Inquest into the Death of Graham, Michael Keith

Coroners Act, 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref No: 45/13 I, Evelyn Felicia Vicker, Acting State Coroner, having investigated the suspected death of Michael Keith GRAHAM, with an Inquest held at Perth Coroners Court, Court 51, Central Law Courts Building, 501 Hay Street Perth, on 18 December 2013 find that death has been established beyond all reasonable doubt, the identity of the deceased was Michael Keith GRAHAM and that death occurred on a date unknown between 15 January and 11 February 2013 in and around the area of 5 mile well on Riverina Station out of Menzies in the following circumstances - Counsel Appearing : Sgt L Housiaux counsel assisting the Acting State Coroner TTaabbllee ooff CCoonntteennttss Inquest into the death of Michael Keith GRAHAM 780-13 page 1.

IINNTTRROODDUUCCTTIIOONN On the morning of 14 January 2013 Michael Keith Graham (the deceased) was noticed to be missing from his campsite by his co-prospector, Peter Ian Holloway (Holloway).

He did not return and police were notified of his disappearance at lunchtime on 15 January 2013.

There followed one of the biggest land search and rescue (LandSAR) operations seen in Western Australia which located no sign of the deceased. The search was about to be scaled down on 22 January 2013 when the land owner of Riverina Station located evidence of recent human activity in the vicinity of a cattle water trough.

The search continued but was unsuccessful in locating the deceased and on 11 February was halted after survival packs, left for the deceased, were found to be undisturbed.

The deceased was 46 years of age in February 2013.

This finding replaces an interim finding produced on 18 December 2013 to assist the deceased’s family to procure a passport for the purposes of travel and family support.

Inquest into the death of Michael Keith GRAHAM 780-13 page 2.

BBAACCKKGGRROOUUNNDD The deceased was born on 14 October 1966 and was a resident of Arcadia Vale, New South Wales, with his wife and two children.

The deceased had worked in various jobs including hospitality, building and landscaping, and while at the time of his disappearance he was not employed he was engaged in breeding reptiles on a semi-commercial basis.

The deceased had suffered two serious motor vehicle crashes in 1998 and 1992 which resulted in health issues which may have been relevant to his capabilities in the bush.

He had had two knee replacements and one kidney removed, and suffered chronic back ailments. He used pain relief in the form of oxycontin to manage his pain. He had a degenerative back condition.

THE EVENTS The deceased travelled from his home in New South Wales to Menzies in WA over the New Year 2012-2013. He arrived in Menzies on 2 January 2013.

The deceased stayed at the Menzies Hotel, owned and managed by David William McKenna (McKenna), whom he was going to assist in managing the hotel while McKenna took a period of leave from the area.

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On 11 January 2013 the deceased and a prospector, Holloway, departed Menzies and travelled to Holloway’s prospecting lease. The lease in located 75 kms north west of Menzies about an hour’s drive on unsealed roads. The lease is upon Riverina Station, a pastoral lease covering half a million acres.

The deceased and Holloway arrived where they intended to make camp at about 3pm on 11 January 2013 and set up camp.

On 12 January 2013 it rained heavily and both Holloway and the deceased spent the day ensuring the camp was rainproof. The deceased was intending to sleep in his motor vehicle, a Nissan X Trail.

On 13 January 2013 the deceased commenced searching for some particular flowers he thought may be a cure for cancer, apparently he believed he may have a condition which would turn cancerous. He and Holloway also spent time panning and looking at the rocks in the vicinity. The deceased retired to his vehicle sometime between 9 and 10pm on 13 January 2013.

The following morning, 14 January 2013, Holloway woke at about 9.00 hours and noticed the deceased was not Inquest into the death of Michael Keith GRAHAM 780-13 page 4.

present. Holloway had a cup of coffee and commenced prospecting assuming the deceased was already out and about.

When Holloway returned to camp at 12.30pm he found the deceased still absent and started tooting his motor vehicle horn to create a noise for the attention of the deceased.

When he received no response he commenced a search of the immediate area heading in a southerly direction.

