The Officer duty that cannot be delegated: When relying on expertise becomes an excuse.

Two fatalities. A modified aircraft. Known risks. Simple controls that were not implemented.

The decision in SafeWork NSW v Goulburn Flight Training Centre Pty Ltd; SafeWork NSW v Ferrara [2026] NSWDC 99 is a sharp reminder that officers cannot outsource their duty under work health and safety laws, even in highly technical environments.

What happened

In June 2021, a tandem skydive ended in tragedy.

A modified step fitted to a Cessna aircraft, designed internally to improve training operations, created a snag hazard. A section of the student’s harness caught on the step during exit.

Attempts to free the pair failed. Both the student and instructor fell approximately 100 metres and died.

The risk of entanglement was well understood in the industry. The modification, however, introduced new and uncontrolled hazards, including gaps, edges and protrusions capable of catching harness webbing.

What the court found

Judge Scotting was direct and unambiguous:

• the aircraft modification was not approved, not assessed, and not safe

• the aircraft should not have operated without an engineering order confirming compliance

• the modified step “massively increased” the risk of a fatal hang-up event

• the risk, while low likelihood, was catastrophic in consequence and well known.

Critically, the Court found that two straightforward controls would have prevented the fatalities:

1. prohibiting use of the aircraft until engineering approval was obtained

2. implementing mandatory pre-jump buddy checks, which would likely have identified the poorly fitted harness.

Both were described as known, simple, and inexpensive control measures.

The failure of systems, not just people

This was not a single point of failure.

The Court identified systemic gaps:

• no effective process to ensure aircraft modifications were verified and approved

• no system to communicate or embed changes to industry rules

• reliance on informal verbal instructions rather than enforceable controls.

This is classic WHS failure: hazards identified, controls known, but systems not implemented.

The Officer duty: where Ferrara failed

This is where the case becomes particularly instructive for Directors and Executives.

Ferrara argued, in effect, that he relied on technical experts to run the operation.

He had no skydiving qualifications.

The Court rejected any notion that this reduced his duty.

Judge Scotting stated that section 27 Officer duty required him to:

• keep up to date with WHS matters relevant to the business

• ensure appropriate processes were implemented.

The failure was not that Ferrara lacked technical expertise.

The failure was that he did not exercise governance and control over risk.

What he should have done

The judgment provides unusually practical clarity on Officer due diligence.

Ferrara:

• knew the aircraft had been modified

• knew an engineering order was required

• gave a verbal instruction not to operate the aircraft.

But he did not ensure the instruction was enforced.

The Court was explicit, he should have:

• physically prohibited use of the aircraft (lock it, remove keys, secure controls)

• ensured formal systems existed to verify compliance before operation

• directed that safety updates and rule changes (such as mandatory buddy checks) were embedded into operational routines

• required that pre-start meetings include safety-critical updates.

In short: he should have converted knowledge into control.

The critical distinction: instruction vs implementation

One of the most important takeaways from this case is the gap between:

• telling someone to do something, and

• ensuring it actually happens

The Court made clear that verbal direction is not due diligence.

Officers must ensure:

• controls are designed

• controls are implemented

• controls are verified.

Anything less is not compliance, it's assumption.

Penalties and accountability

The consequences reflected the seriousness of the failures:

• PCBU: fined (reduced from $800,000) to $100,000

• Officer (Ferrara reduced from $200,000): fined $150,000

The reduction reflected financial capacity to pay, not the gravity of the conduct.

What this means for Boards and Executives

This decision reinforces a fundamental WHS principle: you can rely on expertise, but you cannot rely on it blindly.

For Officers, due diligence requires active oversight of risk, not passive reliance on others.

At a minimum, this means:

• understanding where critical risks sit in the business

• ensuring formal controls and verification processes exist

• requiring evidence that controls are working

• embedding safety critical information into operational routines

• intervene where risk is not demonstrably controlled

Final reflection

This was not a case of complex, unforeseeable failure.

The risks were known. The controls were simple. The consequences were catastrophic.

The Court’s message is clear: if you know the risk, and the control is obvious, failing to enforce it is a breach of duty.

For officers, it is a matter of WHS governance, verification, and control.

And in this case, that standard was not met.