by Pitt, Turia
A contract worth a further $170,000 was signed with documentary film makers Beyond Action to record the ultramarathon as part of Tourism WA’s media coverage of the event.10 The footage was to be used to promote the region through the development and distribution of television programs and documentaries both in Australia and internationally.
The committee was asked to examine the actions of the organiser, RtP, and to consider if RtP took all reasonable steps to identify and reduce risks and maintain the safety of competitors, employees, contractors, spectators and volunteers in the preparation for and running of the event. This included its response to the fire and the injuries, access to medical support and evacuations. Its terms of reference also included an examination of the roles and actions of a range of government bodies before, during and after the event. Among these bodies was Tourism WA, the Department of Environment and Conservation (DEC), the Department of Health (DOH), the Kununurra Shire Fire and Emergency Services Authority (FESA), Western Australia Police, the Department of Regional Development and Lands (DRDL), St John’s Ambulance and the Kununurra Visitors Centre (KVC).
Other individuals were invited to appear, including representatives from other ultra-events organisations, local landholders, the Heliwork WA pilots, race volunteers and competitors. The committee received thirty-three submissions; forty-one people appeared before the committee during the hearings in April and May. The injured competitors were invited to appear on April 30.
Turia was determined to attend and give her evidence in person. It was a huge effort for her to fly to Perth; she had only been out of hospital for three months and was extremely fragile. Sitting in her pressure suit for the five-hour flight was agony and even going to the toilet posed problems. She and Michael flew to Perth the day before she was to appear and were joined by Kate, who had flown across from Melbourne and was greeted by Ian. Hully arrived back from his trek to the North Pole just in time to fly over for the hearing and Shaun, who lived in Perth, was there: he had elected to give evidence on behalf of his father in Africa. Hal offered to come from Sydney too but was advised he wouldn’t be needed.
When the session for the competitors’ evidence formally opened, the media were permitted in to take photos but then all cameramen were asked to leave. Journalists were allowed but there could be no recording devices. Apart from the competitors, media, committee and their researchers, the only other people present were Michael Hoskin, and Greg Walsh, the Sydney lawyer representing Turia Pitt, Michael Hull, Hal Benson and Martin Van der Merwe, and Peter Burke, the Melbourne lawyer representing Kate Sanderson. The session was streamed live on the internet.
By then the committee had already heard a great deal of evidence; they had spent time in Kununurrra talking to locals; and had even flown over the region and viewed the site of the fire and where the competitors had been trapped so had formed a good understanding of what had happened on the day. But nothing could have prepared them for the sight of Turia and Kate. When the two women walked into the room together holding hands, the expressions on the faces of everyone told their own story. Suddenly it was real. No one had seen them before: Turia, stick thin, her face covered by a black mask with only her eyes, mouth and nose tip showing and hands with missing fingers. And Kate, limping in a big black boot, hands clawed and scarred. This was the photo that went out to the world; an image that shocked.
When Turia walked in, the impact on Shaun was overwhelming. He said hello to her but she was too fragile for a hug and he hurriedly left the room for a few minutes to gather his emotions; he couldn’t hold back the tears. Shaun was not a man to wear his heart on his sleeve but seeing Turia brought back that terrible day and everything came to the surface. Hully told him later it was a good thing and part of the healing process. But Shaun could only think that nothing could properly heal Turia’s injuries.
Mary Gadams appeared two days later. Part of her evidence was given in a closed session and not streamed live. Ian Sanderson attended the hearing but his presence was carefully managed so the two did not have an opportunity to meet face to face.
Invited to make a brief opening statement, the RtP CEO began reading out a carefully crafted statement – around twelve pages long. Committee members commented several times on how time-consuming this was, reminding Gadams that the purpose of the hearing was for them to put questions to her, and that there had been ample opportunity to submit written statements prior to the hearing.11 They also had to remind her legal representative not to try to answer questions on Gadams’ behalf.12
Turia, Michael, Kate, Hully and Shaun had not been aware that the RtP owner was flying to Australia to appear that day. As their own evidence was streamed live, they believed she must have known they were also in Perth. They were extremely disappointed she did not make personal contact with them then or since.
Michael was also upset when he later read Gadams’ response to the committee’s question: ‘What responsibility, if any, did RacingthePlanet take for the injuries to Turia and Kate and the others and if it intended to do anything to assist them in the future?’,13 Gadams replied that Racingthe Planet did not know who was liable for the injuries. She said that while their medical director, Dr Waite, had been in touch with the families there had ‘never been a time when I have had an email or call or anything from any member in the family where I said that I would not meet. I remain open to meet with any of the families’.14
The committee then put to Gadams: ‘So that is all you intend to do in the future to assist them?’ Gadams replied: ‘I mean, no one has come to us to ask us for anything, and if someone comes to ask us, you know, I am willing to meet at any time.’15
After obtaining an extension, the committee sat for five months and handed down its report on 16 August 2012. It was the last possible date that would ensure a government response before the parliament rose for the summer recess; after that each committee member would return to the preoccupation of the next State election.
