Inquest into the death of Grace Moulding

CITATION: Inquest into the death of Grace Charlotte Moulding [2025] NTLC 11 TITLE OF THE COURT: Coroners Court JURISDICTION: Alice Springs

FILE NO: A0027/2023 DELIVERED ON: 1 August 2025 DELIVERED AT: Darwin HEARING DATES: 2 - 5 June 2025 FINDING OF: Judge Elisabeth Armitage CATCHWORDS: Single vehicle rollover, unsealed road, driver training, default maximum speed limit

REPRESENTATION: Counsel Assisting: Helena Blundell Counsel for Department of Logistics and Infrastructure: James Stuchbery (WardKeller) Counsel for The Artists of Ampilatwatja Corporation: Sandra Wendlandt Judgment category classification: B Judgement ID number: [2025] NTLC 11 Number of paragraphs: 81 Number of pages: 24

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRLIA No. A0027/2023 In the matter of an Inquest into the death of

GRACE CHARLOTTE MOULDING ON: 17 JUNE 2023 AT: THE SANDOVER HIGHWAY FINDINGS Judge Elisabeth Armitage Introduction

1. Grace Charlotte Moulding (“Grace”) was the only child of Janet Lamb and Ron Moulding. She was born on 10 May 1996 in Leicester, England. She died in a car crash at approximately 1pm on 17 June 2023 on the Sandover Highway in the Northern Territory. She was 27 years old when she died.

2. She went to Primary School at her local village school in Humberstone and completed her secondary education at Judgemeadow School. Grace loved drama, dance and music, including attending festivals, gigs and concerts. She played junior rugby at both club and county level. She completed the Duke of Edinburgh award and was a proficient sailor, skier, hiker and camper.

3. She gained an Honours degree in Globalisation, History and Politics from Brighton University and completed a Master’s degree in Human Rights at Sussex University.

4. After her study Grace travelled to Australia and worked as a volunteer at Warlukurlangu Arts Centre in Yuendumu which ignited a love of the first nations art and culture of Central Australia. Shortly after she arrived, Covid 19 struck and she spent the following months working in various jobs. She worked for the Artists of Ampilatwatja1 (“the Art Centre”) in paid roles on two occasions between 2019-2021 when Caroline Hunter was the Manager, and Grace and Ms Hunter became friends.2

5. Back in England she undertook another Master’s Degree in Curating Collections and Heritage at Brighton University. Her dissertation entitled “Indigenous Curatorial Methodologies: Songlines: Tracking the Seven Sisters” was posthumously published in the Journal of Museum Ethnography.

6. Grace is remembered by her family and friends as a talented and vibrant young woman with an adventurous spirit. She was dearly loved by her parents, grandparents and her friends and they are devasted by her tragic passing.

Immediate Circumstances Surrounding Grace’s Death

7. Grace and her colleague Harriet Brown (“Harriet”) drove from Ampilatwatja to Alice Springs in the Art Centre’s Troop carrier to drop off artworks, do some shopping and have a break in town. They checked out of their hotel on the morning of Saturday 17 June 2023 and set off at around 11 am to drive back to Ampilatwatja. Harriet drove the first section of the trip on the sealed road. They stopped for some lunch and at the start of the Sandover Highway they locked the hubs and engaged high range 4WD. Grace took over the driving on the unsealed road and Harriet was in the front passenger seat.

8. Prior to the crash Harriet estimated that Grace was driving at a cruising speed of between 80-120km an hour.

1 Pronounced Um bludder witch 2 NT WorkSafe Brief, Additional Document 7, Folio 21 at p3

9. The crash occurred between 12.30 – 1.00pm on a straight stretch of road on the Sandover Highway about 42km from the Plenty Highway turnoff. According to Harriet and the crash investigation report, the crash sequence commenced when the Troop carrier’s passenger side wheels hit a rough section on the unsealed road, possibly a loose edge or gravel. Grace steered to the right so that the vehicle travelled to the other side of the road. She then applied steering input to the left causing the vehicle to go into an anticlockwise yaw before she again turned the car back to the right causing the vehicle to broadside before tripping and rolling approximately 70m coming to rest on its wheels. Det Sgt Aila, using FaroZone CAD software to analyse the crash scene data, estimated the speed at the time of the crash at 116km.3

10. Soon after the crash, another Ampilatwatja resident, Kim Gentle, arrived at the crash scene. According to the GPS data from her vehicle she arrived at 1.27pm.

Ms Gentle knew both Grace and Harriet from the community. She found Harriet standing outside the vehicle obviously injured and in a state of shock. She saw Grace inside the car, seriously injured and unresponsive. Ms Gentle was unable to call for assistance at the crash site due to a lack of mobile phone reception and the Troop carrier was too crumpled for her to remove Grace from the vehicle.

