This article was originally published on LinkedIn on 14 August 2025. It has been moved to the riskfacilitator Insights library so the website remains the permanent source.[1]

Learning Report

Case: SafeWork NSW v Garben; SafeWork NSW v Stevens; SafeWork NSW v Crestville Holdings Pty Ltd Medium Neutral Citation: [2025] NSWDC 302 Jurisdiction: Criminal – Work Health and Safety Decision Date: 8 August 2025 Judge: Strathdee DCJ

1. The Human Loss

An experienced climber died after a 12-metre fall when the lanyard of an auto-belay device failed at the Sydney Indoor Climbing Gym. The fall was not caused by recklessness or disregard for rules, it was caused by multiple, predictable, and preventable system failures that allowed a piece of safety-critical equipment to remain in use long after it should have been removed from service.

2. The Systems That Failed

This case was not about one worker making a poor choice. It was about systems designed to protect people that were either absent, incomplete, or unenforced.

1. Inspection and Maintenance

  • No daily, weekly, or six-monthly inspection system in place, despite manufacturer guidance and industry expectation.
  • No procedure to verify that inspections recorded in the log were actually completed.
  • No escalation process when the same fault was repeatedly logged.

Human Impact: Workers and climbers trusted that the equipment was safe because it was on the wall. That trust was misplaced.

2. Servicing and Manufacturer Compliance

  • Manufacturer’s manual required major service every two years , the unit was overdue by three months at the time of the incident.
  • No tracking system for service intervals.
  • Missing integration between manufacturer requirements and the gym’s operational processes.

Human Impact: A known, predictable wear point on the lanyard went unchecked until it failed under load.

3. Fault Resolution

  • Four logged issues about slow retraction/slack were never resolved.
  • No closed-loop process to confirm faults had been fixed.
  • No accountability for ensuring open issues were followed through.

Human Impact: The same warning signs appeared multiple times, but the system allowed them to be ignored.

4. Worker Competency

  • Workers received general induction but no training on identifying wear or mechanical faults in the auto-belay system.
  • Manufacturer-specific inspection points were not part of staff training.

Human Impact: Staff could be standing next to a piece of safety-critical equipment in dangerous condition, and not know it.

5. Director Oversight

  • WHS was not a regular item in directors’ meetings.
  • No governance framework to ensure critical risks were tracked and reported at board level.
  • Officers failed to verify that safety systems existed and worked.

Human Impact: Leadership assumed systems were in place without ever checking, removing a critical layer of defence.

3. Shared Responsibilities – Not Just the PCBU

Under s 23 of the WHS Act, if an importer brings plant into Australia, they are legally considered the manufacturer. In high-risk equipment like auto-belays, this means:

  • Designing in human error tolerance.
  • Ensuring users are trained and competent.
  • Providing accessible, clear, and enforceable maintenance requirements.
  • Following up when servicing deadlines are missed.

Current Gap: The supply chain treated safety as a handover of manuals, not a shared, ongoing responsibility.

4. Lessons for System Design

This incident reinforces that safety depends on systems, not paperwork. The systems that failed here share common traits found in other fatal cases:

  • No feedback loops: Faults were reported but not resolved.
  • No integration: Manufacturer’s safety requirements were not embedded into daily operations.
  • No verification: Leadership and workers assumed checks were happening without evidence.
  • No competence assurance: People were tasked with safety-critical work without the skills to identify risk.

5. Actions to Mature the System

  • Embed manufacturer guidance into operational reality, not just manuals. Link service dates, inspection intervals, and fault criteria to actual workflows.
  • Closed-loop maintenance tracking , an open issue stays live until verified fixed.
  • Competency validation , workers inspecting safety-critical plant must be trained to the manufacturer’s inspection standard.
  • Governance integration , WHS-critical metrics should be reported and discussed at every board meeting.
  • Shared accountability in the supply chain , importers, suppliers, and manufacturers should have systems to follow up on overdue servicing and training compliance.

6. Broader Implication

When systems fail, humans pay the price. The climber who died, the workers who were unknowingly supervising unsafe equipment, and the directors now carrying personal convictions are all victims of a safety management system that existed on paper but not in practice.

The message is simple:

If your system relies on people never making a mistake, it isn’t a safety system, it’s a gamble.

Caselaw

SafeWork NSW v Garben; SafeWork NSW v Stevens; SafeWork NSW v Crestville Holdings Pty Ltd [2025] NSWDC 302[2]

References

  1. Paul Chivers, The Climber Trusted the System. The System Failed Him., LinkedIn, originally published 14 August 2025.
  2. SafeWork NSW v Garben; SafeWork NSW v Stevens; SafeWork NSW v Crestville Holdings Pty Ltd [2025] NSWDC 302, source linked in the original article, accessed 10 August 2026.