CITATION: 	Inquest into the deaths of William George Scott [2015] NTMC 022 & Lanh Van Tran [2015] NTMC 023

TITLE OF COURT:	Coroners Court

JURISDICTION:	Darwin

FILE NO(s):	D0099/2014, D0141/2014

DELIVERED ON:	30 October 2015

DELIVERED AT:	Darwin

HEARING DATE(s):	7, 8 September 2015

FINDING OF:	Mr Greg Cavanagh SM

CATCHWORDS: 	Crocodile attack, taken from boat, unsuitability of small and unstable boats in crocodile waters, fishing from bank of river, dangers inherent

REPRESENTATION:

Counsel Assisting:     	Kelvin Currie
Parks Australia: 	Tom Anderson 
Parks and Wildlife Commission: 	Sonia Brownhill 	

	

Judgment category classification:	B
Judgement ID number:	[2015] NTMC 022 & 023 
Number of paragraphs:	198
Number of pages:	31

IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN 
TERRITORY OF AUSTRALIA

No. D0099/2014
	In the matter of an Inquest into the death of 
	WILLIAM GEORGE SCOTT
	ON 7 JUNE 2014
AT BILL DEAN BILLABONG, KAKADU

	FINDINGS

Mr Greg Cavanagh SM:

Introduction
1.	William George Scott (Bill) was 62 years old. One of his favourite places was the South Alligator River System. For him it held a special fascination. One of his most cherished locations was a place he called ‘Black Horse Camp’ (officially known as Bill Dean Billabong). He camped there two or three times a year and had done so for the 20 years previous to his death. It was there that he went on the Queen’s Birthday long weekend in June 2014 with his wife, family and friends.  
2.	He had just returned from fishing on the river and was standing at the back of his boat when a 4.74 metre Estuarine Crocodile (saltwater crocodile) rocked the boat. As Bill reached out to steady himself the crocodile leapt from the water, closed its jaws around his upper arm, shoulder and chest, flipped him out of the boat and took him under the water. He was not seen alive again.
The Inquest
3.	This Inquest was heard at the same time as another Inquest into the death of Mr Lanh Van Tran who was taken from the bank of the Adelaide River by a saltwater crocodile measuring 4.54 metres just two months later.
4.	Mr Scott was killed in Kakadu National Park administered by the Commonwealth of Australia (Parks Australia). Mr Tran died in an area managed by the Northern Territory Parks and Wildlife Commission (Commission). However because the Inquests were heard together the Commission was willing to participate in the issues raised by both deaths. I thank them for that.
Background
5.	Bill was born in Gunnedah on 30 July 1951 to his parents Margaret and Alexander Scott. He had a brother, John and sister, Margaret. He was the youngest.
6.	On 30 September 1972 he married Roslyn Gai Cameron. They had two children, Aaron and Kylie.
7.	In 1977 the family moved to Darwin and became enamoured with the lifestyle. Bill fell in love with the fishing and camping opportunities particularly around the South Alligator River system. He loved buying maps and planning camping trips to remote locations. He was an experienced bushman, boater and fisherman with over 30 years of experience.
8.	It might often be thought that misadventure in the Northern Territory is due to ignorance or unfamiliarity with conditions. That was not the case with regard to William Scott.
Circumstances
9.	On Saturday 7 June 2014 Bill and Roslyn headed out of Darwin in their vehicle with a 3.5 metre aluminium boat (“tinny”) on the roof and towing a camper trailer. They headed for the Bill Dean Billabong located on the South Alligator River system inside Kakadu National Park. 
10.	It was a long weekend and Bill and Roslyn planned to stay there until Monday 9 June 2014. Meeting them there were Bill’s friends Max along with his wife and Bill and Roslyn’s son Aaron and his family.
11.	Aaron had been raised in the Northern Territory and had visited the billabong many times with his family over the last 20 years. He was very familiar with the area. He had his own camper trailer and 3.5 metre roof top boat and was a keen bushman and fisherman like his father.
12.	Aaron and his family got to the billabong first. They arrived at about 8.00 am, erected the camper trailer and organised the camp. It was about 100 metres from the water.
13.	About 15 minutes later Max and his wife arrived. Max erected his tent and then Aaron and Max cleared the area used as a boat ramp and put Max’s boat into the billabong.
14.	By that time it was about 9.00 am and when they got back to the camp Bill and Roslyn had arrived.
15.	Max and his wife went fishing and Aaron and his family stayed with his parents and had breakfast. After that they put their boats into the water and headed off into the billabong to fish. By that time it was about 10.00 am.
16.	During the process of launching the boats they did not see any crocodiles or signs of crocodiles. However they had seen crocodiles on previous trips. They all knew the dangers posed by crocodiles and were cautious near the edges of the water. 
The Boats
17.	The boats were both Quintrex 3.5 metre Explorers made of aluminium. Aaron’s boat had a 15 horsepower outboard engine and Bill’s had an 8 horsepower engine.
18.	The sides of the vessels are approximately 700 mm high. They are often called ‘roof toppers’ or ‘roof top tinnies’ because they can be carried on the roofs of vehicles or camper tailers and useful when accessing hard to reach places.
19.	When placed in the water with people aboard, the boats have a free board (side height above water) of less than 500 mm. 
The Attack
20.	The boats motored upstream for about five kilometres. They fished for about four hours. At about 2.00 pm they headed back to camp.
21.	On arrival back at the ‘ramp’ they went about filling a large container with water. Aaron obtained a blue 60 litre drum and carried it to the water between where the boats were moored. He entered the water to about knee depth and half-filled it and then carried it to a flat spot on the bank. 
22.	It was intended to put more water in the drum before taking it on a trolley to the camp where it would be left in the sun and used as water for showering.
23.	Bill was standing in his boat. There were two bench seats in the boat. He was straddling the back seat. There were two buckets in the boat. He filled the first bucket by reaching over the right hand side of the boat toward the rear. He then took a couple of steps forward and handed the bucket to Roslyn who was on the bank. She then handed it to Aaron’s wife, Joanne further up the bank. Joanne handed it to Aaron who poured it into the blue drum.
