Coroner Report-Overland Track

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Coroner Report-Overland Track

Postby Rick » Sat 06 May, 2017 11:52 am

Interesting read.

Record of Investigation into Death (Without Inquest)
Coroners Act 1995 Coroners Rules 2006 Rule 11
I, Olivia McTaggart, Coroner, having investigated the death of Kang Jin
Find, pursuant to Section 28(1) of the Coroners Act 1995, that:
a) The identity of the deceased is Kang Jin;
b) Kang Jin died after suffering exposure whilst walking on the Overland Track at Cradle Mountain in the circumstances set out further in this finding;
c) Kang Jin’s cause of death was hypothermia;
d) Kang Jin died on 20 February 2014 on the Overland Track at Cradle Mountain in Tasmania; and
e) Kang Jin was born in Gansu, China on 21 October 1992, and was aged 21 years.
In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Kang Jin’s death. The evidence comprises an opinion of the forensic pathologist who conducted the autopsy, police and witness affidavits, medical records and reports, forensic evidence and documentary material.
I make the following further findings as to how death occurred.
Between 19 and 20 February 2014 Kang Jin, a Chinese National aged 21 years, died whilst walking on the Overland Track at Cradle Mountain with two friends, also Chinese Nationals. These were Bojie Yang, a female aged 24 years, and Lianguan Yu, a male aged 21 years. All three were studying at Deakin University in Victoria.
In February 2014 Bojie Yang and her housemate, Lianguan Yu, decided to walk the full length of the Overland Track at Cradle Mountain. They invited Kang Jin. As described further, their preparation was inadequate for the walk.
The group travelled to Tasmania on the Spirit of Tasmania on Wednesday 19 February 2014 and arrived in Devonport on Thursday 20 February 2014. The group then caught a bus directly to Cradle Mountain and arrived at approximately 11.30am on that day.
The Overland Track is a 65 kilometre walk through the Cradle Mountain-Lake St Clair National Park, part of the Tasmanian wilderness World Heritage Area. The walk has a national and international reputation as one of the great wilderness walks. It is physically challenging and walkers may face rapidly changing weather conditions.
On 20 February 2014, the weather conditions were very poor. It was cold, rainy and windy. The wind was increasing in strength, and was expected to further increase as the day went on. The weather was colder than normal for the month of February, and the conditions were challenging for walkers. At 11.45am the group approached the counter at the Visitor Centre and spoke to Mr Gregory Wall, the supervisor. Mr Wall noticed that the group were carrying 30 litre packs contrary to the common practice to carry a 60 litre pack when walking the Overland Track. The group were wearing light clothing and were asked by Mr Wall if they had a change of clothing, including waterproof pants. The group were informed the weather was going to get colder, and they nodded their heads that they understood.
In his affidavit for the coronial investigation, Mr Wall stated that communication between the group and staff at the Visitor Centre was difficult. He stated that he used the physical movement of wrapping his arms around himself to describe "cold" as he spoke to the group. He was not sure if they understood what he was intending to convey.
Mr Wall asked the group if they had tents, to which Bojie Yang replied that she had a tent for three people. The group was asked if they had sleeping bags and if they were prepared for cold weather. Bojie Yang replied "yes" and Kang Jin and Lianguan Yu nodded their heads. Mr Wall was concerned that the group were not properly prepared and asked the same questions three times. He spent approximately 30 minutes with them before passing them over to Gail Oliver, a customer service officer at the Visitor Centre.
Gail Oliver stated in her affidavit that she spoke to the group and noticed that one of the males had a small pack. She became concerned that the group may not have enough food for a six day walk. Bojie Yang told Ms Oliver that they had enough food for five days as they intended to do the walk in that time frame. Ms Oliver reiterated to the group that they would need extremely good raincoats and wet weather gear, that there were very high winds, and that they would need to keep dry. The group nodded in agreement. The group made payment for three national park passes ($30 each) and three Overland Track passes ($200 each).
The group was observed by Ms Oliver and two other persons repacking their bags with bag liners. They observed that one of the two males was attempting to put his backpack into the bag liner, rather than place it inside the backpack. The group were again asked if they had warmer clothing, to which they stated that they did. They were told to make sure that they were wearing it before they started their walk.
The conditions when the group started the walk were reported as “extreme” by other walkers and the staff at the Visitor Centre. In her affidavit Bojie Yang described the weather as "not really cold but it was raining a little". Mr Steven Day, who was also travelling on the Overland Track at the same time, stated that there were gusts up to 100k/h that on occasions blew him sideways off the track. The wind-chill factor caused a sub-zero temperature effect, with rain and occasional sleet. The weather deteriorated over the course of the afternoon.
