Coroner's Finding: Timson, Peter Anthony

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Peter Anthony Timson Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Peter Anthony Timson (“Mr Timson”); b) Mr Timson died as a result of the combined effects of hypothermia and drowning when a dinghy which he and his son were using was swamped in heavy seas; c) Mr Timson’s cause of death was the combined effects of hypothermia and drowning: and d) Mr Timson died between the 11 and 12 of November 2021 at Norfolk Bay, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Timson’s death. That evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits establishing identity and life extinct;

• Affidavit of Dr Donald Ritchey specialist in forensic medicine and pathology;

• Forensic Science Service Tasmania – toxicological and analytical report;

• Tasmanian Health Service (THS) records of Mr Timson;

• Medical records of Mr Timson obtained from Sandy Bay Doctors;

• Affidavits of Ms Ellu Leol, Mr Timson’s partner and senior next of kin;

• Affidavit of Mr Michael Timson;

• Affidavit of Mr Peter Quealy;

• Affidavit of First Class Constable Thomas Kenny;

• Affidavit of First Class Constable Michael Boucher;

• Affidavit of Constable Mark Williams;

• Affidavit of First Class Constable Bryan Powell;

• Affidavit of Senior Constable Ingrid Pajak;

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CORONIAL DIVISION

• Affidavit of Justin Wolf, Tasmania Police (rank not stated);

• Affidavit of Senior Constable Glenn Bowerman;

• Affidavit of Senior Constable Eileen Langford;

• Affidavit of Senior Constable Todd Plunkett;

• Affidavit of Mr Cameron Cooper;

• Affidavit of Senior Constable Rance Swinton together with photographs;

• Report of Mr Peter Hopkins, General Manager – Recreational Boating Safety and Facilities, Marine and Safety Tasmania (MAST) and further letter from Mr Hopkins; and

• Report of Mr Peter Keyes, Manager of Periodic Surveys, Kedge Marine Surveyors.

This investigation concerns a fatal boating accident which occurred in Norfolk Bay near Premaydena in south-east Tasmania. Norfolk Bay is a large inlet off Frederick Henry Bay and it is west of the Forestier Peninsula and North West of the Tasman Peninsula. In summary Mr Timson borrowed a dinghy from a friend, Peter Quealy, and went fishing with his son Michael Timson in the afternoon of 11 November 2021. Mr Timson and his son got into difficulty during the afternoon as the dinghy was hit by a number of waves which resulted in the dinghy sinking and then capsizing. This resulted in Mr Timson and his son being thrown into the water. Michael Timson was subsequently rescued many hours later. Mr Timson’s body was located on Wiggins Point at Murdunna early the next day.

Background Mr Timson was born on the 11 August 1956 at Marrickville, New South Wales and he was 65 years of age and retired at the date of his death. Mr Timson had 6 siblings. He resided with his partner, Ms Leol, of some 40 years and they have 3 adult children.

Ms Leol says Mr Timson left school at about the age of 14 and worked various jobs. He commenced his registered nursing training at Lidcombe Hospital in about 1975 or 1976. She first met him in about 1980 when they were both training at the Bloomfield Psychiatric Hospital in Orange New South Wales. Mr Timson commenced living with Ms Leol in 1982 and they have been together ever since. In or about 2010 they moved to Tasmania and they have resided in Sandy Bay since that time.

In so far as boating experience is concerned this was limited before Mr Timson moved to Tasmania.

While in New South Wales he had taken boats out on a few occasions. However, after the couple

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION had been in Tasmania for approximately 2 years Mr Timson purchased a flybridge cruiser which he used every week. They would go out fishing or take it on overnight trips. The boat was moored at Kettering and they had it for about 3 years. At the time of this incident Mr Timson had a current powerboat licence however a powerboat licence was not required to operate the dinghy because the outboard being used was less than 4 hp.

Mr Timson became friends with Peter Quealy when they both worked together for Forensic Mental Health where Mr Timson was the state coordinator. Ms Leol says that she and her husband would occasionally travel to Mr Quealy’s shack at Premaydena and on approximately 4 of those occasions Mr Timson had gone fishing with Mr Quealy.

