Wave of hot ash and rocks described in Whakaari court docs

The moment a wave of ash, steam and rocks engulfed tourists on Whakaari/White Island has been set out in dramatic detail in a document released by the Auckland District Court.

The document describes how the material that exploded out of the crater in December of 2019 was too dense to rise into the atmosphere. Instead it became a hot, ground-hugging flow of ash and debris.

"The enclosed amphitheatre-like crater funnelled the surge down the elongated path of the crater and out to the south-east. It is estimated the surge was travelling at 15 metres per second and was more than 200° Celsius," the court document says.

"Some tourists were killed by projectiles of rock ejected during the eruption."

The river of debris, called a "pyroclastic density current", flowed across the crater floor and rapidly engulfed the entire crater.

A total of 22 people died following the explosion on Whakaari on December 9 2019.

The disturbing detail comes from the summary of facts - a document that explains the WorkSafe case against White Island Tours (WIT).

Charges were brought under the Health and Safety at Work Act but, in a surprise move, the Whakatāne-based tour company's lawyers entered guilty pleas in June at a case review hearing just a few weeks out from the trial. The business faces a maximum fine for each of the two charges of up to $1.5m.

There are still nine tourism operators and individuals remaining in the case, so the trial will go ahead on July 10 without White Island Tours.

The summary goes on to describe the events of the day and looks at the measures taken prior to the eruption, which were supposed to keep staff and visitors safe while touring the active volcano.

Six other tours happened on the fateful day, prior to the eruption. They were with several different tour operators but White Island Tours had the largest number of visitors on the island at the moment the crater exploded.

Thirty-eight tourists and four guides were divided into two groups. When the volcano erupted at 2.11pm, one group was close to the crater, the other closer to the wharf.

Meanwhile, just offshore, crew on the White Island Tours boat Phoenix made the call to return to the island to evacuate survivors. They rescued 26 people, many with severe burns who suffered a painful journey back to the mainland.

The summary of facts describes that trip, saying it took over an hour and a half. "During this time the severity of the victims' injuries increased. Burnt skin swelled and blistered. Breathing became difficult for some of the victims and others went into shock. The sun and wind caused additional pain to burnt skin."

The Phoenix crew and passengers did their best to tend the extensive injuries, assigning "passenger buddies" to each injured person.

Supplies onboard the Phoenix including medical kits, emergency blankets and fresh water "were not sufficient to fully assist the number of victims because of the severity of their injuries".

After the Phoenix had departed with the survivors who were closest to the wharf, one tourist from the group that was caught close to the crater managed to find his own way out, even with severe burns. He was 19-year-old Jessie Langford who was then evacuated on another vessel. He has survived his extensive injuries but lost his parents and sister to the eruption.

Rescue pilots located the crater group just over an hour later and loaded 12 people who were still alive into helicopters to fly them back to Whakatāne. "Some died on the way back to the mainland. Of the 12 persons rescued, two have survived."

As well as the 22 people who died either in the eruption, or later, there were 25 survivors. Almost all of them suffered severe or critical injuries.

The summary of facts goes into graphic detail around the type of injuries sustained, including blunt force injuries caused by flying rocks, and chemical and ash burns.

"Many of the victims who survived continue to experience significant pain and injury. Some have had to learn to do basic things like walk, or to function without certain body parts that they lost as a result of the eruption," it says.

It also describes post-traumatic stress disorder, for both the injured and those who acted as first responders.

The court document goes on to detail the factors used to decide whether it was safe for a tour to go ahead, including volcanic alert levels and bulletins issued by GNS (Institute of Geological Nuclear Sciences).

"This decision was generally made by the duty skipper, who would use their own experience of Whakaari to weigh up these factors," it says.

"Skippers were not trained in volcanology, and had only internal training on reading seismographs or interpreting observations made from the online webcams.

"Tours would frequently be cancelled if the sea was too rough to land passengers, and were sometimes cancelled if there was a risk of earthquake or landslide. Tours were never cancelled by WIT (White Island Tours) on the grounds of concerns about the level of volcanic activity."

The company briefed passengers on risks, including those involved with the boat and uneven terrain. The summary of facts says: "The risk of an eruption was referred to vaguely by stating 'a live volcano has risk', but this was not explained further. This meant that tourists were not in a position to make an informed decision about whether the risk associated with the tour was one they were willing to take."

Safety information available before booking varied depending on whether the tour tickets were purchased at WIT’s office, where the safety terms and declaration was provided to tourists and signed before departure, or through WIT’s website or a third party such as an i-SITE. In these cases, they were provided with the information on the day of the tour.

The document adds: "Tourists who booked through Royal Caribbean Cruises Limited were supposed to, but did not, receive the safety terms and declaration document at all. They had even less information on which to assess whether or not to go on the tour than tourists who booked in one of the ways discussed above."

On tours, three different safety briefings were provided. The first, on the boat, focused on boat-specific risks such as life-jackets.

The second was also given on the boat just before arriving at Whakaari. It focused on transfers via inflatable boats as well as directions on fitting hard hats and gas masks.

The third safety briefing happened once the group had arrived on Whakaari, and was the first time that safety information relating to the actual walking tour was provided.

