Coronial
NSWother

Inquest into the deaths of Alan BLINN, James ENGERT, Morgan INNES and Simone MOORE

Deceased

Alan Blinn, James Engert, Morgan Innes, Simone Moore

Demographics

14y, female

Date of death

2007-03-28

Finding date

2010-02-23

Cause of death

Multiple injuries and drowning as a result of collision between ferry Pam Burridge and motor cruiser Merinda in Sydney Harbour

AI-generated summary

On 28 March 2007, the ferry Pam Burridge collided with the motor cruiser Merinda in Sydney Harbour, killing four people: Dr B., James Engert, Morgan Innes (aged 14), and Simone Moore. The collision occurred at 10:50pm near the Harbour Bridge when the ferry (22-23 knots) struck the unlit, slower-moving cruiser. The coroner found the collision resulted from cascading human and systemic errors. The Merinda's navigation lights were not illuminated despite having been on earlier. The cruiser's crew did not keep proper lookout, and the ferry's master did not expect an unlit vessel and was travelling at unsafe speed. Underlying these errors were inadequate training and licensing of recreational vessel operators, lack of clear docking procedures, and absence of a culture for reporting unlit vessels. The coroner concluded the accident was preventable had the Merinda's lights been illuminated. Twenty-four recommendations addressed licensing, training, safety culture, speed limits, and enforcement of marine regulations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

proceduralsystem

Contributing factors

  • Merinda's navigation lights not illuminated
  • Merinda crew not keeping proper lookout
  • Merinda failed to take avoiding action as give-way vessel
  • Pam Burridge master did not expect unlit vessel; inadequate lookout
  • Pam Burridge travelling at unsafe speed
  • Lack of clear docking and underway procedures on Merinda
  • Inadequate training and experience of Merinda crew
  • Helmsman unlicensed; operator had low level training
  • No systematic reporting of unlit vessels to Harbour Control
  • Lack of safety culture regarding unlit vessels on Sydney Harbour

Coroner's recommendations

  1. Sydney Ferries engage specialist in Human Factors and Safety Culture to review progress in developing safety culture
  2. Engage both management and fleet crews in safety culture review
  3. Sydney Ferries instruct masters to use crew as lookouts in wheelhouse at night and in transit zone
  4. NSW Maritime and Sydney Ports promote reporting of unlit vessels to Harbour Control
  5. Sydney Ferries record and archive radio traffic
  6. Sydney Ferries consider imposing night speed limit on fast ferries
  7. Amend Marine Safety legislation to require licensing of registered or registrable recreational vessels powered by engines 4kW or more
  8. Amend NSW boat license requirements to include comprehensive practical training per national standards, including night training and skills test
  9. Include night lookout checklist in Boating Handbook
  10. NSW Maritime liaise with other states for unified national approach to unlit vessels
  11. NSW Maritime consider periodic checks of navigation lights for registered boats
  12. NSW Maritime consider making 50 Point safety check compulsory on periodic basis
  13. NSW Maritime encourage fitting of radar reflectors and warning devices for unlit lights
  14. NSW Maritime provide online complaints section for reporting marine rule breaches
  15. NSW Maritime reconsider Code of Conduct and clarify North/South Rule
  16. NSW Maritime consider enforcement methods for Code of Conduct compliance
  17. NSW Maritime increase night-time patrols during high traffic periods
  18. NSW Maritime enforce speed limits within Sydney Cove
  19. NSW Maritime consider speed limits in Sydney Harbour and tributaries during darkness and restricted visibility
  20. Minister commission comprehensive risk assessment of high-speed vessel operations at night
  21. National Marine Safety Committee seek national minimum standards for recreational boat licensing through Australian Transport Council
  22. NSW Police Marine Area Command increase night-time patrols for unlit vessel detection and marine regulation enforcement
  23. Royal Humane Society award Matthew O'Grady and Con Sakoulas for rescue efforts
Full text
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