Mr Quealy says that he worked with Mr Timson for about 6 months before he moved on however after that point their friendship developed. Mr Quealy says they had a lot in common including their work, an interest in fishing and they enjoyed fixing things together. He says they would often go fishing together which included using Mr Quealy’s bigger boat which was used to go tuna fishing at Fortescue Bay and Eaglehawk Neck. Mr Quealy says Mr Timson also owned kayaks which he would use with his wife but he sold them after a few years due to their lack of use.

In Mr Quealy’s view Mr Timson enjoyed being on the water, he was highly intelligent and a considered thinker. He was organised and would research subjects to ensure he was aware of all options when a choice had to be made. In addition Mr Quealy considered Mr Timson as fit for his age.

Mr Quealy says he owns a property at Premaydena. He stores 2 boats at the front of the property on the foreshore reserve. One is made of aluminium and is about 3.5 m in length and in good condition. It is licensed to carry 4 adults. The second is 2.3 m in length which he described as a white plastic tether dinghy with blue seats. It is suitable for 1 to 2 adults or a couple of children. It is designed for use close to shore. He also stored a 4 stroke 2.3 hp Honda outboard near to where the boats were stored. Three ores were stored nearby. The outboard motor had been serviced about a month prior to this incident. It had been leaking oil. Mr Quealy had used the motor since that service and found no issues with it. Life jackets were also stored in a shed nearby and Mr Timson knew where the key to that shed was kept.

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CORONIAL DIVISION Mr Quealy says Mr Timson visited him at his shack on about a dozen occasions in the past 10 years.

He says they would often use the aluminium boat together to go fishing no more than 100m from shore. He does not ever recall them using the plastic dinghy.

The Circumstances Leading to Mr Timson’s Death Mr Timson and his son Michael left home to travel to Mr Quealy’s shack at about 10:00 hours on 11 November 2021. Ms Leol understood Mr Timson and their son were to meet with Mr Quealy to go fishing together. Ms Leol telephoned Mr Timson at about 13:00 hours and was advised Mr Quealy was still in Hobart. She thereafter deduced Mr Timson and Michael Timson must have decided to go fishing on their own without Mr Quealy.

Michael Timson says they arrived at Mr Quealy’s shack at about 11:00 hours but Mr Quealy was not home. Mr Timson and his son therefore went into Nubeena to get lunch. At about 13:30 hours they returned to Mr Quealy’s shack and prepared the white plastic dinghy which involved affixing a small outboard motor to the back of the dinghy before it was launched from the shore at approximately 13:45 hours.

Mr Quealy says Mr Timson telephoned him on 2 occasions on or about 8 November 2021 to ask if he could use Mr Quealy’s canoes as his son was visiting and they wanted to do some fishing. Mr Quealy told Mr Timson that was fine and they could stay at his shack if they wanted to. He also said they were more than welcome to use the “tinny” down the front if they wanted to catch fish. In addition Mr Quealy says he advised Mr Timson the motor was there and there was petrol near the boat. He says Mr Timson next phoned him at 12:28 hours on 11 November 2021 at which time Mr Timson told him a lot of the pathway from the shack to the boat had slipped away in the rain. Mr Timson indicated he would like to try and fix that for Mr Quealy. Mr Timson indicated he wanted to go fishing and Mr Quealy said that he was in Hobart and that if he waited he would help him set the “tinny” up. He told Mr Timson where the life jackets were and where the keys to the shed were. He also told Mr Timson he could, if he wanted, go inside and watch TV and relax until Mr Quealy arrived. On the way to his shack Mr Quealy stopped at Sorell and Dunalley; arriving at Premaydena at about 14:30 hours. He telephoned Mr Quealy at approximately 14:39 hours but there was no answer.

