Inquest into the deaths from the Appin Mine Disaster

Contributing factors

• Inadequate ventilation of B heading stub due to failure to remove brattice stopping at number 3 cut-through
• Failure to communicate ventilation changeover procedures to deputies and workers
• Lack of gas testing during critical period
• Defective non-flameproof fan starter switch box with power on in gassy place
• Defective safety lamp with corroded gauze and double flint mechanism
• Continuous miners operated with automatic methane monitors held in defeat
• Faulty and poorly maintained brattice ventilation
• Inadequate supervision of the ventilation system changeover
• Systemic tolerance of regulatory breaches by Mines Inspectorate
• Oral approvals given without written authorization
• Incomplete overcast construction with gaps filled with brattice

Coroner's recommendations

1. Amendment of the Coroners Act 1980 and Coal Mines Regulation Act 1912 to prevent conflicts between mining enquiries and coronial investigations
2. Allow skilled police investigators access to mines during rescue operations at the same time as rescue workers
3. Allow medical practitioners, government medical officers, and scientific officers into mines at the earliest possible occasion as part of rescue teams to obtain accurate forensic evidence
4. Establish special training programmes for investigators and medical personnel in mining disaster response
5. Consider appointment of specialist coroners with mining expertise to deal with mining inquest matters