Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Stephen Raymond Carey, Coroner, having investigated the death of



Find That :

'Mrs M’ died as a result of drowning in February 2010 approx 20 metres from shore of Beer Barrel Beach St Helens.

‘Mrs M’ was aged 59 years, a married person who was employed at the time of her death.

Circumstances Surrounding the Death :

‘Mrs M’ was married to John for a period of 36 years and together they had three children.

In February 2010, ‘Mrs M’ and four of her good friends for many years and whom often met on a regular basis arrived at the Burns Bay boat ramp, St Helens Point for a pre-arranged boating trip. The purpose of the trip was to retrieve two crayfish pots which were set previously in the vicinity of the Doughboys (a group of protruding rocks) approximately 300 metres offshore in the area of Beer Barrel Beach.

The boat was a 7 metre aluminium single chine V bottom mono hull boat with watertight cockpit deck and enclosed shelter area forward, named "Sea Change". The boat was built in August 2009 by a local boat builder at his business. The owner of the boat, was considered an experienced skipper and had an association with boating for approximately 40 years and had fished in the area of the incident regularly.

Reports from the Bureau of Meteorology shows the conditions on the day as North East winds 15 to 25 knots reaching 20 to 30 knots offshore, seas 1.5 to 2.5 metres.

The boat was launched and proceeded south to the Doughboys. The boat had back to back seating with two seats at the starboard (helm) side and two beside these on the port side. ‘Mrs M’ was seated on the starboard side, directly behind the skipper who was driving the boat. As the boat approached the area of the Doughboys at approximately 10:00am it had been travelling almost parallel to the shore, cutting across the waves.

The skipper recalls, that at the time the conditions in the area were rough, with a large swell that was not breaking, but the boat was handling the conditions quite well and that he did not feel uncomfortable. The members of the group on board also stated that at no time were they concerned by the conditions. The three females were wearing Stormy Seas V200 brand life-jackets. This model requires the wearer to manually inflate the jacket by pulling down a velcro flap on the left chest that activates the release of gas from a small cylinder that inflates the life-jacket bladder making it buoyant.

When located between the Doughboys and Bear Barrel Beach the boat was hit on the port side by a large rogue wave, which was described as being much larger than others in the area at the time. ‘The skipper’ saw the wave approaching but did not have time to manoeuvre out of the wave. The wave struck the boat and immediately lifted it up and rolled it over onto its starboard side, spilling all occupants into the water.

The skipper and the three other passengers all surfaced under the upturned boat, however it appears that ‘Mrs M’ was thrown clear and did not surface under the boat with them. The four under the boat were able to communicate with each other and were sheltered to a degree by the upturned hull. After a conversation it was decided that they would all leave the hull and attempt to get to shore. At this time that they were very concerned for the deceased’s safety.

One of the passengers surfaced first and he could not see any signs of ‘Mrs M’. As the skipper surfaced he spotted ‘Mrs M’s’ life jacket some distance off in a northerly direction near the Doughboys, but he was unable to tell if she was still wearing the jacket because he could not see her body in the jacket and there was no movement from her.

At this stage it was decided that it was not possible to get to her due to the conditions and the distance she was from the boat. After the other two women surfaced the skipper inflated their life jackets. One of the passengers had previously attempted to inflate her life jacket but was unable to pull down the flap to enable the jacket to inflate. The skipper recalls he had trouble inflating the jackets due to the amount of force required to pull the flap down, he used both hands to manipulate the flap. Neither the skipper or one of the male passengers were wearing life jackets at this time.

Both women moved away from the boat and initially stayed together before one of the females, who was the stronger swimmer of the two made her way towards shore. One of the other female passengers made her way towards another passenger to help support him. He was tiring quickly in the conditions and because he was not wearing a life jacket. He was able to hold onto her jacket enabling him to stay afloat. The skipper remained with the boat until it entered the breakers near the shore and he then washed ashore shortly after.

Two of the passenger’s were picked up approximately five minutes later by the Police launch. A search of the area was conducted and they located the deceased’s body a short time later face down in the water not far from where the boat initially capsized.

The boat was inspected by the Manager of Vessel Standards and Survey Mr Gwyn Alway and he concluded in his report that,

"The boat, its machinery, fittings and equipment appear to have been in very good condition and well maintained prior to swamping. Damage sustained to the boat is consistent with damage that may typically occur during swamping, capsize and recovery."

The Stormy Seas life jacket worn by the deceased was inspected and found to be in proper working order however, it is the opinion of the inspector that "this vest was not fired by the wearer.".

Comments & Recommendations :

I find that the deceased died as a result of drowning.

Dr Donald Ritchey, Forensic Pathologist reports that the deceased sustained two contusions to her head during the incident that although were not life threatening may have been significant enough to cause confusion or possible unconsciousness. It is therefore possible that she was unconscious when she entered the water.

I find that the Stormy Seas life jacket worn by the deceased required her to manually initiate the floatation system for the jacket to be effective. This would not have occurred if the deceased was unconscious or impaired upon entering the water.

It is noted that this brand of life jacket also comes in a self inflating type that automatically inflates when immersed in water. This jacket looks almost identical to the manual inflation type and there is nothing on the exterior of these jackets to alert the user to which type of jacket they are wearing. From the evidence before me I find that there was a mistaken belief by another passenger and perhaps the deceased that the jackets they wore were self inflating.

This tragic accident highlights the need for all boat owners and their passengers to consider if wearing a PFD1 classification of this type of manual inflation vest is suitable for them as they offer no protection to persons in the water who are unconscious or unable to activate them due to injury or other circumstances. It also highlights the need for a skipper, before setting off on any recreational vessel that is carrying passengers, to conduct a safety brief to the passengers about the safety equipment being carried or worn and advising them what to do in the case of an emergency.

I find the skipper of the vessel was not at fault at the time of this incident. However the incident highlights that at times when weather conditions are marginal, as a general rule when considering whether to venture out one should err on the side of safety. The boat was considered to be sufficient in size and in good condition. The skipper was considered experienced enough to handle the conditions under normal circumstances, by all accounts the wave that capsized the boat was unusually large and appeared unexpectedly. However boat owners must be aware that the sea is rarely constant or consistent and that there is always variation which in rough conditions can account for large unexpected waves.

Before I conclude this matter, I wish to convey my sincere condolences to the family of ‘Mrs M’ for their loss.

This matter is now concluded

DATED : Friday 24 September 2010 at Hobart in the State of Tasmania.



Stephen Raymond Carey