Inquest into the Death of Craig Dee Sandy
Deceased
Craig Dee Sandy
Demographics
32y, male
Date of death
2003-01-26
Finding date
2004-07
Cause of death
Multiple injuries sustained in a motor vehicle collision during bushfire fighting operations
AI-generated summary
Craig Dee Sandy, a 32-year-old volunteer bushfire brigade captain, died on 26 January 2003 following a motor vehicle collision on Lancelin Road during a major bushfire response near Ledge Point, Western Australia. While fighting an out-of-control fire that had jumped containment lines and threatened residential areas, Mr Sandy was a passenger on the tray of a fire truck driven by Ms Mellanie Culhane. The truck collided with two vehicles that had stopped due to dangerous fire conditions, causing Mr Sandy's vehicle to roll and a 3,400 kg slip-on water tank to come loose, striking and killing him. The coroner found the death resulted from accident and identified multiple safety issues: inadequate incident management documentation and handover procedures; radio communication failure; unclear command structures; unsafe practice of firefighters travelling unrestrained on vehicle trays; and inadequate securing of slip-on water tanks to vehicles. Multiple recommendations were made to improve fire incident management, communications, and firefighter safety protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Uncontrolled bushfire with rapid fire spread and unexpected wind change
- Failure of VHF radio repeater Channel 28 disrupting communications
- Vehicles stopped on Lancelin Road due to dangerous fire conditions
- Poor visibility due to smoke
- Deceased and colleague travelling unrestrained on the tray of the vehicle
- Inadequate securing of 3,400 kg slip-on water tank which came loose during collision
- Lack of documented incident management log and running sheet
- Unclear command structure and coordination between responding units
- Communication difficulties between different agencies (CALM, FESA, Shire)
Coroner's recommendations
- Use of a log of events or running sheet should be encouraged in fire fighting in Western Australia; a running sheet or log form or booklet should be printed and provided to all Incident Controllers through arrangements made involving local government and FESA
- FESA should liaise with local government to prepare an appropriate resource pack for potential Incident Controllers containing clipboard, paper, pens, draft running sheets with suitable headings, a regularly updated resource register, and a simplified version of the Operations Checklists document
- The provisions of the Bushfires Act 1954 should be reviewed and FESA and local government should work together to determine with precision how and when a change in control should take place in circumstances where a relatively small fire develops into a larger fire requiring increased resources and professional oversight
- FESA should put in place a maintenance program involving regular checking of the effectiveness and reliability of radio repeater backup batteries
- CALM and FESA should provide information to local government about alternative radio channels that can be used at various locations in the event of an emergency, with clear communication of which alternative repeater channels would be available throughout a shire
- Slip-on water tanks must be secured by more than just bolts attached to the tray of the vehicle; there should be a substantial skid frame welded to the tray or a similar strong and reliable mechanism (such as welded shear blocks) to prevent movement of water tanks during collisions
- The practice of firefighters travelling in the rear of a vehicle when not directly involved in fire suppression should be reviewed and the importance of firefighters staying within a vehicle cab when being transported on a fire scene should be emphasised in FESA training
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —