Inquest into the death of Wilfried and Gisela Thor

CITATION: Inquest into the death of Wilfried Matthias Thor and Gisela Thor [2018] NTLC 026 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0017/2017

A0018/2017 DELIVERED ON: 26 November 2018 DELIVERED AT: Darwin HEARING DATE(s): 6 & 7 November 2018 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Nature Park, hot day, short walk, signage obscured by vegetation, boundary fence down, tourists became lost, environmental heat injury

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Department of Tourism and Culture: Jodi Truman Judgment category classification: B Judgement ID number: [2018] NTLC 026 Number of paragraphs: 60 Number of pages: 17

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0017/2017 & A0018/2017 In the matter of an Inquest into the death of

WILFRIED MATTHIAS THOR AND GISELA THOR ON: 10 FEBRUARY 2017 AT: NEAR TREPHINA GORGE, NORTHERN TERRITORY FINDINGS Judge Greg Cavanagh Introduction

1. Wilfried Thor was 75 years of age. His wife, Gisela Thor was 73. They married on 24 May 1969. They had three children: Matthias (1970), Michaela (1971) and Christine (1979). They lived in Schoneiche, a municipality on the eastern edge of Berlin.

2. On 1 February 2017 they took a flight from Berlin via Abu Dhabi to Melbourne. When they left, the temperatures were not getting above zero degrees Celsius in Berlin. They arrived in Melbourne on 2 February 2017.

They intended to stay in Australia until 27 February 2017.

3. They had a detailed itinerary for the 25 days in Australia. They planned to visit Victoria, South Australia, Central Australia, NSW and Queensland.

4. They flew from Adelaide to Alice Springs on 9 February 2017. They arrived at 2.55pm. The itinerary indicated they allowed 25 minutes to get out of the airport and pick up a hire care. They hired a Toyota RAV4 and drove to the Tourist Park where they had booked accommodation.

5. Their plans were that on the next day (10 February 2017) they would go to the East MacDonnell Ranges. The program for the visit to the East McDonnell Ranges was as follows:

• Alice – Ross Highway – Emily Gap – Jessie Gap. The kilometres were recorded as “22” and the time it would take to get there, “20 minutes”. It was noted that there was rock art to be seen;

• Corroboree Rock Conservation Reserve. The kilometres were “30” and the time to get there “20 minutes”. It was noted that there was a 20 minute loop around the rock to be experienced;

• Trephina Gorge via Ghost gum (6 kilometres gravel) “30” kilometres with a time of “35 minutes” to get to the Gorge. It was noted that the things to do were the Panorama Walk (1hr) and the Gorge Walk (1hr).

• It was then indicated that it was 80 kilometres back to Alice Springs calculated to take 1 hour and 15 minutes.

6. Mr and Mrs Thor were seen leaving their accommodation at about 6.00am on the morning of Friday 10 February 2017 in their hire vehicle. They presumably went to the sights they had planned on the way to the Gorge.

Mrs Thor used the camera to take video of the scenery on the way.

7. They were seen by the ranger arriving at the Trephina Gorge day-use carpark at about 9.30am. He specifically noted their vehicle arriving because they parked in the middle of a bay that could accommodate two vehicles. By that time of the morning the temperature was already 31 degrees Celsius.

8. On the satellite image below, marked as a red dot (just below the camping ground) is the place Mr and Mrs Thor parked their hire vehicle.

9. They walked the short distance to the wide creek bed that leads to the Gorge. The last video recorded was of them entering the Gorge. The Gorge stroll is noted as 500 metres. The Gorge walk is a two kilometre walk.

10. For the “Gorge stroll” a person would walk from the carpark down to the sandy creek bed and then turn left and walk up the creek bed toward the marked orange line and back.

11. The “Gorge walk” is a loop that includes walking through the Gorge and then taking a left turn just before the creek bed turns to the right (near the dark shadow in the photograph, just before the orange line). The walk then takes a person back along the rim of the Gorge.

12. There was a sign indicating that the Gorge walk could be walked either clockwise or counter clockwise. It was marked with orange arrows.

