Finding into death of Munif Mohammed
Deceased
Munif Mohammed
Demographics
64y, male
Date of death
2023-06-12
Finding date
2024-10-29
Cause of death
consistent with drowning in a man with ischaemic heart disease
AI-generated summary
A 64-year-old man with ischaemic heart disease died by drowning after falling from an unseaworthy fishing vessel on Port Phillip Bay. He removed his life jacket before entering the water and struggled for 15 minutes to reboard but lacked upper body strength to climb the 470mm freeboard. The vessel had multiple safety defects including water ingress points, missing bung plugs, poor stability, and no boarding ladder. The operator had never received practical emergency training. The death was preventable: a boarding ladder and retained life jacket would have enabled survival. Key lessons include the absence of mandatory seaworthiness inspections at vessel registration (unlike vehicle roadworthiness checks), lack of practical marine licence testing in Victoria, and the need for mandated boarding ladders on recreational vessels with significant freeboard.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- unseaworthy vessel with multiple structural defects
- poor vessel stability due to water ingress and missing bung plugs
- absence of boarding ladder
- deceased removed life jacket before falling into water
- lack of emergency preparedness and safety equipment
- operator had no practical emergency training
- deceased had limited swimming ability and reduced upper body strength
- inability to reboard vessel due to high freeboard (470mm)
- water on deck and dirty bilge water further compromised stability
Coroner's recommendations
- Safe Transport Victoria to explore models for recreational vessel seaworthy inspection and certificate regime to assess prescribed conditions under Marine Safety Regulations 2023 at points of registration, transfer of ownership, and after modification
- Safe Transport Victoria to consider introduction of practical training and assessment as part of Victorian marine licensing regime analogous to regimes in other Australian States
- Minister for Outdoor Recreation to amend Marine Safety Regulations 2023 (Vic) to mandate boarding ladders or similar means of reboarding from water in vessels with freeboard greater than 0.3 metres, irrespective of vessel size
Full text
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