Auckland University human factors group director in the faculty of medicine Dr Kathleen Callaghan voluntarily offered her evidence to the commission.

She said although she had no expertise in the mining industry, she believed the Pike River disaster happened because of issues of an organisational nature.

“Organisational factors may be identified at the level of the company but more importantly from my perspective, reflected the level of the regulator and also government decision-making about the regulator’s function,” Callaghan said.

“In crude terms, the evidence I have seen indicates that Pike River mine was an accident waiting to happen in the sense that ‘an accident’ – not necessarily this accident – was probable,” she said.

Callaghan stressed the Pike River explosion should not only be categorised simply as a mining accident but an accident which occurred following a series of human-based errors.

She revealed there were a number or recurring safety issues at the mine that were never dealt with, on a repeated basis.

“The hazard reports are of concern because they document significant and recurring risks to safety in areas such as housekeeping, emergencies and ventilation,” Callaghan said.

Callaghan relayed some of the safety issues present in the mine’s hazard reports to the inquiry, which included no visible gas detectors in the mine and ignition sources such as aluminum cans being found.

“Firehoses incorrectly coiled, … no gas detectors, so an emergency problem … the aluminum coke can, again that’s an ignition,” the report said.

Other ongoing safety issues highlighted at the mine related to emergencies and the unavailability or breakdown of safety equipment.

“No phones, or phones not working ideally … [and] emergency list phone numbers are out of date,” the report said.

Callaghan also listed the high amount of inexperienced staff at Pike River Coal and the high turnover of staff, particularly in managerial positions, as another one of her safety concerns at the mine.

When asked by Queen's counsel Nicholas Davidson if she had been “shown any Pike record which demonstrates the completion or resolution of matters relating to hazard or incident reporting, something which demonstrates the conclusion or end of a trail of dealing with these matters”, she said she had not.

“These reports in PRC itself are telling, holes appear time and time again in a different context,” Callaghan said.

Throughout her evidence, Callaghan said the Pike River tragedy could have been avoided, had the country learnt from past disasters, such as the 1979 Mount Erebus plane crash and the Cave Creek tragedy in the mid-1990s.

“Sadly but of crucial relevance for future safety, Pike River proves that we have failed to learn from previous accidents,” she said.

Callaghan said management and the body governing mines would need to improve safety culture to ensure another tragedy, such as Pike River, was never repeated.

“To dismiss safety culture as too complex and intangible is to ignore a core element of the disaster at Pike River,” she said.

“It is to ignore the lessons New Zealand should already have learnt, the lessons from Erebus.”