The group began walking at about 1.00pm on 20 February 2014 planning to travel 10 kilometres each day and stay in the huts. The group walked for approximately half an hour and then had a 10 minute rest. They then continued on for approximately 15 minutes and noticed that the wind was getting stronger. Bojie Yang stated that she then began to feel cold and her trousers were wet. Lianguan Yu began to feel cramps in his leg. After a small rest they continued on until they arrived at Kitchen Hut. Kitchen Hut is a fully enclosed weatherproof structure, designated as an emergency shelter, which will protect occupants from wind, rain and snow. It can comfortably accommodate six persons.
Even after experiencing the extremely difficult conditions about which they were warned, they did not stop at Kitchen Hut but elected to continue walking. Both males in the group experienced cramps in their legs. At one point Kang Jin fell over on rocks.
When the track changed from rocks to wood (believed to be at the Barn Bluff track turn off), Bojie Yang noticed that there was “something wrong” with Kang Jin as he could not speak in sentences. Approximately 10 minutes later Kang Jin asked if they could hold each other as they walked. At this stage the group were feeling very tired. Bojie Yang noticed cramps in her own legs and fell in some water.
Kang Jin then began to "walk like a drunk person". Bojie Yang and Lianguan Yu sat him down behind some bushes. Bojie Yang told Lianguan Yu to wait with Kang Jin whilst she went to get help. She ran to Waterfall Valley Hut to raise the alarm. She stated that she believed it took her 15 to 20 minutes to reach that destination. She arrived at Waterfall Valley Hut at approximately 7.00pm and called for help regarding Kang Jin.
At the time Bojie Yang arrived, the hut was full, with approximately 26 people inside. Bojie Yang was described by another walker in the hut as being dressed in flimsy cotton pants and shirt with no wet weather gear.
At the hut, a call was made for volunteers to assist to recover Kang Jin. Most likely due to the extreme weather conditions there were only three volunteers, being Michael Page, Douglas Reed and Steven Day. A rescue party was formed with these volunteers and two rangers, Colin Rowe and Paul Challenge. It is appropriate to provide some detail about the members of the rescue party, in light of their courageous efforts that followed.
Steven Day is a Leading Senior Constable in the New South Wales Police Force who at the time of this incident had been a part of the New South Wales Police Rescue Squad for 17 years. He is also qualified as a Land Search and Rescue Co-ordinator. In this capacity he has co-ordinated and taken part in many land search and rescue operations. He is trained in advanced first aid and resuscitation. On previous occasions he has performed CPR in remote locations for extended periods of time. Mr Day and his walking companion, Douglas Reed, began walking the Overland Track from the Dove Lake Car park on 19 February 2014.
Douglas Reed is a longstanding, active Life Member of Winmalee Rural Fire Service in the Blue Mountains. Until recently, he had been part of the Blue Mountains Remote Area Fire Team, trained in remote terrain fire fighting, navigation, helicopter deployment and other associated skills. Among other activities with the service he had participated in excess of 12 search and rescue operations and several search and recovery operations. He holds advanced first aid qualifications. He has treated burns, dehydration, hyperthermia and hypothermia, fractures and respiratory conditions. He is an experienced bush walker in New South Wales, New Zealand and Tasmania. This trip was his third time on the Overland Track.
Michael Page was a New South Wales resident walking with his partner. He volunteered to assist when it was assessed that additional people may be needed.
All members of the rescue party demonstrated bravery and skill in the face of extreme conditions. Their efforts were made at significant personal risk and likely saved the life of Lianguan Yu.
As the rescue party made it to the top of the valley it was estimated that the wind strength was 80 - 90km/h, with gusts of over 100km/h. The rescue party had a difficult time walking on the duck boards and were blown off whilst making their way to Kang Jin. There were small icy particles in the rain that made the walk to locate him extremely cold and difficult for the rescue party.
The rescue party located Kang Jin and Lianguan Yu on top of an exposed ridge just past the track junction to Barnes Bluff. Kang Jin was located on the eastern side of the trail behind a small bush set two meters back from the trail. Lianguan Yu had set up two umbrellas in an attempt to protect himself and Kang Jin, and they were lying behind them. Kang Jin was wearing thin beige pants, a blue shirt and a light spray jacket and no shoes. A pair of sandals was observed nearby, which he had been wearing.
Mr Day conducted checks for vital signs of Kang Jin but he showed no signs of response. Lianguan Yu told Mr Day that Kang Jin had spoken approximately 10 minutes before their arrival. Members of the rescue party formed the opinion that Kang Jin had only gone into cardiac arrest minutes before the arrival of the rescue party.
At 7.35pm Mr Day began CPR on Kang Jin with chest compressions. Mr Day, Mr Reed and Mr Page set up a rotation system for maintaining CPR on Kang Jin, with one person holding his head to keep the airway open, one performing compressions and the third person holding the emergency blanket up in an attempt to shelter everyone from the rain.
