The skipper of a prawn trawler that sank off WA's Pilbara coast played a role in his own death and the demise of two young crew by modifying the vessel so it became unstable, which was not detected by a Department of Transport surveyor, a coroner has concluded.
While the last contact with the crew of the 13-metre trawler The Returner was July 11, 2015, water police were only advised Mason Carter, 26, Chad Fairley, 30, and 57-year-old skipper Murray Turner were missing four days later when they failed to return to Point Samson as scheduled.
After an extensive search, Mr Turner's body was recovered along with the vessel but the other two men have not been found.
The WA Coroner's Court heard that after Mr Turner bought the second-hand boat, he made various modifications but failed to disclose some of the changes - most notably removing a large amount of ballast - to the surveyor.
Coroner Sarah Linton speculated he may have omitted the crucial information for fear the boat would be required to undergo a costly stability test.
"I have found that Mr Turner played a role in his own demise as he took responsibility for significantly modifying The Returner and did not disclose the full extent of those modifications during the survey process," the coroner said.
She said she didn't believe he would have deliberately put his life and the lives of his two young deckhands at risk, but did not have enough expertise to appreciate the changes he'd made to the vessel's weight had upset its centre of gravity.
While the surveyor was not told the full extent of the changes, he was aware the vessel had been substantially altered, so his decision not to require The Returner to undergo a stability test was unreasonable, Ms Linton said.
She said there was no realistic chance that any of the men would be found alive by the time the Department of Fisheries raised the alarm they were missing, despite losing contact with The Returner through its vessel monitoring system days earlier.
The coroner made five recommendations, including making it mandatory for all vessels to carry emergency beacon systems that automatically deploy when immersed in water.
She also noted safety culture on commercial fishing vessels needed to improve, saying life jackets should be worn, but most in the industry don't.