The death of a young Christchurch teacher who fell from a raft and drowned during an annual trip to the West Coast with work colleagues could have been prevented, a Coroner has ruled.
And while his family accept the findings around his death - just two weeks after his father died - they have expressed "unconditional forgiveness" to his companions.
Samuel Jacob Zarifeh, a 27-year-old physical education teacher and house master at Christchurch Boys' High School, died on December 9, 2017 during a rafting trip on the Landsborough River, which flows from the Southern Alps to Haast.
For about 20 years CBHS staff and others associated with the school have been travelling to the coast for the trip. It was Zarifeh's first time joining in.
The river is renowned as one of New Zealand's most scenic and wildest rivers for white water enthusiasts.
Zarifeh and four workmates were in the raft when it flipped.
They tried to right the vessel, watched by four other colleagues in kayaks, but the water they were in was too rapid, too violent.
Zarifeh was swept away and his body was found 40km downstream.
Police investigated the death and referred the matter to Coroner Alexandra Cunninghame, who released her findings publicly today.
Before making her findings she heard evidence from all of Zarifeh's trip mates, a commercial rafting expert - who was critical of the group - and a water safety and rescue expert.
She concluded that Zarifeh's death was preventable and urged Whitewater NZ, Maritime NZ, and Water Safety New Zealand to include more specific detail in any safety information they provide to recreational river rafters and kayakers.
Zarifeh's mother Julie - whose husband Paul died two weeks before her son - told the Herald she received the Coroner's report last week.
"Ironically very close to the third anniversary of Sam's passing," she said.
"Whilst it was a relief to not be terribly surprised by the summary and recommendations made, it was indeed reactivating of the overwhelmingly sad emotions experienced by all who loved Sam, when first appraised of his death."
She said while she agreed "wholeheartedly" with the conclusion that "different decisions made may have altered the outcome of that fateful day" - Zarifeh's death was a tragic accident.
"Hindsight is a fine thing," she said.
"I would like to - again - express my enormous sympathy and express unconditional forgiveness to Sam's expedition companions on the river, not only experiencing the tragic loss of a friend and colleague, but also having to deal with the vivid memories of the unexpected and rapidly evolving situation of December 9, 2017 - and significant survivor guilt."
Zarifeh is survived by his mother, brother Jared and sister Kristi.
"We miss Sam tremendously, but take solace in the fact that he died whilst totally in his happy place," Julie Zarifeh said.
Coroner Cunninghame's extensive and detailed 32-page report outlined the tragedy.
She revealed that the moment the raft flipped in a flooded river was captured on a GoPro camera attached to one of the kayakers' helmets.
"A great deal of planning went into the trip. No commercial rafting or kayaking
companies were involved in the planning or execution of the trip," she said.
"Everyone was involved in discussions about the trip and that they talked about, and were well aware of, each other's experience and skill level."
Zarifeh had only done "one or two" previous raft trips but others had many more including one man with 42 years' experience who had traversed the river "numerous" times.
On the morning of the trip the group were all aware the river was "high" but was "manageable".
"Prior to setting off, the group held a safety discussion," said the coroner.
"They talked about positions in the raft and the rafters' roles. They discussed paddle signals and terminology."
They also spoke about a plan in case the raft flipped.
The group set off about midday - each wearing a helmet, and Personal Flotation Device (PFD).
They stopped several times in the first section of the river to ensure everyone felt comfortable.
They noted that the rain was easing but the side streams were "quite full" and as the group ventured down the river a lot of water was "cascading in" from there.
"After their last stop, everyone was keen to carry on…. The rafters were happy to
continue, as were the kayakers," said Coroner Cunninghame.
About an hour later the river was flowing "very fast" and the raft entered a large "hole", a water hydraulic which recirculates on itself as a result of water hitting a river feature while dropping in gradient.
"The nose of the raft went over, dropped… and stopped. The raft then spun sideways and flipped," Coroner Cunninghame explained.
"Everyone was thrown out."
Initially all five of the rafters were able to grab hold of the vessel after they emerged from the water.
The kayakers shouted for them to hold on, told them to "lift each other up and get on top" and tried to throw flotation devices to them.
Attempts to right the raft continued, as it neared a section of the river known as the Upper Gates Gorge - known as "Roaring Lion Gorge" due to its intense rapids.
Four men were atop the raft at that stage but two were knocked off into the water.
They swam frantically towards a shingle island with one man saying "he knew he would be a goner if he stayed in the water".
Zarifeh and another man remained on the upturned raft "holding on for dear life".
"They kept going downstream where it was white water and rapids all the way," said Coroner Cunninghame.
