Finding into death of Lydia Denise Carter

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

_ Court Reference: 3796/06

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of LYDIA DENISE CARTER

Delivered On: 22 March 2012 Delivered At: Coroners Court of Victoria

Level 11, 222 Exhibition Street

Melbourne 3000 Hearing Dates: 22 November 2011 Findings of; HEATHER SPOONER, CORONER Representation: Mr: S Stafford on behalf of WorkSafe Victoria Police Coronial Support Unit: Senior Constable Kelly Ramsey

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I, HEATHER SPOONER, Coroner having investigated the death of LYDIA CARTER ,

AND having held an inquest in relation to this death on 22 November, 2011 at Melbourne

find that the identity of the deceased was LYDIA DENISE CARTER | aged 51 years

and the death occurred on 6 October 2006

at The Alfred Hospital, Commercial Road, Melbourne 3004

from:

la. HEAD INJURIES SUSTAINED IN A MOTOR VEHICLE COLLISION

(GO-KART DRIVER)

in the following circumstances:

1. Mrs Carter was aged 51 years old when she died. She was married with children and resided in the family home at 1/5 Maher Street Highett. Mrs Carter worked as an Accounts Clerk with Summit Holden Port Melbourne. She had past medical history that included Crohns disease.

Brief Background and Circumstances Leading to Death

2, A police investigation was conducted into the circumstances surrounding her death. It was apparent. that on the evening of Friday 6 October 2006 Mrs Carter attended a work social function at an indoor go-kart track in Port Melbourne. The company known as AAA Auscarts Imports Proprietary Limited (hereinafter referred to as ‘Auscarts’ and ‘the company’) conducted the business of hiring gokarts to members of the public at the track it operated there.

3. Prior to driving, all patrons underwent a safety briefing. The group of work mates were then divided into three different race teams and Mrs Carter drove in the second team. She wore a full face helmet. While participating in the race Mrs Carter apparently drove cautiously and slowly around the track, She had only travelled a short distance in her first lap when she was observed to fail to make a turn and drive the kart directly into a tyre barrier.

4. The estimated speed of Mrs Carter’s karl was no more than 25km/h. The karts were capable of reaching speeds of up.to 45 km/h. The tyre barrier that Mrs Carter struck consisted of a car lyre positioned directly in front of a concrete wall. The tyres were not connected to each other in any way and were pushed hard up against this wall. In some parts of the track, the concrete barrier was unguarded.

5. Following the collision patrons and staff came to Mrs Cartet’s assistance and emergency

services were notified. Mrs Carter was transferred to the Alfred Hospital but despite intensive efforts at resuscitation she passed away.

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Post Mortem Examinations

6. An autopsy was performed by Dr Noel Woodford, Senior Forensic Pathologist at Victorian

Institute of Forensic Medicine (VIFM). He formulated the cause of death and commented that he found °

no natural disease that was likely to have caused or contributed to Mrs Carter’s death.

7. Toxicology was negative for blood alcohol and other common drugs or poisons.

WorkSafe Investigation and Prosecution

8. An investigation was also conducted by WorkSafe Victoria. An expert report was obtained from Professor Raphael Grzebieta, He concluded that Mrs Carter’s helmet struck the steering wheel hub of the go-kart with sufficient force to result in.a fatal head injury. This was because her seat belt harness was not adequately fitted and because the tyre barrier of the track was too stiff. His investigations determined that:

• The induction session provided to patrons did not include details of basic kart operation such as steering and pedals; information deemed important particularly for first time drivers.

• Patrons were permitted onto the track despite their four point harnesses being loose and not properly fitted, The conduct of the marshals was deemed inadequate and this was likely because

_ they were poorly trained in the importance of a harness.

• Both the patron induction process and employee training program did not adequately address the selection of an appropriately sized helmet and ensuring their correct fitment.

• The car tyres bordering the concrete barriers were not secured and would often move around, requiring staff to reposition them. The concrete barriers were installed in October 2005.1 Auscarts did not undertake crash testing of the barrier system when sufficient expertise was available.

• The track barriers did not comply with the relevant Australian Standard AS3533.1 in that they were not capable of stopping a kart travelling at full speed in a manher so as to protect patrons against injury.

• There was no padding provided on the kart steering wheels, despite AS3533.1 specifying this.

