On 2 August 2011, the Queensland Coroner delivered his findings and recommendations following a Coronial Inquest into the tragic death of Saxon Bird at the 2010 Australian Surf Life Saving Championships.
SLSA has accepted the Coroner’s findings and is working diligently and deliberately to action each and every one of these recommendations.
In addition, SLSA is implementing the recommendations made by the Independent Panel’s Inquiry which SLSA commissioned through legal firm, Lander & Rogers Lawyers immediately after Saxon’s death.
Both the Coroner's Report and the Independent Panel Report have been made available below. Regular updates will be posted on each action taken by SLSA to address the recommendations.
We would welcome constructive feedback to ensure we collectively continue our commitment to constantly improve our standards for water and event safety for members, beach goers and the general community. SLSA can be contacted at firstname.lastname@example.org.
Personal Protective Equipment Project
SLSA is currently undertaking a project to identify suitable personal protective equipment (PPE) for surf life saving (SLS) members whilst they undertake SLS activities (across Lifesaving, Sport and Junior Activities).
The PPE project commenced following the tragic death of Saxon Bird at the 2010 Australian Championships in Queensland. The subsequent Coroner’s report (August 2011) recommended that:
“..SLSA collaborate with the designers of such devices (floatation vests) with a view to making the wearing of them compulsory once the organisation is satisfied they are suitable. Consideration should also be given to the use of helmets by competitors in surf craft events”.
The key goal of the project is to help reduce the risk of personal injury or death to a SLS member by providing them with suitable PPE solutions. Please note, that the use of PPE is only one option in the process of risk mitigation and SLSA will continue to employ a range of risk mitigation strategies for all core SLS activities.
SLSA has conducted a risk assessment and injury analysis into core SLS activities and identified a number of PPE that may assist in reducing activity associated risk. At this stage of the project SLSA is evaluating the following PPE for use in aquatic activities:
§ Head protection devices (referred to throughout as a helmet)
NB: (Other PPE may be considered at a later date)
Project Progress to Date:
PPE Project Group actions so far (in brief):
- Development of a comprehensive PPE project plan (with complete goals, objectives, research methodology, timeframes, communications plans etc)
- Risk assessment of aquatic craft activities: assessing injuries in particular activities, likelihood, consequence and risk ratings)
- Comprehensive competition and training injury study with University of NSW (analysing injury data from 2003-2011).
- Literature reviews (journal and university studies) have been undertaken to examine possible case studies, injury and risk management solutions of other ‘like’ aquatic organisations.
- Liaison with Australian Standards and the Committee who oversees the standard for personal floatation devices (PFDs).
- Examination of the Australian Standards for PFDs
- Testing of various PFDs that meet the Australian Standard for freeboard and duck diving ability.
- Examination of the European Standard for white water helmets
- Establishment of a PPE working group that will specifically oversee further product trials and evaluation in line with the requirements of SLS aquatic craft activities
- Teleconference with the PPE Working Group to confirm the group’s terms of reference and set dates for the first face/face meeting (likely to be held in February/March).
This working group is made up of SLS activity experts and product manufacturers/specialists.
- PPE Project Group will continue to conduct high level research whilst the working group will get their hands dirty testing product in the field.
PPE Project Group is in the process of developing a national member survey to gain the following essential data/information:
- Exposure data (how often members are participating in aquatic craft activities). This will help validate our injury likelihood data in the risk assessment.
- Perception data (perception to personal risk in SLS activities and perception about using PPE)
- Further injury data
We are putting this together with university and academic assistance and it should be ready for distribution in February 2013.
The project team has encountered a number of issues when attempting to apply current PPE solutions to SLS’s unique operating requirements and environments. These include:
(a) Not all SLS aquatic activities are the same; each involve different skills and has different risks, operational requirements and environments.
(b) Current PPE solutions available do not always meet the complete set of SLS safety or operational requirements for all SLS aquatic activities; some may increase risk. This may require different PPE solutions for different SLS activities.
(c) SLSA is committed to complying with Australian Standards where possible.
PFDs: Whilst the current Australian Standard for PFDs (AS:4758) can be applied to some SLS aquatic activities, initial testing has shown that it may not be suitable for others.
Helmet: There is currently no Australian Standard for white water sport helmets. Whilst the current European standard for canoeing and white water sports (EN:1385) can be applied to some SLS aquatic activities, the project team is investigating if it meets the SLS safety and operational requirements for other SLS aquatic activities.
The project group is working with Standards Australia to address these challenges. This process is comprehensive and can take time to resolve.
A copy of the Draft Design Criteria Circular can be found here.
