RECORD OF INVESTIGATION INTO DEATH
Coroners Act 1995
Coroners Regulations 1996
I, Ian Roger Matterson, Coroner, having investigated the death of
Hamish Alan SAUNDERS
WITHOUT HOLDING AN INQUEST
FIND THAT :
Hamish Alan SAUNDERS died on or about the 15th April 2003 at
Pedra Branca Rock, South East Cape, Tasmania.
Hamish Alan SAUNDERS was born in Hamilton, New Zealand on the 7th
June 1976 and was aged 26 years at the date of his death. He was a
single man who was an oceanographer.
I find that despite the absence of a body, the deceased has
drowned, as a result of being washed from Pedra Branca Island into the
ocean by an ocean wave or the cumulative effect of a series of ocean
At the time of the deceased person’s death he was not being
treated by a medical practitioner.
CIRCUMSTANCES SURROUNDING THE DEATH :
BACKGROUND INFORMATION REGARDING PEDRA BLANCA ISLAND
Pedra Branca Island lies 28 kilometres off the south coast of
Tasmania. The island is 270 metres long and 100 metres wide and
reaches a maximum height of 60 metres. It is the only known habitat of
the Pedra Branca Skink and is an important seabird rookery. The island
is classified as a National Park and is a quarantine island and as
such visits to the island are regulated.
The Nature Conservation Branch of the Department of Primary
Industry Water and Environment (DPIWE) undertakes work on Pedra Branca
Island in order to implement the Pedra Branca Skink Recovery Plan as
well as the Threat Abatement Plan for Albatrosses. Personnel are
required to work on Pedra Branca Island in order to undertake research
into the ecology of the island’s seabirds, undertake census work on
seals hauled out around the island’s perimetre, and also to conduct
research on the endemic Pedra Branca Island Skink. This research
requires day trips approximately two or three times per year, as well
as one multi-day visit each year and has been conducted over the
preceding twenty years.
The research trip is the joint responsibility of the Marine Unit
and the Threatened Species Unit of the Nature Conservation Branch
(NCB) of DPIWE. As such Rosemary GALES of the Marine Unit assumed
primary management responsibility for the trip with input from Dr
Sally BRYANT from the Threatened Species Unit.
I am informed by Kieran LAWTON, a biologist employed at the
Australian Antarctic Division, that Pedra Branca Island is a rock
which is easy to traverse by walking as opposed to climbing. LAWTON
states that the areas worked by researchers are the easiest areas to
traverse with the surface being similar to steps, solid in nature and
not loose with the only areas which could be described as overly
slippery being those which are heavily guannoed.
It is LAWTON’s opinion that it is unnecessary to employ the use
of ropes whilst conducting research on the island. In accepting this
opinion I rely upon LAWTON’s experience of having worked for the
Australian Antarctic Division on various contracts for a ten year
period, six months of which was spent as a field training officer, in
addition to which LAWTON has 15 years rock climbing experience during
which he has acted as a guide in Canberra and Antarctica.
PLANNING FOR THE TRIP
I am informed that GALES and BRYANT were responsible for pre-trip
planning and pre-trip meetings. Over the passage of time it has become
the policy of the Nature Conservation Branch that each party
travelling to a remote island is to consist of four persons. This is
to enable each party to operate in pairs, thus providing a safety
watch for each other.
Initially, the core members of the party were David PEMBERTON of
the Tasmanian Museum and Art Gallery (TMAG) of the Department of
Tourism, Parks, Heritage and the Arts (DTPHA); Aleksandrs TERAUDS a
Marine Conservation Officer with the Marine Unit of the Nature
Conservation Unit; and Alan WILTSHIRE from DPIWE. Prior to the
departure of the party WILTSHIRE resigned from DPIWE and his place was
filled by Matthew WEBB of the Nature Conservation Unit.
PEMBERTON had the responsibility of identifying possible risks and
the decision making surrounding equipment in addition to which he
would be the scientific advisor for the expedition. TERAUDS has
assumed the role of logistical planning and WEBB has had no specific
involvement in logistical planning.
A variety of communications equipment was taken for this expedition
which included two CDMA mobile telephones, one satellite telephone,
two marine hand held VHF radios and one EPIRB.