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CORONIAL DIVISION After launching the dinghy Michael Timson says he was seated in the front and his father was seated in the rear so that he could operate the motor and he could reach the oars. They were both wearing red and yellow life jackets and they had both left their phones in the car on shore. Initially they floated around 20 m from the shore and began fishing. They made an effort to stay close to the shore and out of the wind.

Approximately 40 minutes later the wind picked up and began blowing them away from the shore.

Michael Timson told his father they needed to move back towards the shore so they didn’t get blown too far out. Mr Timson started the outboard motor and they moved about 30 m closer to the shore. The motor then cut out and would not restart. Michael Timson mentioned there might be an issue with the fuel so his father checked that and said that the fuel was getting to the motor.

Mr Timson attempted to start the motor a few more times however it would only run for a second before cutting out. Mr Timson then attempted to use the oars but that did not prevent them from drifting further out. At this time Michael Timson says they were about 100 to 150 m from shore so his father attempted to start the motor a few more times. Eventually he realised the kill switch had been engaged and so he disengaged the switch and the motor started.

Mr Timson turned the boat and headed towards shore however Michael Timson says they were travelling too quickly and they hit 2 large waves head on. The boat began to fill with water. Michael Timson attempted to bale the water out with a bucket while Mr Timson turned the boat side onto the waves however the next wave went over the side of the boat which resulted in more water filling the boat. The boat then began to sink and everything fell out. Michael Timson managed to grab the 2 oars and as the boat was sinking it flipped over. Michael Timson managed to flip the boat back over again but it was still around three quarters full with water and waves were still coming over the top of it. Mr Timson was holding the back of the boat and Michael Timson was holding the front and they attempted to swim back to shore. They did this for about 2 hours but they could not make any progress; in fact they were losing ground. At about 15:40 hours Michael Timson told his father he would leave the boat and try to swim to shore as he could see his father was tiring and he would need help. He estimated the distance to shore to be about 2 km. As he was a fairly strong swimmer he believed he could make it. He therefore left Mr Timson and swam towards the shore. He lost sight of his father after about 20 minutes and he continued towards shore for about 6 hours but he was losing ground due to the swell, wind and current. He was kept afloat by his life jacket.

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Just before dark he observed a helicopter flying over the bay and at 22:00 hours when he was blowing the whistle on his life jacket he saw a spotlight searching for him. At approximately 22:30 hours a police boat located Michael Timson and pulled him out of the water.

The Search for Mr Timson and His Son Mr Quealy says at 17:32 hours he rang Mr Timson again. He became concerned as to his whereabouts when he realised the “tinny” was still on the shore and they had taken the small plastic boat. There was no answer. Mr Quealy then telephoned a neighbour and spoke to him and then began looking at Prices Flats which is an area close by but he could not see anything. He then drove in the other direction but had no luck finding either the boat or its occupants. He returned to his shack and telephoned police at 18:13 hours, 18:36 hours and 18:48 hours. Police arrived at 18:48 hours and he briefed Constable Williams. Police determined that both mobile phones and wallets of Mr Timson and his son were in Mr Timson’s vehicle.

On his arrival Constable Williams noted it was calm close to shore but a little choppy from about 100 m out from shore with a slight breeze blowing. The tide was out. After being briefed Constable Williams liaised with the search controller, marine units and helicopter units to provide information and search for the dinghy. He himself searched the shoreline to a point 500 m north of where the dinghy had been launched from but could not locate it. He also arranged for a Hobart Police unit to attend Mr Timson’s address in Sandy Bay in order to speak to his wife.

First-Class Constable Kenny was directed to go to the Lime Bay campsite and search Norfolk Bay from the shoreline all the way back to Premaydena. This he did with no success. Police vessels and the POLAIR unit were deployed to continue the search into the night. At 22:30 hours he was advised by Constable Williams that Michael Timson had been located and he was being transported to hospital.

First-Class Constable Powell says he was performing the role of rescue crew on board the police helicopter which was being flown by Matthew Collingwood. Senior Constable Pajak was on board as an air crew member and there was also an intensive care paramedic from Ambulance Tasmania on board. They were engaged by the Australian Maritime Safety Authority (AMSA) to search for Mr Timson and the dinghy in the Norfolk Bay area. At approximately 7:20 hours on 12 November 2021

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CORONIAL DIVISION they observed a body of a male person on the shore at Wiggins Point Murdunna. The body was recovered and later identified as Mr Timson.

