verdict of the coroner's inquest for ms keltie byrne, formerly a killer whale trainer

8/7/2019 Verdict of the Coroner's Inquest for Ms Keltie Byrne, formerly a Killer Whale Trainer

http://slidepdf.com/reader/full/verdict-of-the-coroners-inquest-for-ms-keltie-byrne-formerly-a-killer 1/5

C ORON ER 'S C OU RT O F B i1 lT 1S H C OL UM BIA

HEI..OAT C o l w o o d S.C.

VERDlCT OF CORONER'S INQUEST

J U N C 5 1 9 3 1Into The De.u.h Of

[ ]K ELTIE LEEB Y R N Esm.]~"- \ME C lV EN NAME

Address: 1524 Oak land Avenue. V icto ria , B ritish Columbia V8T 2L2WE, TIlE JURY, hav ing been duly sworn and seM1l$ .;u. the inquest into I .l l. edea t.bc f the above s ta ted,Q1l the 30th,l,2,3 and

days A "1lI~y of pn IMay 19 91 , have 4.derminod th e following facts:

Ase: 20 Native 0

Date (If Bi'1.b: Decembe>r 6th, 1970 E~. Date of Death: February 20. 1991

Place of Death; Sea1and of the Pacific Est. 1'i.r!re of Death: Between 1330 and 1545 hrs .

. Sealand of the Pacific . F b 20' 1991 bPlace of In}\lIYIl~s: 1327 B h D V ' t .D;\t¢.and TIme : e ruary tn , etween

eac r.. 1c or1a.~,c~- 1 3 2 0 a n d 1 3 3 0 h r s( i ll the w hale poo l) . f : ; ; ~ · . '";"'":'''j

Oceanarium . Code '~' ,-S<1.;~t<Type of Prenoise:

J d !>D t if ic a ti OD Me i li o d Visua l [X J

Idmtij",d By: C o w o r k e r s an d by S eal an d M a n a g e r Al Bcl z

MEDICAL CAUSE OF DEATIf:

(l ) Immedi ate Cause of De ath: (a) D row ni n gDUE TO or as a co nsequence of

~ } F o r c e d s u b m e r s i o n by o r c a ( k i l l e r) w ha l e sDUE TO or a s a consequence of

Antecedent Cause, jf any, ShillS

ri se to the i lnmediate cause (. a) above

Stating !be uDderl] ing cau.. , last.

(c) Fall ing into th e whale pool( 2) O t he r S i&1 :! if ic amM ~ ic al C a us es

Contr ibUling 10Death;

BY W}lAT MEANS: S e e P a g e T w o

o

o~ooA\:Cidenw ~

Suicide 0

Undetermined 0

NarunU

THE JUROR.S

D av i d o u f f u s

M ichae] D oyle

M ar c B , P a k e n h a m

W a y n e youngv,c

Sf'!" Healy

T HI S V E RD IC T wa s received by me, D i a n n e M e s s i e r I a C o r oD . ,e r

fil l Britisb Columbja tb is day of May 6th 1991.

of \ \

P-,~D i a n n e M e s s i e r

ORIGINAL TO REGIONAL CORONER

6 t h

-"



C~""N~ .. ~ •. .,4-0023

COR ONER'S CO URT O F BRITISH G OLU M6

HELDAT 8cv.

