The scene of the crash at Kaingaroa Forest in July 2019. Photo: Supplied / NZ police
The coroner investigating the deaths of four forestry workers says no-one has taken any form of responsibility for an avoidable incident that could have been prevented, if there was lighting on the side of the truck and trailer they crashed into in darkness early in the morning.
In findings released on Thursday, coroner Michael Robb also said toxicology evidence used by the police Serious Crash Unit was flawed in placing any blame on the driver.
In a 41-page report, he has made recommendations for laws covering oversize vehicles on private forestry roads and suggests the deaths be sent to WorkSafe, as he questions why the workplace safety agency never fully investigated.
WorkSafe said it would review its agreement with police "to ensure it is fit for purpose and operating effectively".
The men who never made it home
Storm Lacy (22), Steven Pari (35), Te Tahi Brass (25), Johnston Stoogie Ahuriri (37) and Anaru Brown were in a van heading to work in Kaingaroa Forest early on 29 July 2019.
The sun wasn't up yet and it wouldn't be for about another 40 minutes - it was dark.
Their van collided with the trailer of a logging truck that was blocking the lane on a private forestry road.
Lacy was driving. His death notice said he was tragically taken far too soon.
Brown, who suffered serious injuries, was the only passenger wearing a seatbelt and the only survivor.
The truck had its headlights on, but there was no lighting or reflectors on the side of the truck or its two trailers, coroner Robb said.
"In the night-time conditions, it was not possible for the van driver to see the logging-truck trailer blocking the northbound lane ahead of him, until after he passed the truck's headlights."
The truck was an off-highway double unit, oversized, with an orange beacon on the roof, and was fully laden with logs.
Combined, the truck and trailers were 34.9 metres long, which meant it had to be on an angle to get onto the road.
Its driver described thinking he needed to "hammer it" to try to get the truck to go quicker to move the second trailer from blocking the lane, the coroner wrote.
Then the crash happened. The van hit the very end of the second trailer, while the trailer entirely blocked the northbound lane.
Coroner Robb said it would have taken 15-17 seconds for the van to have come around a blind corner and reach the collision site.
Not enough time, he said, for the truck and trailers to clear the lane, which would have needed 21 seconds.
"The size and weight of logging trucks chosen to be used within the forestry, the planning of distances between side roads and blind corners, and straightforward speed
calculations highlight that this presented a foreseeable safety issue to anyone having to travel to work in the dark on this arterial forestry road," the coroner said.
At about 6.30am, there was no roadside lighting and the log trailers were dark in colour.
"In the night-time conditions, the trailers and logs were difficult to distinguish from their surroundings," the coroner wrote. "It would not have been possible for the driver of the van to see that a trailer was blocking the road ahead of him."
Coroner Robb said, while the lights on top of the truck would have alerted Lacy, there was nothing to tell him the second trailer was there.
The trailers were "virtually invisible", until it was too late, his report said.
The Serious Crash Unit concluded no-one could have avoided the collision.
Coroner Robb said side lighting would have meant the trailers could be seen in the night from 300 metres away.
Van driven appropriately
The coroner said an independent witness stated the van never went over 90 km/h, and was always driven safely and appropriately.
Lacy dipped his headlights, which suggested he was aware of his surroundings.
"What the evidence reveals is that the van driver was driving at or below the speed limit, had been observed driving well for a lengthy period by an eyewitness, passing that
eyewitness in a safe location and at a safe speed," the coroner wrote.
"On rounding a blind corner and seeing headlights ahead of him, the van driver also responded appropriately by dipping his headlights to low beam.
"These are all matters indicative of someone driving appropriately with awareness of his surroundings and in a responsive way to other road users," coroner Robb said.
"The decision to operate a truck and trailer unit of this length and slowness, at this location, at night, without any side lighting created the danger that ultimately led to the death of these four forestry workers," he said.
"These deaths could have been avoided by the forestry/truck operators through appropriate safety considerations."
Laws under the Land Transport Act do not apply to the road where the accident happened, because it is private.
Being an off-highway vehicle, the truck was not subject to heavy-vehicle laws, or the same regulatory requirements as highway trucks regarding weight, size or lighting.
Off-highway trucks had no specific laws or regulation, the coroner said. There was no specified level of lighting, and it was not mandatory or enforceable in any way.
"Ultimately, it is a matter at the discretion of the operator," he said.
The coroner said that police at the time did not understand the truck's operator might have responsibilities to ensure the forestry workers' safety.
He wrote in his findings that was no way to refer the truck driver to WorkSafe, after police decided they could not be prosecuted.
WorkSafe never fully investigated and it closed its file before the Serious Crash Unit completed its own probe, but in his findings on Thursday, the coroner said they were work-related deaths and the responsible authority needed to investigate.
"As I have highlighted many times in this finding, these four forestry workers lost their lives as a result of inadequate steps being taken to ensure their safety, when travelling
to work on these private forestry roads," he said. "So why has there never been a WorkSafe investigation into these four deaths?".