Officer Wolf and Constable Bowerman in their search for Mr Timson came across the dingy which they found in the vicinity of Dunbabin Point in Norfolk Bay. That vessel was observed to be fitted with a small 2.3 hp Honda outboard motor. During the recovery of that vessel Officer Wolf removed the outboard motor from the dinghy and in order to prevent petrol leaking from the motor into their vessel he attempted to close the fuel breather on the petrol tank however he noticed the breather valve was already tightly closed. This he said would prevent the motor from being able to operate for sustained periods and would likely cause the engine to stall due to fuel starvation. Constable Bowerman observed the dinghy to be sitting hard on the rocks with water inside it to the level of the seats. He bailed most of the water out using a bucket from the police vessel and once most of the water had been removed the dingy began to float. He then manoeuvred it into deeper water and threw a rope that was attached to the bow to Constable Wolfe who then towed it out to the other police vessel for transport back to Hobart. Constable Bowerman then commenced a search of the shoreline for any other relevant items that may have been washed ashore before finalising his search and returning to the Murdunna boat ramp.

Investigation

(i) Post-Mortem Examination A post-mortem examination was conducted by Dr Donald Ritchey who is attached to the Office of the State Forensic Pathologist. Samples were taken for histological and toxicological examination.

Dr Ritchey considered the results of those tests and in addition he conducted an external and internal examination. The autopsy revealed a normally developed and nourished elderly Caucasoid man whose lungs were markedly hyper expanded and covered the anterior mediastinum. The gastric mucosa had several small superficial haemorrhagic ulcers1 which Dr Ritchey says are highly suggestive of hypothermia. As a result of his examinations and a consideration of the histological and toxicological results Dr Ritchey says the cause of death was the combined effects of hypothermia and drowning following the swamping of a dinghy in heavy seas. I accept Dr Ritchey’s opinion.

1 These are known as Wischnevsky’s ulcers.

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION An analysis of samples taken at autopsy confirmed Mr Timson had no alcohol or illicit drugs in his blood. The only result of note was that a therapeutic concentration of amlodipine was detected.

This medication is indicated in the treatment of hypertension and angina. Mr Timson’s THS records are minimal and do not disclose any treatment provided for a heart condition. Likewise the records of his general practitioner are very limited. They do however reveal he was prescribed amlodipine.

(ii) Inspection of the Dinghy The dinghy was inspected by Mr Keyes on 16 November 2021. Mr Keyes is a qualified shipwright and has worked as a marine surveyor since 1994. He has been a member of the Australian Institute of Marine Surveyors since that time. In addition he has Coxswain and Master 5 Certificates of Competency. Currently he is the manager of periodic surveys and the senior surveyor with Kedge Pty. Ltd. He is accredited by AMSA and Maritime New Zealand and he performs survey work throughout Australia, New Zealand, China, Europe and Fiji. The regulatory surveys he conducts include commercial vessels up to 35 m and pre-purchase, condition and insurance surveys of vessels up to 65 m.

Mr Keyes’ report indicates the dinghy is moulded from high density polyethylene by Walker Bay Boats; model number WB – 8S. Its dimensions are 2.2 m in length, 1.3 m beam and .49 m depth. It is fitted with 3 seats each appearing to contain some buoyancy material.

The dinghy has a builder’s plate attached which provides for the following:

• Maximum 2 persons of no more than 150 kg;

• Maximum persons and cargo (including motoring fuel) no more than 183 kg;

• Maximum horsepower 2.50 hp.

When inspected the outboard motor which was attached to the dinghy when it was recovered had been removed for transport to the police facility. The motor is a 2.30 hp Honda 4 stroke outboard with an integral fuel tank which has a breather attached to the filling cap.