Holloway returned to camp before 6pm and noticed the deceased was still missing. As a result he telephoned a friend in Menzies and advised him of the deceased’s disappearance, assuming his friend would notify the police.

Holloway set up a light in the trees to attract the deceased should he observe it overnight.

The friend in Menzies spoke with the publican of the Menzies Hotel, McKenna, and they decided it was too late to notify the police that night and that they would speak with Holloway in the morning.

On the morning of Tuesday 15 January 2013 Holloway continued to search for the deceased using his motor vehicle but did not locate him, and when he spoke with his Inquest into the death of Michael Keith GRAHAM 780-13 page 5.

friend in Menzies at lunchtime told him the deceased was still missing.

McKenna and the friend departed Menzies and drove to Holloway’s camp with McKenna calling police and reporting the deceased’s disappearance at 12.50 hours on Tuesday 15 January 2013. The call was taken by the sergeant at Leonora Police Station.

McKenna and the friend arrived at Holloway’s camp at approximately 2pm and there met Holloway. During the course of the afternoon they made contact with the caretaker for Mt Ida.

McKenna and the friend drove back to Menzies that afternoon and the Leonora Police were again contacted at 4.15pm.

TTHHEE SSEEAARRCCHH The sergeant of Leonora police commenced enquiries following the receipt of her phone call from McKenna at 12.50pm on 15 January 2013. She arranged for the caretaker from Mt Ida to attend Holloway’s camp to assist with the search in that area.

After hearing from McKenna at 4.15pm that the deceased had not been located the response was escalated and the Inquest into the death of Michael Keith GRAHAM 780-13 page 6.

sergeant from Leonora notified the Goldfields/Esperance District Office and the WA Police Emergency Operations Unit of the disappearance of the deceased at approximately 4.30pm. Jupiter Mine and Menzies Shire were also made aware of the deceased’s disappearance.

Police were dispatched to Holloway’s camp and travelled along the Mt Ida/Leonora Road where they were approached by the Mt Ida mine site camp caretaker. He stated he had been to Holloway’s camp but could not find Holloway and advised the campsite was difficult to locate.

He advised he had left a mark on the Mt Ida Road for the beginning of the track leading to Holloway’s camp.

The police officers continued along the Mt Ida Road and at the yellow marker took the Global Position System (GPS) coordinates for the camp turnoff. The police then continued to the Menzies Hotel where they spoke to McKenna in person before returning to Leonora to update the police sergeant.

The sergeant at Leonora contacted DFES requesting a LandSAR operation be launched with an air observer, personnel and the conveyance of aviation fuel to the search area. The Police Airwing arranged for a helicopter from Meekatharra to be at that camp area the following morning.

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At 9pm on 15 January 2013 the Leonora sergeant requested Leinster Police to attend and assist with the search.

From the 16 to 22 January 2013 there was an intensive land search assisted by consultant input with respect to the deceased’s timeframe for survival (TFFS). It was initially estimated the deceased would be most likely to be limited in his movements within an 8-10km radius from the camp. It was noted the deceased had left his mobile phone and GPS in his vehicle. The deceased’s wife advised the inquest the deceased never went very far without his mobile phone and GPS and the implication would be the deceased had not intended to move very far from the camp.1 The search was extensive and involved a considerable number of personnel from the police, State Emergency Services, and also used techniques such as lights at night and the activation of police sirens. The day time temperatures were hot and the terrain dense with an uneven ground surface which slowed the search timeframe.

By the end of 22 January 2013 approximately 100 square kilometres of land had been searched by foot, horse and helicopter to a calculated probability of detection (POD) of 90%. The helicopter had searched a total area of approximately 640 sq kms at POD estimated at 80%.

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The consultant with respect to TFFS considered it would be unlikely the deceased had survived any longer despite the fact there had been rain which may have assisted in his survival.

However, on the afternoon of 22 January 2013, the owner of Riverina Station, Donald Edward North (North) was conducting checks of the bores and wells on the station outside the search area when he discovered unusual signs of activity at 5 mile well and the adjacent cattle yards.