24.	Bill then filled the second bucket the same way and handed it to Roslyn. 
25.	There was then some discussion as to whether a third bucket was needed. Roslyn handed one of the buckets back to Bill. 
26.	At that moment the boat rocked. Roslyn noticed a small bow wave in the water as it did so. Bill stumbled and reached out with his left hand toward the motor to steady himself.
27.	A large Saltwater Crocodile rose from the water at the rear of the boat and closed its huge jaws around Bill’s upper left arm, shoulder and chest flicking him out of the boat. Both the crocodile and Bill disappeared beneath the water.
28.	Roslyn watched it happen. She said: 
“Bill was facing the bank with his back to the river, the boat rocked and I saw Bill sort of look up with a confused look on his face and I sort of expected him to say who rocked the boat but he didn’t. Jo was standing next to me on the landing … and Jo and I said something like “look Billy has fallen over” as if it was a bit of a joke.
Bill became unbalanced and put his left arm out to the side to balance himself. That’s when I saw the crocodile come out of the water from behind the motor and grabbed Bill by the left upper arm. As the crocodile went down Bill’s feet sort of flicked up and out of the boat. We all screamed and then there was nothing. No splashing or disturbance in the water.”
29.	Joanne said:
“I then heard a clunking sound coming from Bill’s boat.
I looked over and Bill had fallen down in the boat. I thought he had slipped over. He was facing the water at the back of the boat next to the outboard motor.
I then saw large crocodile jaws covering Bill’s shoulder and he was then pulled into the water. I didn’t hear Bill say anything or shout out there was no splashing he was just dragged into the water.”
30.	Aaron didn’t see the whole incident:
“I was securing the blue tub to a trolley which I intended to take to the camp, about 6 to 8 metres from the water’s edge.
While I had my back to the river securing the tub I heard dad make a noise. The noise sounded like the word, ‘fuck’ which he yelled. I then heard a thump and a splash. I turned and saw a big swirl in the water and a section of tail of a crocodile. I think the thump was dad hitting the boat before being dragged into the water. I did not see my dad or hear him say or yell anything else I only saw the tail of the crocodile. The boat was rocking but still secured to the bank. I saw the blue bucket floating by the water’s edge. There was no sign of the crocodile near the boat.”
31.	In her evidence Joanne said:
“People start to contemplate what they would do in that situation … would they use a gun or something like that and I just want to share with people that it is so quick, it happened in seconds and he was gone, and there’s not a thing that we could do, and a horrible thing for Bill’s family that they had to be there feeling that there was nothing they could do to help him.”
32.	Aaron ran into the water to search for his father. He did not see either the crocodile or his father. Roslyn called to Aaron and helped him back out of the water. He got into his boat, reversed out about 10 to 15 metres, stopped and looked around. He saw a swirl about 50 metres downstream. He followed it but saw nothing. He looked around for a further five minutes but found nothing. Bill’s hat floated to the surface. Aaron continued to look but found nothing and then went to find Max.
33.	A short time after Aaron left, Bill’s body floated to the surface. He was face down in the water. Roslyn got into the boat and tried to paddle out to retrieve Bill’s body but by the time she turned the boat around Bill’s body was gone.
34.	Aaron and Max returned. They continued to search and Roslyn and Joanne drove out to call for help. Aaron and Max stopped searching after it became too dark.
35.	At about 8.30 pm Police and Rangers arrived with two vessels. Twenty three crocodiles were spotted. However no large crocodiles were seen. Police and Rangers searched until 4.41 am when the crews were stood down until first light.
36.	At 6.30am the search recommenced. At 8.30 am a helicopter arrived to assist. Ranger Fred Hunter was in the helicopter. He spotted an oil slick on the water further upstream. It was the same sort of slick he had seen after a young boy had been taken by a crocodile earlier in the year. 
37.	He told the other Rangers and the boats went to the area. Shortly after, a crocodile, fitting the description of the one that took Bill, was shot by Acting Sergeant Wade Rogers of the Water Police. 
38.	An autopsy was conducted at that location on the crocodile by Garry Lindner. As the knife penetrated the stomach of the crocodile an orange fluid trickled out. It had a distinctive smell. The Rangers knew its meaning and went to get the body bag.  Most of the deceased was located in the stomach of the crocodile, the only notable omissions being Bill’s left arm and clothing.
39.	I pause to thank the family of Mr Scott for attending the inquest and giving evidence as to what they witnessed that day. Reliving those moments was not easy and I thank them for their courage.
Bill Dean Billabong
40.	The billabong is approximately 180 kilometres South East of Darwin. Until 1971 it was a favourite spot of Bill Dean for shooting crocodiles.
41.	The billabong makes up part of the South Alligator River system during the wet season. In the dry season it is an isolated billabong about ten kilometres in length and at its deepest about seven metres.
42.	It is not listed among the 23 registered camp grounds in Kakadu National Park and has no official boat ramps. It is not patrolled or surveyed by National Park Rangers.
43.	Nevertheless, the Bill Dean Billabong and other billabongs along the Alligator Billabong Track have been popular camping and fishing locations for locals and visitors. They were popular before the establishment of the National Park and during the early years of the Park. 
44.	In more recent times permits were required to camp and fish there. In 2004 the permits were stopped. 