On advice from Mr Day, they decided not to cover Kang Jin’s body during the resuscitation in the hope that his reduced core temperature may have slowed his brain function sufficiently to prevent damage if he was able to be successfully revived.
Colin Rowe assisted Lianguan Yu to Waterfall Valley Hut. Other occupants at the hut noticed that Lianguan Yu's day pack contained a thin cotton shirt, track pants, a very thin sleeping bag and some snacks. One occupant of the hut described Lianguan Yu as in a deep state of hypothermia, based on observations of him, and the fact that he was not shivering.
At Kang Jin’s location, Paul Challenge set off an EPIRB (which was ineffective due to the location) and continued to attempt to contact emergency services via his satellite phone. Police received his call at 8.38pm and deployed a helicopter.
Resuscitation efforts by the rescue party had continued for approximately 20 minutes. They assessed chest compressions as maintaining blood flow, but there was still no response from him. They decided to put a plastic liner over the bottom part of his body in an attempt to try and protect him from the elements.
The rescue party formed the view that a helicopter would not be able to land in the conditions and that a search party would not arrive by foot for a few more hours. On the suggestion of Mr Day the party agreed to continue resuscitation attempts for another hour. At the end of the second hour Mr Challenge had not been able to make any further contact with emergency services and the group had been unsuccessful in their attempts to revive Kang Jin. By then the members of the rescue party themselves were beginning to suffer from the adverse effects of the extreme weather conditions. They therefore wrapped Kang Jin in the emergency blanket and returned to Waterfall Valley Hut.
At 9.50pm the rescue helicopter that had been deployed could not continue due to inclement weather in the area. A land party was initiated (consisting of two search and rescue officers and a paramedic). At that time it was raining heavily and winds were in excess of 100km/h. The Police Search and Rescue land crew arrived to Kang Jin at approximately 3.30am. Upon checking him, they confirmed that he was deceased.
At 8.00am on Thursday 20 February 2014 the helicopter was again deployed and retrieved Kang Jin’s body. His body was then transported to Hobart.
An autopsy was conducted on 28 February 2014 at the Royal Hobart Hospital by Dr Christopher Lawrence, State Forensic Pathologist. Dr Lawrence determined that the cause of death was hypothermia due to exposure. I accept his opinion. I note that toxicology testing of Kang Jin’s blood did not reveal the presence of any drugs or alcohol.
Comments:
Kang Jin, Lianguan Yu and Bojie Yang were obviously ill-equipped for the walk. Their food supplies and clothing were inadequate. Kang Jin was wearing a thin spray jacket (purchased just prior to the walk at the Visitors Centre), a blue and black windcheater, a cotton shirt, a pair of tan trousers over boxer shorts, and open black sandals. His clothing was wet through to the skin at the time the rescue party reached him.
In his affidavit, Mr Nic Deka, Acting Regional Manager for North-West Tasmania, Tasmania Parks & Wildlife Service (“PWS”), stated that PWS has ‘no effective power to stop people from walking the track’. He stated, however, that the staff at the Visitor Centre try to provide guidance when they identify an individual who is ill-prepared to safely complete the Overland Track.
I am satisfied on the evidence that the staff at the Visitor Centre used their best efforts to attempt to communicate with the group and to provide advice regarding items required, in accordance with their policy. Ultimately communication was problematic due to the language difficulties. However, it also appears that the group, largely inexperienced walkers, considered that they were sufficiently prepared and did not appreciate in any way the weather conditions they were likely to encounter. No further discussion or advice from the staff would have caused them to increase their preparation, better understand the danger posed by the weather conditions, or review their decision to walk.
In response to the incident, PWS conducted an internal review and adjusted procedures to ensure walkers understand the risks involved.
The ‘Walker Safety Checklist’ is a tool developed by PWS to guide walker preparedness for the Overland Track. The items on the Checklist are those identified as the bare minimum requirements needed in order to avoid hypothermia, by allowing a person to stay warm and dry should they encounter any difficulties. Following the incident, a tent has been changed from an optional item to a requirement for completion of the Overland Track.
Although the Checklist was in use in February 2014, there was no requirement at the time for walkers to sign the document or tick items off; it was completed verbally with Visitor Centre staff. Since the incident, the Walker Safety Checklist is now sent to walkers as part of their booking confirmation package and it is a requirement that each individual item is ticked off and the document be signed. Walkers must present a completed, signed copy with them on the day of departure. If a walker fails to bring it with them, copies are available at the Visitor Centre and must be completed before departure.
