Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
16 June 2011
I, Glenn Hay, Coroner, having investigated the death of
Charles Thomas Wiggins
WITHOUT HOLDING AN INQUEST
(a) Charles Thomas Wiggins (‘Mr Wiggins’) was born in Hobart, Tasmania on 15 September 1950; and
(b) Mr Wiggins died as a result of head injuries suffered when struck by a limb from tree he was felling on 22 January 2007; and
(c) no other person contributed to Mr Wiggins’ death.
Mr Wiggins was a farm worker after leaving school and commenced work in the forest logging industry in 1974. He set up a business with his wife known as CT & LJ Wiggins, principally engaged in the log-harvesting contracting industry. He was medically reasonably fit although he was taking blood pressure medication, his condition said to be caused by stress.
Mr. Wiggins was described as a very experienced farmer, bushman, tree-feller and operator of heavy machinery. Mrs. Wiggins said of him that he – ‘was lucky enough to have an ability to drive anything he set his mind to and to make most tasks that others thought impossible look easy that annoyed many including me at times he would asses (sic) and work out the best and safest way of getting the job done.’
At the time of his death the business had been contracted to Gunns Ltd since 2004 and Mr. Wiggins and employees were harvesting logs in Coupe HP005F at the back of Hermons Road, Geeveston. They had been in that coupe since 2004. Gunns Ltd had contracted with Forestry Tasmania for the rights to harvest timber in that coupe.
It was a generally mechanised harvesting operation in that the trees were felled by means of a machine which held the tree while it was sawed and then place the tree onto the ground. Mrs. Wiggins noted ‘When required he would occasionally fall trees manually that the machine could not fall he was a very experienced faller, but unfortunately the machine caught fire on 9 January 2007. Due to our financial commitments and the pressure to produce our quota Charlie regrettably started falling the trees manually. …. We were given coupes that were not suited to the type of gear we had and were given coupes that were dangerously steep with poor quality trees. Charlie had said on a number of occasions that if WST saw the area they would close it down but it would not be worth the hassle, so he hoped they would not turn up’.
It is clear that Mr. Wiggins did all tree felling with a chainsaw within this coupe between 9 January 2007 and the day of his death.
Mr. Wiggins was last assessed in his tree-felling practices with a chainsaw by the Tasmanian Forest Industry Training Board on 29 August 1994 and it is clear from available evidence that he had carried out tree-felling with the aid of a mechanical felling machine for a number of years before his death and had performed little manual felling of trees during that period and up to approximately two weeks before his death.
Mr. Matthew Howat was employed by Gunns Ltd as a forester and responsible for planning and monitoring forest harvesting operations on behalf of the company. He was responsible to monitor the harvesting operations at this coupe HP005F but did not perform any specific or formal safety checks of the Wiggins operation within the coupe other than an initial risk assessment and forest operation safety plan on 26 October 2006 and prior to the commencement of harvesting a week later. Both were undertaken with the cooperation of Mr. Wiggins following coupe inspection By Mr. Howat and Mr. Wiggins. The initial risk assessment identified that a percentage of the trees in the coupe needed to be hand–felled, seemingly due to the steepness of the terrain in some parts of the coupe.
Mr. Howat also visited the operations on eight occasions while harvesting was in progress between 26 October 2006 and 18 January 2007. He was aware that Mr. Wiggins’ felling machine had been rendered inoperable by reason of fire and visited the harvest site the following day 10 January 2007 and was aware Mr. Wiggins had commenced hand-felling, but did not carry out any checks to ensure Mr. Wiggins’ practices were appropriate.
The Events of Monday 22 January 2007
Work commenced around 7am. Employee and work site second-in-charge, Stephen Wilson was near a log landing, grading cut logs about 100 to 150 metres uphill from Mr. Wiggins who was engaged in hand felling of trees with a chainsaw and using a safety helmet and other appropriate clothing and equipment.
Employee Scott Alomes was operating an excavator on the landing nearby to Mr. Wilson.
Employee Jonothan Eiszele was operating a skidder machine and his job was to pull the felled trees out once Mr. Wiggins had felled them. While Mr. Wiggins was felling trees Mr. Eiszele had been preparing the track as it had been raining and slippery underneath and he was spreading bark for better traction.
Mr. Eiszele had taken four logs to the landing. These logs had been felled by Mr. Wiggins the previous Friday. He believes that on that Friday Mr. Wiggins had felled a tree (the first tree) but it had lodged into the top of another tree (the second tree). He was aware Mr. Wiggins had felled several trees this Monday morning and Mr. Eiszele was working some 60 to 70 metres above him, waiting to take newly felled logs to the landing.
It is the evidence of Mr. Wilson that it was Mr. Wiggins intention to only fall a few trees that morning before going off to inspect a new coupe and that there were enough trees already felled to keep the men working for the day.
At around 8am Mr. Eiszele saw the deceased working on the second tree that had the first tree lodged against it during the previous Friday. In placing a back-cut into the second tree the first tree rolled off its stump and the top turned and lodged in the V of the second tree. In doing so part of the head of the second tree broke off and it fell onto the deceased.