• Auscarts employees did not hold first aid qualifications.

• In the three years prior to Mrs Carter’s death, there had been at least seven incidents at the same track where customers had sustained injuries as a result of a collision.

9. Auscarts were subsequently prosecuted in the County Court on three counts arising from breaches of the Occupational Health and Safety Act 2004 (hereinafter referred to as ‘the Act’), It was apparent that the cornpany had in fact gone into liquidation in 2008 and it did not appear at the trial on 4 May 2009,

10. In his Reasons for Sentence His Honour Judge Allen referred to the evidence of Professor Grzebieta and concluded that the breaches of the Act were ‘...serious examples of these offences...’ His

1 Refer io statement of Warren Morley (inquest brief, page 127)

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Honour noted that the practice of the company to permit ‘.... customers to drive go-karts which had not been fitted with properly fitted and adjusted seat belts ... as an outrageous state of affairs ....’. He further found in part:

• ‘..The likelihood of the hazards and risks eventuating, in relation to the inadequate safety barrier, the inadequate seat belts and the practice of permitting people to drive, notwithstanding these inadequacies was obvious. There was a high likelihood that, if collisions occurred, both employees and patrons would suffer injuries as a result of these inadequacies ....

• ...it would have been obvious to any reasonable employer, that a high degree of harm was likely to result if the hazards and risks eventuated ....

• the accused company actually knew that the safety barrier was inadequate. It had removed the NASCAR barrier, it had replaced it with an imported special barrier, it had removed that

• ...the employer, in this case, that is, the accused, not only was fully aware of the nature of the risks, but was fully aware of the ways to eliminate or reduce them ....

• ..the cost of eliminating the hazards or risks are concerned, I am satisfied that the cost was

not prohibitive or unreasonable...’2

11. In fining the company a total of $1.4 million he held that ‘.... the potential consequences were clearly foreseeable and very serious. The company demonstrated a gross disregard for the safety of its employees and members of the public...’

' Family Concerns

12. Mr Derek Carter, the widower of Mrs Carter wrote to the Coroners Court requesting an Inquest following the conclusion of the County Court proceedings. Understandably, his primary concemis related to the prospect of a repeated fatality and the possibility that identified safety issues had not been fully addressed, Mr Carter also raised concerns relating to the regulation of go kart track and driver safety,

13, A one day inquest was subsequently held to further investigate the relevant safety initiatives within the recreational go-karting sector following Mrs Carter’s tragic death in 2006, and whether any outstanding safety concerns remain.

CPU Referral 14, Following receipt of the request from Mr Carter, the Coroner directed the Coroners Prevention

Unit (CPU)* to examine recreational go-kart safety. Considerable information was obtained throughout the coronial investigation and at the inquest, including the following:

2 Reasons for Sentence, page 7, dated.12 May 2009

. 3 Reasons for Sentence, page 10, dated 12 May 2009

4 The Coroners Prevention Unit is a specialist service for coroners created to strengthen their prevention role and provide them with professional assistance on issues pertaining to public heath and safety,

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Brief overview of the recreational go-karting industry

There are two main forms of go-karting in Australia: go-kart racing and the concessional go-kart hire industry which simulates racing. A concession go-kart has been defined as:

A device which meets all of the following specifications: a small single vehicle, unattached to other vehicles or a common frame system, with the seating less than 250 mm above the ground, with a steering wheel, which is powered without connection to a common energy source, which is driver controlled with respect to acceleration, speed, braking and steering, which is intended to operate within the delineated path-of travel of a defined track, which simulates competitive motor sports and which is used by patrons for a fee. A concession go-kart has a maximum capacity of two persons and no cargo capacity. 5

15. Go-kart hire venues can operate either indoor or outdoor. The primary market segments -are corporate events, adult social groups, children’s parties, school groups and the general public, There are also mobile go-kart hire operators who set up temporary facilities at fairgrounds and special events, although the safety risks are dissimilar to permanent tracks.

16. Concession go-karts generally travel at speeds of between 40-50km/h (maximum kart speed can be up to 85km/h)® whilst racing karts reach speeds in excess of 100km/h, Unlike a car, minimal protection is offered to operators in the event of a crash,?