Notably, Mr Deka stated that the individual may still depart if they do not have all of the items on the Walker Safety Checklist. He stated, however, that it does provide for a record that the individual has been made aware of the requirements and of any deficiencies. Additionally, photos are taken of any poor equipment and this may also be used to support concerns that have been raised. As was the case previously, items are available for purchase in the Visitor Centre if a walker’s own items are inadequate. Mr Deka stated that staff continue to provide detailed information during the check-in process, including advice to prospective walkers about the track, the risks and the key safety messages on the day, in order to allow walkers to make an informed decision about their preparedness.
Additionally, same day or ‘walk-up’ bookings are no longer permitted and all bookings must be made prior to a walker’s arrival at the Visitors Centre. This change to procedure has been developed as an additional safety measure to avoid spur of the moment decisions to walk the track when individuals may not be suitably prepared.
Finally, the policy regarding refunds has also been changed, with refunds now able to be offered to walkers who appear inadequately prepared. Previously, a refund was available only where a Bushwalkers Weather Alert was issued by the Bureau of Meteorology. Changes have been made to allow staff the discretion to offer a refund where a walker is deemed insufficiently prepared, in an attempt to dissuade the person from departing. Mr Deka stated that this change has been in place since the 2014/15 booking season and has been used several times since by Visitor Centre staff.
Kang Jin, Lianguan Yu and Bojie Yang should not have embarked upon the walk. In doing so one died and the lives of the other two were endangered. Further, the lives of the members of the volunteer rescue party were put at risk. They performed selflessly under extraordinarily difficult conditions for a prolonged period. I recognise the brave efforts of Michael Page, Douglas Reed, Steven Day, Colin Rowe and Paul Challenge.
It is trite to say that elements of risk will always be present in natural settings and that persons embarking upon such activities must take responsibility for their own safety. In many cases the challenges are part of the attraction of the activities.
I have received a report from the General Manager of PWS, Mr Jason Jacobi, as well as PWS policy documentation. Mr Jacobi stated in his report that PWS approaches risk management in accordance with contemporary methods for protected areas around the world. I accept that this is the case. I also accept the view of PWS that it would be impracticable to inspect all walkers’ equipment/clothing or attempt to fully assess walker preparedness or capabilities.
The procedures that have since been implemented by PWS to enhance the safety of walkers on the Overland Track will no doubt have a positive effect upon walker safety and awareness.
I note that after the death of Kang Jin, PWS intended to introduce language buttons on the Overland Track web page to enable translation into a number of languages. PWS also intended to produce the check list information in several languages. It does not appear that the language buttons on the web page have been introduced. I am not aware of whether the check list has been produced in several languages. It would be prudent to implement these measures. It would also be prudent, in my view, to introduce clear signage in the Visitors Centre in several languages of the potentially difficult and changeable conditions and the need for thorough preparation for the walk.
In cases such as the present, where the walkers are patently ill-equipped for the conditions, PWS takes the view that it cannot prevent them from embarking on the walk. I am not aware of whether this is a policy stance or, alternatively, based upon an interpretation of the relevant legislation.
It appears that the provisions of the National Parks and Reserved Land Regulations 2009 may allow for the prohibition of persons embarking on the walk when they are observed to be inadequately prepared or so lacking in knowledge of the conditions that they pose a risk to the safety of themselves and others. Mr Jacobi has stated in his report that PWS will further investigate the use of the regulations to prevent or direct individuals not to undertake recreational activities in circumstances of obvious and significant risk.
The sad death of Kang Jin serves as a reminder to persons contemplating the Overland Track walk of the need to understand the demands of the walk, to be physically and psychologically prepared and to have appropriate clothing and equipment.
Recommendations:
I recommend that PWS give consideration to the availability and use of legislative powers, and consequent development of procedures, to prevent persons embarking on the Overland Track walk when they are observed to be inadequately prepared for the conditions such as to place the safety of themselves and others at risk.
I recommend that PWS introduces language buttons on the Overland Track web page that enable translation of the information, including the Walker Safety Checklist, into the main languages used by those undertaking the walk.
I recommend that PWS introduces clear signage in the Visitors Centre in the main languages used by walkers, alerting them to the potentially difficult and changeable conditions that they may encounter and the need for thorough preparation for the walk.
I extend my appreciation to investigating officer Sergeant Brenda Orr for her investigation and report.
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Re: Coroner Report-Overland Track