11. She decided that her best option was to take Harriet to the nearest medical clinic at Arlparra Community and report the crash as soon as she had mobile phone reception. She rang 000 when she was 10-15 minutes outside Arlparra. She reported the crash and told the operator there was a seriously injured person trapped in the car and that she did not know if the person was alive or dead, but police and ambulance were urgently required. She took Harriet to the clinic and reported the crash to Arlparra police in person at 2.45pm.

3 Coronial Brief Folio 1, para 20 and Folio 10 para 7

12. Arlparra Police and clinic staff arrived at the crash just after 4pm. Efforts were made to resuscitate Grace but she was declared deceased by Registered Nurse Avalon Hazelman in consultation with Dr David Marcelline at 4.27pm. Police extracted Grace from the wreck and took her to Arlparra.

13. The attending police used a satellite phone to call the Duty Superintendent who advised that the Major Crash Unit would not be attending. They took photographs, picked up debris from the crash and arranged a tow truck. One officer remained at the scene to wait for the tow truck. However, upon their return to Arlparra they were advised that the Major Crash Unit would be attending and they needed to declare and maintain a crime scene. The tow truck had not arrived at this point and police re-attended to set up a crime scene.

14. The Major Crash unit was advised of the crash at 4.53pm. In consultation with the Duty Superintendent, it was decided to attend at first light, noting that the crash scene was some hours away and the sun was setting. Det Sean Aila and Const 1/C Eruera from the Major Crash unit arrived at 7.18am the following day and processed the crash scene.

15. Police arranged for the vehicle to be inspected post-crash. There were no mechanical defects identified which may have contributed to the crash.

16. Both Grace and Harriet were wearing seatbelts. There was no evidence of alcohol or drugs in Grace’s toxicology results.

Previous Crash History – Arts Centre Vehicles

17. This was the 4th rollover on the Sandover Highway involving an Ampilatwatja Art Centre vehicle. The others were:

• 28/5/2010 Troop carrier driven by Caroline Hunter, rollover, 6 passengers, no significant injuries.

• 12/1/2013 Troop carrier driven by Christian Beschamps (Belgian National), rollover, no significant injuries.

• 16/4/2021 Troop carrier driven by Crystal Thomas, rollover, both driver and passenger Ryan Casey seriously but not critically injured.4

18. None of the drivers in these crashes had completed a 4WD course. There were no policies in place that required staff to produce their driver’s licences before driving the Art Centre vehicles, and each of the driver’s prior 4WD experience was not verified.5 Issues for this Inquest

(i) Whether the Artists of Ampilatwatja Corporation had sufficient policies, procedures and systems in place to manage the workplace risk of driving on unsealed roads?

(ii) Whether the Artists of Ampilatwatja Corporation had sufficient policies, procedures and systems in place to ensure that the Corporation’s vehicles were registered and ownership details were current?

(iii) Whether the road maintenance schedule for the Sandover Highway was adequate and followed?

(iv) Whether the default maximum speed limit of 110 kmh for the Sandover Highway is appropriate?

Grace’s Employment with Artists of Ampilatwatja Corporation

19. The Artists of Ampilatwatja Corporation was incorporated in 2003 and has operated the Art Centre intermittently since then.6 It is a registered Corporation under the Corporations (Aboriginal and Torres Strait Islander) Act 2006. It is governed by a Board consisting of artists from Ampilatwatja community who employ staff to work at the Art Centre. The positions included a full time Art 4 Coronial Brief, Folio 25 5 WorkSafe Brief, Additional Document 7, Folio 29, page 18, Day 2 pages 132-134 6 Artists of Ampilatwatja Background Statement, Additional Document 10

Centre Manager and a Studio Co-ordinator but these were not always able to be filled.

20. The Art Centre is a member of Desart which is an umbrella organisation that provides its members with a range of supports. Membership is voluntary and is subscription based.

21. Caroline Hunter was the Art Centre Manager from 2012 until 20 July 2022.7 Ms Hunter’s position as manager was terminated by the Board on 20 July 2022.8 However, by agreement, she stayed on in a consultant capacity and worked remotely to fulfill some ongoing commitments. However, the Art Centre itself was effectively closed once she ceased the manager’s role pending the appointment of a new manager. Ms Hunter retained access to the Art Centre’s generic email account to conduct necessary tasks.9