13. The Northern Territory Parks and Wildlife website stated: “This walk can initially be enjoyed by either walking directly down into the creek bed or alternatively by walking up along the gorge rim.

This loop walk which commences at the creek’s edge, provides scenic views of the sheer red cliffs towering over the tree lined creek. Close observation may reveal the presence of the shy Blackfooted Rock-wallaby.”

14. Because of the relatively short distance of the intended walk, Mrs Thor left her walking shoes in the car and took with her only a small (600 millilitre) bottle of water. Mr and Mrs Thor walked along the creek bed and through the Gorge with a view to completing the walk by looping back along the rim.

The sweeping turn to the right of the creek bed

15. About 400 metres through the Gorge was the trail leading to the rim. It was on the left side just as the creek bed entered a sweeping turn to the right.

The only indication of the trail was an orange arrow located several metres up the trail after it left the creek bed. However, along that side of the creek bed was long grass that significantly obscured the orange arrow and the fact that there was a trail at all.

16. Mr and Mrs Thor did not see the trail and continued to walk along the creek bed through the sweeping right hand turn and toward the boundary of the National Park. There was usually a wire stock fence that went across the creek bed and up the sides of the rock formations bounding the creek bed (at

the position of the orange line on the map above). The fence was primarily to keep stock from the pastoral station that bordered the Nature Park, coming into the Park.

17. In 2016 a tourist had climbed through the wire fence. He got lost and may well have perished but for coming across a grader and driver on the pastoral station. Thereafter, the Park Rangers had a sign laminated to indicate that the fence marked the boundary of the Park and warning not to go any further. That sign was attached to the fence. However the fence was down and the sign was gone due to flooding through the area two weeks earlier.

18. Mr and Mrs Thor kept walking along the sandy creek bed. They followed it around a bluff and then another few kilometres until the creek bed split into two and went around what the rangers referred to as the “Island”. Once around the Island the creek became one again but the terrain became impassable. Mr and Mrs Thor turned back.

Noted on the map is a yellow line in the approximate position where the creek bed became impassable.

19. Mr and Mrs Thor had walked at least five kilometres. During that walk they had stopped at areas where the water still lay in the creek bed to refill the 600 millilitre water bottle. Their movements are known because they were the only footprints in the sand of the creek bed.

20. When the creek bed became impassable they turned and followed the creek bed back around the Island. Four hundred metres further on Mrs Thor took a right turn and walked out of the creek bed. She followed a small sandy trail for a short distance. That gave way to the rocks, tall grasses and small trees that covered the countryside.

21. Why she left the creek bed is not known. However, it is likely that by that time it was very hot. The temperature for the day rose to 39.9 degrees Celsius. She was not wearing a hat and may well have been suffering heat stress and dehydration.

22. Mr Thor did not notice her leave the creek bed. Presumably he was walking in front. It was another 700 metres before he noticed. He turned back and the foot marks in the sand indicate that he retraced his steps looking up each small tributary. Eventually he arrived back at the Island. He had then followed a larger tributary.

23. Mrs Thor continued to make her way through the rocky country. She walked for another 900 metres before sitting down under the shade of a small tree.

At that point she was only 20 metres from a graded track on the pastoral station. However her footprints were not found on the edges of that track and it is probable that she was unaware of the track. She fell sideways. That was the position in which she was found, deceased. From the point of leaving the car to that position she had walked about 10 kilometres.

24. Mr Thor continued to walk along the tributary. There was no water in that area. Three and a half kilometres later he left the tributary to the left. He walked up a small incline and sat on a rock. He is likely also to have been suffering heat stress and dehydration by that time. He had walked 17 kilometres.

The blue on the map indicates approximately where Mrs Thor left the creek bed. The purple denotes where Mr Thor left the creek bed to follow the tributary.

25. It is unlikely that Mr Thor understood his dire situation. He had the camera with him. However he did not record a video message. He lay back on the rock. He was found deceased in that position.

26. It is likely that Mr and Mrs Thor died during the heat of the late afternoon on the same day (10 February 2017) they arrived at Trephina Gorge.

The green dot on the map indicates the approximate position in which Mrs Thor died and the white dot the approximate position where Mr Thor died.