A makeshift shelter made of tin and branches leaning against the fence was located inside the cattle yards however, no foot prints were located. Twenty metres south of the cattle yards was the word “SOS” though North believed the markings in the area were two or three days old.

On checking the water trough North discovered the algae had been removed from the trough to provide clear drinking water and there was a piece of wood across one end. The algae was still relatively moist and the ground nearby damp from water which gave an estimation the algae had been disturbed in the previous 24 hours.

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North searched the area including an old sandalwood camp where he noticed another makeshift shelter but no footprints.

North drove to the Police Command Centre for the search and reported his findings which resulted in a ‘Fast Team’ being deployed to the site and arriving at nightfall. A contact search was made of the immediate vicinity and a pair of green underpants (later identified by Mrs Graham as similar to those worn by the deceased) was located before further searching that night was suspended due to the conditions.

Five mile well is approximately 14 kms south east of Holloway’s camp and 4 kms outside the identified search area.

As a result of those findings the search was continued rather than being deescalated. Search teams were deployed from the area and the Police Forward Command relocated to the 45 mile outpost, approximately 5-6 kms from five mile well.

The TFFS consultant was provided with new information with respect to the findings and the conditions and he considered it likely the deceased would have been in the area of the trough some 1 to 1 ½ days earlier. He thought it likely the deceased would be approximately 1-2 days walk Inquest into the death of Michael Keith GRAHAM 780-13 page 10.

from the 5 mile well but as a result of his weakened condition would have expected it to be within a 3 km radius. He gave some indicators for likely behaviours.

The helicopter was deployed to search the area around 5 mile well and vehicles deployed around tracks leading in and out of the area.

At approximately 10am the helicopter located a marking in the track approximately 1km from 5 mile well which when accessed by the ground team noted “walking very weak” with an arrow pointing west back towards 5 mile well.

The search was continued with the helicopter and ground search teams and four Tactical Response Group (TRG) tracking specialist officers were flown and deployed to 5 mile well to track the deceased.

Survival packs were made up containing food, water and multivitamins. They also contained matches and instructions to the deceased on how to start a fire and to remain at its location.

There was a thunderstorm at approximately 4.20pm on the 23 January 2013 which necessitated the suspension of the search at that time.

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On 24 January 2013 the search was recommenced from 5 mile well and the survival packs deployed along tracks and fence lines, wells and bores.

The Police aircraft commenced a grid search that covered 20 kms north and 20 kms east of 5 mile well.

The helicopter pilot located the word “help” near Kurrajong Well, approximately 7.5kms east of Holloway’s camp. The search redeployed to this area but decided the writing was at least 24 hours old.

The rain from the thunderstorm made it difficult to locate tracks or signs but would have provided water to the deceased, depending on his condition.

The search continued using helicopter, plane, field searches, TRG trackers and police traffic motorbikes over the following days until 28 January 2013. The police FLIR was also used to track heat sources.

Despite this extremely intense and targeted search of areas of interest no sign of the deceased was further located and the TRG trackers were sure they would have located him if he was alive and moving.

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On 29 January 2013 the search was deescalated. No further signs of human activity had been found.

From 29 January through to 11 February the survival packs were checked but no activity was detected and they were removed from their locations on 11 February 2013.

From 29 January 2013 several prospectors and four wheel drive enthusiasts conducted their own searches with the permission of land owners. None reported any findings or signs of life.

OOTTHHEERR IINNVVEESSTTIIGGAATTIIOONNSS Extensive investigations by the police of the deceased’s personal telephone, bank accounts and the campsite failed to reveal any indication the deceased had planned any unexpected activity or disappearance.

There has been no sign of the deceased or indication he may still be alive since the last of the writings were discovered in January 2013.

The deceased’s wife has had no communication from the deceased and in court Mrs Graham felt the fact her husband had left messages indicated a wish to be discovered and return home. 2 2 t 18.12.13 p22 Inquest into the death of Michael Keith GRAHAM 780-13 page 13.

