CORONERS ACT, 2003

SOUTH AUSTRALIA

FINDING OF INQUEST

An Inquest taken on behalf of our Sovereign Lady the Queen at

Kangaroo Island and Adelaide in the State of South Australia, on the 5th

, 18th

and 19th

days of

July 2006, and the 10th

day of August day of 2006, by the Coroner’s Court of the said State,

constituted of Mark Frederick Johns, State Coroner, into the deaths of Dougal Smart and

Daniel O'Donnell.

The said Court finds that Dougal Smart aged 32 years, late of

148 Tryst Park, Edinrugh, Scotland died at Remarkable Rocks, Flinders Chase Flinders

Chase National Park, Kangaroo Island, South Australia on the 9th

day of November 2003 as

a result of salt water drowning.

The said Court finds that Daniel O'Donnell aged 38 years, late of

Gosse Ritchie Road, via Parndarna, Kangaroo Island died at Remarkable Rocks, Flinders

Chase National Park, Kangaroo Island, South Australia on the 9th

day of November 2003 as

a result of salt water drowning.

The said Court finds that the circumstances of their deaths were as

follows:

1. Introduction

1.1. On 9 November 2003 a tragic incident occurred in the vicinity of Remarkable Rocks,

Kangaroo Island, in the State of South Australia. Dougal Smart, then aged 32 years,

of Edinburgh in Scotland, and Daniel O’Donnell, then aged 38 years, of Kangaroo

Island, South Australia, died after being washed into the water while attempting to

rescue another man, Mr Tobias Bruns, who had previously been swept into the water.

2

Both Mr O’Donnell and Mr Smart were drowned in their attempt to rescue Mr Bruns.

Ironically, Mr Bruns survived the episode.

1.2. Post mortem examinations for Dougal Smart and Daniel O’Donnell were performed

by Dr John Gilbert of the Forensic Science Centre on 11 November 2003. In the case

of Dougal Smart, the cause of death was found to be salt water drowning. Dr Gilbert

reported that there were numerous multidirectional brush abrasions over Mr Smart’s

face, chest, upper arms, hands, back, left forearm, knees and shins. Dr Gilbert

expressed the opinion that these abrasions would have resulted from wave action

brushing the deceased’s body against rocks, although some may have occurred during

his initial fall into the water.

1.3. Dr Gilbert found that the cause of death of Mr Daniel O’Donnell was salt water

drowning. He reported linear abrasions over his face, and circular abrasions over his

knees, shins and his left shoulder. Again, these abrasions were reported to be

consistent with Mr O’Donnell’s body being washed against rocks. The abrasions on

the undersides of the tips of his fingers were consistent with him attempting to gain a

purchase on a rough rocky surface. The post mortem report for Dougal Smart was

admitted as Exhibit C19 in these proceedings, and the post mortem report for Daniel

O’Donnell was admitted as Exhibit C20.

1.4. The Inquest heard evidence from the investigating police officer, Senior Constable

Sean Harrison, Mr Dale Smithyman, who was a Ranger at Flinders Chase National

Park at the relevant time, from Mr Michael Grimes, a deckhand on the cray fishing

boat “Rosandra” who was involved in the recovery of the bodies of Mr Smart and

Mr O’Donnell from the water, from Dr John Gilbert, the forensic pathologist who

conducted examinations of the deceased, from Ms Annette Kappler, a Health and

Safety Inspector with SafeWork SA and from Mr Mark Herrmann, who was and is the

Conservator of Kangaroo Island, and is an officer of the National Parks and Wildlife

Service with responsibility for Flinders Chase National Park. In addition, a number of

exhibits were tendered, including statements made by a number of eyewitnesses to the

events of 9 November 2003 at Remarkable Rocks. Unfortunately, none of these

witnesses could conveniently be called at the Inquest because they were visitors from

overseas who were holidaying in South Australia at the relevant time. They were

members of a tour group which included Dougal Smart and Tobias Bruns, and was

3

led by the tourism operator, Mr Daniel O’Donnell, who was operating a business by

the name of “Daniel’s Tours”.

1.5. The events, told from the perspective of members of the tour group, may be gleaned

from Exhibits C5a, C6a, C7a, C8a, C11a, C12a, C13a and C14a. Exhibit C9a is a

statement of Tobias Bruns which I will deal with separately.

1.6. As I have already stated, Dougal Smart and Tobias Bruns were amongst a group of

tourists who arrived on Kangaroo Island in the days preceding 9 November 2003 for

the purpose of attending a tour group being conducted by Daniel’s Tours which was

run by Daniel O’Donnell. 9 November 2003 was a Sunday. Most of the members of

the tour group arrived on Kangaroo Island on the preceding Friday. The members of

the tour group then congregated at accommodation provided by Daniel’s Tours at a

farming property close to Kingscote. On the Saturday, members of the tour group

stayed on Daniel’s farm and visits were made to various locations on Kangaroo

Island. Early on the morning of Sunday 9 November 2003 the group arranged to visit

Flinders Chase National Park. The party left Daniel’s farm at approximately 7:45am

that morning in a bus driven by Daniel O’Donnell. The group arrived at Remarkable

Rocks between 8:15 and 8:30am that morning. A number of members of the tour

group recalled that in the trip to the rocks Daniel O’Donnell used the public address

system on the bus to talk to them about the rocks. He advised that they were

dangerous and very slippery and very steep. The witnesses Jody Morris1, Rebecca

Tea2, Alisdair Clark

3, Annika Born

4, Andreas Burkart

5, Isabelle Bogaers

6, all gave an

account of Daniel O’Donnell having briefed them carefully about the dangers of the

rocks, the strong winds, and one person had a recollection of him having informed the

group that people had previously been swept from the rocks into the water by large

waves. The only member of the group who specifically stated that he was not given

any special instructions about what to do at the rocks was Tobias Bruns. Mr Bruns

stated that he was not warned by anyone not to go down to the waters edge. He also

stated that there were no signs or warnings advising not to approach the waters edge.

As will appear in due course, there were a number of warning signs in place in

1 Exhibit C14a

2 Exhibit C13a

3 Exhibit C11a

4 Exhibit C8a

5 Exhibit C7a

6 Exhibit C6a

4

9 November 2003. A number of the other eyewitnesses gave accounts in which they

clearly recalled the presence of such signs. Mr Bruns’ account is at odds with that of

all other members of the group.

1.7. Perhaps the best account of the events leading to Mr Bruns falling into the water, and

the fateful rescue attempt, is the account of Alisdair Clark contained in Exhibit C11a.

