OFFICE OF THE STATE CORONER FINDING OF INQUEST CITATION: Inquest into the loss of the Malu Sara TITLE OF COURT: Coroner’s Court JURISDICTION: Thursday Island FILE NO(s): COR 592/06(4), 593/06(1), 594/06(7), 595/06(3) & 2766/05(1) DELIVERED ON: 12 February 2009 DELIVERED AT: Thursday Island HEARING DATE(s): 15/2/07, 13/4/07, 16-26/4/07, 10/5/07, 27/7/07, 20/8-6/9/07 & 13/6/08 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: Inquest, DIAC procurement procedures, AMSA survey regime, MSQ boat builder accreditation regime, QPS and ATSB investigation methods REPRESENTATION: Counsel Assisting: Mr Mark Gynther Family of Mr Wilfred Baira: Ms Tracy Fantin (instructed by Wettenhall Silva Solicitors) Families of Flora & Ethena Enosa, Ted Harry & Valerie Saub: Mr Mark Green (instructed by Legal Aid Queensland) Maritime Safety Qld: Mr Jeff Hardy (instructed by MSQ) Australian Transport Safety Bureau: Mr Ron Ashton (instructed by Minter Ellison Lawyers) Australian Maritime Safety Authority: Mr Peter Dunning SC with Ms Rachel Pepper (instructed by AMSA Solicitors) Department of Immigration & Citizenship: Mr Ralph Devlin SC with Mr Mark LeGrand (instructed by Clayton Utz Lawyers) QPS Commissioner: Mr Wayne Kelly (QPS Solicitors) Mr Don Radke: Mr Kevin Priestly (Corsetti Lawyers) Mr Gary Chaston: Mr Michael Fellows (instructed by Farrellys Lawyers) Sergeant Warren Flegg: Mr Steve Zillman (instructed by Gilshenan & Luton) Mr Jerry Stephen: Mr Ryan Ellis (MacDonnells Lawyers) Part 1 – Jurisdiction, investigations and inquest Distribution of these findings....................................................................1 Introduction and jurisdiction .....................................................................1 Issues to be considered ...........................................................................2 Investigations...........................................................................................2 Police investigation ..................................................................................3 Australian Transport Safety Bureau Investigation....................................3 Post-incident “de-brief”.............................................................................4 Evidence and standard of proof ...............................................................5 The inquest ..............................................................................................5 Pre – inquest conference .........................................................................5 The hearing..............................................................................................5 Transcript references ...............................................................................6 Findings ...................................................................................................6 ii. Part 2 – The social and political context Background – the geopolitical setting ......................................................7 The Torres Strait......................................................................................7 The Torres Strait Treaty...........................................................................8 Movement monitoring officers..................................................................8 The Department’s Torres Strait workforce in 2005...................................9 Languages of the Torres Strait ..............................................................10 Searching for “truth” in a cross cultural setting.......................................10 Part 3 - The acquisition of the IRVs The need for new boats .........................................................................13 Production boats or custom built............................................................13 Scoping the boats and settling specifications ........................................13 Regulatory provisions of the request for tender .....................................17 Assessment of tenders ..........................................................................18 Contractual issues of concern................................................................21 Accreditation issues ...............................................................................22 Building and testing of the boats............................................................23 The delivery of the prototype .................................................................27 Safety and navigation equipment...........................................................29 Certificates to be given by builder..........................................................32 The registration and survey of the vessels.............................................34 The statutory regime..............................................................................34 The application of the regime to the IRVs ..............................................39 The delivery and commissioning of the boats ........................................43 Findings .................................................................................................44 Part 4 – Training of MMOs, SOPs and service of the IRVs Training of the skippers..........................................................................47 Mr Baira’s marine qualifications .............................................................49 The vessels go into service....................................................................49 The standard operating procedures.......................................................51 Findings .................................................................................................52 Part 5 - The Saibai Island workshop Planning for the workshop .....................................................................54 The voyage to Saibai .............................................................................55 Training at the workshop........................................................................55 Problems with the Malu Sara on Saibai .................................................56 Other events at the workshop ................................................................57 Who made the decision to undertake the incident voyage?...................57 The carrying of passengers on the incident voyage...............................58 Findings .................................................................................................60 Part 6 - The incident voyage Activities prior to departure ....................................................................61 The decision to sail ................................................................................62 The initial leg..........................................................................................63 The boat becomes lost...........................................................................64 QPS SARMC becomes involved............................................................65 Findings .................................................................................................71 Part 7 – The search VMR becomes involved .........................................................................73 Air support is approved..........................................................................76 AusSAR accepts responsibility ..............................................................77 Searching continues ..............................................................................77 Sighting of a survivor .............................................................................78 Survivability times ..................................................................................80 Critique of the search.............................................................................81 Expert evidence .....................................................................................81 The regulatory framework ......................................................................82 Delay in deploying aircraft......................................................................83 Failure to investigate other search assets..............................................85 “Non confirmed” sightings ......................................................................86 Findings .................................................................................................86 Part 8 - Findings required by s45(1)&(2) Identity of the deceased:........................................................................89 Place of death:.......................................................................................92 Date of death: ........................................................................................92 Cause of death:......................................................................................92 Part 9 - Recommendations i. Review of SARMC training ............................................................93 ii. SARMC to task rescue helicopter ..................................................93 iii. Independent investigation of SARMC’s performance ....................93 iv. Review of DIAC’s procurement policies.........................................93 v. Rescission of MSQ’s boat builder and designer accreditation .......93 vi. Review of AMSA’s paper based boat surveys ...............................94 vii. Vessels, equipment and training for MMOs ...................................94 viii. DIAC Torres Strait emergency response plan ...............................94