Just prior to the release of the committee’s findings, Mary Gadams made a pre-emptive strike by issuing a statement to The Australian denying any liability and hitting out at Western Australian Government agencies for their ‘lack of co-ordination and disregard for fire risk’.16 Gadams said the only way the tragedy could have been averted was ‘to not hold the event in Western Australia in the first place’.17
‘The truth is, we simply would not have had a race there if we thought there was any risk of fire injuring human beings,’ she told The Australian. ‘One of the issues in the Kimberley or Western Australia is who is doing what or who you should contact. In most countries the police is the central agency. How are the tourists in the Kimberley to know there’s fire risk? There was no warning anywhere.’18
That was an interesting statement from Mary Gadams considering the many warnings – and advice about whom to contact – issued in the lead-up to the event.19 As for ‘not knowing there’s a fire risk’, that too was a puzzling statement when RtP team members had been coming across fires in the days before the event and local volunteers expressed concerns about the potential dangers of those fires.20
The committee examined all aspects of the 2011 Kimberley Ultramarathon and made thirty-five findings; notably it found that RtP did not take all reasonable steps to identify risks, reduce risks or maintain the safety of competitors, employees, contractors, spectators and volunteers in the 2011 Kimberley Ultramarathon.21
One of the key findings was that because RtP was aware there had been fires on and in the vicinity of the course prior to and on the day of the race, it should have been aware of the risks that posed. The international standard for risk management (ISO 31000:2009) was a reasonable benchmark but RtP’s management and risk assessment plan and its risk identification process for the Kimberley Ultramarathon were not consistent with that standard.22 This finding was based on several factors:
• RacingthePlanet did not involve people with appropriate knowledge in identifying risks associated with the event
nor communicate and consult adequately with relevant agencies and individuals on its management and risk assessment plan.
• The risks identified in RtP’s management and risk assessment plan appeared to be generic and were notably lacking in causes and consequences.
• RacingthePlanet did not contact FESA about fires it had seen in the days leading up to the race, despite being asked to do so by the KVC and the DEC and being provided with a contact number for FESA in Kununurra.
• RacingthePlanet did not contact St John’s Ambulance prior to the race despite being advised to do so by the DEC and the KVC.
As a result of those shortcomings in its management and risk assessment, RtP deprived itself of the opportunity to develop relationships with key agencies and individuals that might have been able to provide ongoing assistance and to identify and manage risks that RtP may not have fully understood.23
The committee also examined the standards of practice adopted by other adventure racing events organisers operating in remote parts of Australia and found that with respect to RtP’s communications and medical and evacuation planning, it did not meet these standards.24 This finding was based on four key factors:
• RacingthePlanet did not test its communications equipment on the course prior to the race and therefore could not have known if the location of its checkpoints were optimal for communications.
• RacingthePlanet placed its checkpoints too far apart given the limited number of RtP vehicles roving the long course and the inherent difficulties associated with a communication plan based on satellite phones and short-wave radio systems; the committee made particular mention of the inability for sweepers to communicate with checkpoints once out on the course.
• RacingthePlanet did not engage the input and services of St John’s Ambulance in Kununurra.
• RacingthePlanet did not make arrangements for the use of a helicopter in an emergency until the day before the event, despite knowing that this would be the only means of evacuation from Tier Gorge. RacingthePlanet designated the helicopter hired by Beyond Action as first responder in the event of an emergency; however it appeared not to have been aware whether this helicopter was appropriately equipped for an emergency evacuation. It did not engage a back-up helicopter.25
The committee found that RtP did not take all reasonable steps to maintain the safety of competitors.26 They based that finding on the following facts:
• Despite RtP being aware of fires in the vicinity of the course in the days leading up to the event, the committee did not receive evidence that RtP had a plan to monitor those fires or detect new fires – other than what could be seen by RtP staff while driving the course – after the race began.
• Before 11 am, RtP’s event manager, course director and medical director had all received the message at checkpoint two that a fire was approaching. All failed to hold competitors at the checkpoint while they determined the exact location, direction and severity of the fire referred to in this message.
• RacingthePlanet’s event manager and course director met each other on the course approaching checkpoint two shortly after 1 pm. The course director had just sent a volunteer into a potentially dangerous situation in the Tier Gorge – to re-mark the course and assist competitors after seeing smoke in the vicinity of the gorge – without ensuring that the volunteer was carrying communications equipment. Further, this left RtP’s operations manager to continue sweeping the course alone, in contravention of RtP’s own risk management plan.
• The event manager was returning from The Barrels where, somewhere between 12.20 pm and 12.40 pm, she had received reports from competitors coming out of the Tier Range of smoke and flames encroaching on the course. Despite this, neither she nor the course director held competitors at checkpoint two while they determined the exact location, direction and severity of the fire.
• With the information available at 1 pm, if not earlier, RtP should have engaged the media helicopter to determine the exact location, direction and severity of the fire and, if required, warn competitors to return to checkpoint two.