Mr. Eiszele states that he was not aware of any reason why Mr. Wiggins was dislodging the first tree by cutting the second tree, as this was not normal practice and the usual and safe practice was to knock the lodged tree down with an excavator which is what the deceased would have normally done.
There is no clear evidence as to why Mr. Wiggins did it in this way on this occasion.
From all available evidence it is clear Mr. Wiggins died instantly from a head injury. His safety helmet was significantly damaged.
The Investigation; Findings and Comments Arising
Tasmania Police and experienced workplace (including forestry practices) accident inspectors and investigators from the Department of Justice – Division of Workplace Standards Tasmania (WST) attended the scene and conducted a thorough, lengthy and detailed investigation. I have reviewed those investigations including the sequence of events which seemingly caused the branch from the second tree to fall on Mr. Wiggins. In my view that account accords with the available evidence.
WST investigators observed tree stumps and butt ends of trees that had been felled in the close-by area both prior to Mr. Wiggins accident and during the previous two weeks or thereabouts. I accept the opinion of Inspector Geeves that the stumps and butt ends displayed ‘a number of defective tree felling practices’ in that they were not of a standard equal to the standard of the Forest Safety Code (Tasmania) 2002. He found examples (among others) of the following –
no step-up between the scarf and the back cut on the top section of a tree stump;
under cutting of the top scarf cut on the same stump;
under cutting of the top scarf cut visible on the butt end section of a tree together with an inadequate size scarf and no step-up between the scarf and the back cut on the same butt end section;
no holding wood located on the side near chainsaw cutter bar imprint on the second tree, together with a defective top scarf under cut and far too great scarf depth for the diameter of the tree;
no holding wood located on the right side of the stump of another tree and displaying wood still located in the centre section of the scarf and undercutting of the top scarf;
under cutting of the top scarf cut on the butt end of a number of trees together with evidence of an inadequate amount of holding wood located between the scarf and the back cuts;
under cutting of the top scarf cut, no holding wood and a back cut sloping towards the scarf and left side of a separate tree stump;
under cutting on the top scarf cut, no holding wood on the left side of the stump, scarf cut far too deep into the stump and back sloping towards the scarf on a separate tree stump;
butt end section of a tree showing almost non-existent holding wood;
scarf cut far too deep into the stump together with a back cut on the slope on a separate stump;
It is also Mr. Geeves’ evidence that his observations of the butt end section of the second tree which Mr. Wiggins was attending to at the time of his death, disclosed defective tree felling practices and that he had exposed himself to workplace risks in those practices.
While not directly relevant to the accident, Mr. Geeves also found that the onsite log landing area was not equal to a standard required by sections 11.2(a) and (c) and 11.3(a) of the Code, was unsafe and should have been shut down.
I also accept that those observations and opinions are consistent with available evidence.
WST also investigated other suggested or possible factors contributing to the cause of Mr. Wiggins death –
Was Mr. Wiggins operating hastily and possibly not safely due to financial pressure not necessarily of his own making?
From all available evidence it is clear that Mr Wiggins’ business had been suffering financial pressure for some time and that the machine he normally used to fell trees caught fire on 9 January 2007 and he had to manually fall trees to keep up his quota while he waited for the insurance company about repair. However, it is the evidence of Mr. Wilson that on the day of his death, Mr. Wiggins had intended to fell only a few trees before he went off to inspect another coupe and that he had already felled sufficient trees on or prior to this day to keep his men occupied for the day. While I cannot rule out that a general increase in financial pressure as described by Mrs Wiggins contributed in some way to Mr. Wiggins taking ‘short cuts’ in his work practices, I cannot say that it contributed to or was a causative factor in his death.
- Were there other operational pressures which lead to Mr. Wiggins operating hastily and possibly not safely?
During the investigation it was suggested Gunns Ltd and/or Forestry Tasmania had for some time placed unnecessary pressure on the deceased to complete contractual obligations where some areas for contracted harvest land had poor access roads, or provided poor sites to build landings, or were too steep and/or the harvested trees/logs were too rotten to safely harvest. It was suggested that these factors lead to difficulties in permitting Mr. Wiggins to meet his set quota each month and it is the belief of Mr. Wilson this resulted in Mr. Wiggins ‘doing things he should not do’. There is evidence that in 2002 WST had cause to close down a related coupe due to hazardous trees which Forestry Tasmania insisted should have been harvested. Further, in 2002 Forestry Tasmania resisted attempts by and the recommendations of Mr. Wiggins to fell certain hazardous trees by explosive rather than more conventional means, due to the risks to workers and the public. There is evidence Mr. Wiggins believed that due to contractual pressures it was easier to take the risk and fell by manually by chainsaw. WST intervened and required falling by way of explosives in that instance.
It is clear that in 2007 the landing area in the coupe where Mr. Wiggins died was poorly sited, the contract harvest area was steeper than usual, and it was Mrs Wiggins’ belief her husband continued to take a risk in cutting hazardous trees rather than bringing them down with explosives.