Postby walkerchris77 » Sun 07 May, 2017 9:06 am

Good read. Sad story. Just a pity they didn't have the right equipment.
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Re: Coroner Report-Overland Track

Postby South_Aussie_Hiker » Sun 07 May, 2017 9:24 am

I walked the OLT one week before this incident occurred.

It was brutally hot, some days approached 35 degrees, and people (including myself) were running out of water before reaching the next hut. On our return home we were staggered to learn someone had died of hypothermia.

A stark reminder of the changeability of Tasmanian weather no matter the season.
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Re: Coroner Report-Overland Track

Postby DanShell » Sun 07 May, 2017 11:15 am

It should be compulsory to read that coroners report before you leave for your walk.
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Re: Coroner Report-Overland Track

Postby walk2wineries » Mon 08 May, 2017 7:32 pm

I have some difficulty with the conclusion that language or inadequate signage was part of the problem. All three were enrolled at Deakin university in Victoria! Apparently they went to Tas specifically to walk the Overland. It is simply not credible that they were unable to understand the signs, the forms, the website they probably used when they were organising transport, and the workers at the Visitor's centre. Particularly if they invested over 30 minutes of 2 different worker's time! Maybe the signs should read "Reckless endangering of human life is a criminal act. Attempting the Overland Track without the listed equipment is a crime punishable by fines, imprisonment, or.....death."
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Re: Coroner Report-Overland Track

Postby dunamis » Mon 08 May, 2017 8:46 pm

Really felt for those that rendered the first aid. They must have felt pretty wretched physically and emotionally. Amazing and brace. Well done.


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Re: Coroner Report-Overland Track

Postby walk2wineries » Tue 09 May, 2017 12:22 pm

Absolutely. I am glad the coroner recognised them but I also feel for those in the visitor centre. II believe that a few universities such Deakin attract a lot of overseas students, I wonder if there has been any attempt to distribute info there? There are Chinese students's associations for example. Might be the best memorial ...
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Re: Coroner Report-Overland Track

Postby robbieb » Wed 10 May, 2017 11:51 am

walk2wineries wrote:I have some difficulty with the conclusion that language or inadequate signage was part of the problem. All three were enrolled at Deakin university in Victoria! Apparently they went to Tas specifically to walk the Overland. It is simply not credible that they were unable to understand the signs, the forms, the website they probably used when they were organising transport, and the workers at the Visitor's centre. Particularly if they invested over 30 minutes of 2 different worker's time! Maybe the signs should read "Reckless endangering of human life is a criminal act. Attempting the Overland Track without the listed equipment is a crime punishable by fines, imprisonment, or.....death."



I think Universities are all too eager to get the money that comes in from international students, so just because they were at Deakin, I wouldn't hold too much stock on them having good oral English skills. Some people can read an write in other languages but can't always understand the spoken, accents, inflections, all come into play in making a language sound different.
Anyway, doesn't sound like they had a full understanding of the risks and believed they were prepared.
I like the sound of offering a refund. I don't believe that PWS should be responsible for assessing bush walker preparedness. Every other park and walking area is effectively un-managed and relies on bushwalkers filling out registration books only. There is plenty of rugged, dangerous walking in Tas that needs proper preparation and won't have a PWS staff member there to hold you back
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Re: Coroner Report-Overland Track

Postby kjbeath » Wed 10 May, 2017 10:23 pm

walk2wineries wrote:I have some difficulty with the conclusion that language or inadequate signage was part of the problem. All three were enrolled at Deakin university in Victoria! Apparently they went to Tas specifically to walk the Overland. It is simply not credible that they were unable to understand the signs, the forms, the website they probably used when they were organising transport, and the workers at the Visitor's centre. Particularly if they invested over 30 minutes of 2 different worker's time! Maybe the signs should read "Reckless endangering of human life is a criminal act. Attempting the Overland Track without the listed equipment is a crime punishable by fines, imprisonment, or.....death."


Quite possibly they were taking English language courses prior to enrolling in university.
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Re: Coroner Report-Overland Track

Postby Lost » Thu 11 May, 2017 11:48 am

walk2wineries wrote:I have some difficulty with the conclusion that language or inadequate signage was part of the problem. All three were enrolled at Deakin university in Victoria! Apparently they went to Tas specifically to walk the Overland. It is simply not credible that they were unable to understand the signs, the forms, the website they probably used when they were organising transport, and the workers at the Visitor's centre. Particularly if they invested over 30 minutes of 2 different worker's time! Maybe the signs should read "Reckless endangering of human life is a criminal act. Attempting the Overland Track without the listed equipment is a crime punishable by fines, imprisonment, or.....death."


RobieB is right ask any uni about the language skills of some of it's foreign students and see what you get. Money talks.