On inspection Mr Keyes determined the dinghy was structurally in fair condition with the hull intact but with heavy scratches and scrapes over most of the bottom. The gunwale moulding around the

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CORONIAL DIVISION bow was damaged, but he says this would not affect its seaworthiness. All seats were intact and securely attached and it was assumed that buoyancy material was in place but this could not be confirmed due to the moulded construction of the seats. There were no oars with the boat when inspected nor were there any rowlocks.

Although the motor was inspected it was not test run but the inspection showed fuel in the tank and the breather valve was closed. It was confirmed the motor was in the same condition as when recovered. Without the breather open Mr Keyes says the motor would have very limited running time.

Mr Keyes concluded the dinghy is a small boat of the type usually used as a yacht tender in smooth and enclosed waters. It needs to be used in accordance with the weights and horsepower limits set out on the builder’s plate. If these limits are exceeded he says the boat could not be used safely. The dinghy was not registered with MAST but given the motor is less than 4 hp it was not required to be registered and nor was a motor boat licence required to operate the dinghy.

I accept the opinions of Mr Keyes which he is well qualified to provide.

(iii) Inspection of the Motor Mr Cooper is a small engine mechanic employed by the Marine and Rescue Services division of Tasmania police. He is based in Hobart. He has been a small engine mechanic for the past 38 years.

On 16 November 2021 he was requested to examine the Honda 2.3 hp petrol outboard motor which was detached from the dinghy but sitting inside it. Mr Cooper was advised the dinghy had been located in an upright position with the motor still attached to the hull. He was shown photographs of the dinghy sitting on the shore on rocks with the outboard attached to the hull. He was told these pictures were taken by Constable Bowerman at the site where the dinghy was located2.

2 Constable Bowerman says he observed the dinghy on rocks at Dunbabin Point. He says a 2.3 hp Honda outboard motor was mounted on the stern. He was dropped ashore from the police vessel “Avon” by Constable Wolf at which point he took a number of photos of the dinghy in situ.

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CORONIAL DIVISION Without contacting a service agent Mr Cooper was unable to determine how old the motor was but he believed it was built in the early two thousands. It looked in generally good condition. He found water in the engine sump oil which could be as a result of the motor being tipped on its side in transit or when the vessel capsized. This would prevent the engine from starting. He pulled the spark plug out to check if there was any oil or water in the cylinder and there was a small amount present which could have occurred when the dinghy capsized and this would also stop the engine from starting. He cleaned the spark plug and turned the motor over to remove the oil and water from the cylinder and he replaced the spark plug. He drained the carburettor which had a very small amount of water in it. He believes this occurred when the dinghy capsized. He checked the fuel tank and saw moisture and particles in the fuel which he did not think would affect how the engine ran.

The vent of the tank was in a closed position. He says if this had been in the closed position while the motor was operating it would run for a while but it would then run out of fuel because this would prevent fuel getting to the carburettor. The motor would be unlikely to start again until that vent was opened.

He then started the motor which started relatively easily given the conditions it had been subjected to. He pushed the choke in and the motor died almost immediately. This indicated to him the carburettor was blocked in the jets. He repeated the process by starting the motor again with the choke on and then pushing the choke off and again the engine stopped immediately.

He says one of the components of the motor is a kill switch. In relation to this feature he says it “ acts like a key, turns the ignition on when inserted, this is connected to a lanyard, the feature is designed to immediately halt the motor if the operator has it attached to their wrist and falls from the vessel. If the kill switch key is not inserted, starting the motor would be impossible.” Mr Cooper is qualified to provide these opinions and I accept them.

(iv) Inspection of the Life Jacket worn by Mr Timson The applicable legislation with respect to the use of lifejackets is the Marine and Safety (Motor – Boats and Licences) By-laws 2013. Clause 32 of those by-laws provides that a person who is on a motorboat of less than 6 m in length must wear an approved lifejacket. The clause goes on to provide an approved lifejacket, for smooth waters, is one that meets or exceeds the requirements of AS 4758

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CORONIAL DIVISION for level 50 lifejackets. Smooth waters is defined in clause 3 as the waters of any inland lake, river or stream or smooth waters as specified in Schedule 1 to the Marine and Safety (Limits of Operational Areas of Vessels) By-laws 2013. The waters of Norfolk Bay, east of the line between Dorman Point in the north and Whitehouse Point in the south are specified in Schedule 1.