Coroner's Report, Findings of Inquest - Prepared by Queensland Coroner Mr Michael Barnes, August 2011
Coulsen Report, 2010 Australian Surf Life Saving Championships Inquiry - Prepared by Coulsen & Reaburn, Nov 2010
SLSA's Responses to Findings & Recommendations
Surf Life Saving Australia has and will continue to work diligently and deliberately through all findings and recommendations. The following is a status report on all actions taken to date, as at Friday, July 20 2012. Further updates will provided on a regular basis.
A detailed report on the actions taken by SLSA in response to the recommendations of the 1996 (Robert Gatenby) Inquiry was included in submissions/evidence provided to the Queensland Coroner during the Saxon Bird Inquest.
There were six specific recommendations from the 1996 Inquiry. These were all actioned at the 1997 Championships. They have been further refined and enhanced each subsequent year. For example:
- Formal daily briefings on conditions, safety, emergency services, first aid introduced.
- Revised event management committee structure introduced, with clearly defined tasks, responsibilities, accountabilities, chain of command.
- Formal debriefings conducted at the conclusion of every Championships.
- Safety and Rescue Guide produced.
- Formalised Contingency Plans produced.
- Evacuation Plan produced.
- Formalised risk management processes implemented.
The 1996 Inquiry also made several other findings and comments which SLSA has responded to in full. For example:
- Separation of Committees responsible for organizing versus delivery.
- Appointment of a dedicated Safety & Emergency Service Coordinator.
- Appointment of a Surf Boat Panel to advise the Boat Section Referee.
- Appointment of Competitor Liaison Officials.
- Improved contingency sites planning (including “all weather” venues).
- Detailed emergency response plans.
- Review of flotation devices carried out – still under review.
- Review of helmets carried out and introduced as optional (but still under review).
- Lycra vests introduced as optional (now mandatory).
- Rule changes introduced. For example, course ‘gates’ and roll-over rule introduced for surf boat events, along with update of coaches’ accreditation course content.
An audit of SLSA’s responses to the 1996 Inquiry was included in terms of reference of the 2010 Independent Inquiry which noted: “a review of that report clearly demonstrates that the present organizational structure and event management systems are the result of that (1996 Inquiry) report.”
As part of SLSA’s “continuous improvement” approach to event safety management and delivery, many other changes have been implemented over the past 15 years.
In relation to safety in particular:
- Sports Manual has been reviewed and updated – four (4) editions since 1996.
- Review and update of venue-specific safety plans carried out annually.
- Safety and Rescue Guide updated annually for in-water and off-water operations. For example, rescue, hazards, evacuations and disaster responses.
- Risk assessment processes and tools enhanced, for example, a risk assessment iPhone application developed to collect and distribute real time information about: Starters/finishers/DNFs; Roll-overs/capsizes/wayward craft; Injuries (first aid); Age of competitors; Type of competition (boats, ski, board, swim etc); Weather - current and predicted temperature, wind speed and wind direction; Surf Conditions – current and predicted swell size, wave type, swell period and tide.
- Extra teams of lifesavers put into each arena to provide extra 'sets of eyes' to assist and advise Area and Sectional Referees.
- Search and Rescue kits developed and introduced.
- Separate First Aid, Powercraft and Emergency Services Referees positions established.
- Deputy Referee made a standalone position to oversee on-beach risk management process.
- Strict gear and equipment scrutineering introduced for all craft.
- Helmets retained as optional but developments are monitored.
- Age restrictions imposed for some craft events, for example, Surf Boats (16 years+) Skis (15 years+)
- Coaching and Officials Accreditation Courses content updated to include risk management, duty of care modules.
- Additional powercraft (introduced from 1997). Clubs are required to provide crewed craft based on numbers of competitors.
- Introduction of jet skis in 2001.
- Introduced compulsory fluoro lycra vests (2011).
- Standard competition times introduced. For example, 8:00am to 4:00pm (2011).
- Team managers and officials briefings made compulsory (2011).
- Daily competitor briefings, prior to competition commencing (2011).
- Standard risk and competition management checklists introduced for each competition area (2011).
- Real time Championship feedback for members introduced via SLS website (2011).
- An independent Risk Auditor audited the Safety, Search and Rescue Guide (2012).
- An audit and assessment of our Risk Management processes at the championships was conducted (2012)
This Inquiry was commissioned by SLSA through the legal firm Lander & Rogers. The Panel’s report was delivered to SLSA in early November 2010. The SLSA Board considered the report on 5 November 2010.
