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On 2 March 2011 the Parliament established the Joint Select Committee on
the Christmas Island Tragedy to inquire into the incident on 15 December 2010
in which a suspected irregular entry vessel (SIEV) foundered on rocks at Rocky Point
on Christmas Island (CI).
The committee was asked to examine:
- operational responses of all Commonwealth agencies involved in
the response, relevant agency procedures, and inter-agency coordination;
communication mechanisms, including between Commonwealth and
- relevant onshore emergency response capabilities on Christmas
- the after-incident support provided to survivors;
the after-incident support provided to affected Christmas Island
community members, Customs, Defence and other personnel;
- having regard to the above, the effectiveness of the relevant
administrative and operational procedures and arrangements of Commonwealth
agencies in relation to the SIEV 221 incidence and its management; and
- being mindful of ongoing national security, disruption and law
enforcements efforts and the investigations taking place, and considering
appropriate information from the Australian Federal Police (AFP) and the
Australian Customs and Border Protection Service (including Border Protection
Command) to determine, to the extent that is possible, the likely point of
origin of the vessel.
The committee was also asked to consider the findings and
recommendations of the Australian Customs and Border Protection Service (Customs)
(including Border Protection Command) internal review of actions relating to
SIEV221, and the work being undertaken by the Christmas Island Emergency
Structure of the report
This report is divided into three chapters. Chapter 1 (this chapter)
sets out the administrative arrangements for the inquiry, and summarises the
findings of other inquiries into the incident. Chapter 2 sets out the
chronology of events which preceded the tragedy. Chapters 3 and 4 examine the
physical response to the tragedy, and the physical and emotional care and
support offered to survivors, workers and community members after the tragedy
occurred. Chapter 5 forms the conclusion to the report.
Roles of agencies involved
Department of Regional Australia,
Regional Development and Local Government
The Department is responsible for the provision of all State‐type services to the
Territories of Christmas Island and the Cocos (Keeling) Islands.
services are provided through Service Delivery Arrangements (SDAs) between the
Commonwealth and Western Australian (WA) Government. The WA Government manages
the provision of State‐type
services such as schools, water, sewerage and courts. As of April 2011 there
were 41 WA agencies providing services to the Commonwealth for the Territories
The cost of providing these services is completely funded by the
Commonwealth and is cost‐neutral
to WA. The SDAs with the agencies are premised on the communities of Christmas
Island and the Cocos (Keeling) Islands receiving services equivalent to those
of comparable mainland communities.
In addition to the SDAs, the Department also maintains 28 contracts for
the provision of services in the Indian Ocean Territories, including for port
and airport management. Certain services are delivered by the Department
directly, e.g. health and power services by the Indian Ocean Territories Health
Service (IOTHS) and the Indian Ocean Territories Power Authority (IOPA) respectively
– which are business units based on the islands. These services are managed by
the Indian Ocean Territories Administration located on Christmas Island.
Department of Immigration and
DIAC's role on Christmas Island centres on the processing and care of
irregular maritime arrivals (IMAs), the term used to describe people who arrive
without authority by boat. DIAC's two key contractors are Serco and
International Health and Medical Services (IHMS).
Soon after their arrival on Christmas Island, IMAs are provided with the
opportunity to contact their family/close friends to tell them that they are
safe, and the opportunity to access consular assistance. IMAs then undergo a
comprehensive and thorough assessment process, including security checking, to
establish if they have a legitimate reason for staying in Australia. IMAs are
interviewed to establish their identity, where they are from, their reasons for
being in Australia, and any reasons why they may not be able to return to their
If the departmental officer undertaking the interview considers the IMA
is raising claims which, prima facie, may engage Australia’s protection
obligations, the IMA will have their claims assessed under a non-statutory
process. If a departmental officer finds that an IMA is owed protection obligations,
and they also meet health, character and security requirements, a
recommendation is made to the Minister to allow the IMA to apply for a
Protection Visa. If an officer does not conclude that an IMA is owed
protection, the case is referred to an independent assessor. As part of this
review stage, the independent assessor will make a recommendation regarding
whether the IMA is owed protection under the Refugees Convention.
IMAs are provided with publicly funded independent advice and assistance
during the processing of their refugee claims at both the primary and review
Any IMA who is found to not be owed protection obligations is subject to
removal from Australia, and is removed as soon as practicable.
IMA clients may be transferred between immigration detention facilities
on Christmas Island and the Australian mainland to provide accommodation that
is appropriate to their individual circumstances. This includes the use of
community detention for vulnerable families and unaccompanied minors.