The life jacket worn by Mr Timson was examined by Mr Hopkins on 17 November 2021. It is a “Marlin” brand lifejacket with foam buoyancy. It was a level 100; that is 100 newtons of buoyancy and it was manufactured in accordance with AS 4758.1 – 2008 which meets the Tasmanian legislative requirements. In fact the lifejacket’s rating exceeded that which was required for smooth waters.

The labelling on the lifejacket showed it was approved and suitable for persons weighing in excess of 70 kg with a chest fit of between 140 and 160 cm. The size of the lifejacket was noted as XL – 2 XL.

It was manufactured in June 2016.

Mr Hopkins noted the adjusted amount of the waist straps appeared, when clipped, to be adjusted for a larger person. The zipper on the lifejacket was operational and the adjustment straps were in good condition. The jacket itself had a small tear on the back but this would not have affected its performance. Overall it was in good condition. Given Mr Timson’s height and weight, as disclosed by the post-mortem examination, I find the lifejacket was appropriately sized for use by him.

Mr Hopkins goes on to say the lifejacket was not fitted with a crotch strap. He says such a strap, if worn and fitted correctly, prevents the lifejacket riding high on the wearer and in the water and improves the performance of the lifejacket considerably. I accept the opinions expressed by Mr Hopkins in his report.

(v) The Use of an Emergency Position Indicating Radio Beacon (EPIRB) An EPRIB is a compact, buoyant, self-contained radio beacon which constantly emits a radio signal to a satellite for at least 48 hours after activation. All boats operating beyond sheltered waters are required to carry an EPIRB. Given where the dinghy was operating an EPIRB did not have to be carried.

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION When the radio signal is detected by the Rescue Co-ordination Centre in Canberra locally-based rescue services are tasked to respond. MAST’s advice3 is EPIRBs should only be used as a last resort when in imminent danger. Radio and flares should be used first. Kayakers paddling more than 2 nautical miles from shore are required to carry an EPIRB or a Personal Locator Beacon, a VHF radio and a flare kit. If paddling in a group of three, only one is required to carry this equipment.

Ms Leol suggested to my office “that all life vests be fitted with EPIRB devices. I believe this should be compulsory due to the high rate of drowning accidents in Tasmania.” Accordingly I arranged for MAST, as the regulatory authority for recreational boating in Tasmania, to comment upon this suggestion.

In his response to Ms Leol’s suggestion Mr Hopkins says it is likely Ms Leol was referring to Personal Locator Beacons (PLB) rather than EPIRBS as EPIRBS are not designed to be carried on a person.

Before commenting upon this suggestion Mr Hopkins considered it was important to gain a perspective on recreational boating fatalities in Tasmania. He advises since the wearing of lifejackets became compulsory in 2001, on boats 6 m and under, there had been 59 recreational boating fatalities. In the 23 years leading up to 2001 that is from 1978 there were 146 fatalities. In addition he says the boating fleet has almost tripled since 2001. Accordingly the figures are 1.1 fatalities per 10,000 registered boats since 2001 whereas it was 6.4 fatalities per 10,000 registered boats in the 23 years prior to 2001. He quite properly acknowledges that while 59 fatalities in the last 21 years is not acceptable there has been a significant decrease during that period.