45.	In spite of that it is apparent that it is still a popular place for fishing and camping. Two other witnesses in the Inquest stated they had been there for recreational purposes in recent times.
Crocodile Numbers
46.	From 1945 until 1971 crocodiles were hunted for their skins, almost to extinction. In 1971 crocodiles became protected. At that time it was estimated there were approximately 3000 saltwater crocodiles remaining in the Northern Territory.
47.	However they showed remarkable resilience and the population rapidly recovered. By 1980 it was estimated there were 30,000 to 40,000 non-hatchling saltwater crocodiles and that had risen to 80,000 to 100,000 by 2012.
48.	The size of the crocodiles also continues to increase. Saltwater males can grow to about 6 to 7 metres and females to about 3.4 metres. The males are said to generally reach 3.3 metres after 16 years. After that, approximating age according to size becomes more difficult. However saltwater crocodiles are thought to keep growing throughout their lives and can live for 60 to 70 years.
49.	It is estimated that the crocodile populations have almost completely recovered to the numbers at the time of the first non-indigenous settlers.
50.	Aaron Scott is anxious about the dramatic increase in number and size of crocodiles and suggested during the Inquest that the significant number of feral animals in Kakadu provide an additional and bountiful food source such that crocodile numbers may well exceed the populations seen at any previous time. That proposition was given some validity by the Rangers called to give evidence.
51.	Aaron suggested that more effort and resources needed to be put into the reduction of feral animals if the size and number of crocodiles was to be kept under control.
52.	What is different from any other time is that since protection in 1971 crocodiles have become familiar with humans and boats and generally have not developed the fear of humans that once existed when humans were also predators.
53.	As the saltwater crocodile population and size grows larger the risks associated with crocodiles increase. The risks today are significantly greater than they were 20 years ago.
54.	A few decades ago Northern Territorians, including myself, used to swim in many of the waterways of the Northern Territory. That cannot be done today, not without significant danger.
55.	Similarly, a few decades ago a large proportion of the boats used for fishing in such waters were small tinnies. They were very useful because it was difficult to access many of the waterways with a larger boat and trailer.
56.	However, such tinnies, generally around 3.5 metres, are dwarfed by the larger crocodiles. The circumstances of the death of Mr Scott are a reminder that the risks of being taken from a boat by a crocodile have also increased.
57.	It may be the first time that a crocodile has been witnessed to take a person from a boat. It is not however the first time that a crocodile has been known to attempt to do that.
58.	One such attempt related to Jeff Bolitho who gave evidence in this Inquest. He was in a 5.5 metre Trailcraft with friends.  It had a canopy and over that had thrown a mosquito net that went right around the boat. It was about 8.30 pm at night.
59.	He was sitting on a collapsible chair near the right hand side of the boat when a crocodile came over the side and knocked him from the chair. He landed on the floor. He found teeth marks in the back of his head and shoulder. He showed them to the Rangers who estimated it was likely to have been a 4 metre crocodile.
60.	The next night the Rangers re-enacted the scene and a 4 metre crocodile came straight up the river to their boat. It showed no fear. They harpooned it. 
61.	If the crocodile had got a better grip or perhaps if Mr Bolitho had been on a more solid chair he may also have been taken from his boat and killed.
62.	Some sobering research released 15 May 2015 was undertaken by Yusuke Fukuda, Charlie Manolis, Keith Saalfeld and Alain Zuur titled “Dead or Alive? Factors Affecting the Survival of Victims during Attacks by Saltwater Crocodiles in Australia”. They state in part:
“The models showed that the most influential factors were the difference in body mass between crocodile and victim, and the position of victim in relation to the water at the time of an attack. In-water position (for diving, swimming, and wading) had a higher risk than on-water (boating) or on-land (fishing, and hunting near the water's edge) positions. In the in-water position a 75 kg person would have a relatively high probability of survival (0.81) if attacked by a 300 cm crocodile, but the probability becomes much lower (0.17) with a 400 cm crocodile.  If attacked by a crocodile larger than 450 cm, the survival probability would be extremely low (<0.05) regardless of the victim’s size.” 
63.	The Commission notes that recently it has been hearing reports of crocodiles launching at, nudging, banging and in some instances biting at boats.
Crocodile Management Strategy
64.	The current Crocodile Management Strategy for the Park has been in place since 2004.
65.	The Board of Management for Kakadu National Park commenced a review of the Strategy in February 2004. However in March 2015 they decided to hold off finalisation so that any final Strategy could be informed by this Inquest.
66.	Parks Australia works closely with the Commission and seeks to align their safety materials with those of the Commission and particularly those in the “Be Crocwise” campaign.
67.	Accordingly, at the date of the Inquest Parks Australia had not made any alterations to the safety messages as a consequence of the death of Mr Scott.
68.	Perhaps because of the age of the strategy, the safety messages do not include the risks to persons specifically in boats (unless they are sleeping, stranded on mudbanks or have their arms over the sides catching or releasing fish).
Crocodile Signage and Awareness 
69.	Parks Australia promote five messages:
a.	Most of Kakadu is a prime crocodile habitat;
b.	There is some risk of crocodile attack if people enter the water anywhere in Kakadu;
c.	In most of Kakadu, there is a very high risk of crocodile attack if people enter the water;
d.	In a few places steps have been taken to reduce the risk to people swimming but even in those places there is no guarantee and people enter the water at their own risk;