IMAs are managed in accordance with the Government’s Immigration Detention
Values which ensure that all people in immigration detention are treated fairly
Australian Federal Police
The AFP provides community policing services on Christmas Island.
Six sworn AFP members, three Special Constables and one unsworn AFP
employee who is also a Special Constable, perform a variety of community
policing functions including the prevention and control of crime, traffic
management and road safety, emergency management coordination and assisting
members of the community in times of emergency including land based and
maritime search and rescue. The AFP performs the role of Territory Controller
in times of declared emergency.
Regulatory functions include firearm and liquor licensing,
regulation/registration of marine vessels and driver/motor vehicle licensing.
In addition to community policing requirements, the AFP has a People
Smuggling Strike Team deployed to Christmas Island that conducts investigations
and gathers evidence in support of prosecutions of crew and
organisers/facilitators responsible for unauthorised boat arrivals.
The AFP also delivers additional resources to Christmas Island in
response to security and investigations demands such as the sinking of SIEV 221
and the response to rioting at North West Point Immigration Detention Centre in
Australian Customs and Border
Protection Service (Customs)
The Customs area relevant to this inquiry is Border Protection Command
(BPC), whose role is to detect, deter and intercept illegal activity in the
maritime domain. BPC is responsible for coordinating and controlling operations
to protect Australia's national interests against eight civil maritime security
- illegal exploitation of natural resources;
illegal activity in protected areas;
irregular maritime arrivals;
compromise to Bio-security; and
BPC is not a Search and Rescue organisation but its assets, like those
of any private and commercial organisation, can be called upon to respond to
emergencies at sea in accordance with international obligations.
The Australian maritime domain, including the Security Forces Authority Area
for which BPC has responsibility, covers an area of 11 million square nautical
miles (sqnm) and equates to around 11 percent of the Earth’s oceans. The
Australian northern waters area which BPC patrols for all eight maritime
threats, but most commonly encountering irregular maritime arrivals and illegal
foreign fishing, is approximately 1.1 million sqnm.
Australian Defence Force (ADF)/Department
of Defence (Defence)
Defence works in support of BPC to assist in protecting Australia's
borders, primarily through maritime surveillance and interception in
Australia's territorial waters and exclusive economic zone. Assets employed
include Orion P3 surveillance aircraft and Armidale-class patrol boats and a
number of other patrol and response units. In respect of people smuggling,
potential irregular immigrants are transferred to appropriate civilian agencies
by Defence personnel after their apprehension.
Conduct of the inquiry
Notice of the inquiry was posted on the committee's website and in The Australian
newspaper, calling for submissions by 27 April 2011. The committee also
advertised the inquiry in two editions of the Christmas Island newspaper, The
Islander, in English, Malay and Chinese.
The committee also directly contacted a number of interested parties,
organisations and individuals to notify them of the inquiry and to invite
submissions. A total of 22 submissions were received, as listed in Appendix 1.
The committee held public hearings in Canberra on 27 May and 16 June
2011 and on Christmas Island on 6 and 7 June 2011. A list of witnesses who
appeared is at Appendix 2. While visiting Christmas Island, the committee took
the opportunity to conduct site visits to Rocky Point, Flying Fish Cove and
Ethel Beach. This helped to contextualise the oral and written submissions it
On 17 December 2010 Customs initiated an internal review into its
actions, including BPC, related to the SIEV 221 incident. The internal review
was completed on 10 January 2011 as an initial response to the incident rather
than an in-depth inquiry.
The Administrator of Christmas and Cocos (Keeling) Islands and Chair of
the Christmas Island Emergency Management Committee (EMC), the Honourable Brian
Lacy provided draft report to the Minister on 11 January 2011 concerning the
local response to the SIEV 221 incident on 15 December 2010. The draft report
was ratified by the EMC at its meeting on 14 January 2011. The Administrator
provided the final report to the Minister on 24 January 2011.
Summaries of both the Customs and EMC inquiries are set out later in
A coronial inquest into the tragedy is currently underway in Western
Australia. The inquest will look at a number of issues surrounding the tragedy,
including whether SIEV 221 had been detected or monitored before the incident
and whether the rescue effort could have been more effective.
Findings of other inquiries
While a number of inquiries have been (and continue to be) conducted
into the circumstances surrounding the tragedy, the committee has had the
benefit of examining the findings of two inquiries in particular. This chapter
summarises the findings of those inquiries, and progress implementation of
Report of the Christmas Island Emergency
The underlying finding of Mr Lacy's report was that the response of
agencies on the island was excellent, exhibiting close cooperation and good
communication, and that the island's Emergency Plan was effective.