Key stakeholders

V7, The Australian Concessional Karting Association (ACKA) represents the recreational go-kart hire industry. It was formed in 2008 to bring together industry members. ACKA is a sub-committee of the Australian Amusement Leisure and Recreation Association (AALARA) which is the peak national body for the amusement, leisure and recreation industry in Australia, Terry Skene is the Chair of the ACKA Committee and also a Board Member of AALARA. Mr Skene advised the Court that there are around 45-50 independent recreational go-kart operators in Australia8 and 21 have a paid membership with AALARA. Four major Victorian operators are members. He further advised that to be a member of AALARA an amusement business must have an ABN, be registered with a work health and safety authority and maintain a $10 million public liability insurance policy, Around 75% of the amusement industry is a member of AALARA.

18. The Australian Karting Association (AKA) is appointed to administer and control the competitive stream of karting in Australia. There is no relationship between AKA and ACKA.

5 As per AS3533.4.4-2011 6 Refer to the ACKA Industry Code of Practice (clause 4.6) which states: "The maximum attainable speed by any hire kart shall not exceed 85kph, unless a documented hazard identification and risk assessment has been carried out by a competent erson, and shows such a requirement to be unnecessary." Grzebieta, R., Zou, R. & Rechnitzer, G. (undated). Go-Karts - Can they be crashworthy? Unpublished manuscript provided to the Coroner by WorkSafe Victoria. .

Refer to page 32 of inquest transcript,

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19. | WorkSafe Victoria is responsible for regulating the recreational go-kart industry in Victoria. Gokart operators have several obligations under the Occupational Health and Safety Act 2004, including ensuring that non-employees (members of the public) are not exposed to risks to their health and safety as a result of the operation of the business (s.23). Go-karts are classed as an amusement structure and require registration with WorkSafe in accordance with the Occupational Health and Safety Regulations 2007, Go-kart venues are not required to bé registered.

Previous go-karting fatalities and non-fatal injuries:

20, A search of the National Coroners Information System (NCIS), the CPU database and the internet identified a total of eight go-karting deaths in Australia, including that of Mrs Carter, Where sufficient information was available (n=6), three deaths occurred in a racing setting, two deaths occurred at a go-kart hire venue and one death occurred at a disused racetrack. Mrs Carter’s death was the only go-karting fatality identified in Victoria since 2000. ‘

21. There was scant published literature identified that related to go-karting injuries in Australia. A general lack of available injury statistics was also raised at the inquest.

22.. WorkSafe Victoria advised the Court that employers and self-employed persons have an obligation under the occupational health and safety legislation to notify WorkSafe of certain serious incidents. The notification criteria are strict and generally relates only to serious injury and death.?

23. A copy of the meeting notes of an ACKA committee meeting held in April 2010 was provided to the Coroner. In this meeting the committee deemed that research was necessary to establish an industry profile (no, of venue operators, patron, staff, etc) and to gather information on injuries requiring hospitalisation, The committee recommended that an industry research paper be developed.

Mr Skene advised that a national insurance scheme is set up and will in time collate a register of injuries claimed within the industry.

Non-fatal injuries in Victoria

24. The Victorian Injury Surveillance Unit (VISU) provided the CPU with data concerning hospital admissions and emergency department (ED) presentations due to go-kart injuries in Victoria over an eight year period (2002/03 to 2009/10),

25. In this period there were 243 admissions and 760 ED presentations, equating to an annual average of 30 admissions and 95 presentations. Males accounted for over 80% of those injured and most injured were aged 10-19 years (37% of ED presentations and 30% of admissions).

26. A subtle increase in the number of hospitalisations was evident althongh little could be drawn from this as exposure information was not available, Moreover, the data does not indicate where the injuries occurred (i.e. racing, recreational or other settings). Among those admitted to hospital, more

9D Refer to page 66 of inquest transcript.

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than two-thirds required a hospital stay of less than two days and 90% were discharged to private residence.

27, The grouped body regions most commonly injured were the upper extremity (37% of admissions and 29% of ED presentations) and the trunk (28% of ED presentations and 26% of admissions). The specific body region most frequently injured was the thorax (21% of ED presentations and 20% of admissions). Among the ED presentations, collisions were cited as the most common cause of injury (45%) followed by falls (12%) and roll-overs (8%). ;

Evidence at Inquest

28. Mr Michael Nathan a senior engineer at WorkSafe gave evidence going to a letter that was provided by Ms Jodie Burns, a lawyer in the Coronial and Enforcement Group at WorkSafe,l0 Mr Nathan was taken through the correspondence. It was apparent that following Mrs Carter’s death, WorkSafe had conducted a number of targeted and non-targeted compliance visits to industry operators

to ensure they were complying with thcir relevant occupational health and safety duties.

