Finding into death of Ashton Prentice Victor Meadows

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2014 002978

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of ASHTON PRENTICE VICTOR MEADOWS without holding an inquest: find that the identity of the deceased was ASHTON PRENTICE VICTOR MEADOWS born on 21 August 1977 and that the death occurred on or about 19 January 2014 in the vicinity of Kilcunda, Victoria 3995 from: I(a) UNASCERTAINED

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Mr Meadows was a 36 year old man who resided in Croydon Hills with his wife Tamara and their three children. During December 2012 and January 2013, Mr Meadows and his family holidayed in Newhaven, Phillip Island.

2. At about 3pm on 18 January 2014, Mr Meadows took his boat, a model 213C Haines Hunter, out fishing. He launched the boat from the Newhaven boat ramp, leaving his car and trailer in the designated parking area. Mr Meadows navigated to an area of water about 100-200 metres off shore from Kilcunda, where he moored his boat and started fishing. At around

6.30pm, Mr Meadows left the area and started heading back in the direction of Newhaven.

3. At3.30am on 19 January 2014, the Australian Maritime Safety Authority’s (AMSA) Rescue Coordination Centre (RCC) detected the activation of an emergency distress beacon near Kilcunda. The device was an Emergency Position Indicating Radio Beacon (EPIRB) !

registered to Mr Meadows.

! According to AMSA, the Radiocommunicalions (406 MHz Satellite Distress Beacons) Standard 2014 does not require EPIRBs and PLBs to have GPS capability. However, although GPS capubility is not mandatory under current

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The RCC commenced a search and rescue operation, supported by resources from Victoria Police, Ambulance Victoria, State Emergency Services (SES) and the Australian Volunteer Coast Guard Association (AVCGA). At about 5am, an air ambulance helicopter performing a search around the beacon’s location near Kilcunda, located an overturned boat on rocks at the

shoreline.

Shortly after Gam, members of the Water Police arrived at the boat site and started a search of the immediate vicinity, accompanied by an officer from the ambulance helicopter. Mr Meadow’s EPIRB was located by Water Police members close to the boat, laying on the rock platform. The safety latch covering the activation switch was intact and had not suffered any significant damage. Leading Senior Constable Jeffrey Anderson who discovered the EPIRB,

did not believe there was sufficient damage to indicate accidental activation of the device.

The search and rescue operation continued with acrial and coastal searches of the surrounding area, as well as a ground search of the coastline near the boat site. Due to weather conditions, Victoria Police dive teams were unable to access the water surrounding the rocks until 23 January 2014 when they commenced underwater searches of the sea bed. Mr Meadows was

not found during the course of the search and rescue operation.

On 11 June 2014, almost five months later, a commercial abalone diver was diving about 50

metres off the shore of Kilcunda beach when he discovered a human femur that he handed

over to Victoria Police. The femur was taken to the Victorian Institute of Forensic Medicine

[VIFM] where DNA mitochondrial analysis confirmed that it formed part of the remains of Mr Meadows. As a result, on 19 June 2014, Victoria Police Search and Rescue dive teams explored the sea bed in the vicinity of Kilcunda beach but did not make any further

discoveries.

On 19 June 2014, Dr Noel Woodford, (then) Senior Forensic Pathologist from VIFM examined Mr Meadows’ remains and consulted with Anthropologist Dr Christopher Briggs from the Department of Anatomy and Neuroscience at the University of Melbourne. Dr Woodford advised that he was unable to determine the cause of death of Mr. Meadows’ which

remained unascertained despite his examination and the consultation with Dr Briggs.

Australian Standards, it is offered in many beacon models that are available in Australia. The advantages are obvious.

The EPIRB on Mr Meadows’ boat was compliant but did not have GPS capability.

? The longest and largest bone in the human body, extending from the pelvis to the knee, commonly referred to as the thigh bone.

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This finding is substantially based on the investigation and comprehensive brief of evidence compiled by Leading Senior Constable Tim Carlin from Victoria Police Water Police and his thoughtful suggestions for prevention-focused coronial comments and recommendations that

will be discussed below,

There is insufficient evidence to account for the nine hours between Mr Meadows’ departure from his fishing area near Kilcunda, and when the beacon was activated at 3am the following morning, Tamara Meadows advised that Mr Meadows’ had occasionally stayed out overnight on his fishing trips and it is possible that he slept in his boat, attempting the return journey

early on the morning of 19 January 2014.

It is unclear precisely what caused Mr Meadows’ boat to run aground on the rocks at Kilcunda, Although there was extensive damage, the wreck was inspected by a marine assessor on | and 12 February 2014, The marine assessment report did not raise any concerns about the seaworthiness of Mr Meadows’ boat. The evidence also indicates that the boat was equipped with the required safety equipment and was compliant with Victorian maritime

regulations.

It is important to recognise the extent of the search and rescue operation undertaken to locate Mr Meadows. The activation of Mr Meadows’ EPIRB in the early hours of 19 January 2014 triggered a comprehensive search and rescue operation, coordinated initially by AMSA with cooperation from Victorian search and rescue services. In this investigation, I have had the benefit of a report prepared by AMSA accounting for the totality of the search and rescue

operation and the resources that were committed to it.