One issue that was identified was the availability and use of radios,
primarily due to inadequate number of handsets and knowledge of procedure. Mr
Lacy recommended better definition and training in relation to radio
frequencies and their use. Suggested measures to improve communication
Marine radio at each agency with dedicated listening officer
Handheld marine radios
Use of the community radio network
Notices on the community blackboard, and
Use of an air raid siren.
Mr Lacy also noted that management of the Christmas Island airport was
frustrated by a lack of consultation about incoming aircraft, which should have
been managed through the Territory Controller. In particular, it was found that
agencies on the mainland, seeking to provide assistance, failed to consult with
and take account of the community's needs in respect of air movements.
The report listed the following additional resources on the island:
Throwable grenade life jackets
Inflatable life rings
Hand held radios
A properly equipped rescue trailer
Mats for people to lie on after their recovery from the sea
Incident management tabards
A dedicated chiller for use as a morgue
Life rings on the shoreline
Life saving devices, toilet facilities, emergency lighting,
secure shelter and improvements to the boat ramp at Ethel Beach
A jet ski and rigid hull inflatable boat
Accident/incident familiarisation training for community members,
Upgrade of the marine rescue headquarters.
The Department of Regional Australia, Regional Development and Local
Government accepted, and have actioned all of these recommendations, with the
exception of the following:
lighting, toilets and shelter at Ethel Beach, on the basis that
the beach should be used only in daylight emergency conditions;
the purchase of a rigid hull inflatable boat, on the basis that
the planned upgrade of existing boats will render the purchase unnecessary.
While not declining the recommendation to procure a jet ski outright,
the Department undertook to evaluate the suitability of a rescue vessel such as
a jet ski for use in the seas around the island.
The committee has assessed the Department's response to the
recommendations, and considers it appropriate.
Customs' internal review
On 17 December 2010, the Chief Executive Officer of Customs ordered an
internal review of the SIEV 221 incident to be conducted by the Acting National
Director of Enforcement and Investigations, Ms Sharon Nyakuengama. The Report
was delivered on 10 January 2011.
The report concluded that:
neither Customs, nor BPC appear to have had any actionable intelligence
that would indicate that the vessel that foundered at Christmas Island on 15 December
2010 had departed Indonesia or was likely to arrive at Christmas around that
the positioning of the Customs and ADF vessels on the morning of
15 December 2010 was in accordance with the relevant policies, processes
notifications relating to SIEV 221, first as a Contact of
Interest (COI) and then as a vessel in distress, were on the whole made and
dealt with in accordance with the relevant policies, processes and procedures, and
the individual work areas appear to have acted in an appropriate manner
demonstrating good judgement;
safety equipment held onboard HMAS Pirie was in accordance
with Navy requirements and that held onboard Australian Customs Vessel (ACV) Triton
was in accordance with her certification. All equipment was serviceable and
crew were appropriately trained in its operation;
HMAS Pirie’s small rigid hull inflatable boats (RHIBs) and
ACV Triton’s tenders were deployed in seas states above certification for
normal operations. This deployment was in accordance with relevant policies, processes
and procedures for emergency circumstances. The RHIBs and tenders experienced
engine difficulties due to intake of kelp and debris from SIEV 221 but the
crews appear to have acted appropriately to quickly rectify problems and return
to the Search and Rescue (SAR) effort as soon as practicable;
a variety of communications equipment was used at Christmas
Island to coordinate activities, and the reported success rate of these communications
devices was varied; and
critical Incident Guidelines, the Occupational Health and Safety
Risk Management Practice Statement, and associated Counselling and Employee
Assistance Program Instruction and Guidelines were applied to provide support
to officers involved in the incident at the earliest opportunity given the
remote location of the incident.
The internal review made eight recommendations, which are set out below
together with a summary of the action taken to implement each of them.
That, as part of the normal border command operational
planning cycle, the operational polices, processes and procedures informing the
posture of assets be reviewed in light of the current number of irregular
The changes made include:
building in greater flexibility (within contractual limitations)
for the planning of aerial surveillance deployments, by making changes to the
mix of aircraft undertaking surveillance in some areas to release AP-3C
surveillance capability to undertake increased flights to Christmas Island;
planning through a 'rolling' structure to enable the process to
be more responsive to operational feedback;
improving up front planning by ensuring all guidance is included
in the asset planning process; and
Enhancing the integration of assets to deliver the stated outcomes.