I am informed that the selection of expedition members is based
upon an individual’s qualifications and ability. The members of the
expedition had the following experience:
- 1982 - 1987 field work in Mount William National Park in North
- 1987 - 1999 employed in various positions which involved field
work by the Tasmanian National Parks and Wildlife Service.
- 1999 commenced employment with TMAG.
- Expeditions of varying lengths to approximately 200 offshore
Tasmanian Islands some of which were sub Antarctic in nature.
- Survival training whilst undertaking National Service in the
South African Army, Australian National Antarctic Research
Expedition (ANARE) Remote Field Training which involved remote
area survival, communications skills, camp site placement and
maintenance and rope skills.
- Nine or ten previous expeditions to Pedra Branca Island.
- Three years employment at the CSIRO including in excess of four
month’s sea time. This included expeditions off the West Coast
of Tasmania and down to 50 degrees south for up to three weeks
- Seven years employment by and working with the NCB including 43
months on Macquarie Island between 1996 and 2001.
- Thirteen expeditions to offshore Tasmanian Islands including
Maatsuyker and Mewstone Islands which are situated off the south
coast of Tasmania. These expeditions involved working in weather
conditions which ranged from calm winds to those measuring 60
knots accompanied by ‘big’ seas.
- Involvement in planning and co-ordination of all of the thirteen
- Level 2 First Aid, Remote Area Search and Rescue (SAR) training,
ANARE Remote Field Training, a minimum of four SAR sessions
covering ‘remote area access’, ‘remote area rescue’ and
how to work as a team during SAR incidents.
- General rock climbing experience in Tasmania and Africa.
- No previous expeditions to Pedra Branca Island.
Matthew Houston WEBB
- Degree in Environmental Resource Management which is a Batchelor
Degree with Honours in Zoology which included field work in the
area of the Dip River in North West Tasmania.
- Field work in Kakadu National Park, Northern Territory.
- Five and one half months field work on Macquarie Island.
- ANARE Remote Field Training.
- No previous expeditions to Pedra Branca Island.
Hamish Alan SAUNDERS (the deceased)
- Master of Science Degree (1st class honours).
- PADI Open water SCUBA Diving Certificate, New Zealand Boat
- 1999 - 2001 employed by New Zealand National Institute of Water
and Atmospheric Research (NIWA) and undertook duties as a
Geographic Information Systems (GIS) Technician on sea floor
mapping expeditions in the areas of the Kermadic Trench which is
northeast of New Zealand and the Southern Ocean.
- July 2001 - December 2001 employed as a GIS Technician for
Transport of London, Great Britain.
- March 2002 - September 2002 carried out volunteer duties as a
GIS specialist for the Department of Botany, Charles Darwin
Research Station at Galapagos Islands, Ecuador.
- No previous expeditions to Pedra Branca Island.
I am informed by Kieran LAWTON that in his opinion PEMBERTON and
TERAUDS are extremely experienced and competent personnel who are
considered within Australia to be outstanding for an expedition of
SELECTION OF THE DECEASED AS AN EXPEDITION MEMBER
I am informed that Dr BRYANT received an email from Alan SAUNDERS,
a colleague and friend whose judgement and opinion she holds in high
regard, who is employed at the Department of Conservation in New
Zealand on 12th March 2003. In this communication SAUNDERS enquired as
to the possibility of volunteer work for his nephew, the deceased.
Approximately six days later the deceased telephoned BRYANT and
arranged a meeting which took place on 21st March. This meeting lasted
approximately 90 minutes during which discussions centred on the
deceased’s background, skills and qualifications. The deceased also
supplied a copy of his curriculum vitae and completed a ‘volunteer
registration form’ during this meeting.
After a subsequent telephone conversation during which the deceased’s
interest in an expedition to Pedra Branca was discussed a further
meeting was arranged. This meeting took place on 31st March which
lasted for two hours. During this meeting the program for the Pedra
Blanca expedition was discussed and arrangements were made for the
deceased to meet with PEMBERTON.
