Su, Che-Wei

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Che-Wei Su TITLE OF COURT: Coroners Court JURISDICTION: Cairns FILE NO(s): 2014/590 DELIVERED ON: 14 July 2014 DELIVERED AT: Cairns HEARING DATE(s): 7 July - 10 July 2014 FINDINGS OF: Jane Bentley, Coroner CATCHWORDS: Coroners: inquest, drowning, Mossman Gorge, Daintree National Park, Queensland Parks and Wildlife Service, Voyages Pty Ltd, Mossman Gorge Visitor Centre, Mossman River, Rex Creek

REPRESENTATION: Counsel Assisting: Ms Stephanie Williams Department of National Parks, Recreation, Sport and Racing and Queensland Parks and Wildlife Service: Mr Kevin Parrott, Crown Law Queensland Fire and Emergency Service and Queensland Police Service: Mr Michael Nicholson, Counsel Voyages Indigenous Tourism Australia Pty Ltd: Mr Joshua Trevino, Counsel Douglas Shire Council: Mr Douglas McKinstry, Williams, Graham, Carman Lawyers Queensland Ambulance Service: Ms Fiona Banwell

Background Information Mossman Gorge Mossman Gorge is located just east of the township of Mossman, approximately 80 kilometres north of Cairns along the Captain Cook Highway. It is on the southern end of the Daintree National Park. The main swimming area is located at the edge of Rex Creek where it joins with the Mossman River. This part of Rex Creek is fed from the Julatten Range that sits just above Mossman Gorge.

The amount and velocity of water in the swimming area varies significantly depending on the amount of rain that has fallen in the ranges above the gorge.

Visitors access the gorge via a constructed walkway from the upper car park area.

The walkway leads to the main swimming area. Visitors enter the water via a sandy beach. The water just adjacent to the beach is invariably calm and safe to swim in.

There is also a sandy beach on the other side of the creek.

A few metres out from the beach the water becomes deeper and much faster flowing.

There are a number of large boulders in the middle of the stream, some partly submerged and some submerged, depending on the water level. The water flowing through the boulders creates rapids and strong currents.

Management of the Gorge The Mossman Gorge Visitors Centre (the Centre) The Centre is situated at Lot 7 on SP 212661 which land is owned by the Indigenous Land Corporation (ILC). The ILC is a Commonwealth statutory corporation and its purpose is to assist indigenous people to acquire and manage land to achieve social, cultural, economic and environmental benefits.

Voyages Indigenous Tourism Australia Pty Ltd (Voyages) is a wholly owned subsidiary of the ILC.

The land on which the Centre is situated was purchased by the ILC in 2008 and construction of the Centre was completed in June 2012. Voyages conducts the business of the Centre. The business was created through cooperation from various parties including:  Queensland Department of National Parks, Recreation, Sport and Racing (the Department) of which Queensland Parks and Wildlife Services (QPWS) is a division;  Douglas Shire Council (formerly the Cairns Regional Council);  The Mossman Gorge Aboriginal Community entity (Bamanga Bubu Ngadimunku Inc);  Jabalbina Yalanji Aboriginal Corporation RNTBC which represents the local traditional owners.

The Centre’s operations comprise four business units:  The shuttle bus service;  Dreamtime guided walks; Findings of the inquest into the death of Che-Wei Su 1

 A residential training and development centre;  Café and retail shop The Centre is open every day (excluding Christmas Day) from 8am to 6pm.

The Shuttle Bus Service The Centre provides a shuttle bus to take passengers approximately two kilometres along the Mossman Gorge Road from the Centre to the entrance of the Mossman Gorge section of the Daintree National Park (the upper car park). A boardwalk leads from the upper car park to a walking track. Approximately 300 metres along the track is the small sandy area on the banks of the Mossman Gorge which is a well known and popular swimming area.

The shuttle service operates under the terms of an agreement between the ILC and the Council which commenced in March 2012.

The ticket prices for the bus are determined annually with approval from the Council.

As at June 2014 the prices were $8.50 for an adult and $4.25 for children 5 to 15 years. There was a discount price for families of $21.25.

The road to the upper car park is closed to other motorized traffic between 7.40am and 6pm (by agreement with the Council) by means of a boom gate. Access by pedestrians, cyclists and government departments is unrestricted.

The Centre does not monitor or assess weather conditions, rainfall or water levels in the Gorge.

The Department All activities within the Daintree National Park are the responsibility of QPWS. This includes track maintenance, safety issues and signage.

Weather Conditions Rainfall data indicates that the Mossman River at Mossman was in moderate flood from 7 February 2014 to 16 February 2014. The flood peaked on 8 February and receded up to 16 February 2014. This was due to rainfalls in the catchment area of 150 and 60mm on 8 and 9 February 2014, respectively.