That the trial of a land based radar surveillance system
of the northern maritime approaches to Christmas Island be completed and
considered as a priority.
Work on the concept for a radar trial at Christmas Island began in July 2010,
as a measure to assess whether a radar on Christmas Island would enable better use
of aircraft and vessels in this area. There were fears that radar surveillance
may have limited capability, particularly in high seas and bad weather. The
trial was established to test assumptions about the benefits and limitations of
such an approach to surveillance.
The field testing phase of the trial began in early February 2011 and was
scheduled to conclude with site remediation by 30 June 2011 and the evaluation
report by 1 August 2011. During the first Canberra hearing, Customs advised the
committee that it planned to extend the radar trial beyond 30 June 2011. The
extension will give Customs 'the opportunity to test some different hardware
and further develop the software by gathering data from the monsoonal season'.
Integral to the effectiveness of the system is sophisticated software
which can analyse the radar signal and determine if the object is travelling at
a constant speed and in a single direction – this is tracking the object. Only
by tracking the radar targets over several minutes can small vessels be
detected in heavy seas. The software incorporated in the trial radars is being
The radar picture of the marine environment around Christmas Island is extremely
complicated, as it results from a range of objects including waves, clouds and
birds, as well as vessels. Simply detecting an object with the radar is not
sufficient to identify it as a small boat.
In calm seas, trial radar has detected a large merchant vessel out to the
radar horizon – the theoretical limit of detection for radars at this height
which is 35 nautical miles (nm). However it should be noted that this detection
involved the radar tracking the vessel from the time it left port at Christmas
Island to the limits of the radar capability. This does not necessarily suggest
that the radar would have detected the vessel out at 35 nm unalerted.
As well, the RHIBs used by Armidale Class Patrol Boats (ACPB) have been
monitored out to distances greater than 10 nm using the ACPB as a reference
point. Again there is no guarantee this could be achieved without being
As at the date of Customs' submission, no SIEVs have been detected, but,
on two occasions after SIEVs were apprehended, a subsequent analysis of the raw
radar data showed that each was seen by the radars even though the detection
and tracking software was not able to identify the contacts as a vessel. These
sightings occurred in relatively calm seas (low to moderate Sea State and
insignificant to low swell) and good weather conditions.
Radar performance in heavier seas will be assessed in the subsequent test
program using calibrated radar targets, which will provide a baseline to assist
the performance specification of any follow-on system.
That the current arrangements for reporting of incidents
(including sightings of SIEVs by non border command personnel) to the Customs
National Operations Centre (CNOC), and CNOC’s responsibilities for transferring
information of relevance to Australian Maritime Security Operations Centre’s (AMSOC)
responsibilities, be confirmed and reinforced.
On 24 January 2011 immediate steps were taken to reinforce to officers existing
reporting arrangements for reporting of sightings of COI (other than by BPC
assets) to CNOC, who in turn advise the AMSOC.
This initial advice was subsequently formalised by an Instruction and Guideline
(I&G) on 'CNOC Operations' which replaced the extant instructions from 2007,
which required updating.
Another I&G on 'Reporting of and response to possible SIEVs
including onshore arrivals' has been finalised, and was informed by the debrief
noted in a later Recommendation. This I&G includes provision for regional
officers to maintain their operational readiness and assist in operational
planning. Key responsibilities are outlined in order to assist land based
Customs officers with the actions that should be performed in the event of a
SIEV arrival. The I&Gs were approved on 21 April 2011.
That, in collaboration with relevant agencies, specific
procedures be developed, documented and exercised for dealing with SIEVs
arriving directly at Christmas Island in severe weather conditions.
While Customs already has in place Critical Incident Guidelines which
apply to all areas of the agency’s business for reporting of incidents and significant
operational matters, there is no procedure specifically tailored for reporting
among agencies on Christmas Island.
The Department of Regional Australia, Regional Development and Local
Government promulgated a draft Emergency Management Plan for the Territory of
Christmas Island, which details the emergency prevention, preparedness and
response arrangements for the island. The Plan identifies the AFP as the
designated organisation for the management of all incidents in the Indian Ocean
Officers on Christmas Island have reviewed these existing arrangements contained
within the draft plan and have separately documented a contact list specific to
the agencies with responsibilities and capabilities that would support search
and rescue responses to a SIEV arriving directly at Christmas Island in severe
Customs conducted a multi-agency exercise on Christmas Island in May
2011 to assess and validate the contact list and agency responsibilities, to
further inform the draft Plan.
