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Coroner urges caution for recreational boat users

Tuesday 12 July 2022

Victorian Coroner Audrey Jamieson has today urged recreational boat users to be vigilant after the deaths of three Victorian men in separate incidents in 2021. 

Coroner Jamieson said the cases highlighted the critical importance of education and competency training, with vital safety issues observed across the fatal incidents – namely operators exceeding vessel conditions, a lack of operator experience and use of personal floatation devices (PFD).

“Recreational boating is an integral part of the lifestyle of many Victorians”, said Her Honour, “all persons operating a vessel or persons onboard should be aware of the incidental risks of undertaking such activities, especially in locations that entail heightened risk.”

On 20 January 2021, Terry Chandler, a 42-year-old Nambrok man, was in deep water pulling his capsized boat in Jack Smith Lake State Game Reserve, Woodside, when a large swell hit him. Mr Chandler had limited boating experience and was intoxicated at the time of the incident. He was found unresponsive in the water with his PFD partially inflated. 

Just three days later, on 23 January 2021, David Coulter, a 58-year-old Lancefield man, drowned at Anglesea when the boat he was fishing on was hit by waves and capsized. Mr Coulter was an experienced fisherman. He was found unresponsive in an uninflated PDF. Her Honour concluded the PDF was likely not inflated due to the insufficient time Mr Coulter had to respond to the incident.  

On 8 March 2021, Michael Hanratty, a 60-year-old Nambrok man, had been fishing when his boat capsized heading into shore. Mr Hanratty was an experienced fisherman and the only one of the deceased to hold a marine licence. While Mr Hanratty had initially been wearing a PFD, he removed it sometime during the trip. He was found unconscious in the water and could not be revived.  

Coroner Jamieson concluded that whilst it was not possible to say that the use of fully inflated PFDs would have prevented the men’s deaths, the devices would have enhanced their chances of survival. 

Her Honour commended Transport Safety Victoria’s awareness campaign “Prepare to Survive: Know the Five” – “know the weather, practise getting back on, carry a distress beacon, lock in a buddy plan [and] wear a lifejacket” – and said ongoing education efforts were critical to ensuring the public are made aware of this basic but essential advice.

In the interests of public health and safety and with the aim of preventing like deaths, Her Honour has recommended that the Maritime Safety Division of Transport Safety Victoria:

  • highlight and disseminate the circumstances in which all three deaths occurred in its upcoming educational materials and safety promotional campaign. 
  • produce and disseminate awareness campaign such as the “Life Jacket Label-Read It” campaign  as advanced by the National Safe Boating Council of the United States.

Copies of the findings can be found here:

Finding into the death of Terry Chandler –

Finding into the death of David Coulter –

Finding into the death of Michael Hanratty –

Media contact: 
Claudia Hodgens 
Phone: 0407 403 371