Terms of Reference:
1.1 Lander and Rogers requested the Inquiry to:
(a) Review the planning arrangements for the Australian Surf Life Saving Championships (“the Championships”) including:
(i) Risk management;
(ii) Safety systems;
(iii) Contingency systems;
(iv) Emergency services coordination;
(v) Communications systems;
(vi) Command and control systems;
(vii) Rescue and recovery systems;
(viii) Personnel welfare (including volunteer officials and paid staff as well as competitors and
their support teams);
(b) Review the adequacy and operational effectiveness of the above systems generally and in the context of the incident and the Championships;
(c) Review the culture of the Championships to determine whether there is pressure on competitors to compete regardless of the conditions;
(d) Review relevant event rules for the Championships particularly safety perspective;
(e) Review competitor and other stakeholder (e.g. coaches, team managers) feedback mechanisms and whether and how it should be considered by SLSA;
(f) Review relevant event equipment, particularly from a safety perspective and whether craft and boat competitors should wear safety gear, for example, helmets and PFDs;
(g) Review the circumstances of the specific incident in terms of compliance with relevant systems and processes;
(h) Review; in conjunction with Lander & Rogers, the commercial and financial arrangements for the Championships;
(i) Review the 1996 incident report to assess whether and to what the extent the recommendations from that report have been adopted and implemented by SLSA;
(j) Identify any issues and consider options for improving the effective and safe delivery of the Championships, including improved documentation, systems, communications and reporting arrangements;
(k) Examine the relationships between the various entities within SLSA in respect to the Championships and particularly, but not only, the parties in the chain of command and control; and
(l) Seek submissions from, and consult widely with, relevant, interested parties.
Submissions to this inquiry were broadly sought from, and provided by, SLSA members and other key stakeholders. The Inquiry's report was provided to the Queensland Coroner for the Saxon Bird Inquest.
- The Carnival Committee acted in accordance with policies and procedures in place at the time.
- Unconvinced that any change to any rule would have definitely prevented the collision between Saxon Bird and the surf ski.
- The initial response to the incident was undertaken by individuals using their own initiatives, whether by entering the water or by the immediate deployment of rescue assets… however unclear what coordinated action was immediately taken.
- A review of inflatable lifejackets had indicated that none currently available were identified as suitable for widespread adoption at this stage.
- An audit of SLSA’s responses to the 1996 Inquiry was included in terms of reference of the 2010 Independent Inquiry which noted: “a review of that report clearly demonstrates that the present organizational structure and event management systems are the result of that (1996 Inquiry) report.”
SLSA has initiated actions on each of the seven (7) specific recommendations via specific task groups:
1. That SLSA incorporate into its carnival procedures the positions of Emergency Controllers.
Actions to date:
- Championships Safety and Emergency Services Coordinator role maintained.
- Deputy Safety and Emergency Services Coordinator also appointed in 2011. Three (3) deputy safety and emergency services coordinators appointed as well in 2012.
- Separate (new) dedicated First Aid Coordinator position introduced in 2011 (previously part of the Safety and Emergency Services Coordinator role).
- Safety teams in each arena under leaders – providing 'extra sets of eyes' to monitor competitors and advise Referees, introduced in 2011.
- Risk & Safety Coordinators appointed to each competition area in 2012
2. That the duration of the Championships be extended to provide for more lay days of competition to account for adverse weather.
Actions to date:
- 2011 program extended by 2 days (prior to receipt of this report) to allow welfare breaks and program flexibility if adverse weather/conditions prevail.
- 2012 program slightly modified based on member feedback (survey) and enhanced contingency venues, still incorporating ‘lay’ periods.
3. That SLSA undertake a review of the organisation and conduct of events so as to make any relocation more efficient, simpler, and less time consuming.
Actions to date:
- Further back up venues located and locked in from 2011.
- Relocation plans for all Alternate Venue/s further refined from 2011.
- Provision of pooled equipment at alternative venues considered impractical, given all other actions.
4. That SLSA conduct a review of the performance and capability of the IRB as opposed to the jet ski as the primary rescue asset in big sea conditions.
Actions to date:
- A specialist panel completed the review during 2010-11.
- IRB determined as the preferred craft for all four (4) roles: surveillance, rescue, transport of carnival water equipment and judging.
- Jet skis determined as valuable for surveillance and rescue roles.
5. That SLSA undertake a review of the suitability of radio communication equipment used in the event of an emergency.
Actions to date (updated 1 October, 2011):
- A specialist panel completed the review during 2010-11.
- Designated radio’s were in place for the 2011 Championships that allowed communications with Emergency Services agencies. These agencies included the Queensland Water Police, Westpac Lifesaver Helicopter, Care Flight Helicopter and Queensland Surf Com.