29, In 2009 WorkSafe began drafting a guidance document to provide information to duty holders, although this was deferred due to the development of the new Australian Standard (AS) 3533.4.4 that specifically relates to concessional go-karting.

30. Mr Terry Skene gave evidence via video link. Mr Skene attended to give evidence as an industry representative and he detailed the industry-driven safety developments following Mrs Carter’s death.

31. The first major output of ACKA was the development of an industry code of practice for the gokart hire industry which focussed on the safety of customers and staff whilst the track was in operation.

This code formed the basis of the subsequent draft of AS 3533.4.4. All operators are asked to comply with the ACKA code of practice and to operate within AS 3353.4.4,

32. The most notablé achievement appears to have been the establishment of the specific industry safety standard for concessional go-karting in Australia, AS 3533.4.4, Mr Skene advised that ACKA has made a submission to work health and safety authorities to have AS 3533.4.4 translated into a formal OH&S code of practice for go-kart hire.

33. Mr Skene has also taken on the task of contacting and communicating with as many go-kart operators in Australia as possible. If a workplace health and safety notice or alert is received by ACKA for exaniple, it is automatically emailed and distributed to known operators. He advised the inquest that operators are primarily identified through the Yellow Pages. ,

10 Letter dated 16 November 2011 found in Victoria Police inquest brief.

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Australian Standard 3533.4.4-2011

34, The objective of the standard is to provide designers, manufacturers, proprietors and operating staff with requirements and guidance specific to the design, construction, operation and maintenance of concession go-karts and facilities that will protect the health and safety of both operating staff and patrons of these devices,

35. The Standard references and modifies the requirements of the USA’s American Society for Testing and Materials ASTM I'2007-7a-Standard Practice for Design, Manufacture and Operation of Concession Go-Karts and Facilities.

36. It also complements the general requirements for amusement rides and devices specified in AS3533,1 - Amusement rides and devices - Design and construction, and AS35332 - Amusement rides and devices - Operation and maintenance. Prior to the existence of this standard, only minimal advice specific to go-karts was contained in AS3533.1 and 3533.2,

37. Several safety issues identified in the course of investigating Mrs Carter’s death have been dealt with in AS 3533:

Content of patron induction sessions

38. AS3533.4.4 provides more detailed information relating to driver instruction prior to the operation of the go-kart than both the ASTM standard and AS3533.2, Clause 7.11 of AS3533.4.4 states that:

All patrons shall be instructed, personally or by audio and/or video recording, in the following matters before being allowed to participate in concession go-kart activities:

(a) Rules and procedures for safe operation of the go-kart and for the safety of patrons.

(b) The location and meaning of warning signals and the importance of strictly following all messages conveyed from signals displayed.

(c) The location of the entry to the loading/unloading area so that patrons may return to this area in a safe manner. :

(d) Instructions on overtaking - procedure, collision response, vigilance and patron responsibility.

(e) Drivers shall keep both hands on the steering wheel and drivers and passengers shall keep feet and arms within the body of the kart, while the karts are in motion.

(f) Any misbehaviour or failure to observe these safety instructions and procedures may result in karts being slowed, or stopped, and the driver being removed from the track.

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Padding on steering wheels

39, The new AS 3533.4.4 does not contain any reference to padding for the go-kart steering wheel.

Mr Skene explained atthe inquest that if the driver was sitting in a kart with a correctly fitted harness and a correctly fitted helmet, the steering wheel should sit almost at stomach height rather than face level. The committee responsible for the development of the standard did not recommend padded

• steering wheels as this could encourage a ‘bumper car style’ mentality and instead recommended that all helmets be a full face type. Moreover, a patron securely restrained within the kart should prevent such movement that would result in contact with the steering wheel.!!

