'A tragedy that could have been avoided'
CELLPHONES were banned at the Sir Edmund Hillary Outdoor Pursuits Centre.
"Bye bye Mummy," joked Tara Gregory in a text before she handed in her mobile.
In Auckland, her mother read the text and panicked. "She never called me Mummy. I showed it to my mother, and we just said, 'My God, what's going to happen?' I wanted to get in my car and drive to OPC and drag her home."
She never saw Tara alive again.
There are photographs. Pictures, recovered from another dead child's camera, of Tara and her Elim Christian College classmates. Smiling, strong, kitted out in wetsuits, hours before they died on a canyoning adventure in the Mangatepopo Gorge.
On the afternoon of April 15, 2008, OPC instructor Jodie Sullivan made the decision to leave a rock ledge above the Mangatepopo Stream and enter what has been described as a "maelstrom" of water. She ordered her group, some of them roped in pairs, to follow at five-minute intervals.
Sullivan and three students survived. A teacher and six Year 12 students drowned: Antony McClean, Natasha Bray, Portia McPhail, Huan (Tom) Hsu, Anthony Mulder, Floyd Fernandes and Tara Gregory.
Their school filled with flowers. Their funerals made national headlines. Parents were devastated but, apparently, forgiving.
The Sunday Star-Times first met Tara's mum, Catherine Linnen, a week after February's coroner's inquest into the tragedy. She was still rubbing her arms – bruised from where she gripped them tightly as witness after witness dissected the day her only child died.
"I could cry every day if I wanted to. But I decided no more tears. It's not getting me anywhere. My minister declared at Tara's funeral that we did not believe this was the will of God. The God we believe in is not the Grim Reaper who goes around cutting down young people."
For months now, Linnen and other parents have been living with the shocking contents of a confidential independent review into the Mangatepopo incident, commissioned by trustees of the Turangi-based Outdoor Pursuits Centre.
Finally made public on Tuesday, it reveals that while individuals made fatally bad decisions on the day, there was a history of death and near-misses in the gorge. An extensive Star-Times investigation has revealed other damning reports, raising significant safety concerns at the outdoor education centre, years before the Mangatepopo tragedy. OPC was unlucky the Elim incident happened, said one source: "But they were also lucky it took 40 years."
"I haven't seen that information before," says Linnen. "You think you're prepared... "
Key findings of the independent review to OPC trustees: the inadequate design and development of the centre's adventure challenge programme; failure to maintain staff with sufficient instructing experience; deficiencies in the identification and management of hazards; a lack of institutional memory because of high staff turnover; financial and production pressure on the centre's operations.
And then, at paragraph 425: "Prior to the Mangatepopo incident, there were clear indications the risk of accidental death at OPC has been greater than the risk of accidental deaths for an adolescent in everyday life for much of its history. OPC had not only previously had a death, on the same adventure challenge programme, about the same section of river which held up Jodie Sullivan's group as they tried to exit the gorge, but had also recorded in its accident records three other deaths (from a fatal fall and an avalanche) and at least seven close calls. Some causes of the April 15 incident were neither recent developments nor limited to the Mangatepopo Gorge tragedy."
Was OPC a loaded gun?
LAST WEEK, the Star-Times received an email from Australia. It said that in 2000, Grant Davidson, chief executive of OPC at the time of the gorge deaths, had been commissioned to write a report on the drowning of a southern New South Wales student on an unaccompanied outdoor education hike. Davidson criticised organisers for not receiving updated weather reports, inadequate hazard analysis and a lack of trained instructors on the trip, stating, "this was a tragedy waiting to happen".
"Outdoor professionals in Australia found it incredibly ironic that many of Dr Davidson's own recommendations about what is best practice in the outdoors were not put into play in his own outdoor education centre," said the email.
Davidson says there were "significant differences" – OPC did have systems in place; "on the day... they were not followed by certain staff".
In fact, Judge Anne Kiernan, presiding over last year's Department of Labour prosecution of OPC, said of the Mangatepopo incident: "This is a tragedy which should not have occurred and a tragedy which could have been avoided."
Alarm bells had been sounding for years. In February, the Star-Times reported, from sources independent of the material suppressed by coroner Christopher Devonport, a 1976 death in the gorge and a near-miss in 1994 when students from Auckland's Kristin College got caught by floodwaters and a rescue party became stranded.
With the lifting of coroner's suppression orders, we can now report 19 incidents – eight of them directly related to rapidly rising or fast-flowing water – had been recorded by OPC staff working in Mangatepopo Gorge (see sidebar on C5).
