Mei 到處 8

DEBBIE WHITMONT: At two in the morning, on a dark, windy night in the waters off northern Australia, five people in a small boat were fighting for survival.

LILLIAN AHMAT, WILFRED BAIRA'S SISTER: It was very rough, yeah. The wind was blowing, I don't know, about 40 knots, yeah and raining. Yeah it was so dark that night.

GEORGE NONA, WILFRED BAIRA'S BROTHER: He said the last phone call he ever made I heard the women crying out.

DEBBIE WHITMONT: The two women, two men and a five-year-old child had been lost at sea for more than 10 hours.

Their engine stalled, their leaky boat, filling with water, they bailed desperately.

They couldn't have known it would never save them. Their small boat, owned by the Commonwealth Government, had been doomed from the day it was built.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: There was overwhelming evidence that this particular boat was unseaworthy, was completely unsuitable for its purpose and was always going to sink; it was just a matter of how long it would take to sink.

DEBBIE WHITMONT: The skipper and deck hand were both employed by the Department of Immigration. It sent them to sea - with no charts, no GPS and no radio. Then when they called for help, local police and the national rescue authorities didn't take them seriously.

GEORGE NONA, WILFRED BAIRA'S BROTHER: I'm angry with the Immigration, the Police, I'm angry, I'm, of course I'm angry. They took our brother away and they got their jobs back and they walked off.

DEBBIE WHITMONT: Tonight on Four Corners, a totally avoidable tragedy - how five people died needlessly because state and federal agencies didn't do their jobs - and how, even now, not one of them has been held to account.

LAURIE NONA, WILFRED BAIRA'S UNCLE: People should be fried over this. It looks like we're from out here on the island, people have lost their lives. Who gives a shit down there?

(On Screen Text: A Totally Avoidable Tragedy, Reporter: Debbie Whitmont)

DEBBIE WHITMONT: It's where the Australian mainland is finally overwhelmed by ocean.

Once, Torres Strait was a land bridge to Papua New Guinea.

Now, tiny islands and submerged reefs lie scattered across our northernmost border.

For the last twenty years, the border's been monitored- under a treaty- by Indigenous patrol officers employed by the Department of Immigration.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: So we check passes when the boat comes in. We work closely with the quarantine officer. We have the opportunity to look after our people, you know.

We're out there in the field; we're the front-liners for the Torres Strait waters you know, and I feel so proud to be there, you know.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: We have 18 movement monitoring officers in the Torres Strait, Indigenous Australians, Indigenous Torres Strait Islanders, whose knowledge of the strait, whose knowledge of the traditional movements of people between PNG and Australia is invaluable; it's a key part of our work.

DEBBIE WHITMONT: But now in Torres Strait, after a 2 year long inquest, the Department of Immigration is under a cloud. In February, the Queensland Coroner found the Department of Immigration, its Regional Manager, a Queensland Police Officer, Australian Search and Rescue and a local boat builder had all played a part in the deaths of five people.

What no one here can understand is why not one of them has been charged or punished.

LAURIE NONA, WILFRED BAIRA'S UNCLE: It won't be put to rest until someone gets sacrificed up there, because people have died and we're what, we're just going to ok let's just wait for the next couple of people to die, you know.

MARK BOUSEN, EDITOR TORRES NEWS: There certainly is a case for saying they're in the bloody Torres Strait, it doesn't matter, they're at the end of the earth.

DEBBIE WHITMONT: The problem began on Thursday Island with the Department of Immigration's new Regional Manager, Garry Chaston. A former federal policeman, Chaston was in charge of the Department's Torres Strait patrol officers. One of his first jobs was to buy them six new patrol boats.

From the start, Chaston told the Department he knew nothing about boats or Government contracts. Proof of that came when he advertised for tenders and left out the most crucial requirement - that the boats would be used in the Torres Straits open waters.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: Mr Chaston couldn't explain how those words came to be omitted from both the advertisement and the request for tender documents.

DEBBIE WHITMONT: Couldn't explain at all?

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: He simply couldn't explain it. He knew that the relevant area in which the boats would be operating was regarded as open waters, which was distinct from smooth or partially smooth waters, but when he was asked about how those words came to be admitted, from memory he couldn't explain it.

