A Department of Conservation volunteer who disappeared while on remote Raoul Island probably fell into the sea and drowned while taking water temperature readings, Coroner Brandt Shortland has found.
He held an inquest into the death of Mihai Ioan Muncus-Nagy, 33, of Romania, who disappeared on January 2, 2012, while working alone on Fishing Rock on Raoul.
His body was never found.
In the finding the coroner said that the weekly water temperature was not needed by DOC but was collected for government agencies GNS Science and Niwa.
Since the death it had not been collected. Neither agency had replied to DOC over whether they needed it anyway.
The court heard that the temperature was taken from a platform on the rock and involved casting a buoy with a thermometer into the sea. It would then be retrieved.
Raoul, 1100 kilometres northeast of Auckland, is partly staffed by DOC which maintains the environment on the volcanic island.
Muncus-Nagy went alone to do the reading. It was only later in the morning that it was realised he was missing. A shed door was open and the buoy was still in the water.
A major search was launched, both on the island and from New Zealand, and Muncus-Nagy's jacket was found on rocks.
"Despite every effort his body was never found and there is no evidence to suggest that he made his way off the island and is living in another place in the world," the coroner said.
Fishing Rock was not the most stable platform and waves sometimes washed over it.
Evidence at the inquest showed that that was unlikely on that day.
However, it was likely the buoy had been trapped by rocks, Muncus-Nagy had gone down to retrieve it and he had fallen in the water.
The coroner said the death was preventable.
"However it must be examined in the context of this beautiful environment against the hazards and risks that Raoul Island presents," he said.
"The system for recording seawater temperatures on Raoul Island worked on a balance of old-fashioned pragmatism coupled with how the island always operated."
DOC had openly and honestly reviewed procedures to ensure such a tragedy did not happen again.
"Despite all the changes and positive restructuring there are never any watertight guarantees that death will not occur again despite the best efforts. That is the reality of life," the coroner said.