27. The next morning two tourists in the campground at Trephina Gorge noticed the Thor’s rental vehicle still parked in the day-use carpark. They drove the three kilometres to the Ranger Station. At the junction of the road to the Ranger Station they flagged down a ranger. It was his day off. He was in his vehicle with his family headed to Alice Springs. The tourists told him of the vehicle still in the day-use carpark. The tourist returned and left a note on the Thor’s vehicle to say they had reported them missing to the rangers.

28. The ranger and his family went to Alice Springs. It would have been better if prior to doing so he had investigated the vehicle and reported the matter.

However it must be remembered that the walks were relatively short. The longer walk, the Ridgetop walk, was four to five hours each way.

Sometimes people would walk it (albeit in the cooler weather toward the middle of the year) and camp overnight at the other end returning the next day. There had also been no previous issues with tourists becoming lost in the park (apart from the man that climbed through the fence the previous year).

29. On his return from Alice Springs that afternoon, the ranger went to investigate whether the vehicle was still there. It was. He noted it to be the same vehicle he had seen park across the two bays the previous day.

30. He drove back to the ranger station, got a quad bike and rode through the Gorge to the boundary. He noticed many footprints going past the boundary where the fence had previously been. After about 100 metres they turned back. However there were two sets of footprints that did not. He followed them for a few kilometres until it began to get dark. He returned to the Ranger Station, contacted his supervisor and reported the situation to Police.

31. Police prepared for a search and rescue the next day (12 February 2017).

They traced the vehicle to the hire company and obtained the identities of Mr and Mrs Thor, they obtained pictures of them arriving at the Alice Springs airport.

32. They went to Trephina Gorge the next day with 12 people, quad bikes and a helicopter. One of the officers followed the footprints, the others worked in a pattern looking for Mr and Mrs Thor. However, they were not found that day.

33. Police obtained the opinion of Dr Luckin that afternoon. Dr Luckin has a great deal of experience in search and rescue. He advised: “I note that the two missing persons have come from a German winter to a hot dry climate. They will not be acclimatised and therefore unable to dissipate heat effectively. Now +55 hours; three days and two nights. I note the extreme daytime temperatures, warm hot nights, low humidity, rocky terrain reflecting heat and lack of shelter. All of these will cause rapid dehydration, hyperthermia and collapse. They will by now have died from hyperthermia and dehydration UNLESS they are stationary at a source of drinkable water. Survival to the present time for these specific individuals under the conditions described is extremely unlikely … if at water would expect small chance alive by daylight Monday 13 February 2017.”

34. The following day (13 February 2017) the search continued and at 12.15pm the helicopter when turning at the outermost margin of the search area sighted the body of Mr Thor. His body was recovered. The search and rescue coordinator estimated that he had been deceased “at least a few days”.

35. The next day (14 February 2017) at 12.54pm the helicopter pilot spotted the body of Mrs Thor. The search and rescue coordinator thought from the condition of her body that she had been deceased “at least a few days, potentially longer”.

36. An autopsy was carried out by Forensic Pathologist, Dr John Rutherford. In his opinion both Mr and Mrs Thor died of “environmental heat injury”.

37. The deaths of Mr and Mrs Thor were a tragedy. They were experienced walkers. They were on a holiday that was extremely well planned and researched. The only available explanation is that their decision making became impaired by the heat and dehydration after walking out of the Park.

Departmental Response

38. The Senior Director of Parks and Wildlife Operations provided evidence that there are 7 parks and reserves that make up the East MacDonnell SubDistrict. They cover 38,800 hectares. Travel to get to the outlying Parks is a 450 kilometre drive. There are two rangers and a caretaker for that SubDistrict. A significant component of their role relates to land management.

That includes weed management, fire management, feral animal control and flora and fauna research and monitoring.

39. February has the least number of visitors to Trephina Gorge. The number increases tenfold towards the middle of the year. During that time the rangers are rostered on seven days a week and conduct programs for visitors including guided walks, camp fire talks and other activities aimed at promoting the values of the park. However in the hotter months the rangers are rostered on only on business days.

