ATSB TRANSPORT SAFETY INVESTIGATION REPORT Marine Occurrence Investigation No.222 Final Independent investigation into the loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel Malu Sara in Torres Strait, Queensland, Australia 15 October 2005 ATSB TRANSPORT SAFETY INVESTIGATION REPORT Marine Occurrence Investigation No. 222 Final Independent investigation into the loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel Malu Sara in Torres Strait, Queensland, Australia 15 October 2005 Released in accordance with section 25 of the Transport Safety Investigation Act Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office location: 15 Mort Street, Canberra City, Australian Capital Territory Telephone: 1800 621 372; from overseas + 61 2 6274 6590 Accident and serious incident notifi cation: 1800 011 034 (24 hours) Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474 E-mail: [email protected] Internet: www.atsb.gov.au © Australian Government 2006. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this mate- rial in unaltered form (retaining this notice). However, copyright in the material obtained from non-Commonwealth agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau. Please direct requests for further information or authorisation to: Commonwealth Copyright Administration, Copyright Law Branch Attorney-General’s Department, Robert Garran Offi ces, National Circuit, BARTON ACT 2600 www.ag.gov.au/cca ISBN and formal report title: see ‘Document retrieval information’ on page v. ii CONTENTS DOCUMENT RETRIEVAL INFORMATION v THE AUSTRALIAN TRANSPORT SAFETY BUREAU vii 1 EXECUTIVE SUMMARY 1 1.1 Background 1 1.2 Findings 1 1.3 Safety actions taken 2 1.4 Further recommendations 3 2 SOURCES OF INFORMATION 5 3 NARRATIVE 5 3.1 Malu Sara 7 3.2 Torres Strait - DIMIA operations 11 3.3 Malu Sara’s crew 13 3.4 Immigration Response Vessels 13 3.4.1 History 13 3.4.2 Management and the IRV replacement programme 14 3.4.3 Operational procedures 17 3.5 The Incident 18 3.5.1 Workshop on Saibai Island 18 3.5.2 Malu Sara’s passage from Saibai Island 21 3.6 Attempted rescue 26 3.7 The search 27 4 COMMENT AND ANALYSIS 31 4.1 The investigation 31 4.1.1 Interim recommendations 31 4.1.2 Malu Sara’s sister vessels - tests 32 4.2 The passage from Saibai Island 33 4.2.1 Passage planning 33 4.2.2 The decision to sail 35 4.2.3 Saibai Island - southbound 35 4.2.4 EPIRB activation 37 4.2.5 The sinking 38 4.2.6 Fatigue and the skipper’s decisions and perceptions 40 4.3 The DIMIA Immigration Response Vessels 42 4.3.1 Vessel tender and contract specifications 42 4.3.2 Construction 43 4.3.3 Reserve buoyancy 45 iii 4.3.4 Freeboard, stability and swamp test 46 4.3.5 Watertightness 49 4.3.6 Deck drainage arrangements 51 4.3.7 Registered length 53 4.3.8 Vessel marking 54 4.3.9 Vessel fit-out 55 4.3.10 Fuel storage arrangement 57 4.3.11 Vessel quality assurance 58 4.3.12 Equipment 60 4.4 Regulatory oversight 64 4.5 Organisational oversight 69 4.6 Crew training and certification 72 4.6.1 General 72 4.6.2 Malu Sara’s skipper 72 4.7 Lost - See Supplementary report 73 5 CONCLUSIONS 81 6 SAFETY ACTIONS TAKEN 85 6.1 Department of Immigration and Multicultural Affairs (DIMA) 85 6.2 Australian Maritime Safety Authority (AMSA) 86 6.3 Maritime Safety Queensland (MSQ) 86 7 RECOMMENDATIONS 87 8 SUBMISSIONS 89 9 MALU SARA 91 10 APPENDIX 1 - MARINE ORDERS PART 62 - COMMONWEALTH SHIPS 93 11 APPENDIX 2 - FREE SURFACE EFFECT 101 12 MEDIA RELEASE 103 iv DOCUMENT RETRIEVAL INFORMATION Report No. Publication Date No. of pages ISBN ISSN 222 May 2006 112 1 921092 48 3 1447-087X Publication Title Independent investigation into the loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel Malu Sara in Torres Strait on 15 October 2005. Prepared by Australian Transport Safety Bureau PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements The chart section in this publication is reproduced by permission of The Australian Hydrographic Service. © Commonwealth of Australia 13 October 2002. All rights reserved. Other than for the purposes of copying this publication for public use, the chart information from the chart sections may not be extracted, translated, or reduced to any electronic medium or machine readable form for incorporation into a derived product, in whole or part, without the prior written consent of the Australian Hydrographic Service. Abstract In the afternoon of 14 October 2005 the six