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Chapter 3

The response to the tragedy

3.1        This chapter looks at the immediate response to the tragedy from those on and around the island, including by the community of Christmas Island and government agencies both on shore and waterborne, and the after-incident search and rescue effort that was mounted.

Rescue efforts by Christmas Island residents

3.2        Unfamiliar with the conditions and unaware that relative respite from the strong wind could be found on the east side of the island, SIEV 221 battled large swells in a bid to reach the nearest part of the island, Rocky Point. When its engine failed shortly after 5.40am and the boat began drifting toward the rocks, residents heard screams for help and gathered on the lower base of the cliff. While gesturing in vain for the boat to stay away from the rocks, residents began to throw life jackets into the water. There was nothing anyone present on the shore or the boat could do to prevent the vessel, by now completely at the mercy of the ocean, from hitting the rocks. The committee received deeply disturbing evidence of what transpired as the boat, crammed full of men, women and children, was repeatedly smashed against Christmas Island's jagged rocks by powerful waves.

3.3        Photographs taken at the time indicate that the vessel impacted rocks approximately 800 metres west of its original position when first sighted.[1] Eight Australian Federal Police (AFP) officers were stationed on Christmas Island at the time of the tragedy, and all responded. Together with officers from other agencies, on duty and off, and residents who volunteered, up to 60 people gathered on the rocks and tried their best to haul people out of the water with ropes tied to life jackets on those struggling to survive a few metres away.[2] Conditions were such that only one person, a man, managed to grab hold of the rock and scramble to safety.[3] Efforts to pull others out of the water over the rocks were unsuccessful, notwithstanding the clearly herculean efforts made by those trying to assist. Other, lighter, floatation devices thrown into the water were blown back onto the rocks, away from the people in the water, by strong winds.[4]

3.4        Jutting out from the Settlement area of Christmas Island, Rocky Point is overlooked by a number of houses and hotels. It is not an isolated spot, so it is not surprising that SIEV 221 could be seen from shore in the early hours of the morning of 15 December 2010.

3.5        Mr Raymond Murray, a resident of Rocky Point and the first person to arrive at the scene, told the committee of the powerlessness felt by those witnessing the tragedy unfolding before their eyes:

[T]here was this overwhelming feeling of helplessness. Standing right out on the edge of the rocks, there were times when that the boat was closer than you are to me now. I will never forget seeing a woman holding up a baby, obviously wanting me to take it, and not being able to do anything. It was just a feeling of absolute hopelessness. It was like it was happening in slow motion. A wave would pick the boat up and almost hit the rocks and then go back again, and then finally it was like it exploded.[5]

3.6         Mr Murray saw the boat when it was approximately 50 metres from shore. As others arrived at the scene, they grabbed as many life jackets as they could—from their own boats, parked nearby, and from local dive operators—and hurled them as far as they could into the water.[6] The committee heard that none would have escaped with their lives had it not been for the life jackets thrown from the rocks above.[7]

3.7        Many residents wanted to do more. Mr Murray articulated the particular frustration he felt as a member of the local Volunteer Marine Rescue (VMR):

I am a member of the VMR and, again, sort of feeling ridiculous that I am a member of this group that is called Volunteer Marine Rescue, and we had nothing we could do. The boat was not capable of being launched in that weather, we had no equipment or no nothing. We were a volunteer rescue group by name only.[8]

3.8        As volunteer and professional rescuers did what they could from shore, it became abundantly clear that throwing big, bulky life jackets into the water against strong winds was immensely difficult.

3.9        The committee notes that the availability of grenade life rings may have assisted those attempting to get immediate support to people in the water. The following description of grenade life rings was provided for the committee by the Department of Regional Australia, Regional Development and Local Government:

The best way I can describe them is this way: think of an old German potato masher grenade. It has got a bulbous thing, a bit of a handle on it. You throw it, it hits the water and it has a mechanism that says, 'I am in water', and it then explodes up into a life ring. It seemed a very good idea. We had not encountered them as a concept until some of the locals from the volunteer marine rescue said: 'These have come on the market. They are a good idea'—this is after the event—'We should get some'.[9]

3.10      Although it is impossible to know whether grenade life jackets would have resulted in a different outcome on the day, the committee notes that the Department has accepted advice to acquire the equipment.[10] The committee strongly supports this decision.