PEMBERTON is described as being impressed by the deceased’s work
on the Galapagos Islands and in addition the meeting covered the
necessity for old clothes and suitable footwear due to the nature of
the work which would be conducted on Pedra Branca which could be
classified as dirty and uncomfortable. I am informed that PEMBERTON is
particular as to the type of footwear worn by expeditioners stating
that heavy boots or footwear which has a smooth, or non grip sole are
The deceased makes reference in his diary to his belief that BRYANT
‘pulled strings’ in order for him to join the expedition. I am
satisfied that this did not occur and that there was simply no-one
else available to fill this position. I am satisfied that the deceased
gained selection based on his own merits and the recommendation of his
uncle Alan SAUNDERS.
I am satisfied that the deceased did attend meetings with BRYANT,
PEMBERTON and TERAUDS which could be classified as being introductory
in nature. I am, however, critical of the fact that the deceased went
on this expedition having failed to attend a formal pre-expedition
planning meeting and that there was no inspection/review of his
personal equipment by an experienced expeditioner. These criticisms
are relevant in light of the ‘volunteer’ status of the deceased
and that this was going to be his first trip to Pedra Branca Island.
WEATHER and SEA CONDITIONS
I am informed that the weather conditions on Pedra Branca Island
are best reflected by observations and forecasts based on observations
from Maatsuyker Island and the south Bruny Island lighthouse.
A wave rider buoy located at Cape Sorell (off the west coast of
Tasmania) recorded, for the period 13th April until 18th April, an
average swell of 2 metres. This increased to eight metres on the 15th
April and gradually decreased to 2.5 metres on 18th April. The wave
rider buoy measured a maximum wave of 13.8 metres at 4.00pm on 15th
April. The sea conditions at the buoy would not be significantly
different to those at Pedra Branca Island despite being approximately
100 kilometres apart. As such the seas recorded at the buoy would have
travelled past Pedra Branca Island between one to two hours earlier.
The Bureau of Meteorology issued the following forecasts and
warnings during the period of the expedition:
- 14th April, 11.09am: “… possibly 35 knots off shore. Winds
tending westerly tomorrow morning, and then south westerly later
at similar speeds. Seas two (2) to three (3) metres increasing to
three (3) to four (4) metres tonight and west to south west swell
to two (2) metres gradually increasing to three (3) to four (4)
metres tonight and five (5) to seven (7) metres tomorrow.”
- 15th April, 4.22am: “Locally 40 knots over the south west and
swell west and south coasts west to south west three (3) to four
(4) metres building to five (5) to seven (7) metres.”
- 15 April, 11.26am: “Renewal of gale warning for all Tasmanian
coastal waters. West to south westerly winds 25 to 35 knots,
locally 40 knots over the south west. Swells west and south
coasts, west to south west three (3) to four (4) metres building
to five (5) to seven (7) metres today.”
- 15th April 5.00pm: The coastal waters forecast- Tasmanian
boating weather forecast issued at 5.00pm and valid until midnight
Tuesday. IDT 1230012 South West Coast, South East to Low Rocky
Point. A gale warning has been issued. Westerly winds 35 to 45
knots, reaching 55 knots at times, tending south westerly later at
similar speeds. Seas four (4) to five (5) metres. West to south
west swells three (3) to four (4) metres building to five (5) to
seven (7) metres.”
A further boating forecast was issued at 10.50am on 15th April and
valid until midnight Wednesday. IDT 1230012 South West Coast, South
East Cape to Low Rocky Point “a gale warning is current. West to
south westerly winds 25 to 35 knots, possibly 40 knots at first about
Maatsuyker Island, easing to 20 to 30 knots overnight. Winds turning
south to south westerly at 15 to 25 knots tomorrow morning and easing
10 to 20 knots later. Seas three (3) to four (4) metres today. South
West swells three (3) to four (4) metres rising to five (5) to seven
(7) metres tonight.”
I am aware that a preamble disclaimer is associated with weather
forecasts which indicates that winds may be 40% greater than forecast,
and swells may be twice as high as forecast, this disclaimer having
been introduced by the Bureau of Meteorology as an initiative
following the 1998 Sydney to Hobart Race disaster.
I have been supplied data from the National Tidal Facility
Australia in relation to the tides in the Pedra Branca Island area on
15th April. This data indicates that there was little tidal influence
at approximately 4.00pm on 15th April with a low tide of 0.6 metres at
2.27pm and a high tide of 0.8 metres at 10.30pm.