• RacingthePlanet’s plan to use the Beyond Action helicopter in the case of an emergency (and that it be designated first responder) was neither enacted correctly nor well understood, due in part to the plan having been determined only the day before.27
The committee found that had reasonable steps been taken, it was possible that Turia Pitt, Kate Sanderson, Michael Hull, Martin Van der Merwe and Mary Gadams would not have been injured.28
The report did not make findings of any legal liability, noting that was the role of an appropriate court.
The committee was asked to examine the roles and actions of various government departments before and during the event. The department which had the greatest responsibility for helping to ensure the event ran smoothly and safely was Tourism WA in its capacity as the sponsor.
Tourism WA told the committee that it considered it particularly important to adopt a standard of ‘responsible sponsorship’29 in the emerging category of adventure sports. The committee examined key tenets of the responsible sponsorship concept as applied to the 2011 Kimberley Ultramarathon and found that Tourism WA and its events agency, Eventscorp, failed to meet their own standards.30
The first tenet required the event organiser to demonstrate that it had a competent risk management plan. Tourism WA was found to have signed off on the sponsorship agreement with RtP the day before the event without first viewing its risk management plan. When the plan was shown to Eventscorp’s director of events on the same day, according to his submission to the committee, he only ‘had a few minutes to mull it over’.31 A copy of part of the risk management plan was emailed to Eventscorp four days after the event.
Yet Tourism WA had no protocols in place to ensure the plan could have been properly assessed had it been provided in full any earlier – even though a risk management plan that both parties agreed on was one precondition of the milestone payment sponsorship agreement – $20,000 was to be paid on provision of marketing, operations, communications and risk managements plans. In a series of emails between RtP and Eventscorp from 9 to 31 August, neither party made mention of risk management planning.32
The committee found serious flaws in Tourism WA’s approach to making sure risk management plans for events it sponsored were properly assessed; it appeared all Tourism WA required was that a plan be produced. With RtP a relatively new entrant in the Western Australia market and operating in a remote region, Tourism WA should have been making some effort to have the company prove the adequacy of its risk management plan, the committee said.
‘It’s not unreasonable to assume that it could have used its event facilitation processes to introduce RtP to the relevant government agencies who could have provided comment and assistance in relation to the company’s risk management planning,’ the committee reported.33
The committee also found that Tourism WA had signed a sponsorship contract without knowing if RtP had the appropriate insurances; Tourism WA confirmed it had not received, assessed or requested the required insurance documents. Tourism WA subsequently requested the insurance certificates for its files from RtP on 9 December 2011, more than three months after the race; it received them on 15 February 2012, more than five months after the race. The insurance certificates were not accompanied by their policies and schedules. Without that documentation the committee had difficulty in determining whether appropriate insurance cover was in place for the injured competitors.34
Importantly, clause 15 of the sponsorship agreement stated:
The Event Holder must provide Tourism WA with information relating to any matter relating to the Agreement within five days of receiving a written request . . . all such information must be full, true and accurate in all aspects to the best of the Event Holder’s knowledge at that time.35
The committee was not supplied with any documentary evidence that RtP complied with any of the obligations imposed by the sponsorship agr
eement. However, the committee received advice that the documents presented relating to public liability insurance were ‘. . . of no apparent value to Tourism WA or to an injured participant’.36
In respect of the other documents the committee was advised:
The worker’s compensation ‘Notice of Insurance’ document appears to be valueless. It is not an insurance contract. The nature of cover is unknown. The Hong Kong insurer presumably is not an Australian Prudential Regulation Authority (APRA) approved insurer and not an approved insurer for the purposes of Workers’ Compensation and Injury management Act 1981 (WA). Whether employees of RacingthePlanet are covered for workers’ compensation under Hong Kong law if injured in Western Australia is unknown.37
Among RtP’s documents was a flyer for a medical emergency insurance company – this was of little use to Tourism WA or an injured participant. The committee did not receive any evidence that there was any personal accident insurance cover for volunteers.38
Criticisms of other government agencies largely concerned the lines of communication between various parties. While the committee found the onus was on RtP to make contact with relevant agencies (e.g. FESA, DOH, Shire of Wyndham East Kimberley, DEC), after initial direct contact by RtP or when a relevant agency had heard about the event from a third party, not enough effort was put into follow-up investigation of the event and the progress of its organisation.39
If FESA, in particular, had been brought into the planning process, the emergency response on the day may have been markedly different; in fact, in the committee’s view it may not have been needed as FESA asserted it would have advised RtP to re-route or cancel the race.40
The KVC advised FESA’s district fire manager about the event three days prior and was told that RtP would be calling for advice on fire. RacingthePlanet was advised by both the KVC and the DEC to contact FESA in Kununurra, and given contact details. The district fire manager was waiting for RtP to make contact but no contact was made. The committee found that when RtP did not make contact, it would have been ‘reasonable and prudent’ for FESA to contact RtP.41