A damning review into the deadly Mount Maunganui landslide has revealed a litany of failures by authorities who “missed several opportunities” to evacuate campers to safety in a disaster that was “preventable”.

The 238-page review was prepared for the Tauranga City Council by retired High Court judge Paul Davison, KC, who made 10 “systemic recommendations” and another five directed to emergency response officials.

Davison’s report shows that despite geotechnical consultants warning of landslide risks and rockfall hazards to the campground years prior to the deadly landslide, plans to mitigate risks and educate staff on warning signs, were not implemented.

Experts had warned the council of risks as far back as December 2023, and again in June 2025, but recommendations to improve safety were not acted on.

“This was a systemic failure with tragic consequences,” the report said.

The six people killed in the Mauao landslide were (clockwise from top left) Pakuranga College students Sharon Maccanico and Max Furse-Kee, both 15, Rotorua's Susan Doreen Knowles, 71, Morrinsville's Lisa Anne Maclennan, 50, Swedish tourist Måns Loke Bernhardsson, 20, and Rotorua's design store co-founder Jacqualine Wheeler, 71.

It is the first of five investigations into the slip, with the Government, WorkSafe, police and the Coroner running separate probes.

The landslide crashed down from Mauao into the campground at its base about 9.30am on January 22, after record rainfall.

The slip also hit the Mount Hot Pools next door.

The victims were recovered and identified over an 11-day emergency response.

They were: Pakūranga College student couple Sharon Maccanico and Max Furse-Kee, both 15; Rotorua friends Susan Doreen Knowles and Jacqualine Wheeler, both 71; Morrinsville educator Lisa Anne Maclennan, 50, and Swedish tourist Måns Loke Bernhardsson, 20.

The council estimated the landslide involved 12,000 cubic metres of earth.

It was one of 42 slips on the iconic mountain in Tauranga’s wettest 24 hours on record.

The Bay of Plenty was in a state of emergency the day before, in anticipation of the storm, and was under a MetService red weather warning.

MetService reported that from 9am, January 21 to 9am, January 22, 274mm of rain fell in the city, which had an average January rainfall of about 79mm.

Another landslide into a home about 4am that day killed a grandmother and her 10-year-old grandson on Welcome Bay Rd, Pāpāmoa. They were Austen Keith Richardson and his grandmother, 71-year-old Yao Fang.

Yao Fang, 71, and grandson Austen Keith Richardson, 10, died in a landslide on Welcome Bay Rd on January 22.

Mayor responds

Tauranga Mayor Mahé Drysdale said it was important to begin by acknowledging the importance of the maunga to the community. 

He acknowledged the lives of the six people lost in the holiday park land slip and offered his condolences to their loved ones. 

"While this tragedy has had a profound and lasting impact on our community, it is those who lost their lives, and the families and friends who continue to live with that loss."

He said he and his fellow councillors had been "determined" to get answers about the events of January 22 as quickly as possible.

"Today, those answers and that clarity are being released in full to the public in the Davison report", he said. 

"The affected families and our communities were deserving of a full and independent examination to see the actions taken and circumstances leading up to the event. We needed to understand if more could have been done." 

Drysdale said the documents referred to in Davison's report were pre-emptively released in March this year. 

"The report we release predates the government inquiry and investigations currently being undertaken by the coroner, police and WorkSafe. As such, it only forms part of the broader picture.

"We would like to thank Mr Davison for his professionalism, his expertise and unwavering commitment to thorough analysis and meticulous research, all of which has ensured this review is both robust and credible."

Teacher tried to warn

Experts recommended a Trigger Action Response Plan, which would have helped staff identify risks like muddy water and forecast rain as a trigger for evacuating campers. 

“Had a TARP been in place, evacuation would likely have occurred well prior to the fatal landslide”. 

The failures are not limited to inaction years prior to the deadly event on the morning of January 22. The first missed opportunity to evacuate those staying at the Mount Maunganui Beachside Holiday Park was when Metservice issued a rare red heavy rain warning. 

The next was the obvious signs of danger that morning which included “smaller slips above the campground” and a “stream of muddy turbid water” flowing from the foot of the slope. 