Andrew GREGORY of the Cape Bruny Lighthouse, who has 33 years
experience in conducting weather observations and gauging swells, has
informed me that he did not observe a ‘rogue’ wave on the 15th
April. GREGORY states that the period of time between swells is used
as an indicator as to the weight of a wave and that on this day the
swells were 16 to 18 seconds apart. He has described the swell as
being extremely weighty which is indicative of a wave that contains a
large volume of water and whilst the swell was large it was not
unusual. Significantly he has categorised the rate of the increase of
the swell as being unusual in that it built up faster than usual. He
has confirmed that Bureau of Meteorology forecast in relation to the
wind and swell was consistent with his own observations.
SITUATION ON PEDRA BLANCA ISLAND
The expedition party were delivered to Pedra Branca Island by a
Tasmania Police Marine Division vessel PV Freycinet on 10th April
2003. The seas at this time were calm with a one (1) to two (2) metre swell. Access was on the eastern side of the island. The campsite was
established on the eastern ledge which was 15 metres above the sea
level. This ledge is approximately five (5) metres wide and 40 metres
long. This location, I am informed, is the best camp site in southerly
or westerly weather conditions and it is these conditions which are
predominant. A communications survey of the island was conducted by
TERAUDS and it was ascertained that communications were available from
all parts of the island.
On 11th April, sometime after dark, the wind changed direction and
intensity causing sea spray to be washed into the campsite. On one
occasion a large amount of spray was lifted onto the campsite and
caused a tent pole to break and as a result the campsite was relocated
to an area of the island known as the helipad. The rationale of this
decision was comfort as opposed to safety.
On 12th April the campsite was again relocated to an area known as
the Western cave, this location affording greater shelter from
easterly winds. On 13th April the campsite was returned to the
original eastern ledge location remaining overnight of the 13th and
for the 14th April.
I am informed that PEMBERTON, TERAUDS and WEBB state that they had
little trouble keeping their footing prior to the 15th April. These
members are able to recall that the deceased whilst tentative for the
first day and a half gradually improved his agility to the point that
WEBB felt that the deceased was better on the rocks than himself.
Unfortunately none of the survivors are able to specifically recall
the footwear that the deceased wore other than to describe it as being
of a type of light walking boot. This differs with the account of
Abigail GILBERT who states that the deceased had taken a pair of old
‘running’ shoes. GILBERT states that these shoes had holes in them
and were ‘pretty worn’.
Given the windy, wet and guano covered surfaces that the
expeditioners would be working on I am of the opinion that quality
footwear would be essential. Despite this I am satisfied that the
quality of the deceased’s footwear paid little part in his being
swept from the island.
On the 13th and 14th, the forecast swells of three (3) to four (4)
metres rising to five (5) to seven (7) metres necessitated a
postponement of the proposed departure date of the 13th. I am informed
that a swell greater than two (2) to three (3) metres makes the
extraction of personnel and equipment difficult to effect and as such
it was determined that the risk of injury through a sea or helicopter
extraction was greater than the risk associated with a postponement.
The forecast swells of five (5) to seven (7) metres caused no undue
discomfort or threat to the expedition as evidenced by the manner in
which they went about their tasks. Whilst on the western side of the
island in an area near to the western cave campsite the expeditioners
noticed that the swell size was increasing and a decision was made to
discontinue work on this side of the island and to return to the
eastern ledge campsite.
Once at the campsite the expeditioners discussed the situation in
relation to the swell and whilst this took place some water began to
wash onto the ledge from both the south and north. Collectively it was
decided to climb to higher ground and reassess the situation. At
approximately 3.40pm all members left the eastern ledge with
PEMBERTON, TERAUDS and WEBB carrying backpacks. TERAUDS has informed
me that the deceased did not have a backpack with him because the he
was keen to have his hands free. All four persons were wearing full
yellow plastic waterproof personal protection equipment, however none
of the party was wearing their Stormy Seas PFD1 vests due to a concern
regarding accidental activation by either rain or spray.
TERAUDS climbed to higher ground via the helipad site on the
western side of the island, however, after observing a wave to wash
across this area this route was considered unsafe. The remaining
members climbed to higher ground on the eastern side of the northern
prow of the island. This is a non preferred route as sea birds nest in
this area above the 30 metre mark.
