A coroner has harshly criticised a Central North Island outdoor pursuits centre where six students and a teacher died in a river tragedy two years ago, saying it was complacent and under-estimated risks.
The group from Elim Christian College in Auckland was caught in the flooded Mangatepopo Gorge during a school activity at the Sir Edmund Hillary Outdoor Pursuits Centre (OPC), in Tongariro National Park.
Teacher Antony McClean and students Natasha Aimee Bray, Portia Caitlin McPhail, Huan (Tom) Hsu, Anthony Walter Mulder, Floyd Mariano Fernandes and Tara Rochelle Gregory were swept away.
Coroner Christopher Devonport today found all seven drowned, and made more than 20 recommendations "with a view to preventing deaths occurring in similar situations in future".
It was "clear there were certain things that could have been done to prevent the crisis arising...or to minimise delays in the provision of assistance once the crisis occurred", he said.
"Outdoor adventure is an important tool in youth development," he said.
"Risk taking is developmentally normal, and safety in an outdoor adventure activity can never be guaranteed 100 percent, but for parents and family serious injury and death are not acceptable for their children that they have nurtured from birth, and whose care they have entrusted to an organisation with apparently skilled managers and instructors."
The OPC lacked environmental awareness and did not use instructional historical information, he said.
It had used inexperienced instructors, and lacked proper assessment of whether water levels might rise above a safe level during the trip.
There was inadequate communication between the instructor in the gorge and the field manager or OPC base staff.
The OPC failed to implement a crisis plan and quickly send response teams, and it had under-estimated risks, he said.
Young people learned from new experiences and some of those experiences involved risk, Mr Devonport said.
"That does not necessarily mean that it is inappropriate that risks be taken."
Proper risk identification and risk management was vital to avoid serious injury or death, he said.
In his recommendations he said:
* The catchment for the stream be identified and all relevant staff at OPC (and in particular the field manager and instructors) be made familiar with that catchment;
* A more accurate map of the gorge be prepared by OPC for instructors including showing points of exit and places of refuge;
* Instruction be given to OPC staff leading gorge trips of what conditions in the catchment result in water levels rising in the Mangatepopo Stream and the extent and duration of rising;
* More emphasis be placed in instructor training on the skill in assessing the likelihood of water levels rising;
* There be adequate monitoring of rainfall in the stream's catchment (including visual and rain radar monitoring) three hours before students go into the stream and while they are in there;
There should be a conservative approach taken to entry into the gorge if there was heavy or steady rain in the catchment three hours before any trip, the coroner said.
That could include trips being abandoned due to heavy rain.
Communications between the centre and its field manager needed to be improved and the field manager should be aware of any students in the gorge, when they went in, and when they came out.
Two instructors should go on gorge trips and both should carry waterproof radios with regular scheduled radio links.
All adults on a gorge trip should know points, safety positions and how to use the radios.
Instructors should be told to get out of the gorge as soon as a rise in water level was noticed.
Mr Devonport said that while his inquiry was limited to the tragedy he had also issued another seven recommendations that the government consider the licensing outdoor education/adventure operations catering for people under 18 years.
In doing so he hoped to prevent deaths elsewhere in similar circumstances.
He recommended:
* People should be warned that the linking of individuals swimming or floating in moving water was potentially dangerous;
* MetService include severe weather warnings in applicable regional forecasts;
* MetService issue written forecasts with the time of the preparation of the forecast clearly displayed;
* MetService review its procedures around follow up communications to forecast recipients when there was an error in a forecast.
Outdoor New Zealand was told it should review its policies and procedures around safety audits and training provided to its auditors.