Mr Clark stated that sometime after the arrival at the rocks he saw Tobias Bruns

walking towards the bottom of the rocks. Mr Clark said that he called out to

Mr Bruns to be careful, and that Mr Bruns yelled back that he would be “okay”.

Shortly after this, Mr Clark said he heard someone yelling out for help from the

waters edge and turned around. He could then see Mr Bruns in the water just out

from the rocks and he immediately raised the alarm with Daniel O’Donnell. Daniel

O’Donnell, Dougal Smart and Mr Clark and another member of the group called Jody

ran towards the waters edge to get a better look. Daniel O’Donnell and Dougal Smart

grabbed a life buoy attached to a sign and went to the rocks at the waters edge.

Daniel O’Donnell then threw the life buoy into the water towards Mr Bruns but it was

washed away from Mr Bruns. Mr Clark stated that “a huge wave came up and swept

Daniel and Dougal from the rock they were on sweeping them into the water.” The

witness Jody Morris7 described this as follows:

‘All of a sudden a wave come out of nowhere and took Daniel and Dougal off the rocks

and into the sea. The water was very spasmodic and wasn’t very calm, every now and

then it would get a bit rough for about 5 minutes.’

1.8. Rebecca Tea, a witness from England, whose statement is Exhibit C13a said that,

having seen the people washed into the water she went back to Daniel’s vehicle to see

if they could drive it back to get help. There was no radio in the vehicle and their

mobile telephones did not have reception. She was unable to find the keys at first but

after some ten or fifteen minutes she located the keys. She went back to the rocks and

she and Mr Burkart8 then drove Daniel’s vehicle back towards the direction of the

Rocky River Visitor Centre at Flinders Chase National Park. On their way, they met

another tour bus, being driven by Mr Jason Lauridsen of Wayward Tours who was

then able to raise the alarm using his mobile telephone which apparently had

reception. It may be that Jason’s mobile telephone was a CDMA mobile, as other

evidence before the Inquest indicated that some CDMA telephones would have

7 Exhibit C14a

8 Exhibit C7a

5

reception on the rocks and in the vicinity of the rocks, although normal mobile

telephones did not.

2. Mr Dale Smithyman

2.1. At this point it is convenient to continue the narrative from the perspective of Mr Dale

Smithyman who gave evidence at the Inquest. I have already stated that

Mr Smithyman was a Ranger at the Flinders Chase National Park in November 2003.

Through him, the National Parks and Wildlife Service communications log of the

day’s events was tendered9. Mr Smithyman stated that he was on patrol that day and

his duties included general enforcement of the National Parks and Wildlife Act in the

Flinders Chase National Park. He was the only Ranger in charge of the entire western

end of Kangaroo Island on that day. When he arrived at the Flinders Chase Visitor

Centre at Rocky River, it was just after 9:00am. Another staff member, Ann Warner,

informed him that a report had come in that people were in the water at Remarkable

Rocks. The communications log10

shows that this report came in from Mr Lauridsen

at 9:10am. The log show that at 9:12am, Mr Smithyman reported the situation to

Anthony Maguire, the Senior Ranger and Duty Officer at Penneshaw that day. The

report was to the effect that persons were in the water at Remarkable Rocks, that

Mr Smithyman was going to investigate and that he would also activate emergency

services. The communications log then shows a 000 call by Anthony Maguire at

9:15am, and a further 000 call seeking ambulance assistance at 9:20am.

2.2. Mr Smithyman said that before leaving the office at Rocky River he gathered together

some basic medical emergency equipment, including oxygen, an ambulance kit,

radios, spare batteries and a mobile telephone, and departed Rocky River for

Remarkable Rocks.

2.3. On arrival at the Remarkable Rocks, Mr Smithyman was met by Jason Lauridsen, the

operator of Wayward Tours and they ran together down the boardwalk leading to the

rock and proceeded to the top of the dome of the rock where a group of people had

gathered together. They pointed out to Mr Smithyman the location of Mr O’Donnell

and Mr Smart and Mr Bruns in the water.

9 Exhibit C16a

10 Exhibit C16a

6

2.4. Mr Smithyman observed that there was one person face down in the water

approximately 100 metres due south from Remarkable Rocks. Some distance away,

south west of the rock, and approximately 150 metres from shore, there were two

people together one of whom appeared to be supporting the other. Shortly afterwards,

the two people in the water separated from one another and one of them moved

towards the shore and was able to climb out onto the rocks. The other person

remained face down in the water. The person who managed to escape from the water

was Mr Bruns.

2.5. At about this time Mr Smithyman noted the presence of three cray fishing boats some

distance offshore and he requested that the Regional Duty Officer try to contact these

boats to obtain assistance from them. According to the log11

at 10:06am

Mr Smithyman was reporting to the office at Flinders Chase the fact that the cray

fishing boats were turning towards Remarkable Rocks. As the boats neared

Remarkable Rocks, Mr Smithyman was able to make contact with them directly via

the incident control centre at Penneshaw. Apparently Mr Maguire who was at

Penneshaw relayed Mr Smithyman’s signal to the cray boats. The boats came in quite

rapidly and pulled up short of the rocks. One of the cray boats lowered a zodiac and

the crew of the zodiac recovered the bodies and returned them to one of the cray

boats. That boat then departed. Mr Smithyman subsequently learnt that it went to

Vivonne Bay where the deceased were handed over for transport to the hospital at

Kingscote.

2.6. Mr Smithyman gave evidence that Mr Bruns had made it out of the water but was still

in the wash zone. He asked Jason Lauridsen to go down and assist Mr Bruns up to the

dry rocks in case he collapsed and fell back into the water. Mr Bruns was encouraged

to climb up to a flatter rock which was out of the wash zone and he remained there

until he was airlifted out. Shortly after this, a volunteer ambulance crew arrived from

the nearest location namely Gosse. Volunteer ambulance officers Buck and Anderson

were the attending officers and were in fact the first emergency services to arrive.

This was some 45 minutes after Mr Smithyman’s arrival at the rocks. He stated in

evidence that there is “quite a response time” for emergency services to attend

locations at that end of the island because of its remoteness.

11

Exhibit C16a

7

2.7. Shortly after the arrival of the ambulance officers Senior Constable Harrison arrived

at the scene. Mr Smithyman then briefed Senior Constable Harrison on what had

transpired and what was happening at the time. Mr Smithyman then handed over

control of the scene to Senior Constable Harrison who spent a considerable amount of

time reporting to police communications in relation to necessary matters. Shortly

afterwards, Ms Reeves from the Ambulance Service arrived – she is the most senior

person in the South Australia Ambulance Service on Kangaroo Island. A short time

after her arrival the State Emergency Services personnel arrived. The Gosse

ambulance crew had by this stage made it down to the rock on which Mr Bruns was

perched and the State Emergency Services volunteers joined them shortly after their

arrival. Two media helicopters then arrived and then shortly afterwards, the State

Rescue helicopter attended.