More damning is a confidential safety audit obtained by the Star-Times, showing that, in 1996 at least, staff stress levels were such that half of all OPC employees were deemed to have a 50% risk of being involved in a serious accident or illness; 11.1% had a 79% chance. That audit highlighted high staff turnover, non-compliance with agreed organisational policy and an "autocratic, unfriendly and demotivating" management dynamic as significant safety risks.
In 2006, another document identified more problems, mostly "the result of financial constraints". The report, an evaluation of staff training and assessment at the centre, critiqued the three-week induction for newly graduated instructors. It said some compulsory competencies were impossible to assess prior to instructors being given sole responsibility for students and warned that current systems created the potential to place instructors in more demanding situations than those they had been signed off for.
All of which will sound worryingly familiar to anyone who sat through last month's inquest. From the witness box, John Maxted, centre manager at the time of the Mangatepopo deaths, said he believed that staff in 2008 were under significant pressure to deliver programmes with very little resource. At exit interviews, employees said they were overworked, not supported and disillusioned. The weeks leading to the incident had been particularly stressful – senior managers were involved in the Summits for Sir Ed tour, organised after the centre's patron died. An open day before the Elim Christian School visit meant most workers had only one day off that weekend and the centre's field manager had been distracted on April 15 by the unexpected presence of an external auditor. Maxted said there was pressure to get new instructors into productive work mode as soon as possible, poor institutional memory of previous incidents and an ineffective mentorship system for new staff.
IN THE almost two years since the tragedy, much has been detailed about the day in question. From the inaccurate weather report (the word "thunderstorms" was omitted from the MetService fax), to poor radio communications, low staff-to-client ratios and ambiguous sign-off procedures for entry to the gorge – the list goes on. The coroner's recommendations squarely address those areas of concern (see sidebar on C5).
But are there wider issues to be considered? Is there something wrong with a sector where staff with just two years on the job can be considered "senior", where fragmentation and lack of leadership are identified as serious problems across the entire industry, where it takes seven deaths for anyone to consider establishing formal qualifications for an activity like canyoning?
One former staffer, referring to OPC's workplace culture, used the term "risk drift" – the practice of partaking in increasingly riskier behaviour until, essentially, you are gambling. Could that term have applied to the outdoor education sector generally? How can you be sure your child is safe in the outdoors?
At the highest level is a letter, last September, from Prime Minister John Key to the minister of labour, expressing concern about the number of incidents in the adventure and outdoor commercial sectors and calling for a review that would include ways of improving risk management and safety.
Preliminary findings, released in February, determined there had been 29 deaths in the past five years. A total of 448 workplace accidents which resulted in serious harm were reported, and six prosecutions had been taken. A full review is due on May 31. Although it doesn't specifically look at outdoor education facilities, operations like OPC will, by default, fall under its gamut, because of its commercial nature.
According to the Department of Labour, there is no specific legislation covering the health and safety of participants in adventure tourism. The sector is, instead, regulated by the Health and Safety in Employment Act.
Last March, the department ordered OPC to pay $440,000 compensation and fined it $40,000 on two charges: failing to ensure the safety of their employee and failing to ensure their employee's actions did not harm others.
Parents like Linnen have demanded more individual accountability – a practising licence for instructors, for example, which could be suspended if an instructor is involved in a serious incident. She says she has not seen justice for her daughter and has written to the prime minister and the ministers of justice and labour, saying "whilst New Zealand charges only organisations, and only fines them, there is no reason for any individual to pull up their socks and do their job properly... I think you want to look at changing the laws around prosecution".
A secondary school teacher, Linnen has to maintain a practising certificate. "If it runs out, I can't teach any more. In the outdoors industry, it seems you can just wander into somewhere and get a bit of training and take people out into these very dangerous situations ... if they did something wrong, even if they can't be charged criminally, they might think `OK, I might lose my practising licence, and my job, and never be able to work again'. It might just make them think a bit. I don't want to see anything closed down. But I want to see safety measures stuck to, and accountability for people's action... Policies are only as good as the people who do or don't follow them."
THE CORONER'S final recommendations in the Mangatepopo inquiry go some way to addressing Linnen's concerns. Christopher Devonport has asked the government to consider the licensing of outdoor education/adventure operations which provide activities to persons under 18 years of age to ensure minimum standards are met.