metre Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) vessel Malu Sara was returning from Saibai Island at the northern extreme of the Torres Strait to its home community on Badu Island. During the mid afternoon, the skipper reported that he was lost in reduced visibility. There were five people on board: the two male DIMIA crew, two adult females and a four year old girl. There was no suggestion of panic or distress. With the onset of darkness, at about 1915 on 14 October, the Thursday Island Police took over coordination of the search for Malu Sara. The skipper was instructed to activate the boat’s emergency position indicating radio beacon and the boat’s position was eventually established. Later the skipper reported that he was close to an island and could see a shore light. It appeared that Malu Sara was in a sheltered position. At 0215 the skipper again made contact by satellite telephone and reported that the boat was taking on water and sinking. Despite an extensive search over six days, involving the Queensland Police Service and the Australian Maritime Safety Authority’s Rescue Coordination Centre, no trace of the boat was found. The body of one of the females on board was recovered by Indonesian fishermen near Deelder Reef about 50 nautical miles west of Malu Sara’s last known position and landed to Indonesian authorities. The body was subsequently repatriated to Australia for burial. The investigation report covers key aspects of the tragedy including the seaworthiness of Malu Sara, the equipment it carried, fatigue and decision-making and regulatory oversight. v vi THE AUSTRALIAN TRANSPORT SAFETY BUREAU The Australian Transport Safety Bureau (ATSB) is an operationally independent multi-modal Bureau within the Australian Government Department of Transport and Regional Services. ATSB investigations are independent of regulatory, operator or other external bodies. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. Accordingly, the ATSB also conducts investigations and studies of the transport system to identify underlying factors and trends that have the potential to adversely affect safety. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and, where applicable, relevant international agreements. The object of a safety investigation is to determine the circumstances to prevent other similar events. The results of these determinations form the basis for safety action, including recommendations where necessary. As with equivalent overseas organisations, the ATSB has no power to implement its recommendations. It is not the object of an investigation to determine blame or liability. However, it should be recognised that an investigation report must include factual material of sufficient weight to support the analysis and findings. That material will at times contain information reflecting on the performance of individuals and organisations, and how their actions may have contributed to the outcomes of the matter under investigation. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. While the Bureau issues recommendations to regulatory authorities, industry, or other agencies in order to address safety issues, its preference is for organisations to make safety enhancements during the course of an investigation. The Bureau is pleased to report positive safety action in its final reports rather than make formal recommendations. Recommendations may be issued in conjunction with ATSB reports or independently. A safety issue may lead to a number of similar recommendations, each issued to a different agency. The ATSB does not have the resources to carry out a full cost-benefit analysis of each safety recommendation. The cost of a recommendation must be balanced against its benefits to safety, and transport safety involves the whole community. Such analysis is a matter for the body to which the recommendation is addressed (for example, the relevant regulatory authority in aviation, marine or rail in consultation with the industry). vii viii 1 EXECUTIVE SUMMARY 1.1 Background At the time of the incident, the then Department of Immigration and Multicultural and Indigenous Affairs (DIMIA)1 operated a fleet of eight small aluminium vessels, six of which were used by Torres Strait ‘Movement Monitoring Officers’ to patrol the reefs and islands of the Torres Strait as an element in their role of monitoring persons visiting the Torres Strait ‘Protected Zone’.