e.	There are ways for people to reduce the risk of crocodile attack if they are fishing, boating or near water.
70.	At 4.4 of the Crocodile Management Strategy the following is found:
“Motorised boating and fishing
Most estuarine crocodiles are wary of people unless the people are in the water or are stationary close to the water. People place themselves at significant risk if they fish while standing in water and at some risk if they fish from the water’s edge. People boating will be at significant risk if the boat capsizes or is stranded on a mudbank.
Some crocodiles become habituated to people fishing or boating in an area and may then be more likely to attack. The animals pose some risk to people while launching and retrieving boats and while fishing from boats, particularly if fish are held in the water for some time while being caught or released. Cleaning fish near water attracts crocodiles. Cleaning fish within 50m of the water’s edge is prohibited under the EPBC Regulations.”
71.	Actions for mitigating the risk follow:
“ACTION 4.4- FISHING AND MOTORISED BOATING
To reduce the risk of crocodiles attacking people who are fishing either from boats or from the land, and people who are boating, Parks Australia will educate people about safe practices, monitor the behaviour of crocodiles in high visitor use areas and take measures to manage crocodiles that have become habituated to people.
Procedures
Park staff will educate people about safe fishing and boating practices through ranger patrols at boat ramps and on waterbodies, signs, brochures, liaison with fishing associations and organisations and other methods.
Parks Australia will warn people not to fish while standing in water.
Parks Australia will maintain fish cleaning facilities at boat ramps.”
72.	The crocodile safety signs state: 
“Danger Crocodiles inhabit this area. Attacks cause injury or death. 
•	Do not enter the water. 
•	Keep away from the water’s edge. 
•	Do not clean fish near the water’s edge. 
•	Remove all fish and food waste.”
Crocodile Experts
73.	Because this Inquest was conducted at the same time as that of Mr Tran, I had the benefit of hearing from the personnel from Kakadu National Park and also from the Parks and Wildlife Commission in the Northern Territory about the issues affecting both Inquests. 
74.	It is unlikely that there are any persons who would have more expertise in dealing with crocodiles in the Northern Territory. I will collectively refer to them as “the Rangers” and I wish to thank them very much for their attendance and assistance.
75.	The first to give evidence was Garry Lindner. Dealing with crocodiles runs in his family. His father Dave Lindner was heavily involved with crocodiles and captured the 5.1 metre crocodile named Sweetheart now found in the Museum and Art Gallery of the Northern Territory. Since 1986 he has been working with crocodiles and is the Crocodile Management Supervisor and Coastal Surveillance Supervisor for Parks Australia.
76.	Calvin Murakami gave evidence also. He is a Kakadu Ranger and has been working with crocodiles for 20 years.
77.	Fred Hunter then gave evidence. He is also a Ranger. He was born at Mudginberri Station in Kakadu National Park and has been working in that job with crocodiles for the last 28 years.
78.	If there is a person with comparative expertise it is Tom Nichols who gave evidence for the Parks and Wildlife Commission of the Northern Territory. He is a Parks and Wildlife Ranger and an iconic figure in Darwin. He was born in Darwin and has been working with crocodiles for 35 years. 
79.	The evidence from the rangers was to the following effect:
•	A big crocodile is a smart crocodile;
•	If there are crocodiles in the area you will be observed by them (whether you can see them or not);
•	If there is a fish scent from your boat that will increase their interest;
•	Boats used for fishing are likely to have that scent;
•	If you have rubbish or fish carcasses that may further increase the interest of crocodiles;
•	Any activity that replicates the activity of their usual prey will increase crocodile interest. That is most often from splashing and includes slapping the water with a paddle, ladling water with a bucket or pulling in a fish;
•	The increase in large feral animals have led to predatory crocodiles well versed in taking prey off the land including boars, horses and cattle;
•	Many crocodiles no longer see humans as a threat;
•	A person in a boat is little different from a crocodiles perspective to a person on the bank of a river;
•	Deep water beneath a boat provides a platform for a crocodile to launch from the water;
•	The risks to persons in boats are greatest in small unstable boats. 
Boat Stability
80.	Instability in boats was seen as one of the major safety issues. If the boat hits something in the water and tips over or if a crocodile tipped it by launching at, nudging, banging or biting at the boat the persons tipped from the boat would be at considerable risk.
81.	Acting Sergeant Wade Rogers said: 
“stability seems to be the biggest issue with the smaller rooftop vessels, whether it be something that interacts with the vessel and shifts the centre of gravity and obviously can overturn a vessel, or if you’re travelling along in one of those vessels and potentially hit something, then you’re more likely to throw people out of the vessel or tip the vessel over.”
82.	With the disparity in size between the increasing numbers of larger crocodiles and the smaller boats seen on the Top End waterways it is not difficult to imagine why a larger boat is preferable.
83.	Boat stability was considered so important that some of the Rangers had gone to the extra expense of purchasing the pontoon style craft for their personal recreational boats.
84.	However, the size of boats as well as the design affects stability.
85.	Mr Nichols was asked what he thought of “roof toppers” on the Adelaide and Mary River systems. He said “I certainly wouldn’t be in one myself … certainly too dangerous”.
86.	Mr Lindner was of the opinion that the minimum size to take into the river systems was 4.0 to 4.2 metres.
87.	In spite of the perceived importance of stability there are no messages or warnings as to boat stability or size of boats when in Top End waters by either Parks Australia or the Commission.