But any way you can put up as many signs and notices as you like and there will be some if not many that will ignore them just to get that perfect photo you can thank social media for that. It's a unique problem that is is getting worse take wedding cake rock and figure 8 pools in the Royal national park. Five years ago about 2000 people walked the coastal track a month now it's 10,000 a month and most of those just go to wedding cake rock for a look at me photo to put on there FB, WeChat or whatever there social media is. Parks had to put up a fence to stop them going to the edge to get that perfect photo but no they just jump the fence or worse damage the fence to get in.
http://www.news.com.au/lifestyle/real-life/news-life/take-a-selfie-at-wedding-cake-rock-and-cop-a-300-fine/news-story/e206a6bca3bd7ac9e2831cbc0c50fd24

Figure 8 pools is worse it's always been known to the locals to pick your tides and don't go when there is big seas.Blind Freddy can see it's dangerous at times but still there are people who push the limits. Five years ago not many people did this walk now it's like Pitt st and will be on the news when big seas are on and washing people over the rocks. http://www.nationalparks.nsw.gov.au/things-to-do/lookouts/figure-eight-pools you can't get any more warning than that and this warning is now at the start of the track.

Happens all around the world. http://www.news.com.au/travel/travel-advice/travellers-stories/mount-everest-climber-found-hiding-in-a-cave-to-dodge-fee/news-story/3d82b29e6a58484b43a5daee6894330b
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Re: Coroner Report-Overland Track

Postby Gadgetgeek » Thu 11 May, 2017 7:37 pm

Its a sad report, but I think the important take-away is that the center staff did all they could to try to communicate the risks. However I've met many people who just don't understand that they can ever be in danger. Add to that the possible language confusion, "Do you have warm clothes" "yes I have clothes for warm weather" or worse, "Why, it was 35* last week" I run into it all the time where people assume that hypothermia is something that happens in "cold" latitudes, but if it can happen in the tropics, it sure can happen in 100km winds.
Without some form of effective translation (and that is near impossible to measure until its too late) or the center staff being able to bar entry from the track, I don't know there is much more to be done. But I also don't think the OLT is the same as other tracks, there are plenty of harder and easier tracks, but when a track is popular, the perception is that its easier or safer, and that causes a lot of the problems.
Hard for those involved though, I can't imagine the guilt they must feel.
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Re: Coroner Report-Overland Track

Postby South_Aussie_Hiker » Sat 13 May, 2017 8:31 am

I spent several years training Chinese students to learn to fly.

The most notable trait was they were intent on answering questions how they thought I wanted them answered.

Do you understand - YES!
Are you sure - YES!
Is the world flat? - YES! (Even though they know otherwise)

This is not a criticism of the Parks staff (in fact it's quite the opposite because I think they did a great job identifying at risk walkers and trying to mitigate that risk), and Parks staff can't be trained to deal with cultural issues from multiple backgrounds.

But yes/no questions have to be avoided with people from many cultures.
The question:
Do you have enough warm clothes
Should in many cases be replaced with
Tell me about your clothing.

I think the Parks staff and the rescuers all did an excellent job.

Just a very sad outcome. You can lead a horse to water...
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Re: Coroner Report-Overland Track

Postby paidal_chalne_vala » Mon 15 May, 2017 10:13 pm

A most unfortunate and cautionary tale. I have yet to walk the O.T. The crowds and the fees make me think twice. However I do see some very ill prepared people at places such as the Southern Loop of the Prom and other Nat. parks.
Think about how feral the weather can be at Wilson's Prom. , I am surprised no one has come to grief there recently.
Last edited by paidal_chalne_vala on Wed 17 May, 2017 4:17 pm, edited 1 time in total.
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Re: Coroner Report-Overland Track

Postby Nuts » Wed 17 May, 2017 4:00 pm

This is the third coroners report iv'e read, and third from Cradle Mt area. Personally, there are so many intricacies in any incident that there is less than is obvious to be gleaned from such reports. Less so again for those less experienced.

They had sleeping gear and a tent that went unused, this aspect wasn't a lack of gear, but of experience... ?

Anyhow, that and there's much more.

Some of the (report) suggestions are, perhaps inevitably, quite detached. In their language? How many Chinese have you seen on the track? Refuse entry, why? they don't appear prepared? Upend their pack? Or how do you really know? Leave the decision (and some liability) with park staff.. What of those that are let through, a group well prepared? How many PLB's? one each? What is the outcome for those let through who turn out to be under-prepared? The consequences for that particular staff member?

As a generality, where is the examination of what caused this group to be out there. What lit the spark?
What sort of info was included, did they see a pretty summery pic, was it captioned?
Were they coaxed by a targeted tourism campaign?