"Their plan was to get to the edge of the river, but the raft was midstream and moving really fast and they had no opportunities to do so.
"The raft hit another hole and Mr Zarifeh was thrown off. He managed to grab a rope on the side and hang on."
The raft hit another hole and Zarifeh became detached from the raft and drifted behind.
His body was found later that day, the raft just 400m downstream, caught up in logs.
Coroner Cunninghame called on three experts to assist with information and opinion about the fatal trip.
Queenstown Rafting operations manager Guido Leek told her that his own guide decided the river was "too high" for a rafting trip the day Zarifeh died and that they would "stay put" until conditions improved which was a "no brainer".
Grant South - a rafting guide and adventure tourism company owner - knows the river well and was critical of the group's decision to enter the water that day and to do so at all without a guide.
He said it was a "mistake".
"A good weather forecast and low to medium water levels would be more favourable for a river team with limited experience," he told the Coroner.
South said the group "underestimated" the weather and river level.
"Then it was the lack of raft guiding experience that caused the raft to flip and follow from that the lack of rescue knowledge and equipment to be able to contain the situation."
South recommended that recreational rafters be encouraged to be involved in-river rescue training courses and believed they should build their skills on lower graded rivers, using advice and training from experienced guides.
Some of Zarifeh's workmates took "exception" to South's comments but he "remained unshaken" .
"It was a lack of knowledge and understanding... It is likely had they had a guide with guiding skills this raft may not have flipped. And in the aftermath of the flip, once again due to the lack of up-to-date rescue knowledge and skill, the 'clean-up' or rescue was not carried out well enough to save a person's life."
Steve Glassey - Public Safety Institute Ltd director and public safety consultant specialising in technical rescue and emergency management - found that the group had "reasonable recreational experience" in rivers and were "generally well equipped".
He considered it "inconclusive" whether a qualified rafting guide would have been immune to the dynamic conditions created by the flood water.
And, he said it was not reasonable to expect recreational groups to meet the higher guiding standards of a commercial industry.
"The lack of resources and guidelines for recreational rafting specifically is of concern.
"More safety information and training courses should be made available to ensure as many participants as possible are able to self-rescue and contribute to a rescue scenario."
Coroner Cunninghame ruled there were two key factors in Zarifeh's death.
The first was the decision to make the trip when the river was in a "dangerous condition".
The second was the group focusing on righting and retrieving the raft at the expense of assisting the rafters to the shore.
"These factors led to prolonged cold water immersion which is likely to have affected Mr Zarifeh's ability to stay afloat," she said.
She said Zarifeh's death was wholly preventable - but it was not her job to lay any blame or find liability against any individual.
"A more critical assessment may have meant that the trip downriver was aborted."
Staying in the water to try to right the raft was also a crucial error for the group as the cold water would have "impaired" their ability to swim and to climb back on to the raft.
"While the group were making decisions under pressure, in adverse river conditions, the decision to keep people with the raft rather than rescue them one by one with kayaks meant that an opportunity to attempt to get everyone to shore before the raft entered the gorge was lost."
Coroner Cunninghame said while having a professional guide "resulted in different
decisions being made" it was not reasonable to criticise the group for not including a qualified raft guide.
"To make such criticism would imply that the rivers in this country cannot be explored except by way of a commercial expedition led by a guide, or by way of a private arranged expedition where someone with qualifications is invited along," she said.
"Such requirements would require regulatory oversight and an enforcement and compliance regime."
She was not suggesting that in the wake of Zarifeh's death, Kiwis should not explore the country's "wilderness" rivers without professional guides or training.
"Unexpected challenges can arise in the outdoors. What is important is that recreational river users are appropriately experienced so that if mishaps occur, they can utilise the best rescue methods available," she said.
"Furthermore, all groups who venture into the wilderness in this country should be able to assess weather conditions and flooding risk, and should be prepared to change their
plans should conditions become, or threaten to become, adverse."
Coroner Cunninghame said as the popularity of river rafting and kayaking increased "every effort should be made to ensure that anyone on a river is as well prepared and as informed as possible".
She urged bodies related to water activity to include more specific safety information for recreational river rafters and kayakers to "ensure they have the best chance at survival should they get themselves into danger."
She listed a number of specific points that she wanted to see shared widely.
Coroner Cunninghame concluded her report with a message to Zarifeh's family - including Christchurch Crown Solicitor Mark Zarifeh - extending her condolence and acknowledging "the great distress his death has caused to those who knew him".
"I also acknowledge the bravery shown by those who were with him on the day of the accident."