However, while I cannot rule out an indirect connection between operational pressures and the felling of the trees on the 22 January 2007, there is insufficient evidence for me to make any finding that the method of felling the two trees involved in the death of Mr. Wiggins was directly related to those pressures.
It is clear Mr. Wiggins died as a result of injuries he received in the process of falling a tree by way of a back cut with a chainsaw that another tree had lodged into when a limb of that tree fell on him. There is no explanation why Mr. Wiggins did it in this way on this occasion. Instead of adhering to usual safety procedures and for reasons known only to him, Mr. Wiggins took a short-cut that ultimately ended his life.
His death was accidental, however from the extensive and detailed investigation report including numerous and detailed photographs I accept that Mr. Wiggins, despite his enormous forest practices experience, did not comply with proper tree-felling practices prior to and at the time of his death.
From all available evidence I find that Mr. Wiggins’ tree-felling practices were not of a standard equivalent to the standard required by the Forest Safety Code Tasmania 2002 section 5 and especially the method used by Mr. Wiggins in attempting to fell the second or supporting tree was not of a standard equal to that required by section 6.6.
There were no suspicious circumstances.
Despite the enormous experience of Mr. Wiggins and the regard in which he was held by his fellow forest workers and others, his practices were wanting. In my view more regular checks of his competency in felling practices and especially chainsaw use may have minimized the risks and hazards to him. He was last checked for chainsaw use competency in 1994. He was aged 56 years at his death and he was taking blood pressure medication, this condition said to be caused by stress. Since 1994 there had been no objective testing of his forest practices competency nor of his physical health to ensure that he complied with all best practices.
I am informed that at some time in the distant past such forest workers were required to undergo annual practical re-assessment in tree-felling practices to keep their competency and operating licence current. It seems that requirement disappeared because it was perceived it was too expensive and was replaced by a requirement that following an initial competency test the annual licence was automatically renewed by payment of a fee and a declaration by an employer that an employee has been involved in tree-felling for 6 of the 12 prior months.
In this case Mr. Wiggins was self employed and there was not even that subjective check from an employer. It is probable that in all those circumstances Mr. Wiggins’ skills had not been objectively measured and there was no assessment of his health to ascertain his physical fitness or otherwise to perform the necessary heavy duties.
While I am conscious of the potential cost to employers and employees, I recommend that tree-fellers undergo annual competency re-assessment and also provide a certificate of health fitness to undertake the tasks required of them. In my view this recommendation will provide an objective review of competency for the protection of the worker, fellow workers, the employer and the community.
2. I recommend that principals in forest harvesting contracts not only undertake weekly audits of compliance by contractors with environmental standards and correct log segregations, but also take a more active role in the safety auditing of those harvest sites.
3. Only seven months before the unfortunate death of Mr. Wiggins, Coroner Chandler handed down findings in the tree-fall death of Mr Jamie Collins, in circumstances not dissimilar. Coroner Chandler made the following recommendations and comments -
"Records retained by Workplace Standards Tasmania show that in the sixteen year period from 1990 twenty two persons have died in Tasmania in workplace accidents involving falling trees or limbs. The death of Mr Collins is the sixth to have occurred within the last three years. These bald figures do demonstrate that tree-felling is an inherently dangerous occupation. They demonstrate too that deaths within Tasmanian forests are continuing to occur all too regularly and this is so despite the forestry industry’s occupational safety initiatives. These matters lead me to conclude that there is a real need for all stakeholders within the forestry industry, in conjunction with Workplace Standards Tasmania, to put in place a practice whereby the mechanical harvesting of trees becomes the norm, at least in those areas with trees of small to medium diameter.I appreciate that the widespread implementation of mechanical harvesting may impose short term challenges for the industry but these are challenges which its stakeholders together will need to address and overcome if the number of Tasmanian forestry deaths is to be minimised."
I am informed that since that time little has changed other than less than 12 months ago an industry re-structure program has commenced. Under proposed National Harmonized Safety legislation expected to come into effect on 1 January 2012, a National Forest Safety Code is currently being developed.
The WST investigator Mr. Geeves, is also the WST representative on the Forest Safety Standards Committee and as such has raised the need for industry to wherever possible move into mechanical tree-felling. Following the recommendations of Coroner Chandler, WST wrote to all employers to reinforce that recommendation.
Despite all of that I am informed that following one safety incident and one report from a contractor, WST has been required to issue two ‘section 38 notices’ prohibiting manual felling within two coupes where it was considered manual tree felling was objectively considered to be too hazardous.I adopt the recommendations of Coroner Chandler and again urgently call upon all stakeholders including Forestry Tasmania to put in place a practice whereby the mechanical harvesting of trees becomes the norm, at least in those areas with trees of small to medium diameter and that requirement form part of all forest harvesting contracts.
I conclude this matter by extending my sincere condolences to Mrs Wiggins and all members of Mr Wiggins’ family.
DATED : 16 June 2011 at Hobart in Tasmania.