CHAPTER 2 - BACKGROUND AND EVIDENCE TO THE INQUIRY
Introduction
2.1
The following chapter outlines the background and
events that led to the Committees inquiry into the role of AusSAR in the
search for the Margaret J and
crew. It will provide an overview of the
vessels movements and the timeline of the voyage and foundering. The chapter also examines the salient issues arising
from the coronial inquest into the deaths of the crew and in evidence to this
inquiry.
The Margaret J
2.2
The fishing vessel Margaret
J departed from its home port of Ulverstone,
Tasmania on 7 April 2001 and sailed to Stanley
on the first leg of a planned fishing trip.
The vessel carried two crew members, Mr Hill and Mr
Giles, and collected a third, Mr
Kirkpatrick, at Stanley. [5]
2.3
The vessel left Stanley
on 9 April 2001 with the
intention of sailing to and fishing around Robins
Island.[6]
2.4
The crew planned to return to Ulverstone via Stanley
on 12 April 2001. The Margaret J failed to return and was reported as
overdue on 13 April 2001.[7]
2.5
The Coroners report notes the lack of direct evidence
in establishing the circumstances surrounding the foundering of the Margaret J. The Coroners findings were based on
circumstantial evidence and the probable circumstances in which the vessel sank
and the three men aboard lost their lives.
2.6
The Coroner found that the Margaret J sank on its
day of departure, 9 April 2001. The Coroner also found that the three crew members
launched and entered the vessels life raft at that time. He estimated the probable time of sinking as
approximately 11:27am, based on a
mobile phone call made by one of the crew and the time at which a recovered
clock had stopped. No radio contact was
made and neither of the two Emergency Position Indicating Radio Beacons (EPIRBs)
on board the vessel was activated. [8]
The Search for the Margaret J
2.7
Before embarking on a chronology of events with regard
to the search in question, it is useful to refer to the division of
responsibility between state and Commonwealth agencies when a search and rescue
operation is initiated.
2.8
The agreed demarcation of responsibilities, reflected
in the National Search and Rescue Manual (the Manual), holds that state
authorities are responsible for coordinating searches and rescue operations for
fishing boat or pleasure craft crew. This is confirmed in a specific search and
rescue agreement between the Commonwealth and Tasmania.[9]
2.9
The protocol for transferring responsibility for
coordinating search and rescue operations is the subject of further discussion
later in the report.
2.10
In accordance with this division of responsibilities, Tasmania
Police coordinated the initial search for the Margaret J.
On 13 April 2001, Tasmania
Police authorised an aerial search from Smithton to Cape
Grim. An additional aerial search was organised by
the friends and family of Mr Kirkpatrick. The search area covered the coastline between
Smithton and Cape Grim,
all rocky outcrops and islands including Trefoil
Island, Steep Head, South Black
Rock, Albatross, Bird, Stack, Hunter, Three Hummock,
Walker
and Robbins Islands
and Penguin Islet.[10]
2.11
On 14 April
2001, two aircraft and one helicopter searched the same area and
extended the search eastwards. The Tasmania
Police vessel Van Diemen searched the
Hunter Island
group of islands.[11]
2.12
On 15 April
2001, police vessels continued to search south to Studlands
Bay and north to the western side
of Hunter Island
and other offshore islands to the west. At
approximately 10.30pm on 15 April,
Tasmania Police suspended the search until "further information was
available".[12]
2.13
The decision to suspend the search on 15 April 2001 was based on AusSARs
response to a facsimile from Tasmania Police outlining the search procedures to
date and requesting assistance to search the greater Bass Strait
area.
2.14
AusSARs reply stated:
Search actions detailed in Ref A [Tasmania
police description of search] fully supported. However, in view of length of
time vessel has now been missing (6 days) consider further search activity
impractical due to size of potential search area and little likelihood that
persons in the water would have survived.
Based on Ref A, consider police search would have located the vessel or
survivors had they been in the police search area. It is noted that vessel had the means to
communicate a distress situation had it been able to; namely, HF and VHF radios
and an EPIRB. No confirmed beacon has
been detected in the area over the last week.
In the absence of further intelligence AusSAR does not intend conducting
a search of the greater Bass Strait.[13]
2.15
On 16 April
2001, the Margaret J was located in approximately 15 metres
of water by a passing aircraft. Tasmania
Police conducted a search of the vessel, specifically searching for the bodies
of the crew. Information supplied to
police regarding the existence of a life raft was not conveyed to police divers.[14]
2.16
On 17 April
2001, Tasmania Police requested information on drift patterns from
AusSAR. The information provided
indicated a minimum possible search area of 50 000 square nautical miles. AusSAR advised Tasmania Police that:
it would not be possible to search an area of this size because
we could not get enough search aircraft to cover the minimum area in one
day. Typically it would take over 100
aircraft (with track spacing of one nautical mile), each doing a four hour
sortie and if this was not achieved it would take even more aircraft each
subsequent day because the search area will continue to grow with the extra
drift time.