Signage, Warnings and Advice as at 15 February 2014 At the entrance to the walkway there is a large sign which provides information about visiting the gorge and, in a small section on the lower right hand side, also advises: Swimming in the Mossman Gorge and adjacent creeks is extremely dangerous due to a combination of strong currents, flash flooding, cold deep water and slippery rocks. People have been injured and deaths have occurred at Mossman Gorge.

There is a second sign on the walking track at the entrance to the swimming area which states: Swimming, wading, jumping and diving in this river is dangerous. A combination of swift currents, slippery rocks, deep water and flash flooding Findings of the inquest into the death of Che-Wei Su 2

make this river dangerous. People have been seriously injured and deaths have occurred here.

This sign includes the warning symbols for rapidly rising water, no diving, slippery rocks and deep water.

There are a number of pamphlets available to visitors in the Centre:  “Park Guide” issued by Department of National Parks, Recreation, Sport and Racing advises, “It is dangerous to enter the Mossman River due to a combination of strong currents, flash flooding, cold, deep water and slippery rocks. People have been injured and deaths have occurred.”  A pamphlet provided by the Centre which advises that visitors can, subject to weather and water conditions, have a refreshing swim at “the beach”.

 A second pamphlet provided by the Centre advertises “a swim at the beach” on both guided tours and provides a map which indicates swimming at the main swimming area. There is no warning provided on this pamphlet.

There was no formal advice provided to visitors during the trip on the shuttle bus.

The Centre carries out risk assessments every morning for the walking tours but there is no such risk assessment carried out for the self-guiding visitors who catch shuttle bus and enter the national park to walk and/or swim.

The Mossman Gorge Visitor Centre Website provides the following photograph and accompanying information: A picnic lunch at one of the many swimming holes will allow you the time to just sit and appreciate the wonders of your surroundings. Find yourself under the towering canopy of the rainforest, beautifully framed by the striking mountains. An Findings of the inquest into the death of Che-Wei Su 3

image of the crystal-clear water of the Mossman River cascading over granite boulders is one every photographer will treasure.

All of the walking tracks are clearly signposted and maps are also provided upon entry.

Swimming The crystal-clear water of the Mossman River cascading over granite boulders forms watering holes surrounded by lush green rainforest. These sheltered retreats offer the perfect location for a refreshing dip to break up your walk through the Gorge. Let the troubles of the daily grind float away in the tranquil surroundings and take the time to appreciate nature at its best.

The QFWS Website provides information about Mossman Gorge including the following information: Staying safe It is dangerous to enter the Mossman River, due to a combination of strong currents, flash flooding, cold, deep water and slippery rocks. People have been injured and deaths have occurred at Mossman Gorge.

Stinging trees are found occasionally alongside walking tracks in Mossman Gorge. They grow approximately 3–4 m high and have large, heart-shaped leaves with serrated edges. Do not touch these plants as this will almost certainly result in a very painful sting. If you are stung and symptoms are severe, seek medical advice.

Do not leave cars unattended overnight as they could be vandalised.

If you intend to hike within the park beyond the rainforest circuit track, you must discuss your plans with park staff. Remember to tell a responsible person where you are going and when you expect to return. Let them know your route and contact them on your return. Have a contingency plan in place if you fail to contact them by the agreed time. If you change your plans, inform them.

For more information, please read the guidelines on safety in parks and forests( http://www.nprsr.qld.gov.au/experiences/safety_in_parks_and_forests.html ).

Circumstances Surrounding Mr Su’s Death Mr Su was a Taiwanese national who resided in the city of Kaoshiung. He and his girlfriend, Rong-Zhen Liu, arrived in Australia in about June 2013 and they had been travelling around Australia on a two year working visa. At the time of his death Mr Su and Ms Liu were working on a fruit farm at Mareeba.

Mr Su was fit and healthy and had completed military training in Taiwan. He was a strong swimmer.

On the afternoon of 15 February 2014, Mr Su, Ms Liu, and three friends who were also working at the farm, Robert North, Charlene Devine and Christopher Gallacher, hired a car and travelled from the farm to the Mossman Gorge.

Findings of the inquest into the death of Che-Wei Su 4

They arrived at the Centre at about 2pm and paid for a ticket to catch the shuttle bus from there up to the upper car park, arriving there at about 2.15pm.

Ms Devine had researched the Centre on its website and said that she knew she had to pay for a ticket for the bus to get to the gorge. Ms Devine saw the warning on the sign at the entrance to the walkway and the second warning sign at the entrance to the swimming area.

Mr North didn’t notice the warning on the first sign. He saw the second sign before the swimming area but did not stop to read it. He could tell from the symbols that it was a warning sign.

They walked along the track to the main swimming area. There were people in the water when they arrived.

The water looked calm to Ms Devine but once she was in knee deep she noticed that the current was strong and the water got deep very quickly.

Mr North entered the water and swam towards a rock on the other side. He was not swimming hard at first but as it got deeper he realized that the current was strong.

He started panicking a bit and swam “really hard” to get to the rock. He climbed up on the rock and looked around and could see that the water was flowing very fast.

