Finding into death of Ronald Edgar Kolody

Contributing factors

• Vessel capsized in rough water near reef
• Poor swimming ability
• Neither occupant wearing personal flotation device
• Hazardous reef location with inadequate safety marking
• Sea conditions more severe than forecast (2-3 metre swell versus 1 metre predicted)
• Treacherous local water conditions with standing waves and turbulent surges
• Overfilled fuel tank potentially restricting fuel flow to engine
• Unclear understanding of 'heightened risk' definition among recreational boaters

Coroner's recommendations

1. Maritime Safety Victoria should conduct a systematic review of existing safety markings of Victorian coastal reefs to assess their adequacy and where necessary provide additional signage and cardinal markers
2. The legislation regulating the use of PFDs should be reviewed, in particular as to the adequacy of the definition of 'heightened risk' and whether it should include boating in coastal reef areas and adverse weather or water conditions other than the ones currently specified
3. Maritime Safety Victoria produce and disseminate educational information about the dangers of coastal reefs and the advisability of wearing PFDs at all times, particularly given the unpredictability of weather and water conditions