Inquest into the Death of Damien Mark MILLS

Contributing factors

• intoxication from alcohol consumption
• rough sea conditions during return journey
• inadequate crew supervision of passengers
• failure to conduct proper final headcount upon return
• absence of lifejacket
• low railings on vessel
• passengers sitting on esky near edge of boat
• loud noise from engines and music preventing communication
• distraction of crew and passengers by other falling passengers

Coroner's recommendations

1. AMSA to promote the conduct of multiple headcounts (at least two) for charter operations through industry committees, publications, safety awareness bulletins, and SMS workshops to ensure safety standards are maintained
2. Operators of small charter vessels should incorporate mandatory multiple headcounts into their Safety Management Systems as part of risk assessment processes
3. Crew should conduct proper final headcount before passengers disembark to detect missing persons immediately
4. Charter operators should provide safety briefings before return journeys advising passengers of expected conditions and requirement to remain seated
5. Crew should maintain proper supervision of intoxicated passengers during rough sea conditions, remaining on deck to monitor passenger safety
6. Organisers of group events on charter boats should consider implementing buddy systems to ensure all participants are accounted for
7. Public education campaigns should emphasise the significantly increased survival chances when wearing lifejackets in open water, as the Department of Transport currently promotes
8. AMSA should maintain clear compliance presence with focus on headcount procedures for high-risk charter operators conducting regular reviews of safety standards