Jumping Crocodiles
88.	However stability is not the only issue. Mr Scott was not exposed to the crocodile because the boat was unstable. That was not the case in the attack on Mr Bolitho either.
89.	The boat of Mr Scott was at the smaller end of the scale but that was not the case with the boat of Mr Bolitho.
90.	The simple fact is that crocodiles are able to propel themselves from the water to take hold of their prey. Where that is from the water’s edge on land the dangers are relatively well known. However the dangers when in a boat seem not to have been well recognised as similar.
91.	The most likely means of decreasing that danger is through the use of barriers. 
92.	The vulnerability of people in boats was becoming clear to the Rangers even before Mr Scott was killed. Some had started to put railings on their personal boats.
93.	After Mr Scott was killed the process of installing railings speeded up. The Park Manager of Kakadu National Park directed that safety railings be installed on a number of the smaller operational boats. 
94.	Water Police followed that initiative also putting railings on some of their boats. Acting Sergeant Wade Rogers said: 
“Obviously this incident was a bit of a wakeup call, not just to the general public, but definitely guys in our section and I’m sure in some other professional workplaces as well hopefully”.
95.	The railings reach to head height when sitting in the boats, particularly the punts and on the larger boats wrap around the back area to protect the driver and the front area to protect those needing to be near the front in the course of their duties.
96.	The Commission and Parks Australia are hesitant however about recommending railings as a general mitigation measure for fear that in some types of boats (particularly small “V” shaped hulls) railings may increase instability.
97.	The Commission indicated that they would be using the “Be Crocwise” campaign to provide information on their efforts to ascertain from recreational boat manufacturers the merits and risks of installing railings on various types of boats.
Parks Australia current messaging and warnings
98.	The messages and warnings in the Parks Australia Strategy are about to be updated. However, in their current form they do not entirely accord with the circumstances described in this Inquest.
99.	For instance: 
“Most Estuarine Crocodiles are wary of people unless the people are in the water or are stationary close to the water.”
100.	It would not seem entirely apt to describe the crocodile that killed Bill Scott as ‘wary’. It was not detected prior to rising from the water to take hold of him. That characteristic would seem better described by the words of the “Be Crocwise” campaign “unseen” and “deadly”.
101.	Or perhaps the term might be more applicable if it were indicated in the Strategy that being in a boat is tantamount to being “close to the water”.
102.	In the messages and warnings from Parks Australia or the Commission there is no express warning that there is a risk of crocodile attack simply by being in a boat (of whatever size) on the water.
103.	The statement from the Commission “that recently it has been hearing reports of crocodiles launching at, nudging, banging and in some instances biting at boats” suggests that it is time to include messaging about the vulnerability of persons in boats. The death of Mr Scott in such circumstances makes the importance of those risks being part of the messaging much more pressing.
Parks and Wildlife Commission messaging and warnings
104.	The Commission’s Management Program for Saltwater Crocodiles is more recent than that of Parks Australia. It was updated following the death of Briony Anne Goodsell in March 2009 and then again in 2014/2015.
105.	The primary innovation has been the “Be Crocwise” public education campaign, first launched prior to the end of 2009.
106.	The program seeks to raise community awareness of the dangers of saltwater crocodiles and to change the behaviour of people in or near the waters of the Top End.
107.	The program has been guided by research that demonstrates that of the known 21 fatalities and 45 people injured by crocodiles in the Top End since 1971, 85% of the fatalities and 95% of the injuries were suffered by local Territorians.
108.	That has led to the campaign being targeted at the local population seeking to change behaviours and complacency.
109.	The risk of a crocodile taking a person from a river bank and the water’s edge has been a recurrent “Be Crocwise” message. It is suggested that people stand at least five metres back from the edge of the water when fishing.
110.	However until the death of Mr Scott it was not recognised that being in a boat, particularly a small boat low in the water, is little different than standing or sitting at the water’s edge.
111.	The Commission indicated they would be adding key messages to their documents that would say: “Saltwater Crocodiles can attack people in boats and the smaller the boat the greater the risk”. In my opinion that is a necessary addition.
112.	Pursuant to section 34 of the Coroners Act (“the Act”), I am required to make the following findings:
“(1) A coroner investigating –
(a) a death shall, if possible, find –
(i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act;
113.	Section 34(2) of the Act operates to extend my function as follows: 
“A coroner may comment on a matter, including public health or safety or the administration of justice, connected with the death or disaster being investigated.”
114.	Additionally, I may make recommendations pursuant to section 35(1), (2) & (3):
(1) 	A coroner may report to the Attorney-General on a death or disaster investigated by the coroner.
(2) 	A coroner may make recommendations to the Attorney-General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the coroner.
115.	I will deal with recommendations concerning the circumstances of Mr Scott’s death at the end of these findings.
116.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was William George Scott born 30 July 1951, in Gunnedah, New South Wales, Australia. 
(ii) 	The time of death was 2.30 pm on 7 June 2014. The place of death was Bill Dean Billabong, Kakadu, Northern Territory. 
(iii) The cause of death was a crocodile attack. 
(iv)  The particulars required to register the death: 
1.	The deceased was William George Scott.
2.	The deceased was not of Aboriginal descent. 
3.	The deceased was a self-employed builder and cabinet maker. 
4. 	The death was reported to the coroner by Police. 
5.	The cause of death was confirmed by post mortem examination carried out by Terence John Sinton. 
6. 	The deceased’s mother was Margaret Scott (nee Robertson) and his father was Alexander George Scott.