He saw a couple of submerged rocks upstream and decided to swim for them as hard as he could. As he jumped off the rock he felt the water pushing him downstream. He could not get to the rocks he saw so decided to swim as hard as he could for the bank.

When Mr North got back to the bank he was breathing heavily. He did not say anything about the current but presumed that the others had seen the difficulty he had in getting back to the bank.

Mr Su then entered the water and swam to the boulder near the far side bank on which Mr North had stood. He climbed onto the boulder and shouted to Ms Lui that the water was very fast. He then jumped off the boulder to swim back but was immediately swept downstream. He floated on his back with his head facing downstream. He was swept down the rapids. His friends ran along the bank and saw him being taken by the current between a series of boulders.

Ms Devine walked along the water back down to the car park but did not see Mr Su again. When she arrived at the car park she told the bus driver that Mr Su had been swept downstream and they had lost sight of him.

Mr Gallacher also walked along the bank trying to find Mr Su. He met a man from the Centre who was also looking for Mr Su. Mr Gallacher saw a bus driver and called out to him to get help. That man said that his phone was dead.

The Rescue and Retrieval Effort The Centre Sam Savage, the driver of the shuttle bus, was the first person to be alerted to the incident. He was waiting at the upper car park to take visitors back to the Centre when he was approached by Ms Devine. He waited for the other passengers to get on the bus and then drove back down towards the centre. He stopped on the way at a point where he could see the river (that location is known as Mary’s rock). Some Findings of the inquest into the death of Che-Wei Su 5

passengers got out of the bus to look for Mr Su. The driver asked everyone to get back onto the bus. He tried to call the Centre but had no reception on his hand held radio.

The driver returned to the centre and asked one of the staff there to phone the police.

Glenn Perris, Operations Manager of the Centre, returned to the Centre at about 3pm on 15 February 2014 and was told by two staff members that there was man floating down the gorge. He told them to remain at the Centre and to attend to communications and he would go and search for the man.

Mr Perris is trained in basic swift water rescue (SWR) techniques. He took his equipment and drove to a location on the gorge known as the “Hippie Hole” which is a narrow shallow point. He had a radio and a phone.

On arrival at the Hippie Hole Mr Perris came across a number of visitors who were searching for Mr Su. He told them to stay on the road or return to the centre. He walked into the Hippie Hole and then headed upstream. About 150 metres upstream from the Hippie Hole Mr Perris saw Mr Su. Mr Su was underwater and wedged between some rocks. Mr Perris knew that he was deceased.

Four visitors arrived at Mr Perris’ location and he asked three of them to go back to the roadway and tell someone that he had located Mr Su as he had no radio or phone reception at that location.

Mr Perris waited for about 20 minutes and when nobody had arrived to assist he asked the remaining visitor to walk back to the road and alert emergency services of his location. About five minutes later Senior Constable McCluskey arrived and he took responsibility for the operation.

Emergency Services Police received call at about 2.50pm from a female who did not identify herself and who stated that there was a deceased male in the Mossman Gorge River. She then hung up. She spoke with an indigenous accent. It is likely that she was a staff member from the Centre.

Queensland Ambulance Service (QAS) received a call at 2.52pm.

Paramedics attended the upper car park. Two officers arrived at 3.04pm and met up with Senior Constable McCluskey and Police Liaison Officer Port. At that time none of the officers knew who they were looking for or where the incident had occurred.

After discussion they decided to go down to the community at the bottom of the road to locate the rescue party. They arrived at the community without seeing anybody.

The officers then decided that the police officers would drive back to the upper car park and then walk back towards the Centre on foot and the paramedics would walk up on foot – both going in different directions – until they met up in the middle. They had no means of communication with each other or with their Communications Centres. There was no mobile phone or satellite phone coverage and no radio contact.

At about 3.15pm Senior Constable McCluskey was able to telephone the District Duty Officer and brief him. He ensured that QAS and Queensland Fire and Findings of the inquest into the death of Che-Wei Su 6

Emergency Services (QFES) had been notified as well. He requested the deployment of QFES swift water rescue team (SWRT) from Cairns.

After the Ambulance officers had travelled about 300 metres on foot through difficult terrain they received a phone call and were advised that Mr Su had been located upstream on the other side of the river.

Senior Constable McCluskey was told by a group of people on the side of the road that Mr Su had been located. He followed their directions and found Mr Su and Mr Perris.

Senior Constable McCluskey saw that it was too dangerous to attempt to retrieve Mr Su. He telephoned the District Duty Officer, Sergeant Trevor Perham, and provided a briefing on the situation.

The Far Northern Region Fire Communications Centre (Firecom) received a call from QAS at 3.52pm. A special response vehicle was mobilized out of Cairns station at 3.55pm. At 4.15pm Clint Tunnie, Inspector, QFES, was briefed and he advised that he would attend the location. He picked up two additional SWR technicians en route from the Cairns Fire Station. The Special Rescue Appliance arrived at Mossman Gorge at 5.25pm but required further swift water crews to retrieve Mr Su.

