Pike River Mine, which needed to have the best of everything to succeed in its tough environment: the best geological knowledge, the best equipment, the most rigorous safety discipline, sufficient capital, we now know had the worst of everything.
The miners were unaware the regulator was ineffective applying safety rules and were led by a board that did not adhere to the most basic risk-management governance practices. They watched a revolving door of management and were using expensive, but inappropriate, equipment for the harsh conditions. They were whipped along by the company's lofty ambitions and supposedly supported by a union that was not welcome. Of course none of these factors meet any police forensic criteria.
Next in this cruel farce is the case being bought early next year by the government's health and safety agency, the Ministry of Business, Innovation and Employment (Mobie), against Pike chief executive Peter Whittall. He is facing 16 charges under the Health and Safety Act.
This is the same agency under a different name that was responsible for the lack of regulatory oversight at Pike as the Department of Labour (DoL). In its own investigation of how it managed its relationship with Pike, it said: "DoL's performance as health and safety regulator of Pike was ineffectual and dysfunctional." The Minister of Labour resigned. The police have now conveniently passed the baton to Mobie but how will it succeed where the police failed?
Mr Whittall has a get-out-of-jail-free card, surely, in the prosecuting agency's own admission of ineffectiveness. He had left the mine for head office in Wellington nine months before the first explosion. The hearing has been moved to Wellington from Greymouth at his behest and is to hear more than 100 witnesses over three months. More heart shredding for the families coming up.
Even if it was moved to Madagascar, the families would be there. Their level of mistrust and anger is deeply rooted in the way they were treated by the company management and the incident controllers in the five fateful days between the first two explosions at Pike.
The horrific CCTV footage of the first blast exiting the main portal, which represented only some of the explosion's anger as it also exited the 100m ventilation shaft more than 2km underground, was seen by Pike management and police on site a few hours after the blast on Friday evening.
Back in November 1979, when an Air New Zealand DC10 crashed into Mt Erebus killing all 257 people on board, the nation saw within 48 hours the telling image of the koru tail insignia lying on the icy slopes. None of that definition, that vital reality check was forthcoming from Pike.
Within those five days, the damming evidence of a mine on fire from a suspicion first recorded in the NZ Fire Service log six hours after the first explosion, then backed up by comprehensive scientific testing within 24 hours, was brushed aside by Pike management and government agencies.
Yet these koru-like exhibits of finality were incredulously held back from the families for four days and six family briefings.
The betrayal of the 29 families by Pike management and the incident controllers was cruelly compounded at the Wednesday afternoon families briefing when Mr Whittall clumsily began his address with his interpretation of the rescue team he saw at the mine earlier, having medicals and briefings in preparation for any favourable changes in the mine's deadly atmosphere.
Only after he announced incorrectly that "a rescue entry was being planned" to clapping and cheering, did incident controller Superintendent Gary Knowles step in after waving the crowd to be quiet, to announce an unsurvivable second explosion occurred at 2.37pm.
Five days of misleading information from Pike management and government agencies, an eternity of mistrust and anger for the families.