DEBBIE WHITMONT: The winning tenderer was a Cairns company called Subsee Explorer. Subsee's quote was the cheapest by far, and the only one close to the amount the Government had allocated.

DEBBIE WHITMONT: Bill Collingburn admits he tendered nearly twice as much. His company, in Yamba NSW, has been supplying Government boats for more than three decades.

BILL COLLINGBURN, YAMBA WELDING & ENGINEERING: Ah the project was under-funded right from the go. Ah they couldn't possibly have vessels to do the job safely for the price that was allowed.

DEBBIE WHITMONT: To what extent were they under-funded?

BILL COLLINGBURN, YAMBA WELDING & ENGINEERING: At least 50 per cent.

DEBBIE WHITMONT: So do you believe that a safe boat could have been built for the kind of money they were requiring?

BILL COLLINGBURN, YAMBA WELDING & ENGINEERING: No, I don't.

DEBBIE WHITMONT: Forced to cut costs, Subsee put the pressure on other suppliers - like Greg Pope and Tess Sard who sell marine equipment on Thursday Island. Subsee asked Pope and Sard to quote on the motors.

GREG POPE, WAIBEN LIGHT MARINE SERVICES: Ah we'd given them quotes on the same motors as we'd just fitted to certain another Government department and um, we thought oh everything was quite good. But it wasn't too long before we were actually asked to yeah, sharpen our pencils and cut our prices.

DEBBIE WHITMONT: Pope and Sard gave two more quotes, for cheaper and then cheaper motors, but it wasn't low enough.

TESS SARD, WAIBEN LIGHT MARINE SERVICES: Well, we were just yeah, it just got to the stage where we thought well, how many corners can you cut? And we didn't want to be a part of corner cutting. That's how we felt at the time and we said no, we didn't want to be a part of it and we weren't.

DEBBIE WHITMONT: But the main problem was that Subsee's boats were simply unseaworthy. Designed by a Subsee director - Don Radke - the boats had no reliable means of floatation, such as foam.

DEBBIE WHITMONT (to Bill Collingburn): Well this is a plan of a very similar boat. I mean where would the foam go here?

BILL COLLINGBURN, YAMBA WELDING & ENGINEERING: The foam would be under here, under the deck level, right the way through.

DEBBIE WHITMONT: And having it down there, I suppose that means that water can't get in?

BILL COLLINGBURN, YAMBA WELDING & ENGINEERING: Water can't get in, and if any does get in there it supplies additional buoyancy anyway.

DEBBIE WHITMONT: But foam would have cost Subsee around $6,000 a boat. So Don Radke used air. Which would have been alright - if he'd done it properly.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: Mr Radke essentially constructed a vessel that relied for its positive floatation on a single compartment below the deck, um so if that compartment was not watertight in any respect for example because of shoddy welding - which is exactly what happened - then the entire positive floatation for the vessel was utterly compromised.

DEBBIE WHITMONT: The single air compartment - let alone the shoddy welding - didn't meet basic standards. But no one found out because the boats were never inspected.

With no inspection, the boats couldn't get compliance certificates - and without the certificates, they should never have been able to be registered.

MARK GREEN, BARRISTER, FAMILIES OF DECEASED: Now Mr Chaston didn't obtain those certificates, yet when he wrote to the relevant Government body in order to get registration under the marine orders, in order for the vessels to operate under the employ of the Commonwealth, he wrote a document that effectively said that he had received all of the relevant certificates.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: So here we have a person with over 20-years experience as a Federal Police officer before his career with the Department essentially falsely swearing a certification about certain facts that he knew at that time were not true so that the boats could be given certification and go into service.

DEBBIE WHITMONT: It was also Chaston's job to fit out the navigational equipment. This time, the problem wasn't money but attitude.

GREG POPE, WAIBEN LIGHT MARINE SERVICES: Yes, that was early in the piece when I did say to him about the equipment that would be fitted to the boats, especially the navigational equipment as in GPSs, depth sounder, radios, etcetera, and he said no. No, we won't be needing that ah. There's, these guys are two generations behind. Wouldn't be able to use 'em.

DEBBIE WHITMONT: What did you think of that when you heard it?