Morrinsville teacher Lisa MaClennan and her partner Travis McClennan woke around 4.30am to the sound of a slip hitting the back of their campervan. 

The report says the pair urgently tried to call the holiday park to tell them what had occurred, but a phone call made at 4.43pm went through to a security guard who explained that no one was on site.

Consultants ignored for two decades

Davison’s final thoughts said his review had been “sobering in its simplicity”. “This was not a hazard that was unknown, hidden, or beyond the reach of foresight. 

“For more than two decades, one competent consultant after another identified the landslide hazard to the campground.” 

He said this landslide hazard was located on the very slope that failed. Davison said there was a previous warning that a holiday accommodation beneath Mauao’s slopes was “imprudent” and the risk to sleeping occupants was “high”.

He said this warning, which identified risk above the Harbour Amenities building, was repeated over many years. 

“What was missing was not knowledge, but an organisation able to hold, assess, and act on it.” 

Davison said if a TARP had been in place, it would have prompted an evacuation and the landslide victims would not have been within the path of the landslide.

“The loss of life could in all likelihood have been averted.”

Failure to act on geotechnical warnings

Davison said the review did not find any individual accountable.

“It does not find that any individual did anything intentionally or deliberately wrong, or that any one or more persons’ acts or omissions caused these tragic deaths.”

He said the review also found the tree removal in 2019 did not cause the landslide. However, Davison said the tragedy was preventable. The report said the council had a “highly qualified natural-hazard specialist” when external reports in 2023 and 2025 identified landslide risk at the campground. Davison said this specialist “appeared to be the most well qualified person within TCC” to assess geotechnical and natural-hazard risks.

However, his role was considered to be advisory. The campground owner was expected to carry forward the recommendations of these reports. Davison found, in his view, the specialist was “entirely unaware” of one of these reports. 

The report said the specialist first became aware of the reports identifying landslide risk at the campground after the fatal Mauao landslide. 

In an interview with Davison, the specialist said: “It is something that concerned me a lot seeing that report, that something of significance is being produced within Council, but then, in my role... I am not aware, consulted or given any insight”.

The specialist said this was not an isolated oversight, but a “feature of the way TCC operated”.

The specialist conducted his own analysis, which determined the fatal Mauao landslide was “between 100 and 1000 times above the threshold of tolerable risk.”

He calculated a likelihood of one fatality every two-and-a-half years, should the rainfall between January 21 and January 22 reoccur. 

Photos taken in the immediate aftermath of the Mount Maunganui landslide. Photo / Bill Baker

The specialist said water flowing from the landslide site “at least” required people to evacuate. The report said the staff member who had the authority to make this decision had been given no training or information on landslide risk. 

Davison said the failure to evacuate everyone from the landslide area was “deeply systemic”. He said it was the consequence of a failed organisational structure and risk management process, despite widespread knowledge of landslide risk at the campground. 

“Warnings sufficient to prompt consideration of evacuating the toe-of-slope campsites were received, and the appropriate precaution was articulated on the ground.” 

However, there was no framework to recognise, escalate, or act upon landslide risk or TARP to guide the decision.

Multiple warnings over 25 years

High Court Judge Paul Davison KC said he was engaged to conduct an independent and external review in February this year.

He said the review "required me to consider the decisions and actions the Tauranga City Council took on that day in connection with the area that was affected by the landslide after the state of emergency had been declared the previous day."

This included whether council emergency operations had taken appropriate and timely actions, and what it had known ahead of the landslide.

"In carrying out my review, I have spoken to those TCC staff who were directly involved with the events of the 21st and 22nd of January, I have reviewed records, documents and photographs related to the event, including photographs taken by one of the landslide victims herself."

Davison said he has also spoken to former TCC staff, the families of the victims, witnesses, and a geotechnical consultant.

"I have looked into and reviewed the TCC organisation and how it carried out its natural hazard risk recording, assessment and management and what its processes were and how they were carried out."

He said assessing what was known by council required reviewing geotechnical reports going back 25 years, including a 1999 report assessing the stability of the northeastern to southeastern slopes of the maunga.