All four (4) persons rejoined each other approximately ten (10)
metres above the helipad before continuing up the northern prow due to
increased wave action. In order to reach the highest point on the
northern end of the island the group traversed the western side of the
Upon reaching a level 45 metres above sea the equipment was stowed
by TERAUDS on the north eastern side of the prow. TERAUDS moved to the
eastern side of the prow, PEMBERTON was positioned with the equipment
whilst WEBB and the deceased were on the western side of the prow. At
this point no waves had reached this level of the island.
TERAUDS, and WEBB relocated to the eastern side of the northern
prow after which a wave hit the island resulting in heavy spray coming
up to and over the 45 metre level. PEMBERTON, TERAUDS and WEBB all
describe being hit with a large volume of water and having to hang on
to the rock surface. At this moment the deceased was on the western
side of the northern prow and would have been exposed to a greater
degree than his companions.
After being stuck by the water WEBB has immediately looked in the
direction in which he had last observed the deceased but was unable to
sight him. WEBB is unable to state if the deceased was swept off on
the western or eastern side of the prow.
I am informed by the three survivors that it is estimated that
prior to this wave no water from a wave had reached this level on the
island since September 2002, the date of an earlier expedition. The
rationale for this conclusion was the nature, size and quality of bird
nests on the island. The impact of the wave that struck the 2003
expedition was such that it seriously disturbed the nests to a degree
that PEMBERTON was showered in the remains of a nest or nests.
With the disappearance of the deceased, the remaining members of
the expedition relocated to a higher elevation and observed that the
waves continued to increase in size. After failing to sight the
deceased a call was made to Constable STANLEY on the Police Vessel
Freycinet for emergency assistance, this officer having been stationed
in the D’entrecasteaux Channel after the aborted extraction of the
SEARCH FOR MISSING PERSON
The first call for emergency assistance was made at 3.46pm on 15th
April. During the intervening period until the arrival of the rescue
helicopter at approximately 4.50pm waves continued to threaten the
three survivors who were 55 metres above sea level.
Constable BIDGOOD, a crew member of the rescue helicopter described
the weather as, “approximately 35 knot winds with frequent higher
gusts and approximately eight (8) metre swells with a two (2) metre sea on top”. On arrival a datum buoy, which can be tracked and
supplies information in relation to water movement and assists in the
determination of search patterns, was deployed and the helicopter
circled the island searching the surrounding sea for the deceased,
however, this was without success.
The focus then shifted to the recovery of the survivors from the
highest part of the northern end of the island. I am informed that
during this process the larger waves hitting the island were causing
spray to go completely over the island.
Following the rescue of the survivors the helicopter conducted a
search north east of Pedra Branca Island, this being the direction of
the wind and waves. Once again, however, there was no sighting of the
Upon receipt of the initial emergency call Constable STANLEY caused
Sergeant STEANE of the Tasmania Police Marine and Rescue Division to
be advised, this officer assuming the duty of Search Controller. A
rescue co-ordination centre was established at the Marine and Rescue
office in North Hobart. Inspectors S. WILLIAMS, Officer in Charge
Police Marine and Rescue and S. SCOTT, Officer in Charge Kingston
Division, which includes the Pedra Branca Island area, were notified
with Inspector SCOTT assuming the duties of Operation Commander.
The Search Controller contacted Coast Radio, Hobart, and a ‘mayday’
call was issued to vessels in the area to assist in the search. The
‘Bluefin’ a training vessel from the Australian Maritime College
answered the call and reached Pedra Branca at approximately 9.00pm
approximately five (5) hours after the last sighting of the deceased.
The skipper of this vessel, Robin WALKER, described the conditions as
swells of eight (8) to ten (10) metres in height with wind gusting at
45 knots with huge seas which banked onto Pedra Branca Island.
The ‘Bluefin’ searched throughout the night without success.