GREG POPE, WAIBEN LIGHT MARINE SERVICES: Oh I knew it was wrong.

TESS SARD, WAIBEN LIGHT MARINE SERVICES: Yeah, I was standing there when he said it too, and um, when Greg asked him and he said they were two generations behind and I just walked away. I was pretty shell-shocked that somebody could say that.

If you're working up here, you need to work with the culture and with the people and not think just because you're white you're better than them or anything like that, we're all equal.

LAURIE NONA, WILFRED BAIRA'S UNCLE: That's what caused it you know, is that you have a boss that doesn't understand you, doesn't understand the Torres Strait, doesn't understand the people and doesn't understand his own work colleague, you know.

DEBBIE WHITMONT: It's clear Chaston's comment wasn't a one off. From early 2004 - and for more than year - the Indigenous staff at Thursday Island had been complaining to the Department of Immigration that Garry Chaston was heavy handed, dictatorial and arrogant.

The complaints went to Human resources and repeatedly to the State Director in Brisbane. But nothing changed.

One staffer says he complained to the Department's Secretary in Canberra - though the Department denies that.

Andrew Metcalfe has been Secretary since mid-2005.

DEBBIE WHITMONT (to Andrew Metcalfe): Were there in the past complaints about the regional manager?

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: I'm not sure about that.

(On Screen Graphic: Fax message and emails from Department of Immigration)

DEBBIE WHITMONT: That seems surprising. The department's Indigenous staff were directed in writing, not to talk to Four Corners. But in late 2005, internal emails show the history of complaints - claims that Chaston lied, blamed and threatened staff and was racist - was put together and summarised for senior management and the Department's lawyers.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Now were there complaints, did they reach up to other people, I just don't have any background on that.

DEBBIE WHITMONT: Well if if there were complaints and they consisted of complaints of bullying, racism, harassment. They went up to the level of the State director, up to the secretary in Canberra and nothing was done, does that indicate that the problem was bigger than the regional manager?

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: It depends what problem you're talking about. Um the Coroner.

DEBBIE WHITMONT: Bullying, harassment, racism.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Well in terms of that um, I'm just not in a position to make any um, assessment um, about it.

DEBBIE WHITMONT: Back in 2005 as the Department copped a battering over wrongful detention, its Thursday Island office had what looked like good news - the new patrol boats. The Minister - Amanda Vanstone - was eager to come to Thursday Island. Canberra pressed the Regional manager - Garry Chaston - for a launch date.

MARK BOUSEN, EDITOR TORRES NEWS: It had been Chaston's almost obsession with making sure everything was ready and and fit for the, for the Minister, who at the time was Amanda Vanstone, for her visit.

DEBBIE WHITMONT: Mark Bousen owns and edits one of the country's few independent newspapers - the Torres News.

MARK BOUSEN, EDITOR TORRES NEWS: And he kept ringing and saying you're coming down to get photos, you're coming down to get photos. Yes, Garry we'll be there provided nothing else happens. Oh but you've got to be there, the Minister's coming.

DEBBIE WHITMONT: The six custom boats were finished in record time.

GREG POPE, WAIBEN LIGHT MARINE SERVICES: Basically they were rush jobs. The time it took for them to be built was incredibly quick and yeah, the welding on them yeah, just looked shoddy.

MARK BOUSEN, EDITOR TORRES NEWS: As it turns out the commissioning ceremony would've been close to a circus if the consequences six weeks later hadn't been so, at the opposite end of the scale, so tragic.

(Excerpt of photographs of Amanda Vanstone's visit to Thursday Island)

DEBBIE WHITMONT: The Minister wanted the new boats to be named by local school children.

They called one the Malu Sara. In the language of the western Torres Strait it means the Seagull.

(End of Excerpt)

Soon after the launch, the six boats went by barge to six Torres Strait islands.

The Malu Sara went to an island famed for its sailors - called Badu.

Its skipper Wilfred Baira was the adopted son of Badu's best known seafaring family - the Nonas.

In the 1930s, the Nona family made Badu prosper. The Nona Brothers pearling luggers became the biggest and best fleet in Torres Strait. Tanu Nona built Badu's biggest church and Nona Brothers boats raised the money to pay for it. Two generations later, the church still dominates Badu.

