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District Court 24 March 2026

SafeWork NSW v Goulburn Flight Training Centre Pty Ltd; SafeWork NSW v Ferrara

[2026] NSWDC 59

Other
CRIME PROSECUTION WORK HEALTH AND SAFETY CIVIL AVIATION REGULATION OF MODIFICATION TO AIRCRAFT LIKELIHOOD OF THE RISK OCCURRING

Citation: [2026] NSWDC 59
Court: NSW District Court (Criminal)
Date: 24 March 2026
Judge(s): Scotting DCJ

Background

On 27 June 2021, a skydiving instructor (Stephen Hoare) and his tandem student (Alex Welling) died after becoming caught on a modified step fitted to a Cessna 182 aircraft at a skydiving school operating as "Adrenalin Skydive" near Goulburn. The step — designed, fabricated, and installed by the skydiving school's Chief Instructor, James Czerwinski — had been fitted to the aircraft's wheel strut in the days before the incident to assist skydivers exiting the plane. Critically, the modification had not been authorised or inspected by a qualified aeronautical design engineer. As Mr Hoare and Mr Welling jumped, a Y-strap on the student's harness snagged on the step, leaving both men suspended beneath the aircraft in what is known as a "hang-up." Despite attempts by Mr Czerwinski (who was also piloting the aircraft) to cut them free and a dramatic effort involving a vehicle driven along the runway, the pair eventually fell from approximately 100 metres. The reserve parachute was activated but did not open in time, and both men suffered fatal injuries.

SafeWork NSW prosecuted two defendants. The first was Goulburn Flight Training Centre Pty Ltd (the corporate operator of the skydiving school), charged under sections 19(1) and 19(2) of the Work Health and Safety Act 2011 (NSW) with failing to comply with its primary duty of care to a worker (Mr Hoare) and another person (Mr Welling), thereby exposing each to a risk of death or serious injury, contrary to section 32 of the Act. The second defendant was Attilio Giovanni Ferrara (also known as John Ferrara), charged under section 27 of the Act as an officer of the corporation who failed to exercise due diligence to ensure the company's compliance with its health and safety duties. Both defendants pleaded not guilty.

The trial involved extensive expert and lay evidence, including testimony from SafeWork inspectors, skydiving instructors, aeronautical design engineers, a forensic pharmacologist, and representatives of the Australian Parachute Federation (APF). Significant credit issues arose in relation to several witnesses, including a receptionist who volunteered potentially critical evidence only when recalled late in the trial, and the Chief Instructor, whose credibility the court assessed in light of drug use and other factors.

  • Did the corporate defendant fail to comply with its primary duty of care under s 19(1) (to a worker) and s 19(2) (to other persons) of the Work Health and Safety Act 2011 by failing to take reasonably practicable steps to ensure the health and safety of Mr Hoare and Mr Welling?
  • Did John Ferrara, as an officer of the corporate defendant, fail to exercise due diligence under s 27 of the Act to ensure the corporation complied with its s 19 duties?
  • What reasonably practicable steps should the defendants have taken, having regard to the hazard of parachuting equipment snagging on the modified aircraft step?
  • Was the risk of the hang-up reasonably foreseeable, given that the step was designed and installed without engineering approval in apparent breach of Civil Aviation Regulations?
  • Did the defendants' respective breaches of duty expose Mr Hoare and Mr Welling to a risk of death or serious injury (the element of causation required under s 32)?
  • What role, if any, did factors such as the obviousness of the snagging hazard, the failure to obtain an engineering order from a qualified aircraft design engineer, the absence of mandatory buddy checks, and drug-related impairment play in the causal chain?

Decision

Guilty verdicts on all charges. Scotting DCJ found both defendants guilty of the section 32 offences.