40. After the deaths of Mr and Mrs Thor, Parks and Wildlife conducted a review that identified a number of issues that included the absence of the boundary fence, the adequacy of the signage and track marking, the adequacy of safety messaging available to visitors before visiting the park, the failure to immediately commence a search on initial notification and the lack of mobile or Wi-Fi coverage. Those issues were considered and where within their power, acted upon.

Boundary Fence

41. It was noted in the review that the boundary fence was a typical stock fence.

On 22 January 2017 Trephina Gorge received 72mm of rain. The following day it received another 20mm. The fence was inspected on 24 January 2017.

It was still in place but the laminated sign had been damaged. It was replaced.

42. On 25 January 2017 a further 55mm of rain fell. Trephina Creek was flowing a metre deep over the access road and the Park was closed the following day. It was reopened on 27 January 2017 to Four Wheel Drive vehicles and the following day after the road was graded, to all vehicles.

The creek continued to flow until 5 February 2017. That made access to the creek bed and the boundary fence by vehicles impossible.

43. On 9 February 2017 fencing repairs were scheduled for 13 February 2017.

That was however after the visit by Mr and Mrs Thor. The absence of a boundary fence was obviously a significant contributing factor to Mr and Mrs Thor leaving the park and becoming lost.

44. Accordingly the Department put a new procedure in place that included the placing of signs after a “flow event” warning that the boundary fence may be damaged or missing and placing emergency fencing materials on high ground near the boundary fence so that it could be repaired without the need to wait for vehicular access.

45. Signage was also placed on the trees across the creek rather than the fence to alert visitors that they marked the boundary of the park and that no access was permitted beyond that point.

Track marking and definition

46. New signage was put in place that indicated one direction to undertake the Gorge walk. That was the anti-clockwise direction, through the Gorge and then taking the trail to the rim. The signage was improved and the grass cleared near the start of the trail. A signpost was installed near the edge of the creek bed noting the entrance to the trail.

Independent review

47. An independent review was also commissioned that made further recommendations all of which have been considered and most taken up and implemented. Those include a specific safety message on signage across all Nature Parks.

Emergency Response Procedure

48. A new Emergency Response Procedure was implemented that requires all potential incidents to be reported immediately whether rangers are on duty or not. The procedure also requires action when vehicles are located by staff where there may be missing persons.

“Beat the Heat” Safety Campaign

49. A campaign was launched at the beginning of November 2018 in response to the deaths of Mr and Mrs Thor and two other deaths since from the effects of the heat. It has been launched on Facebook and there is a factsheet on the government website as well as posters and leaflets provided to tourism information centres, car hire companies and accommodation providers.

Lack of Telephone reception or Wi-Fi

50. The Department cannot provide telephone reception or Wi-Fi to the area.

There has been consideration of Personal Locator Beacons. It is unlikely however that visitors would hire or buy such a beacon for a trip to a Park such as Trephina Gorge unless perhaps doing the longer walks.

51. However Matthias Thor (the son of Mr and Mrs Thor) made the following suggestion: “Nowadays almost every traveling party has at least one smartphone, even elderly people. So my recommendation is to encourage people traveling to remote locations without mobile coverage to download a GPS application to the phone upfront as well as an offline map for the destination area. There are plenty of basic apps available free of charge. Offline maps are also available free of charge or for maybe just a few dollars. Nothing else is required. People should just have the mobile phone with them, which is something most people will do anyway. In the event of getting lost they should switch it on, start the GPS app, wait for the signal and just follow the arrow on the display to the road, carpark or next human settlement.

In my opinion there are three important criteria to match, if you want that people follow your recommendation:

1. Easy to implement

2. Free of charge or at least not expensive

3. No special skills required My recommendation matches all these criteria. There is a simple one time activity required before you start traveling, done in a couple of minutes (loading the app as well as the map). Everything you need is available free of charge. And finally, no special skills are required, as it is not about a complex navigation scenario in an urban area. The typical situation of getting lost in the bush is that there aren't that many man-made structures in your area. So following the arrow on the display back to the road, carpark or whatever should be really very easy.”

4. At the time of the inquest the Department seemed a little ambivalent about recommending the use of such applications. The major issue for the Department appeared to be that technology might fail.

