The way police investigated a crash in which two men died in a truck rollover resulted in an an eight-year fight for their families.
A second coroner's findings, released on Monday, now say blaming the driver was "inaccurate and unfair". File image Photo: RNZ / Tim Brown
Now they have won, with new findings exonerating the driver, but their fight to ensure others are not put through the same mill continues.
Tapanui Four Square worker Dale Waitokia said "When you know something's not right, don't accept it lying down".
"Just because the police or somebody tells you it's right, doesn't mean it is. So just stand up and fight."
She lost her husband Toby eight years ago when the truck he was in - driven by Wayne Brenssell - rolled on State Highway 90 near Gore. The truck ended up completely upside down.
Police at the 2015 inquest blamed it on the driver braking.
Waitokia and Shona Brenssell have fought for their husbands since.
"We just kept questioning and questioning, and every time we question, we get another report from the chief investigator," Waitokia said.
"This crash investigator was set on the fact that Wayne braked and caused the crash."
But the 2015 coronial finding described Wayne Brenssell as "very safety conscious".
A second coroner's findings, released on Monday, now say blaming the driver was "inaccurate and unfair".
Instead, two old, cracked steel A-frames supporting heavy concrete panels on the truck trailer most likely failed, pulling the truck to one side on an uneven road.
Southland Community Law Centre manager Denise Lormans backed the families.
"These families were incredibly courageous," Lormans said.
"They knew their men.
"They were very, very determined to make sure that the right findings were published... but also that the process would not be repeated for any other families that were aggrieved in this way."
The new findings showed the first inquest was hampered by lack of forensic evidence and lack of knowledge from the crash scene, including:
- A lack of detailed photos of tyre marks and furrows, and of where the A-frames and the concrete panels they were supporting on a trailer ended up.
- A lack of knowledge such as about the welds on the A-frames that were already cracked.
It was not determined who designed the frames.
Engineers told investigators they would "inevitably have failed". This failure was counted as one of three reasons for the crash in the first inquest, the first being "driver error".
Investigation concerns
A senior police crash investigator questioned the report from the police crash unit that the first inquest relied upon.
Following meetings with the families and a review of the first police investigation, the Independent Police Conduct Authority (IPCA) raised concerns.
"Police agreed to review the matter and subsequently undertook a second investigation which included the obtaining of further expert opinion. The authority did not review the second police investigation," the IPCA said in a statement.
Issue not over
Waitokia is still looking for accountability.
"I'm thrilled that is the outcome. I'm just sad, really upset, that at the beginning so little thought was put into the boys' safety."
If the A-frames had been sound, none of the other factors - an uneven road surface, a load what as a bit too heavy and riding high, and the way the air suspension behaved - would have come into play, she said.
Lormans said the police, WorkSafe and Waka Kotahi - the New Zealand Transport Agency (NZTA) - eventually did their job, and she received assurances from them their lack of cooperation had been addressed.
But Lormans remained unconvinced and expected to take the issue up with the police and others, now the new findings were out.
"We want to make sure there are no other families that go through this.
"That's been one of the driving factors for these families.
"I've got a number of coronial inquest on my book - not just fatal accidents, but quite a number of other ones, too and it strikes me for every single one of them, that agencies aren't working together well.
"And they really should be."
NZTA looking into new recommendation
The NZTA said it was now looking into the Coroner's new recommendation to introduce engineering checks - certification, as it is called - of the design and manufacture of A-frames.
Something similar was also in a suggestion backed by the coroner six years ago, addressed to the Ministry of Business, Innovation and Employment, but it did not happen.
Coroners' recommendations are not binding.
The police declined to comment on whether gaps between themselves and other agencies have been plugged.
RNZ understand police and WorkSafe have been in recent talks about this.
"We do think to say it was a poor investigation is slightly unfair," the police media team said.
"We do, however, accept that there were some faults in the original investigation and we re-investigated the matter, including engaging with a number of experts, after the families expressed their dissatisfaction with the original investigation.
WorkSafe was approached for comment.