2.8. Mr Smithyman stated that on Senior Constable Harrison’s arrival, the latter became

the senior rescue person at the scene, and accordingly Mr Smithyman handed over

control of the scene to him.

2.9. Mr Smithyman said that the rescue helicopter lowered an operator from a winch.

Mr Bruns was strapped into a stretcher and winched up. The helicopter arrived at

approximately 1:00pm. He had first requested its presence at 9:30am.

2.10. Shortly after the departure of the ambulance the National Parks and Wildlife Service

arranged food and drink for everyone on the site to be made available at the car park

at Remarkable Rocks. The remaining members of the tour group were then taken

back to Rocky River where a debriefing was held. Those present at the debriefing

included Mr Smithyman, Mr Maguire, the ambulance officers, Ms Reeves and other

staff of the National Parks and Wildlife Service. Interestingly, Senior Constable

Harrison was not made aware of the debriefing but Mr Smithyman explained that he

understood that Senior Constable Harrison had been required to attend at Vivonne

Bay to assist in recovery of the deceased. The debriefing consisted of a very general

discussion resulting in an agreement to discuss the matter later.

2.11. Mr Smithyman stated that there was a further debriefing on 11 November 2003 which

he described as a good debriefing. Minutes of it were produced and admitted as

Exhibit C16c. Mr Smithyman stated that the general consensus of those present was

that the National Parks and Wildlife Service had responded adequately given its

8

capacity and those present did not think that anything had been done badly. There

was discussion about radio communications and signage and logistical difficulties in

contacting staff on a Sunday. The notion of distress flares and emergency beacons for

raising the alarm earlier was also discussed.

2.12. Mr Smithyman said that since the incident signage has been upgraded at Remarkable

Rocks. He stated that his position on top of the rocks gave him mobile telephone

coverage via his CDMA telephone for most of the time of the incident. He stayed at

the top of the rock in order to maintain communication as the incident controller. He

stated that if he had left the top of the rock no one would have been effectively

controlling the incident.

2.13. Mr Smithyman was asked whether he considered the use of a second life buoy which

was present on the eastern side of Remarkable Rocks. He stated that he did not

because he deemed it unsafe. He stated that he would not have launched the life buoy

himself and would not have asked anyone else to do it. He stated that the area at the

bottom of the rocks is extremely dangerous and he never considered this as an option.

He stated that the nearest landline telephone was situated at Cape du Couedic which is

7 kilometres away and after that at Flinders Chase Visitors Centre which is 20

kilometres away. He noted that flares may have been useful if they had been situated

and accessible on the rock on the day because of the fact that the cray boats were in

the vicinity of the rocks. On the other hand he noted that there were public safety

issues in having flares publicly available.

3. Senior Constable Sean Harrison

3.1. Senior Constable Sean Harrison gave evidence at the Inquest. His account of events

corresponded closely with that of Mr Smithyman. He stated that he commenced duty

at 8:30am on 9 November 2003. He received the tasking to Remarkable Rocks while

he was at Cygnet River which is 10 kilometres south of Kingscote and approximately

120 kilometres from Remarkable Rocks. A call came to him via police

communications that there was an incident at Remarkable Rocks with people in the

water. This message came at 9:42am via police radio. Senior Constable Harrison

stated that normally the trip would take 1½ hours from where he was to Remarkable

Rocks but with lights and sirens he made the journey in just over one hour. He stated

that the communications centre asked him to give a situation report when he arrived

9

“in case” they needed the Rescue One helicopter. Communications centre had put

Rescue One helicopter on standby. Senior Constable Harrison stated that when he

arrived two people had already been taken away by boat and one had been rescued

from the water.

3.2. Senior Constable Harrison said that he arrived at Remarkable Rocks at 10:57am and

went immediately onto the rock. He was told that the cray boat was heading towards

Vivonne Bay with two bodies onboard. He said ambulance officers were with a

person off to one side of the rock who he later understood to be Mr Bruns. Once he

arrived at Remarkable Rocks he sent a situation report and requested that Rescue One

be sent to recover Mr Bruns as he did not think it would be possible to get him up

from where he was by the rocks. He said that Rescue One attended in due course and

transported Mr Bruns to the Flinders Medical Centre where he was treated.

3.3. Senior Constable Harrison said that Mr Smithyman was at the rocks when he arrived

and that Mr Smithyman was of great assistance to him.

3.4. Senior Constable Harrison spoke to a number of the people in the Daniel’s tour group.

Effectively, he commenced the investigation at that point. He later returned to the site

and took photographs which formed part of Exhibit C10. Senior Constable Harrison

expressed the opinion that Tobias Bruns, in order to reach the point where he was

swept into the sea, would have to have walked past signs which were placed in the

western gully of Remarkable Rocks. The first of those signs that he would have

encountered is, or was as at 9 November 2003, a wooden sign with the word “danger”

cut into the wood. A photograph of the sign forms part of Exhibit C10c. The sign

was quite clear and obvious. The next warning that would have seen by Mr Bruns as

he made his way down to the base of the rock was a white sign supported by two

posts. The sign had a pictogram depicting two persons walking with a red cross

through them and the words in English “Do not go beyond this point”. Significantly,

an orange life buoy was attached to the rear of the sign. This was the life buoy which

was ultimately thrown towards Mr Bruns by his would-be rescuers Messrs Smart and

O’Donnell. The significance of a life buoy attached to a sign which bears the words

“Do not go beyond this point” is so plain that it need hardly be elaborated upon.

Nevertheless, Mr Bruns would have gone past this sign as he made his way to the

base of the rocks.

10

4. Mr Tobias Bruns

4.1. As I have already stated, Mr Tobias Bruns was a German tourist who was a member

of Mr O’Donnell’s tour group on 9 November 2003. Mr Bruns was then 22 years of

age. He was interviewed by Senior Constable Calahan soon after 9 November 2003.

Senior Constable Cahalan reduced her notes of the interview to a statement which was

unfortunately not signed by Mr Bruns. The copy of the statement which was tendered

as Exhibit C9a in these proceedings bears a facsimile transmission header from

“Traffic Div Sturt” bearing the time and date 9 November 2003 2019 hours. From

this I infer that Senior Constable Calahan interviewed Mr Bruns on 9 November 2003.