Inspector Tunnie arrived at the scene at 5.39pm and briefed the crews. The SWRT arrived at 5.50pm. The team carried an inflatable platform over the terrain. One of the officers split her nose open on a rock. A generator and lights were also carried in. Four SWRT entered the water and worked their way across the river towards Mr Su. Three firefighters were positioned at different locations on the bank, as the down river safety team, to throw safety lines to the crew if required. By 6.12pm the team had worked their way across the river and at 6.17pm they secured Mr Su’s body. At 6.36pm Mr Su was brought back to the bank.

It was observed that Mr Su had several large bruises and a large cut on his forehead.

Queensland Ambulance paramedics pronounced him deceased.

Autopsy Results An external autopsy was conducted and it was concluded that the cause of Mr Su’s death was undetermined but consistent with drowning. He had abrasions on his left and right forehead and two lacerations – one above and one below his left eyebrow.

The inquest A pre inquest conference was held on 7 May 2014. The parties were given leave to appear and the inquest adjourned to commence on 8 July 2014. Counsel Assisting advised that the issues to be explored at the inquest were the circumstances surrounding the death of Che-Wei Su, including but not limited to:

1. The safety risks to visitors at Mossman Gorge;

2. The current safety management system at Mossman Gorge; and

3. The availability of rescue and emergency personnel at Mossman Gorge.

At the commencement of the inquest 78 exhibits were tendered. Mr McKinstry, who appeared for the Douglas Shire Council, advised that he did not wish to be present for the evidence but would appear for submissions.

Findings of the inquest into the death of Che-Wei Su 7

Counsel Assisting submitted that, considering the further evidence received since the pre inquest conference, the third issue for the inquest no longer required consideration since it was clear that training and maintaining a SWRT at Mossman was not a practical possibility. All parties agreed.

Thirteen witnesses gave evidence at the inquest.

The Witnesses Anthony Moynihan Detective Acting Sergeant Moynihan gave evidence that he attended the gorge in relation to the death of Mr Su. He was not the first police officer on the scene but attended later when it had already been established that Mr Su had died.

Since Mr Su’s death Sgt Moynihan has discussed emergency procedures with Mr Perris. He has been told that if police and/or emergency service personnel were required the bus driver would call down from the upper car park. Mr Perris said that some of the staff at the centre were trained in SWR and would be available to assist in such emergencies if required.

Sgt Moynihan is of the opinion that the safety information at the entrance to the walkway is not very prominent and there could be a separate sign warning of the dangers in swimming at that location. He also said that he thought there could be signage on the bus and at the centre to warn visitors of the dangers of swimming in the river.

Sgt Moynihan has often visited the gorge, the Centre and has caught the shuttle bus.

He has never seen warning signs on the bus or in the Centre. He has never seen the staff or bus drivers giving any advice to any customers.

He has seen all types of people swimming in the gorge. He said that most stay on the shallow edge but a number, mainly men, swim across the gorge to the bank on the other side.

Sgt Moynihan agreed that the pamphlet provided to visitors by the Centre had no warnings about swimming.

Sgt Moynihan said that he has looked at the QPWS website in relation to the gorge but can’t recall seeing any warnings about swimming on that site.

Sgt Moynihan said that on 15 February 2014 there was no mobile phone coverage at the location where Mr Su was found. Officer Port was walking back and forth from the road to the location to relay information via the radio in the police car.

There is no phone at the car park. Sgt Moynihan is of the opinion that a landline at the car park would be very useful in conducting police and rescue operations.

Sgt Moynihan travels the road to the upper car park frequently. It is narrow and shared by shuttle buses, local’s vehicles, pedestrians and cyclists. There is no footpath or track for pedestrians.

Findings of the inquest into the death of Che-Wei Su 8

Trevor Perham Sgt Perham lived in the Mossman Gorge area for thirteen years.

He and his children swam in the gorge on numerous occasions. He said that it is very popular with locals and visitors. He regularly saw more than 20 people in the water in the summer.

Sgt Perham said that the warning at the entrance to the park was on the bottom right of the large sign. He said that he thought that visitors could miss the second sign if they were concentrating on their surroundings.

Matthew Smith Sergeant Smith is the officer in charge of the Mossman Police Station and has lived and worked in Mossman for 13 years. He said that he was called to a fatal drowning in the gorge in April 2009 and a few months later he was called in when two people became stranded on a boulder due to rising water. He has heard of at least four or five other occasions when swimmers got into trouble and were saved by other swimmers. He said that it is generally tourists rather than locals who get into difficulty. The majority of people who swim at the gorge are tourists.

Sgt Smith said that he has swum with his family at the gorge on many occasions.