If you're a parent who assumed that regime was already in place, you couldn't have been more wrong. The Ministry of Education has confirmed it has never held a list of approved outdoor education providers.
"Individual schools are responsible for the safety and security of children in their care," said Rawiri Brell, deputy secretary, early childhood and regional education. "There have been lists and directories of providers compiled by city councils and the former Hillary Commission. These lists were not `approved' providers, they were simply directories."
After the Mangatepopo deaths, then Education Minister Chris Carter called for a review of school guidelines on outdoor education. Completed last year, it admits "it can be a challenge" to assess the quality of providers. The onus is on schools. One suggested test is to ask whether an organisation has a quality assurance accreditation such as OutdoorsMark or Qualmark.
In an example of odd timing, OPC was being assessed for the renewal of its OutdoorsMark accreditation on the day of the gorge tragedy. Auditor Jill Dalton actually wrote the time log for the rescue attempt. She recorded the discovery of body after body. And then she granted accreditation. The report to OPC trustees notes: "Parents could have consented to their children attending the programme based on a faulty impression of the significance of OPC's achievement of the OutdoorsMark".
Linnen: "I decided after the inquest that presumably it wasn't worth the paper it was written on." The coroner has recommended a review of policies and procedures around OutdoorsMark safety audits and auditor training.
OutdoorsMark accreditation is administered by Outdoors New Zealand. In an interview before the release of the coroner's report, general manager Paul Chaplow said the Mangatepopo incident was "not a very good look" for the audit service. "But we still stand by the product... and it will continue to evolve in light of what the coroner comes out with."
Dalton has offered her resignation. "I'm not sure if that auditor will continue to work or not at this point," said Chaplow. "When someone has something like this happen to them, in a lot of ways they're more valuable to us as an organisation than they were before."
Chaplow says OutdoorsMark can measure systems. "But when you drill down really carefully, you can start to pick up some flaws maybe in bigger things...like the culture of the organisation."
Grant Davidson, the former OPC chief executive, has a PhD in risk management. He started his OPC career as an instructor in 1984 and resigned this January.
Former centre staff the Star-Times spoke to said OPC's organisational structure distanced Davidson from blame in the event of an accident. They criticised his high salary package – Davidson confirmed he was paid "a little over" $100,000 and said instructors like Sullivan could earn $30,000-$48,000.
He said he believed both poor judgement and system failures came into play on April 15.
"As chief executive, I'm ultimately accountable for those system failures and I've acknowledged that from day one.
"I think OPC, at that time, was as well equipped in terms of staff and safety systems as any outdoor education organisation in New Zealand, but we're always operating in the outdoors which does have real risks ...systems and judgement calls have to be made that prevent real risk from being put in front of students."
Davidson agreed more should have been done to learn from past "near misses" – the centre's internal safety committee had asked for a list of previous incidents, but it was never compiled.
High staff turnover was common across the outdoor education sector. OPC's trust board had looked at the issue after the 1996 safety audit. Contributing factors included the centre's isolation, lack of work opportunities for partners and spouses and the desire of younger staff to travel overseas.
"When we compared it to other centres, we found identical trends."
Davidson said deleting the Mangatepopo experience from adventure challenge courses had never been considered. "The belief was, amongst everyone there, and if you went there today I think you'd find the same, that the risks are controllable."
Flooding had been identified as an issue. "All of that was written down in policy but unfortunately, on the day, mistakes were made.
"Take away the flash-flood scenario and that canyon or gorge walk is a beautiful and awe-inspiring place with very little danger."
According to Davidson, the outdoor education sector had been working to become more cohesive for the past five years. "But I really hope that this tragedy will force people to look closely at what they're doing and collaborate and work even harder to make the outdoors a more managed environment to work in."
Davidson started a new job on Monday. He's now chief executive of Skills Active Aotearoa, the organisation that recently joined with the Mountain Safety Council and the Outdoors Instructors Association to announce the establishment, this year, of a national Outdoor Qualification Registration Scheme which would provide "a central point for organisations to register their outdoor qualifications and set appropriate revalidation criteria".
Star-Times inquiries found canyoning was a sport completely unregulated by mandatory qualifications, something noted by industry a year before the gorge deaths.
IN 2007, Outdoors New Zealand identified a "growing confusion about the plethora of outdoor standards and qualifications that have existed in New Zealand". Particular gaps were identified: trekking, hunting, fishing, biking, horse trekking, river sledging – and canyoning.