22. The positions of Art Centre Manager and Studio Co-ordinator were advertised in September and October 2022 with support from Desart. Philip Watkins, Chief Executive Officer Desart, told the Inquest that Desart assists with recruitment if a member Art Centre requests it. 10 Mr Watkins said that applications would ordinarily be sent to the Art Centre’s email address and then forwarded to Desart and that this arrangement was in place.11 However, according to the “Position Description” documentation, applications addressing the selection criteria were to be sent to the Corporate Services Manager at Desart.12 Mr Watkins said that Desart did not receive any applications for these positions. Email correspondence from Angie Stahl, the General Manager of Desart, to Ms Hunter and Mr Watkins dated 21 October 2022, refers to one incomplete application 7 NT WorkSafe Brief, Additional Document 7, Folio 29 pp-6-7 8 WorkSafe Brief, Additional Document 7, Folio 215 9 WorkSafe Brief, Additional Document 7, Folio 214, Day 2 Transcript, page 125 10 Transcript, page 196 11 Transcript, page 197 12 WorkSafe Brief, Additional Document 7, Folios 194-195

being received.13 Ms Hunter recalled that three applications were sent to the Art Centre’s generic email address but none of the applicants were suitable.14

23. In any event, it is clear that efforts at attracting suitable applicants via advertising were unsuccessful. I heard from Mr Watkins that it is often difficult to recruit for these positions and that it is common not to receive any applications.15

24. Ms Hunter visited Grace in London in October 2022. They discussed the vacant Manager’s position and Ms Hunter said she would support Grace’s application if she wished to apply. Ms Hunter said that Grace sent an Expression of Interest in the position which was ultimately approved by the Board.16 Email correspondence between Angie Stahl (Desart) and Caroline Hunter dated 27 October 2022 suggests that Mr Watkin’s was consulted about that time, following which Grace was offered a 12 month contract for the Manager’s position.17

25. I heard evidence from Rosemary Turner who is a current member of the Board of Artists of Ampilatwatja Corporation and some of the other artists at Ampilatwatja. It was unclear whether any of these artists were Board Members at the time of Grace’s recruitment, and it was unclear whether the group I heard from properly understood that Grace was employed in the Manager’s position or how she was recruited.18 Inexplicably, there is no mention of Grace being appointed as the new manager in the minutes of the AGM on 17 February 2023 after Grace had commenced in the role, although both Ms Hunter and Mr Watkins recall her being in attendance.19 However, Grace’s employment contract for the Manager’s position dated 3 February 2023 was signed by Beverly Luck (Executive Member).20 13 WorkSafe Brief, Additional Document 7, folio 220 14 Transcript, page 125 15 Transcript, page 201 16 Transcript, page 125 17 WorkSafe Brief, Additional Document 7, folio 220 18 Transcript, page 186 19 Transcript, pages 165-169 20 Coronial Brief Folio 20

26. According to Ms Hunter there was no interview process, but she was well qualified, well known from her previous work at the Art Centre and was the right fit for the job.21 I note that Grace’s recruitment took place in the context of the Art Centre having closed due to the lack of a manager, and there being no other suitable applicants. However, her recruitment was somewhat informal and irregular and the opportunity to ensure that she met all essential criteria was lost.

27. It appears that whilst Grace submitted an “Expression of Interest” for the manager’s position, there is no evidence she submitted an application against any selection criteria.22 The selection criteria for the Manager’s Position when advertised by Desart listed “a current driver’s licence and ability to drive a manual 4WD” as an essential criterion23 and Ms Hunter was aware that Grace only held a Learner’s licence.24 Mr Watkins said that a learner’s licence did not meet this criterion. He agreed that whilst sometimes an applicant may be appointed if they met most, but not all, of the essential criteria, given all the Art Centres are in remote locations, a driver’s licence is essential.25

28. After the crash Ms Hunter told WorkSafe Inspector Weller that she had spoken to the Board and it was agreed that they could work around the licence issue by ensuring there was a licenced community member who could drive with Grace.26 However, in her evidence at the Inquest Ms Hunter said she had spoken to Kathleen Rambler, an Art Centre worker, and Ms Rambler had said she would speak to the Board.27 On the evidence before me, I cannot conclude with any certainty that the Board was aware of Grace’s licence status prior to her appointment.

21 Transcript pages 162-163, Day 3 page 206 22 WorkSafe Brief, Additional Document 7, folio 29 page 37 23 Exhibit 8 24 Coronial Memorandum p 12 (Brief p 14): Grace held a UK Provisional Licence which is equivalent to a Australian Learner’s Licence and obtained an Australian Learner’s Licence on 6 February 2023 which remained current until 5 February 2025.

25 Transcript, page 206 26 WorkSafe Brief, Additional Document 7, Folio 29 page 33, Day 2 Transcript, pages 123-124 27 Transcript, page 164

29. On the issue of recruitment, I note that Harriet was also employed somewhat informally to the position of Studio Co-ordinator due to there being no applicants for the position. She was a friend of Grace’s from University and provided her resume and cover letter to Grace who was, by then, in the Manager’s position.