CCOONNCCLLUUSSIIOONN AASS TTOO TTHHEE DDEEAATTHH OOFF TTHHEE DDEECCEEAASSEEDD I am satisfied the deceased was a 46 year old part-time prospector who travelled out to Riverina Station with Holloway who operated a lease in the area.

The two men arrived at Holloway’s campsite on the 11 January 2013 and initially prospected together.

On the morning of 14 January 2013 the deceased moved away from the campsite, alone. He left his GPS and mobile phone in his vehicle implying it was not his intention to travel very far from the campsite. The deceased had prior operations on his knees which may have affected his mobility in adverse conditions.

The deceased was never seen alive again.

When Holloway became satisfied he could not locate the deceased the Police were notified and as a result a very intensive land search operated from the 15 to 22 January 2013.

On 22 January 2013 the owner of Riverina Station noticed activity indicating the deceased had been in the area recently.

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The search was extended but despite locating messages from the deceased he was not found and the search was finally halted on 11 February 2013.

I am satisfied on the evidence the search was extensive and it is not conceivable the deceased survived any longer in the conditions with which he was faced.

I am satisfied beyond all reasonable doubt the deceased has died and that death occurred in and around the 5 mile well on Riverina Station.

I am satisfied death occurred some time between the 15 January to 11 February 2013 although I am unable to state with any certainty how precisely the deceased died.

He could have become injured and died as a result, his writings seem to imply he was becoming disorientated and acting strangely by not remaining with a water source, and it is likely he was suffering the effects of a lack of appropriate sustenance.

While I am unable to say precisely how the deceased died in all the circumstances surrounding the death I find death arose by way of Misadventure.

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EEVVIIDDEENNCCEE OOFF SSUUPPEERRIINNTTEENNDDEENNTT DDAARRRREENN SSEEIIVVWWRRIIGGHHTT Darren Seivwright, Superintendent, Goldfields/Esperance District Office wished to give evidence to the inquest about the land search for the deceased, and specifically the use of personal locating beacons (PLB) where people are expecting to be in remote areas where mobile phone coverage can be non-existent.

Superintendent Seivwright pointed out that under the WA Emergency Management Act 2005 and Emergency Management Regulations 2006 responsibility for search operations within Western Australia falls to the WA Police to conduct land searches where lost persons require significant coordination of search operations.

More recently there have been significant and tragic land incidents involving missing gold prospectors in remote eastern Western Australia. These LandSAR incidents are extremely costly to the WA community both by way of life and resources. As such the Police are anxious there be improved discussion and education on potentially preventative initiatives which could be implemented to achieve desirable outcomes, mainly improved survivability of missing persons, and a reduction in cost of the LandSAR incidents.

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Superintendent Seivwright advised the inquest that professional or hardcore prospectors3 carry PLB devices of some sort or another in any event, and Police concern was more with the occasional or hobby prospector.

Superintendent Seivwright caused a review of WebEOC holdings from 1 January 2012 to 3 December 2013 in an attempt to provide information relating to persons who, in the course of prospecting, had become lost or distressed. His inquiry indicated the following results from that time period: (cid:1) There had been 20 LandSAR incidents involving prospectors, mainly in the Goldfields/Esperance district, but also in the mid-west, Gascoyne and Pilbara districts.

(cid:1) In those LandSAR incidents there had been 20 deployments of Police personnel, 8 of SES personnel, and 9 air resources.

(cid:1) There had been a total of 226 hours of LandSAR time averaging out at 11.3 hours per search.

Analysis of those incidents found: (cid:1) Prospectors reported missing by family on 9 occasions, where the person was not actually missing but had not communicated at expected times.

(cid:1) 11 cases where the prospector had become lost whilst conducting prospecting, 3 had returned or found themselves and 8 required location by search teams.

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(cid:1) In one of the incidents the prospector was in possession of an EPIRB which he activated and, as a result, was found by the search team in 4 hours.

(cid:1) On 4 occasions the prospectors were in possession of a GPS however this had not assisted the search because they had either, lost, forgotten or were unable to supply details to the searchers because of being unable to communicate.