And the Nona's adopted son - Wilfred Baira became the Department of Immigration's Badu patrol officer. His nickname was Musu.

LAURIE NONA, WILFRED BAIRA'S UNCLE: Musu's sea knowledge is from birth, to a, to his end you know that's his sea knowledge. He was probably I think 41-years-old or something but that whole life is spent on sea, island and sea.

LILLIAN AHMAT, WILFRED BAIRA'S SISTER: Oh he was really proud of that job when he first got the job. Dressed up well, had a good sense of humour and respected his position, yeah. He's the person who follow the protocols, you know, and would take orders from his superiors.

DEBBIE WHITMONT: About six weeks after he got his new boat - and without any training on it - Wilfred Baira and his deckhand Ted Harry were told to take the Malu Sara across Torres Strait - to the island of Saibai for an Immigration workshop.

LILLIAN AHMAT, WILFRED BAIRA'S SISTER: Yeah, I remember it quite clearly. I was standing on the beach and um watching him packing his stuff, unloading the gear on to the boat. Yeah I kept watching the boat til it disappeared.

DEBBIE WHITMONT: The voyage to Saibai was nothing like the kind of island patrolling the boats were intended for. From here at Badu to reach Saibai it's about 90 kilometres much of it across open and quite dangerous waters.

No one doubted Wilfred Baira's experience, he knew the way well. What he didn't know is that his boat was fatally flawed, in any bad weather with every kilometre the Malu Sara would turn quite literally into a death trap.

DEBBIE WHITMONT: The Malu Sara arrived safely at Saibai. But one afternoon in what should have been a warning sign one of the skippers saw the boat was taking on water.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: Ted spotted the Malu Sara was anchored on the side of the wharf and Ted call out to me, hey, sis, come and have a look at the boat, it's taking water, um the Malu Sara and it was just anchoring on the side of the wharf.

DEBBIE WHITMONT: They told Garry Chaston.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: Garry was outside the office and Ted said to Garry "oh there's um Malu Sara is taking water. It's pretty deep now. It's down nearly the knee mark", and he said "oh well see Wilfred. It's your boat." Then he just walked off somewhere else. He didn't worry.

DEBBIE WHITMONT: On the last day of the workshop as everyone was heading home, it was wet and windy.

NED DAVID, FORMER DEPT OF IMMIGRATION OFFICER: It was very, very rough the morning. It was like this, a little bit of rain in the morning. But the wind, we were concerned about the wind.

DEBBIE WHITMONT: It's clear that Wilfred Baira didn't want to travel. Of all the skippers, he had the longest trip home, and the most difficult.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: Wilfred said to Garry "um ah I think it's rough. We should stay. Can we go tomorrow or when the weather drops down you know?" And he said "ah nah, nah. Got to go." He just said "look I'm not going to accommodate youse. The training's over, got to go."

DEBBIE WHITMONT: And what did Wilfred do when he said that?

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: Nothing. He just stand there really quiet and just looked over to me and Ted. He was afraid to say no because he was thinking about his job.

DEBBIE WHITMONT: Wilfred Baira was offered somewhere to stay with friends but he didn't take it.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: I think with my people we're people of a great respect and honour to our elders. And Gary was the superior you know, the boss for Ted and Wilfred they just say okay, that's what he said, 'cause that's what they said, that's what the boss man said, we got to go, we got to go.

GEORGE NONA, WILFRED BAIRA'S BROTHER: What European said it was always right, it was always right, right, right, right. That's how it probably now that the Islanders realise that, these Europeans or (inaudible) is the Island word for it, do make mistakes but some people still you know stuck in this yes Boss, yes Boss.

DEBBIE WHITMONT: Wilfred's boss, Garry Chaston flew back to Thursday Island in a helicopter. Some others left in a small plane.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: And we said goodbye cause I had to go catch the plane and that's when I said goodbye to um my two brothers. It was the last time.

DEBBIE WHITMONT: The Coroner found that in the conditions that day, the Department's standard operating procedures would almost certainly have prohibited the use its of patrol boats.

SERAI ZARO, FORMER DEPT OF IMMIGRATION OFFICER: I remember when we lift off by plane, it was really foggy, to look down to the sea it was white and you know when the sea's really white down there it's rough.

