An investigation into last year's fatal boat capsizing in Kaikōura has found a fuel leak contributed to the deaths of five people.
The i-Catcher - chartered for a birdwatching trip - overturned in Goose Bay on 10 September with 11 people on board. Initial reports suggested the vessel might have hit a whale.
Five were already dead by the time emergency services arrived.
Transport Accident Investigation Commission (TAIC) chief investigator Naveen Kozhuppakalam said petrol almost certainly leaked from flaws in the 8 metre aluminium pontoon's fuel system.
The five who died all showed symptoms of petrol exposure, consistent with inhalation and absorption of petrol fumes, an interim report showed. Exposure can lead to "confusion, loss of consciousness and sudden death", the report noted.
"A pipe connected to the secondary fuel tank vent hose had a hole that was the main source of leaked fuel," Kozhuppakalam said. "It presented a hazard that risked fire or explosion if fuel leaked when filling the tank, or risked fumes in the air pocket if the vessel overturned.
"The secondary vent hose was also ineffective because it didn't vent to outside air; instead, it vented into the sealed metal tubing of a frame fitted to the rear of the boat."
And that was not all.
"And there was another leak from the primary fuel tank vent hose where it joined the fuel tank and should have been secured with a hose clamp."
The i-Catcher had been inspected by five different marine surveyors during its 13 years of service, and not a single one picked up any problems.
The commission called on Maritime New Zealand to improve its boat survey system, which did not require a vessel's entire fuel system to be inspected.
"Surveyors are more likely to discover deficiencies if they are required to inspect the whole fuel system as a critical item - not just the parts that are easy to get to," Kozhuppakalam said.
TAIC's inquiry was still ongoing, with more recommendations expected. The direct cause of the capsizing was still being investigated.
"This is about more than the i-Catcher; it is system-wide, nationwide because there are hundreds of boats like i-Catcher in our commercial fleet, tens of thousands more in the recreational fleet. And everyone on board a boat deserves for it to be safe."
The deceased were Catherine Margaret Haddock, 65 and Susan Jane Cade, 63 of Lower Hutt, Diana Ruby Stewart, 68, Peter Charles Hockley, 76 and Maureen Patricia Pierre, 75 all of Christchurch. All were members of the Nature Photography Society of New Zealand.