April 28th, 1995.

Fourteen people died at Cave Creek on the West Coast of the South Island when the viewing platform they were standing on collapsed from beneath them dropping the group thirty metres into a ravine. The party was made up of students, an interpreter and one Department of Conservation field centre manager. Five students and the interpreter escaped possible death as they were not on the platform at the time. Of the eighteen people crowded onto the platform only four survived the fall with some suffering horrific injuries. One student was left a tetraplegic. The first half of the ill-fated class were to later report they had felt unsafe on the platform the day before the collapse.

A Commission of Inquiry was formed to investigate what happened. It found that the Cave Creek platform, which was built by the Department of Conservation, was poorly built and did not comply with building standards. The findings also stated that "DoC had acted incompetently and inappropriately, and a lack of a proper project management system had caused the platform, which did not comply with the building standards, to fall with such tragic consequences." 

Amongst the findings it was discovered that those who constructed the platform did so without having the plan on site, and they failed to attach the platform to the concrete steps which were intended to act as a counterweight. Nails were used where bolts would have been appropriate. 

In the final analysis the commission of inquiry refrained from apportioning blame. The report summed up is as follows:

Primary Cause

1. Failure of the structure to support the weight of the people on it.

Secondary Causes

2. Failure to provide qualified engineering input into the design and approval of the project.

3. Failure to adequately manage the construction. There was no qualified carpenter on site during construction and no one seems to have been in charge of the project. 

4. Failure to comply with statutory requirements, hence no proper inspections by statutory authorities before, after or during construction. Recent regulatory changes were not clearly communicated to field personnel.

5. Lack of inspections by qualified DoC personnel.

6. Lack of warning signs indicating that the platform had a maximum loading of 10 people. This was only a guesstimate and was suggested during planning, exactly why no one was sure. The signs were produced but for a maximum of five. They never left the workshop.

Other Causes indirectly responsible:

1. Systems failure, failure of the West Coast Conservancy of DoC to use existing checks to ensure proper procedures where followed. As well there was a general lack of communications between overworked managers at various levels and field staff. The management structure was inadequate to cope with expected duties.

2. Cost cutting measures including staff reductions (West Coast Conservancy had lost since 1987, 112 person years, at the same time visitation had increased by at least 25% and paper work loads had also increased). This
led to key personnel having to cover several job descriptions. Some staff were working almost double the expected hours. Although the commissioner states that budget cuts were not a reason for the deaths about 20% of the report dealt with the problem of lack of qualified staff, overwork, and lack of training of managers.

3. Poor work planning practices. There was in essence no time frame or work loads attached to the construction of the platform or the accompanying trail. The platform was eventually built by a 'volunteer' work party of five
employees. 

Of interest:

1. The interpreter had on the pervious visit noticed something "wrong" with the platform. She did not think that the platform would collapse but was concerned enough to bring the problem to the attention of the field centre
manager. He accompanied the group the next day to check out the situation -- and became a casualty.

The inquiry also noted that because of the isolation of the site it was a major problem to reach, extract and treat the casualties. 

Once the findings were released DoC director-general Bill Mansfield resigned from his post. The conservation minister at the time, Denis Marshall, resisted resigning but eventually did so a year later. Initially senior managers of the Department of Conservation accepted responsibility for the Cave Creek platform collapse on behalf of the department as a whole, however then head office management suddenly started blaming the West Coast staff of the department. This ran counter to the findings of the commission of inquiry which targeted systemic failure and chronic underfunding as the root cause of the tragedy.

Several years down the track some families of victims still cannot understand why criminal charges were never laid and some have requested police reopen the file and make the information contained in police records available to the public. 

The New Zealand Government has paid compensation to family members and those who suffered injuries. This equates to around NZ$2.7 million. Part of the agreement was that the amounts of compensation paid to individual claimants remain confidential and it is understood one of the terms of the agreement precludes families from taking any future action. 

As a result of this tragedy Government discussions have taken place over whether its own departments should be exempted from prosecution under building and safety laws.