The accepted best practice publication on the subject is Sparc's Outdoor Activities – Guidelines for Leaders. The section on canyoning thanks Kerry Palmer, OPC field manager at the time of the Mangatepopo deaths, for his contribution. The three-page "how to" guide says bush, rock climbing, abseiling, caving and river rescue qualifications are all relevant to canyoning. Leader responsibilities include ensuring sufficient assistant leaders, disclosing known risks, obtaining information on participants' health, fitness and swimming ability and checking water levels and latest weather forecasts – all areas for which OPC has come under fire.
In fact, it has taken the seven Mangatepopo deaths to prompt the development of formal qualifications. Matthew Claridge, Water Safety New Zealand general manager, confirmed that as a direct result of the tragedy, work was under way, with the first report due next month. The project is being led by Stu Allan, OPC director from 1979 to 1986 and now head of Sport and Recreation New Zealand's new Sir Edmund Hillary Outdoor Recreation Council.
That council was born out of submissions to Sparc's outdoor recreation strategy from 61 agencies, many of which called for an overarching, representative body.
"There is no national representative body for outdoor recreation in New Zealand, nor is there one government agency with sole responsibility for outdoor recreation," said a Sparc report.
The Star-Times wanted to talk to Stu Allan. Sparc referred us instead to its recreation manager, Deb Hurdle. She provided a "sector map" showing interaction between 20 umbrella outdoor groups. "As you can see, there is a lot of fragmentation. That's one of the key things that drove the Outdoor Recreation Strategy."
Will the new council save lives?
"We will work with safety organisations," says Hurdle. "But that is not our primary focus."
Hurdle admits the quality of outdoor education instructing for school children "varies hugely" – some institutions rely on parents and teachers who may have experience in the outdoors but no qualifications.
"I know people who are outdoors instructors who have gone on school camps with their kids who are horrified by what the school is letting the parents do."
Hurdle, interviewed before the release of the coroner's recommendations, didn't believe compulsory licensing of individuals, as called for by some parents, was the answer.
"When you're talking about the outdoors, there is only one way you can save 100% of lives, and it is to not go into the outdoors. And that's just ridiculous.
"When you let your child have an element of independence to try new experiences, there is always a risk. All you can do is try to manage that risk. That shouldn't be a deterrent to people. Everybody along the line needs to take responsibility, from the kids to the parents to the teachers to the centres to the instructors."
PARENTS ARGUE they were never adequately told of the risks – and neither were their children.
"What responsibility could they take when they were being led by someone they thought was a professional who knew what she was doing?" says Linnen. "It appears they didn't know it was life and death, they weren't told it was life and death – that's what all the survivors seem to be saying."
"Outdoor adventure is an important tool in youth development," said the coroner. "Risk-taking is developmentally normal, and safety in adventure activity can never be guaranteed 100%, 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. All reasonable steps must be taken to minimise the chances of serious injury."
Rupert Wilson, legal spokesman for the OPC trust, said all recommendations since the deaths would be fully implemented.
"The emphasis now has moved right to the super high level of safety. There is a huge amount of caution and care and review of peer judgements."
A letter from the trust to schools in February advised it had commissioned a review of core adventure challenge courses, introduced a new safety programme, enhanced staff induction processes, required two instructors on some activities on moving water or steep slopes and made all instructors aware of previous incidents and possible risks. Mangatepopo Gorge remained closed, although last week Wilson said it may reopen in summer.
Speak to parents who lost their children at OPC, and two names come up for consistent scrutiny: field manager Kerry Palmer and guide Jodie Sullivan.
According to centre policy, Sullivan should have signed her trip off with Palmer. Coronial evidence painted a "he said, she said" scenario: she thought she had permission to enter the gorge, he thought that if she went in, she wasn't going very far.
"There is no doubt that with the benefit and clarity of hindsight, that I could have done some things differently," says Palmer, who, in 2006, was part of a trio awarded the New Zealand Bravery Medal for their rescue of three trampers stranded on the Kaimanawa Ranges.
"I was operating in the context of a system. I believe that I did everything I was required to do that day – expected to do by the organisation.
"It's very easy to blame somebody, but it's much more difficult to find the cause of the problem. And the most difficult thing is to try and find how you can prevent these things happening again."
Palmer, responsible for 10 instructors in the field on the day of the tragedy, wants deeper analysis of OPC's organisational culture.
"One surely has to acknowledge it was an organisation at its limit on April 15, 2008." He no longer works at OPC. High staff turnover is ongoing. Sullivan, who attended every dead child's funeral but was absent from later restorative justice meetings with parents, is still not commenting. "I'm not ready to talk to anyone in the media at this point in time," she said in response to Star-Times requests.
