Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of

Zachary George Doyle


Find :

a) Zachary George Doyle (‘Mr Doyle’) died on 13 March 2009 on board the vessel ‘Perseverance 1’ (‘Perseverance’) at Roaring Beach near Dover.

b) Mr Doyle was born on 17 February 1990 and was aged 19 years at the time of his death. 

c) Mr Doyle died from haemothorax (exanguination) due to laceration of the aorta following a crush injury of the chest related to the operation of a crane on Perseverance.  

Circumstances Surrounding the Death :


  1. Huon Acquaculture is a producer of live salmon farmed in pens sited upon leased portions of the D’Entrecasteaux Channel.  Its plant includes Perseverance, a vessel purpose-built for salmon farming. 

  2. Since about February 2007 Mr Doyle had been employed by Huon Acquaculture as a farm hand. 

  3. Leigh Edmund Walford had been employed by Huon Acquaculture as a farm hand for approximately 5 1/2 years.  His duties included acting as skipper of Perseverance.

  4. Andrew Colin Strong was also an employee of Huon Acquaculture and on 13 March 2009 was working as a deckhand on Perseverance.  This was the second day of his employment. 

  5. Perseverance is equipped with an HAIB XS crane 422 Hi Duo crane (‘the crane’) mounted near its bow on the starboard side.  The crane can be utilised to load and unload flotation buoys.  It can be operated by a hand-held remote device which the operator is able to carry using a strap worn around the neck.  The device is fitted with control levers and buttons which duplicate and mirror a set of fixed controls located at the base of the crane.

Events Leading to Mr Doyle’s Death

On 13 March 2009 Mr Doyle arrived at work at around 6.00am. and joined Mr Walford and Mr Strong to crew Perseverance.  Together they left Hideaway Bay and sailed to a lease at Garden Island where they changed some flotation buoys on some fish pens in that area.  At about 8.30am. they left Garden Island and sailed to the area of the Roaring Beach leases arriving at about 9.00 am.  The Perseverance was moored approximately 800 meters off shore.  At this time the weather was fine and the sea conditions calm.  

At the Roaring Beach leases the crew was tasked to change the pens’ flotation buoys replacing the existing buoys with larger ones.  This necessitated lifting the existing buoys onto the deck of the Perseverance using the crane and then replacing them with the larger buoys.  Mr Doyle was operating the crane using the hand-held remote device and Mr Strong was assisting by undoing the shackles attached to the smaller buoys and attaching them to the larger ones.  Mr Walford was also assisting on the deck but too was attending at the wheelhouse as required.  

At around 10.15am. Mr Walford left the deck and went to the wheelhouse on the upper deck to receive a radio call from the vessel Jumbo which was working nearby.  At this time the crew had been finalising the placement of one of the larger buoys.  In readiness Mr Doyle was standing on the port side of the vessel holding the remote with its strap around his neck.  Whilst waiting for Mr Walford’s return Mr Strong picked up a piece of rope from the deck and moved towards the stern of Perseverance to place it in a rubbish container.  He then lit a cigarette.  At this point he was standing in the area of the wheelhouse and his view of Mr Doyle was obscured by buoys which lay on the deck. 

As Mr Strong began to return to the bow area he observed Mr Doyle who appeared to be pinned upright between the rail on the port side of Perseverance and the boom of the crane.  Mr Strong alerted Mr Walford to the situation by throwing several mussels against the wheelhouse window to attract his attention.  Mr Walford immediately returned to the deck and used the remote control device which was still around Mr Doyle’s neck to retract the boom and thereby release Mr Doyle.  He then used the wheelhouse radio to request co-workers to seek immediate medical assistance.  Mr Strong commenced cardio pulmonary resuscitation. 

Staff of Huon Acquaculture contacted Dr Kenneth Clare of the Esperance Multipurpose Health Centre and arranged to transport him to the Perseverance.  He arrived at about 11.15am and immediately examined Mr Doyle.  It was apparent that he was deceased.  Dr Clare formally declared life extinct at 11.25am.  

Post-mortem Examination

A post mortem examination was undertaken by forensic pathologist, Dr Donald Ritchey.  He reports; “The autopsy revealed a well developed, well nourished man with a severe crush injury of the left upper chest resulting in multiple rib fractures and transection of the aorta that caused rapid, severe internal bleeding (haemothorax) leading to rapid loss of consciousness and death.” 

Dr Ritchey states the formal cause of death to be haemothorax (exanguination) due to laceration of the aorta following a crush injury of the chest.  It was noted that toxicology testing of a sample of Mr Doyle’s blood produced negative results for alcohol and drugs. 


The circumstances of Mr Doyle’s death were investigated by Tasmania Police with the assistance of Inspectors from Workplace Standards Tasmania (‘WST’).  That investigation established that:

  • The crew had largely completed the task of replacing the smaller flotation buoys with larger ones at the Roaring Beach pens. 
  • One of the last of the smaller flotation buoys had been removed from the water, disconnected from its chain and placed on the deck.  Its larger replacement buoy had been placed in the water but it had not been set free, its chain remaining attached via a rope to the crane’s hook.
  • At the same time a small thin rope was tied on the port side of the Perseverance and secured the chain until the rope could be removed from the hook on the boom of the crane. 
  • Mr Doyle had previously worked on the Perseverance on two occasions only. 
  • Huon Acquaculture had not established a standard operating procedure for the task being performed by the Perseverance’s crew on the day of Mr Doyle’s death. 
  • On 2 November 2007 Mr Doyle had been issued with a Statement of Attainment from Seafood Training Tasmania.  It indicates that Mr Doyle had been assessed as having fulfilled the requirements of Marine and Safety Tasmania to operate deck machinery and lifting appliances.  However, the assessment was not specific to the crane including its remote control device. 
  • At the time of Mr Doyle’s death no employee of Huon Aquaculture had received any formal training specific to the safe operation of the crane.
  • Mr Walford had instructed Mr Doyle on the operation of the crane but he had not been provided with any information upon its safe operating procedures.
  • Although Mr Doyle had previously operated the crane and others similar to it he had normally done so by using the fixed controls. 
  • Mr Walford was of the view that prior to the day of his death Mr Doyle had operated the crane by using its hand-held remote device on one previous occasion only. 
  • Mr Doyle had not received any training specific to the use of the remote control device.
  • There were no visible delineation markings on the deck of Perseverance to indicate the hazardous work area created by the boom of the crane as recommended in the Operator’s Manual. 
  • Neither Mr Walford, Mr Strong nor Mr Doyle had been made aware of the crane’s standard operating procedures nor had they read the Operator’s Manuals for the crane and the remote control device.  The crane’s Manual includes this warning; ‘If you have not studied the Operator’s Manual for your crane carefully, this can lead to fatal accidents or serious damage.’
  • The remote control device is fitted with a large and distinctive Stop button.  When pressed all crane functions are stopped.  It has to be turned clockwise to release. 
  • The Operator’s Manual for the remote control device includes this warning; ‘Avoid unexpected loader movements!  Press in the Stop button: At every interruption in crane operation.  Also when you are walking from one working position to another!
  • Mr Walford had never used the remote control device’s Stop button on the occasions when he operated the crane.   

On 17 March 2009 a full operational test was carried out on the crane including its remote control device.  It operated correctly without any malfunction being detected.  WST approved the resumption of its use. 

Since Mr Doyle’s death employees of Huon Aquaculture have received specific training upon the safe operation of cranes from a representative of the crane’s manufacturer. 