He, and other locals, know that it is not safe to swim at the gorge when it is cloudy up in the hills as that indicates that rain is falling in the catchment area which could cause flooding in the gorge. This can be the case even when it is fine at the gorge.

Sgt Smith took some visitors to the gorge, via the shuttle bus, about three months ago. There was no information provided as to swimming on the bus or at the Centre.

Sgt Smith said he doesn’t think the signage is very visible. He knows there is a sign at the entrance to the swimming area but he has not read it.

Sgt Smith said that once one leaves the Centre radio coverage is intermittent and that a landline in the top car park would be useful. Sgt Smith has recently been told that there is a phone in the ranger hut which can be used by emergency personnel.

The ranger hut is about 40 metres away from the entrance to the walkway.

Sgt Smith said that he thought that pedestrians could be at risk due to the lack of any walking track as they have to walk on the road.

Jim Whitehead Inspector Whitehead, Disaster Management, QPS, gave evidence that he has seen the signage at the gorge and is of the opinion that it does not adequately portray the dangers of swimming to visitors. He believes that large signs with symbols are required and that the warning at the entrance to the walkway should be on a separate sign.

Edward Lukin Snr Sgt Lukin was the officer in charge of the Mossman Police Station and lived there for five years. He is now the officer in charge of the Smithfield division.

He said that he swam at the gorge with his family three to four times per week when he resided in Mossman. He said that at the main swimming area water is channelled Findings of the inquest into the death of Che-Wei Su 9

between large boulders and quite often swimmers would get caught in the currents produced and dragged through those boulders.

When off duty and swimming at the gorge Snr Sgt Lukin saw quite a lot of people get into trouble at the swimming area. Most of those managed to get to the bank unassisted or with the assistance of other swimmers. All of the people he saw in difficulty were tourists. He said that during the summer season there would be up to 100 people visiting the gorge at any one time and sometimes 40 to 60 people swimming.

Snr Sgt Lukin recalls being called, as a police officer, to a drowning and two other incidents where people were stranded on rocks and the far bank when the water rose quickly and unexpectedly.

Snr Sgt Lukin visited the Centre on 15 February 2014 after Mr Su had died. There was a hand written note on a piece of paper on the counter which read, “No swimming today.” Michael Gunzberg Mr Gunzberg is a paramedic with the QAS. As there was no satellite or mobile phone or radio service in the gorge when they were looking for Mr Su, he stayed with the vehicle as it was a repeater for the portable radios. He could then convey information back to their Communications Centre.

Mr Gunzberg said that the lack of communication capabilities in the gorge has impeded ambulance operations in this case and in other cases as one officer either has to stay with the vehicle or walk back to it intermittently.

Clint Tunnie Inspector Tunnie, QFES, is a qualified Level 1 SWR officer. Level 2 officers are qualified to enter the water to undertake rescues.

Superintendent Tunnie said that QFES have regular and ongoing meetings with stakeholders in regard to Josephine Falls in regard to risk management, signage, water levels and whether the area should be closed to the public when it is too dangerous to swim there. The decision to close the swimming area is made by

QPWS.

Similar meetings have been held in relation to Mossman Gorge but they are not regular or ongoing.

QFES monitors water levels in the Mossman Gorge. The information is relayed to stakeholders and used by QFES to assess available resources etc.

The QFES has three local action plans in relation to Mossman Gorge and these are updated on a regular basis.

On 15 February 2014 it was necessary, due to the lack of radio and phone coverage in the Mossman Gorge, to leave a firefighter on the road to relay briefings to the Communications Centre.

William Brown Acting Assistant Commissioner Brown, QFES, provided a statement to the inquest in which he advised that the QFES identifies potential risks in the region and this Findings of the inquest into the death of Che-Wei Su 10

process can include consultation with the relevant stakeholders. He said that, in respect of Mossman Gorge, it is the intention of QFES to engage proactively with stakeholders including QPS, QPWS and Voyages with a view to establishing a risk identification and action process.

AC Brown stated that when the recommendations arising from this inquest are delivered, he will task the Northern Area Commander to commence consultation processes at an operational level.

Sam Savage Mr Savage drives shuttle buses from the Centre to the top car park of the gorge. He has been employed by Voyages in that capacity for approximately 12 months. He said that he has been trained in relation to the buses and the route and the Incident Plan.

Mr Savage said that two way radios have now been installed in the shuttle buses and drivers can now always communicate with the Centre.

If an incident occurs on the bus, the procedure is that he radios the Centre and staff there phone emergency services. Mr Savage has not received any training or advice in relation to incidents which occur in the gorge and has not received any training in relation to any such procedures since Mr Su’s death.

Mr Savage said that he monitors the river conditions when he drives past Mary’s rock as it is possible at that point to see the river from the road. He then tells the duty manager if he considers that conditions are dangerous and it is his understanding that the manager will inform customers that it is dangerous to swim. He also tells passengers if he considers it is dangerous to swim. He tells them to be careful as there are strong currents in the river. On occasions when the river level has been very high he has been told by management to tell customers that there is no swimming allowed.

