A series of interrelated events led to the fatal crash of Georgian luger Nodar Kumaritashvili, according to the final report by the International Luge Federation (FIL), released on Monday.
But questions remain as to how the sport can be made safer in the future.
FIL secretary general Svein Romstad suggested "there was no single reason" for the accident, "but a complex series of interrelated events which led to this tragedy" - many of which the FIL claims could not have been foreseen.
The fatal accident took place during training on Feb. 12, hours before the opening ceremonies for the 2010 Winter Olympics. Networks broadcast the accident, which showed the 21-year-old Olympian bouncing out of the Whistler Sliding Centre track into a metal pillar.
While the track was proclaimed as the fastest in the world, with athletes breaking the 150 km/h mark, the FIL stood by its original assessment that the course was safe despite the high speeds.
Since the track opened in 2007 there have been 32,646 runs at the Whistler Sliding Centre, including 19,543 luge runs. Only 203 crashes have been reported for all three disciplines. The FIL has maintained that the number of crashes on the course is not unusual, especially for a new track. However, FIL did take steps to address the speed issue by requesting additional training days before the 2010 Games, including three runs from the novice start, two runs from the junior start and one run from the ladies start before moving up the track to the men's start.
While the question of experience has been debated, the FIL confirmed that Kumaritashvili met all the international requirements to compete in the 2010 Games,
While the Georgian team did not compete in any of the test events held at the track, for financial reasons, they did take part in the second of two training weeks held at the facility in November 2009. In that session Kumaritashvili posted 20 runs on the track, nine of them from the men's start. He also completed six training runs - four from the men's start - before the 2010 Games.
As for what went wrong, the FIL report confirms that Kumaritashvili likely made a few errors in the final corners:
"...the run appears to have been routine until the exit of curve 15. At that time Nodar appears to have hung on to the curve too long. This resulted in him being sent to the right hand side of the straightaway (going into curve 16)... When Nodar did enter curve 16 late as a result he appears to have made the decision to try to hold the sled down rather than letting it go high up in the curve which is the normal path when coming too late into curve 16. This resulted in him having a low trajectory through the beginning of the curve."
When the G-forces kicked in it's believed that Kumaritashvili "lost control of the sled," which shot up towards the roof of the curve. Usually the roof would bump the rider back down onto the ice, but the FIL said Kumaritashvili's right hand and spiked glove came down on the ice, which in turn subjected his right shoulder to G-forces that prompted "a radical steering motion of the sled."
The FIL compared the effect to engaging the hand brake of a car at high speed.
"This resulted in sending the sled down towards the wall on the other side at an exceptional angle," said FIL.
While it's not unusual for lugers to hit walls, one of two things should have happened: the sled should have broken on impact to absorb the shock or the sled and rider should have been bounced back down the ice.
"In the case of Nodar neither happened. Nodar appears to have hit the wall at an exceptional angle that caused the sled to compress rather than break or bounce off. This resulted in the sled serving as a catapult when it decompressed, launching him and the sled into the air...
"This bowing of the sled has not been seen before and was therefore not predictable by technical and safety experts. No athlete would have control in dealing with this type of catapult effect."
The investigation by the RCMP and FIL experts determined that the track and sled met all safety criteria, despite the higher speeds.
As to what role the higher speeds and G-forces played in the accident, the report is less certain. The computer model before construction suggested that the top speed would be around 136 km/h, while the actual top speed recorded in Whistler was the 153.98 km/h, posted by German luger Felix Loch.
The investigation also didn't find any issues with the ice on the track, like bumps or cuts on the surface that could have contributed to the accident.
The investigation also looked at the height of the wall on curve 16, which was temporarily modified after the accident to keep sliders on the course if they came into the exit of the wall too high. According to the report, "In the case of the wall height at the finish area where the fatality occurred, neither computer simulations nor the technical experts who homologated (certified) the track and subsequently monitored the runs since the inception of the track foresaw the possibility of the event that happened."
In regard to the 2014 Games, FIL was already in contact with organizers at Sochi before the accident and said they would not certify a track if top speeds exceeded the 130 to 135 km/h range.
As for the future of the Whistler Sliding Centre, the facility will host a FIL World Cup event in 2012, followed by the FIL world championships in 2013. The FIL plans to use the original men's and women's starts but will have several meetings with technical experts to determine whether the start should be lowered again. No permanent renovations or alterations to the course design are being planned, although given the accident the FIL is currently re-evaluating track designs.
"The existing safety wall, which had already been lengthened and raised in the area of the accident, was deemed to have been correctly calculated and constructed to handle a crash in this area and to prevent the departure from the track by an athlete (under normal crash situations)... With the unknown and unpredictable dynamics of this crash the calculation and construction of the walls in that section of the track did not serve to prevent the tragedy that happened."
FIL concluded that any changes to the sport, including track design and sled technology, will be reviewed by its expert commissions before implementation.
The Vancouver Organizing Committee and Whistler 2010 Sport Legacies Society released a joint statement on Monday in support of the FIL report.
"Nodar lived his life for the love of his sport and the FIL has made it clear in this report that this accident's circumstances were indeed unique," said John Furlong, CEO of VANOC. "We are grateful for their affirmation of the safety measures at the (Whistler Sliding Centre) that they took to protect all athletes and for their determination to learn from this tragedy."
Keith Bennett, president of Whistler 2010 Sport Legacies, said, "We commend the FIL on the thorough preparation evident in this report and look forward to the opportunity to host them and their member athletes in future training and competition. Nodar's death - but also his determination and drive - are part of the Whistler Sliding Centre history, and we will always honour his memory, working with all parties to ensure that, while sliding sports are speed-based, safety remains our number one priority in running both a high performance and recreational facility."