4.2. Senior Constable Calahan records that Mr Bruns studied English for eight years and

spoke near fluent English. He had been employed as at 9 November 2003 for two

weeks as a storeman with a business known as “Mr Bankrupt” on the corner of

Marion and Richmond Roads at Richmond. The statement does not indicate one way

or another whether Mr Bruns could read English. However, it is difficult to believe

that someone who studied English for eight years and speaks it almost fluently would

be unable to read it. I therefore think that Mr Bruns must have been able to read the

signs. However, he told Senior Constable Calahan that there were no fences that

stopped him going down to the waters edge nor signs or warnings. He stated he was

not warned by anyone not to go down to the waters edge. This account stands in stark

contrast with the account of almost every other witness about the warnings that were

given by Daniel O’Donnell. It is also inherently unlikely that Mr Bruns would not

have seen the signs.

4.3. It is necessary to say something about the geographical nature of the location.

Remarkable Rocks is an extremely large solid rock which stands as a prominence on

the southern coastline of Kangaroo Island. It is surrounded by low scrubby bush to

the west, east and northern sides. It is approached from a car park north of the rock.

The car park has an information bay containing warning signs. The approach from

the information bay is through thick scrub by means of a wooden boardwalk. There

was at the time a warning sign as one walked along the boardwalk. On arrival at the

rock one is confronted with a truly remarkable geographical feature.

4.4. According to the Flinders Chase National Park, Kelly Hill Conservation Park, Ravine

des Casoars Wilderness Protection Area and Cape Bouguer Wilderness Protection

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Area Management Plans12

, at page 30, Remarkable Rocks is a site which has been

listed in the fifth volume of “Geological Monuments in South Australia” (Geological

Society of Australia SA Division 1984). The visitor to the rock is confronted first by

a large upward sloping sweep of rock which appears to be in the shape of a very large

dome. The rock would be approximately 100 metres from side to side across this

dome. On top of the dome there are bizarrely shaped individual rock formations

which seem to have been placed haphazardly. As one proceeds to the southern-most

part of the dome overlooking the ocean, one finds that the rock is even larger than

first impressions might suggest. The rock continues for some considerable distance

descending steeply down towards the ocean. On the eastern and western sides of the

rock there are gully formations where the rock meets the surrounding scrubland. It

was the western-most of these two gullies down which Mr Bruns descended in order

to reach the rocks from which he was swept into the ocean. The same route was taken

by Messrs Smart and O’Donnell in their hapless bid to rescue him. It would be very

difficult for a person descending to the rocks near the ocean by means of this gully to

fail to observe the signs which have been referred to earlier in these findings.

4.5. For the sake of completeness, the gully on the eastern side of the rock also provides a

logical pathway to the ocean on that side of the rock. There is a life buoy placed in

that gully also. Evidence at the Inquest showed that the placement of the life buoys,

each of which is on a sign marked “Do no go beyond this point” was determined as

the point beyond which it was unsafe to venture further, and the logical place to put

life buoys for that reason.

5. Mr Michael Grimes

5.1. Mr Michael Grimes gave evidence at the Inquest. He also provided a statement to

Sergeant Pain which was admitted as Exhibit C17 in these proceedings. Mr Grimes

was a deckhand on the cray boat “Rosandra” on 9 November 2003. He has been a

fisherman working on Kangaroo Island for the last 23 years. He stated that he was

aboard the Rosandra when it attended at Remarkable Rocks on 9 November 2003 in

response to a radio message that there were people in the water. He said that on

receiving the message the Rosandra was approximately 3 miles from Remarkable

Rocks. The Rosandra stopped 200 to 250 metres short of the rocks because the

conditions were too rough to approach any closer. He said that they arrived at 12

Exhibit C22p

12

approximately 9:30am or thereabouts. He said that the wind was blowing from the

south-east at approximately 15-20 knots, conditions which he regarded as

unfavourable for fishing, and that the Rosandra was about the leave the area

immediately before the radio message because of the adverse conditions.

5.2. Mr Grimes said that two other boats, Moonshadow and Jodie KD II were also in

attendance having responded to the message at the same time as the Rosandra.

Mr Grimes stated that he and the skipper of the Rosandra launched the rubber zodiac

inflatable that was kept aboard Rosandra. Mr Grimes alone boarded the inflatable and

navigated it to Jodie KD II and picked up a crew member from that vessel. He then

moved towards one of the bodies which was floating face down and retrieved it onto

the zodiac. Mr Grimes checked for a pulse and did not detect any. He stated that the

deceased was bruised and battered. The zodiac was then directed to the second body

and the procedure was repeated. Again a pulse check was made, and none was found.

The second deceased was bruised and battered also. Mr Grimes said that the zodiac

then proceeded to the Moonshadow which had a gateway at the stern which made

transferring the bodies of the deceased more straight forward than on either of the

other two vessels. Mr Grimes then returned to the Rosandra and had no further

involvement in this matter.

5.3. Mr Grimes stated that it took 25 to 30 minuets for the Rosandra to cover the three

nautical miles to reach the Remarkable Rocks. His view was that any rescue vessel

would need to be in a very close vicinity, perhaps no more than one nautical mile,

from Remarkable Rocks to be able to effect a rescue quickly enough to prevent a

person from drowning.

6. Ms Annette Kappler – SafeWork SA

6.1. Ms Annette Kappler gave evidence at the Inquest. She is a Health and Safety

Inspector at SafeWork SA, the government department with responsibility for

administering the Occupational Health, Safety and Welfare Act 1986. She conducted

an investigation into the incident at Remarkable Rocks the subject of this Inquest and

an investigation summary prepared by her was tendered and admitted as Exhibit C21

in these proceedings.

6.2. The purpose of the investigation was to determine whether there had been any breach

of the Occupational Health, Safety and Welfare Act. She stated that her

13

recommendation was that no action should be taken against any person under that Act

for any of the events which took place on 9 November 2003. Ms Kappler stated that a

report was made to the Director of SafeWork SA by her which noted that the

Department for Environment and Heritage which is responsible for management of

the Flinders Chase National Park, had conducted an investigation which in itself had

made a range of recommendations including that signs at Remarkable Rocks be

updated and replaced; that provision be made for the more dangerous parts of the rock

to be proclaimed as a “prohibited area” under applicable legislation; that safety

obligations be made and explicit licence conditions imposed for commercial tour

operators; that there be revegetation of paths in high risk areas; and that marine band

radio be installed to provide direct contact with boats. Ms Kappler recommended that

no further action be taken by WorkSafe SA apart from monitoring the implementation

of the Department for Environment and Heritage’s proposed recommendations.