AusSAR recommends that without some specific new information to
indicate that the missing men are actually in the life raft or some information
about the location of the life raft that it is not possible to mount a
realistic search effort.[15]
2.17
Based on this advice from AusSAR,
Tasmania Police again suspended the search
for the crew of the Margaret J.[16]
2.18
The Margaret J was
salvaged on 30 April 2001 and,
following a review of the available evidence and at the request of Tasmania
Police, AusSAR assumed responsibility for the search coordination that afternoon.[17] It was then determined that a search of the
uninhabited islands around Flinders Island
should be undertaken.[18]
2.19
On 2 May 2001,
the life raft from the Margaret J and the
body of one crew member was located on Prime
Seal Island. A second body was located on Flinders
Island. The body of Mr
Kirkpatrick was not found.[19]
Issues
2.20
The primary issues raised in evidence to this inquiry pertained
to:
(a)
The life-saving potential of a better coordinated and
more effective search and rescue effort following reports of the missing Margaret J crew;
(b)
The effectiveness of communication between AusSAR and
the Tasmanian Police, particularly with regard to the transfer of
responsibility for search and rescue coordination from State to Commonwealth
authorities; and
(c)
The accuracy and effectiveness of AusSARs information
recording and documentation procedures.
Survival prospects for the crew of the Margaret J
2.21
The Coroner found, on the basis of the limited evidence
available, that the three crew members died on 11 April 2001.[20] In relation
to the possibility of a more effective coordination of the rescue effort saving
the lives of the crew, he stated that:
I am satisfied that at the time the matter was first reported to
police (13 April 2001), the
crew of the Margaret J
had perished.
It therefore follows that a search of the waters to the east of
what was subsequently identified as the splash point[21] would not
have saved the lives of the three (3) men.
I further find that it would not have been reasonable to expect
that a search should have been undertaken further to the east in the initial
stages of the search due to the lack of communication from the vessel and the
absence of a splash point.
To suggest that a large number of planes should have been
launched for a vessel that may or may not have sunk, for a life raft that may
or may not have been launched, would have been placing the lives of a number of
searchers at risk. Such a risk in the overall circumstances was not warranted.[22]
2.22
The Committee notes the evidence of forensic
pathologist Dr Kelsall
to the coronial inquiry estimating the time of death of Mr Hill as between 9-16
April and that of Mr
Giles between 16-27 April 2001.[23] In evidence
to the Committee the CEO of AMSA, Mr Davidson,
interpreted Dr Kelsalls
evidence as follows:
My understanding of it is that what the pathologists concluded
was from an examination of the bodies. That was the period that they could
determine, as best they could, the time of death given the evidence in front
of them. Other factors had to be brought to bear in order to refine that, and
that was indeed what the coroner did.[24]
2.23
In his evidence to the Committee, local marine expert Mr
Jim Hooper stated
that the men would have lived beyond April 11. He based this assertion on the
resilience of the life raft, which he had recently serviced, the quantity of
rations that had been consumed by the crew and his estimation of the warmer
water temperature in Bass Strait at that time of the
year.[25]
Communication between authorities and transfer of responsibility
2.24
Early communications between the Tasmanian Police and
AusSAR focussed on seeking advice as to a potential search area based on the
likely drift of the missing crew. AusSARs refusal to attempt to calculate a drift
pattern on April 13 was addressed by the Coroner, stating that:
In respect of the request for the drift pattern, Mr
Adrian Johnson,
an AusSAR officer, indicated without a reliable splash point the figures would
be meaningless, and I have no hesitation in accepting this statement. At this
point in time the vessel could have been anywhere, and without basic
information of a last sighting or position, it would be impossible to calculate
the effects of wind or current on a vessel.[26]
2.25
Under the relevant 1977 search and rescue agreement
between Tasmania and the
Commonwealth, transferring responsibility from Tasmanian authorities to AusSAR occurs,
"should an operation which is the responsibility of [Tasmanian] Authority
overreach that Authoritys capacity, responsibility will be transferred to, and
accepted by, the Commonwealth Authority".[27]
2.26
The Committee notes that this 1977 arrangement was not
as clearly defined as that with other states under the same agreement, whereby
a transfer of responsibility occurs by mutual agreement as to overreached
capabilities.[28]
2.27
On 13 April 2001
an AusSAR officer explained this arrangement to Tasmania Police, who had just
received report of the missing vessel, indicating that AusSAR would take over
only after an adequate search had been undertaken and Police resources would
not allow a more extensive search.[29]
2.28
The Committee finds that a transfer of responsibility
consistent with the search and rescue agreement between Tasmania
and the Commonwealth could have been effected on 15 April 2001. It is clear that an intended transfer
request from Tasmania Police was thwarted by AusSARs reluctance to assume
responsibility for coordination of the search for the Margaret J.[30]
2.29
In relation to a recorded telephone conversation
between Mr Lloyd of AusSAR and Constable Archer of Tasmania Police on 15 April
2001, relating to a Tasmania Police request for assistance, the Coroner notes:
... Constable Archer was taken by surprise by the approach of Mr
Lloyd and does not proceed with what was his obvious intention, of transferring
coordination to AusSAR.[31]
2.30
In a response to a question taken on notice from the
Committee about this matter, AMSA said:
The Police facsimile asked for assistance with a search of the Bass
Strait area. AusSAR responded by facsimile ... indicating that
AusSAR fully supported the Police search actions but concluded that further
search activity was impractical given the length of time (six days) since the
vessel was last sighted because of the size of the search area and the little
likelihood of survival of anyone in the water. AusSAR noted that no
communication had been received although the vessel had a radio and distress
beacon. In the absence of further intelligence AusSAR advised that it was not
intending to search the greater Bass Strait.[32]
2.31
The Committee notes AMSAs statement that Tasmania
Police "asked for assistance with a search of Bass Strait".