She told the Inquest that Grace spoke to the Board and that she got the job based on her qualifications and Grace’s recommendation. Again, there is no evidence that she was required to address any selection criteria for the position.28 Induction and Training

30. Grace arrived in Australia in early February 2023. She travelled to Alice Springs with Ms Hunter and her partner Joe Sykes, who had also worked on a casual basis for the Art Centre for many years. The three of them drove out to Ampilatwatja in the Art Centre’s Troop carrier. This was the same vehicle involved in the fatal crash.

31. Mr Sykes said that Grace drove about 200km of that trip and it gave him an opportunity to assess her driving ability. He described her driving with common sense and caution.29 Mr Sykes also said that he showed her around the community roads with Grace doing the driving, this included back roads and on one occasion driving to Amaroo Station for a couple of hours. Mr Sykes was an experienced 4WD driver but was not an accredited instructor and had never undertaken 4WD training himself.

32. Mr Sykes told me that he gave Grace a 4WD manual to study in her own time that had been left behind by a previous worker who had done a 4WD course. He also familiarised her with the general workings of the Art Centre Troop carrier.

She changed a tyre, looked “under the bonnet” to check oils and fluids, and he instructed her on how to engage 4WD.30 28 Transcript Day 1, page 57 29 Transcript, page 99 30 Transcript, page 101

33. Ms Hunter conducted a three week handover with Grace when she commenced in February 2023. She was unable to recall who approved this induction arrangement but agreed that she invoiced the Art Centre for this work.31 As I understood her evidence, this was effectively a one-on-one handover where she showed Grace the Art Centre’s systems. Mr Watkins told the inquest that Desart was not involved in Grace’s induction and he was not aware of the nature or scope of the induction conducted by Ms Hunter.32

34. Ms Hunter said that she developed procedures manuals and business plans when she commenced as the manager in 2012.33 When she gave evidence, she no longer had access to the Art Centre resources but was able to provide the inquest with a draft Policies and Procedures Manual dated February 2012 V1. This document was an incomplete template copied from another Art Centre and lacked specific details of the Ampilatwatja Art Centre or any of the relevant appendices. It contained no policies regarding work vehicles and driving. Ms Hunter said that the Procedures Manual was completed in 2015 or 2016 and this final version was the one she used during Grace’s induction.34 Ms Hunter said that the 2015/2016 Procedures Manual was kept in a white folder in the Art Centre office and there was also an electronic copy. Ms Hunter also said she used the Handover Guide and Healthy Corporations Checklist during Graces’s induction and that she gave Grace the filled in versions of those documents.35 Neither of these documents provide specific guidance as to the use of vehicles or safe driving.

35. As to policies relevant to the use of the Art Centre vehicle, Ms Hunter said that only the Manager could approve vehicle usage, and its use was limited to employed staff. She did not recall any specific written policies relating to vehicle 31 Transcript, page 164 32 Transcript, page 222 33 Transcript, page 122 34 Transcript, pages 121-122 35 Coronial Brief, Folio 21 and Day 2 Transcript, page 122

use or driving on unsealed roads.36 Ms Hunter herself had not undertaken any training in Work Health and Safety (“WH&S”) nor had she done a 4WD course.37

36. Although a copy of this 2015/2016 Procedures Manual was requested to be produced at the Inquest, neither WorkSafe Inspector Weller, Det Sgt Aila nor Meaghan Jacobs, who took over as the Manager after Grace’s death, were able to locate any Procedures Manual or any Art Centre policies or procedures relevant to vehicle use or driver training.38 Harriet also said that when she started her position in April 2023, Grace explained the job but there was no formal documentation used in her induction.39

37. On the evidence available I am unable to determine whether there was a finalised 2015/2016 Procedures Manual but: relying on Ms Hunter’s evidence, I am satisfied that there were no written policies concerning the use of the Art Centre’s vehicle when Grace was employed; and, relying on Harriet’s evidence and the searches undertaken, none had been developed by April 2023.

38. After Ms Hunter provided Grace with the three-week induction, Ms Hunter left the community but continued to mentor Grace remotely. Ms Hunter said that more than once she told Grace that she needed to do a 4WD course but that it was Grace’s responsibility as the Manager to arrange this.40 Harriet said that a 4WD course was discussed with her before she started her job, but it never eventuated, and that everything she knew about driving on long remote unsealed roads she learned from Grace.41 36 Transcript, pages 122-123 37 Transcript, pages 112-113 38 Transcript, page 18, WorkSafe Brief Additional Document 7, Transcript, page 29 39 Transcript, page 58 40 WorkSafe Brief, Additional Document 7, Folio 29, page 38, Transcript pages 128-129, Transcript page 41 Transcript, page 62, WorkSafe Brief, Additional Document 7, Folio 13 pages 20-21

39. During Ms Hunter’s tenure as Art Centre Manager there were three roll-overs involving the Art Centre’s Troop carrier, yet no specific written policies or procedures addressing driver safety were produced. Ms Hunter said that she mitigated risk by ensuring that the Troop carrier was regularly serviced and by limiting access to employees. There was a first aid kit in the vehicle, but it was not regularly checked. There was also a satellite phone but its use was sporadic.42 Grace’s Driving Experience

40. Prior to arriving in Australia in February 2023 Grace was the holder of a UK Provisional driver’s licence (equivalent to an Australian Learner’s Licence) and she obtained an NT Learner Licence on 11 June 2023.43 Despite some confusion about this, there was no evidence that Grace had ever held an open unrestricted driver’s licence.