6.3. Ms Kappler stated that as part of that monitoring role, a Principal Inspector with

SafeWork SA, Mr Carl Asker attended at Remarkable Rocks on 1 December 2004 to

check the standard of signage installed in and around the rocks warning the public of

potential dangers. Mr Asker was satisfied with the installation of signage which had

been effected some time prior to December 2004.

6.4. Ms Kappler very helpfully provided a bundle of photographs of a further visit she

made to Remarkable Rocks on 3 July 2006. That bundle of photographs, some 44 in

number, was tendered and admitted in these proceedings as Exhibit C21d. They

provide a comprehensive overview of the signage at the rocks as at July 2006. I am

grateful to Ms Kappler for her assistance in this matter and I consider that SafeWork

SA has discharged its responsibility adequately in relation to this matter.

7. Mr Mark Herrmann

7.1. The final witness in this Inquest was Mr Mark Herrmann who is the Conservator of

Kangaroo Island and is employed by the Department for Environment and Heritage.

Previously he worked in Queensland for the Parks and Wildlife Service in that State,

having responsibility for the entire northern half of Queensland in that capacity. As at

November 2003 he had been in this State for a few weeks only and was the most

senior Department for Environment and Heritage officer on Kangaroo Island. He was

advised on 9 November 2003 of the incident at Remarkable Rocks that day by the

14

Regional Duty Officer, Mr Maguire. He prepared a report following the incident

entitled “Remarkable Rocks Incident: A Review of Current Management” dated

5 December 200313

. This report provided a summary of the incident on 9 November

2003, and a reference to previous incidents at the rock which included the following:

• February 1995 – An Austrian backpacker slipped off rocks at the waters edge at

Remarkable Rocks and was retrieved from the water after 2½ hours by staff of the

Department for Environment and Heritage.

7.2. Mr Herrmann became aware of anecdotes concerning an incident in which three

people lost their lives in 1976. The report described the current situation at

Remarkable Rocks, the fact that a risk audit had been conducted by the South

Australian Government Captive Insurance Corporation (SAICORP) in 1999 and a

description of the signage at the rocks as at November 2003. The report also provided

an assessment from the Department’s point of view of the response to the incident of

9 November 2003 and future management options. Finally the report contained

certain recommendations. The report included an appendix setting out ten possible

management options some of which were recommended and some of which were not.

8. Signage as at November 2003

8.1. I have already provided some indication of signage as it stood in November 2003. A

summary of the signage as it stood at that time may be obtained from Exhibit C10.

The first signs a visitor would see at that time were set in the shelter of a small

structure near the car park at the entrance to the boardwalk which affords access to the

rock itself. The structure had three signs at that time, two of which remain unchanged

today. Those two signs are educational in nature and provide an explanation of the

geography, geology and wildlife of the vicinity. The third sign was in the nature of a

warning about the dangers of the rock. It was a photograph of the rock taken from the

seaward side bearing the following writing:

‘It won’t happen to me!’

Early danger warning signs at Remarkable Rocks were extremely explicit. In modern time

they have become more subtle, relying on visitors to heed the caution.

However, in the mid-nineties an over adventurous visitor chose to ignore the warning

signs and ventured down the steep dome face. An unexpected wave wet the rock he was

sitting on. When he attempted to retreat, he slipped and fell into an unrelenting rough sea.

The man spent two hours in the water. By the time he was rescued he was lapsing in and

out of consciousness.

13

Exhibit C22

15

This visitor was extremely lucky.

Due to the steepness and the slimy marine growth (seen as a darker patch in the

photograph) it is impossible to get out of the sea here.

Please heed the warning signs.’14

8.2. The next warning sign was a wooden sign halfway along the boardwalk bearing the

words “CAUTION. Strong Winds / Slippery Rocks”15

.

8.3. At the top of the rocks there was a sign on the seaward edge stating “Do not go

beyond this point”. In the western gully were the two signs which have already been

described, one bearing the word “Danger”, and the other bearing the words “Do not

go beyond this point”; the latter having the life buoy attached to it. An identical sign

with life buoy attached was also placed in the eastern gully which has been described

already.

8.4. It is pertinent to note that the two signs just described in the western gully are some

distance from the waters edge as are the corresponding signs in the eastern gully.

9. Signage as at July 2006

9.1. The Court visited Remarkable Rocks in July 2006 for the purpose of taking a view.

The warning signs as they stand in 2006 are as follows: The small structure near the

car park still contains three signs, two of which are unchanged since November 2003,

namely the educational signs. The warning sign under the shelter has now been

changed to read as follows:

‘It won’t happen to me!’

It could happen to your or your rescuers!

Drownings have occurred at Remarkable Rocks… the most recent in November 2003.

A visitor chose to ignore warning signs and ventured to the water’s edge. He was washed

into the sea. Two men from the visiting party tried urgently to rescue him.

An unexpected large wave knocked them off their feet, and they were swept into the sea.

The visitor was rescued after being washed back onto the rocks.

He was seriously injured.

Tragically both rescuers died as a result of drowning and the injuries they sustained from

falling.

Please heed the warning signs.’16

14

Exhibit C21 15

Exhibit C21 16

Exhibit C21d

16

The text appears on the same photograph as the corresponding text in the previous

sign described above.

9.2. Additionally, new signs have been placed in the men’s and women’s toilets which

adjoin the small shelter. The signs in the toilets are as follows:

‘Drownings

… have occurred at Remarkable Rocks.

Please – be aware of the Prohibited Area.

Unexpected large waves wet the algae growth on the rocks making them very slippery.

Extremely strong winds can make walking around the steep granite dome treacherous.

Children must be supervised.’17

These words are printed on a background photograph showing white capped waves

crashing against the base of the rock.

9.3. The sign halfway along the boardwalk has been upgraded and now bears the words

“CAUTION. Strong Winds / Slippery Rocks”. Further along the boardwalk is a new

sign which contains a photograph of the base of the rock with white capped waves

crashing against it, and an aerial overview photograph of the rock which is inset in the

first mentioned photograph. The aerial overview contains a red line drawn across the

top of the dome of the rock and parallel with the coastline either side of the rock. The

text on this sign is as follows:

‘YOU could endanger a life…

Remarkable Rocks can be a very dangerous place.

17

Exhibit C21d

17

Be aware the granite dome dips steeply into the sea.

Unexpected large waves wet the algae growth on the rocks making them very slippery.

Extremely strong winds can make walking around the steep granite dome treacherous.

Children must be supervised.

Do not enter the Prohibited Area.