3.11      Although some resident volunteers described feelings of powerlessness, the critical contribution made by local residents in trying to pull people from the water was nonetheless described to the committee as nothing short of heroic:

Everyone stepped up. I had a situation where we almost had too many people wanting to help. Between Myles [Mr Miles Pickett, District Manager, Customs] and myself, once they saw us take a lead on the front groups they jumped in behind us to assist. There was certainly no shortage of people on the shoreline that day and people volunteering and wanting to know what they could do to assist...there were a couple of people who we pulled back from the edge of the rocks.[11]

3.12      A statement from a survivor, read aloud at a memorial service for the deceased, echoed this poignantly:

I don't know how to bring forward my feelings and thoughts to you. It's amazing that people who live together here have such a big heart and that everyone tried their best to help other humans. This is not just me saying this to you. It's my family, my relatives over there in Iran and here in the camp. Here on Christmas Island we have met the kindest people on Earth...From my heart I appreciate all your help. I hope this never happens again.[12]

3.13      Although Rocky Point claimed so many lives, the committee heard that more might have perished had the boat crashed at a more remote location on the island, or at a different time:

If SIEV 22l had made it to the island one hour earlier that day, one kilometre further up the coast, all hands would have been lost because there would not have been anybody there to hear people cry for help. If there were somebody there, one kilometre up is a dead zone for cell phones. It is almost fortunate that it happened where it happened because it got the greatest amount of people who could have possibly been helped on that day. If it had happened one week later, most of the residents on that part of the island would have been gone and there may not have been anywhere near as much help.[13]

3.14      The community's trauma is still apparent, and living so close to the sea makes it hard to escape reminders of the tragedy and the threat of a recurrence:

Every time there is a boat out there you worry if the weather is rough. If the weather is really rough you think, 'Is there a boat out there?' because we do not want to see this happen again.[14]

Committee view

3.15      The committee recognises the courage and selfless efforts of local residents on the day of the tragedy. The committee particularly notes the residents' quick thinking in gathering life jackets to throw into the water. Without these, many more lives would undoubtedly have been lost. The committee notes from its time on Christmas Island and evidence taken that many people who chose not to make submissions to this inquiry were nevertheless impacted deeply by this tragedy. The efforts and sacrifice of those who chose not to speak to the committee are nonetheless remembered.

3.16      Of particular note to the committee was the importance of volunteers in responding to the tragedy, but also to the daily lives of Christmas Islanders. In addition to a significant number of other actions being taken in response to the tragedy, the committee is aware that the training of volunteers in emergency management is now under active consideration by the Department of Regional Australia, Regional Development and Local Government and supports this initiative.[15]

Rescue response from government agencies

3.17      The rescue response from government agencies, including the AFP, Australian Customs and Border Protection (Customs) and the ADF, went through a number of phases. The sighting initiated a move to intercept the SIEV, which increased in tempo once it was known the SIEV had lost power. Once the vessel was reached, a search, rescue and recovery operation took place. Once survivors had been rescued, there followed a disaster victim identification process and repatriation and burial of the deceased.

3.18      The AFP takes lead responsibility for emergencies on Christmas Island. Alerts are issued through a variety of means, including VHF radio, mobile radio, and emergency locator beacons. A response appropriate to the level of urgency and weather conditions is then coordinated.[16]

3.19      The committee heard that events unfolded quickly on the day and the situation evolved rapidly from being a routine interception of a SIEV, to a distress and then a mass Safety of Life at Sea (SOLAS) situation:

We initially prepared for a boarding of the SIEV. The information we got at 0605 was were we aware of another SIEV to the north of Flying Fish Cove. We were not at that stage. So we simply made all the preparations. If they can see it, if it is in Flying Fish Cove, we obviously needed to be there for the boarding itself. As it unfolded, 20 minutes later it then became a distress, then mass SOLAS situation. Our response does not change. We always [go] into a boarding with a SOLAS in mind as the worst-case scenario. So preparations... and speed of response does not change whether it is a vessel in that position or if it is a vessel foundering. If it is 10 miles out our response will change, our tactics will change, but it is that close to the rocks, 500 yards to the coast I guess is a better term, Australian territory, that sort of concept, our response to a boarding or a SOLAS is unchanged.[17]

3.20      The committee notes that SIEV 221 moved in heavy seas towards the cliff for over 40 minutes after it was first sighted, before impacting on the rocks somewhere between 6.25am and 6.35am.[18] Authorities on Christmas Island (including the Christmas Island Chief of Police and Customs personnel) issued numerous reports of the impact between 6:29am and 6:35am, stating that the SIEV had impacted the rocks in the vicinity of Rocky Point.[19]

3.21      The Christmas Island Emergency Management Plan was activated at 6:20am following consultation between the Administrator and the AFP officer in charge on the island, Sergeant Peter Swann. The plan's activation meant that all those involved in the rescue attempt—including residents—were under direction from Sergeant Swann, who simultaneously managed the site where the incident occurred and Ethel Beach, the site where survivors and bodies of the deceased were offloaded.[20] The process at Ethel Beach is discussed in detail in the next chapter.