Three other vessels, ‘Kenway Star’, ‘Yootha’ and ‘Booran’
sheltered at Recherche Bay due to the risk attributable to the heavy
Australian Search and Rescue (AusSAR) in Canberra were contacted
and gave advice in relation to search patterns and categorised the
situation of finding the deceased as ‘very, very difficult’. I am
informed that Constable STANLEY measured the water temperature at his
location as being 14.4 degrees Celsius. AusSAR provided an estimate of
survivability of a 27 year old male, weighing 73 kilograms with 17.26%
body fat, exhausted and immersed to the neck wearing a jacket in heavy
seas in 14.4 degrees to have a 75% chance of reaching the maximum
survival time of 3.1 hours (approximately 6.36pm on the day), and an
overall maximum of survival time of five (5) to seven (7) hours
(approximately 8.30pm on the day). This estimate is a best possible
scenario and does not factor in any injuries that may have been
sustained by the deceased. I reiterated that the arrival times for the
rescue helicopter and the vessel ‘bluefin’ were approximately
4.50pm and 9.00pm respectively.
The search continued on 16th April in an area to the north east of
the island this being determined on drift information from the datum
buoy, local knowledge of fishermen and observations as to drift
pattern of dead birds and debris in the water. The rescue helicopter,
fixed wing aircraft and up to six (6) vessels participated in this
search during which the seas were estimated to be four (4) metres
The search included land searches of the shoreline of south Bruny
Island where it was established that debris from Pedra Branca Island
would wash ashore. The only items recovered were water containers
marked ‘NCB’ these being located on the 16th and 17th. On the 17th
the search area was once again covered using the rescue helicopter and
fixed wing aircraft and Police Vessel Freycinet. The Police Vessel ‘Observer’
also participated on the 18th.
The search for the deceased was classified as a Class 2 Operation
as per section 18.104.22.168 of the Tasmania Police Manual. I am informed
that Sergeant STEANE aimed for a coverage factor of 0.5, and in fact
achieved a greater coverage of the search area than that, with a
probability of detection of approximately 80%. This translates into an
80% chance that the deceased would have been located. Of note is the
fact that searchers reported sighting numerous dead birds and the
datum buoy itself on two separate occasions which would confirm that
the search was conducted in the correct area.
I am informed that the expedition on Pedra Branca Island was in
regular contact with Rosemary GALES and Tasmania Police Marine
Division. As an aside, GALES’ concern for the wellbeing of the
expeditioners was not only professional but also personal as she is
married to David PEMBERTON.
The Workplace Health and Safety Act 1995 and the Workplace Health
and Safety Regulations1998 set out the organisational responsibilities
and obligations for occupational health and safety. DPIWE has an
Occupational Health and Safety (OH&S) policy statement which is
dated 15 October 2001.
The NCB has established its own OH&S protocols and has
identified the General Manager as the responsible person and the
Manager NCB as the accountable person. These protocols state the
- Identification of hazardous activities.,
- Evaluation of risks including OH&S audits.,
- Implementation of reasonable and practical control measures to
eliminate or minimise risks. And
- Regular evaluation and review.
An expedition to Pedra Branca Island is identified as a hazardous
activity which attracts the following seven (7) OH&S guidelines:
- Effective means of communication - satellite telephone, EPIRB,
mobile telephone or CDMA telephone where feasible, radio (for
communication with helicopter or Parks and Wildlife Service as
- First Aid - Current certificate, remote area first aid, standard
first aid kit including personal medical supplies where
- Minimum number in party of two.,
- Work program details provided to supervisor and family, inform
Parks and Wildlife Service base if appropriate.,
- Appropriate clothing and equipment including wet weather gear,
sun protection, water and food, maps and compass, protective
glasses (where appropriate).,
- Experience appropriate to the task (eg navigational skills). And
- Callout procedure if overdue.
In planning for this expedition to Pedra Branca Island there was no
formal written process carried out by the principal organisers TERAUDS
and PEMBERTON or DPIWE Managers BRYANT and GALES. The only
documentation that I have viewed are brief diary entries made by
TERAUDS. TERAUDS and PEMBERTON have both indicated that their risk
assessment process is reflected in the equipment that they took to
Pedra Branca Island. As such after conducting a review of the planning
and equipment taken I can confirm that it complies with the OH&S
guidelines that I have previously detailed.