Driver restraint devices and checking systems

40. The Australian Standards in place at the time of Mrs Carter’s death made no reference to the need for harnesses to be adequately fitted to the patron, only to wear a seat belt at all times (clause 4,3.5(c) of AS3533.2),

41, | WotkSafe Victoria advised that they had considerable input into the issue of driver restraint devices throughout the development of the new AS3533.4.4, They emphasised the need for restraints to not only address the risk of ejection from the kart, but also the potential for patrons to impact other parts of the go kart, such as the steering wheel hub, in a collision. With respect to seat belts, clause 5.10 of AS 3533.4.4 now states: ,

Seat belts of the retractable lap/sash configuration, with inertial activation, four point harness configuration, or five point harness configuration complying with AS 2596 shall be fitted to all concession go-karts, to control the risk associated with patron ejection and/or impact with other parts of the kart during collision, unless a documented hazard identification and risk assessment has been carried out by a competent person, and shows that a safer outcome can be achieved by not fitting seatbelts to the go-kart, ‘ : 42, A system for checking that restraints are sufficiently tight and fitted is critical, The previous AS3533.2 referred only to checking a patron’s hair and whether they were wearing loose. or baggy clothing (clause 4.3.3). ‘

43. Clause 7.8 further states: Concession go-kart track attendatits shall verify that drivers and passengers are secured properly in provided restraint devices consistent with the manufacturer’s specifications prior to authorizing go-

kart operations to commence.

44, The need for checking is again mentioned in clause 7.19.

IL Refer to page 25-26 of the inquest transcript.

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Selection and fitting of helmets

45, Clause 7.18 is a new section that did not exist in the ASTM standard. It deals with the protection of drivers and passengers, including helmets:

(b) Full face helmets with visors shall be worn by the drivers and passengers of concession gokarts. Helmets shall comply with AS 1698!2 and be maintained in a fit and hygienic condition. .

(c) Where the visor of a full face helmet is not used, alternate eye protection shall be provided to drivers and passengers. ,

46. Clause 7.19 introduces the requirement for helmet checks by the track attendant and this did not feature in the ASTM standard or AS 3533.2:

A check shall also be made of the driver's ability to reach controls (pedals and steering wheel) and where seat belts are fitted that they are correctly secured and adjusted on the patron. Safety helmets and their straps shall also be checked for correct fitting.

Barrier systems

47, Mr Skene advised the inquest that operators were now considerably more aware of the injury risks with respect to certain barrier systems. He noted that barriers bolted together, clearance runoff and clearance behind barriers have now become an accepted standard throughout the industry and are an operational practice, "not just a rule that is written,"13

48, The importance of using a barrier system that is capable-of absorbing the impact of a kart at full speed to minimise injury is reflected in the new Standard. Consideration of rigid structures behind the barrier is also mentioned whereas the previous AS 3533.1 did not touch on this, Clause 6.1 of AS3533.4.4 states:

Concession go-kart tracks shall have a barrier system to contain the go-kart within the designated track route where departure from this route will present a risk to the driver, or others, e.g. entering another section of the track surface, a track attendant station or spectator area.

The barrier system shall be designed and installed so as to limit its displacement to that which prevents a risk to the driver or others whilst providing sufficient energy absorption to stop a kart at full speed with minimal risk of injury to the driver or patrons.

NOTE: More substantial barriers may be required on corners, as the kart may need to be stopped rather than deflected, and in areas with rigid structures behind the barrier system where there is limited displacement distance in which to stop the kart, Sec also Clause 6.1.8.

12 AS/NZS1698:2006 - Protective helmets for vehicle users Refer to page 30 of inquest transcript.

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49. With respect to tyre barrier systems, clause 6.1.1 goes on to state:

Tyre barrier systems, if. used without a track side continuous band, shall consist of common 15 or

16 inch road tyres or 18 to 24 inch racing tyres, or equivalent, in groups no less than 4 tyres long

secured together in such a way as to be in one continual length. When tyres are bolted no bolts are

to be exposed or able to come in contact with a kart.

NOTES:

1. The use of four wheel drive, tractor or commercial vehicle tyres is not recommended due to their

increased rigidity.

2. Tyres may also be used to assist in delineating the track surface either individually

Padding on steering wheels

or in groups.

50. Clause 5.7.2(e) of AS3533.1. in place at the time of Mrs Carter’s death stated that steering

wheels shall be sufficiently padded.