DEBBIE WHITMONT: By midday the tide had changed and was now running against the wind. In Torres Strait, that makes for notoriously dangerous conditions - known as boxing seas.

NED DAVID, FORMER DEPT OF IMMIGRATION OFFICER: Well if, the tide go against the wind, it's pushing the wave up and it's like making, making like a box wave and then it's sort of like has a white cap on it. And it's not small, it's really big.

DEBBIE WHITMONT: The Malu Sara didn't leave Saibai til 20 past 12 on Friday. It had five people on board - Wilfred Baira, his deck hand Ted Harry - a former policeman - and three passengers - Valerie Saub, Flora Enosa and Flora's five year old daughter Ethena.

Though Garry Chaston denied giving Wilfred Baira permission to take passengers, the Coroner found it most likely he did.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: Wilfred Baira had never disobeyed a directive or order from his regional manager Mr Chaston, he'd always been a compliant employee of the Department. He had never carried passengers without authority before.

DEBBIE WHITMONT: At first, the Malu Sara headed south west. Around two PM, Wilfred Baira made a scheduled phone call to the Thursday Island office.

The junior duty officer was Jerry Stephen. Baira said he was turning south looking for calmer waters alongside a reef. But the Malu Sara had no charts, no depth sounder and no GPS. Before long, Wilfred Baira became lost in fog.

GEORGE NONA, WILFRED BAIRA'S BROTHER: It was foggy and the water was dirty how can you see a reef? You look up at the sky there's nothing up there. There's no stars because it was cloudy, it was foggy, the water was dirty you're just left there to have a guess.

DEBBIE WHITMONT: As night fell, Jerry Stephen - now at home - was trying to help Wilfred find a course to steer on.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: The regional manager Mr Chaston didn't even bother to come into the office when he knew the vessel was missing. He left Jerry Stephen, a junior officer to staff the phone and have individual contact with the vessel throughout the night.

DEBBIE WHITMONT: That contact - on the boat's satellite phone - proved difficult. No one had told Wilfred the antenna would only work properly with the phone in its cradle. Nor, tragically, did anyone tell him that one of the phone's functions might have saved him.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: The terrible thing about the phones of course was that the phones had the capacity to provide their location to anyone who had been trained in the use of them.

DEBBIE WHITMONT: By 6pm the Malu Sara was two hours overdue - lost in open sea with five people on board. Garry Chaston contacted Sergeant Flegg at Thursday Island Water Police.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: Mr Chaston failed in an absolutely critical way during that period by not telling Sergeant Flegg or Jerry Stephen that the boat in question had been taking on water during the workshop on Saibai. It was clear that if he had told them that, that might have had an effect on the search and rescue.

DEBBIE WHITMONT: Instead, Garry Chaston and his wife went to the local bowls club for dinner. Greg Pope and Tess Sard saw him there.

TESS SARD, WAIBEN LIGHT MARINE SERVICES: We were sitting inside, he was sitting out on the veranda.

DEBBIE WHITMONT: Did he seem concerned?

GREG POPE, WAIBEN LIGHT MARINE SERVICES: No.

LILLIAN AHMAT, WILFRED BAIRA'S SISTER: I felt disgusted, yeah. I mean how can you as a, you know a manager dining away with your wife when someone who is accountable for you, you know, that is lost in, in the sea, you know.

DEBBIE WHITMONT: At around 7pm Wilfred Baira set off his distress beacon - or EPIRB. Those who knew him say he must have been in trouble.

GEORGE NONA, WILFRED BAIRA'S BROTHER: That's serious. If he would've set off that EPIRB, he knows it's serious. Wilfred would do anything try before he would set the EPIRB off.

DEBBIE WHITMONT: But at Thursday Island water police Sergeant Warren Flegg - decided the Malu Sara's EPIRB wasn't a distress call.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: The fact that Sergeant Flegg assumed it was not a distress situation was consistent with other evidence from the Queensland Police Service about a culture within the Queensland Police Service.

DEBBIE WHITMONT: At the inquest, police told the coroner the local joke about EPIRBS.

