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Coroner's office rules luger's death an accident

The B.C. Coroner's Service this week released its report on the death of Georgian luger Nodar Kumaritashvili, who was killed during a training run hours before the opening ceremonies of the 2010 Olympics took place on Feb. 12.

The B.C. Coroner's Service this week released its report on the death of Georgian luger Nodar Kumaritashvili, who was killed during a training run hours before the opening ceremonies of the 2010 Olympics took place on Feb. 12.

The report, which is 16 pages long, concludes that there were a number of factors to blame for the accident, including high speeds, technical challenges and the combination of physical forces with physiological stresses which "converged at a critical moment, overwhelming the athlete and causing the irretrievable loss of control of the sled."

It also suggests that parties "failed to anticipate this incident or mitigate the outcome," and that inexperience may have played a role in the incident: The relative lack of experience Mr. Kumaritashvili had on this challenging track set a backdrop for the incident and was a significant disadvantage, as far as safety was concerned, for the athlete entering the high pressure environment of the Olympic Games."

Given these factors, the Chief Coroner for the Province of British Columbia, concluded that the death was accidental, while making recommendations to the luge federation and Whistler 2010 Sports Legacies Society.

It was a tragedy that overshadowed the start of the Games, leaving IOC and VANOC delegates visibly shaken during the opening ceremonies. In the days that followed the decision was made to lower the start for luge athletes, while a few of Kumaritashvili's teammates pulled out of the competition because of safety concerns. A track that was praised as being the fastest and most technical in the world was now being questioned by the global media.

Video footage of the accident shows Kumaritashvili losing control of his sled coming out of Corner 15, which sent him into the final long curve at the bottom of the track at the wrong angle. As a result he exited that curve too late and slid into the wall on the uphill run-out section at a high angle at high speed. He was bounced from the track and slammed into a metal post that was holding up a section of roof. Attempts to revive the 21 year old failed. Kumaritashvili was pronounced dead at 11:49 a.m., 59 minutes after the accident.

It is believed that Kumaritashvili was killed on impact as a result of trauma after striking the post. While he contacted with other surfaces of the track, it's not believed that they were responsible for any of the slider's injuries.

The coroner's investigation mirrored many of the findings presented by the International Luge Federation's (FIL) own investigation, which was completed in April. That includes the sequence of events leading up to the accident. The coroner's office also acknowledged the FIL's assessment of the sled itself, which they say should have broken when it hit the wall coming out of the final curve, but instead helped to catapult Kumaritashvili out of the track.

The coroner's report also looked at how the track might have contributed to the accident. Among their discoveries was the fact that track speeds were not discussed when the location was being decided in 2003, despite the fact that the Whistler track would be the steepest in the world with a vertical drop of over 150 metres.

When the track went into the design phase and analysis in 2004, the coroner's service found that international federations "were looking for a fast and difficult track, but it was the new curve configurations that were expected to provide the main challenge, and not the speed alone."

The analysis of the track also came up short, projecting that the maximum speed on the course would be 135.3 km/h for men's luge, when the actual luge speed record for the track is now 154 km/h - far faster than the seven per cent tolerances that were built into the design.

During the homologation process in 2008, it was revealed that speeds were at least 10 km/h higher than forecast. All of the sliding sports changed their qualification standards for racers at that point, mandating that sliders should train at lower start positions and work their way up.

For its part, the FIL mandated that sliders had to make three starts from the Novice start, two runs from the Junior start and one run from the Lower Women's start before they could move up to the race start.

In 2009 the president of the FIL wrote a letter to the track designer expressing surprise at the speed of the track, given that a top speed of 154 km/h had already been recorded. He wanted to know why the calculations of top speeds were incorrect during the design phase - although he noted that athletes were able to cope with the speeds because of the ice conditions. His concern was for what would happen if speeds increased, something that has been observed at other tracks as athletes learn the curves, suggesting that "overstepping this limit would be an absolute unreasonable demand for the athletes."

But while the FIL expressed concerns, the president confirmed to the coroner's service that they did not ask VANOC or the engineer to lower the speeds in any way.

VANOC also received a copy of the letter, but believed that the FIL's objective was to prevent similar mistakes when designing the track at Sochi, Russia, which was being touted as even faster than Whistler.

According to the coroner, "VANOC's Director of Sport later indicated to this investigation that his organization's assessment at that time was that the track was indeed faster than originally pre-calculated, but there was no indication that the athletes would be unable to manage the speeds safely."

VANOC also told the investigators that they were developing the track on behalf of sports organizations, and that they did not claim to have the expertise to make decisions on behalf of those sports.

The track designer replied to the FIL in April of 2009 that their miscalculations were the result of not taking into account "recent developments in sliding equipment" at "high average slopes and high velocities." The reason they did not have that information is that a lot of design and development work on sleds is done in secret.

Given the available information they wrote that the new maximum limit on the track was actually closer to 161 km/h without any danger of turnover - 26 km/h faster than they originally forecast.

The FIL and the other federations believed that this could be mitigated by giving sliders more training runs and by sliders working their way up from the lower starts.

This system appeared to be working. By the end of January 2010, the WSC had hosted over 30,000 descents, including 18,000 luge runs without any serious incidents.

While experience matters, the coroner concluded that it "is reasonable to conclude that more exposure to this difficult track would have given Mr. Kumaritashvili a greater ability to adjust to the difficulties."

Kumaritashvili and his teammates skipped the first International Training Week held at the Whistler Sliding Centre (WSC) in 2008 and the World Cup test events in February 2009. But by the time of the accident he had taken 20 runs from various start positions. Kumaritashvili crashed on two of his runs, but was not injured.

As well, the coroner recognized that the speeds made it hard for Kumaritashvili to recover from a driving error, even if other lugers were successfully able to negotiate the course at higher speeds.

The corner's recommendations include:

• For the Whistler 2010 Sports Legacies Society to make a safety audit of the track looking at the design, track speeds, placement of crash barriers and other protective measures.

• For the international sliding federations to review practices and protocols for track homologation (testing and benchmarking) and other aspects of their involvement and input into track design and construction, and considering other safety measures - such as audits of tracks for safety.

• For the FIL to require more compulsory, venue-specific training before major competitions like the Olympics, and in the qualifying period before events to give athletes "a higher level of comfort on an unfamiliar track."

Kumaritashvili's father was upset by the coroner's report, specifically the allusion that his son's "relative lack of experience" was a factor in the accident. He told the AP that his son wouldn't have qualified for the Olympics if he lacked experience, and that an athletes' mistake should not end in death.

Georgy Natsvlishvili, the Georigan sports minister, also rejected the coroner's findings and blamed the organizers for an unsafe track.

There are no further investigations recommended for the incident, other than the call for a safety audit at Whistler Sliding Centre.