3.22      When the boat was first sighted the Customs National Operations Centre (CNOC) initiated standard operating procedures for a sighted vessel; that is, nearby Navy and Customs vessels were instructed to intercept and board the SIEV. They moved to do so, inhibited by the appalling weather conditions, as they would any other boat arrival. As soon as the ACV Triton was advised of the sighting, the ACV Triton and HMAS Pirie communicated and agreed that the Pirie would respond and the Triton would stay with the hulk of SIEV 220.[21] By 6:10am the Pirie had altered course to the north and commenced preparations to intercept the vessel as per standard practice.[22]

3.23      At the same time, 6:10am, Customs was advised of a report from Western Australia Police (WAPOL) Operations that two 000 calls had been received. Details of the calls indicated that a vessel was between Ashmore Islands and Christmas Island and that it may have been on fire. Staff initiated an investigation of approaches to Ashmore Island for a vessel matching that description and requested an update from the Operational Response Vessel (ORV) near the island. The response from the Ashmore Island ORV was that no sighting had been made near the island. At 6:55am the Australian Maritime Security Operations Centre (AMSOC) advised the Australian Maritime Safety Authority (AMSA) Rescue Coordination Centre (RCC) that the two 000 calls appeared to relate to the SIEV at Christmas Island.[23]

3.24      At 6:12am Customs learned that the SIEV's engine had failed.[24] Its fuel drum had gone overboard and no fuel was getting to the motor. Diesel was clearly visible in the water, and crew members could be seen persistently trying to start the motor until the battery was exhausted.[25] From this point on, the vessel's direction of movement was beyond the control of its passengers or crew.

3.25      Customs staff at Christmas Island contacted the CNOC at 6:16am and advised that the SIEV had broken down, was 100 metres offshore and that a major catastrophe was unfolding. By 6:25am, the HMAS Pirie, already en route to intercept the SIEV, was advised that the vessel had lost its engines and was drifting towards the rocks.[26] By this time officers on the Triton and the Pirie '...did not have to be told it was a SOLAS; you could work up to that.'[27]

3.26      At approximately the same time, the AFP officer in charge contacted the local hospital and asked staff to be on standby in the event of casualties.[28] The HMAS Pirie was directed to proceed at full power to the scene but was still 30 minutes away.[29] En route, the Pirie experienced an engineering fault in the port main engine and despatched her Ridged Hull Inflatable Boats (RHIBs) ahead.

3.27      ACV Triton was at this time proceeding north to take custody of the SIEV 220, which had arrived the previous day. At 6:40AM she was advised of HMAS Pirie’s problems. She then increased speed and commenced preparations to launch tenders. Attempts by onshore respondents to throw life jackets over the cliff to approximately 60 people in the water were by this time already well underway.

3.28      Both RHIBs from the HMAS Pirie arrived on scene at 7:05am and the ACV Triton’s tenders were closing on the scene by 7:14am, a rapid response given how quickly the tragedy unfolded after the SIEV was first sighted approaching the island.

3.29       The RHIBs and tenders were deployed in seas states above certification for normal operations, but their deployment was in accordance with relevant policies, processes and procedures for emergency circumstances.

3.30      The committee heard that the HMAS Pirie and ACV Triton were also conducting their  activities above operating guidelines, and that everything possible was done to save lives:

From my point of view, we were at the absolute limit of what our ship could do, so in terms of procedures or equipment there is nothing really that could be any different. What we were working with was probably beyond what it was even built for and was especially above our operational procedures. I guess in a perfect world, if you had more tenders and there had been other boats in the area, they could have been deployed and with more rigs in the water we could have taken more people on board, but with what we had I cannot see any changes that would have made a difference....

...[T]o put it in perspective, in our operational procedures we have our limit which is a sea state 3 to 4. The sea state on the day was more 7 to 8, so it was well above it. Those procedures usually get put to the side when you are talking about saving a life at sea....