The Prohibited Area has been delineated by DANGER/NO ACCESS signs. Section 42.3

of the National Parks and Wildlife Act 1972 states: “A person must not be within a

prohibited area unless authorised to enter the area by a permit issued by the Minister

under this section”.

Penalties apply.’18

9.4. At the end of the boardwalk, and immediately at the base of the rock is a further

warning sign which is also new. It has a red danger sign on top, followed by small

diagrams corresponding to each of the following items “strong winds”, “steep slippery

rocks”, “unexpected large waves” and “supervise children”. Each of the diagrams

contains stick figures in situations which are internationally recognised as providing

warnings against each of the contingencies referred to in the text.

9.5. The western gully, which previously had the two signs which have already been

referred to, now has a further sign which has been placed beyond the sign with the life

buoy attached to it. This sign reads as follows:

‘DANGER

NO ACCESS

Unexpected Large Waves

Slippery Rocks’19

18

Exhibit C21d

18

9.6. The word “Danger” is white against a red background, and each of the following three

messages is accompanied by an internationally recognised diagram. Corresponding

signage has been placed on the eastern side of the rock also.

9.7. Finally, the signage on the dome of the rock has also changed. The sign which

formerly read “Do not go beyond this point” and which was a single sign on the dome

of the rock has been replaced by five smaller signs which are spaced strategically

along the line of the prohibited area which has been referred to already. These signs

are smaller, being approximately 100 centimetres by 100 centimetres in size. They

bear the words “DANGER NO ACCESS”20

with a diagram of a person set within a

red circle with a red line drawn through the middle of the circle and the person. This

is an internationally recognised diagram to prohibit access.

9.8. On the eastern-most and western-most points on the rock at which the prohibited area

line meets the rock, are larger signs bearing the words:

‘DANGER

NO ACCESS

Unexpected Large Waves

Slippery Rocks’

With accompanying diagrams as previously described.

19

Exhibit C22a 20

Exhibit C22a

19

10. Department for Environment & Heritage response to Mr Herrmann’s report of

5 December 2003

10.1. As I have already noted, the report of 5 December 200321

contained an appendix

listing ten possible management options for Remarkable Rocks. These options were

as follows:

1. Signs upgrade

2. Prohibited area

3. Commercial tour operator management

4. On ground works

5. Closure of rocks

6. Barrier fencing

7. On-site staff

8. Access by guided tour

9. Emergency beacon/alarm

10. Marine band radio

10.2. The first option of a signage upgrade was implemented. The prohibited area option

was also implemented as was the recommendation in relation to commercial tour

operators. The options of on ground works which were essentially revegetation, were

not implemented. Nor were any of recommendations 5-9, namely closure of rocks,

barrier fencing, on-site staff, or access by guided tour or emergency beacon/alarm.

The closure of the rocks was not implemented as it would deny access to the site by

the 115,000 odd tourists a year who visit it. Barrier fencing was thought to be too

intrusive on a site which is as already noted a “geological monument”. On-site staff

was regarded as too expensive and of limited effect bearing in mind that it would not

be possible to prevent visitors from accessing the rock outside of staffing hours. The

same applied to the guided tour option. The option of emergency beacon/alarm was

regarded as too susceptible of vandalism. The option of marine band radio was listed

for further evaluation.

10.3. By letter dated 16 August 200422

all commercial tour operators with access to the site

(each of whom holds a licence to permit such access) was advised of the changes in

signage and the prohibited area at the rocks. They were reminded that the conditions

of their licence for access to the site required them to abide by the new prohibited area

restrictions.

21

Exhibit C22 22

Exhibit C22a

20

11. Memorial plaque

11.1. In addition to the alterations to the signs already referred to, a memorial plaque was

placed in the sheltered area underneath the structure containing the three signs which

have previously been referred to. This plaque was erected at the request of

Mr O’Donnell’s family. The plaque reads as follows:

‘In memory of Daniel O’Donnell and Dougal Smart who displayed admirable courage

and bravery in their attempt to rescue a German tourist at this spot on November 9, 2003.

This plaque is a symbol of admiration and gratitude for their unselfish actions which

ultimately led to their death.’23

11.2. This plaque obviously serves as a fitting memorial to the lives of Daniel O’Donnell

and Dougal Smart. In addition, Mr Herrmann gave evidence that it adds a sense of

realism to the warning signs which the visitor encounters both in that shelter, and in

the areas already referred to.

12. Survey of visitor behaviour

12.1. Mr Herrmann stated that a survey of visitor behaviour at the rocks was commissioned

by the Department for Environment and Heritage in January 2005. It was carried out

between January and March 2005, and a copy of the report was received and admitted

as Exhibit C22i in these proceedings. The report was written by Mr Bok-mun Ho and

the survey recorded the behaviour of some 1800 visitors observed visiting the rocks

during the survey period.

12.2. For the purposes of the survey the rock was divided into three zones. Zone 1 was the

relatively flat area on the dome of the rock. Zone 3 was the area defined by the

prohibited area. Zone 2 was an area between Zone 1 and Zone 3. The purpose of the

designation was thought to be that Zone 1 was the area which most visitors would

enter and remain in. Zone 2 was an area which might be ventured into by the more

adventurous visitors. Zone 3 was the prohibited area. The survey noted that of the

1,800 visitors who were counted, 90% remained in Zone 1, 9% ventured into Zone 2

and 1% ventured into Zone 3. The percentage who ventured into Zone 3 may have

been misreported by the consultant because, according to Mr Herrmann, the

consultant misinterpreted the boundary for Zone 3 and the prohibited area in that he

thought that the prohibited area was closer to the dome of the rock than it actually is.

23

Exhibit C22d

21

The effect of this would be to reduce the number of visitors who ventured into Zone 3

even further.

12.3. Mr Herrmann said, and I agree, that the survey demonstrated that the site was being

used as intended.

13. Commercial tour operators

13.1. The commercial licence which applied to Daniel’s Tours as at 9 November 2003 was

tendered and admitted as Exhibit C22j in these proceedings. I note that clause 4.4 of

the commercial licence which was issued pursuant to the National Parks and Wildlife

Act, 1972 and the Crown Land Act,1929 provides:

‘The Licensee shall, to the extent reasonably required by the Minister, caution all persons

involved in any activity connected with this licence (including the Permitted Activities)

about the hazards likely to be encountered in the Licensed Area or in connection with the

use of the Licensed Area.’24

No evidence was adduced at the Inquest in relation to what, if any, requirements may

have been made by the Minister pursuant to clause 4.4 of the then commercial licence.