MARK GREEN, BARRISTER, FAMILIES OF DECEASED: One of the police officers gave evidence to say that for the area in the Torres Strait, EPIRB is known by the acronym within the police service as Empty Petrol I Require Boat.

DEBBIE WHITMONT: The Water Police did call Australian Search and Rescue - or AusSAR - in Canberra. Four Corners has obtained the audio tapes of the conversations that night.

(Excerpt of audio from AusSAR tape)

AUSSAR REPRESENTATIVE: Good evening Australian Search and Rescue.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Good evening it's Warren from TI water police how are you?

AUSSAR REPRESENTATIVE: G'day Warren what can we do for you?

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Mate I have an overdue vessel.

AUSSAR REPRESENTATIVE: Oh mate.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Immigration of all people.

AUSSAR REPRESENTATIVE: Immigration's vessel?

(End of Excerpt)

DEBBIE WHITMONT: John Young is the General Manager of Emergency Response at the Australian maritime Safety Authority.

DEBBIE WHITMONT (to John Young): Who's responsible if it's a Commonwealth vessel, an Immigration vessel for the search and rescue?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: The primary responsibility for setting up infrastructure for such a circumstance would belong with AMSA.

DEBBIE WHITMONT: Why didn't it take responsibility then that night?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: In this particular incident, Queensland Police were advised of it first in accordance with a contingency plan that they had with Immigration. They elected to continue co-ordinating it, neither Queensland Police nor AMSA saw any reason to change that, um and that's why co-ordination remained as it was.

DEBBIE WHITMONT: The Police told AusSAR the Malu Sara had only lost its way. And AusSAR didn't ask too many questions.

(Excerpt continued)

AUSSAR REPRESENTATIVE: They're going to activate their beacon, are they?

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: They have, yeah.

AUSSAR REPRESENTATIVE: Oh Okay. Once we get a position, we'll let you know.

(End of Excerpt)

DEBBIE WHITMONT (to John Young): Are you satisfied with the way AusSAR performed on the night?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: AusSAR did what was asked of it. Um it was asked to provide um information about the position of the beacon and I'm entirely satisfied that they did that correctly.

DEBBIE WHITMONT: But isn't a beacon a signal of distress in itself?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: We would normally react to a distress beacon as a signal of distress. Ah in this particular case, um we had other information that indicated it was not.

DEBBIE WHITMONT: But shouldn't AusSAR have asked some questions? AusSAR is the search expert?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: The Queensland Police were also search experts. The search and rescue system comprises nine equal search and rescue authorities of which the Queensland Police is one and we expect to be able to rely on their advice.

DEBBIE WHITMONT: By 9.30pm, the Malu Sara was in serious trouble. Water was coming into the boat. Wilfred was trying to pump it out. But he couldn't.

According to evidence at the Inquest - when Garry Chaston heard that he commented, "well they'd better f***ing bail faster, hadn't they?"

GEORGE NONA, WILFRED BAIRA'S BROTHER: Wilfred would've done everything he can on that boat to save those people, that's one thing I know for a fact.

DEBBIE WHITMONT: Around 2.15 on Saturday morning - after nearly 14 hours at sea - Wilfred Baira finally sighted an island. He could see a light a few kilometres away. But it was too late. He told Jerry Stephen the Malu Sara was taking water fast and sinking. In the background Stephen could hear women screaming.

LILLIAN AHMAT, WILFRED BAIRA'S SISTER: Gerry said that he could hear the two women screaming at the back, background and a child crying, and Wilfred was saying that you know, the boat was sinking. You know that was the last phone call, then it cut off.

DEBBIE WHITMONT: Jerry Stephen told the police the boat was sinking. But Sergeant Flegg didn't pass it on.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: As best I can recall he said he didn't pass it on either because he didn't believe it or he didn't take it seriously at the time.

DEBBIE WHITMONT: But Sergeant Flegg did ask AusSAR if they could send in a helicopter.

(Excerpt of audio from AusSAR tape)

AUSSAR REPRESENTATIVE: Australian Search and Rescue.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Yeah it's Warren from TI again.

AUSSAR REPRESENTATIVE: Yes Warren.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: That was the immigration on call officer at the moment. They said that they're starting to take a bit of water in and they're bailing out so I just wondered if you could send in a helo to try and look for this EPIRB. Is that beacon still activating up there in the.