While this may have not constituted a direct request for a transfer of
responsibility, it suggests that as of April 15 the Tasmania Police
communicated to AusSAR that the search effort had gone beyond their operational
capacity.
2.32
The clearest opportunity for the transfer of
responsibility occurred on 17 April 2001, the day after the sunken
vessel was located (and consequently a splash point had been identified). On
this occasion advice was sought from AusSAR on possible drift patterns and a
likely search area (see paragraph 2.16).
2.33
In evidence to the Committee, Tasmania Police officers indicated
that they were unable to conduct a search of the magnitude required to locate
the missing life raft:
We were positioned and capable of conducting coastal searches,
which we had done to that point. When you are getting involved in a search of
the magnitude of Bass Strait, which involves two jurisdictions Tasmania and
Victoria you then start to get to the point where it is way beyond the
capabilities firstly to conduct the search and secondly to conduct it.[33]
2.34
The Committee notes that Tasmania Polices decision to
suspend the search for a second time was again based on insufficient resources
and AusSAR advice that it was not possible to mount a realistic search effort
(see paragraph 2.17). A transfer of responsibility for the search did not
occur; the search was suspended by the Tasmanian authorities on the advice of
AusSAR, not by AusSAR itself.
2.35
In relation to AusSARs responsibilities following the
location of the sunken vessel on 30
April 2001, the Coroner concluded that:
Had AusSAR been placed in the position of being responsible for
the search on the 17th
April 2001, I believe they would have ... coordinated a search of
the uninhabited islands in Bass Strait, which may have
led to an earlier retrieval of the life raft.
It is regretful that AusSAR did not give closer consideration to
the situation as at the 17th April and offered to undertake a review
of the search at this time.[34]
The Committee supports the
Coroners conclusion on this point.
2.36
AMSA emphasised to the Committee that what they judged
to be a remote possibility of locating survivors was not worth the risk
associated with attempting to undertake a comprehensive search over a large
area of Bass Strait on 17 April 2001.[35] In evidence
to the Committee officers contrasted this judgment with the 30 April 2001 decision to conduct a
search of the northern Tasmanian coast and along the beaches on islands on the
eastern side of Bass Strait, which soon after located
two of the bodies. In evidence to the Committee, they stated that this later
search was for debris, not survivors, and was therefore targeted more precisely
at coastline areas.[36]
2.37
The Committee is not comfortable with AMSAs
explanation of the decision-making that rejected AusSAR-coordinated search
activity on 15 and 17 April 2001
but endorsed such coordination on 30
April 2001. The success of the restricted search activity on 30 April 2001 leaves the Committee
unwilling to accept that earlier similarly targeted search activity would not
have yielded a similar result.
Information recording and documentation
2.38
The Committee notes that deficiencies were present in
the information recording procedures of both state and Commonwealth
authorities. In relation to AusSAR, the Coroner regretted an absence of
accurate note keeping of conversations held and actions taken, resulting in
inconsistent information being available to him on which to reach positive
findings.
2.39
He specifically referred to a lack of recorded
information on AusSARs understanding of whether or not the Tasmania Police had
already searched Flinders Island
when responsibility was transferred. This, it was stated, restricted the
Coroners capacity to draw conclusions as to the accuracy of conflicting
statements regarding this aspect of the search.[37]
2.40
Moreover, the Coroner highlighted AusSARs mishandling
of information on the ships generator and its effect on the seaworthiness of
the Margaret J. Citing
dramatic changes - over a short period of time - of recollected facts passed
between AusSAR officers, the Coroner stated that:
There is a need to ensure that information received is
accurately recorded and should not be subject to embellishment.[38]
2.41
In evidence to the Committee, AMSA conceded that the Margaret J incident had highlighted problem
areas in the organisations procedures:
We are always looking for improvements in our practices. We can
always do better. We are never satisfied. The basis of our approach is continuous
improvement.[39]
2.42
The Coroner also made a number of criticisms of the recording
procedures of Tasmania Police. However, the Committee notes the terms of
reference and its emphasis on inquiring into the role of AusSAR, rather than Tasmania
Police, in the search for the Margaret J. The Committee also notes advice from
the Clerk of the Senate indicating that the Committee does not have the
authority to pass judgment on, or censure the conduct of, state office holders.[40] Accordingly,
the Coroners criticisms of Tasmania Polices procedures will not be addressed
in this report.