Clinton Handcock had no warning of a difficult jump ahead as he mountain biked through Rotorua's Whakarewarewa Forest with family two days after his birthday in November 2022.
The 48-year-old was an experienced rider who rode with caution and competently handled difficult grade five and six trails, a coroner's report into his death has found.
But on that day, he took a left fork in the grade three Taura Tail that he, his brother-in-law and nephew were riding, and was confronted with a jump divided by a diagonally fallen log immediately next to a tree.
It is believed the Rotorua engineer veered left to the easiest part of the jump and that his left handlebar clipped the adjacent tree, causing him to go over the handlebars.
He suffered catastrophic head and spinal cord injuries and his life support was turned off in Rotorua Hospital three days later, on 13 November.
Coroner Ian Telford opened an inquest into Handcock's death and in his findings released on Thursday, said there was no warning of the danger and difficulty of the trail.
He also said New Zealand's trail grading standards were inconsistent and made sweeping recommendations to overhaul the system at a national level.
At a hearing in January, evidence was given that Handcock had 24 years experience mountain biking and he was not a risk-taker, avoiding highly technical jumps he knew were beyond his capability.
The coroner said Handcock's experience, the way he rode and his equipment did not contribute to the crash.
Instead, the coroner focused on New Zealand's track grading and signage, saying there was no consistent national standard across the country.
That was because the sport began as a "fringe activity" in the 1980s and tracks being "out of grade" was generally seen as part of the experience, the coroner said.
The Ride Rotorua website described the Taura Trail as a hand-built grade three with several features closer to grade four.
However, the coroner found the jump - which had a drop off behind it - was more consistent with a grade five designation, putting it two grades higher than what Handcock was expecting.
Coroner Telford said over time mountain biking had grown in popularity and its participants had become more diverse, particularly with the advent of e-bikes, which brought new challenges.
"I consider this heightens the importance of ensuring track grading and maintenance meets the expectations of users and provides a safe experience."
At Whakarewarewa Forest alone there were 122 trails where the Recreation Aotearoa standards were used for trail design, construction and grading.
Those standards were not consistently in use around the country and ultimately, entities in charge of recreational tracks - where there were no competitions - could chose to work to any standard, the coroner said.
It meant a grade four trail in Rotorua might be considered grade three in Nelson.
After Handcock's crash a red sign denoting "XXX" was erected at the fork in the trail where the accident happened and work was done to make the jump less difficult.
But the coroner noted safety signs at the start of the trails did not explain the meaning of the numerous "XXX" signs across the forest trails and this posed a danger.
As well, it was possible an "easy" sign pointing to the right-hand fork of the trail was not seen by Handcock because of its poor placement.
The coroner said at the time of Handcock's crash, the signage and track grading did not comply with the standards voluntarily adopted and advertised by the Rotorua Lakes Council.
He made a number of recommendations including that the council urgently identify any portions of track "out of grade" and where riders should be warned of upcoming significant changes or danger, and that XXX signs be sited in all those areas pending more comprehensive investigation.
Coroner Telford also recommended entry signs clearly explaining XXX signs, and that the council investigate whether the forest's sign system should be redesigned so that grades are clearly identified and where an XXX area was within each trail.
He also recommended an annual audit and regular checking of trails for hazards.
At a national level, the coroner recommended consultation with the mountain biking industry to identify the best trail grading standards for adoption across all settings including private land and similarly for a single national signage standard.
He directed his findings be sent to the council, Rotorua Trails Trust, Sport New Zealand, Recreation Aotearoa, Cycling New Zealand, the Department of Conservation, Ministry of Business, Innovation and Employment, ACC, Ministry of Transport, WorkSafe, Standards New Zealand, Mountain Bike New Zealand, Trail Fund NZ and the police.
Handcock's partner, Rosie Sargent, told the inquest on the morning of the accident Handcock was pleased to have the day off to go mountain biking with family and was looking forward to showing them some of his favourite tracks.
"Clint crashed on the homeward leg of their ride on a track he had ridden many times before and I know it's a cliché, but... he was doing something he loved with people that he loved."
