Previously released report 19 May 2006
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.
Supplementary Report PDF 3.0Mb
Reopening the ATSB investigation
In the second half of 2007, a coronial inquest into the deaths of the five persons on board Malu Sara was held on Thursday Island. The findings of the inquest were handed down by the Queensland coroner on 12 February 2009.
During the inquest, the SMC provided evidence to the coroner which showed that the actions of, and the communications between, the two search and rescue agencies involved in the search response during the night of 14 October, were not as effective as they should have been. The evidence concerned crucial information regarding the state of Malu Sara at 0220 on 15 October not being passed on, the mistaken assumption regarding the availability of a well equipped helicopter in the Torres Strait region early in the incident, and the apparent reluctance to source and dispatch a search aircraft.
These actions and communications deficiencies consequently had a significant impact on the final outcome of the incident.
This significant evidence was not provided to the ATSB during the initial safety investigation in 2005-06. For the purpose of correcting the public record which was contained in the initial safety investigation report, the ATSB reopened the investigation in the latter part of 2008.
This supplementary report is the result of the reopened investigation and examines the evidence surrounding the initial search and rescue response, as provided to the coronial inquest. It replaces Section 4.7 (Lost) and some conclusions and safety actions recorded in the ATSB Transport Safety Report No. 222.
The on-line version of the initial report has been modified to reflect the subsequent changes.
|Date:||15 October 2005||Investigation status:||Completed|
|Release date:||19 May 2006||Occurrence category:||Serious Incident|
|Report status:||Final||Highest injury level:||Fatal|
|Type of operation||Centre console, welded plate aluminium boat|
|Damage to vessel||Substantial|
|Departure point||Saibai Island|
|Departure time||1222 on 14 Oct 2005|