Coroner Report: Victorian inquiry into fishing death finds failure to use lifejackets
The Victorian coroner has handed down recommendations following an inquiry into the death of a crew member in late 2021. The fatality occurred when a fisher was struck by a large wave whilst working on the open deck of commercial fishing vessel in Bass Strait and was swept into the sea.
Despite considerable efforts by the skipper and crew, the person was unable to be recovered and presumed to have drowned. It was dark and the reported weather conditions were wind strength 20 to 30 knots with two metre swells.
The vessel had just retrieved trawl nets for a moderate catch and the skipper called for an immediate reset of the gear. The crew member was standing on the starboard stern quarter of the vessel shovelling fish. He was facing towards the stern of the vessel where the nets are released and retrieved, which was completely open to the sea with no guard rail or barrier installed to make the area secure. As the crew were sorting the previous catch and preparing for the second release of the net, the skipper was slowly manoeuvring the vessel into the best position to release the net.
Without warning a large wave, approximately two to three metres high, struck the starboard side of the vessel and washed over the working deck. The force of the wave took the crew member by surprise and washed him off the deck through the open stern where the nets are released and retrieved.
He was wearing wet weather gear (overalls, a jacket and sea boots), but not wearing a Personal Flotation Device (PFD) or buoyancy vest, nor did he have a strobe light or personal locator beacon (PLB) with him.
The crew member was visible approximately 30 metres from the stern of the vessel with the benefit of powerful working deck lights and they could hear his cries for help. The skipper reversed the vessel to within six metres of the stricken man, but three attempts to get a life ring to him failed as he was being battered by the waves. Shortly after this last attempt the crew lost sight him in the waves.
The water temperature was between 12-13 degrees and medical advice was that he was unlikely to survive more than five hours in the water.
Investigations found several deficiencies on the vessel including:
- Stern ramp protective arrangement missing,
- Life jacket stowage not marked correctly,
- Life jacket vessel identification missing,
- Winch control stations do not have clear vision of deck area,
- Anchor windlass missing, anchor not available to be dropped immediately,
- Safe means of rapid rescue for persons overboard not located on board, and
- Satellite phone not working.
Coroner findings included:
- that without a PFD to keep him afloat, a light to indicate his location in the dark or some type of GPS tracking device, it is difficult to see how any rescue effort was going to be successful,
- the vessel’s Safety Management System (SMS) was unclear on when a PFD should be worn by the crew – there was no clear ‘trigger’ stated in the SMS,
- no one on board this night was wearing any type of floatation, which was deemed normal practice. Crew stated it is very hard to work with the life jacket on top of wet weather gear,
- life jackets were readily available and there were lots on board. Each crew had a PFD and there are extras,
- hard to reconcile vessel practices with the stated SMS. If lifejackets are not worn, after sunset, in winds of 20-30 knots with wave height of two to three metres in an area of Bass Strait on the edge of the continental shelf where the water temperature is 12 degrees – then what is the trigger?
The Coroner noted:
- that modern PFDs are much less bulky than older models and often have built in locator beacons,
- that AMSA requirements since 1 August 2023 require vessel owners to explicitly address lifejacket wear and personal beacon requirements in their SMS’s risk assessment and written management procedures,
- that since January 2021, AMSA has required carriage of float-free emergency position-indicating radio beacons (EPIRBs) on certain types of DCVs but these are activated when in contact with water.
The Coroner recommended that AMSA (in collaboration with the seafood industry and the manufacturers of PFDs):
- review existing PFDs currently available in the market to determine suitability for use by commercial fisherman (consistent with the recommendation in the Batchelor and Bugeja report February (2003),
- if the review finds existing PFDs are not suitable for use by commercial fisherman, then encourage and work with the manufacturers to design a suitable PFD that would be acceptable to commercial fishermen and compatible with the appropriate Australian Standard,
- engage with the Australia New Zealand Safe Boating Education Group and other industry stakeholders to raise awareness of and support for this work.