Pale, dreadlocked and recently returned from working in an American summer camp, Sullivan was the only survivor required to testify in person to the Coroner's Court. Student statements were suppressed by the court. But the internal review pieces together the final, terrifying moments before their classmates and teacher died.
"The water reached the ledge and came up to the knees of the teacher, standing on a lower part of the ledge. Students sitting or crouching towards the back of the ledge, where the wall overhung somewhat, had to stand to keep out of the water. They huddled on the highest part of the ledge. Those on the outside could feel the current strongly on their calves. It was slippery and difficult to hear. The students were cold. Jodie Sullivan began to make preparations to leave the ledge..."
Survivors said they were unprepared for the power of the water.
"None of them thought Sullivan might not be able to retrieve them. None of them thought Sullivan might not succeed in exiting the river. None of them were aware of the particular hazard posed by the spillway."
Catherine Linnen has canyoned the Mangatepopo Gorge. After Tara's death, she visited the centre several times. There are more photographs, in her album of Tara's "lasts", of her own experiences there.
"This is the ledge," she says, pointing at a picture. "We had to get off the ledge and put ourselves in the water right where they were, which was pretty upsetting. The water is maybe slightly up on normal flow. You can imagine what it must have been like for them."
She closes the album. The saddest cliches are the truest: nothing will bring back her only child, the daughter she raised on her own, since Tara was three years old.
A police investigation into the tragedy found no evidence of criminal offending, "particularly looking at manslaughter under the Crimes Act", says Inspector David White. "Like any investigation, you could always review that if new evidence came to light."
At least one set of parents have considered civil action against OPC, contacting lawyer Grant Cameron, who previously represented families involved in the Cave Creek platform collapse which killed 14 students and a Department of Conservation worker. So far, financial constraints have stopped the query progressing.
FLOYD FERNANDES' funeral was held the day before his 17th birthday. His parents, Jennifer and Francisco, brought their eldest son and his sister Janis to New Zealand from India "for a better life".
Today, they nurse a four-month-old boy, Judah Floyd Fernandes. "God's grace," says Jennifer. "After this, we've learned the value of life a bit more."
She sits on a sofa in Howick, in front of the 1970s-style coffee table Floyd dragged home from an inorganic rubbish collection. The family no longer eat at the dining table. Too many memories.
"What breaks my heart is he was crying out for help as he went down. He knew what was happening. That is...you know..."
Soft tears. Because, on the eve of the second anniversary of Floyd's death, the Fernandes family are, mostly, angry.
"At the coroner's inquest, Jodie was asked if she was sure she could catch everyone. She was not sure. That is very hurting to know. That, in spite of knowing, she made them jump," says Francisco.
Evidence showed floodwaters in the Mangatepopo Gorge peaked around the time the group left the ledge. Both the OPC report and the coroner's findings show, had everyone stayed on the ledge, they would probably have survived. Two other instructors, concerned about the weather, had chosen not to take groups into the gorge on that day. But Sullivan had no experience of the stream in flood. She had done the gorge trip only five times before the tragedy.
The coroner's findings show she had completed a 12-week outdoor educator's course at the centre, worked two weeks as a volunteer and had been employed fulltime for two months before the incident. While she had "signed off" on four of the six competencies required for the downstream gorge trip (the Elim group was taking part in an "upstream" activity), she had not been signed off on competencies for removing students from the halfway ledge or abseil point in the gorge. Despite the identical location, the upstream trip had less stringent competency requirements – a disparity criticised by parents during the course of this investigation.
"I feel blame, myself," says Jennifer. "While I was signing his consent form, my pen just stopped. I said, `Sorry Floyd, I'm not sending you.' I sort of wondered then."
The Fernandes family wrote to John Key: "For a nationwide tragedy such as this to take place and no one is held accountable is rather surprising to us and some of the other parents whose kids did not return back home. What is the surety of the industry stepping up to the required standards for children that go there for outdoor training and leadership camps, when there is no accountability?"
Key replied, 10 days before Christmas. In a two-page letter, he said he could not comment on the police investigation, which had to remain free of political influence or interference.
"I am advised that in order for an individual employee to be prosecuted by the department [of Labour]...the investigation must show they were provided with sufficient opportunities and resources to ensure the safety of those in their care.