Specifically addressing guideline 6 ‘Experience Appropriate to
the Task’, there is no doubt in my mind that PEMBERTON and TERAUDS
were more than suitably qualified to undertake this expedition. In
relation to the deceased he was not as experienced as these two
members but I note that he had previously worked in Antarctic waters
and the Galapagos Islands.
Addressing guideline 7 ‘Callout Procedure if Overdue’ in light
of the methods of communication which I have previously detailed I am
satisfied that the expedition had sufficient means of communications
with those agencies that could have rendered assistance.
There is a Risk Management Australian New Zealand Standard, number
4360:1999 which describes the risk management process, the development
of risk evaluation criteria and the risk treatment process. Applying
this standard to this expedition there does not appear to have been
any risk assessment considered in relation to extreme weather and sea
conditions. I have drawn the inference that this is due to the
communications that were available to the expeditioners and their
ability to access the Bureau of Meteorology, Marine Police vessels,
DPIWE and the belief of the expeditioners that sufficient warning
would be received of extreme conditions thus enabling the planning of
an appropriate extraction from the island.
Utilising the aforementioned standard the expedition would have
been classified as ‘low risk capable of being managed by routine
procedures’. If a similar classification process was to be carried
out with the benefit of hindsight the following factors would be if
- The expeditioners were moving from a perceived place of safety
on the eastern ledge (exposed to the prevailing swell) to a high
point to assess the swell conditions.
- The surviving members of the expedition did reach high ground
from where they were safely winched aboard the rescue helicopter.
- At the time of the survivors being removed from the island the
swells were at their peak and whilst the swell gradually abated it
was still large the following day.
- In the event that the deceased had not been swept from the
island it is likely that conditions would have been such that a
helicopter extraction would have been likely.
- If the request for a helicopter extraction had been made any
later it would have been dark upon the arrival of the helicopter.
As such it may have not been possible to effect and if possible
the resultant risk of death or injury would have been very real.
I am aware that advice has been sought from the Solicitor General
of Tasmania, Mr W.C.R. BALE QC as to the application of the Workplace
Health and Safety Act 1995 in relation to the events that occurred on
Pedra Branca Island. I am unfortunately informed that the Act is
deficient in regards to its application to the events that occurred in
THE RESCUE OF THE SURVIVORS
Dangerous situations that require the rescue of survivors of
necessity place the rescuers at risk. This was particularly true of
the Tasmania Police personnel in both their sea rescue helicopter who
attended Pedra Branca. Their true professionalism and unwavering
attention to detail in both the rescue of the survivors and the search
for the deceased is very evident.
The crew of the helicopter worked in atrocious conditions. I
particularly wish to mention Constable Damien BIDGOOD who, without
showing concern for his personal safety, was winched onto the rock to
recover the three survivors. During the winching operations there were
waves breaking over the rock. After the three survivors had been
winched to safety Constable BIDGOOD was finally winched back aboard
the helicopter. All the crew of the helicopter deserve a commendation
I also express my gratitude for the excellent work performed by
Constable J. DEVRIES (No 964) in the investigation and presentation of
the file in this matter.
COMMENTS & RECOMMENDATIONS -
Before I conclude this matter, I wish to convey my sincere
condolences to the family of the deceased.
In relation to this incident I make the following recommendations:
- Prior to any future expeditions to Pedra Branca Island, or
similarly exposed island, that strategically placed rock bolts and
rings be fitted in order that they act as anchor points.
- A compulsory formal induction process for all volunteer
expeditioners is to be implemented by DPIWE.
- DPIWE develop appropriate documentation which requires that a
specific process be adhered to in relation to expeditions to
remote/exposed sites. This documentation is to contain the
organisational hierarchy which discloses an identified chain of
command, and identifies those persons responsible for the
management of identified risks.
- The volunteer registration form currently utilised should be
amended in order that it accurately records the degree of relevant
experience and recognised training that volunteers possess.
- The Workplace Health and Safety Act 1995 should be amended to
ensure that it is binding upon all Governmental agencies in all
- In conclusion from the information before me I am satisfied that
there are no suspicious circumstances surrounding this death and
that Hamish Alan SAUNDERS died as a result of an act of nature.
This matter is now concluded
DATED : Friday 5 November 2004 at Hobart in the state of Tasmania
Ian Roger Matterson