- Similar Operation requirements and procedures will be built into all Championship Operational and Safety plans for other Championship venues other than the Gold Coast.
6. That SLSA undertakes its own evaluation trials as to the effectiveness of high visibility lycra vests in conditions which are difficult or when visibility otherwise is impaired by weather or environmental conditions.
Actions to date:
- Introduced fluoro lycras (prior to receipt of report) for 2011 Championships.
- A survey was conducted at 2011 Championships to gauge feedback on lycras – fluoro lycras to remain.
- SLSA Sport Standing Committee made fluoro lycras mandatory for the Australian Surf Life Saving Championships at its November 2011 meeting.
7. That SLSA conduct its own review as to the future direction of the Championships.
Actions to date:
- Terms of Reference for this “top to bottom” review drafted for SLSA to sign off.
- Australian Sports Commission approached, and agreed to assist.
- A Steering Committee has been confirmed by the SLSA Board and has met on several occasions to date.
- The “top to bottom” review is progressing and consultation with key stakeholders including members, SLS officers and committees, supporters and Government has commenced. A draft report is anticipated in August/September of 2012.
SLSA has acknowledged and accepted the Coroner’s report and findings, including:
- The Coroner noting the risk context of surf life saving competitions.
- That SLSA ought to take a more conservative approach to risk management in heavy surf conditions in the future. That is, SLSA should be more willing to suspend or postpone competition events in conditions heavy enough to cause difficulties or danger.
- The Coroner identifying a number of SLSA’s processes, including decision making at the 2010 Championships, which can be strengthened. For example, the pace of decision making, formally securing and considering feedback and communications from/to internal and external parties.
- The Coroner acknowedging the valuable steps taken by SLSA after the 2010 Championships to improve gaps in processes and decision making since the 2010 Championships.
- That SLSA must ensure there are processes in place to “put more eyes on events”, and to ensure reports of any concerns are escalated in a more timely manner.
- The Coroner acknowledging the valuable social service that SLS provides on Australian beaches and the value of competition in incentivising participation by young people.
The Coroner did not:
- Suggest that key systems and officials were unfit, incapable or negligent in roles.
- Make any findings which might give rise to any criminal referral.
- Recommend disbandment or other form of review of SLSA.
- Find that commercial interests had anything to do with events continuing at Kurrawa.
Before setting out his recommendations, the Coroner noted the proactive steps taken by SLSA since the 2010 Championships - (Refer to previous “Additional Refinements from Annual Review Process” and “2010 Independent Panel’s Inquiry” reports).
Coroner's Recommendation 1: “Make safety paramount”: The Coroner recommended that SLSA review the safety section in the Surf Sports Manual with a view to ensuring event organisers are directed to focus on safety in a way that does not invite them to seek to balance competing views as to whether competition should continue.
Action to date:
- SLSA updated the Surf Sports Manual (to the 34th edition) with the Coroner's recommendation in January 2012.
- Section 1, Page 1, Subsection 1.1 states the following:
The provision of a safe environment at all SLSA competitions is paramount.
Prior to the commencement of any competition the Referee must be satisfied that all competition and non-competition arrangements provide the necessary safety for competitors, officials and other personnel involved at the competition. The Referee must also be satisfied that the surf conditions are satisfactory for competition to proceed. Tests may be undertaken to assist in these assessment processes. An Event Safety Guide Sheet/Tool/Application and Referee Pre-Competition Checklist may be used to assist in the assessment processes (refer Appendices A and B for samples or contact SLSA).
Should, at any stage prior to or during competition, there is a credible basis for concluding there is an unreasonable risk of serious injury occurring, officials shall suspend all or parts of the competition. The Competition Committee (refer Section 12), shall then decide whether to postpone, cancel or relocate all or parts of the competition.
Lifesavers compete in SLSA competitions to demonstrate their physical and mental skills. Competition officials and competition organisers conduct competitions to support and encourage competing lifesavers to demonstrate their lifesaving skills and organisational efficiency, whilst patrolling lifesavers and beach support personnel, actively display their prowess as the lifesaving authority in that competition.
At all competitions, the organising group conducting the competition shall provide sufficient and properly equipped and qualified water safety personnel (at each venue) as required by the appropriate life saving authority. The provision of rescue craft and communications is essential at all competitions.
If an emergency arises during a competition, correct control and discipline shall be maintained under the direction of the Referee or Safety and Emergency Coordinator.
During an emergency, any member of SLSA entering the water or handling any rescue gear must only do so at the direction of the Referee or Safety and Emergency Services Coordinator and/or the Area Risk and Response Officer and/or under the direction of the Police or emergency authority.