No. D0141/2014
	In the matter of an Inquest into the death of 
	LANH VAN TRAN
	ON 18 AUGUST 2014
AT Adelaide River near the Adelaide River Bridge

	FINDINGS

117.	Lanh Van Tran (the deceased) was 57 years of age. He had come to Australia from Vietnam on 4 May 2013 and was working with his wife as a farmer in the hope that one day he would have his own farm. He was shown how to fish and became a keen fisherman. 
118.	On 18 August 2014 he and his wife started work early so as to have time to go fishing in the afternoon. At about 2.30 pm they arrived at their favoured fishing spot. It was on the Eastern side of the Adelaide River not far from the bridge. 
119.	They knew there were crocodiles in the area and they stood about three metres back from the water. They fished with hand lines and baited hooks. One of their lines snagged. At about 5.30 pm they packed up to leave and thinking the snagged line might be problematic for others Mr Tran tried to remove it. 
120.	Media reports at the time suggested that he was attempting to retrieve a lure. However that was not the case. 
121.	The tide had receded and Mr Tran stripped down to his underwear and waded through the mud to the water’s edge. With a stick he reached out and attempted to release the line. A crocodile came from his left and took hold of his outstretched arm. He called out, “Chet roi, troi oi!” (Oh my god, I am dead) before he was dragged beneath the water.
122.	Ms Le gave evidence at this inquest. She was clearly distressed reliving the details of the death of her husband and I thank her for her courage.
Background
123.	Mr Tran was born on 21 October 1956 in Hai Phong, Vietnam and lived there most of his life. He was the third of five children.
124.	He married and had four children. They all now have children of their own. He was widowed in 2006. 
125.	Mr Tran was a pleasant and generous man. He worked hard and made friends wherever he went. In 2010 he met Thi Ban Le when she was visiting Vietnam from Australia. They married in 2012 and he arrived in Melbourne 4 May 2013.
126.	Initially, he worked on a farm near Melbourne but found it cold, particularly with 4.00 am starts, and in August 2013 Mr Tran and his wife came to Darwin to work on farms.
127.	One of the other farm workers took Mr Tran and his wife fishing and taught them how and where to fish. 
128.	They were aware of the crocodiles in the Adelaide River. Ms Le had been to Darwin before and knew that crocodiles could jump and told Mr Tran about them. Ms Le had seen them at Adelaide River and was told that she had to watch out for crocodiles on the big tides.
129.	Sometimes Mr Tran went to the water’s edge to get a bucket of water and Ms Le would remind him to watch out for crocodiles.
130.	They had frequently fished at the same spot on the Eastern side of the Adelaide River. They would generally meet other people fishing there.
131.	However they didn’t see any crocodiles in the water. Ms Le asked people where they had gone and she and Mr Tran speculated that perhaps they preferred to be fed by the jumping crocodile cruise boats.
Circumstances
132.	On the afternoon of 18 August 2014 Mr Tran and Ms Le left the farm at about 1.30 pm and headed to the Arnhem Highway. They drove across the Adelaide River Bridge and about 100 metres past the Bridge turned left onto a dirt road that took them down to the fishing spot arriving at about 2.30 pm.
133.	The tide was up and had just started to run out. Ms Le thought she could see a crocodile on the far bank. However it was a long way away and Mr Tran was of the view that it was just a piece of wood.
134.	At the fishing spot there were two areas that were open to the river about ten metres apart. There were no other people there and they each fished from one of the openings. They were not concerned about crocodiles as they were standing back about three metres.
135.	Ms Le hooked what she thought was a big fish on the line, but while reeling it in the line got stuck. Mr Tran tried to free the line without success. He tied it off to wait for low tide.
136.	By 5.30 pm they had caught two sharks and some yellow head and they decided to head for home. Ms Le wanted to cut the snagged line but Mr Tran said doing so may cause problems for others later.
137.	By that time the water had receded and looked shallow. He said he would check to see if it was snagged on a branch or something else that could be moved.
138.	There was about three metres of mud between the bank and the water so Mr Tran took off his shirt and trousers, folded them and put them in a basket. He asked Ms Le to pack up the car while he got the line.
139.	Mr Tran made his way through the mud to the edge of the water. He held the line in his left hand and with a stick in his right hand reached out trying to get under the line to release it.
140.	Ms Le picked up the box of gear and was taking it to the car when she heard her husband yell, “Chet roi, troi oi”. She turned hearing a big splashing sound and saw a crocodile tail turning in the air.
141.	She grabbed a knife and ran down into the mud. She pulled on the line thinking Mr Tran might still be attached to it. She waded into the water and struck around with the knife but there was nothing. 
142.	She yelled for help. None came, and she drove to the other side of the river where she found Mr Blums of the Adelaide River Queen Jumping Crocodile Cruise. He rang “000”.
143.	Ms Le then drove back to the fishing spot but couldn’t see the crocodile or her husband. 
144.	At the request of the Water Police, Wildlife Ranger Tom Nichols arrived at about 8.30 pm along with Ranger Emma Jackson. They launched their boat and went looking for “eye shines”.