On the day of this incident a strong wind warning had been issued. The closest weather station is at Dunalley and from 14:00 hours to 19:00 hours the wind did not register under 20 knots that is just on 37 km/h and it was gusting to 36 knots or almost 67 km per hour. The Bureau of Meteorology weather observations for 11 November 2021 confirm a maximum wind gust of 67 km/h with the wind speed being recorded at 39 km/h at 9 AM and then 48 km/h at 3 PM. Mr Hopkins notes Mr Timson had a choice of 2 of his friend’s boats namely the boat which was chosen and a heavier aluminium dinghy. Mr Hopkins deduced from his examination of the lifejacket worn by Mr Timson that he was not a small man. Without knowing the weights of those on board, the gear they carried and the weight of the outboard motor Mr Timson says he believes the wrong boat was chosen especially given the weather forecast. He says MAST has advocated both at public events and also in 3 See pages 32-33 of Tasmanian Safe Boating Handbook published by MAST.

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CORONIAL DIVISION recent public relations campaigns that the best safety equipment anyone can carry is their head; that is safe boating is about making the right decisions and using sound judgement. He goes on to say “[c]arrying a PLB will not result in instant rescue, much depends on whether the PLB or EPIRB has been activated, if the PLB is registered with AMSA and whether or not the PLB is GPS enabled. Once a PLB has been activated it could be some time before search and rescue is mobilised.” Mr Hopkins concludes by saying the following: “Having checked a number of retailers, the cost of a PLB varies, but they are mostly upwards of $350 per unit. Considering there are almost 32,000 boats in Tasmania with an average of 5 lifejackets per boat, the cost to have a PLB on each lifejacket would be in the vicinity of $56 million. When kayaks, canoes and other unregistered vessels that require a life jacket are considered, the cost to the community would most likely exceed $100 million. In addition, few lifejackets have a “pocket” or the ability to store a PLB. Further to this, in last year’s Sydney to Hobart yacht race where PLBs are compulsory when on deck (mostly carried in “bum bags”) there were 28 false alarms in one period of around 24 hours. If this transpired to recreational boats and their crew in Tasmania there could be dozens of false alarms each day which would need to be assessed by AMSA and search and rescue authorities.

MAST considers that personal PLB’s on each lifejacket are not warranted. MAST will continue its education campaign in respect to decision-making for those going boating. Included in this will be recommending a torch be carried to enable signalling at night, the carriage of a mobile phone in a waterproof pouch and using a boat that is fit for purpose for the trip being undertaken. As always, MAST will continue to urge people to consider the weather prior to going boating.” I agree with the position taken by MAST with respect to the suggestion made by Ms Leol for the reasons expressed by Mr Hopkins. I also agree with the recommendations he has suggested in the last paragraph. These recommendations should be made clear in any further education campaigns or public relations exercises conducted by MAST.

Accident Cause Given the evidence of Michael Timson with respect to the waves which struck the dinghy and the evidence of those officers involved in the search and rescue that the weather conditions were windy I conclude those conditions were not conducive to using this dinghy. In addition the combined weight of Mr Timson and his son alone, that is without including the weight of any equipment

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CORONIAL DIVISION including the engine, exceeded the recommended maximum weight limit of 183 kg by approximately 24 kg. In those circumstances the dinghy could not be used safely.

Although Mr Timson had been fishing at this location previously there is no evidence he had ever used the dinghy which he used on this occasion. Although there were no structural or mechanical faults with the dinghy or the outboard motor it seems it was not being operated correctly because the breather vent on the fuel tank was closed and this may well have led, in addition to the kill switch being engaged, to the problems encountered by Mr Timson with the outboard motor.

While I readily accept Mr Timson was a considered and careful person it is probable the dinghy capsized as a result of one and/or a combination of the factors listed above.

Comments and Recommendations I extend my appreciation to investigating officer First-Class Constable Kenny for his investigation and report.

I commend the efforts of those many officers who were involved in the search for Mr Timson and Michael Timson and the rescue of Michael Timson.

The circumstances of Mr Timson’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

This case serves as a timely reminder of the dangers of recreational boating in this State. Weather conditions in the waters around Tasmania can be variable and unpredictable. If a person is not familiar with the equipment which they are using and/or are not using the equipment in accordance with the manufacturer’s recommendations then this can, as this case demonstrates, have tragic consequences.

I convey my sincere condolences to the family and loved ones of Mr Timson.

Dated: 11 August 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner