Coronial inquiry and drift into failure: a “rule based approach to driver behaviour was fraught with risk”

This inquiry covers the drowning death of a motorist as he drove off a vehicle ferry about 20m away from the bank.

I’ve skipped a lot of the detailed findings to focus on a few of the SMS-related items.

The coroner observed that:

• Although the driver may have been impaired by alcohol, drugs and health issues, “In the context of a vehicle ferry, the issue is what measures were in place to prevent vehicles going overboard

• While a “substantial chain” was supposed to be installed on each ferry ramp to act as a barrier, this wasn’t fitted. Hydraulic booms were eventually fitted, but then removed after some time due to risk of injury to deckhands.

• Consequently, ropes and bollards were used as visual aids to warn drivers; not a physical system of vehicle containment

• Regarding the ferry SMS, “it is clear that many standard shipboard procedures are addressed … [but] there is no suggestion on the face of the documents that the procedures were risk assessed”

• That is, not ensuring that “the hazards associated with a procedure were identified, the risks assessed, and appropriate control measures selected and incorporated into a reviewed procedure”

• The procedures were said to be “mere documenting of how tasks are performed or ‘how we do things around here’ on the assumption that experience (albeit limited) dictates what is safe”

• Some of the procedures were said to be “ill conceived”, such as the person-overboard procedure. Vehicle overboard were identified, and the overboard procedure was said to have been regularly drilled. However, the drill focused on a conscious person overboard, not an unconscious person

• Nor was the ferry equipped to handle an unconscious person overboard; there was no dinghy, it had limited capacity to move for a retrieval and hence the overboard procedure was “reliant on raising the alarm with the shore base and a person being available to access a dinghy on the bank”

• The procedure was said to be “hardly adequate” and “not developed to address unintended or inadvertent or premature departure of a vehicle”

• The coroner, while recognising the impact of hindsight, then curiously falls into a similar pattern by proposing counterfactuals, e.g. “If the crew were trained … there would likely be a different mindset”

• The coroner introduces Dekker and drift into failure – you can read the below image yourself

• The coroner observes “To my mind, these incidents clearly demonstrate that a rule based approach to driver behaviour was fraught with risk”

• And rather than merely relying on traffic management rules, there should have been a form of physical containment of vehicles

Finally, previous AMSA (the marine regulator) report findings were cited, including SMSs that relied predominantly  “on documentation rather than good risk management”.

Ref: Coroner’s Court Qld. Inquest into the death of Julian Werner Wlodarczyk. 2013/1511

Report link: https://www.courts.qld.gov.au/__data/assets/pdf_file/0010/538948/cif-wlodarczyk-jw-20171004.pdf

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