Had a Korean nurse living in Sydney worn the seatbelt provided, she may not have been killed, or even injured, when the tour bus in which she was travelling on the Te Anau-Milford Highway slid on black ice and overturned, throwing her out and crushing her, last year.
It was one of the remarks in the formal finding released by Otago-Southland regional coroner David Crerar last week, after the coroner's court hearing, in Te Anau, on May 11 this year.
Mr Crerar recommended a copy of his finding be forwarded to the New Zealand Transport Agency so his comments on the wearing of seatbelts by bus passengers could the subject of an education programme.
The agency could also continue with an oversight of road maintenance programmes, Mr Crerar recommended.
"The phenomenon of black ice has caused the deaths of a number of road users in the past and continues to be a hazard about which continued vigilance is necessary."
Mr Crerar said in his finding nurse Kyung Hee Park visited New Zealand as a tourist and died near Te Anau Downs Station, on July 9, 2009.
The cause of death was compression asphyxia, complicated by aspiration of blood and cerebral lacerations complicating severe basal skull fractures, he said.
Mr Crerar rejected claims lodged in an anonymous letter.
He said there was no meeting of contractors in Te Anau which delayed the timely inspection of the road on the morning of the incident.
Appropriate staff and resources were tasked on the Te Anau-Milford Highway from 7am.
"The roading contractor did everything that could have been done," he said.
The ice hazard was gritted and the specific area of the crash was not considered a hazard by independent witness Peter Taylor, an accommodation owner, who said the gritted area appeared to be free of ice when he drove on it, and Downer EDI staff, Mr Crerar said.
Senior Constable Andrew Grant, of Te Anau, said Ms Park was one of 12 Korean nationals on a five-day bus tour of the South Island.
After an overnight stay in Te Anau, the group was travelling in a bus driven by driver-guide Whan Ki Choi (John Choi) on State Highway 94 towards Milford Sound, when Mr Choi lost control of the bus on black ice, and it skidded and rolled.
The incident happened about 700m north of the Redford Stream Bridge, near Te Anau Downs.
Snr Const Grant said Ms Park was seated in the front of the bus and was thrown out of it when it overturned.
She became trapped under the bus and received fatal injuries to her head.
Five other bus passengers were injured and were taken by helicopter to hospitals in Dunedin and Invercargill.
Mr Crerar said the driver of the bus "was doing everything he should have been doing, but not necessarily everything he could have been doing".
Mr Choi, as driver and tour manager, owed "a duty and a responsibility" to his passengers to remind them to use the seatbelts provided, to the extent of telling them it was their legal obligation.
Mr Choi told the hearing he was driving the bus at 50kmh to 55kmh, slower than normal, before he lost control.
He had noticed a sign at the start of the Milford Rd indicating icy conditions, although he had never seen the road iced over in the location of the accident.
