O'Neill, Timothy Gerard

Contributing factors

• moonless night and high tide making rock seawall extremely difficult to see
• unlit rock seawall at mouth of Brisbane River
• significant background lighting from Port of Brisbane obscuring the seawall
• outdated 2002 Navman electronic chart that did not show the rock wall or reclamation area
• GPS device in highway mode which does not display hazards or navigation markers
• skipper's lack of understanding of cardinal navigation mark flashing sequences
• skipper's misinterpretation of North Cardinal Mark as indicating shoal water rather than rock wall
• skipper's sole reliance on GPS pathway and visual observation without reference to alternative charts
• skipper's unfamiliarity with night navigation through Brisbane River mouth
• recreational boat licensing regime insufficient for night navigation safety
• no requirement for practical testing of night navigation skills in recreational boat licensing
• skipper unaware of scale settings on Navman Course Deviation Index
• skipper did not use pre-established waypoints on GPS system
• boat maintained speed of 20-25 knots without appropriate caution in unfamiliar night conditions

Coroner's recommendations

1. Recreational boat licence should be reviewed to add additional certification for operation of a boat between sunset and sunrise, with sufficient theoretical and practical testing of night navigation knowledge and on water practical skills
2. Consider restricting existing recreational boat licence holders to daylight operation until their licence is upgraded with night navigation certification
3. Consider implementing five yearly theoretical refresher test of knowledge of boating rules and navigational knowledge
4. Future navigation skill testing should include both chart based understanding and interpretation, as well as operation and understanding of satellite navigation devices, with cross-referencing between these aids to navigation
5. Change the light of the existing North Cardinal Mark to a 'very quick' sequence to improve its visibility and attract mariners' attention given considerable background lighting from the port
6. Maritime Safety Queensland should direct the Port of Brisbane to light the face of the rock seawall, with appropriate shrouding to draw attention without adding to light clutter
7. Alternatively, consider testing a series of marker buoys or special markers as deployed during the construction stage of the rock seawall
8. Maritime Safety Queensland conduct an information and education campaign reaching marine vessel licence holders and registered owners of recreational vessels in Queensland and neighbouring NSW, including charter operators and organisations, highlighting the need to use all available navigation information not solely GPS, ensure updated electronic charts are available, travel at safe speeds when entering port at night, and access Notices to Mariners