"The [CIMS] structure was cumbersome and unsuited to the rapidly changing situation faced by the rescuers at the mine. Instead of decisions being made at Pike River, where mining and rescue experts were gathered, many were made by non-experts in Wellington.
"This slowed the emergency response and could have impeded a rescue had one proved possible.
"Preparations to seal the mine to reduce the chances of further explosions were hindered, and some experts at the mine became disillusioned."
This criticism was mainly targeted at the CIMS system, and not at the individuals or groups involved in the response.
The commission praised the New Zealand Police for "expert management" of the many logistical demands throughout the response effort.
The report said the mine manager should have called emergency services within minutes of the 3.45pm explosion, when he was told that there was no communication from underground and no calls to the control room. This was an unprecendented scenario at the mine.
Instead, emergency services were called at 4.25pm, when a body and toxic gases were found.
"The delay probably made no difference to the survival of the men, but the mine manager was not to know this."
The commissioners said the emergency response was hampered by a lack of information about the mine and the workers underground. The number of missing was not known until the morning after the explosion.
Pike River had no back-up communications system and there was no way of extracting sample of air quality deep inside the mine for five days following the explosion.
"There could be no rescue attempt without information on the mine atmosphere," the report said.
The fresh-air base in Pike River, designed as a safe haven for rescue, was "a fresh air base in name only" because it was not effectively sealed and had no guarantee of an air supply in an emergency.
Rescuers were criticised by some for not re-entering the mine immediately after the gas explosion, when supposedly the methane gas was burnt off and there was a window of opportunity for rescue.
The report was dismissive of this suggestion.
"The commission rejects this criticism and any suggestion of a lack of courage on the rescuers' part."
It added: "The window of opportunity fallacy has claimed many lives in mines throughout the mining world. - International best practice is to re-enter an underground coal mine only on the basis of representative and reliable atmospheric information. This did not exist at Pike River."
Pike River Coal has been criticised for not developing a reliable second exit to the mine for an emergency. The report said that because the explosion did not cause a roof fall big enough to block the main tunnel, the absence of a second exit "did not affect the men's chances of survival".
The commission noted that there was no prescribed timeframe for the recovery of the bodies, and the risks involved in re-entering the mine made body recovery "very uncertain".
Solid Energy, the new owner of the mine, has signed an agreement with the Government to recover the bodies if it could be achieved safely, was technically feasible and was financially credible.
