A group of professional ice skaters, judges and their families were on a late night cruise when their boat, the Merinda, and a HarbourCat ferry, the Pam Burridge, collided under the bridge on March 28, 2007.

Deputy State Coroner Hugh Dillon said the crash, which left the Merinda torn in half, was the result of both individual and systemic failure.

Skating star Morgan Innes, 14, elite skating judge Simone Moore, NSW Ice Skating Association president Alan Blinn, and Mr Blinn’s friend James Engert were killed in the crash.

Mr Dillon told Glebe Coroners Court in Sydney conditions on the night had been “near perfect” and that neither the crew of the Merinda nor of the Pam Burridge kept a proper lookout.

He found the Merinda did not have any navigation lights on at the time of the crash and that the Pam Burridge had been speeding, although he could not determine by how much.

Mr Dillon made 24 recommendations, including a night speed limit for ferries on the harbour and for Sydney Ferries to review its safety culture.

Where possible, Mr Dillon advocated that radio traffic generated by Sydney Ferries also be recorded and archived for a suitable period, along with a “unified national regulatory approach” to boat lighting and licensing.

The recommendations also put forward the need for an online complaints section for the NSW Maritime website where boat operators can report “serious breaches of marine rules and legislation”.