Mr Savage said that he has never seen a landline telephone at the top car park. He was unaware of the location of the rangers’ hut.

Glenn Perris Mr Perris has been the Operations Manager at the Centre for seven months and prior to that was employed at the centre as the maintenance officer. When he commenced there he was provided with a general induction which included cultural awareness training. Mr Perris is trained in SWR, level 1. He was involved in the meetings which took place after Mr Su’s death and the reviews of the emergency response procedures for the Dreamtime walking tours.

He said that at the end of 2013 he was told that swimming was not allowed on the walking tours because of the water levels in Rex Creek. That prohibition remains in force.

Mr Perris said that there is a sign on the counter stating that swimming is not allowed in the Mossman Gorge – he is certain that it has been there every day since Mr Su’s death.

Mr Perris said that the tour guides assess the level of the water in the gorge every day and the staff members who sell tickets advise visitors that the conditions are Findings of the inquest into the death of Che-Wei Su 11

dangerous. The guides take tours four times per day and also give feedback to the staff about the conditions in the gorge.

Mr Perris said that he has carried out three rescues at the main swimming area. All of those occurred prior to Mr Su’s death. On the first occasion a lady dislocated her knee near the far bank. Mr Perris enlisted the assistance of a visitor to the gorge who had brought a kayak with him to help him bring the lady back to the near bank.

On the second occasion Mr Perris enlisted the assistance of an off duty lifeguard who was visiting the gorge to rescue two people who became stranded on the far bank due to rising waters.

On the third occasion Mr Perris helped a family back to the bank. They had got stuck on a rock in the river.

Mr Perris said that there was no rangers’ hut in the area of the top car park. There is a storage shed but he is unaware of whether there is a phone inside that building.

He said that mobile phone coverage at the gorge is intermittent and drops out at Mary’s rock.

Greg Erwin Mr Erwin is the General Manager of the Centre. It is his responsibility to ensure that the Centre is managed effectively and safely and to promote the business of the Centre.

About 250,000 people pass through the Centre to visit the gorge annually. An average of 50 to 70 people per day go on the Dreamtime walking tours.

The guides use visual cues to ascertain the levels at Rex Creek and whether it is safe to take tour participants swimming there.

New procedures were implemented on 18 February 2014 which encompass responses to incidents occurring in the gorge.

Mr Erwin stated that there has been no swimming on the tours since late 2013 due to the sustained high water levels in Rex Creek. The safety rope which spans the creek at the swimming area (known as “the beach”) went under the flood waters in November or December 2013. It then broke. The water has not yet receded to a level to allow it to be repaired.

Mr Erwin said that there was a cyclone warning issued on 5 February 2014 and everyone at the Centre was aware that water levels were high. There was a notice up on the counter stating that the gorge was flooding and it was there for several days. Mr Erwin has not been able to ascertain whether that sign was on the counter at the time of Mr Su’s death.

He said that there has been a sign stating “No Swimming” in the Centre every day since Mr Su’s death. There are four of those signs and they are on the counter at the location of each cash register – where bus and tour tickets are sold.

Mr Erwin stated that Voyages is willing and keen to review its procedures and the information that is provided to customers at the Centre, on the website and on the buses. The company would be willing to engage consultants to provide advice in that Findings of the inquest into the death of Che-Wei Su 12

process. The company would also like to receive advice from emergency services and QPWS as to the water levels and consequent safety risks but at this time does not receive any such advice.

Voyages is considering appropriate wording for its signs, the best ways to warn customers of the risk of swimming in the gorge and also, how the water levels could be monitored and who should do that.

Mr Erwin said it would be beneficial to establish a committee to consider all of the safety issues and how to move forward to progress the matters identified. He said he has had casual conversations with some of the stakeholders and they have agreed that such a committee would be beneficial.

Mr Erwin said that the Centre would like to be able to give appropriate warnings to customers as to the dangers of swimming but doesn’t have enough information available to do so currently. He is of the opinion that the information should be consistent rather than informal e.g. bus drivers may give different information to different groups at different times of the trip; the information given by staff selling tickets may vary with each customer. He is of the opinion that it may be of use to develop flyers that provide information and warnings depending on the level of water in the gorge at the time and hand that to customers as they purchase their ticket for the bus. Such information could also be put up on signs at the Centre.

The company is willing to review the information which is imparted on the video which is played on the bus. The company is willing to engage a consultant to advise on safety issues and how those issues can best be addressed.

Mr Erwin stated that, as the vast majority of visitors to the Mossman Gorge pass through the Centre, there is an opportunity to address and improve safety issues at the Gorge over and above that in other similar swimming areas.

Brendan Malone Mr Malone is the Senior Ranger for the Daintree National Park. His office is in the Centre. He is in that office for the majority of his working day.

