Inquest into the Death of Mason Laurence CARTER and Murray Allan TURNER and Chad Alan FAIRLEY
Deceased
Mason Laurence CARTER and Murray Allan TURNER and Chad Alan FAIRLEY
Demographics
57y, male
Date of death
2015-07-11
Finding date
2018-02-28
Cause of death
immersion (drowning) - for Turner confirmed by post mortem; for Carter and Fairley presumed immersion (drowning) based on vessel capsize and sea conditions
AI-generated summary
Three fishermen died when the fishing vessel 'Returner' capsized in Nickol Bay, Western Australia on 11 July 2015. Murray Turner (57) owned and extensively modified the vessel; Chad Fairley and Mason Carter were deckhands. Extensive modifications between December 2014 and April 2015 made the vessel fundamentally unstable: ballast was removed, heavy equipment added high in the vessel, and fuel tanks doubled in capacity. The Department of Transport surveyor accepted the modifications as 'minor' without requiring mandatory stability testing. In deteriorating weather conditions, the unstable vessel capsized rapidly. Turner was found on the wreck; Fairley and Carter presumed drowned at sea. Critical failures: Turner did not disclose ballast removal to the surveyor; the surveyor inadequately verified information and relied excessively on owner claims; key information about fuel tank capacity was not accurately communicated; the vessel monitoring system operator delayed alerting rescue authorities by two days. Stability testing would have identified and necessitated rectification of the vessel's instability, likely saving three lives.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- vessel instability due to modifications
- removal of ballast without disclosure
- addition of heavy equipment high in vessel raising centre of gravity
- doubled fuel capacity increasing displacement
- inadequate surveyor verification of information
- surveyor characterised major modifications as minor
- failure to require mandatory stability testing
- deteriorating weather and sea conditions
- rapid vessel capsize and flooding
- delayed alert to rescue authorities
- vessel monitoring system not monitored 24/7
- failure to activate emergency position indicating radio beacon
- soft boom stays contributed to capsize risk
Coroner's recommendations
- AMSA as National Regulator should give consideration to establishing a transitional approach to ending the grandfathering of safety standards for existing vessels, with priority to compliance of vessel operations and safety equipment
- AMSA should give guidance to accredited surveyors to remind them of the importance of independently verifying key information when assessing a vessel's stability, given the critical importance of stability in allowing safe vessel operation
- Department of Fisheries should give guidance to its staff that there is an important secondary safety aspect to the VMS system, staff should prioritise communicating with vessels that have issued ALC alerts, if unsuccessful within 4 hours they should notify Water Police with relevant information, and Fisheries should consider ways to monitor VMS 24 hours a day 7 days a week where practical
- AMSA as National Regulator should give strong consideration to making changes to regulatory requirements concerning EPIRBs to include mandatory requirements for carriage on both new and existing vessels of float free EPIRBs that deploy automatically when immersed in water where appropriate
- AMSA working in conjunction with Worksafe in Western Australia should promote and encourage the wearing of life jackets while working on commercial fishing vessels, noting these are workplaces and there is a need to improve safety culture on fishing vessels
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