FIN D IN GS a nd R EC O M ME ND A TIO NS a s a R ES UlT ,o f th e IN Q UE S Tinto The Death 01

~~~BllYRillN~E ~1 ~ 1 _ _ ~K~El~T~I~E~L~E~E ~

BY WHAT MEANS:

Keltie Lee Byrne died as the result of an accident on February

20th, 1991. After conducting a whale show at 1305 hrs., a

"play" sessior. was in.itiated by the trainers at the whale pool.

After, Ms Byrne picked up her coolers, used for carrying .fish,

and proceeded along the east side of the inner walkway of the

whale pool. For reasons undetermined, she fell into the whale

pODl at approximately 1320 hrs. and While attempting to get out

the whales intervened moving her away from the pool's edge.

Rescue attempts with safety equipment by fellow staff members

were th...arted by the whales. Over the course of the next ten

minutes (approximately), Ms Byrne was submersed repeatedly for

va. rying intervals. Afte r thi s pe r i o o , Ms By:tne appeared to be

unconscious. Attempts by trainers to b:ting the whales under

control were unsuCcessful although for brief periods one or more

whales appeared to respond to stationing cues, used to still the

whales. Furthermore, distraction attempts were also

unsuccessful. Concurrent rescue attempts, including the use of

a large net to separate the Whales from the victim and the use

of a reaching pole and lifebuoy failed. Fol1owin9 that, the net

was thsl1 weighted and used tD aragthe pool t¢ recover the body

of M~ Byrne. Ms Byrne was removed from the water at lS35 hrs.

using the aforementioned net - no life signs were evident;, No

resuscitation attempts were made and the body was removed from

the scene at approximately 1630 hrs.

01 II


I

I

I

!

II



C-I'<o. 91-164-0023CORONER'S COURT OF BRITISH COlUMBI

HELD AT B.C.

F IN D IN G S and.RECOMMENDATIONS a s a R ESU lT o f th e IN Q UE S TInto The Dea!h 01·

"'---BY-R-NE~----~----'I [ t::E~IILJ£ E

R ECOMME N DAT I ONS OF THE JUR Y:

TO: Workers' Compensation Board of British Columbia (WeB)

6951 Westminster Highway

Richmond, British Columbia

V7C le G

l) The Worke~s' Compensation Boa~d (WeB) create a specific

category for the type of activity conducted at Sealand and

other similar businesses and develop safety standards

accordingly.

2J The Workers' compensation Board (WeB) develop e

comprehensive a nd regUlar inspection program to cover a l l

aspects of workplace and activities at Seal and. A

c ompl ete record o f the inspe c ti o n wi l l be fi l e d bX the

Inspector.

3) The Workers' Compensation B~ard (WeB) shall direct the

Application for Com~ensation and Re~ort of Industry or

Industrial Disease (Form 6/ and the Employer's Report of

Injury or InoustriQl Disease (~oIm 7) and the Physician's

Report Form to the Occupational Health and Safety Officer

f or a ss es sm en t.

3Page.t of U




~ ea.. No . 91-104-0023

CORONER'S COURT OF BRtTISH COLU"" .

HELOAT !l.G.

FINDINGS andRECOMMENDATIONS 8S a RESUlT of the INQUEST

tnto Tile Death 01·

.....----a-YR-NE--------,------,I! K ELTIE ~E E

TO: Sealand of the Pacific Ltd.

1 327 B ea r:h Dr ive

Victoria, British Columbia

VBS 2N4

4) At least one staff person be actively monitoring safety in

and around the pool areas while tne general public is in

the area. This person $hall not have other duties which

could interfere with an immediate response to a breach of

safe practice by the general public or Zealand staff.

5} Zealand shall develop a system to quickly and se<;;urely

isolate one or more whales in the main pool.

6) Sealand co~ntarie$ shall include safety messages for the

public regarding motion of platform and security around

sa£ety barriers.

7) Public s<lfety siqns should Yarn of sudden deCk movement.

8) Sealand shou~d consider translating safety signs into the

lanquages of their major clientele.

9) Sealand shall install aadltion~l switches, in strategic

locationsr to trigger the emergency alarm system.

10) Sealand shall install two life-lines around the inner

periphery of the whale pool. It should be fixed at

regular intervals, and placed at the pools ide uppe~ edge

of the inner wall and at the lower edge of the inner wall,

at; or just below, the v~te~ level. This is to provide

hand and foot holds in order to eas~ the exit fIom the

p o o l .

Page:Of \\

ORIGINAL TO REG10NAL CORONER



CORONER'S COUR{ O F BRIT IS H C OLU1 'J ;E ': 1

HElDAr 3_C

FIN D IN GS a nd ·R EC O MM EN D ATIO NS a s a ReSULT of the I N QU E S Tlnlo The Death Of·

..------SY-R-N-E--------;1 I Ke1ti~ Lee

I I } Se a l a nd shall c onsider the use o f so ft, throwing d ev i c e s

with floating, tangle-free line.

12) S e a l a n d staff shall wear a personal flotation devi c e

!P.F.D.l in t~e immediate pool area (o n 5tage or inside

the guard rail). Consideration should be given to a type

o f de vi c e wi th a c o mbi na ti o n, i nhe r e nt buo ya nc y (i . e .

fo am) a Dd i nfl a ta bl e buo ya nc y_

1 31 ~ l l a ni ma l di vi si o n sta ff shall r e ce ive l ife - sa vi ng

training to a minimum of Royal Life Saving society of

Ca na da (R LSSC1 , Bronze Medallion Award or higher.

l~) Al l a ni ma l division staff shall take part, in all aspect$#

of realistic rescue simulations in the Whale pool.

15) AllaniJnal division staff shall have safety orientation

training, dtstinct from on-the-j ob training.

1 6) All s",fety a nd tr a i ni ng i nfo r ma ti o n wi l l be i n wr i ti ng a nd

di str ibute d to all staff.

17) Containment of whales in the 'module' should be limited to

ve te ri na ry a nd husbanary functions only. Separation of

the whales for behavioural reasons should be accomplished

using partltion(s) in the main p o o l .

5Page ~ 0 1 \l


verdict of the coroner's inquest for ms keltie byrne, formerly a killer whale trainer

Documents