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The death of a Georgian luger on the Whistler luge track proves the need for a renewed focus on safety issues at the facility, not just for competitors but for spectators, says a coroner's report released Monday.



"The athlete and his equipment left the track resulting in his death. We don't want to have a similar incident occur where someone who is assisting with the race or a spectator becomes injured or killed," Jeff Dolan, director of provincial operations for the BC Coroner's Service, said in an interview, hours after the release of the 16-page report.



Mr. Dolan was referring to possibilities at the purpose-built track at the Whistler Sliding Centre where 21-year-old Nodar Kumaritashvili, ranked 44th out of 70 athletes in World Cup standings, suffered fatal injuries on Feb. 12, 2010, during the final training session the day before Winter Olympic competition was to begin.

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"[Nodar Kumaritashvili's]death has proven the Whistler track capable of producing a serious incident, despite all of the safety measures that have previously been considered adequate," coroner Tom Pawloski wrote in his report.



"Further and greater scrutiny of safety issues at the track is advisable."



Commenting on the report, Batu Kutelia, Georgian ambassador to the U.S. - a posting that also covers Canada - said Monday that the report does not change the fact that "no sports mistake should be fatal."



"Nodar was a young, gifted athlete, who worked hard and dreamed about Olympic success," he said. "The fact that the organizers altered the track after the death of this athlete speaks for itself."



The report says that the Whistler 2010 Legacies Society, which now operates the $119-million track, should look at track design, track speeds, placement and configuration of crash barriers and other protective measures to address the possibility of athletes or sleds leaving the track and potentially causing injuries to the athlete, track workers or spectators.



Mr. Kumaritashvili, 21, died from multiple blunt-force injuries to the head and torso after colliding with an ice wall, and being ejected to the outside of the track where he struck a metal post. At the time, the luger was travelling at 144.3 kilometres an hour.



The B.C. coroner deemed the Georgian's death an accident. Mr. Pawloski was in Whistler at the time of the crash, on scene in case of such incidents, so began his research immediately, Mr. Dolan noted Monday.

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Various factors, including high speed, exacting physical forces, and technical challenges "converged" at a critical moment, overwhelming Mr. Kumaritashvili and causing a critical loss of control.



"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."



The report called for an independent "and previously unaffiliated" entity to carry out a safety audit "in order to provide either a new perspective or a corroborative perspective capable of restoring confidence in the Whistler track."



Mr. Pawloski conducted his research through an "inclusive" process that saw him communicate throughout with stakeholders, which may have explained the general embrace of his findings released Monday.



In a statement, the president and CEO of Whistler Sport Legacies deemed the report "thorough, balanced and informative," and said work was already under way on framing the terms of reference for a safety audit.



"While [Whistler Sport Legacies]was not the owner or operator of the facility when the accident happened, we take the Coroner's Report seriously and will respond to the recommendation for a comprehensive safety audit," Keith Bennett said in a statement. "It is our hope that the Coroner's Report provides closure."

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John Furlong, CEO of the 2010 organizing committee, described the report as "thorough."



Mr. Kumaritashvili had run the course only 26 times, and "more training runs may have eliminated some of the pressure and may have offered Mr. Kumaritashvili a greater level of comfort," said the report.



In August, a report by the International Luge Federation concluded driver error was to blame for the crash.



The BC Coroners Service is ruling out an inquest in the case, concluding such a process would not unearth any additional, relevant information, said a statement released with the report.

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