41. There was also no evidence that Grace had any experience driving on long unsealed remote roads before commencing at the Art Centre in February 2023.

Grace did not have access to, and did not drive, the Art Centre work vehicle when she worked there on the earlier two occasions.44

42. Before Harriet’s employment in April 2023, Grace only drove into Alice Springs a couple of times.45 The requirement to have a licenced driver accompanying her likely restricted her ability to undertake more frequent trips. Harriet said that after she arrived, she and Grace drove to Alice Springs three times and once to Tennant Creek. She said that their trip planning involved checking vehicle fluid levels, taking water, sharing the driving and notifying someone in the community of their trip. They did not take a satellite phone and she did not know that the 42 Transcript, pages 136-137 43 Coronial Brief, Folio 19; Coronial Memorandum p[12 (Brief p 14) 44 WorkSafe Brief, Additional Document 7, Folio 29 page 22, Transcript, page 123 45 WorkSafe Brief, Additional Document 7, Folio 29 page 38

Art Centre had one.46 This trip planning was done voluntarily and based on their own shared sense of precaution. There was no written policy or procedure.

43. Harriet had an unrestricted driver’s licence but little experience driving on unsealed roads. Harriet knew that Grace was subject to speed restrictions on her learner licence. They shared the driving with Harriet tending to drive on the sealed roads (as she could drive at higher speeds) and Grace driving on the dirt, as even her limited experience driving on unsealed roads was greater than Harriet’s.47 4WD Training

44. Craig Pankhurst owns and operates Central Australian Driving School (CADS) which delivers 4WD training. Mr Pankhurst has delivered this training for 20 years. Before that he was firefighter in South Australia which, among other things, involved driver training. He holds a multi-combination driver’s licence and is an instructor and assessor for licences ranging from cars to road-trains.

Additionally, he has participated in professional offroad buggy racing and has won the Australian Driver’s Championship.48 I consider him a lay expert and have treated his evidence as such.

45. Mr Pankhurst explained the nature of 4WD training which includes participants practising and demonstrating competency in pre-starts, changing a tyre, how 4WD operates, when to operate it, how to use low and high range, and how to brake on unsealed roads.49 Mr Pankhurst does not accept Learner’s licence holders on his 4WD courses because he considers that the content of the course requires more driving experience than a learner driver would possess.50 46 Transcript, page 59 47 Transcript, page 62, WorkSafe Brief, Additional Document 7, Folio 13 page 31 48 Transcript, pages 76-77 49 Transcript, page 78 50 Transcript, page 79

46. Mr Pankhurst was provided with the crash investigation report and he considered that the skills he teaches are directly applicable to this crash scenario. In particular, the relationship between speed, steering input and braking. He teaches his students that a safe maximum speed for an unsealed road is 80kmh and in his courses he provides a practical demonstration of braking on an unsealed road at this speed. It is his view, based on his training and experience, that 80kmh provides a reasonable safety buffer for most drivers on unsealed roads in that it allows most driver’s time to adjust to unexpected changes, for example, in the road surface or stray animals entering the road.

47. As to the efficacy and value of 4WD training courses, I heard evidence that it is a requirement of Desart and the Department of Logistics and Infrastructure (DLI) that their staff complete a 4WD course before they are permitted to drive on remote unsealed roads as part of their employment. Mr Watkins said that following Grace’s death, Desart diverted funds from other programs to pay for its member Art Centre’s staff to undertake 4WD training. This has now been reduced to a $200 subsidy and capped at two staff per Art Centre per year due to budgetary restrictions.51 It was very clear from the evidence that requiring employees to complete of a 4WD training course is a recognised and efficacious risk management tool.

48. Both Harriet and Ms Jacobs (the current Art Centre manager) told me that they have now completed the CADS 4WD training and found it to be informative and extremely helpful. Harriet said she was taught how to get out of a skid and “it explained to me, like, how - what happened and we could’ve avoided that. Well, maybe not avoided it, but lessened the risk of the accident”.52 I understood her to be referring to the crash in which Grace was killed and she was the passenger.

