Safety of boats operated by government department and agencies
Sunday, 27 June 2010
When looking around the Pacific region one cannot fail to see an increasing number of small boats of various designs are being used by government departments and agencies to deliver service to its customers. Some of these departments and agencies are those that look after education, health, police, agriculture, customs and fisheries. While this initiative is commendable, a number of avoidable incidents have occurred, some with tragic results as ighlighted below.
In analysing these incidents/accidents, the following common features are noted: overloading, lack of training/incompetent operator, fatigue/poor decision-making, weather conditions, unlicensed/unsafe operation, inadequate/defective equipment, inappropriate boat design, deficient construction and regulatory confusion. When some of these factors combine they inevitably result in often preventable loss.

These departments and agencies are encouraged to liaise with the relevant authorities for advice prior to embarking on such initiatives and during current operations to improve safe delivery of service to their customers.

The Australian Transport Safety Bureau (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 six metre boat Malu Sara in Torres Strait on 15 October 2005*.

According to the final investigation report by 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 he was familiar with 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 the 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 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.

*Media Release by ATSB on Loss of DIMIA Vessel Malu Sara in Torres Strait, Queensland 19 May 2006. Full Report - publications/investigation_reports/2005/mair/mair222.aspx.


Last Updated ( Sunday, 27 June 2010 )
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