Lessons from Loss: What the Andrew Seton Inquest and the Major Incidents Report Teach Us

When systems break down in the field, the consequences are rarely abstract. They are human, immediate, and irreversible. Two recent publications, the coronial findings into the death of backcountry skier Andrew Seton and the 2024–25 Major Incidents Report, reinforce the same blunt truth. Time, communication, and decision clarity determine outcomes.

I have seen this reality firsthand. As a former member of Bush Search and Rescue Victoria (BSAR), regularly called out to assist in searches for missing persons in the high country, I know how minutes can feel like hours and how quickly uncertainty hardens into consequences once light, weather, or information deteriorate.

Safety Jon and BSAR members receiving a police brief for a missing person.

The Seton inquest, when minutes turn into days

The findings of the NSW Coroners Court into the death of Andrew Seton provide a sober, evidence-based account of what occurred and, just as importantly, what did not.

In Sep 22, Andrew Seton ventured solo into the alpine backcountry near Watsons Crags, NSW, and never returned. The Coroner confirmed that his fall was instantly fatal. That finding, however, did not end the inquiry and the focus shifted to the response system and how it functioned under uncertainty.

The inquest found that:

• Early concern raised by family did not result in immediate escalation

• A formal search was not commenced for approximately two days

• Communication and escalation arrangements between police, parks, and rescue agencies lacked clarity

• Although Mr Seton carried a personal locator beacon, it was never activated

• No trip intention information had been lodged to support early detection or targeting

The full findings are publicly available and should be read in full by anyone involved in field operations, emergency management, or adventure activity governance:https://coroners.nsw.gov.au/documents/findings/2024/Inquest_into_the_death_of_Andrew_Seton.pdf

This was not a case about blame; it was a case about time. In alpine and remote environments, detection and mobilisation are critical controls. Once an incident occurs, survival probability collapses rapidly. After that point, system performance is all that remains.

From a search and rescue perspective, those early hours are decisive. When information is incomplete and conditions are dynamic, hesitation does not pause risk, it compounds it.

As Officer in Charge during Air Force Cadets' alpine activities, emergency planning is paramount.

The Major Incidents Report, the same weaknesses at scale

The 2024–25 Major Incidents Report, released through the National Emergency Management Agency and prepared by the Australian Institute for Disaster Resilience, examines more than 40 major incidents across Australia.

While broader in scope, its conclusions align closely with the Seton inquest.

The report highlights that:

• Concurrent and compounding events now define the emergency landscape

• Inter-agency coordination, particularly around command clarity and public warnings, remains fragile

• Data, communication, and consequence-management systems consistently fail at the same pressure points, speed, consistency, and shared understanding

Modern emergencies are rarely single, isolated events. They are intersections of fatigue, weather, terrain, information gaps, and delayed decisions.

Shared lessons, where systems really fail

Taken together, the Seton inquest and the Major Incidents Report expose a recurring pattern. Systems often look robust on paper, but fracture in the same places when exposed to real terrain and time pressure.

Those fracture points are familiar:

• Ambiguous escalation thresholds

• Fragmented communication loops

• Unclear authority and decision ownership

• Delays driven by waiting for certainty rather than acting on probability

In search operations, I have watched time stretch uncomfortably while thresholds are debated and confirmation is sought. Meanwhile, families wait, volunteers mobilise, and conditions worsen. A system may remain technically compliant, yet operationally, it is already behind.

Resilience is not improvised; it is built well before the call comes in.

Trip intentions, a simple control with outsized value

One of the clearest practical lessons from the Seton inquest is the lack of accessible trip-intention information.

Trip intention forms are not paperwork for paperwork’s sake. They are a low-effort, high-impact control that shortens detection time and improves search accuracy when something goes wrong. I never enter the alpine environment without completing one.

An example of a practical, publicly available template is the Victoria Police Trip Intention Form, used widely for remote and alpine activities: https://www.police.vic.gov.au/bushwalking-and-hiking-safety

Forms like this capture route, timing, equipment, and emergency contacts, information that can save hours or days during early response.

Key takeaways for safety and operational leaders

Whether you manage field operations, logistics, emergency response, or adventure activities, the implications are consistent.

Ensure trip or task intentions are documented and accessible. Design redundant communication pathways that assume failure will occur. Define escalation triggers that remove ambiguity under pressure. Exercise systems to test decision speed, not just procedural completeness.

Preparedness is not administrative hygiene. It is the difference between coordination and chaos.

Stay safe out there, adventurers!