Marine safety investigations & reports

Second supplement to the independent investigation into the loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel Malu Sara in Torres Strait, Queensland on 15 October 2005

Investigation number:
Status: Completed
Investigation completed


Download Final Report
[Download  PDF: 1.84MB]

This supplementary report replaces Section 4.7 (Lost) and some conclusions and safety actions recorded in the ATSB Transport Safety Investigation Report No. 222: 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, which was released on 19 May 2006. This supplementary report has been published following the release, and subsequent analysis, of significant new information that was provider to the Coroner during the coronial inquest into the loss of Malu Sara and its five occupants on 15 October 2005 and which related to the initial search and rescue response.

This supplementary report should be read in conjunction with the original ATSB report: Loss of the DIMA vessel Malu Sara in Torres Strait Queensland

This report may contain times that differ from those associated with the same occurrence in the original ATSB report. This is the result of the evidence provided to the coronial inquest.

This report identifies the following safety issues: the lack of follow-up and reporting procedures for immigration response vessels which were not engaged on patrol activities in the Torres Strait; the lack of procedures dealing with an immigration vessel which was overdue at its destination or reported being lost; the absence of training for immigration staff in the reporting and follow-up procedures and general search and rescue overview training; search and rescue coordination responsibility for small Commonwealth vessels; and post search and rescue incident analysis practices.

This report acknowledges the actions taken by the Department of Immigration and Citizenship and the Australian Maritime Safety Authority to address the identified safety issues.

Download Final Report
[Download  PDF: 1.84MB]
General details
Date: 15 October 2005   Investigation status: Completed  
Time: UTC+10   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Torres Strait    
State: Queensland    
Release date: 24 September 2009   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Vessel Malu Sara  
Flag AUS  
Type of operation Centre console, welded plate aluminium boat  
Damage to vessel Substantial  
Departure point Saibai Island  
Departure time 1222 on 14 Oct 2005  
Destination Badu Island  
  Crew Passenger Ground Total
Fatal: 2 3 0 5
Total: 2 3 0 5
Last update 03 April 2020