The 21-year-old Georgian lost control of his sled during a practice run at the $110 million (£71 million) Whistler Sliding Center and was thrown from the track, colliding with a metal pillar and being killed instantly.

The Coroners Service launched an investigation into his death, examining numerous factors related to the athlete, his sled, the track condition and design, training and preparation, and the circumstances surrounding the fateful training run.

Coroner Tom Pawlowski's report, concluded Kumaritashvili died from multiple blunt force injuries, but blamed the accident on several factors, including the speed of the track and Kumaritashvili's inexperience.

"The relative lack of experience of 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," he wrote.

"The collision was a result of an interaction of factors, including high speed, technical challenges and exacting physical forces ... overwhelming the athlete and causing the irretrievable loss of control of the sled."

The report found that Kumaritashvili did "commit driving errors," and that he ran into trouble on the 15th curve in the track, where he "hung on to the curve too long".

"February 12th [the day of the accident] proved that this track was capable of producing a serious incident when unfavourable factors converged," Pawlowski concluded.

The report also contained an extensive review of the construction and operation of the track and made three recommendations to enhance safety not only at the Whistler track, but also at luge tracks around the world.

Those recommendations were for an independent safety audit to review the operation of the Whistler track, for tighter standards for the design and construction of tracks internationally, and for more compulsory training on newly constructed tracks for athletes before major events.

"As much as the athletes accept that risk exists in their sport, the organisers, regulatory bodies and venue owners must ensure that no effort is spared to anticipate the unforeseeable as far as safety is concerned," Pawlowsk wrote.

A report into the accident published by the International Luge Federation (FIL) in April had blamed driver error.

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