Mr Malone is responsible for the management of staff and visitor facilities. He manages the rangers who are responsible for maintaining signage in the park and make sure that it is clean, visible and free of vegetation etc.

The rangers go to the gorge at least three times per week but usually once per day where they carry out tasks such as removal of rubbish, cleaning of facilities and blowing down of walking tracks. They are there for about an hour each time they visit.

Each time they visit the rangers look at the swimming area to make sure there are no hazards such as fallen logs etc. They observe the level of the river but do not report back to him or, necessarily, the Centre staff, about their observations.

Mr Malone has said that he has never passed on information to Centre staff about high river levels and he has never directed his staff to do so.

Mr Malone is aware of the poor mobile reception in the gorge and is of the opinion that it would be beneficial to visitor safety and to his operations to have coverage.

He was involved in a rescue at the gorge in 2013 and it was evident then that Findings of the inquest into the death of Che-Wei Su 13

communications issues hampered the rescue effort. After Mr Su’s death he wrote to Telstra and requested that the issue be considered but he has had no reply as yet.

Mr Malone said that there was a blue emergency phone at the gorge but it could not be maintained due to the high rainfall there – the lines would fill with water and it was unreliable. There is a landline in the ranger’s hut behind the facilities. Only rangers can access the phone and QPS have a master key.

Mr Malone is of the opinion that the current signs at the park are adequate but that their may be some scope to improve upon them to better engage visitors to warn them about the risks of swimming.

Pamela Harmon-Price Ms Harmon-Price is the Manager, Community and Visitor Services, QPWS.

She has been involved in the management of signs, with the Department, since 1987.

She is currently setting up a working group which will review the signage in those national parks where there has been a fatality or serious injury in the last five years.

She said that usually she is asked to review signage when there has been a fatality in a park but in this case she hasn’t received any such request.

Ms Harmon-Price is of the opinion that the signage at Mossman Gorge could be improved. It will be one of the parks for which the signage is reviewed.

James Newman Mr Newman is the Regional Director, Northern Region, the Department. He stated that the signs in the park were appropriate and adequate. He said that he would be very willing to be part of a committee to consider safety issues.

The Submissions Counsel Assisting Counsel Assisting submitted that I could make the following recommendations:

1. All of the stakeholders who operate in, or respond to incidents at, Daintree National Park form a committee and consider the issues raised at this inquest;

2. Voyages Indigenous Tourism Australia Pty Ltd engage a safety consultant to review the safety management in respect of its operation concerning: a) The advice to be given to visitors concerning their safety in the Daintree National Park; and b) The management of emergency incidents that occur in the Daintree National Park.

Ms Williams submitted that the inquest had identified several possible risks to the safety of visitors at Mossman Gorge but it is also apparent that the possibility of injury at the gorge is quite low given the numbers of visitors over the years and the incidents that have been reported to emergency services.

Findings of the inquest into the death of Che-Wei Su 14

Ms Williams stated that there are a number of entities working towards identifying and managing the risks at the gorge including Voyages, QPWS, QAS and QFES.

They have been successful given the low number of incidents that have occurred however, it became evident during the inquest that although they are working towards a common goal they are doing so separately and with no consultation between each other.

Ms Williams submitted that the Centre, as a conduit for visitors to the gorge, offers an opportunity to provide information to visitors that doesn’t exist at other national parks.

Queensland Ambulance Service Ms Banwell advised that QAS agrees with the first recommendation, above, and as a key stakeholder, would be a willing participant in such a committee.

Douglas Shire Council Mr McKinstry for the Douglas Shire Council advised that his client agrees with the first recommendation and would also participate in such a committee, as far as the matters under discussion were relevant to the Council.

Voyages Mr Trevino, for Voyages, submitted that, since its inception in 2012, the Centre has had a positive impact on the safety of visitors to the gorge as the road to the national park is now much less congested. The Centre has also had a positive impact for the local community in that it trains and employs large numbers of local indigenous people.

Mr Trevino submitted that the Centre has no control over what occurs inside the national park and it does not operate within the national park. Despite that and despite the fact that Voyages submits it has no duty of care to visitors to the national park, Voyages recognises that the Centre provides a unique opportunity for and plays an important role in improving the safety of visitors to the gorge. Voyages submits that it can improve safety by providing more advice to visitors and by assisting in communicating with and supporting emergency services.

Since Mr Su’s death Voyages has already taken steps to address improvements in relation to visitor safety. It has implemented new procedures. Those took effect from 18 February 2014 and set out the appropriate response when an incident occurs in the national park. New high powered radios and a repeater station have been installed so that bus drivers can communicate with the Centre from any place on their route. New maps are in the process of being drafted and it is envisaged that these will include information about the dangers of swimming in the gorge. A video is now played during the bus trip to the national park which incorporates a warning about swimming in the gorge.