AMSA detected the beacon activation at 3.30am and at 3.45am the ‘HEMS 1’ ait ambulance helicopter was tasked with homing to the beacon’s position. Mr Meadows’ boat was located shortly after the beacon’s signal was first detected. However, given its position on the rock platform below the cliffs near Kilcunda, there was some delay before rescue teams could

safely access the area.

Unfortunately, Mr Meadows was not located with his boat or with his EPIRB. From the point where the beacon was recovered the search and rescue operation continued without the benefit of a specific location to search. Victoria Police attempted to predict Mr Meadows’ probable location using search and rescue mapping software and RCC continued to provide aerial searches of the surrounding area. Search and rescue operations concluded on the afternoon of

24 January 2014 without finding any trace of Mr Meadows.

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Coroner’s Investigator, Leading Senior Constable Tim Carlin, from the Victoria Police Water Police, identified that search and rescuc assets have a significantly greater chance of finding a

person in distress when an EPIRB or Personal Locator Beacon [PLB] is used. Due partly to

his involvement in the search for Mr Meadows, he suggested that distress beacons would be more effective if they directed search and rescue teams to the location of the person in distress

rather than the vessel, by being fitted directly to the person’s personal flotation device [PFD].3

Considering the circumstances of Mr Meadows’ death, I requested the assistance of the Coroners Prevention Unit [CPU] to seck input from maritime safety authorities by convening a round-table meeting, inviting the attendance of representatives of Transport Safety Victoria (TSV), the AMSA, AVCGA and Victoria Police, The aim of the round-table meeting was to obtain informed input from relevant agencies regarding the use of EPIRBs and PLBs in recreational boating, with the aim of assisting me to make prevention focused and, if possible,

consensus comments and/or recommendations.

The round-table meeting was held on 17 February 2016 at the Coroners Court of Victoria and.

Chaired by Lachlan Broadribb from the CPU. Representatives from Water Police, Transport Safety Victoria, the Australian Volunteer Coast Guard Association, the Police Coronial Support Unit, the Coroners Court In-House Legal Service and the Coroners Prevention Unit

participated as well as myself. All participants were invited to openly discuss the use of

‘EPIRBs and PLBs, and their use in recreational boating.

Some consensuses was achieved between the participants that PLBs, in particular those with GPS capability, could improve the chances of survival during a rescue situation, particularly when a person becomes separated from their vessel. It was further identified that certain high tisk activities are inherently more dangerous than others, such as solo boating, and operating at night or during limited visibility. Boat operators are required to wear a PFD during times of heightened risk and if the PFD is also fitted with a PLB, in particular those with GPS capability, then the person’s ability to request emergency assistance is improved even if they are forced to abandon their vessel and the chances that they will be located by rescuers

improved commensurately.

COMMENTS

3 There are practical difficulties here as EPIRBs are generally considered too large to attach to a PFD. The practical alternative to this suggestion would be to mandate or at least encourage the attachment of a PLB, preferably with GPS capability to PFDs.

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Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments in connection

with the death:

1. A concern was raised by the round-table participants that the assignment of search and rescue assets to an operation reduces their capacity to respond to other incidents occurring at the same time. It is therefore a priority of search and rescue elements to find a person in distress as quickly as possible, not only to maximise the opportunity for survival, but so that resources are available to contribute to other search and rescue operations. It is also important to note that weather conditions in search and rescue operations are often dangerous and reducing the length of a search operation also reduces the risk to search and

rescue officers and volunteers.

I note that the AVCGA have now fitted PLBs to all of the PFDs in use by their organisation.

Commander Andrew Robb, who attended the round-table meeting, advised the Court that it is a standing order within the AVCGA that “any persons travelling on a Coast Guard vessel must wear a life jacket while the vessel is under way”. For each of the 19 primary rescue

vessels operated by the Coast Guard, cach is equipped with six PLBs attached to PFDs.

A similar initiative is employed by Yachting Australia, who require that all crew members

must carry a PLB with them while they are on deck, during all category 1 and 2 races.

I would like to formally thank all those who participated in the round-table meeting and their

organisations for their cooperation and invaluable contribution to this coronial investigation.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)

connected with the death:

That Transport Safety Victoria progress the implementation of Emergency Position - Indicating Radio Beacons [EPIRB] and Personal Locator Beacons (preferably those with GPS capability), amongst recreational boaters in Victoria, to cnsure that cach vessel has an EPIRB and that, at times of heightened risk, crewmembers wear Personal Flotation Devices, with at least one Personal Flotation Device per boat being fitted with a Personal Locator Beacon

(preferably one with GPS capability).

That Transport Safety Victoria considers promoting the use of Emergency Position-Indicating

Radio Beacons and Personal Locator Beacons (preferably with GPS capability) within the

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Victorian recreational boating community, so that devices are carried by all recreational boats,

not just vessels operating further than two nautical miles from the shore.

I direct that a copy of this finding be provided to: The family of Mr Meadows Leading Senior Constable Tim Carlin, c/o O.L.C. Water Police, Victoria Police Transport Safety Victoria The Australian Maritime Safety Authority The Australian Volunteer Coast Guard Association Yachting Australia

Participants at the round-table mecting

Signature:

“Ppawos

PARESA ANTONIADIS SPANOS CORONER Date: 6 April 2015

cc. Manager, Coroners Prevention Unit

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