Safety overhaul recommended after Dianne, Cassandra inquest
FAMILIES of the eight men who met their untimely deaths while working at sea were today handed the findings from a five-day inquest into two maritime tragedies.
Central Coroner David O'Connell made nine recommendations in his findings from the inquest into the sinkings of fishing vessels Dianne and Cassandra.
Sea cucumber fishing vessel Dianne capsized and sunk off the coast of Seventeen Seventy on October 16, 2017.
Ruben McDornan was the only crew member to survive.
The bodies of Adam Hoffman, 30, and skipper Ben Leahy, 45, were found by police divers in the Dianne but Eli Tonks, 39, Adam Bidner, 33, Zach Feeney, 28, and Chris Sammut, 34, were never found.
Prawn trawler Cassandra sunk near Fraser Island in April 2016, and the bodies of skipper Matt Roberts, 61, and crewman David Chivers, 36, were also never found.
Mr O'Connell was critical of the Department of Agriculture and Fisheries' roll out of the Vessel Monitoring System, a tracking device installed on commercial vessels, including the Dianne and Cassandra.
Mr O'Connell said the affidavit provided by the Department of Fisheries to the inquest stated on four occasions that the VMS did not have a safety function.
But as the inquest progressed, counsel for DAF conceded the VMS did have a safety component. They said if a regular radio signal was not issued by a vessel, the monitoring computer would generate a report that a poll had been missed.
"The worst aspect was it took until sometime during the inquest before any concession was made by the Department that not only was this function of the VMS currently available, and that it already exists, but that it had existed for quite some time," Mr O'Connell said.
"What I find unacceptable is that a government department can 'sell' a system to the industry claiming it has a benefit to the industry but then not implement the system with that benefit; but worse is to take a demonstrably wrong position to claim that the system cannot do this function and maintain that in their statements to the inquest."
Mr O'Connell said he had no doubt the crewmen on the Cassandra had excellent trawling capabilities and those onboard the Dianne were "extremely fit" and "experienced divers".
During the inquest Mr McDornan gave evidence, detailing what it felt like when the vessel capsized and his desperate escape.
Describing Mr McDornan as a "very impressive witness", Mr O'Connell said without the survivor's evidence it would be impossible to piece together what happened on the night of October 16, 2017.
Mr McDornan said at 7.15pm he felt the vessel roll to port but it did not come back to starboard.
"So (he) instinctively braced himself against the wall of the cabin ... but he immediately knew something was wrong," Mr O'Connell said.
"What is of some importance was it felt like any other motion of the vessel that night, it was not violent nor accompanied by any other action 'out of the ordinary' as can occur with a 'freak wave'."
Disorientated and in complete darkness, Mr McDornan managed to force open the door of the wheelhouse and squeeze himself out.
He made his way onto the upturned hull where he could hear two voices from inside the vessel. But at 10.30pm he could no longer hear any voices.
After swimming all night, Mr McDornan was found by pure chance by a couple onboard a 40-foot sailing catamaran.
The sailors made a mayday call. It would be 12 hours since the capsize had occurred that any rescue authority was made aware.
Mr O'Connell said it was "inconceivable" that four hours had passed after the Cassandra capsized before the rescue began, and that a rescue did not begin until 12 hours after the Dianne sunk.
"Delay puts lives in peril, it also increases the search area for rescue authorities making the exercise far more costly and personnel intensive," he said. "In respect of the co-ordinated air and sea search, I make no criticism whatsoever."
Also considered by the coroner was how the rope of the drogue came to be around the propeller of the Dianne, when inspected by police divers.
The drogue was stored and folded on the rear duckboard, and it was speculated it could have worked its way loose by the rough seas that night.
But Mr O'Connell said he could not determine if the rope came loose before or after the vessel capsized.
He said if it had worked free from where it was stored it would have slowed the vessel's forward momentum and the experienced skipper Mr Leahy would have noticed.
The Dianne was likely overcome by heavy seas, with a wave recorded of 3.69m in the area that night, when it capsized Mr O'Connell said.
Mr O'Connell found the likely cause of the capsize of the Cassandra was likely while retrieving a snagged trawl net from a seabed 'hook-up'.
There was no time for the crew to find an EPIRB, get lifejackets or deploy the life raft.
Mr O'Connell said it was not clear if the crewmen could have escaped after it rolled because they could have been trapped by equipment.
Mr O'Connell said there were reasonable, practical and inexpensive safety measures to be implemented to reduce the likelihood of similar incidents happening again.
In his recommendations Mr O'Connell called for the Department of Agriculture and Fisheries to immediately implement the 'failure to poll' function of the VMS system to allow QPS to be notified by text and email.
He also recommended for vessels to have emergency Grab Bags in the sleeping cabin and at the helm and self-illuminating LED strip-lighting and emergency exit signs.
He said bulky items should be restrained by straps and that fishermen wear inflatable style PFD vests while working on the decks of a vessel.
The fishing industry has been encouraged to investigate solutions to ensure doors on vessels can be opened against water pressure and review the use of quad gear in the Sandy Straits area for trawling.
Mr O'Connell said the circumstances around the inquest were significant, given 18 commercial fishermen had died at sea in the waters off Queensland since 2004.
"Too many people in the fishing and trawling industry have been lost over the years and despite a number of inquests recommending improved safety measures little has actually changed or been implemented despite technology being available," he said.