There are aspects introduced in promotion and control (permit systems) that very much express some duty of care is needed..
Government, institutional form of risk assessment? Where nobody is truly held responsible? other than as a measure of their own conscience?
On the OLT, by example, good enough to put designated campsites under or near big trees?
Good enough to designate an emergency accommodation and leave the use to personal interps? (KH is used a Lot, probably mostly by the less planned or less dutiful?)

Back to the top, responsibility back to upper management and their political prodders.
Combine park management with tourism and attaining full saturation (or whatever the end goal may be??) :roll:
Roll out booking systems and control methods with reckless abandon. Evidence of meticulous responsibility at the planning stage?

No, at the end of the day, we can't save some people from themselves. But any walk, especially in the mountains, is a serious undertaking, never merely a means to extract money.. with crossed fingers.

PS. As a more positive contribution, The Overland Track .. at least, could easily start with a walk to & or the first night at Waldheim. A chance to turn back or ''re-supply'' there, as even the other walkers will have been telling you.
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Re: Coroner Report-Overland Track

Postby Xplora » Thu 25 May, 2017 6:51 am

This coroner's report should be sent to ParksVic as a lesson for the impending Falls to Hotham iconic walk which seems to be more about enticing people, as Nuts has suggested, with a summery pic of beautiful mountains. Nuts is also correct that we cannot save people from themselves when they are intent on causing their own ruin through ignorance. The trouble for me is a sense of responsibility once the threat becomes known which would then lead to guilt if things go bad and I did not do enough (in my mind) to prevent it. I have been in that position a number of times and fortunately things have not gone bad. I recently read the book King Lake 350 which talks about the devastating fires around King Lake. Part of the book talks about the type of people who do heroic things. I am not surprised that of the 26 people in the hut only 3 volunteered. Two of them are described in detail and it is certain why they came forward. It is their nature to do so and the other 23 people would probably think them fools. From this report I see the Parks service is only engaged in limiting their liability which is mostly what happens after someone dies. I genuinely feel sad for all those who had any involvement with this event, including those in the hut who were not involved in the rescue. They would still be affected. At least two involved in the rescue would likely be, strangely enough, less emotionally affected as their efforts no doubt saved another life and they did all they could in their attempt to save the other. They had seen death before and enough of it to have mechanisms of coping. I can speak with some personal authority on this but it is a generalisation.
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Re: Coroner Report-Overland Track

Postby Lophophaps » Thu 25 May, 2017 8:52 am

It is the nature of many entities not to do much until disaster strikes. Yesterday the Lindt report was released, and it took two death to identify administrative and operational shortcomings. It will be similar for the issues regarding the OLT to be acted on elsewhere. I see nothing heroic about going out in rubbish weather. Uncomfortable, tiring, cold, wet, but not heroic. A long-held code is that we look after each other. Maybe the blow-ins sipping tea in the hut had not heard of this.

Henry V, Act 4, Scene 3
We few, we happy few, we band of brothers;
For he today that sheds his blood with me
Shall be my brother; be he ne'er so vile,
This day shall gentle his condition;
And gentlemen in England now abed
Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin’s day.
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Re: Coroner Report-Overland Track

Postby paidal_chalne_vala » Thu 25 May, 2017 8:37 pm

Not many people with limited outdoors experience have any concept of what the kind of weather that can kill you is like when you are out in the Oz Alps and conditions become utterly excremental.You have only so much time that you can waste being cold, wet and wind blown above the tree line in zero visibility before Hypothermia begins to set in.Even just walking from Cope hut to Cope Saddle hut on the AAWT on the BHP, if inappropriately dressed in very bad weather could spell trouble.
We know the story ........
We tried to warn those people but no , they knew better even if they were dressed in rubber thongs and a cotton shirt....etc.
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Re: Coroner Report-Overland Track

Postby Solohike74 » Fri 09 Jun, 2017 2:24 pm

I've seen European backpackers on the walk who were woefully under prepared. One guy was from the UK in a flimsy rain jacket looked like bought from a gas station or Kmart, waterproof pants, and was wearing trainers (joggers). Another similarly dressed but with boots from Germany who would have a meal in a can each night for dinner. On this trip in March a few years ago, we had 6-12 inches of snow at Pelion Gap and snow had started falling during our second night at Windermere Hut. I was walking the track alone.

I think, based on what I've seen, the issue goes much further than language barriers.

So many people scrimp on proper preparation in alpine area walks. I took someone to a Mt Stirling Hut in September for her first day telemark skiing with me, she performed ok on the skis actually. I recall she was without thermals and her synthetic sleeping bag was not adequately rated for a winter alpine camp in Australia. Though the damper was turned down to slow our fully stoked up fire, she woke in the middle of the night distressed and I had to render assistance. She may have underestimated the likely effects of the cold due to the considerable amount of alcohol she had consumed that evening in the hut, and the fire being on, but you can't fill up hut fire boxes to run all night they don't hold enough wood. She's a bit of a drinker actually, so may have underestimated the effects on her body of the alcohol and how it would affect her staying warm through the night.