Superintendent Seivwright described the GPS as being a device the prospector could carry with him which would allow him to locate himself, which would be useful if he had coordinates for where he wished to go, and was in a position to mobilise. In the event the carrier of the GPS was unable to mobilise the GPS would not assist anybody in locating him.

The other two devices in use are EPIRBs and PLBs.

EPIRBs are generally heavy duty and used in the marine environment, while the PLB is a small device, approximately the size of a GPS, which can be carried with a person at all times, and once activated provides information to searchers by way of satellite.

As Superintendent Seivwright pointed out prospectors almost always go missing in a remote location without any good coordinates of the place last seen or known position which results in the probable search area being large and impacts Inquest into the death of Michael Keith GRAHAM 780-13 page 18.

on initial Police input due to the distances and difficulties in identifying useful information to assist in the search.

In addition, there are certain behaviours most prospectors adopt when becoming lost. They generally continue to walk in an attempt to geographically acquaint themselves. While this has apparently been successful in a minority of cases, it also leaves the walker vulnerable to dehydration, excessive exertion and consequent hallucination and disorientation.

Of the 11 cases mentioned earlier where there had been reports of missing prospectors, 3 had found themselves, but the other 8 were located by search teams after a considerable expenditure in time and resources. Had any of those activated a PLB the search would have been much more effective, reduced the search area, and ensured a successful outcome.

Superintendent Seivwright pointed out most prospectors carry a GPS to assist them in their prospecting activities, and while, if used properly, these may enable a prospector to return to a known location, they cannot be used by external parties in locating the prospector. A PLB is no bigger than a GPS but carries the essential function of being able to locate its position by satellite.

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In an incident where a lost prospector had activated an EPIRB, he was located 4 hours later. This produces considerable savings when one considers the average search time as being in excess of 11 hours. Superintendent Seivwright pointed out in that case the search itself was initiated by the EPIRB activation, which is a considerable safety factor for people becoming lost, and knowledge a person carries on PLB often reduced anxiety for family members not hearing from a remote loved one. As Superintendent Seivwright pointed out:4 “Predominantly these LandSAR incidents are resolved by locating the prospector safe and well. The two primary methods of locating the prospector are by air and by road. The method of preliminary search is determined by the precision of the information provided by the reporting party. If precise locations are known, officers can locate by road alone. If the initial search area is more general, then air assets are deployed until the person is located, then officers are deployed by road to conduct the welfare check.

Far more rarely, an incident is resolved by locating the prospector reported missing who has actually experienced mechanical or physical difficulty and required assistance.

Even more rare, are incidents where prospectors are reported missing and it required a large scale search involving a multiagency approach and substantial resources. “ Superintendent Seivwright contacted the General Manager of Investigations with the Department of Mines and Petroleum (DMP) to negotiate with him a requirement prospectors are compelled to carry PLBs or similar 4 Exhibit 1 Volume 1 Tab 40 Inquest into the death of Michael Keith GRAHAM 780-13 page 20.

equipment. The response indicated the DMP felt this was a matter of education, rather than compulsion.

Education is always the foremost means of ensuring compliance with safety considerations. Superintendent Seivwright is anxious DMP contribute more to the community effort, as implemented by the Police, to assist with the location of missing persons.

The issue of compliance with any compulsory requirement is always a resource issue. Education is often preferable and usually more effective. In the case of the deceased the fact he left his GPS at the campsite would seem to imply he was not intending to wander far from the campsite. It leaves open the issue as to whether he would have taken a PLB with him had he had one.

Nevertheless, I do suggest more discussion between those responsible for search and rescue in WA, the Police, and the DMP would be advisable around the issue of education and resourcing searches where those involved in prospecting do not carry PLBs.

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I RECOMMEND WAPOL consider ongoing negotiation with the Department of Mines and Petroleum in educating prospective prospectors of the benefits of carrying a personal location beacon when travelling in remote Australia.

E F VICKER ACTING STATE CORONER 8 January 2014 Inquest into the death of Michael Keith GRAHAM 780-13 page 22.