An Inquest taken on behalf of our Sovereign Lady the Queen at Marla and Adelaide in the State of South Australia, on the 6^th day of October, 1999 and 7^th day of April, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Nyumpi Fox.

I, the said Coroner, do find that Nyumpi Fox, aged 5 years, late of Pipalyatjara Community, died at Pipalyatjara Community on the 5^th day of November, 1997 as a result of electrocution. I find that the circumstances of death were as follows:-

1. Background

1.1 During the evening of 4-5 November 1997 a fire broke out in a house at Pipalyatjara in the Far North-West of South Australia, on the Anungu Pitjantjatjaraku Lands ("the AP Lands").

1.2 Mr. John Chapman, a building contractor, was staying in a house across the road. He saw the fire during the night, at about 2.00a.m. (T.9), and went over to the house but nothing could be done to save it.

1.3 Mr. Chapman was intrigued by the fact that the conductors on the stobie-pole supplying power to the house were "venting the fire" (T.6). In other words, he saw smoke coming out of the top of the conduit on the pole and thought that the smoke was from the fire in the house.

1.4 Later, after dawn, Mr. Chapman realised that electricity would be a hazard at the site, so he went to the circuit breaker on the stobie pole and turned it off. He said:-

"The circuit breaker was still on and was very difficult to turn off. It took two thumbs to actually pull the switch down and it was a very difficult exercise".

(T.7)

In his statement (Exhibit C.5a), Mr. Chapman also observed that the switch felt "gritty" (p.2). Having turned the circuit breaker off, he understandably thought that the house site was now safe from electricity.

1.5 Nyumpi’s mother, Yangi Yangi Fox, said that her son went out to play with some other boys about his age at about 8.00a.m. (Exhibit C.4a). Although there is no evidence of what happened, it seems likely that the boys went to play near the burnt-out remains of the house. Nyumpi either went inside, or underneath the house and touched part of the metal framework and received a fatal electric shock.

1.6 Dr. Kerry Gell, a medical practitioner based at Fregon, coincidentally arrived at Pipalyatjara at about 8.40a.m. She saw some women wailing and Nyumpi’s mother in extreme distress.

1.7 Dr. Gell went to the burnt-out house and went inside. She saw a tap running. The remains of the house were no longer hot. She found Nyumpi’s body on the ground below the floor-beam near the front door. As she bent down to touch him, her left elbow brushed the metal door-frame and she received an electric shock causing pain (Exhibit C.1a, p3).

1.8 The generator supplying power to the entire community was turned off and Nyumpi’s body was retrieved. He had been lying in water.

1.9 Dr. Gell formally declared life extinct at 9.05a.m. When she examined the body later at the clinic, she saw that wires had been caught in his pants, under the body. His jaw and fist were clenched. There were no signs of trauma to the head or body.

1.10 Mr. Harry Quick is a works manager employed by Cowell Electric Supply Co. Ltd. The company supplies electricity and infrastructure on the Anungu Pitjantjatjaraku Lands. Mr. Quick arrived at the scene at Pipalyatjara at about 4.30p.m. on 5 November 1997 with a linesman. A linesman scaled the stobie pole, and having checked that the line was not live, removed the circuit breaker from the box. He also cut down the burnt service wire to the house which was attached to the mains (Exhibit C.6a). It was confirmed at that time that the circuit breaker was in the "off" position, as Mr. Chapman had asserted (see the statement of Mr. Goodchild, Exhibit C.9b).

1.11 A post mortem examination was carried out on the body of the deceased boy by Dr. A.J. Bourne and Dr. N. Manton, pathologists, on 7 November 1997 at the Womens and Childrens Hospital. Although definite electricity entry wounds were not identified, their findings were consistent with death by electrocution (see Exhibit C.2a).

2. The cause of the fire

2.1 Detective Mark Harrison, of Coober Pedy Criminal Investigation Branch, told me that, in consultation with Sergeant Connolly from the Police Fire Investigation Unit, it was concluded that the fire was caused by a candle which was left burning in the bathroom of the house (T.12). A statement taken from Andrew Kenny (Exhibit C.9) indicates that the lights were not working in the house, so candles were used instead.

