A coroner says a bus driver in a difficult position made two critical mistakes leading to the death of 11-year-old Hannah Francis in a crash on Mt Ruapehu.
Coroner Brigitte Windley has called for passenger seatbelts on buses and emergency run-off lanes to be investigated after Hannah died in 2018.
And WorkSafe is now investigating, after the inquest into Hannah's death helped far more information emerge than public agencies previously had access to.
Hannah's extended family were optimistic the findings might lead to safety improvements and prevent another tragedy.
The bus crashed in July 2018 on Ohakune Mountain Road, between Turoa ski field and Ohakune.
Terry Choi was driving a 1994 Mitsubishi Fuso with a unforgiving braking system reliant on extremely careful driving, Coroner Windley said.
Choi, a father himself, was deeply remorseful and not pursuing name suppression.
The coroner said an examination of the bus found no mechanical faults that caused the brakes to fail.
But an unmarked switch was noticed on the drivers' console previously used to operate "flicker chains" on wheels for traction in ice and snow.
This "extraordinarily dangerous feature" was undetected for years and Ruapehu Alpine Lifts (RAL) acknowledged responsibility for this defect in decommissioning, Coroner Windley said.
The bus had an air-over-hydraulic brake system which was considered old technology by today's standards, Coroner Windley said.
"Brake fade can set in rapidly, and where overheating occurs to the point of failure, there is little, if anything, the driver can do to rapidly recover braking function."
But she said the way Choi drove the bus was the main cause of the brake failure and crash.
"Mr Choi had made two critical mistakes."
He used third gear when driving the steep upper reaches of Ohakune Mountain Road with a fully loaded bus.
Coroner Windley said that put the brakes at risk of irrecoverable failure.
"Mr Choi's second critical mistake was in failing to change down from third gear to second gear, as he said he usually did, before the hairpins."
That caused the brakes to overheat, and the driver was going too fast to get back into gear before the crash.
"From that moment on, there was no ability to recover brake function and the crash was essentially unavoidable," Coroner Windley added.
She said the inquest showed how narrow the margin for brake and gear selection mismanagement was.
This created a "knife edge between an uneventful journey and a catastrophic one" down the road, she said.
"While the bus was capable of undertaking the journey safely, the inquest evidence was that it was operating at the edges of its design envelope."
The coroner said contributing crash factors were the absence of passenger seatbelts or better braking capability relative to loaded mass.
She said a dedicated run-off area for brake failure might also have prevented Hannah's death.
The coroner said a voluntary scheme known as the Alpine Code had started implementing safety improvements but more effort was needed.
The coroner said the Bus and Coach Association, Waka Kotahi and WorkSafe should audit the code within two years.
Coroner Windley recommended a review of Class 2 approved driver training course training standards.
Rather than being left to on-the-job learning, drivers needed specific instruction and practical training, she said.
Coroner Windley said WorkSafe and Police had a chaotic relationship after the 2018 crash.
"A breakdown in communication between Police and WorkSafe meant there was no focused investigation into potential workplace health and safety breaches."
Steve Greally of New Zealand Police told the Herald both agencies had been working hard to build a good relationship.
He said police had already started skifield operations in partnership with Waka Kotahi to educate drivers about safety and compliance.
This year, the operation was renamed "Operation Hannah", with the permission and support of Hannah's family.
WorkSafe said it endorsed Coroner Windley's recommendations and was meeting with police every month to review all fatal incidents involving heavy vehicles.
WorkSafe also confirmed it was investigating the crash after the inquiry brought new information to light.
Coroner Windley recommended Ruapehu District Council, Waka Kotahi, and DoC consider roading and signage improvements.
Coroner Windley said Hannah attended Glen Eden Intermediate School, and had a flair for creativity, a love of reading, and hopes for a future where she could work with animals.
Hannah's parents, step-parents and siblings issued a statement yesterday, ahead of the findings being released.
"Although nothing will bring our Hannah back, we are all very pleased with the findings and recommendations detailed in this report," Hannah's family said in a statement.
"We are optimistic that these will go a long way to preventing such a tragedy happening to another family."
Ruapehu Alpine Lifts said it endorsed the coroner's recommendations. Chief executive Jono Dean said that included calls to strengthen the Alpine Code of Practice, which RAL initiated shortly after Hannah's death.
He said the company supported the call to legislate for passengers to wear seatbelts, and a new NZQA "micro-credential" for alpine passenger service driving.
"Our thoughts are with the family and friends of Hannah Francis, and also all of the people who were on the bus the day the tragic accident happened," Dean added.
Alpine driver welcomes seatbelt proposal
John Schaeffer has driven tour buses on some of the country's trickiest roads, including South Island alpine passes.
"Personally I do think it would be a good idea for tour buses to have at least some sort of restraints for passengers," he said.
Schaeffer said higher road traffic volumes, at least before the Covid-19 pandemic, reinforced this view.
He said tour bus drivers and front-row passengers frequently had to wear seatbelts.
Schaeffer said it made sense for seatbelts to be mandatory for tour buses carrying dozens of passengers on steep or winding roads.
He said driving for long stretches on alpine roads could be a difficult job.
"We are human, we aren't robots. We do get distracted, we do make mistakes."