AUSSAR REPRESENTATIVE: Sure is.

(End of Excerpt)

DEBBIE WHITMONT (to John Young): Do you think on hearing that from the Queensland Police Officer, AusSAR was being asked to offer a helicopter to help?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: Clearly the rescue coordination centre did not think so.

DEBBIE WHITMONT: So you're satisfied with that response?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: Yes.

DEBBIE WHITMONT: What would it have taken for the AusSAR Officer to accept responsibility and take some steps to go and look for the distress beacon?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: It would've required a clear statement from the Queensland Police coordinator that there was a distress situation evolving here.

DEBBIE WHITMONT: In fact, the Coroner found that over the next six hours Sergeant Flegg did ask AusSAR for air support four times. He only got a clear response the last time, when he was told to take care of it himself.

MARK GREEN, BARRISTER, FAMILIES OF DECEASED: If there had been an appropriate response at any time within that time period then one would expect that lives would have been saved rather than lost.

DEBBIE WHITMONT: A night rescue helicopter - based nearby - could have reached the Malu Sara in about 80 minutes.

DEBBIE WHITMONT (to John Young): It does seem looking at what happened that evening that the AusSAR officers were reluctant to take any responsibility. Do you think that's a fair comment?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: Um no I don't. The AusSAR officers did what was asked of them.

DEBBIE WHITMONT: Finally, around dawn Sergeant Flegg mentioned that the boat was sinking. But AusSAR seemed unconcerned.

(Excerpt continued)

AUSSAR REPRESENTATIVE: They keep me up all night with these bloody alerts. It's like a shotgun in the Torres Strait at the moment.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Yeah, Yeah well I've been on this bloody thing for, we were notified at 1930 local.

AUSSAR REPRESENTATIVE: Yeah.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: And it just started out, you know, they were lost.

AUSSAR REPRESENTATIVE: Yeah.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: And now it's gone and turned into "oh we're sinking. Can you come and get us?"

AUSSAR REPRESENTATIVE: Yeah, yeah. Funny how these things develop.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Oh yeah.

AUSSAR REPRESENTATIVE: Okay mate, let you get on with it.

WARREN FLEGG, SERGEANT, THURSDAY ISLAND WATER POLICE: Thank you.

AUSSAR REPRESENTATIVE: Thanks Warren, bye.

(End of Excerpt)

DEBBIE WHITMONT (to John Young): In one of the phone calls in the morning, the AusSAR Officer says words to the affect "oh those beacons are going off like a shotgun in the Torres Strait, it's been keeping up." Does it concern you that this event was trivialised?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: I err, don't take that conversation as indicating that the event was trivialised.

DEBBIE WHITMONT: What does it indicate?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: It indicates that ah, the Officer on duty here had a number of issues to deal with and, and he was dealing with them and he shared that with a colleague on the other end of the phone.

DEBBIE WHITMONT: Can you understand why the families feel that this rescue wasn't taken seriously?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: The, the families must draw their own conclusions.

DEBBIE WHITMONT: The next morning, the Queensland Police finally sent out a helicopter. It found the EPIRB at about 10.30 in the morning. But there was no sign of the Malu Sara, which wasn't surprising.

The Coroner found it sank around six hours earlier, at about four in the morning.

AusSAR finally took on the air search around midday on Saturday. The next afternoon - nearly 36 hours after the Malu Sara went down - a volunteer searcher Deborah Marshall was looking for survivors.

DEBORAH MARSHALL, SES VOLUNTEER: I yelled object in water at 11 o'clock and the Pilot then said does that look like someone in a life jacket to you? And I was so elated that I'd actually, we'd actually found somebody alive, um he was actually laying back in the water ah waving his arms above his head and it was just amazing, absolutely amazing to think that we'd found somebody.

DEBBIE WHITMONT: But when the plane came back, the person had vanished.

DEBORAH MARSHALL, SES VOLUNTEER: Um we kept circling and circling, ah we never caught sight of him again.

DEBBIE WHITMONT: AusSAR listed the sighting as "unconfirmed". The Coroner said that was illogical, and hindered a '"constructive review" of all that had happened.