That both an officer level de-brief of this incident and
ongoing desktop activities be conducted to further enhance interagency command
and control capabilities relevant to such an incident.
This has been implemented, with debriefs completed and the program of
ongoing desktop activities commencing on 13 May 2011. Following is a summary of
the outcomes of the de-briefs, which took place in Darwin and Canberra.
Command and control, and in particular uncertainty about
the when an activity ceases to be a border protection operation and becomes a
search and rescue operation, and the command and control structure once a
safety of life at sea (SOLAS) event is underway. Two actions were identified to
enhance command and control which aim to ensure the transition of command responsibility
in such incidents is clearly identified and communicated to all relevant
parties. These were:
The formalisation of on-scene commander arrangements for Customs assets
through the production and distribution of a Customs Marine Unit Notice, a
draft of which was under consideration at the time of Customs' submission;
Preparation of an I&G regarding operational interaction with
AMSA, including SIEV SOLAS incidents, which was due to be implemented in April
The production and distribution of an Operational Notice to make
Customs staff aware of the need to keep calls to the AMSOC to a minimum during
times of high workload.
Communications, in particular the confusion arising from
the 000 calls, challenges in radio communications at the scene, and the
importance of recording calls to AMSOC. These issues were addressed and
responded to through the implementation of other recommendations in the review.
Systems, in particular the refinement of guidelines and
instructions on the keeping of logs, and the possibility of providing real-time
chat facilities between Customs vessels.
Staffing, the conclusion being that employee assistance
provided in the period after the tragedy was beneficial and well utilised, and
that further ability to provide short-term 'surge' staffing in AMSOC during
busy periods would be beneficial. Participants also supported the introduction
of a Crisis Action Team (CAT) in AMSOC to manage one-off critical incidents,
freeing up other staff to manage normal border protection operations. A
feasibility study for a CAT is in train.
That the procedural documentation for tender operations
in ACV Triton be revised.
ACV Triton's extant procedures were subsequently reviewed,
amended and trialled at sea in conjunction with the new response tenders. These
trials incurred some delays due to poor weather and high operational tempo,
however they were finalised and promulgated on 31 March 2011.
That communication protocols and procedures between
Customs and Border Protection at Christmas Island and BPC response vessels
should be reviewed.
The BPC Communications Plan (COMPLAN) was amended to cover communication
channels with Customs officers on Christmas Island, and further amendment is
expected. In addition, a new I&G was developed detailing existing
communication equipment, channels and radio call signs, as well as the specific
circumstances for communication between officers on Christmas Island and BPC
Further principles based instructions, that allow for flexibility in emergencies,
and provide guidance as to how to establish emergency communications networks
locally when necessary, will be developed to complement this I&G.
Officers on Christmas Island have undertaken an audit and identified the
technical capabilities and limitations of communications equipment currently
held on Christmas Island. Additional work has now commenced on documenting
clear business requirements which will inform a technical capability gap
analysis between what is currently available and the specified business
As an interim measure to address equipment availability issues, four Ultra
High Frequency (UHF) handsets have been deployed to Christmas Island.
Deployment of the handsets is being accompanied by appropriate instruction in technical
use and procedures.
That critical incident support follow-up activity
continues to monitor the ongoing safety, health and wellbeing of officers
directly involved in the incident.
Support was offered to officers and their families immediately after the
tragedy. This included provision of numerous support staff and counsellors on
Christmas Island from 15 December 2010 to 20 December 2010, and follow up
support in Fremantle, to where officers involved in the tragedy had returned.
Wellbeing interviews commenced early in January, and all staff were cleared for
A psychologist returned to Christmas Island over 6–8 February 2011 following
a request for additional support on the Island for employees and families. A
further visit occurred over 3–8 March 2011, to provide support and to attend
the Memorial Service for the deceased from SIEV 221. During the visit, counselling
support was provided to employees and their families on the island and to
marine staff from ACV Triton then embarked in the ACV Ocean Protector,
which was at Christmas Island at the time.
In addition, a coordinated legal support effort is being made available
to those officers required to give evidence at formal proceedings to ensure they
are informed, prepared and supported during this phase. Additional strategies
are also being implemented for remaining staff who had involvement in the
incident due the anticipated heightened media attention generated by the WA
Coroner’s Inquest hearings.
The committee thanks all those who contributed to the inquiry by making
submissions, providing additional information or appearing before it to give
Note on references
References in this report to the Hansard for the public hearings are to
the proof Hansard. Please note that page numbers may vary between the proof and
the official transcripts.
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