A coroner has found a Northland helicopter pilot and a Department of Conservation firefighter might have stretched their own thresholds of safety for the sake of saving others in a raging bushfire.
The pilot, John de Ridder, known as Prickles, who was 68, and William Macrae, who was 54, were killed when the Eurocopter flown by Mr de Ridder crashed into the sea at night off the Karikari Peninsula in November 2011.
Coroner Brandt Shortland said confusion had erupted when a small scrub fire exploded across manuka-covered hills, threatening baches and a Department of Conservation (DOC) camping ground.
Two separate command posts were set up: one by the local fire service, and one by DOC in Kaitaia sanctioned by the head of the newly-formed Northland Rural Fire Authority.
The Fire Service called in Mr de Ridder, with a helicopter and monsoon bucket, to back up local brigades.
By 8.30pm, he had stopped firefighting because of strong winds, but at DOC's request agreed to do a reconnaissance flight with Mr Macrae.
The coroner said, by this time, the Fire Service Communications Centre was taking 111 calls from distressed people stuck on a beach, and told the local firefighters the helicopter should be sent to help.
"By 9.10, North Comcen was recorded saying: 'This is now critical. That helicopter has to be diverted to those people. They are now in the ocean. Over,'" Mr Shortland said.
Mr Shortland said the operator, who was 260km from the fire, was removed from the realities facing those at the scene.
And only police could order rescues, he said.
He found there had been no direct command for a rescue, but Mr de Ridder had been asked to help urgently and said he would do his best.
Smoke likely to blame for helicopter crash
People on the beach heard the helicopter flying low and expected it to land, but could not see it in the dark and the smoke, and they then heard a loud bang and a splash.
Mr Shortland said it was likely the experienced and safety-conscious pilot was caught out by a sudden wind change that blew thick smoke towards him, enveloping the helicopter and causing him to lose his bearings.
It was likely the two men were trying to get under the smoke to the beach, to provide a first-hand report, rather than a rescue, he said.
But they knew people's lives were at risk and might have pushed the boundaries for that reason.
An internal Fire Service report had found that confusion over who was in charge, and failure to stick to a new fire plan, had been factors in the fatalities.
But the coroner said in 2011 the newly formed Northern Rural Fire Authority was doing the best it could with available resources, and had since matured, developing new approaches to the challenges of the summer fire season.
He said a new standard adopted by the National Rural Fire Authority would come into force in September, aimed at ensuring the co-ordination and safe use of aircraft at wildfires.
Mr Shortland found Mr de Ridder died of multiple blunt force trauma - and Mr McRae died after suffering a head injury.
"In hindsight ... these deaths were unnecessary in my view. These men lost their lives trying in some way to help others."
No-one has ever been charged with starting the fire that led to their deaths, although police believe it was arson.