All members not engaged in actual rescue work should assist in maintaining a clear area so that any rescue attempt can be carried out efficiently.
The above directions are mandatory and essential to the safe and orderly conduct of surf lifesaving competitions.
- This statement is reinforced at all training and briefings of event organisers, referees and officials.
Coroner's Recommendation 2: “Continuing review of safety devices ”: The Coroner acknowledged that it is impossible to eliminate the risk to a competitor in a surf ski or board event being struck, and recommended that SLSA collaborate with designers of such devices with a view to making the wearing of them compulsory once the organisation is satisfied they are suitable. Consideration should also be given to the use of helmets by competitors in surf craft events.
Actions to date:
- A cross SLSA Business Unit working party was formed in October 2011 to continue to investigate Floatation Devices, Tracking devices, Helmets and Fluoro vests, in addition to the research already undertaken. The main focus is how to include the Sport, Lifesaving and Nippers and the practical implications of any “across the board” implementations.
SLSA has received 17 samples of floatation devices from 10 interested manufacturers. These Prototype Device Samples and Conceptual Ideas are still in design stage.
SLSA has specifically received;
15 Floatation Device prototypes
2 Self Inflation Device concepts
SLSA has provided guidance and support to manufacturers in designing and re-designing their products.
After a comprehensive review of the Australian Standard AS: 4758 for PFDs, it has been agreed that any PFD that is endorsed by SLSA must meet all the requirements as detailed in Parts 1,2 and 3 of the standard.
Additionally the SLSA working party has recommended that the standard also include a requirement for the device to have the ability to allow a wearer to submerge to a minimum depth of 2 metres to avoid rogue craft and/or wave action. A draft design criteria document for floatation vests was completed in July 2012 for review by manufacturers and Australian Standards. It is available to view here.
SLSA continues to work with Manufacturers, Standards Australia (PFDs) and the SLSA membership in developing and designing suitable Floatation Devices. In the mean time, consideration of the implementation plan for making floatation vests compulsory has commenced.
Helmets continue to remain optional as per Section 2, General Competitive Conditions:
(d) The wearing of helmets is optional in surf boat, IRB, craft and board riding events. If helmets are worn they may replace the competition cap. All helmets used are to be in club colours and design. The wearing of helmets must conform to SLSA rules regarding the wearing of caps.
SLSA has previously endorsed the Gath Rescue “Gedi” Helmet, for Rescue Operations. As there are no Australian Standards for Marine Helmets, SLSA has adopted the universally recognised European, Irish Standard I.S. EN 1385; 2012, for Canoeing and White Water Sports.
These Helmets can be used in Competition, but it’s specific design is for use in Search and Rescue Operations.
A draft design citeria position statement has been completed by the Working Party. It is available to view here.
SLSA will continue to conduct testing in accordance with the I.S. EN 1385; 2012 standard to deem the suitability of head protection devices for Surf Sports competition.
SLSA has received 3 proto types for tracking devices from interested parties. These are still in conceptual design and development stages.
Coroners Recommendation 3: Emergency Response/ “QPS SARMC”: The Coroner acknowledged that the concerns relating to the decision not to utilise swimmers to search for Saxon is not easily addressed, and the search was carried out in accordance with procedures. He recommended that the QPS contingent at large surf life saving events includes at least one officer with advanced marine search and rescue training that will equip the officer to plan and coordinate the emergency response should a competitor go missing in the water.
Actions to date:
- QPS actioned this recommendation, to the knowledge of SLSA.
Coroner's Recommendation 4. “Surf patrols for marine MPs” (Missing Persons): The Coroner noted that planning and procedures for swimmer based searches might be problematic, however should be undertaken and included in suite of emergency/rescue response options. He recommended that SLSA investigate whether surf patrols could coordinate a search by swimmers for a person missing in the sea as an alternative to a search by power craft in appropriate cases.
Actions to date:
- At the 2012 Australian Surf Life Saving Championships, SLSA had further developed a specific protocol for the Aussies, which was published 7th March 2012 and which was put into operation as soon as Matthew Barclay was reported missing.
The specialised squad was in the water within 2 minutes. It was a squad dedicated to performing a search for a missing person. The primary rescue function remained with the water- borne and beach – based personnel in each competition area
- Initial briefings held with key State personnel about changes to event safety and emergency planning, risk assessment tools and processes etc. for application for major state based events.
- OH&S risk management training has occurred with key officials and SLSA staff.
- SLSA contracted an external risk management expert to conduct an audit of SLSA's procedures and systems, focussing on sport event risk management documentation, processes and procedures. This included an on-site audit at the 2012 Australian Surf Life Saving Championships.