Coronial
TASother

Coroner's Finding: Leary, Leslie John

Deceased

Leslie John Leary

Demographics

44y, male

Date of death

2011-07-05

Finding date

2015-01-16

Cause of death

Drowning

AI-generated summary

Leslie John Leary, a 44-year-old rock lobster fisherman, drowned on 5 July 2011 after falling from or capsizing an aluminium dinghy while retrieving lobster pots near Actaeon Island, Tasmania. He was not wearing a personal flotation device (PFD) and was dressed in heavy, water-absorbent clothing weighing 72kg when wet. Sea conditions were marginal with 2-3 metre swells and 25-30 knot winds. Critical failures included: Leary's non-compliance with PFD requirements, the skipper's failure to ensure PFD use and maintain visual contact with the dinghy operator, use of poorly maintained equipment, and inadequate safety planning for single-handed dinghy operations in challenging conditions. The coroner emphasised that all these factors combined to create a preventable tragedy and recommended mandatory PFD use, appropriate clothing selection, equipment maintenance standards, weather-appropriate work practices, and continuous observation of dinghy operators.

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

Error types

systemcommunication

Contributing factors

  • Failure to wear personal flotation device (PFD)
  • Heavy, water-absorbent clothing (72kg wet weight)
  • Skipper's failure to ensure PFD compliance
  • Skipper's failure to maintain visual contact with dinghy operator
  • Poor condition of aluminium dinghy (corrosion, cracks)
  • Marginal sea conditions (2-3 metre swell, 25-30 knot winds)
  • Single-handed dinghy operation in challenging conditions
  • Inadequate safety planning and discussion between skipper and crew
  • No observation system in place for dinghy operator safety

Coroner's recommendations

  1. Properly functioning and appropriate PFDs must be worn by all persons using a dinghy tender to set or recover lobster pots, regardless of circumstances or experience
  2. Persons operating tender dinghies must ensure clothing is not of a type or amount that would add significant body weight when immersed; boots and lower garments should be quickly discardable where practicable
  3. PFDs must not be worn under clothing as this adversely affects operation, particularly inflation-type devices
  4. Single-handed operation of tender dinghies should only occur in favourable weather and not where there is reasonable possibility of capsize; should only occur where dinghy is configured to minimise risk of falling overboard or capsizing
  5. Equipment in professional lobster fishing fleet must be to best industry standard; risk of mishap should not exist due to substandard equipment
  6. Where a person operates a tender dinghy single-handed, continuous watch must be maintained during work to ensure immediate response to mishaps
  7. All persons in professional fishing industry must comply with Work Health and Safety Act 2012 obligations
  8. Development of a Code of Practice for professional rock lobster fishing industry to address inherent workplace risks
  9. MAST should liaise with Tasmania Police to address processes for lawful issue of certificates of competency and ensure compliance with applicable legislation
Full text
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