Southerners can no longer tolerate the "elephant in the room" that is our drink-driving culture, says Otago-Southland coroner David Crerar, who has found speed and drink, rather than a dangerously modified vehicle, caused the deaths of three Invercargill teenagers last July.
"I now regret the focus I allowed to develop in respect of the mechanical condition of the Honda," Mr Crerar said in his formal findings released this week on the deaths of freezing workers Jesse Langeveld (19), Tylar Parry (16) and Ethan Peek (16).
The trio died when the modified Honda car in which they were travelling went out of control, after hitting a bump, and struck a wall, in Leven St, Invercargill. The vehicle was travelling at a speed of 144kmh.
Mr Langeveld, the driver, had a blood-alcohol level of 86mg, almost three times the legal limit for his age.
Some family members of the dead teenagers had raised concerns that the uncertified modifications to the vehicle - a more powerful engine and an adjustable suspension - might have contributed to the crash and that the car should have been put off the road by the authorities.
But Mr Crerar found the main reason for Mr Langeveld losing control of the Honda was because he was drunk.
Perceived failures by police to breath-test the drivers and passengers or search and order the Honda off the road by putting a pink sticker on it, were peripheral and at the outer limit of what he considered to be relevant to the circumstances of the deaths.
"The real circumstances of the death were the decisions of Jesse Langeveld to drive, while drunk, at a very high speed, in a vehicle which he knew was unsafe, and the decision of his passengers to accompany him.
"The more relevant question is why were Ethan and Tylar, both 16, drinking and where did they get the alcohol?"
He recommended police investigate policy and procedures relating to stopping and questioning the people in that car that night.
In response, Southland police district area commander Inspector Barry Taylor said police had followed the law when they stopped the car earlier that night.
There was no evidence of a breach of the liquor ban and the vehicle was in a low-risk area on the boundary of the liquor ban.
Even if they had contemplated searching the car, the occupants had to be given the opportunity to leave the liquor ban area.
Police were proactive in addressing alcohol-related incidents in the city and, between June last year and March this year, had issued 99 infringement notices to minors consuming or possessing alcohol in a public place, a much higher number than in other police areas. Dunedin, for example, had issued 38 notices in that period, he said.
Mr Crerar also recommended the New Zealand Transport Agency (NZTA) revisit the pink sticker regime and investigate whether it was appropriate to introduce powers allowing immediate impounding of vehicles with obvious defects that could affect safety, to ensure the vehicles stayed off the road until fixed.
NZTA national manager for vehicles Don Hutchinson declined to comment until he received the coroner's recommendations, but noted a regime that linked pink stickers to the vehicle registration database was put in place this month. It allows police to identify and, if necessary, impound vehicles, even if the pink sticker has been tampered with or removed.
Insp Taylor said police would support any law change so that any pink-stickered vehicle which continued to be used, should be impounded.
Mr Crerar said it was the culture of young people, alcohol and driving that continued to be a problem, specifically in Invercargill.
He noted alcohol was a causative factor in all eight deaths of people aged between 15 and 20 on Southland roads last year.
"Whilst we are failing to notice, ignoring, accepting, condoning, excusing, tolerating and encouraging, the `elephant' of drink-driving flourishes."
Jesse Langeveld's mother, Jan, told the Otago Daily Times the coroner's findings left her with more questions than answers. She and her husband had never condoned drink-driving and had taught their children never to do it.
"We accept Jesse was that night, but we know something must have happened to make him get behind the wheel."
She still questioned the police's actions that night, certain they had several opportunities to avert what was to happen later. She also had serious concerns about how the car had been able to get a warrant of fitness.
Mr Hutchinson said he expected NZTA would investigate how the Honda came to receive warrants of fitness, as per what he understood to be another recommendation from Mr Crerar.
Southern police district road policing manager Inspector Andrew Burns welcomed the coroner's drink-driving remarks.
"The car was dangerously modified, but the fact is if it had been driven at the legal speed by a sober driver, this crash, and the resulting grief, would never have happened."