Organisational drift into failure: a case study of the 2010 Pike River Coal mine disaster

Time is an important and often overlooked element in understanding decision-making under uncertainty. Whether looking forward or backwards in time, decision-makers need to be aware of trends and patterns consisting of multiple factors and cognitive biases. The case study considers the key decision-makers' actions over the three years leading up to the Pike River coal mine disaster (2010), that killed 29 people on the West Coast of the South Island of New Zealand. Using high level risk factors and Dekker's approach to accident analysis, four time periods or episodes were identified and all relevant management information was considered within the period it related to. This episode perspective helps understanding why the key decision-makers were confident in their views and how their unchallenged uncertainty aversion led to disaster, both in financial and human terms. The lessons from this case study have a universal applicability, both for teaching purposes and organisational analysis.