...[T]hat is the thin line of risking your life to save someone else's. I think we were right on the edge of that.[30]

3.31      The rescue effort was carried out in terrible conditions, and survivors could not be easily transferred directly to the HMAS Pirie and ACV Triton, so a life-raft was launched as a staging point. Customs officers on shore acted as spotters from the cliff top, guiding the RHIBs towards possible survivors in the water.[31] Visibility was reduced to 200 yards. The RHIBs and tenders, not primarily designed for search and rescue activity in these conditions, suffered mechanical breakdowns due to ingestion of kelp and debris from the SIEV. Forty one survivors were recovered from the water.

3.32      The committee recognises that the fact that survivors, with one exception, were all pulled from the water at sea does not detract from the obvious efforts made by rescuers on shore. The committee also notes the coordination by authorities on shore, which resulted in an organised rescue effort which did itself not claim additional lives despite the significant risk posed to rescuers.

3.33      The committee recognises the pivotal role played by crews on board the HMAS Pirie and ACV Triton, and makes particular note of the efficiency of their response to rapidly unfolding events on the day. Given that the vessel was first seen just after dawn—in appalling weather conditions which severely diminished visibility—and that government vessels were not stationed near the scene of the impact overnight, the committee is impressed that rescuers managed to reach the foundering SIEV as quickly as they did.

Risks faced by rescuers

3.34      Professional and volunteer rescuers on shore and out at sea placed themselves at considerable risk on the day. This section of the report looks at some of the risks residents and agency staff took while trying to save lives.

3.35      Out on the water, rescue boats deployed from the Customs and Navy vessels were hindered by floating debris from the disintegrating SIEV. Planks of wood and a tarpaulin were among the objects which were sucked into rescue vessels' engines, hampering their ability to quickly reach people in the water. Once their engines were compromised in this way, rescue boats risked being thrown onto rocks themselves. Diesel from the SIEV, which had by now leaked into the water, coated survivors and made it harder for rescuers to grip onto them. Life jackets that were caught in debris had to be cut, in order to pull people from the sea.

3.36      The committee notes that the entire rescue operation was hampered by the same weather conditions that brought SIEV 221 onto the rocks. This not only limited rescuers' ability to reach people in the water, it also meant that decisions had to be made about the safety of crew on board the RHIBs and tenders:

Doing nothing is not an option. You cannot sit 300 yards away and watch it unfold. It certainly was a big decision for me to send the team in knowing that they were risking their lives. I did not force them to do that. Basically my instructions at Ethel Beach were: 'Get there as quickly as you can, make an assessment and do what you can.' I am not going to tell a fellow who is sitting a metre above a seven-metre wave a metre from a cliff face to keep going. If he feels unsafe or otherwise, I rely on his good judgment and training to pull back when he has found his limit. We were at those limits, but I was relying on their judgment to make the final decision that enough was enough.[32]

3.37       The committee notes that these boats were operating in conditions that could have endangered the lives of crew members on board the RHIBs and tenders, and those onshore risked slipping on sharp, uneven rocks into deep ravines and into the sea. One loss of traction followed by a blow to the head would have been all it took for a fatality.

3.38      The committee agrees with Ms Marion Grant's praise of the heroic work performed:

All on board ACV Triton and HMAS Pirie—and particularly the Customs and Border Protection and defence personnel who navigated their small vessels in such treacherous seas amongst the debris of the shipwreck and close to the very rocks that had destroyed SIEV221—put the lives on board that SIEV before their own. This was nothing short of heroic. All these officers should be recognised for their professionalism and bravery in such treacherous conditions.[33]

3.39      The committee also echoes Lieutenant General Hurly's high praise for the personnel involved:

The entire search and rescue effort was undertaken in difficult and dangerous circumstances. The crews of HMAS Pirie and ACV Triton deserve our highest praise. They put their own lives at risk in extremely dangerous circumstances to rescue 41 people from the sea.[34]

Boats available on the island

3.40      Decisions also had to be made about launching boats from the island. A number of serviceable, non-rescue Commonwealth vessels were on the island that day, as well as a large number of private vessels whose owners were part of the volunteer marine rescue service. The harbourmaster and AFP lead officer in charge on the day deemed the launching of boats from the island to be an unacceptable risk due to dangerous weather conditions, and prevented residents from doing so. The committee was told that this decision potentially saved lives, and has no reason to doubt the wisdom of the decision made.[35]

3.41      At the time of the incident the AFP considered launching a vessel it had on Christmas Island, the MV Colin Winchester. Ultimately, the AFP officer in charge decided against attempting to launch, assessing that the weather conditions were too severe and would put the lives of the crew at grave risk. This has been the subject of some scrutiny, as the AMSA had previously placed the MV Colin Winchester under limited use restrictions, calling into question its seaworthiness.[36] The committee took evidence that the vessel is not a suitable candidate for remedial modification, and will likely be replaced.[37]

3.42      The committee explored this issue thoroughly, noting that although the MV Colin Winchester had failed an annual inspection in August 2010, AMSA had granted a three-month extension to its survey approval and advised that the vessel could be launched in a SOLAS situation even after the survey certificate had expired.

