A coronial inquest has found a worker's death could have been prevented by simple and inexpensive actions like proactively maintaining personal protective equipment, which, among other things, sends a clear message to workers on the importance of using PPE.
Allan Geoffrey Russell, 72, was working as a deckhand for Tasmanian abalone fishing company Clark Fishing Pty Ltd when he fell into cold water and drowned in April 2015.
Following a WorkSafe Tasmania investigation, the PCBU was charged with breaching the State Work Health and Safety Act 2012, but the complaint was dismissed by a magistrate in July last year, and Coroner Simon Cooper subsequently held an inquest into the fatality.
The Coroner heard that Russell and Clark Fishing director Darren John Clark had taken the Clark Fishing vessel Breaksea to the Tasmanian south coast and were fishing in calm conditions when the incident occurred.
The task involved Clark diving from Breaksea's dinghy while Russell, who couldn't swim, operated the dingy, maintained Clark's air hose and collected inflatable catch bags of abalone that Clark sent to the surface.
After several hours of diving, Clark felt his air hose tighten and swam to the surface, where he found the dinghy upside down and Russell struggling in the water and coughing, without a lifejacket on.
For the next 40 minutes, he fought to keep the "incoherent" Russell afloat, but Russell eventually stopped breathing and he was forced to let him go. Russell immediately sank, and his body was later recovered by another fishing vessel.
The Coroner found Clark's efforts to try to save Russell were "highly commendable", but there were a number of things he could have done to prevent the incident, like making "the very simple enquiry of Mr Russell whether he could swim".
Clark's claim that no one in the industry had been aware that the highly experienced deckhand couldn't swim was not sufficient to discharge his safety obligations to him, the Coroner found.
"The job involved working alone, unsupervised, in a small dinghy in remote areas subject to extremes of weather. Never having seen Mr Russell swim and simply assuming that he could was not enough. In my view an enquiry as to the ability to swim when employing someone to work as a deckhand is a basic precaution that should have been undertaken," he said.
Other preventative measures included having more comprehensive procedures and instructions on the use of lifejackets, and taking steps to ensure Russell's lifejacket was correctly serviced, he found.
"It is recognised that there is no evidence of a failure of servicing of the lifejacket playing any role in Mr Russell's death, but it seems to me that such a level of attention to detail may have helped emphasise to Mr Russell the importance of wearing his lifejacket.
"Any of these things, simple actions and inexpensive to implement, may well have, in my respectful view, altered the outcome when Mr Russell found himself in water," he said.
He added that it was possible Russell wasn't wearing his lifejacket when he fell in the water because: he removed it while Clark was fishing; he wasn't wearing it correctly and it came off when he entered the water; or he didn't have it with him or wasn't wearing it before Clark entered the water.
Clark verbally directed Russell to wear his lifejacket, at times, but this verbal policy was clearly inadequate, he said.
The Coroner conceded that it was difficult for small organisations to introduce written safety management systems, but said Russell's "tragic death starkly illustrates why such policies are necessary and must be rigorously implemented".
He recommended that:
- WorkSafe Tasmania and the Tasmanian Abalone Council Ltd review the relevant safety Code of Practice to consider improvements to systems on the engagement and qualifications of deckhands, the wearing of lifejackets and the condition of vessels like dinghies used for diving; and
- the Australian Maritime Safety Authority review the safety survey requirements for tender vessels like dinghies, noting that such vessels often operated with considerable independence and autonomy.
Coroner Cooper said there was not enough evidence to determine the cause of the Clark Fishing dinghy capsizing, but heard it might have become unbalanced by a rogue wave in the otherwise small swell, or been caused by Russell falling into the water and trying to climb back into the boat.