Coroner’s Findings Highlight the Importance of Alpine Safety

NZ Mountain Safety Council (MSC) says the coroner’s findings into the tragic death of 26-year-old Wednesday Davis on Mount Ruapehu in June 2024 reinforce the need for careful preparation and sound decision-making in alpine environments.

Coroner Matthew Bates found Wednesday died from a head injury after falling about 250 metres while attempting to reach Whangaehu Hut with three others.

He identified a combination of factors that contributed to the incident, including icy conditions, high-consequence terrain, inadequate alpine skills and equipment, and poor communication and group decision-making.

MSC provided a report to the inquiry that outlined contributing factors and made recommendations aimed at preventing similar incidents in the future.

“People recreating in the backcountry should never underestimate New Zealand’s alpine environments. Conditions can change rapidly, and even experienced individuals can be caught out.”

On 29 June, the group set out at around 9.30 am to climb to the hut. They had anticipated some ice on the climb, but conditions changed drastically after they crossed the ridgeline above the hut, where the surface transitioned to harder ice. Coroner Bates found the group was caught out by the unexpected conditions from the ridge down to the hut and was unprepared for them.

To reach the hut from the ridgeline, the group needed to descend across steep, icy terrain with no safe run-out area below. While traversing an ice face, Wednesday either slipped or tripped and began sliding. Referring to MSC’s report, the coroner noted that due to the impenetrable ice conditions, the slide would have happened quickly and the opportunity to self-arrest would have been very limited, even for an experienced mountaineer.

While Wednesday was fit, active and an experienced hiker, her mountaineering experience was limited to basic instruction using crampons the day before the incident. On the day, she was wearing a helmet and crampons with flexible-soled hiking boots, which were not compatible with the manufacturer’s guidelines. Additionally, although she was carrying an ice axe, the group had not practised self-arrest techniques the day before due to impenetrable ice conditions.

In his findings, Coroner Bates endorsed MSC’s assessment of key factors that led to the incident and endorsed its safety recommendations. He agreed that a combination of environmental conditions, equipment limitations, skill gaps and group decision-making contributed to the tragedy. This included:

• Steep, exposed and icy terrain, with large rocks, cliffs and bluffs below.
• A lack of alpine skills and experience for the conditions the group encountered.
• A failure by the group to communicate about increasing risks and to respond to the changing situation.
• A lack of understanding of the hazards associated with the route and conditions.
• A group dynamic that created an ‘expert halo’ bias, where group members relied on one person’s perceived expertise.
• Unsuitable footwear for mountaineering.

Key safety learnings

MSC says the coroner’s findings reinforce that alpine terrain can quickly become high-consequence when conditions change, particularly for people without mountaineering skills and experience, and appropriate equipment.

“We want people to have successful and safe alpine adventures, and make it home safely. That requires an in-depth understanding of the environment and thorough planning,” says Daisley.

MSC recommends the following for anyone planning a trip into New Zealand’s alpine:

• Don’t underestimate alpine environments: New Zealand’s alpine environment has high-consequence terrain and dynamic conditions where falls often have severe consequences. Mount Ruapehu is particularly complex, with steep slopes, deep gullies, bluffs and cliffs, and conditions are often icy.
• Get the training and plan thoroughly: Before heading into alpine terrain, beginners should complete formal training with an alpine professional in a controlled setting. Researching the route and understanding the hazards and skills required are critical for all members of the group.
• Check the conditions: Alpine conditions can change quickly and should be monitored closely and assessed for increasing hazards. Groups should be prepared to change their plans or turn around if conditions become unsafe.
• Establish effective group dynamics and communication styles: All trips need open communication and shared decision-making between all members. If a leader is appointed, this should be intentional and discussed openly.
• Use equipment correctly: Follow the manufacturer’s recommendations and ensure equipment is compatible and appropriate for alpine conditions.

Since Wednesday’s death, MSC has updated Plan My Walk information for the Whangaehu Hut route to better highlight the key hazards identified in the inquiry.

The team at NZ Mountain Safety Council extends its sincere condolences to the whānau and friends of Wednesday Davis.

Mount Ruapehu fatalities

A review of coronial records by MSC, found eight fatalities on Mount Ruapehu between 2010 and 2024, with over 60% mountaineering at the time of the incident. Of the mountaineering fatalities, all were due to a fall and occurred during June to September.

PHOTO CREDIT | Andrew C, Plan My Walk | Whangaehu Hut