Committee view

3.43      The committee agrees with the decision not to launch the vessel, and considers that it was made due to hazardous weather conditions, not because the vessel was not certified, and that the decision would have been the same had the vessel passed inspection.[38] The decision not to launch, the committee notes, is in keeping with the harbourmaster's decision not to allow other boats to be launched due to appalling weather conditions.

3.44      However, the fact that a vessel could not have assisted on 15 December does not detract from the need for the island to have a fit and permanent replacement for the Colin Winchester, and the committee took evidence on the difficulty being experienced by the Department of Regional Australia, Regional Development and Local Government in obtaining reliable expert advice on an appropriate vessel for the task. The committee wrote to the Australian Maritime Safety Authority seeking clarification on whether it was in a position to advise the Department on suitable vessels for the search and rescue role, and was told in response that it could provide such advice within the context of a procurement process.[39] This being the case, the committee urges the Department to complete the procurement process and provide for the delivery of a replacement vessel as soon as possible.

Post-incident search and recovery effort

3.45      Later that morning at 9:54am ACV Triton transferred one seriously injured survivor to HMAS Pirie which was already proceeding at best speed to Ethel Beach to offload survivors from SIEV 221. ACV Triton and her tenders continued to search for survivors. With no further survivors located in the water, the effort changed to recovering the deceased. This process lasted several days.

3.46      ACV Triton tenders recovered 28 bodies. At 1:55pm on 15 December ACV Triton reported that it was leaving the search area based on HMAS Pirie’s return with its RHIBs deployed after completing the transfer of survivors and deceased at Ethel Beach. The transfer of survivors and deceased onboard ACV Triton commenced shortly after 2:20pm, and upon completion at approximately 4:07pm ACV Triton commenced return passage to the search area. The committee notes that at this time ACV Triton continued to be responsible for the safety of the 108 persons embarked from SIEV 218 and SIEV 219.

3.47      From 11:00am until around 5:00pm, officers from Customs at Christmas Island assisted with the offloading of survivors and deceased at Ethel Beach, with the scene under the control of the AFP.

3.48      Around midday, preparations were made for an AP-3C aircraft located in Darwin to proceed to Christmas Island to contribute to the search and rescue effort, but the aircraft was forced to turn back after smoke was noticed in the cabin. It eventually made the journey the following day. While two debris fields were located, no survivors or deceased were found.

3.49      Both HMAS Pirie and ACV Triton continued searching the area until last light on 15 December, with the surface search formally suspended at 7:50pm. Both vessels repositioned to seek shelter on the lee side of the island overnight and HMAS Pirie replaced the steaming party in SIEV 220 hulk.

3.50      At dawn the following day, 16 December 2010, Customs and the Navy resumed their search and rescue operations at sea while the AFP conducted shoreline searches for the deceased, debris from the boat and material relevant to its investigations.[40] ACV Triton also reported several large pieces of wooden debris located close to the coast and later that day two further bodies were recovered.

3.51      By that time search and rescue responsibility had been handed over to the AMSA. AMSA's oversight continued until its search was ceased on 17 December 2010. The recovery phase of the operation continued for another two days, and resulted in a total of 30 bodies being found. The 20 people still missing are presumed dead.

Reliance on local divers

3.52      Due to the time it would have taken to transport professional divers to Christmas Island from mainland Australia, the AFP advised that local divers were '...contracted to undertake searches at sea' for bodies in the immediate aftermath of the tragedy:[41]

If the AFP did require the assistance of diving services, as we did on this day, they are available on island and we can use them. This really goes to the particular skill make-up, the currencies and competencies of the relatively small number of men and women who serve on island permanently and the kinds of skill sets that you want to maintain as a core competency of skill sets. As in the case with this particular tragedy, in the very first instance, because of the time frame that unfolded, we rely on the local community before we can get in the professional police divers to carry out those very difficult tasks.[42]

3.53      Two more bodies were retrieved by divers after the incident. The committee is aware that some concerns exist around this issue:

...[I]f you had had people trained up to expect the sorts of things that people had to encounter with this incident, that would have been very helpful, I am sure. I think many people have not dealt with their trauma at all well, or at all—maybe hiding from it. I reflect on why people are not coming today. Some have told me they do not want to be here. The recovery of bodies from a wreck is a pretty traumatic job, I would have thought.[43]

3.54      The committee is mindful that reliance on local divers for this function placed them in a position for which they may not have had adequate psychological preparation, but also that the retrieval of the bodies was a time-critical exercise and took place in a very remote location. The committee asked a number of questions in order to establish whether appropriate measures were taken to support the mental health needs of the divers, and mitigate the traumas the divers experienced.