TRACY FANTIN, BARRISTER, WILFRED BAIRA'S FAMILY: It was clear that if the findings about the observations were accepted it meant that for at least a couple of days after the boat sank there were still people in the water in life jackets, possibly able to be rescued. Which makes the delay in dispatching the aerial search even more critical.

DEBBIE WHITMONT: After days of searching, only one body was found - more than a week later. It was that of Flora Enosa.

DEBBIE WHITMONT (to John Young): Would you have been happy if this had been your beacon or someone in your family setting off this beacon and you had heard the kind of conversations that went on between AusSAR and the Queensland Police?

JOHN YOUNG, GENERAL MANAGER, EMERGENCY RESPONSE AMSA: I dare say if it was my family I would grieve in the same way as the families affected in this tragedy.

DEBBIE WHITMONT: The Coroner described the loss of the Malu Sara as a wretched and catastrophic chain of events. But he found no-one acted maliciously.

The Coroner recommended AusSAR should review its operator training. The boat builder Don Radke - hasn't been charged and it's unlikely he will be. And Sergeant Flegg, who the Coroner found was incompetent, is still with the Queensland Police Force.

MARK GREEN, BARRISTER, FAMILIES OF DECEASED: And what is incomprehensible about it is how you can get so many people fail in doing their job properly to the point where at any stage any one of them could have stopped this process.

Any one of them could have led to the prevention of the loss of life, and yet nobody did their job properly.

DEBBIE WHITMONT: The Coroner found Garry Chaston was indolent and incompetent. Earlier this year Chaston resigned from the Department of Immigration with all his entitlements.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Of course the Coroner recommended that I take disciplinary action against Mr Chaston. I commenced that the day that the Coroner's report was ah made public. Mr Chaston chose to resign shortly afterwards and that brought to a halt any proceedings we had against him.

DEBBIE WHITMONT (to Andrew Metcalfe): I don't really understand why you couldn't take action before the end of the inquest.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Ah that's something that we did explore and the advice I had is that we basically could not ourselves form a view as to his competency or his actions without that interfering with the other processes that were underway at the same time.

DEBBIE WHITMONT: But that explanation from Andrew Metcalfe rings hollow. In two separate reviews - both after the five deaths - the Department of Immigration rated Garry Chaston as effective and found he had not mismanaged the Thursday Island office.

DEBBIE WHITMONT (to Andrew Metcalfe): Wasn't there an assessment done by the State director for his period of work from 2005-06, which covered that period, and it found, I understand, that Mr Chaston was fully effective. How do you reconcile that?

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Um I find that hard to reconcile. Um I'd have to go back and check the particular time ah, that that related to and the particular work that he was doing.

DEBBIE WHITMONT: And then an internal investigation, in fact found there was no mismanagement by the Thursday Island office.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Ah there was an investigation by the Department in the immediate aftermath of the, the, ah of the tragedy. That was to do a couple of things, firstly to establish the facts as we could possibly know ah they were, to secure the material um and to quickly ah, talk with people about what had occurred.

DEBBIE WHITMONT: But your investigation said no mismanagement.

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: Um that ah um, was a quick process undertaken at the time, um and in the knowledge at that particular time that there would be other processes underway.

DEBBIE WHITMONT: What would you say about that finding now?

ANDREW METCALFE, SECRETARY DEPT OF IMMIGRATION AND CITIZENSHIP: I would say that clearly there was mismanagement in relation to ah the acquisition, management, um and operational arrangements of the Malu Sara and the other immigration response vessels. In terms of the broader management of the Thursday Island office I'm unable to comment.

DEBBIE WHITMONT: The communities of Torres Strait were told they played an important role in protecting Australia. But now they're left wondering why the Government cared so little and how it can be that five people can die - Wilfred Baira, Ted Harry, Valerie Saub, Flora Enosa and her daughter Ethena - without anyone being held to account.

TESS SARD, WAIBEN LIGHT MARINE SERVICES: The community up here aren't like our fractured white community down south. They're family, and they've lost five family members and the Torres Strait may be very well spread out but it's a small community of people that have lost five people.

http://www.abc.net.au/4corners/special_eds/20090629/tragedy/