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Nathan Deutschbein, a New South Wales police officer and father of two girls, died on November 29, 2018, when he was caught in an avalanche and became buried while descending the Eugenie Glacier in the Aoraki – Mt Cook National Park with a climbing companion.
The 40-year-old, who was a senior constable in the Blue Mountains Area Command, was an experienced climber who had visited New Zealand several times before, climbing Mt Aspiring, Nuns Veil, Hoschsdetter Dome and Mt Aylmer.
Coroner David Robinson held an inquiry into Deutschbein's death to establish cause and circumstances, if it could have been prevented, and if there were any appropriate recommendations or comments to make.
In findings released today, it was revealed that on November 25, 2018, after six months of planning, Deutschbein travelled to New Zealand with two friends, and initially had to wait out some bad weather.
On November 27, they asked about avalanche danger and were told the local advisory had just been downgraded from high to moderate.
But they still rented avalanche transceivers and probes, and about midday on November 28 set off on foot from the Hooker Valley car park to arrive at the Sefton Bivvy just before 4pm.
The next morning, they woke at 3.30am but delayed their start because it was raining.
They set off just after 6am – with one member of the party soon feeling unwell, and deciding to turn back.
Deutschbein and his friend Ion Mihaila kept going, reaching the saddle at the top of the Eugenie Glacier on the Main Divide at midday.
The weather started getting worse and it was starting to rain.
They could see snow sliding down the mountain a couple of hundred metres away.
The pair descended back the way they came, staying roped together.
At about 1pm, when they were halfway down the glacier, they were hit by a "naturally occurring loose wet avalanche".
They were carried about 250 vertical metres.
Mihaila was relatively unscathed and started looking for Deutschbein.
He found him about 5m away. His legs were exposed on the surface and his upper body was trapped under the snow.
Mihaila used gloves and a shovel to dig down to Deutschbein's face, which was about 50cm below the surface.
His mouth and nose were full of snow. He was purple and Mihaila "knew he was gone".
As part of Coroner Robinson's inquiry, he commissioned an independent review of Deutschbein's death from the New Zealand Mountain Safety Council (MSC).
The report identified weather and snow conditions as causative factors.
The MSC noted that even when the Eugenie Glacier route is in good climbing condition, the morning sun impacts the snow surface quickly and can "significantly alter the stability as the angle is steeper and faces directly east into the rising and warming sun".
It was also found that the group incorrectly interpreted the avalanche dangers, with the "moderate" risk level being of elevations about 1400m.
They also failed to recognise the heightened avalanche risk and should have turned back earlier.
"Due to their late departure and slow travel, the pair were not descending until the afternoon, on a day that had not seen any overnight freeze. By this time, the snow would have received many hours of solar radiation, causing warming and melting," the coroner's findings state.
The MSC made a number of recommendations to mountaineers, which the coroner endorsed, including that all mountaineers attend an official avalanche training course, always understand the official local avalanche advisory, be willing to change plans to match the environment, and always establish a "turn around time" for return trips, especially in mountains where snow melt can bring significant risks as the day progresses.
The final recommendation is in line with International Commission for Alpine Research recommendations, which says CPR should always be administered for avalanche victims, although Coroner Robinson raised doubts it might have altered the outcome in this case.