51. The new AS 3533.4.4 does not contain any reference to padding for the go-kart.s Mr Skene explained at the inquest that if the driver was sitting in a kart with a correctly

eering wheel.

fitted harness

and a correctly fitted helmet, the steering wheel should sit almost at stomach height rather than face Iével. The committee responsible for the development of the standard did not recommend padded steering wheels as this could encourage a ‘bumper car style’ mentality and instead recommended that all

helmets be a full face type. Moreover, a patron securely restrained within the kart should prevent such

movement that would result in contact with the steering wheel, !4

Staff training

52, AS3533.4.4 now states:

7.1 Safety training - Safety training shall be provided for each concession go-kart shall include, but not be limited to, the following:

7.1.1 Instruction on concession go-kart operating procedures.

7.1.2 Instruction on specific duties of the assigned position.

7.1.3 Instructions on general safety procedures,

7.1.4 Instructions on emergency procedures.

7.1.5 Demonstration of the physical ride or device operation.

attendant and

7.1.6 Supervised observation of the concession go-kart attendant’s physical operation of the

ride,

14 Refer to page 25-26 of the inquest transcript

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7.1.7 Additional instructions deemed necessary by the operator.

7.2 A written training outline/checklist shall be used in all training programs.

53. A requirement for a person qualified in first aid to be on duty at all times when the track was in operation was specified in clause 4.3.2 of AS 3533.2 which was in place at the time of Mrs Carter’s death, Clause 7.21 (a) of AS3533.4.4 now states that:

First aid training (Level 2 is considered the preferred standard) should be attained by at least one staff member on duty at any one time.

Conclusions

54. Since the death of Mrs Catter in 2006 considerable progress has been made in relation to concessional go-karting safety:

• WorkSafe Victoria initiated compliance visits to go-karting operators across Victoria to verify compliance with occupational health and safety duties.

• The Australian Concessional Karting Association (ACKA) was formed as a sub-committee of AALARA in 2008 to collectively address safety issues.

• An industry-specific Code of Practice was developed by ACKA and last updated in April 2010, which formed the basis of the draft Australian Standard.

• An Australian Standard for recreational go-karting was developed and subsequently released in December 2011 (AS3533.4.4-2011 Amusement rides and devices Part 4.4; Specific requirements - Concession go-karts), Safety issues recognised in Mrs Carter’s death informed the development and content of the Standard.

• Overall, industry awareness and the general state of knowledge with regard to safe karting operations seem to have improved across Australia and communication channels now exist for ACKA to regularly liaise with industry counterparts.

Findings

Mrs Carter’s needless death from head injuries whilst driving a go-kart at a venue operated by Auscarts was preventable.

This most unfortunate death has however resulted in industry action and a greater awareness of the

injury risks associated with go-karting, particularly around the design of barrier systems and the vital importance of secure safety harnesses. The concern of her husband Mr Carter, to prevent another go-

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karting fatality has. been shared by the industry, which has worked toward the development of the Australian Standard.

Whilst the Australian Standard 3533,4.4-2011 remains a voluntary document, the underlying health and safety dutics for go-kart venue operators are stipulated under the Occupational Health and Safety legislation and WorkSafe possess sufficient powers within the legislative framework to issue prohibition notices or to close down a venue if necessary.

RECOMMENDATIONS: Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death: ;

1, The significant effort of both the recreational go-karting industry and WorkSafe Victoria to improve the safety of recreational go-karting across Victoria (and Australia) is acknowledged and recognised.

In an effort to ensure the ongoing safety of patrons at recreational go karting venues, il is recommended:

• That WorkSafe Victoria develops guidance material to support concessional go-kart venue operators in meeting their occupational health and safety duties, as per their previous intention.

This material could also be used as an instrument to further publicise Australian Standard AS 3533.4,4 and industry association contact details,

• That, in order to inform ongoing safety efforts, the Australian Concessional Karting Association work towards establishing a better industry profile, including operator numbers, and monitoring patterns of injuries sustained by patrons at a national level to facilitate a more proactive response to emerging safety concerns,

I direct that a copy of this finding be provided to the following: °

The family of Mrs Carter Investigating Member

Mr Terry Skene, Chair, ACKA

Ms Jodie Burns, WorkSafe Victoria

Signature:

COINS Oo

HEATHER SPOONER CORONER

Date: 22 March 2012

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