Mr Erwin and Mr Perris said that since Mr Su’s death signs have been placed in the Centre which indicate to visitors that they should not swim in the gorge. Those signs have not been seen by any witness to this inquest who has visited the gorge since Mr Su’s death. Voyages accepts that this is the case and that the signage should be reviewed.

Findings of the inquest into the death of Che-Wei Su 15

Voyages has undertaken these changes without receiving any advice or assistance from the other stakeholders and would welcome the opportunity to be a member of a committee formed to discuss the safety issues.

Voyages would welcome a recommendation that the company engage a safety consultant to review issues of safety management in relation to its operations.

The Department Mr Parrott, for the Department, submitted that the signage at the gorge was adequate and appropriate and it did not contribute to the death of Mr Su.

The efficacy of safety measures relied on by the Department is illustrated by the low incidence of deaths and injury at the gorge.

People who are determined to act dangerously will do so regardless of warnings and signage.

Mr Su must have known that the currents were strong on the day of his death because he had just seen that Mr North had difficulty swimming across the river.

Regardless of that knowledge, he decided to enter the water and swim across the river.

The Department does not contend that the actions or inactions of the Centre contributed to Mr Su’s death in any way, however, recognises that the presence of the Centre is an opportunity to provide safety information to visitors to the gorge.

The Department agrees with Mr Erwin’s suggestion that links to information could be added to the Centre’s brochures and websites and that information could be provided in a flyer format at the point of sale.

The Department will be reviewing its signage in the national park.

The Department agrees with the recommendations submitted by Counsel Assisting.

Comments and recommendations Comments I am satisfied that no actions or inactions of any of the parties to the inquest contributed to the death of Mr Su.

All of the parties to the inquest employ their best efforts to manage the risks and facilitate the safety of visitors to the gorge and their success in those endeavours is evidenced by the relatively small number of incidents that are reported to QAS and other emergency services. There have been only two deaths at the gorge since 2003 and in the last five years only 31 incidents reported although approximately one million people have visited in that time.

However, those favourable statistics should not result in complacency. The Mossman Gorge is an unpredictable and inherently dangerous waterway and the danger increases in (the frequent) times of high rainfall when flash flooding can result. Whilst the water at the edge of the swimming hole may be calm and shallow, Findings of the inquest into the death of Che-Wei Su 16

the depth and strength of currents increases quickly once a swimmer moves out a short distance from the edge.

The majority of visitors to the gorge are tourists who have no local knowledge, may not understand the dangers of the volume of the water passing through the gorge and may not have English as their first language or be able to understand English at all.

A number of witnesses at the inquest identified possible improvements to safety procedures, in particular the way in which information about the risks of the gorge is provided to visitors.

As the vast majority of visitors to the Mossman Gorge pass through the Centre there is an opportunity to address and improve safety issues at the Gorge over and above that in other similar swimming areas where there is no such visitor centre and the only mechanism of delivering warnings is by the standard permanent signage.

As was stated by Counsel Assisting, the stakeholders are utilising their best endeavours in regards to safety at the gorge but they are working alone.

All of the stakeholders agree that it would be beneficial to form a committee to review the safety risks and how they are best managed.

The government departments who appeared at the inquest and Voyages have made every effort to provide this Court with information and advice as to possible improvements. The spirit of cooperation and willingness to address the issues demonstrated by the stakeholders at this inquest is commendable and has been of much assistance.

Recommendations I make the following recommendations with which the parties to the inquest are in agreement:

1. All of the stakeholders who operate in, or respond to incidents at, Daintree National Park form a committee and consider the issues raised at this inquest, including but not limited to: a. The safety of pedestrians and cyclists on the Mossman Gorge Road and whether a separate walking and bicycle path should be established; b. The information provided to visitors at the Centre including the content of that information and how it is delivered; c. The signage in the national park; d. Information sharing between rangers and Centre staff in regard to water levels in the gorge and associated risks to visitors; e. Whether at any time it would become appropriate to prohibit swimming in the national park due to high water levels in the gorge; f. Review of procedures relating to responses to emergencies occurring in the national park; Findings of the inquest into the death of Che-Wei Su 17

g. Changes to the Centre’s website and brochures; h. Access to the landline in the rangers’ hut for all stakeholders; i. Improved mobile phone coverage in the national park.

2. Voyages Indigenous Tourism Australia Pty Ltd engage a safety consultant to review the safety management in respect of its operation concerning: a. The advice to be given to visitors concerning their safety in the Daintree National Park; and b. The management of emergency incidents that occur in the Daintree National Park.

Findings required by s. 45 Identity of the deceased – Che-Wei Su How he died – Mr Su died when he was swept downstream by strong currents whilst swimming in the Mossman River. He struck his head on boulders and drowned.

Place of death – Mossman River MOSSMAN GORGE QLD

4873 AUSTRALIA Date of death– 15 February 2014 Cause of death – Mr Su died from drowning I close the inquest.

Jane Bentley Coroner Cairns 14 July 2014 Findings of the inquest into the death of Che-Wei Su 18