145.	At approximately 9.00 pm in a small channel about 300 metres downstream they found an eye shine of a larger crocodile. On approaching the crocodile they saw that it was about 4 metres in length and had a human hand and part of an arm in its jaws.
146.	Tom Nichols shot the crocodile in the head and signalled to the Police Boat. They then saw Mr Tran’s body nearby. His body was retrieved excepting only for his left leg and some of his right arm. 
147.	The crocodile was tied to the side of the boat and taken back to the boat ramp.
148.	There Tom Nichols cut the crocodile open and found Mr Tran’s left leg in the crocodile’s stomach.
149.	The crocodile was male and 4.54 metres in length and had a whiter head than usual. It was well known as a jumping crocodile with the cruises that were conducted just across the river. He was named “Michael Jackson”. 
150.	In the opinion of Tom Nichols the crocodile was in very good condition, particularly considering that he had no front legs and one of its back legs was missing. He was obviously well fed.
Crocodile Awareness
151.	As is the case with many rivers in the Top End, the water in the river was brown and murky and it was impossible to see what was in the water or how deep it was. 
152.	In evidence Tom Nichols said: 
“Adelaide River itself has a large number of crocodiles … and you can’t see what’s there. That is the biggest thing. You go through the day and you may only see a few crocodiles, depending on whether the tide is in or out, but during the night you see red eye shines … all around the place”.
153.	Mr Tran and his wife had not seen any crocodiles in the times they had been fishing on the banks of the Adelaide River. They had been fishing there for almost a year.
154.	Ms Le said:
“I told my husband sometimes there were a lot of crocodiles here but my husband said not, that there were no crocodiles here because they all go off somewhere to hunt”.
155.	Ms Le had seen the warnings about crocodiles on the television. However she “didn’t ever think that it would lie under the water and wait”.
156.	She had been at that spot for well over two hours catching fish and had not seen any indication there was a crocodile in the area. She had been vigilant. 
157.	She was of the view that as she and her husband had not seen any crocodiles it was safe to go near the water.
158.	To many, that may seem a naive view and it is doubtful that many would even go into mud to try and release a fishing line, let alone into mud near a river with crocodiles. 
159.	However, to dismiss the circumstances on that basis maybe missing the issue.
160.	People fishing are often seen at the water’s edge or even in the water. Some net bait-fish from the river, cast from the bank, fill buckets of water from the river, wash their hands in the river and retrieve their fish at the water’s edge.
161.	This Inquest was heard along with the Inquest into the death of Mr William Scott. The evidence included Mr Scott’s son entering knee deep into the water with a container to get water for showering. It was only moments later a large crocodile lunged from the water, just metres from where he had been, to take hold of and remove Mr Scott from his boat.
162.	Before it attacked no one had seen that crocodile either. 
163.	It would seem obvious that people will think the water is safer if a crocodile is not sighted. However the deaths of Mr Tran and Mr Scott suggest that may well not be the case.
164.	Another false indicator of safety is likely to be the experiences people have in an area.
165.	Not seeing a crocodile over many visits or not having any issues with crocodiles over an extended period may lead to complacency as to the risks.
166.	Mr Murakami, one of the Kakadu Rangers gave evidence about the complacency that creeps in: 
“because nothing ever happens to you for a long period of time, I do it. I get complacent and I’m pretty sure everyone in this room that fishes at times gets a bit complacent because nothing happens.” 
167.	Mr Lindner spoke of the “she’ll be right” attitude. He said that after these tragic incidents:
“there’s a period where you go through and everyone’s on full alert and six months later everyone is complacent again … and that’s despite croc signs, media, television, face to face … I think it’s been saturated and part of the reason why we’re here today is to listen to suggestions on how we get the message out there”.
168.	It is apparent that there is a level of risk many people are willing to take. Sometimes the activity may be attractive in part due to the risk.
169.	However the circumstances in this case would suggest that Mr Tran genuinely believed there was no risk. 
170.	The actions he took were simply out of politeness to those people that might later use the area. He went to considerable trouble to attempt to remove the snagged line and it is difficult to believe he would have done so if he thought there was any risk.
171.	He appears to have been of the view that all that was required for his safety was to keep a proper lookout. If that is the case it was a failure in communication of the safety messages with regard to crocodiles.
172.	The predominant message is that it is dangerous to go into the water or close to the water’s edge. It must be assumed Mr Tran understood that for he stayed three metres back from the edge while fishing for just that reason.
173.	If there was a message that he didn’t understand it was that if a crocodile approached it may well do so in a manner that prevented him being aware even when keeping a lookout.
174.	Indeed, as noted above a common thread between the deaths of both Mr Tran and Mr Scott is that the crocodiles were not seen or even suspected to be lurking under the water prior to them attacking. 
175.	It is hoped that the information provided as a result of the death of Mr Tran through the media and this Inquest will inform people that just because they cannot see a crocodile in the water doesn’t mean there isn’t one nearby watching them.
