Mosby, Phillemon Edward

Contributing factors

• Inadequate width of side decks for safe personnel movement
• Failure to enforce personal flotation device wear
• Wet and slippery deck surface
• Poor visibility and lighting conditions
• Vessel design features creating obstruction to safe deck access
• Lack of harness or fall protection systems
• Poor vessel maintenance and safety culture
• Absence of crew training and safety procedures
• Regulatory oversight failures by Maritime Safety Queensland
• MSQ failure to action prior safety complaints

Coroner's recommendations

1. General Manager MSQ establish why no action was taken regarding Mr Richie's May 2004 complaint about the Alert's seaworthiness, with view to ensuring no repeat of such failings
2. MSQ consider Torres Pilots safety culture information and future complaints when targeting monitoring activities
3. General Manager MSQ review whether TOMSA should be amended to require accredited marine surveyor to complete certificate of seaworthiness for annual registration renewal of all commercial vessels rather than relying on operator self-declaration
4. Principal Pilotage Officer develop guidelines and explanatory notes as matter of urgency to clarify what constitutes compliance with Pilot Vessel Standard provisions, particularly regarding adequate width of side decks
5. Director of Division of WH&S and General Manager MSQ review operation of inter-agency MOU to consider whether changes needed to encourage greater collaboration in responding to incidents involving both agencies' jurisdiction
6. General Manager MSQ review manner in which this marine incident was investigated to establish why no consideration was given to initiating prosecution action under TOMSA