"In the case of this tragedy, the department found that the centre had failed to ensure that the two critical employees in question had those opportunities and resources. As such, the department decided that charges should be pursued against the centre, rather than the individuals concerned..."
The letter ends with the prime minister's condolences, and a final sign-off: "Know that the sympathies of thousands of New Zealanders are with you. Kia kaha."
Previous incidents in Mangatepopo Gorge:
1976: Student dies after being swept away following river crossing. It is agreed "only stronger groups" should use the gorge.
1984: Group caught by rising water, instructor breaks his leg en route to assistance.
1987: Student with suspected hypothermia evacuated – "minor incident but dangers of a gorge trip must be realised".
1988: Student fractures ankle – staff training day to look at gorge rescue and group management actioned.
1989: Near-miss as students try to cross river before instructor signals they can; individual almost swept over waterfall.
1990: Student strains ankle jumping into water against instructions. 1992: "Cold" injury; gorge activity recommended not standard until spring.
1994: Student swept under water, another hit by a rock, as trapped group retreats from "dangerous torrent". Rescue group stranded on ledge overnight. Standard operating procedures for gorge developed. 1996: Two students jump into plunge pool and swept past "get out" point. Student falls backwards into river and is held under by force of current.
1999: "Overweight" student falls on upstream gorge trip with solo instructor.
2001: Rocks dislodged on group in gorge; student falls on gorge descent, "throw bag" rescue initiated.
2004: Instructor swept under submerged log; student loses footing, goes over waterfall, held under water by rope; group enters gorge while flow is over maximum limit, student is swept underwater for 20 seconds.
2005: Student falls 3m off waterfall; student loses footing on river crossing and is swept away – rapid management discussions initiated.
Source: Report to Trustees of the Sir Edmund Hillary Outdoor Pursuit Centre of New Zealand – October 2009
Staff familiarisation of Mangatepopo catchment and conditions that result in water level rise.
A more accurate map showing points of exit and refuge.
Adequate rainfall monitoring during and three hours prior to gorge entry.
Field manager to be responsible for "overall picture" of environmental conditions.
Radio communication with field manager when entering and exiting gorge.
Field manager can countermand any trip.
Two instructors on any gorge trip, both carrying waterproof radios with earpieces.
If necessary, a radio repeater installed to ensure adequate radio communication between staff in the gorge and centre staff. Radios should be audible and kept on throughout gorge trips, or a communications schedule devised.
Alternative methods of communication of distress if radio communication fails. All accompanying adults to be aware of exits, safety positions, how to use radios and fall back communication devices.
Instructors to be fully trained and have "competencies" in all available gorge exits. Policies requiring immediate exit from gorge if water levels rise. Instructors to provide field manager with time plan of proposed trip.
Action plan for seeking assistance and performing gorge rescue if group is in difficulty or overdue and rescue exercises undertaken. Government consider licensing of outdoor education/adventure operations which provide activities to persons under 18 years of age to ensure minimum standards are met.
Emphasis to public and training institutions about potential dangers of linking individuals in flowing water.
MetService to include severe weather warnings in applicable regional forecasts and review procedures around errors in forecasts.
Outdoors New Zealand to review its policies and procedures around OutdoorsMark safety audits and auditor training.
Underlying causes of Mangatepopo tragedy:
Inadequate instructor "competency" requirements for the trip
Lack of clarity about field manager's supervisory role over field staff
Failure to identify students' required swimming ability
No culture of regular checks for updated weather reports
Failure to radio in before entering gorge Unclear policy around when gorge could be entered
Three-week induction for newly graduated instructors inadequate
Flawed Risk Analysis Management System (RAMS) form for gorge trip – no map or identification of previous incidents or some hazards
Over-reliance on solo instructors
No specific rescue plans for gorge trips (instructor may have stayed on ledge if she had known help was possible)
Failure to learn from previous incidents with contributory themes: inexperienced and solo instructors, non-confident swimmers, insufficient knowledge of environment, flooding/high water flow
Source: Report to Trustees of the Sir Edmund Hillary Outdoor Pursuits Centre of New Zealand – October 2009
Changes at OPC since tragedy:
Appointed permanent external safety review team
Commissioned a review of its core adventure challenge courses
Introduced new safety programme designed to ensure instructors allow for substantial margin of safety to benchmark their "go or no go" decisions and to reduce the potential for errors in human judgement
Enhanced training and induction processes
Identified activities which require two instructors present
Better instructor awareness of previous incidents and possible risks and responses
Subscription to MetService severe weather warning service
Sunday Star Times