3.55      Representatives of the ADF and Customs explained to the committee that neither the Triton nor the Pirie had qualified divers on board because both vessels are primarily tasked with surveillance, not rescue.[44] As such, neither has an operational need for qualified divers:

From a Customs and Border Protection point of view, it is not something that we need on board our vessels. As you have heard, diving is a particular skill set. It has quite an onerous set of competencies to be maintained. So, once you are qualified in our way of operating, there is the issue of how many diving hours you must maintain to keep your skills current. We just do not have the work for a diver to do, and we would not even be able to keep people competent to the standards if we did employ divers to come on board our vessels. There is just no mission requirement for a diver.[45]

3.56      The committee sought further clarification from the AFP on the circumstances of the local divers' involvement in the recovery operation, and on support provided for the divers after the incident. A response was sent in writing to the Committee Secretary, indicating that the divers had access to the same counselling services as the rest of the Christmas Island community:

During the recovery operation, the divers were asked through the Christmas Island Harbourmaster to assist. There was no formal contract. In effect they were asked and readily agreed and went out to help. Counselling services for the two local divers were provided immediately after the incident and on an ongoing basis by the Indian Ocean Territories Health Service. Dr Graham, in her evidence to the Committee on 7 June 2011, addressed their counselling services in some detail.[46]

The committee wishes to acknowledge the assistance provided by local divers in performing the time-critical task of searching for the deceased. The committee understands that this was necessary due to the remote location of the island, and that their work was of enormous importance to the families of the deceased. The committee believes the Indian Ocean Territories Health Service went to great lengths to identify individuals who might benefit from counselling after the event. This is outlined in Chapter 4.

Committee view

3.57        The committee believes the response by Customs, Navy and AFP on the day was a tremendous rescue effort made in atrocious circumstances. Video footage taken on the day gave the committee an insight into the enormity of the challenge posed to rescuers. Once the SIEV 221 impacted on rocks, and began to break up and people were thrown into the water so close to the jagged cliff, saving lives became a task fraught with difficulty, and saving every life an impossibility. With deep regret for every life lost that day, the committee commends the rescuers whose efforts saw 41 survivors pulled to safety.

3.58      The committee is pleased to note evidence provided from Customs that seven out of the eight recommendations contained in its comprehensive Internal Review have been implemented, and the last is in train. The committee considers that the broad acceptance and implementation of the recommendations will do much to fill in any gaps that may be apparent in retrospect, and the streamline the response to any similar emergency in the future. In giving evidence to the committee, the Deputy Chief Executive Officer of Customs submitted that:

The events of that day are well-recorded and demonstrate the bravery of those aboard HMAS Triton and HMAS Pirie, as well as the people on Christmas Island, who supported the rescue and had to deal with those of the deceased who were recovered. In response to this tragedy, Customs and Border Protection, including Border Protection Command, undertook an internal review to identify the effectiveness of the internal policy, processes or procedures used to respond to the incident. This review, which forms part of our submission, provides details of events that occurred on the morning of 15 December. The review noted that Customs and Border Protection followed and acted in accordance with its policies, processes and procedures. The internal review also looked at the lessons learned from this event and made eight recommendations. At the time we lodged our submission, five of the recommendations were fully implemented, with the remaining three underway. I am pleased to update the committee that seven of the eight recommendations are now fully implemented.[47]

3.59      The committee believes the eight recommendations listed in Customs' SIEV 221 Internal Review were appropriate and comprehensive.

3.60      In addition, on the weight of evidence provided the committee supports the findings of Customs' review and agrees that everyone involved acted in accordance with policies and processes relevant to their role. The committee believes that all applicable response, interagency communication and search and rescue procedures were followed by each agency. The committee is satisfied that interagency capabilities worked extremely well on the day, especially given the difficult conditions in which the tragedy unfolded. The committee has not come across anything in the course of its inquiry that would lead it to question the quality of the response and rescue effort mounted.

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