49. Mr Pankhurst also described a range of devices that are available to help mitigate remote driving risks. These include vehicle mounted and small hand-held 51 Transcript page 223 52 Transcript, page 63

devices that can monitor speed and manner of driving in real time, have a duress alarm and automated text features. Some of these devices allow an organisation to monitor an employee’s driving (for example, to ensure they are complying with any speed limit restrictions or rest breaks) and provide a communication function in the event of a crash or other critical event when travelling on roads without mobile phone coverage. I heard that these devices range in sophistication and cost, but that low-cost and reliable models are readily available.

Vehicle Registration

50. The Art Centre Troop carrier (Registration Plate CE33QU) had been gifted to the Ampilatwatja Arts Centre in 2022. Ms Hunter had applied for the vehicle through a grants scheme. The vehicle originally belonged to NT Fleet and was registered until 31 March 2023. After it was gifted, it was collected by Ms Hunter on or about 14 April 2022. Transfer documents were completed and dated 14 April 2022. However, neither NT Fleet nor the Art Centre lodged the transfer documents with the Motor Vehicle Registry. At the time of the crash, it was still in the name of NT Fleet and was unregistered.

51. Ms Hunter was unable to explain why ownership had not been transferred and accepted that it was her responsibility to do this.53 Similarly, Ms Hunter was unable to explain how she had allowed the registration to expire or why its unregistered status was not otherwise identified. Accepting that the Art Centre would likely not have received a renewal notice (because the transfer ownership was not completed), there were no systems in place, such as logbooks or an asset register, designed to ensure registration was current.54 Road Maintenance – Sandover Highway

52. I received a detailed Institutional Response and heard evidence from Mr Gunalan Sivachelvan, Acting Regional Director, Transport and Civil Services, 53 Transcript, page 141 54 Transcript, page 143

Department of Logistics and Infrastructure (“the Department”). I was greatly assisted by his evidence and the Department’s response.

53. The Sandover Highway is deemed to be a Category D Highway due to its status as a secondary rural road. This corresponds to a category 4 classification under the AustRoads System. This classification guides how the Department resources its duty to maintain the Highway and reflects the low volume of road users (40 vehicles per day55), as well as its role as a secondary connector. Nevertheless, its maintenance is a high priority due to its critical role in supporting communities along its route. In the years between 2018-2019 to 2022-2023 $4,315,135 was spent on maintenance.56

54. The Department uses a software application called GBM Konect which provides clear, real-time, documentation of scheduled maintenance inspections, maintenance work completions and it allows for external users to raise maintenance issues. The Department contracts out its road inspection, road maintenance and compliance work to various contractors under a tender process.

55. Work is done in accordance with road asset and maintenance inspection rules.57 Contractors conduct road inspections at a frequency set out in the rules. The inspectors look at characteristics such as corrugations, softness and slipperiness and where those things result in a safe travel speed of less than 70% of the maximum travel speed this will trigger an intervention to remedy the identified defect. The contractors are then required to remedy the identified defects within specified response times. Departmental staff use GBM Konect to audit this work which utilises photographs, video and documents to show the completed works.

The Department also conducts randomised in-person audit inspections whereby departmental officers drive the relevant roads to verify compliance.58 55 Transcript, page 240 56 Additional Document 8, Affidavit of G. Sivachelvan paras 26-27 57 Additional Document 8, Affidavit of G. Sivachelvan, Annexure GS 14 58 Transcript, page 237

56. In the timeframe specific to Grace’s vehicle crash, the Sandover Highway was identified as requiring grading on 30 March 2023 and grading of the entirety of the road commenced on 28 April 2023.59

57. Mr Sivachelvan could not identify any defect in the road surface at the crash site on GBM Konect or on the crash investigation photographs. He also said, based on the police photographs, that in his opinion the vehicle was being driven on the running surface of the road not on the unstructured part of the roadside60 which is consistent with the findings of the Major Crash investigators.61

58. The Department’s records show that it is meeting the maintenance requirements for the Sandover Highway.62 I was also told that there are significant funded improvements planned for the Sandover Highway in recognition of its importance to remote communities and other landowners.63 Default Speed Limit – Sandover Highway

59. The default speed limit on the Sandover Highway is 110kmh except where signposted otherwise. The default speed limit for open roads which are sealed and unsealed rural roads was introduced in the NT on 1 January 2007. Prior to that there were open speed limits on these roads, that is, there was no default maximum speed limit.64 Speed limits are set by the relevant road manager and default speed limits are set by the relevant Minister. The default speed limit on regional and remote roads in NSW, QLD, TAS, SA and ACT Australia is 100kmh but for the NT and WA it is 110kmh.

60. The default speed limit is not signposted and the signage at the commencement of the Highway says “Warning, Gravel Roads, Surface Conditions Change 59 Transcript, page 238 60 Transcript pages 241-247.