He said the deaths were avoidable, and were not investigated or recognised as matters that should be looked into by WorkSafe. The whānau of the four young men had not seen any entity take any form of responsibility for their avoidable deaths.
Coroner Robb said he would refer the four deaths to WorkSafe for investigation.
WorkSafe earlier said it could not investigate any proceedings more than 12 months after an incident, but the coroner, in turn, told WorkSafe the same law allows an investigation within six months of a coroner's findings.
"Under the current Coroners Act, I cannot mandate an investigation nor can I mandate a response to any recommendation," he said.
"However, if WorkSafe is unwilling to carry out an investigation, as a matter of courtesy, I ask that they provide an explanation to the Coroners Court and the four whānau of these young men."
Further coroner's recommendations
Coroner Robb also recommended laws or regulations for oversized off-highway vehicles, so the health and safety of those on private forestry roads was protected.
He has called for trucks and trailers to be lit "in such a way that the entire length of the vehicle can be clearly observed by any oncoming vehicle beyond the activated headlights of the oversized vehicle".
The haulage company, Rotorua Forest Haulage Ltd, had advised it used a current code of practice, but the coroner said this code had its limits.
The company told the coroner that after the crash it recognised the danger of oversized, slow-moving vehicles at night that had no side lighting.
"They moved initially to cease all night-time operating and then worked to ensure side lighting was in place thereafter," the coroner said.
He noted the Log Transport Safety Council recommended side lighting "where feasible".
"That does not go far enough, where four young workers have lost their lives in avoidable circumstances, which could occur again in the future," Robb said.
After the accident, RNZ reported that WorkSafe said it would only become involved, if police identified any workplace elements to the crash.
In his findings, the Coroner said he was concerned police, when investigating accidents, were untrained and unfamiliar with work health and safety laws.
"I recommend that the process by which the New Zealand Police and WorkSafe investigate and determine responsibility for investigation of forestry road deaths be reviewed," he said.
"WorkSafe remained of the view that it was appropriate for them to close their file, without even waiting and reviewing the SCU report, or at any time considering whether the incident ought to be investigated from a Health and Safety at Work Act perspective."
"I find that response and the arrangement between WorkSafe and the New Zealand Police in the investigation of forestry roading deaths most troubling."
Flawed toxicology evidence
The coroner said those who knew driver Storm Lacy were adamant he drank little, kept fit, and did not smoke cigarettes or cannabis.
Lacy's partner, employer and whānau were united on this, coroner Robb said. Toxicology results for him were challenged.
Robb said the severe injuries the men received meant samples could not be relied on, in part because there were no processes to make sure they came from the right people.
Two of the men were so badly hurt, they could not be visually identified.
Coroner Robb said he could not safely rely on the toxicology analysis attributed to Lacy.
"There was no oversight or scrutiny by the police, nor evidence provided recording the process of taking and attributing samples, nor proof of chain of custody and provision to ESR and attribution of results," he said.
The coroner said the Serious Crash Unit incorrectly recorded the driver was under the influence of cannabis, which is not what the analysis said.
"While cannabis is detectable in blood and urine samples, that analysis does not therefore mean that the individual was 'under the influence' of cannabis," he wrote.
The coroner said the SCU report writer ignored the fact the trailer could not be seen in the dark and instead pointed to cannabis consumption.
"Analysis of those circumstances, as detailed ironically in the SCU report, highlight the contrary, highlight that the driving behaviour of the van driver was in fact inconsistent with him being under the influence," the coroner said.
Coroner Robb said the circumstances point to Lacy being "entirely sober".
He said there was no evidence in any way showing he was slow to respond or failed to pay attention.
"The van driver's actions in that moment demonstrated a very fast reaction time and an appropriate physical reaction," the findings say.
"There was no evidence that he was driving in a manner which showed that he was taking longer to respond and had reduced ability to pay attention. The evidence established the contrary."
The coroner found Lacy was not responsible for the crash and there was no evidence he used cannabis.
He found the Serious Crash Unit report incorporated a flawed statement.
The coroner offered condolences to the dead men's whānau, "who grieve as a result of these avoidable deaths".
WorkSafe considering next steps
WorkSafe will review its relationship with police after the Coroner questioned why it never fully investigated.
Responding to the findings, WorkSafe said it was police that take the lead under a Memorandum of Understanding.
"Although they can and do refer any work health and safety matters to WorkSafe," it said.
"Since 2020, we have met monthly with police to review all heavy vehicle fatalities, to ensure clarity over which agency will investigate and to ensure investigations are thorough and robust."
But WorkSafe said it will review the Memorandum of Understanding between it and Police to make sure it is "fit for purpose and operating efficiently".
With the Coroner's findings now out, WorkSafe has six months to file any charge.
WorkSafe extended its sincere condolences to the friends and whānau of the four men.
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