In the 1999 report, Dr Laurie Richards identified the historic landslide scarps as presenting a risk to the campground occupants.

"In my review report, I have described how TCC received geotechnical reports over the 25-year period since Dr Richards' report, in which the landslide risk to the campground presented by the historic landslide scarps located around the lower slopes of the mountain and above the campground has been repeatedly identified."

A series of reports in 2005 and 2006 specifically identified the area of the slope which failed on January 22, noting the risk of landslide causing multiple fatalities.

"Whenever new staff were engaged or appointed, that were those to whom Avalon reported, it repeated its historic or background reports so that the new people had an overall view of what Avalon's position was in relation to this risk and those scarps."

'Deeply systemic flaws'

In December 2023, another geotechnical consultant WSP recommended TCC put in place a TARP to reduce the risk of landslides. 

A similar recommendation was made by HD Geo, another geotechnical firm, in June 2025. "In neither case were these recommendations taken any further or acted on by TCC, that as at 22 January this year, there was no tarp for the campground in place," Davison said. 

"That would have signalled the need to evacuate the area of the campground, because of the forecast of an extreme and heavy rainfall event or the arrival of that extreme rainfall event or the clearly observable signs of potential slope failure as evident from a flow of muddy water seeping from the foot of the slope above and behind the harbour amenities block. 

"Neither the campground manager nor any of the other TCC staff on hand at the campground on that morning had the knowledge or training to what were clear indications of potential slope failure and an elevated risk of land and danger. 

"This history of warnings and missed opportunities to develop effective measures to mitigate or reduce the risk presented by landslides to people at the campground is fully set out in my report." 

Davison said he has found the failure to prepare for an extreme weather event or place effective risk mitigation in place reveals "deeply systemic flaws" within TCC. 

Davison said the level of rainfall forecast for January 22 had previously caused landslides on maunga.

Victims last moments recounted

At 5.45am, a member of the public reported two landslides to 111, and through that contacted Fire and Emergency New Zealand. 

"As a result of that contact by Fire and Emergency to the TCC contact centre, TCC's walkways supervisor was contacted and alerted to the occurrence of these slips up behind the surf club. He moved straight away to head to the scene and on the way he saw the scale of these slips and he contacted the manager that he was responsible to, and a decision was made immediately to close access to the mountain."

Davison said TCC's response was directed at closing the maunga tracks and track users, which was done competently and promptly. 

"But it was not accompanied by consideration being given to the implications of those slope failures to the occupants of the ocean beachside campsites who were camping around the foot of the mountain.

"After these calls, the Maclennans continued unsuccessfully to locate campground staff, having ongoing concerns about people camping near the base of maunga. The manager offered to arrange a refund of their camping fees and to find a replacement electric cable for the one which had been covered by the landslip which had come down under their campervan.

"He said he would be back to see them and they waited for him and he drove off."

The time of that conversation has been verified photographically as at about 7.40am. 

At 8am, "a stream of turbid, muddy water" was flowing from the base of the mountain, "carrying a considerable volume of silt and gravel". 

"By then, a total of four small slips had occurred in the vicinity of the initial one", Davison said. 

But the significance of that turbid water, that flow of water from the slope, as a precursor of slope failure was not appreciated by anybody."

A photograph taken by Lisa Maclennan at 6.17am shows the beginning of the muddy water, while a later picture at 7.41am depicting what has been described as silt, small rocks and water "forming almost a carpet-like coverage" of the campground driveway. 

The Maclennans arranged to check out after refunding their camp fees, but each planned to shower before leaving. 

"Before 9:30 am, several people were in or near the harbour amenities block. 

Lisa Maclennann had gone in for a shower, so had Sharon Maccanico and her boyfriend Max. 

"A minute or two before 9:30 am, the slope above the amenities block suddenly failed.

"A large mass of water saturated clay of water-saturated clay, soil, colluvium, rock and debris slid rapidly down from the slope above the harbour amenities block and within seconds it had engulfed the whole building. It was rapid." 

Council staff, family members and members of the public responded immediately to the landslide, in what Davison described as "desperate efforts" to locate those trapped. 

"Several of them climbed up onto the displaced amenities building roof to dig and search." 

