Inquest into the death of Zoe Woolmer

Contributing factors

• Tour guide demonstrated and encouraged descent onto dangerous cliff ledge for photographs
• Inadequate training of tour guides regarding safety protocols and permit conditions
• No clear company policy prohibiting or discouraging the dangerous practice
• Unsafe practice had been ongoing for years without management intervention
• Tour operator management failure to monitor and enforce safety standards
• Parks and Wildlife Commission failure to enforce permit conditions and safety requirements after 2010 warning letter
• Lack of enforcement mechanisms by permit authority
• Practice normalised through social media promotion by staff without management sanction
• Lack of distinction between 'adventurous' and 'dangerous' activities in company culture

Coroner's recommendations

1. Parks and Wildlife Commission implement as soon as possible the Six Point Plan including: amending permit conditions to prohibit photographs depicting dangerous activities for marketing purposes; requiring all tour guides to complete an induction course; requiring guides to sign acknowledgement forms regarding permit conditions, safety rules, and WHS obligations; monitoring compliance through social media monitoring, visitor debriefing, and undercover observer patrols; initiating high-level contact with permit holders for breaches and notifying NT WorkSafe; and sending zero-tolerance policy letter to all permit holders
2. Parks and Wildlife Commission consider changes to permit application and renewal forms to restore questions regarding past incidents and operator performance, as removal of incident reporting questions was inappropriate