A van driver was wrongly blamed by police investigators after four young forestry workers were killed in a 2019 crash with a logging trailer without side lighting that was "invisible" in pre-dawn darkness, a coroner has ruled.
Storm Lacy, 22, Steven Pari, 35, Te Tahi Brass, 25, and Johnston Ahuriri, 37, died when their work van collided with a truck and trailer transporting logs blocking their lane on Bonisch Rd in the Kaingaroa Forest, Bay of Plenty. A fifth worker survived with serious injuries.
In his report, coroner Michael Robb has urged that mandatory side lighting be legislated for oversize off-highway vehicles operating in private forestry areas.
He also found fault with a subsequent police serious crash unit probe that blamed Lacy, the van driver, for the collision. Health and safety regulator WorkSafe was also criticised.
The 35m logging truck and two trailers was crossing from a side road onto Bonisch Rd when the collision occurred about 6.30am on July 29.

The roadway was in darkness, with no roadside lighting and sunrise not until 7.18am.
The truck took 21 seconds to clear the intersection, but vehicles travelling from a blind corner could reach the intersection in 15-17 seconds at that speed, Robb found.
The logging truck had its headlights on but no side lighting or reflective material on the trailers, which were dark in colour and laden with logs.
"As the van drove towards the truck headlights the unlit trailers were invisible until it was too late for driver to avoid the collision," Robb wrote.

With the bright headlights of the truck highly apparent, the coroner determined it would have been impossible for Lacy to see the rearmost and still-horizontal trailer blocking his lane until after passing the truck's headlights 32 metres away.
He was travelling at 80-90km/h, below the 100km/h speed limit.
"Travelling at 80km/h the van driver had one second to try and avoid the collision," the coroner said. "Nobody could have avoided a collision in those circumstances."
Police crash unit criticised over cannabis conclusions
The coroner cleared Lacy of any responsibility for the collision, rejecting suggestions in a police serious crash unit report that toxicology evidence showed cannabis consumption.
The coroner found serious flaws in the chain of custody for toxicology samples and said Lacy's partner and colleagues had consistently stated he did not consume cannabis.

The surviving worker, who was in the front passenger seat and knew Lacy well, told the coroner that Lacy did not smoke cannabis, although others he worked with did.
A police serious crash unit report blamed Lacy for the crash, suggesting the van driver may have been under the influence and should have seen and avoided the trailer.
But the coroner said instead that Lacy had demonstrated "an impressively quick reaction time" by attempting to swerve left to avoid the collision, and there was no evidence he was driving in a manner consistent with being intoxicated.
The coroner said the police report also inappropriately drew conclusions about a glass pipe found in the debris, suggesting it could have been used for consuming cannabis.
"No analysis of the glass pipe was undertaken to ascertain whether it had ever been used for the consumption of cannabis," Robb wrote.
"Even if it had been analysed with a positive result for cannabis, in the debris of the van following the collision it is impossible for anyone to determine where the pipe had come from, who may have used it, nor when it may have been used."
Robb said the crash unit report writer was "inappropriately influenced" by a toxicology report reference to cannabis and provided an opinion "inconsistent with the facts of the collision and prejudiced by the toxicology analysis".
Mandatory side-lighting recommended
The coroner found the deaths were avoidable workplace fatalities that occurred because of the decision to operate a long, slow-moving truck at night without side lighting on forestry roading that he deemed unsuitable for such operations.
Robb said side lighting would have prevented the deaths and should have been used.
He noted the Log Transport Safety Council currently recommends side lighting only "where feasible", leaving it to industry discretion.
"I am concerned that this would leave the decision whether to sidelight as an essentially industry-controlled process," the coroner said.
"That does not go far enough, where four young workers have lost their lives in avoidable circumstances, which could occur again in the future."
The coroner wanted side lighting mandated for all oversize logging trucks that operated on private forestry roads.
He also recommended forestry roads be designed to ensure sufficient distance between side roads and blind corners to allow heavily laden trucks to clear intersections safely, and called for a review of how police and WorkSafe investigate forestry road deaths.
Robb also commented on seatbelt use.
The sole survivor had been wearing a seatbelt in the front passenger seat, while the three men in the back seats were not wearing seatbelts. The coroner recommended ongoing education to ensure seatbelt wearing is mandatory in work vans.
Robb said he had concerns that police remain untrained and unfamiliar with the Health and Safety at Work Act when investigating forestry deaths. The coroner added that WorkSafe should have investigated the deaths as workplace safety failures.
Rotorua Forest Haulage Ltd, which owned the logging truck, temporarily ceased night-time operations after the collision and then introduced side lighting, although the coroner noted photographs showed only temporary strings of lights.
Timberlands, which manages more than 200,000 hectares in the central North Island, including 9500km of private forestry roads, supported introducing regulation but suggested using the code of practice rather than mandatory legislation.
The coroner offered his condolences to the whānau and friends of the four men.
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