5. However, it is one more system. This tragedy illustrates that systems such as signage and fencing can fail. The purpose of having backup systems is that failure of one does not necessarily result in tragedy.

6. Recommending such a system may simply be a matter of the provision of sufficient information to ensure that such applications can be a useful backup (as opposed to the primary system).

7. During the course of the inquest I visited Trephina Gorge with the Department and family members. One such app was tested (Locus Map). It was free, simple to use and accurate throughout our visit.

8. When the inquest resumed the Department representative, Mr Day, stated: “I think we are very happy to look at that [recommending GPS apps] as an option, as an area of potential improvement.”

9. I was impressed with the response of the Department and I commend them on the comprehensiveness of their response and the speedy implementation of changes.

10. I was also very impressed with the astute and thoughtful approach of the family to the issues surrounding the death of their parents. Matthias, his partner Anita and his sister Michaela flew out from Germany to attend the inquest. At the conclusion of the inquest Matthias gave the following evidence: “So, my parents were an active and dedicated couple who really loved travelling and visiting foreign countries. So, they really loved being in the nature, spending times with all the activities, like hiking and walking. So, in recent years since they had retired, they travelled to destinations like United States, Canada, Namibia, South Africa and when they planned their trip to Australia and asked me about my experiences I always told them, “You will love this country even more.” And, what we know from emails and messages they have sent during the first week, they really enjoyed the trip. When heading from Adelaide to Alice Springs the week they spent in the Red Centre was

supposed to be the highlight of their trip. Then the journey came to that sudden end here at Trephina Gorge.

So, since those things happened, we have been in permanent contact with the authorities and Coroner’s Office to get as much information as possible because I think its human nature that, in cases like this, you like to get answers to questions, like what exactly happened and why did it happen. In this particular case under these circumstances, it was pretty clear to us from the beginning that there will be a lot of questions we never get answered.

We have been provided with a lot of information, including the coronial brief, but when they have informed us about this inquest and chance to attend here, it was not easy to make this decision to attend or not, because sometimes it can be hard to go through all these things again, more than one and a half years after they happened.

But, to attend this inquest here was definitely the right decision.

Because, we are very impressed by the detailed investigation and how serious all involved parties are taking this. The deaths of my parents was a tragedy and for us, it is not to blame somebody, an institution or even a particular person.

So, the only thing we can do is to learn from it and to do our best to avoid those tragedies will ever happen again. So, for example, it was very good to see this morning during the on-site visit that a lot of recommendations regarding the signage in the park has been implemented already.

For us personally, it was also very good to listen to the people involved here, because it still makes a difference between just reading through a statement or report and listening to a person talking about this. So, we are pretty sure that attending this inquest will help us a lot to get over these things.

Finally, I don't want to miss an opportunity to say thank you to all the Northern Territory authorities and to all the people of Alice Springs for all the support and the sympathies we have received during these hard times. This is something I always mention whenever people are asking me about the deaths of my parents.

We met a lot of very nice people here in Alice Springs and we even made new friends and this is something we will never forget.

Thank you.”

59. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased were: a. Wilfried Matthias Thor born on 15 August 1941, in Gramschuetz, Germany.

b. Gisela Thor born on 24 December 1943 in Gottschimmerbruch.

(ii) Both deceased died on 10 February 2017 near Trephina Gorge in the Northern Territory.

(iii) The cause of death in each case was Environmental Heat Injury.

(iv) The particulars required to register the death:

1. The deceased were of German descent.

2. The deceased were retired at the time of their deaths.

3. The deaths were reported to the Coroner by Police.

4. The cause of both deaths was confirmed by Forensic Pathologist, Dr John Rutherford.

5. a. The deceased Wilfried Thor was the son of Bruno Thor and Frieda Rahlmeier; b. The deceased Gisela Thor (nee Krueger) was the daughter of Erich Krueger and Hanna Hartmann.

Recommendation

60. I recommend that the Department of Tourism and Culture do all such things as may be necessary to advise visitors who may visit its parks in areas without telecommunication reception of the existence of GPS applications and the use to which they might be put when visiting those areas.

Dated 26 November 2018.

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JUDGE GREG CAVANAGH TERRITORY CORONER