61 Coronial Brief, Folio 1, page 8 62 Additional Document, Folio 11 63 Additional Document, Folio 8, Affidavit of G Sivachelvan, para 27 64 Transcript, page 248

Often, Drive Carefully”. I was told that it is the practice not to signpost the default speed limit so as to not identify a speed for people to aim for. 65 The effectiveness of this approach was not supported by the evidence in this Inquest, because the default speed limit is widely known. Mr Pankhurst said that his students are generally aware of the 110kmh default speed limit on unsealed roads66 and expressed the view that, “If somebody says 110, the inference is that it’s safe to do 110”.67 Similarly, Harriet said she knew the speed limit was 110kmh and that it was her assumption that “if you were allowed to do it, it must be safe”. Even Mr Sivachelvan accepted that a person with limited unsealed driving experience, like Harriet, may perceive that the default speed limit was indicative of a safe speed limit. Harriet said that she only learned her assumption was incorrect when she took her 4WD course.68

61. The NT has the highest rate of road deaths in Australia. The Northern Territory Speed Management Strategy acknowledges that there is a strong relationship between speed and poor safety outcomes. Research consistently demonstrates the positive and exponential relationship between vehicle speed and crash risk as well as the increased severity of crashes.69 Det Sgt Aila produced a table demonstrating the energy of higher speed crashes which clearly shows that in a crash the greater the vehicle speed the greater the distance the vehicle will roll.70 It is obvious that the greater the distance a vehicle rolls, the greater the likelihood that the vehicle will be more severely damaged and the greater the likelihood of serious or fatal injuries resulting. There is no doubt on this issue.

62. Mr Pankhurst opined that the maximum speed limit on the Sandover Highway should be 80kmh. He was not swayed by the argument that the lower speed would negatively impact driver fatigue. He said that driving at higher speeds 65 Exhibit 13, Transcript page 249 66 Transcript, page 80 67 Transcript, page 93 68 Transcript, page 58 69 Additional Document, Folio 8, Affidavit of G Sivachelvan, Annexure 22 70 Exhibit 4

required increased concentration and cognitive effort which also negatively impacted fatigue levels. He maintained his opinion that 80kmh was the appropriate speed limit for this road when asked to balance speed and longer journey time.71 As I have already indicated, I considered him an expert lay witness. Mr Sivachelvan maintained that drivers should ‘drive to the conditions and exercise caution and common sense where they were unfamiliar with unsealed roads. His personal view was that 80kmh was a bit low.72

63. Mr Sivachelvan did his best to explain speed reviews. Apparently, the “85th percentile” is the percentage of people who drive within the mandated speed limit. He said that the percentage of people who drove above the speed limit tended to do so on sealed roads. However, he conceded that the Department did not conduct speed surveys on unsealed roads and this assertion was based on individual observations.73 There was therefore no objective evidence as to the actual speed of vehicles on the Sandover Highway.

64. As already discussed, road maintenance is triggered to occur when characteristics such as corrugations, softness and slipperiness result in a safe travel speed of less than 70% of the speed limit. 70% of 110km is 77kmh. Mr Sivachelvan accepted the logic that, applying that repair schedule, at any given time portions of the road may have a safe travel speed well below the default speed limit of 110kmh and he acknowledged that this was a relevant factor that had not been explicitly considered when setting default speed limits.74 Mr Sivachelvan said that reviewing speed limits on the unsealed network is an action identified in the “Towards Zero Strategy”, though the focus had been on sealed roads. 75 71 Transcript, page 90 72 Transcript, page 260 73 Transcript, page 262 74 Transcript, page 264 75 Transcript, page 251

Findings Artists of Ampilatwatja Corporation Policies and Procedures – Driving Risks

65. When she crashed, Grace was not travelling at a safe speed for the conditions.

There was no evidence that she was a reckless person or a risk taker. I conclude that she was travelling at an unsafe speed because of her inexperience as a driver more generally and because of her inexperience driving on unsealed roads more specifically. Grace is not to be blamed for being inexperienced. She should never have been placed in a position that permitted her to drive a large 4WD on the Sandover Highway.

66. In light of the three earlier single vehicle rollovers involving Art Centre vehicles, the serious risks of driving the Art Centre vehicle on remote unsealed roads was demonstrated and known. Insufficient weight and consideration was given to Grace being the holder of a learner’s licence when she was offered the Art Centre Manager’s position. The steps taken, namely, restricting the use of Art Centre vehicles to employed staff members, ensuring she was accompanied by a licenced driver, and informal verbal warnings to drive cautiously or with common sense, were inadequate to mitigate the risks. There was simply no adequate policy, procedure or system in place to protect Grace from the combination of the known risks of driving on unsealed remote roads and her inexperience as a driver.

67. Although Ms Hunter told Grace to do a 4WD course and the Desart Guidebook highlighted this as important, her employer, the Artists of Ampilatwatja Corporation, had no mechanism in place to ensure this occurred. Moreover, it could not occur because on a learner’s licence Grace was ineligible to be accepted into the CADS 4WD course.