Explanatory Scenario from WST 

Daniel Barr, an Inspector with WST, has provided a comprehensive affidavit detailing the investigation.  In that document Mr Barr includes a possible scenario to explain Mr Doyle’s death.  It is:

  • That Mr Doyle attempted to complete the last step of the flotation buoy exchange by himself without waiting for the assistance of Mr Walford and Mr Strong.
  • That Mr Doyle has proceeded to remove the rope from the hook of the crane and in doing so placed himself within the crane’s hazard work area.  At this time Mr Doyle was holding the remote control device by the strap around his neck and it’s Stop button had not been engaged.  
  • That the operating buttons on the remote control device accidentally came into contact with a hard object thereby activating the crane and causing its boom to suddenly slew sideways. 
  • The end of the boom struck Mr Doyle in the chest and crushed him against the port side of the Perseverance.

Prosecution in the Magistrates Court

Following the investigation of the circumstances of Mr Doyle’s death WST laid a complaint in the Magistrates Court against Huon Aquaculture citing three breaches of the Workplace Health and Safety Act 1995 and its Regulations.  On 18 November 2010 Huon Aquaculture pleaded guilty to the complaint.  It was convicted, fined $15,000.00 and ordered to pay costs. 

Findings, Comments & Recommendations :

I am satisfied that Mr Doyle’s death has been fully investigated and there are no suspicious circmstances. 

I accept the opinion of Dr Ritchey and find that the cause of Mr Doyle’s death was heamothorax (exanguination) due to the laceration of the aorta following a crush injury of the chest arising from the operation of a crane on the Perseverance.

There were no eyewitnesses to those events that immediately preceded Mr Doyle’s death and the evidence generally is not sufficient for me to make specific findings upon Mr Doyle’s precise actions at this time.  Nevertheless, I am, upon the evidence, able to make these findings, firstly,  that at the time of his death Mr Doyle was working within the crane’s hazard work area, secondly that at this time Mr Doyle was carrying the remote control device around his neck and thirdly that the device’s Stop button was not engaged.  The concurrence of these three elements enabled the crane’s boom to suddenly and unexpectedly move thereby causing Mr Doyle his fatal crush injury. 

The use of overhead cranes is an intrinsically dangerous activity which requires the application of properly considered risk management practices to minimise the risk of harm to all persons working within their vicinity.  In this case such practices should, in the least, have included:

  1. The creation of a standard operating procedure for the safe exchange of flotation buoys utilising the crane,

  2. Proper training and instruction of the crew in the application of the operating procedure,

  3. The appointment of a crew member, in this instance most probably Mr Walford, to be supervisor and the person responsible for the task being undertaken and to ensure that the operating procedure was complied with,

  4. The standard operating procedure should have included these specific requirements:
    • That the crane operator have proper training in the use of the crane including the remote control device.  Such training should include familiarisation with the equipments’ Operator’s Manuals and most specifically the directions concerning use of the Stop button.
    • The delineation on the deck of the Perseverance of the hazardous work area created by the boom of the crane.
    • A specific instruction that the Stop button on the remote control device be engaged and remain engaged at all times whilst a crew member was within the crane’s hazardous work area. 
    • A specific instruction that the crew member responsible for the operation of the remote control device not carry out any other tasks whilst wearing that device.

In my view there is a very real likelihood that Mr Doyle’s death would have been prevented if Huon Aquaculture had, following a proper risk management assessment, put in place and followed a standard operating procedure which incorporated those elements which I have set out above. 

This tragedy should serve as a reminder to the aquaculture industry in particular and industry generally of the very real need for the risk assessment of all aspects of their operations and for the creation and implementation of strategies designed to minimise the risk of harm to their employees.  

The evidence that I have had presented to me shows that Mr Doyle was a much loved son and brother with many close and loving friends.  I conclude these findings by extending to them all my condolences for their tragic loss. 

Dated the      31 day of October 2011.   

Rod Chandler


Explanatory Note

I have not held an inquest into the death of Mr Doyle in response to a request made of me by his senior next-of-kin.  I made that decision because I was satisfied, having regard to all the circumstances known to me, that it would not be contrary to the public interest or the interests of justice for an inquest not to be held.