13.2. Mr Herrmann stated that revised terms and conditions were issued for commercial

tour operators with effect from March 2005. Clause 10.6 of those terms and

conditions specifically deals with Remarkable Rocks and provides as follows:

‘In this Licensed Area the Licensee shall ensure that its drivers and guides:

• Brief their clients on the specific safety risks at the site prior to accessing it;

• Accompany their clients at all times while they are at the site;

• Do not allow their clients to enter the Restricted Access Area.’25

13.3. The new terms and conditions are clearly an improvement on the old terms and

conditions in imposing specific obligations to take safety precautions in and around

Remarkable Rocks.

14. Other measures taken by Department for Environment and Heritage

14.1. Mr Herrmann gave evidence that the Department for Environment and Heritage

regularly convenes meetings of commercial tour operators to which all commercial

tour operators are invited. The meetings provide a forum for the discussion of matters

of common interest. The minutes of the Kangaroo Island Commercial Operators

24

Exhibit C22j 25

Exhibit C22k

22

Liaison Group, as this forum is known, for 15 June 2004 were tendered and became

Exhibit C22l in these proceedings. The minutes record that on that date the meeting

of the group was informed that there had been a review of the Remarkable Rocks site

from a risk perspective and that there would be a new sign package, a restricted

access/prohibited area, updated information signs and a new sign that outlines specific

days and prohibited areas.

14.2. Mr Herrmann made reference to a regular publication by the Department for

Environment and Heritage called “Inside Parks South Australia”. This document is

apparently distributed to commercial tourism operators in South Australia. One such

document was tendered and admitted as Exhibit C22m in these proceedings and is the

issue of “Inside Parks” for Summer 2006. It contains an article relating to the

amended licence conditions for Remarkable Rocks and refers to the fatalities which

were the subject of this Inquest, the survey which has already been referred to and the

amended licence conditions.

14.3. Mr Herrmann also gave evidence that brochures are widely available to visitors to the

Flinders Chase National Park. The brochures are available at the visitors centre and

are also widely distributed to commercial tour operators. The brochures are available

in English and have also been translated into German, French, Spanish, Japanese and

Italian. The brochures contain the following message in addition to other

information:

‘Remarkable Rocks can be a very dangerous place:

• The granite dome dips steeply into the sea.

• Unexpected large waves wet the algae growth on the rocks making them very

slippery.

• Strong winds can make walking on the steep granite dome treacherous.

• Children must be supervised.

Drownings have occurred at Remarkable Rocks: please obey the warning signs.’26

14.4. Mr Herrmann said that staff are trained to identify the needs of people who do not

have English as a first language.

26

Exhibit C22n

23

15. The prohibited area

15.1. I have already adverted to the Department’s decision to prohibit access to those parts

of the rock which are deemed to be too dangerous for members of the public to have

access to. The prohibited area is depicted on the site by means of the aerial

photograph sign which has already been referred to, and the five smaller signs which

are placed along strategic lines of sight on the boundary of the prohibited area itself

around the dome of the rock on the seaward side. Mr Herrmann gave evidence as at

July 2006, about the prohibited area, which according to the photographic depiction of

it and the accompanying text is supposed to be an area from which access is

prohibited by virtue of section 42(3) of the National Parks and Wildlife Act, 1972.

Section 42(1) of the Act provides as follows:

‘Where the Minister is satisfied that it is expedient for the purpose of protecting human

life or conserving native plants or animals the Minister may, by notice published in the

Gazette, declare any portion of the reserve to be a prohibited area.’

Any such notice must, according to subsection (2), state the grounds upon which the

declaration is made.

15.2. Mr Herrmann stated27

that as at the time of him giving evidence, the prohibited area

had not been declared in accordance with section 42(1) of the Act. He stated that the

area has been physically delineated on the rock by means of the warning signs, and

“we are utilising another section of the Act to provide the authority if the prosecution

is used”. The section which the Department is relying on for that purpose is a

provision of the regulations which provides that disobedience of signs is an offence.

It was suggested by Counsel for the Department for Environment and Heritage that

part of the reason for the delay in bringing into effect the prohibited area is that a

survey would be required. The response from Mr Herrmann seemed to be rather

equivocal, but I suspect that this is the likely reason for the delay in the legal creation

of the prohibited area as required by section 42 of the Act. It is unfortunate that the

Department has not put the declaration in place. It seems that the signs were in place

some time ago; I consider that the declaration should have been placed in the Gazette

as required by section 42(1) much sooner than this. However, I note that the

Department has made considerable efforts to upgrade the signage and safety of the

27

T137

24

area and it is a pity that it should let itself down by failing to deal with an important

procedural matter such as the declaration itself.

15.3. Reliance on the other provision referred to in the regulations may well be sufficient,

and the very delineation of the prohibited area as depicted on the relevant signage is

itself an important safety measure. However, although the safety message has been

achieved, it is unfortunate that the accompanying legal requirement has not been

attended to. I hope that it will be followed through in the very near future.

16. Marine radio at Flinders Chase Visitor Centre

Mr Herrmann explained that the option of a marine radio at the Flinders Chase Visitor

Centre has not been implemented to date. Negotiations have taken place between the

Department for Environment and Heritage and the Volunteer Coastguard for

installation of repeater stations in order to make such an installation at Flinders Chase

Visitor Centre effective. At present, the repeater stations have not been constructed,

and there would therefore be no point in installing a marine radio facility at Flinders

Chase Visitor Centre. In any event, the evidence in the Inquest shows that a marine

radio facility would be of limited usefulness; it was really fortuitous that the cray

boats happened to be in the vicinity at the relevant time. In order to have saved

Messrs Smart and O’Donnell, the boats would have had to have been virtually on the

spot at the time they fell into the water. In those circumstances, a marine radio

facility would hardly have been necessary. If the boats were as far away as two or

three nautical miles, the likelihood is that they would not be able to reach the scene in

time to effect a rescue in any event. I do not consider that the Department should be

criticised for failing to complete this proposal at the moment. However, I do not

doubt that it would be desirable from many points of view for a marine radio facility

to be installed at Flinders Chase Visitor Centre. Not the least of these would be the

measure of safety that might be accorded to mariners themselves who sail in the

waters south of Kangaroo Island. I would therefore encourage the Department and

the Volunteer Coastguard organizations to continue to pursue this option.

