Pinned against a dangerous log he had not been warned about, kayaker Tim Jamieson fought to escape the rapids of the Buller River for 15 minutes before shouting: "I cannot hold myself up any more".
Despite valiant rescue efforts by fellow outdoor education student Joshua Reynolds and instructors from their polytech course, the 21-year-old student drowned in front of them 20 minutes later.
A roading contractor who watched the tragedy unfold from above the river on the remote part of State Highway 6 desperately drove several kilometres to find cellphone coverage to call a rescue helicopter, but it arrived too late to help.
Yesterday, more than three years on from the accident, Nelson coroner Ian Smith has recommended Greymouth's Tai Poutini Polytechnic continually review and upgrade its safety procedures "in particular its hazard registry".
During the inquest last year, Mr Smith referred to the kayaking industry as a "closed cartel" because of the limitations of assistance police and the Maritime Safety Authority (MSA) reported in trying to complete their respective investigations.
"The perception was of a reticence of the experts to assist if it meant criticism may occur of one of their own members or friends."
But yesterday he said: "While this attitude may have initially hindered this investigation, the court is satisfied the end result has ensured a very thorough investigation."
In his recommendations, Mr Smith said course instructors should be made aware of "possible external services that may assist in an emergency and to make prior contact with those services when in a particular area".
Contracted staff, such as Brett Whiteley who was Mr Jamieson's instructor on the day he died, should be peer reviewed by the full-time tutors to ensure potential hazards were known to everyone involved in teaching students.
Mr Whiteley knew about the log in the river but forgot to warn the students before they set off.
He voluntarily handed in his New Zealand Outdoor Instructors Association qualifications before the organisation handed down a decision to suspend him after the accident.
That followed the MSA report that said Mr Whiteley was at fault and should be censured. Police also investigated, spending $8000 on impartial witnesses from overseas, but did not lay charges.
Mr Whiteley was a part-time tutor at the polytech, contracted by his brother Ian, who was at that time the head of the department Mr Jamieson was studying in.
Tai Poutini Polytechnic chief executive Don Campbell said the recommendations made by the coroner were already in place and would be constantly reviewed.
The polytech also purchased a satellite phone, which is taken on river trips such as the one during which Mr Jamieson died.
Since handing in his qualifications, Mr Whiteley has not worked in the industry.
Last year he asked the NZOIA to review his suspension.
Yesterday Matt Cant, the organisation's president, said that review had been completed but the suspension would remain in place.
It was up to Mr Whiteley to complete "the necessary recommendations" before his qualifications would be returned. That would not be before "certain endorsements as to good practice and judgment on a variety of strategies in group management on a variety of river runs had been obtained from a minimum of two NZOIA level 2 instructors".
Mr Smith hoped the Jamieson family would take "some comfort from the fact that as a consequence, reviews of safety have taken place so that others may be saved from the anguish you have endured".
Joshua Reynolds was awarded the Royal Humane Society of New Zealand's Bravery Award for his efforts in trying to save his friend.
River tragedy
Tim Jamieson drowned while kayaking on the Buller River on February 1, 2002.
He was an outdoor instructor student at Greymouth's Tai Poutini Polytechnic, the same polytech that lost 13 students at Cave Creek.
Nelson coroner Ian Smith says the polytechnic must continually review and update its safety procedures.
He ruled that Mr Jamieson died of accidental drowning.
Kayaker's drowning leads to call for safety reviews
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