Emergency services arrived within minutes, he said.

Teaching couple's warnings ignored

Describing the events of that morning, Davison said victim Lisa Maclennan, a Morrinsville teacher, was awoken by the slope slipping and striking her campervan. 

"She straight away went and woke the occupants of a small blue tent which was pitched right beside their campervan on the next campsite, waking the man who was in it with his young daughter, got them up and she then moved their campervan off the campsite out onto the driveway, in reasonable proximity to, but still well away from the landslip."

He said that nearly five hours before the fatal landslide, Maclennan's husband Travis – a teacher in Cambridge – had informed holiday park management of the slip. 

"His call went through to a security firm that has a contract to provide people on site at the holiday park overnight, but they didn't have anybody on site at that time of the morning." 

The call was rerouted to TCC, where he spoke to a an operator and informed her of the slip. At 5.21am, he was called by a member of the EOC welfare team.

"It was resolved and handled as a welfare and accommodation matter. The issue of whether the slip that had caused the damage or had caused them to be awoken that morning was a geohazard that was not addressed in this context," Davison said.

Recommendations

Davison's report includes several recommendations. 

“Single accountable ownership of every risk to life, including those that cross internal administrative and organisational boundaries. 

“The mandatory recording, escalating and tracking of expert advice. 

“A central register of geotechnical technical and natural hazard reports, and the preservation of hard-won knowledge through restructuring processes and handovers from staff member to staff member. 

“The quantitative assessment of both individual and societal risk against defined tolerability criteria is a further recommendation, as is the independent commissioning of safety assessments and the engagement of the council's own specialist expertise to evaluate reports and issues around risk. 

“Further, the development and maintenance of trigger action response plans for populated sites and the contracting of scheduled of known hazard sites by experts. 

”Also, I am recommending that before physical works are undertaken on or above populated areas susceptible to landslide, that geotechnical assessments in every case be obtained.

“I'm recommending that there is improved coordination and management of the campground interface so that there is cooperation and the sharing of knowledge and information across that interface. 

“I'm recommending that there be independent assurance obtained that risks are being in fact identified and managed. 

“And I recommended a process that will require reports which come into the council not to be considered and finally determined in terms of their use by those who receive them, but that a copy of them automatically is sent to the people who are capable of evaluating the risks, those responsible for evaluating so the matter is not left in the hands of those who may not be qualified or experienced enough to make those decisions.”

Mayor apologises to families and community 'that have been put at risk' over 27 years

Davison said the victims had come to enjoy a beachside holiday and did not return home to their families, who are left with the grief and loss that "no report" could change. 

Tauranga Mayor Mahé Drysdale said the findings of the report were "clear" and "deeply confronting". He said Tauranga City Council had missed multiple opportunities to manage and mitigate risk, revealing several shortcomings across the organisation. 

These were across systems, culture, accountability, and organisation decision making. Drysdale said he accepts all the findings and recommendations on behalf of the council. He said the families of the victims were the first to hear the findings, and he has committed to them that change will be implemented so "no other family has to deal with this kind of devastating and ultimately preventable loss". 

Drysdale said he has apologised to the families of the victims on behalf of the council. 

"As I told them, our organisation should have done better. I also offer that same apology on behalf of Tauranga City Council to all those in our community that have been put at risk over the past 27 years.

"This report is difficult to read because it makes it clear the opportunities existed to reduce the risk by putting mitigations in place." 

Drysdale said the community "rightly expects" risks to be identified, communicated, escalated and managed, and those expectations had not been met. 

"As a governance team, the councillors and I have already demanded change from this organization. We have made it clear that it is our expectation that every recommendation made by Mr Davidson is implemented." 

Drysdale said on September 1, a report will be released to "provide a road map" for the council's next steps. 

"We give you the same commitment as I have given the families. That we will hold this organisation accountable for delivering substantial and lasting improvements in terms of risk management performance." 

Drysdale said he and his fellow councillors are "steadfast" and will be "unrelenting" in ensuring meaningful change happens. 

He acknowledged the courage of those involved in the response that day, including the Maclennans, fellow campers, members of the public, and first responders.