176.	Information of that ilk is to be found in the “Be Crocwise” materials and can be found on the Parks and Wildlife Commission website.
177.	The first “Crocodile Fact” on the site is:
“Large saltwater crocodiles can stay underwater for at least one hour because they can reduce their heart rate to 2-3 beats per minute. This means that crocodiles can wait underwater until they see prey, or if people are using the same spot regularly, the crocodile can wait underwater until someone approaches the water’s edge.”
178.	The other message that it is hoped people using the waterways of the Top End will receive is that the dangers from crocodiles are increasing simply because there are more crocodiles, they are larger and there are more people visiting their habitat than ever before. 
179.	Many of those crocodiles do not fear humans and have become adept at taking large mammals from Top End waters and river banks. 
Be Crocwise
180.	The “Be Crocwise” program was launched by the Parks and Wildlife Commission in 2009 after Briony Goodsell was killed by a crocodile while swimming with friends in a lagoon on the outskirts of Darwin. 
181.	The aim of the program is to raise community awareness and understanding about the dangers of saltwater crocodiles and to change behaviour.
182.	It is an innovative program that has gone to some lengths to identify attitudes, people most at risk and how best to influence people such that they modify their behaviour near crocodiles. 
183.	The program does a lot of work with children, both in the towns and in remote areas. It has gained a noticeable presence in a relatively short period. I commend the Commission on the program. 
Formal findings
184.	I have already outlined my statutory responsibilities and functions at paragraphs 112 – 114.
185.	In connection with my functions I note that there was no sign warning of the danger of crocodiles at the fishing area from which Mr Tran was taken. Since the death of Mr Tran a warning sign has been placed there. 
186.	However it is doubtful that a sign warning only of crocodiles and that people should stay back from the edge of the water would have made any difference. Ms Le didn’t think so, she said “despite all the warning, no one can expect that there will be a crocodile [under the water]”
187.	It is not known whether a sign warning of the dangers of crocodiles lurking unseen under the water might have made a difference. However, the circumstances of the death of Mr Tran and the evidence of Mr Scott’s son walking into the water to fill a container (when it is now known there was a crocodile lurking there) suggest that is the part of the messaging most likely to be missed, forgotten or ignored.
188.	The Commission might consider whether there could be more emphasis on the hidden danger crocodiles pose in their messaging. 
189.	In warning of crocodiles it is accepted that the implicit message is that there are unseen dangers. However consideration might be given to whether there is a need for it to be more explicit.
190.	The Crocodile Safety Signage Guidelines provided by the Commission do not have any signage quite that explicit. 
191.	Mr Andrew Bridges the CEO of the Commission provided a lengthy and informative statement to this Inquest and attended to hear the evidence. I have every confidence that the evidence in the Inquest and these observations will be given due consideration.
192.	I make no formal recommendation arising from the circumstances of Mr Tran’s death.
193.	Pursuant to section 34 of the Coroner’s Act, I find as follows: 
(i) 	The identity of the deceased was Lanh Van Tran born 21 October 1956, in Vietnam. 
(ii) 	The time of death was 5.30 pm on 18 August 2014. The place of death was the Adelaide River near the Adelaide Bridge in the Northern Territory. 
(iii) The cause of death was a crocodile attack. 
(iv)  The particulars required to register the death: 
1. 	The deceased was Lanh Van Tran.
2. 	The deceased was not of Aboriginal descent. 
3. 	The deceased was a farm hand. 
4. 	The death was reported to the coroner by Police. 
5.	The cause of death was confirmed by post mortem examination carried out by Terence John Sinton. 

Recommendations relating to the circumstances of the death of Mr Scott
194.	Currently there is no regulation around the size, type and strength of ‘pleasure craft’ on waters in the Top End. Likewise, there is no regulation of the age and abilities of those who pilot those boats. 
195.	It is therefore most important that information be provided to those likely to purchase or pilot such boats of increased risks and dangers depending on their choice of craft and their abilities and experience.
196.	I recommend that the Parks and Wildlife Commission: 
a.	provide information to the public about the increased risks of boating and fishing on Top End waters by reason of crocodile attack including the importance of the stability and the size of the vessel;
b.	provide information to the public on how those risks can be reduced.

197.	The effect of the evidence is that any changes implemented by the Commission are likely to be followed by Parks Australia.
198.	However for clarity I recommend that Kakadu National Park:
a.	add the key messages noted above at paragraph 111 to their messaging and warnings; 
b.	provide information to the public about the increased risks of boating and fishing on Top End waters by reason of crocodile attack including the importance of the stability and the size of the vessel;
c.	provide information to the public on how those risks can be reduced.

Dated this 30 day of October 2015.
	_________________________
	GREG CAVANAGH
                                                                             TERRITORY CORONER