A polar bear ripped open the tent of a 17-year-old and dragged him out causing "mortal wounds" to his head, a report into the death of an Eton pupil on an Arctic adventure holiday found.
Horatio Chapple, 17, from Salisbury, died on an expedition to Svalbard, Norway, organised by the British Schools Exploring Society.
The reliance on a trip-wire warning system is criticised in the report.
It also advised an overhaul of rifle training to prevent future tragedies.
'Rare occurrence'Sir David Steel was appointed by the British Schools Exploring Society (BSES) - which is now called British Exploring - to conduct an inquiry into the death
Its publication was delayed to coincide with an inquest into Horatio's death, which opened earlier on Monday.
"This tragedy was caused by the rare occurrence of an intrusion of a starving polar bear into a camp situated well inland in Svalbard," Sir David wrote.
"It was a remote possibility but not unforeseeable."
Sir David said the trip wire alert system had "missing pieces of equipment" and was "not an adequate substitute for a bear watch".
Poor storage and deployment of the group's rifle also led to several failures to discharge the weapon, he wrote in the report's conclusions.
The report was ordered a month after the incident and completed in 2012, but its publication was delayed at the request of Horatio's parents.
The student was asleep in a tent when the bear attacked in August 2011.
Four others were seriously hurt before the animal was shot dead by one of the group leaders.
The Chapple family said in a statement - released before the start of the inquest into Horatio's death and before the report's findings were made public - that they "accept some of the conclusions in the Steel report".
However, they said they "do not believe the account of Horatio's death to be accurate".
Polar bear 'dragged boy from tent'
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