He said many had "risked their own safety in desperate efforts to save those trapped beneath the landslide". 

"Their actions demonstrated remarkable bravery and selflessness. We thank and acknowledge them today."

He also acknowledged those involved in supporting the families in the aftermath of the tragedy, particularly the Mauao Trust.

CEO asked if he will resign

Tauranga City Council chief executive Marty Grenfell addressed media by acknowledging the loss of life on January 22. 

"As the Chief Executive of Tauranga City Council, I am sorry that the organisation has over many years failed to take appropriate steps to manage the risk to the campground. Likewise, as the chief executive, I'm accountable for the performance of the organisation and ensuring it addresses those issues identified in this report."

Grenfell said this report answers many of the questions asked by the council, community and families of the victims. 

"We must learn from these and implement the recommendations with urgency. As a council we have dedicated people who turn up every day to do their best. No one intended for this to happen." 

Grenfell said several TARPs have been implemented across the city since January 22 after an internal review. He said there are three investigations underway, so he cannot comment on whether there may be civil or criminal action. He said his focus is on implementing the recommendations when asked if he personally accepts responsibility for the tragedy. 

"There are a number of people across this organisation who had the opportunity to respond to and address these risks." 

When asked again if that includes him, he said "each of those people, including myself, have obviously reflected." 

"We carry the burden, we carry the weight of the loss of the family the loss of these victims, and we also carry the impact for that."

Grenfell said it was a "fair question" to ask whether he had offered his resignation, but would not outright answer the question itself. 

"My focus is solely on implementing these recommendations, making the changes to the organisation that are necessary."

Tauranga City Council chief executive Marty Grenfell. Photo / Alyse Wright

How the review was done

The council faced scrutiny over whether the campground deaths could have been prevented, including whether campers should have been evacuated sooner.

It had closed Mauao’s popular tracks earlier that morning after slips.

The campground was owned and operated by the council, while facilities arm BayVenues ran the Mount Hot Pools. The council jointly manages the iwi-owned Mauao Historic Reserve with the Mauao Trust.

The council launched an external review into the landslide tragedy in February.

In an emergency meeting, several councillors emphasised the need for a transparent process that could deliver rapid answers.

According to the terms of reference, the review led by Davison was to consider the facts, timeline and decision-making processes before the fatal landslide, and the immediate response before Fire and Emergency NZ took over.

It was to also look at the adequacy of risk assessments and monitoring systems, as well as any lessons or improvements needed to strengthen future safety.

It would not examine the emergency response, or make findings or comment about the civil, criminal or disciplinary liability of any person.

People view a roadside memorial for landslide victims in Mount Maunganui in February. Photo / Anna Heath

The Government’s inquiry, which also encompasses the Welcome Bay Rd slip, is led by retired Supreme Court Judge Sir Mark O’Regan.

Public submissions are open and a final report is expected in December.

Mauao today

Mauao, the holiday park and the hot pools remain closed, along with the nearby Mount Maunganui Lifeguard Service building.

The street they are on, Adams Ave, and the Pilot Bay boat ramp closed again last month after a “major regression” of the campground slip, which saw about another 8000 cubic metres of earth shift.

Shipping containers have been placed between the slip site and the road, and the council is adding rock-filled bags outside the containers as an additional protective measure.

It aims to reopen Adams Ave and the boat ramp by the end of the month.

The Bay of Plenty Times revealed on Monday that the owner of Rustica pizzeria, opposite the campground, had “pulled the plug” after the fresh slip.

Several nearby businesses say the prolonged disruption since the slip has taken a significant financial toll.

Decisions about the long-term future of the facilities have yet to be made.

There was a major regression at the site of the fatal Mauao landslide. Photo / Tauranga City Council

The council has completed repairs to Mauao’s slip-damaged Motukauri 4WD summit track, which remains closed to the public.

Remediation work was underway on Te Ara Tūtanga base track.

Ground movement on Mauao was being monitored through inspections and geotechnical monitoring systems.

Tauranga City Council recovery manager Charlie Rahiri told the Bay of Plenty Times in June that Mauao was a “couple of months away” from reopening.