68. The current Art Centre manager, Ms Jacobs, gave evidence that the Art Centre now has a range of policies and procedures applicable to remote driving on unsealed roads. These include a comprehensive Work Health and Safety (WH

& S) Management Plan, a Remote Travel Risk Register, a Remote Travel and Work Checklist, and a Risk Register.76 Included in these policies is the requirement that staff are not permitted to drive an Art Centre vehicle until they have completed or are enrolled in a 4WD course. I note that both current employees at the Art Centre have completed a 4WD course. I understand that there is no specified speed limit for the Art Centre vehicle on unsealed roads and in light of the evidence received in this inquest I will be recommending that one be considered.

69. It was concerning but not surprising to discover that the Board of the Artists of Ampilatwatja Corporation have little understanding of their legal responsibilities concerning work health and safety. This risk has been identified in the Art Centre’s WH&S Management Plan and acknowledged by Desart. I am advised that capacity building work and training is being undertaken by Desart with this and other boards. For example, it was encouraging to learn that in response to Grace’s death, Desart, in conjunction with NT Work Safe, conducted a WH&S training workshop in November 2024 attended by members from 13 Art Centres.

I acknowledge that capacity building is an ongoing body of challenging work, made more difficult given the large number of languages spoken across the art centres, and the lower levels of literacy and education in remote Aboriginal communities. I commend and endorse the continued efforts of Desart in their efforts at educating and developing the capabilities of its membership boards.

Ampilatwatja Corporation Policies and Procedures – Vehicle Registration

70. The Artists of Ampilatwatja Corporation did not have policies, procedures or systems in place to ensure that its vehicles were registered and ownership details current. However, I have heard evidence that the Art Centre now maintains a range of systems to track registration renewals including telephone calendar 76 Additional Document 5

alerts, vehicle logbooks and it maintains individual hard copy folders for its vehicles.77 Road Maintenance

71. There was no defect in the road surface that contributed to the crash on 17 June 2023.

72. The road maintenance schedule for the Sandover Highway complies with the relevant requirements applicable to a secondary rural road and its maintenance schedule, and inspections and repairs are being done in compliance with the relevant guidelines.

Default Speed Limit – Sandover Highway

73. On the evidence before me, I am satisfied that the default maximum speed limit of 110kmh for the Sandover Highway is too high. That was the effect of the evidence of Mr Pankhurst, supported by the “energy of higher speed crashes” table prepared by Det. Sgt Aila78 and the data and examples contained in the Northern Territory Speed Management Strategy 2023-2027.79 In coming to that conclusion, I have also taken into account the road repair intervention level which effectively means that at any given point in time the safe travel speed of sections of the road may be reduced to as low as 70% of the maximum safe speed, namely, 77kph, in conjunction with the evidence that road users know and do assume that the default maximum speed limit is a safe travel speed.

Formal Findings

74. Pursuant to section 34 of the Coroners Act, I make the following formal findings:

(i) The identity of the deceased is Grace Charlotte Moulding, born on 10 May 1996 in Leicester in the England.

77 Transcript, page 47 78 Exhibit 4 79 Additional Document 8, Affidavit of G. Sivachelvan, Annexure GS 22

(ii) The time of death was approximately 1pm on Saturday 17 June 2023.

The place of death was the Sandover Highway, Northern Territory.

(iii) The cause of death was multiple blunt force injuries in the context of a single vehicle rollover (driver).

(iv) The particulars required to register the death have been provided to the Office of Births, Deaths and Marriages.

Recommendations

1. I recommend that the Artists of Ampilatwatja Corporation amend their driving policy to restrict the use of work vehicles to employees who have completed a 4WD course.

2. I recommend that the Artists of Ampilatwatja Corporation conduct a risk assessment to consider if a maximum speed limit should be included in its policies and procedures concerning the use of work vehicles.

3. I recommend that the Artists of Ampilatwatja Corporation amend its Remote Travel and Work Checklist to include a requirement that the roadreport.nt.gov.au is checked prior to undertaking any remote driving.

4. I recommend that the Artists of Ampilatwatja Corporation adopt technology for its work vehicles which provides a means of communication along the length of the Sandover Highway.

5. I recommend that the Artists of Ampilatwatja Corporation adopt technology for its work vehicles that allows it to monitor driver behaviour, and at a minimum, technology that records driver speed so that its policies and procedures can be enforced.

6. I recommend that Desart review and update its templates to ensure that recruitment processes include strict driving licence criteria whenever remote driving is part of a position description.

7. I recommend that the Department of Logistics and Infrastructure ensure that a comprehensive speed limit review for the Sandover Highway be conducted within 12 months, and that this review prioritises the safety of road users.