Hamish Saunders - Coroners Inquest Findings
The reason that I have this on my website is that I love these remote locations of Tasmania but I am aware that in strong winds these areas can be very dangerous. I want people to be properly informed about the risks & dangers. I hope this doesn't make it worse for the people involved in the incident on 15 April 2003. For more information about Hamish Saunders there is a memorial website.
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 waves.
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 perimeter, 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:
Matthew Houston WEBB
Hamish Alan SAUNDERS (the deceased)
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 this type.
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 unsuitable.
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:
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 prow.
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 13th.
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 deceased.
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 seas.
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 swells.
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 184.108.40.206 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 following procedure:
An expedition to Pedra Branca Island is identified as a hazardous activity which attracts the following seven (7) OH&S guidelines:
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 significance:
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 this case.
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 for bravery.
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:
This matter is now concluded
DATED : Friday 5 November 2004 at Hobart in the state of Tasmania
Ian Roger Matterson