Inquest Into The Death Of Katie Bender

Contributing factors

• Use of excessive cartridge explosives (480-500kg vs 130kg originally advised)
• Abandonment of cutting charges in favour of untested kick-charge methodology
• Use of steel backing plates against column webs without any testing or verification
• Reconfiguration of blast toward spectators without reassessment of safety measures
• Inadequate sandbagging and incomplete protective measures on the lakeside facing spectators
• Insufficient height and extent of bund walls
• Half-moon cutting method approved without understanding implosion context
• Failure to calculate and formally communicate appropriate exclusion zone
• Failure of project manager to supervise contractor's methodology changes
• Failure of contractor to supervise subcontractor's explosive work
• Absence of independent structural engineer or demolition explosives expert oversight
• WorkCover inspectors lacked expertise in explosive demolition and failed to adequately scrutinise methodology
• Government promotion of public event without consulting contractors on safety implications
• Absence of regulatory agency examination of demolition proposal before commencement
• Poor communication between government entities and demolition contractors regarding public event

Coroner's recommendations

1. Shotfirers' permits should be issued for a fixed and definite period capable of renewal, subject to review on meeting specific criteria as to suitability
2. The quantity of explosives must relate to each specific project; individual separate applications required for each explosive project with accountability for residue after completion
3. A person seeking to use explosives for a particular purpose should be required to obtain permission from relevant authorities for each and every proposed project
4. Inspectors should have rights to examine the use and storage of explosives on a regular basis
5. WorkCover and DGU should be independent statutory authorities with appropriate funding, created as one autonomous statutory unit answerable to the Minister of the Legislative Assembly, modelled on interstate approaches
6. The status of the land in the ACT should never confound the respective roles of government agencies in regulating activities; early close consultation and liaison at all government levels is essential where public safety is paramount
7. The ACT Building Controller and National Capital Authority must be consulted on demolition projects regardless of land status
8. In any future large-scale public works project or public event, all administrators must ensure safety of the public is not compromised and is absolutely protected
9. Public participation by spectators in such projects should be actively discouraged
10. The tender process must remain at arms length from government
11. Any special requirements or conditions sought by government that may affect public safety should be disclosed prior to tender
12. Any claims by tendering bodies as to ability to meet special requirements must be independently and objectively checked before contract letting
13. Degree of implementation of special requirements should be at ultimate discretion of the contractor
14. WorkCover should be established as independent statutory authority completely removed from departmental or government influence or control
15. Funding of WorkCover should come directly from government or combined with levies on insurers
16. Special requirements or conditions unable to be disclosed prior to tender should be disclosed to relevant parties at earliest practical opportunity
17. Where government contract of significant nature may involve public gathering, relevant department, regulatory agencies, and legal representatives should engage in full consultative process to ensure proper safeguards
18. Status of land in Australian Capital Territory should never be permitted to confuse or cloud respective roles of government agencies in regulating activities
19. The review of ACT Demolition Code of Practice should be comprehensively undertaken to address deficiencies identified in the Inquest
20. Appropriate protective measures should be employed where blasting occurs, such as bund walls, raised earth mounds, protective sheeting, and timber barriers