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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.

Supplementary Report - Lost (2009)

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