The corporate defendant's breach of duty: The court was satisfied beyond reasonable doubt that Goulburn Flight Training Centre Pty Ltd failed to take some of the reasonably practicable steps to ensure the health and safety of both Mr Hoare and Mr Welling. The modified step created a risk that parachuting equipment — specifically harness straps — could snag during exit from the aircraft. This risk materialised fatally. The step had been designed and installed by the Chief Instructor without any authorisation or inspection by a qualified aeronautical design engineer, in apparent contravention of Civil Aviation Regulations governing modifications to aircraft. The court examined whether an engineering order would have been issued had the proper process been followed, and whether the snagging hazard was obvious. The prosecution particularised a number of steps the defendant should have taken, which included (among other things) ensuring that any modification to the aircraft was properly engineered and approved, conducting or requiring adequate risk assessments and buddy checks on equipment before each jump, and implementing systems to address the risk of equipment snagging on the step. The court found that the corporate defendant's failures in these respects were causally significant — that is, the breaches were significant or substantial causes of the exposure of Mr Hoare and Mr Welling to the risk of death or serious injury.

John Ferrara's breach of duty as an officer: As an officer of the corporate defendant, Mr Ferrara was required under s 27 of the Act to exercise due diligence to ensure the corporation complied with its primary duty. The court found that he failed to do so. While the judgment acknowledges that the skydiving industry is highly regulated — with oversight from both the Civil Aviation Safety Authority and the Australian Parachute Federation — the obligations of a person conducting a business in such an industry do not diminish the personal responsibility of officers to take reasonable steps to satisfy themselves that the business is meeting its WHS duties. The court was satisfied that Mr Ferrara's breach similarly exposed both deceased persons to a risk of death or serious injury.

Causation, foreseeability, and intervening factors: The court addressed several arguments raised by the defence. On foreseeability, the court found that the risk of equipment snagging on an unapproved modification was reasonably foreseeable, even if the precise sequence of events was not. The court also considered the role of drug-related impairment — evidence from a forensic pharmacologist was adduced regarding the Chief Instructor's use of drugs — but the court's focus remained on whether the defendants' breaches were themselves significant or substantial causes of exposure to risk. The defence relied in part on expert evidence challenging the prosecution's causation theory and the suggestion that an engineering order would necessarily have been issued, but the court ultimately preferred the prosecution's position on these points.

Credit findings: The court made detailed credit findings about the witnesses. Of particular note, the court expressed concern about evidence volunteered by the receptionist, Ms Hall, when she was recalled late in the trial — evidence about a conversation between Mr Ferrara and Mr Czerwinski regarding the step installation. The court noted the likelihood that Ms Hall had learned of another witness's anticipated testimony before she recalled the conversation, and was concerned her evidence may have been influenced by a desire to assist Mr Ferrara. The court accepted the evidence of the SafeWork inspectors and a number of experienced skydiving witnesses, while scrutinising the evidence of the Chief Instructor and defence experts.

Orders Made

  • The corporate defendant, Goulburn Flight Training Centre Pty Ltd, was found guilty of both s 32 offences (breach of duty under s 19(1) exposing Mr Hoare to a risk of death or serious injury, and breach of duty under s 19(2) exposing Mr Welling to a risk of death or serious injury).
  • John Ferrara was found guilty of both s 32 offences (failure to exercise due diligence under s 27, exposing each of Mr Hoare and Mr Welling to a risk of death or serious injury).
  • (Note: The available judgment text deals with the liability phase. Sentencing orders are not included in the truncated text provided.)

Key Takeaways

  • Unapproved modifications to equipment create foreseeable WHS risks. The District Court found that the installation of the step without engineering approval was central to the breach, holding that undertaking equipment modifications outside regulatory approval processes gave rise to foreseeable risks and established liability, even where the modification was designed by an experienced operator.

  • Under s 27 of the WHS Act, officers bear a personal duty of due diligence that cannot be delegated. Mr Ferrara's conviction confirmed that officers of a PCBU cannot discharge their due diligence obligation by relying on the expertise or judgment of operational staff, such as a Chief Instructor. Active inquiry and oversight are required to satisfy the officer's duty.

  • Operating in a highly regulated industry does not diminish WHS obligations. Compliance with industry-specific regulatory frameworks, such as Civil Aviation Regulations, does not of itself satisfy the general duty of care owed under work health and safety legislation. The Court held that the two sets of obligations operate concurrently and independently.