CHAPTER 3 - CONCLUSIONS
Crew of the Margaret J
3.1
The Committee notes that the conclusions of the Coroner
in relation to the estimated time of death of the crew of the Margaret J.
3.2
The Committee recognises the anguish experienced by the
family and friends during the search for the Margaret J and extends its deepest sympathy for
their loss.
3.3
The Committees findings are informed by a commitment
to strengthening the effectiveness of AusSARs performance and maintaining
community confidence in the national search and rescue agency.
Responses to AusSARs identified deficiencies
3.4
The Committees primary source of concern stems from
the issues - raised by the Coroner and in evidence to the Committee - relating
to the effectiveness of AusSARs systems for guiding the conduct of search and
rescue operations. Principally, these relate to:
(a)
The relationship between AusSAR and state authorities;
(b)
Protocols for officially transferring search and rescue
responsibilities from state police to AusSAR; and
(c)
The accurate recording of information gathered by
AusSAR.
3.5
These issues were addressed by the Coroner in making
the following recommendations and comments:
8. There
needs to be a closer working relationship between those officers in Tasmania Police who are involved in Search and Rescue
and those employed by AusSAR.
This should include meetings or
conference on at least an annual basis when ideas, techniques and all matters relevant
to search and rescue could be discussed, and would have the added advantage of
ensuring that each organisation and its members can appreciate the role of the
other , which, in my view, would lead to an improved system.
...
14 Need
to ensure that information is accurately recorded.
... criticism of AusSAR would be in
relation to their failure to accurately record information supplied and
accurately convey such information to senior officers who are required to
endorse actions to be undertaken.
...
17. There
should be adopted a standard form to be used for the transfer of
responsibility.
There is little doubt, if a standard
form had been readily available and had formed part of the manual, either the
Police Manual or the National Manual, transfer of responsibility for the search
of the life raft and the crew would have been passed to AusSAR at an earlier
date... .[41]
Relationship with state authorities
3.6
In response to Recommendation 8 in the Coroners report,
AMSA emphasised ongoing efforts to improve AusSARs working relationships with
state authorities via various meetings, debriefing sessions and workshops. The
Committee was advised that AMSA and Tasmanian authorities had met in Launceston
for a joint workshop in April 2002 to discuss improved operational protocols,
followed by regular meetings and debriefings after particular search and rescue
incidents.[42]
While welcoming evidence of the April 2002 workshop, the Committee is concerned
that not all state and Commonwealth officers responsible for important
decisions on the conduct for the search of the Margaret J, including decisions about the
transfer of responsibility for search and rescue coordination, participated.
3.7
In evidence to the Committee, AMSA indicated that coordination
processes between AusSAR and state authorities had been defined in greater
detail in the National Search and Rescue Manual (the Manual).[43]
3.8
Section 1.3.14 of the Manual firmly encourages
overreached authorities to request early assistance, warning that delay
"may lead to reduced chances of survival and/or significant increase in
the size of the search area".[44]
3.9
The Committee also notes section 1.3.29 of the Manual.
This outlines the information sharing procedures that must be undertaken
between multiple search and rescue authorities, where full coordination
responsibility has not been transferred, but where certain functions have been
passed to another authority. For example, this may occur where assistance when
an air search is requested of AusSAR by a state authority. These procedures include:
(a)
Initial consultation with all participating
authorities;
(b)
Frequent reviews by mission coordinators; and
(c)
The production of overall situation reports at regular
intervals.[45]
3.10
The Committee is of the opinion that the Manual
presently provides appropriate guidance as to the coordinating roles and
responsibilities of authorities jointly assisting in a search and rescue
operation. However, the Committee recognises that inadequate understanding of
the protocols by state and/or Commonwealth officers negates their effectiveness
and, in some circumstances, may impede the effective coordination of search and
rescue activities and put lives at risk.
3.11
The Committee is not satisfied that Tasmania Police or
AusSAR demonstrated effective understanding of the protocols related to the
transfer of coordination responsibility during the search for the Margaret J.
Accurate recording of information
3.12
Internal operational protocols contained in the AusSAR
procedures manual were updated (particularly section 3.4.2.4).[46] This section stipulates
the manner in which information is to be recorded when it is received.
3.13
The Committee notes, however, that the protocols for
recording incident information existing in April 2001 should have provided
sufficient guidance to AusSAR officers involved with the search.[47] Section 3.4.2.4,
stipulating the manner in which incident information is to be kept, appears not
to have been observed in particular instances during AusSARs communication
with Tasmania Police.
Formalising the transfer of responsibility
3.14
The completion of a standard form is now a compulsory
requirement for the transfer of search and rescue responsibility. This is
included in section 1.3.7(d) of the current version of the Manual.[48] The Committee
also notes the protocols specified in section 1.3.7, including the requirements
for consultation between the mission coordinators of each authority before a transfer,
and for the documentation and passing of all details of action already taken to
the authority taking over.[49]
Conclusion
3.15
The Committee finds it cannot conclude whether more
effective coordination of the search for the Margaret J would have yielded a positive outcome. This finding does
not ameliorate the Committees concern about ineffective communication between
AusSAR and the Tasmanian authorities and the absence of appropriate record
keeping by AusSAR officers during the search for the Margaret J.
3.16
Although the Committee is satisfied with the protocols
for the coordination of search and rescue operations now accessible through 'the
Manual', the Committee is of the view that a more formal arrangement utilising
clearly written and accessible protocols would have been of considerable value at
the time the search for the Margaret J
and its crew was being undertaken.
3.17
The Committee concurs with the Coroners finding that
the Tasmanian officers were not confident or assured in their dealings with AusSAR,
and that more assistance in guiding these officers through the process would
have been beneficial.[50]
Clear operational protocols available to state authorities would have assisted
this occurring. The Committee urges AMSA to ensure AusSAR officers adhere to
these protocols at all times when communicating with and assisting other search
and rescue authorities.
Senator the Hon. Bill Heffernan
Chair