3. Electrical issues

3.1 The obvious question which arises in this case, and one which has not proven easy to answer, is why electricity continued to flow into the burnt-out building, so that it killed Nyumpi Fox, after Mr. Chapman had turned off the circuit breaker.

3.2 Mr. J.H. Watson is a Principal Technical Standards and Safety Officer with the Office of the Technical Regulator, Department of Energy. Mr. Watson travelled to Pipalyatjara on 24 November 1997 and inspected the house remains.

3.3 The power entered the burnt-out house via wires which were connected to the overhead mains. These wires were encased in a PVC conduit pipe attached to the vertical part of the stobie pole. The conduit finished at the circuit breaker. On the other side of the circuit breaker, the consumer’s wiring commenced via a main to the house.

3.4 The end of the conduit furthest from the circuit breaker (i.e. closest to the overhead main) was badly burnt (see Exhibit C.11, photographs C to G). This would appear to account for the smoke seen by Mr. Chapman.

3.5 On the morning of the inquest (6 October 1999), Mr. Watson tested the circuit breaker which had been removed by Mr. Quick on 5 November 1997. It had been held at the Marla Police Station ever since. The circuit breaker malfunctioned, in the sense that even at a current of over 100 amps, it failed to trip off. It should have done so at 65 amps. Mr. Watson confirmed Mr. Chapman’s evidence that the toggle was excessively tight (T.23).

3.6 However, when the circuit breaker was "off", no current passed (T.23). So the excessive stiffness in the tripping mechanism did not account for the electricity continuing to flow after Mr. Chapman had forced it to the "off" position.

3.7 Mr. Watson advanced the following explanation for this:-

• the fire in the house caused destruction of the domestic fuse box, and a consequent short circuit in the house;

 

• the short circuit produced an over-current which should have tripped the circuit breaker on the pole, but did not;

 

• the insulation between the two conductors (wires) at the top of the conduit, above the circuit breaker, had become damaged (e.g. through ultra-violet rays, or attack by birds or for some other reason);

 

• as a result of the damage, and heat from the over-current, the plastic insulation around the conductors melted and the two conductors (active and neutral) came into contact, creating an arc;

 

• the arc caused further melting of the insulation around the conductors and the conduit casing;

 

• once the insulation had burnt away, the two conductors came into contact and became "common", in the sense that the neutral conductor (which normally is tied to the earthing system in the house) became active, and the whole metal framework of the house also became active;

 

• the electrical current running down the neutral conductor through the house frame to earth by-passed the circuit breaker (which only governs the active conductor), so that even after Mr. Chapman turned it off, current continued to flow (T.29).

 

3.8 Mr. Watson established that, according to the manufacturer’s specifications, the cable should have a life of fifteen to twenty years in the temperate regions of Australia, but in Central Australia, he estimated that the life of such cable could be as low as five to seven years (T.27).

3.9 Mr. Watson suggested that since the harsh environment seems to have rendered the circuit breakers ineffective, he would recommend the use of high rupturing capacity fuse cartridges, which have no moving parts and which will operate in any conditions. In his opinion, this would have prevented the conductors up-stream from becoming hot, melting the insulation and joining to become active (T.30).

3.10 Following the inquest hearing in October 1999, Mr. Watson arranged for further testing of the circuit breaker, having brought it back from Marla. In a further report dated 7 February 2000, Mr. Watson advised that the circuit breaker (a Heinemann type CF1 65 amp model) was tested in a similar situation to that in which it was installed at Pipalyatjara.

3.11 The tests revealed that the force applied to the switch in the subject circuit breaker exceeded 22 newtons, and yet the mechanism did not trip. A similar circuit breaker which operated correctly required a force of less than one newton to trip.

3.12 Mr. Watson attributed the malfunction in the circuit breaker to corrosion, and a distortion of the arcing barrier between the switching contact and the tripping mechanism (p.2).

