FV Cassandra and FV Dianne

Contributing factors

• FV Cassandra: attempted retrieval of snagged net using high-tension winching method instead of safe alternatives such as snatch block technique
• FV Cassandra: possible reduced reserve stability from earlier twin-boom trawler modifications not reassessed after refit
• FV Cassandra: vessel operating near limit of safe trawling area close to uncharted pinnacles and reefs
• FV Cassandra: life raft painter entangled on wheelhouse structures preventing deployment
• FV Cassandra: manual EPIRB insufficient time to activate during rapid capsize
• FV Dianne: inadequate securing/lashing of drogue on aft deck during steaming
• FV Dianne: drogue rope fouled propeller, eliminating forward propulsion in sea state
• FV Dianne: 12-hour delay in authorities receiving distress notification due to failure of manual EPIRB activation and lack of automatic 'failure to poll' alerts from VMS
• FV Dianne: vessel monitoring system 'failure to poll' safety function not implemented despite existing capability for nearly 30 years
• Both vessels: lack of automatic/self-activating EPIRBs (not yet mandated at time of incident for these older vessels)
• Both vessels: absence of emergency exit lighting in enclosed spaces
• Both vessels: absence of emergency grab bags with portable air source
• Both vessels: crew unable to access safety devices during disorienting capsize event
• Both vessels: unsecured wheelhouse equipment (e.g. refrigeration) may have impeded escape routes
• Systemic: regulatory inaction on known safety improvements; departmental obstruction regarding VMS safety implementation

Coroner's recommendations

1. Industry be encouraged to place emergency Grab Bag of necessary basic equipment in sleeping cabin and near helm to assist crew to exit capsized vessel
2. Self-illuminating LED strip-lighting and emergency exit signs be encouraged in existing vessels within two years; after two years, consider mandating in all commercial fishing vessels
3. Industry be encouraged to secure all bulky wheelhouse items by restraining straps or bolts to prevent movement during capsize
4. Fishermen be encouraged to wear inflatable style PFD vest with PLB whilst working on decks or at helm
5. Regulatory authorities and industry investigate appropriate workable solutions to enable doors to be opened against water pressure whilst maintaining designed purposes
6. Regulatory authorities and industry review use of quad gear in Sandy Straits area for trawling due to uncharted pinnacles and reefs
7. Regulatory authorities and industry investigate and proceed towards ensuring all vessels have SMS copy of original plans, modification details, and stability test documentation; duplicates held by owner on land and by regulatory authorities; mandatory stability test report at time of vessel sale if configuration changed from original
8. SMS should include safe methods for retrieving snagged net from hook-up by snatch block or leaving net for later retrieval
9. Department of Agriculture & Fisheries immediately implement sharing of VMS 'failure to poll' function to notify QPS by SMS and email of any vessel failure to poll