17. Life buoys

17.1. A letter to the Court from Mr O’Donnell’s partner, Naomi O’Donnell, was admitted

in evidence in the Inquest as Exhibit C18. In that letter, Ms O’Donnell said that the

National Parks and Wildlife Service are accountable for the deaths of Daniel

25

O’Donnell and Dougal Smart by virtue of maintaining life buoys at Remarkable

Rocks. She argued that the presence of such life buoys would create a danger for

would-be rescuers such as Mr O’Donnell and Mr Smart who, if the life buoy had not

been there, would not have been induced to descend to the base of the rocks for the

purpose of launching the life buoy.

17.2. This matter was the subject of considerable examination in the Inquest. Mr Herrmann

maintained in evidence that it would be possible to launch the life buoy from a

reasonable distance from the waters edge, thus maintaining the safety of the rescuer.

On the other hand, it will be remembered that Mr Smithyman quite vehemently stated

that he would not have attempted to effect a rescue by means of the second life buoy

which was still present in the eastern gully on the morning of 9 November 2003. He

regarded it as unsafe to do so, and stated that he would not expect anybody else to do

so.

17.3. Mr Herrmann was asked whether it would have been appropriate for the life buoys to

be displayed in a more prominent location so that it could be deployed by persons

who may not necessarily be aware that it was available otherwise. He displayed some

reluctance in relation to such a notion, taking the view that if it were in a more

prominent position it would be likely to be vandalised. However, at T172 he also said

that unless a person is experienced and knows how to launch a life buoy they

probably should not be doing it. At T173 he stated “it’s not something we

encourage”. He stated that the location of the buoys are a long way from the top of

the dome and are generally not visible. And at T175 he agreed to the proposition that

far from advertising the fact that the life buoys are there, the Department is concealing

them. In the end, he came back to the justification of protecting the life buoys from

vandalism.

17.4. In my view the Department has a dilemma in this respect. It is true that the presence

of life buoys may induce would-be rescuers to place themselves in peril in attempting

to effect a rescue. On the other hand, I would be most reluctant to suggest that the life

buoys be removed; in fact I do not think they should be removed. At the end of the

day, I consider that the Department has done its best to strike a balance between the

various factors that operate here; there is the risk of vandalism if the life buoys are

maintained in a visible location (in this respect Mr Herrmann said that at one point the

life buoys had been maintained in the public car park area and were the subject of

26

constant vandalism – hence their removal to a more obscure location), there is the risk

of would-be rescuers who are not competent to do so placing their own lives in danger

and finally there is the possibility that the life buoy, if deployed competently by a

person able to do so, may one day save a life. In my opinion, the Department has

adopted a course which is perfectly justifiable.

17.5. It might be said that there are a number of exposed, windy, steep and isolated sections

of the South Australian coastline which, if not as spectacular as Remarkable Rocks,

are nevertheless very beautiful, and undoubtedly are attractive to members of the

public who might wish to visit them. The Department, and other agencies responsible

for such areas of coastline, have not taken the step of placing life buoys in all such

locations. I surmise that life buoys were first placed at Remarkable Rocks in response

to some early fatality there. Presumably, the reasoning at the time would have been

that it was reasonable to place life buoys at Remarkable Rocks and not at other

dangerous locations on the ground that no fatalities had occurred at those other

dangerous locations. Whatever the reason, the life buoys are there now, and in my

view the Department is adopting a reasonable position in leaving them in their present

locations.

17.6. While I have the deepest sympathy for Ms O’Donnell’s point of view, I do not accept

that the Department should be criticised for making life buoys available in this

location.

18. Conclusion

18.1. Remarkable Rocks is a spectacularly beautiful geographical monument in a

spectacularly beautiful national park. It is a wild and remote place, unspoilt by

development. It is a unique coastal landmark. It is a drawcard for most of the

115,000 visitors per annum who visit the location.

18.2. As I have already stated, the Court took a view of Remarkable Rocks. I walked

around the rocks, and walked as far as the point at which the sign bearing the life

buoy was located. In my view, the nature of the terrain itself would serve as sufficient

warning to most visitors not to go beyond a safe point. The warning signs even as

they were in 2003 would have served to reinforce this message. Mr Bruns must have

walked past the “danger” sign and the “do not go beyond this point” sign bearing the

life buoy in order to place himself in the dangerous location he did. His actions were

27

foolish in the extreme, and no sensible measure could have saved him from his own

folly.

18.3. Tragically, Messrs Smart and O’Donnell responded to that instinct that is inherent in

what Counsel referred to as “the human condition” namely, the instinct to rescue

another human being in mortal danger. In doing so they imperilled their own lives,

and made the ultimate sacrifice. Ironically, it was Mr Bruns who by some fluke of

chance was washed towards shore by a favourable wave, and managed to scramble to

safety. His brave and selfless rescuers were either already dead, or would soon

succumb, even as he reached the safety of the shore.

18.4. I believe that the Department for Environment and Heritage and its officers responded

appropriately to this incident. I consider that the emergency services, represented by

Senior Constable Harrison, the volunteer ambulance officers, and the State

Emergency Service all responded appropriately also. I note that there was some delay

in the arrival of the Rescue One helicopter, however, that delay could not have altered

the outcome in any way. It merely meant that there was some delay in Mr Bruns’

ultimate retrieval to the Flinders Medical Centre but no harm came to him as a result.

I consider that the signage and other measures taken by the National Parks and

Wildlife Service as at 9 November 2003 was adequate and appropriate. The

Department had responded to the incident in 1995 and had used that incident as a

vehicle for driving home the safety message in its signage. The Department has

responded to the November 2003 incident in an extremely thorough manner; by

upgrading the safety signs, by incorporating in the messages the short summary of the

tragic incident of 9 November 2003, by displaying the memorial plaque, by increasing

the number of signs in different locations, and by the physical delineation of the

prohibited area. The Department has taken further measures also which have been

outlined above including, but not limited to, amending the terms and conditions of

access by commercial tour operators, conducting visitor behaviour surveys and so on.

In my opinion, the Department has responded to this incident in a highly responsible

manner and I commend it. I consider that the response of the SafeWork SA to the

incident was appropriate and adequate. In particular, I commend Ms Kappler for her

thorough preparation for the Inquest and her assistance to the Court. Finally, I

commend Senior Constable Harrison for his very helpful assistance in this matter, and

28

for the very good work he did in trying circumstances on 9 November 2003.

Mr Smithyman should also be commended for similar reasons.

19. Recommendations

19.1. I do not regard it as necessary or appropriate to make any recommendations in this

matter.

Key Words: Drowning; Foreign tourists; National Park; Safety measures.

In witness whereof the said Coroner has hereunto set and subscribed his hand and

Seal the 10th day of August, 2006.

State Coroner

Inquest Number 21/2006 (3260/03 & 3261/03)