23/02/2025
Victorian Coroner Leveasque Peterson last week released her findings (https://www.coronerscourt.vic.gov.au/inquests-findings/findings) in the deaths of Charlie Howkins and Jack Brownlee, due to the incident at the Winterfield Estate in Winter Valley on March 21, 2018.
Rather than go through the entire documentation, a somewhat briefer summary is provided here.
Case COR 2018 001329 - Charles Clarence Howkins
Case COR 2018 001357 – Jack Brownlee
Other than the mechanism of death for each of the deceased, the findings are the same for each case.
Cause of Death - Charlie
“The post-mortem examination revealed Charlie sustained significant head injuries including a hinge fracture and a subarachnoid haemorrhage. Hinge fractures occur when the head receives severe blunt force usually to the side of the head (as in this case).
Although the head injuries Charlie sustained were severe, and sufficient to cause death, Dr Almazrooie could not exclude the contribution of suffocation (oxygen deprivation under the soil), to Charlie’s death.
Toxicological analysis did not identify the presence of any drugs or alcohol.
Dr Almazrooei provided an opinion that the medical cause of death was 1(a) Head Injury.”
Cause of Death - Jack
“The post-mortem examination revealed acute compartment syndrome in Jack’s arms and legs, together with several other injuries including a subarachnoid haemorrhage, cerebral ischemia, and bilateral plural effusions.
Acute compartment syndrome can lead to metabolic derangement and death.
Toxicological analysis identified the presence of midazolam, morphine and ketamine that were provided as part of resuscitative efforts and did not contribute to Jack’s death.
Dr Parsons provided an opinion that the medical cause of death was 1(a) Complications of injuries sustained when a trench wall collapsed.”
Note: Jack passed away from his injuries at the Royal Melbourne Hospital on March 22, 2018.
Family Concerns
The families of both victims had a number of concerns that they felt hadn’t been adequately addressed in the criminal prosecution of Pipecon by Worksafe. Two are of particular interest to us as rescuers, specifically:
- The positioning of Jack and Charlie prior to the trench collapse, had not been adequately clarified in previous investigations and legal proceedings.
- The rescue may have caused an exacerbation of Jack’s injuries due to the use of the excavator.
In particular, the Brownlee family was concerned that the use of the excavator in Jack’s rescue may have been a contributing factor in his death. David and Janine wanted to know whether Jack’s injuries may have been exacerbated by the pressure that resulted from the use of the Pipecon excavator in the rescue.
The Brownlee family, together with Dr Cormie (Charlie Howkin’s widow), urged the court to obtain further evidence and expert reports.
Some Answers
Positioning - Based on the evidence of Jon Haynes (attending Paramedic), the Coroner found, on the balance of probabilities, that Jack and Charlie were not in the trench at the time of the collapse, rather they were on the edge of the trench.
The Use of an Excavator - There is no evidence to suggest that either the choice to use the excavator or the operation of the excavator caused or contributed to Jack’s death.
There is no evidence to suggest that an alternative rescue approach was preferable, possible or warranted.
Expert Evidence:
Expert reports were obtained from medical, geotechnical and rescue experts. Dr David Eddey (a medical expert), Mr Patrick Wong (a geotechnical expert) and Mr Mark Dobson (a rescue expert) were commissioned by the Court to assist with the investigation. The CFA also provided an additional expert geotechnical report from Mr Alex Rodriguez.
Expert Geotechnical Evidence:
Based on the information and photographs contained in the brief, Mr Wong made a number of calculations of the earth pressure induced by the excavator used during Jack’s extrication.
In his first report Mr Wong considered that the use of the excavator would have caused a relatively small increase in soil pressure (2.5 kPa). He observed a pressure of 2.5 kPa is equivalent to the water pressure on a person at 25 cm water depth, and this pressure is very small when compared to divers who routinely dive to significantly greater depths without difficulties.
In his supplementary report Mr Wong concluded that the additional analyses using revised geometry of the collapsed trench resulted in a small increase in pressure from his original calculations. However, the revised calculations did not alter Mr Wong’s conclusion that the absolute increase of pressure was relatively small.
Mr Wong also concluded the excavator would have only caused relatively low-level ground vibrations during excavation, adding the only time excavators cause ground vibrations is when they are travelling at highspeed and then undertake a turn whereby the excavator tracks slew which causes high friction on the ground. This scenario could be excluded based on the evidence to hand describing the rescue.
Mr Rodriguez provided a description of the geology of the trench collapse, noting the soil was a sandy clay. Mr Rodriguez considered the soil composition, the layout of the trench and the excavator specifications. He then calculated the lateral earth load noting that this would lessen as soil was removed from the site.
Mr Rodriguez concluded that the weight of the excavator did not add to the crushing forces on Jack. His conclusion was based on the fact that the distance of the excavator was too great for vibration from the excavator motor to increase the crushing pressure on Jack. Mr Rodriguez noted the action of the excavator bucket would have a slight effect on lateral soil pressure however, the additional load from the bucket action would have been quickly offset by the reduction in soil weight.
Mr Rodriguez concluded that: the weight of the excavator would not have added to the crush force on Jack, the vibrations may have contributed, albeit insignificantly; and the effect of use of the excavator so as to minimise its forces was likely not significant.
Expert Rescue Evidence:
Mr Dobson concluded:
a) The nature of the excavations at the site of the trench collapse, poor ground conditions, and the presence of intersecting trenches, would have prevented the effective use of any form shoring system to assist in Jack’s rescue;
b) The decision to use the on-site excavator, to assist in removing a large amount of earth and soil near where Jack was trapped, was the correct one;
c) Anyone who undertook training to achieve competency in undertaking trench rescue would consider the use of an excavator as a legitimate method of removing large amounts of earth and soil to assist in the rescue of the victim; and
d) The excavator was used effectively, and as safely as possible in this situation, to remove large amounts of earth and soil to not only expedite Jack’s extrication but to also create a safe working environment for rescue personnel.
To summarise:
The rescue operation was performed carefully and thoughtfully, ensuring that emergency services personnel were working as safely as practicable in the dire circumstances.
