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The ATSB has found that deficient boat design and construction, inadequate equipment and training, fatigue and poor decision-making, weather conditions and regulatory confusion, all combined in the tragic loss of five Torres Strait Islanders travelling on board the 6 metre boat Malu Sara in Torres Strait on 15 October 2005.

According to the final investigation report by the Australian Transport Safety Bureau (ATSB), the boat did not meet basic freeboard or stability requirements. When operating at slow speed or stopped, water flooded the boat's cockpit from the stern freeing port. The four remaining sister vessels had weather decks that were not watertight which allowed water to leak into the hull.

The skipper carried no chart and the only navigation aid with which he was familiar was a magnetic compass. There is strong circumstantial evidence that the skipper did not fully understand the use of either the outboard motors with their separate lubricating oil systems or the satellite telephone system, not having had proper training in either before embarking on the voyage. This was a tragedy waiting to happen.

Malu Sara was one of six boats built in Cairns and commissioned in late August 2005 for the then Department of Immigration and Multicultural and Indigenous Affairs (DIMIA). The ATSB found that the Commonwealth regulatory regime governing the construction and survey of the vessels did not provide sufficient clarity or unambiguous guidance. This led to some confusion by DIMIA, who did not have, or employ, the expertise necessary to prove the seaworthiness of the vessels or understand the various risks inherent in small boat operations.

On 14 October the Malu Sara, was returning from Saibai Island to its Badu Island base, a passage of about 58 miles, with four adults and one four year old child on board. In the afternoon the skipper became lost in reduced visibility. Over a period of almost eleven hours both the DIMIA duty officer and later the Queensland Police Service mission coordinator using emergency position indicating radio beacon (EPIRB) positions, attempted to guide the boat to safety. At 0215 on 15 October 2005, when Malu Sara was just seven miles from its home island, the skipper reported that the boat was taking water and was sinking.

Despite an extensive search over six days no trace of the boat or four of its five occupants was found. One body was recovered by Indonesian fishermen about 50 miles west of Malu Sara's last known position. While there is no certainty as to what happened on the passage from Saibai Island, according to the ATSB, the probability is that fatigue and disorientation in the reduced visibility led to poor decision-making. Satellite telephone position records show that from about 1930 on 14 October Malu Sara remained within 18 km of either Mabuiag or Badu Islands and spent prolonged periods in static positions, probably at anchor.

The parties concerned have implemented wide ranging safety actions to prevent any similar tragedy in the future which are documented in the ATSB report. The ATSB has also made two additional safety recommendations.

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Last update 23 May 2016