3.13 Australian Standard 3111, clause 6.3.2(e) provides that "the calibration of the circuit breaker shall be such that it will - (e) trip within ten seconds when carrying 600% rated current for circuit breakers having current ratings of 50 amps and above".

3.14 The circuit breaker from Pipalyatjara did not trip in ten seconds, nor indeed in forty seconds. In that regard, it failed to comply with the Standard.

 

3.15 As a result of his testing, Mr. Watson recommended that:-

"1. All infrastructure circuit breakers, installed for the protection of consumer mains and isolation of the customer’s electrical installation from the infrastructure, be replaced with high rupturing capacity fuses where they are not adequately protected against external influences affecting their effective and continuous operation; or

 

2. They be tested periodically to ensure their continuous, safe and effective operation".

 

3.16 In a further report dated 5 March 2000, Mr. Watson expanded upon his findings:-

• rain-water, condensation and/or dust could have entered the circuit breaker housing leading to its failure;

 

• another Heinemann circuit breaker of the same type had seized in the "off" position at Pipalyatjara, since this incident, for similar reasons;

 

• the area of the consumer main at the sharp bend in the cable under the cap at the top of the conduit housing on the stobie pole is the point most likely to fail and produce an arcing fault in the event of an over-current (this, however, would have been protected if the circuit breaker had operated correctly);

 

• the impedance of the circuit between the neutral cable, the house frame and earth was sufficient to keep the current to 15 amps, below that necessary to trip any up-stream (i.e. at the generator) over-current protection device. The one which had been installed at the generator was rated at 200 amps;

 

• Mr. Watson visited the AP Lands with Mr. John Rowett, a project officer from the Department of State Aboriginal Affairs (DOSAA) again in December 1999. They carried out an inspection of the electricity distribution system throughout the Lands at that time. He ascertained the following:-

. the Pitjantjatjara Council own the electricity generating and distribution systems in the AP Lands;

 

. the day-to-day operation of the systems is managed by Essential Services Officers employed by the AP Council;

 

. DOSAA, in consultation with the AP Council, provide programmed maintenance and break-down maintenance by contracting the work to appropriate contractors (in this case Cowell Electric).

 

4. Finding

4.1 I find that Nyumpi Fox died on 5 November 1997 as a result of electrocution. This occurred when he was playing in the remains of a burnt-out house at Pipalyatjara. A fire the night before had burnt the house, and a short circuit occurred when the domestic electrical distribution board was damaged. This caused an over-current which should have been broken by the Heinemann type CF1 65 amp circuit breaker attached to the stobie pole, but was not because the circuit breaker malfunctioned due to corrosion and dust infiltration. The over-current caused the insulation on the service conductors to melt, allowing the two wires to come into contact. The neutral (earth) wire thereby became active, causing the metal frame of the house to become active as well. When the boy touched the frame of the house, he was electrocuted. Because the neutral wire did not go through the circuit breaker, Mr. Chapman’s well-intentioned actions in switching the circuit breaker to the "off" position did not prevent this tragedy from occurring.

5. Recommendations

5.1 Pursuant to Section 25(2) of the Coroners Act, I am empowered to make recommendations which, in my opinion, may prevent, or reduce the likelihood of an event similar to the circumstances of Nyumpi Fox’s death. Pursuant to that section I make the following recommendations:-

• I recommend that the Pitjantjatjara Council Inc., in conjunction with the Department of State Aboriginal Affairs, conduct an extensive review of the electrical distribution systems in place in the Anungu Pitjantjatjaraku Lands. The serviceability of the systems, and in particular the serviceability of the circuit breakers, should be closely examined;

 

• following such a review, a programme should be put in place to ensure that either:-

(a) the circuit breakers are housed, installed and maintained appropriately, and are tested regularly to ensure their continued operation; or

 

(b) they are replaced by high rupturing capacity cartridge fuses;

 

• all other authorities responsible for power generation and distribution, particularly in the outback of South Australia, should conduct similar reviews, and a similar programme of regular testing or replacement of the circuit breakers should be put in place.

 

 

 

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