It included the mandatory use of hard hats, the optional use of gas masks and a brief explanation of the risks of eruptions, landslides and uneven ground. Tourists were told "in the event of an eruption, to seek shelter behind something larger than themselves and follow the instructions of their guides".

The summary goes on to say, "If tourists wanted to withdraw from the tour after receiving the safety briefings, they could choose to stay on (or return to) the boat. Many had planned to participate in the tour for some time and had travelled to Whakatāne especially. WIT’s approach to providing safety information meant that tourists were not in a position to make an informed choice about whether to participate in the tour until a very late stage where, to a large extent, they had already committed to it."

When Whakaari was at Volcanic Alert Level 2, which it was on the day of the eruption, the tour would send a scout ahead of the group to assess the risk. "The main ‘rule of thumb’ adopted was if the crater was ashing, it was okay to land passengers; however, if it was evident from the boat that projectiles were being ejected, the tour would not proceed. Once on the island, if a scout reported that rocks were being ejected higher than the main crater’s edge, the tour would not proceed up to the main crater."

At Volcanic Alert Level 2 the guide-to-passenger ratio would be 1 to 10 and they would reduce the time spent at the crater’s edge, or not take the tour near the crater’s edge at all. Guides would remind passengers of the extra risk, and give them the opportunity to stay on board if they wish.

After a tour, guides who had been on Whakaari that day were required to fill out a daily debrief form that recorded observations or changes on the island. The forms were read by the following day's guides.

"WIT had a responsibility to carry out, or have carried out, a proper assessment in order to fully understand this risk."

The summary said while White Island Tours did carry out assessments, they were "inadequate in several respects".

"They did not consider how well, if at all, an eruption could be predicted," the document says. "They did not consider the type of eruption that could occur at Whakaari, despite WIT being aware of this information. They incorrectly assessed its controls as reducing the consequences of a volcanic eruption.

"In fact, because WIT had not properly assessed the possible consequences of an eruption and that any eruption could involve a pyroclastic density current (a surge of fragmented rock, volcanic ash and hot gases), those controls were inadequate."

While White Island Tours monitored Volcanic Alert Levels set by GNS and received Volcanic Alert Bulletins issued when conditions changed, it never engaged GNS to help its risk assessment.

That's despite the licence agreement with the company that owns the island - Whakaari Management Limited - requiring it to do so, according to the summary.

"As a result, WIT did not have an accurate understanding of the risk posed to its tourists and tour guides by volcanic activity on Whakaari."

The document points out that information about the island only went one way. While GNS was providing bulletins and volcanic alert levels to the tour company, guides who noticed and recorded changes on Whakaari through daily observation sheets, had no way of communicating this information back to GNS.

"Given that WIT did not have expertise in volcanology, these observations were of little to no use in assessing risk. However, they may have been of use to GNS in determining the current risk of volcanic activity."

The summary also notes White Island Tours failed to ensure its workers were supplied with appropriate PPE. Apart from their uniform and enclosed footwear "the workers were not required to wear fire resistant clothing".

It was mandatory to wear hard hats and to carry gas masks. "However, the gas masks were inadequate. They did not provide adequate protection against the high concentrations of hydrogen sulphide and sulphur dioxide on Whakaari. The masks were also ‘one size fits all’ but did not fit all face shapes and sizes or those with beards.

"These failings exacerbated the injuries suffered in the event of an eruption. While adequate PPE would not have prevented the harm that would occur in the event of an eruption, it may have reduced the extent of the injuries."

“

Some tourists assumed they would be safe as they expected WIT would not operate tours if it was unsafe

—  Court summary of facts |

The last few pages of the document detail the ways White Island Tours failed in its duties to protect tourists and workers, including:

"As a result of WIT’s failings, tourists on Whakaari did not understand the hazards that existed on the island, nor the risk of injury or risk to life that could, and did, result from those hazards. Instead, some tourists assumed they would be safe as they expected WIT would not operate tours if it was unsafe.

"Because WIT itself did not properly understand the risks associated with Whakaari, it could not accurately communicate those to tourists."

White Island Tours was purchased by Ngāti Awa in 2017 with the intention of bringing more employment to the iwi. It has taken a massive financial hit since the island closed, but says it remains focused on helping the community heal.

A spokesperson told 1News the iwi took advice from lawyers in its decision to plead guilty. A sentencing date will be set in August.

The guilty plea by White Island Tours brings the number of defendants in the WorkSafe hearing to nine, including other tour operators, as well as the island's owners.

Some of the detail in the White Island Tours summary of facts will be relevant to the case starting on July 10.

The charges cover the years in the the lead up to the eruption, not the time after. So the case doesn't include the actions of pilots who landed on the island afterwards to rescue the few who were still alive.

However some of the tour companies facing charges, include cases of pilots who took tourists to the island prior to the eruption. Under the act, those businesses are accused of putting themselves and their customers at risk.

It's hoped the case will result in a clear picture of all the factors that led to having so many people in such a vulnerable position, so tragedy's like this can be averted in the future.

On the day charges were filed in 2020, WorkSafe chief executive Phil Parkes said “that’s an expectation which goes to the heart of our health and safety culture. As a nation we need to look at this tragedy and ask if we are truly doing enough to ensure our mothers, fathers, children and friends come home to us healthy and safe at the end of each day.”