The wind outside was light and there was some cloud, nothing of concern for a properly prepared camper.

This was the moment of realisation that wearing 2 cotton t-shirts is not a substitute for using thermals, and after filling her water bottle with hot water to put in the sleeping bag, I sent her to bed with my down vest on. She may turn up in Tidal River when she returns to Australia after touring Europe.

The presence of the huts I do enjoy but am concerned that there being huts and a busy track many inexperienced people neglect proper preparation. Walking myself with proper preparation, I found it steady some days, demanding on others, but very rewarding.
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Re: Coroner Report-Overland Track

Postby north-north-west » Fri 09 Jun, 2017 4:34 pm

May have mentioned this before, but I recall a trio doing the OT north to south while I was doing it south to north, maybe 2003. Met them at Waterfall Valley Hut.

One had gear like mine - nothing flash, but good reliable, well-used and maintained equipment, perfectly adequate for the conditions. A sensible experienced walker.

#2 had all the bells and whistles, all brand shiny new, top of the line gear and no idea how to use/set-up most of it. A clueless newbie numpty.

#3 was in overlong flared jeans, down-at-heel plimsolls, no socks, no wet-weather gear, carrying one of those canvas suitcases with harness. An emergency looking for a place to happen.

They headed out from Waterfall for Windermere the day I walked out to Pencil Pine, with fog and cold winds turning to sleet, hail and snow in near gale conditions. It was bad enough going down the Horse Track that day; I hate to think the state that third bloke must have been in by the time they made Windermere. Assuming they did make it . . .

The thing is, you still get people like that out there. You can't tell some people what they don't want to know. The OT is on their bucket list and they're determined to do it and simply will not believe anyone who tries to get through to them just how bad the conditions can get and how those conditions might affect them.

Coming off the Baw Baw one Spring day with a good slathering of snow still up top, I passed a group setting off to do the AAWT. Amongst other things, one was carrying a large (maybe 10 litre) aluminium cooking pot. They laughed when I mentioned the depth of the drifts still on the plateau; genuinely thought I was kidding.
Bumped into the only properly equipped member of the group six months later and she said most of them had given up before they reached Stronachs, and she and the other continuee didn't get past Rumpff Saddle.

Matt's written an excellent, well-thought out analysis of the issue in the latest edition of the eMag. And, as he says, there isn't really a solution. You can't tell how much you don't know until you've learnt enough, and that learning takes time.
We can't prevent things like this happening unless we make it totally impossible for anyone to ever go bush, anywhere, any time. And then they'll die prematurely from other things. Life isn't safe. Nor should it be . . .
"Mit der Dummheit kämpfen Götter selbst vergebens."
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Re: Coroner Report-Overland Track

Postby Xplora » Sun 11 Jun, 2017 7:44 am

I also thought the article in the eMag was interesting and the take home was with the power to stop someone comes liability if you allow them to continue. Stuffed both ways. Perhaps a disclaimer or waiver to be signed with the permit and checklist. Stupid people will always do stupid things. Decisions made based on ignorance or inexperience reaps their own rewards. Regulating people is not always the answer and in the end responsibility lies with the individual. In the harshest sense it is a form of natural selection which we feel the need to manipulate simply because most of us value human life. As authorities muddle their way through ways to manage or reduce risks they create flow on effects which then cause more problems. As an example, unrelated to bushwalking, when authorities clamped down on drink driving many years ago with the advent of RBT the incidence of alcohol related domestic violence increased. Men who would drink a moderate amount in the pub and drive home turned to drinking considerably more at home.
I have been talking elsewhere about signage on the Bogong High Plains and see there is a need for improved signage as the area has been promoted more for day trips and tourists but this can also encourage people without the resources in the physical (gear) or mental (experience) to feel safer when they are not and extend themselves beyond their ability.
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Re: Coroner Report-Overland Track

Postby paidal_chalne_vala » Mon 12 Jun, 2017 5:11 pm

Bring on the "no Idiots, Nuff Nuffs , Numpties and mOngers allowed on this track " signs !!!
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Re: Coroner Report-Overland Track

Postby GPSGuided » Mon 12 Jun, 2017 6:45 pm

A very sad read that could happen to many. To me, it's a case of highly variable Tassie bush weather added to ignorant enthusiasm of youth. I concur this should have been compulsory reading for any inexperienced potential walker/s.
Just move it!
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