was no ventilation engineer, and the tradespeople - many of the electrical staff were from overseas - were a "mixed bag''.
There was some good underviewers, although one had returned to Australia.
Mr Stewart raised a number of concerns, including the lack of a remote gas monitoring system, which meant the control room had no idea what was passing through the main fan, or the general body of the mine.
"I certainly did not agree with where the [main] PRC fan was to be located (on the surface).''
The ventilation system needed a lot more work before hydro mining could begin, as it released lots of methane.
"There is little room for error unless all the backup safety systems are well established.''
Debris and obstructions in the tunnels leading to the escapeway had not been addressed by his last visit. The lack of stone dusting, to reduce the risk of fire, also concerned him.
The vertical escapeway was impracticable for lots of people, he said.
"Only the fittest would escape through this route.''
Mr Stewart was concerned that blasting was sending rock flying into stoppings; a blast screen was erected but on a later visit it was damaged, and had not been re-erected.
He had heard that gas sensors on some machines were overridden, but had not seen it for himself.
Friction sparks from the mining roadheader machines hitting hard stone had started methane fires, so Pike River had turned to shot-firing instead.
The gas drainage lines were discharging into the main return, which seemed "uncontrolled''. The lines could potentially be damaged by vehicles travelling the main roadway.
Mr Stewart said he was confident when he left in April, that things would change.
The hearing continues.
- Greymouth Star
