Coronial
WAother

Inquest into the Deaths of SIEV 221 Victims (Christmas Island)

Date of death

2010-12-15

Finding date

2012-02-23

Cause of death

Drowning from immersion in the sea; for those whose bodies were not recovered, drowning or injuries from impact with shore or debris

AI-generated summary

SIEV 221, a fishing vessel carrying 92 people, sank on Christmas Island on 15 December 2010, killing 50 asylum seekers and crew. Thirty bodies were recovered; 20 remain missing. The vessel lacked adequate lifejackets, safety equipment, and a trained crew; the captain departed midway. The crew's decision to sail west into monsoon weather, away from sheltered waters, proved fatal. The coroner identified multiple systemic failures: no effective surveillance to detect the vessel early, unsuitable emergency response vessels on Christmas Island (two rescue vessels out of service), delayed notification to naval and customs assets, and inadequate search-and-rescue capability. Although naval and customs personnel heroically rescued 41 survivors, the coroner found more lives could have been saved with earlier detection and proper rescue vessels. Fourteen recommendations addressed surveillance improvements, search-and-rescue capability, vessel provision, and maritime infrastructure at Christmas Island.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

systemdelay

Contributing factors

  • Unsuitable and unseaworthy vessel for monsoon season transit
  • Insufficient and poor quality lifejackets
  • Overcrowded vessel
  • Inadequately trained and qualified crew; captain departed midway through voyage
  • Poor safety equipment (no radio, faulty bilge pump, unsecured fuel, GPS thrown overboard)
  • Crew decision to travel west into prevailing weather instead of east toward sheltered waters
  • No effective surveillance capability of northern approach waters
  • Delayed emergency notification to HMAS Pirie and ACV Triton
  • Absence of suitable emergency response vessels on Christmas Island
  • Two rescue vessels (Colin Winchester and Sea Eye) out of survey and unsafe due to uncorrected deficiencies

Coroner's recommendations

  1. Border Protection Command to continue examining ways to improve surveillance capability around Christmas Island to reduce risk of SIEVs arriving undetected
  2. Border Protection Command to implement surveillance strategy with heightened coverage during rough weather and sea conditions, with possible assistance from other Commonwealth authorities and AFP
  3. AFP to determine whether access can be obtained to National Search and Rescue Council endorsed SARMAP program covering Australian Search and Rescue Region and adjoining tiles for Indonesia
  4. AFP to ensure appropriately trained officers who have completed National Police Search and Rescue Manager's Course are on Christmas Island at all times with ongoing upskilling
  5. AFP to be provided with search and rescue vessel suitable to specific conditions of Christmas Island and replacement vessel to cover periods when primary vessel is unavailable
  6. Consideration be given to acquiring two personal water craft for deployment by appropriately trained and equipped staff of AFP or VMRS on Christmas Island
  7. Commonwealth and Shire of Christmas Island to significantly upgrade Ethel Beach boat ramp with shelter in form of rock groyne or similar buffer and stable footing provision; or implement alternative means of deploying rescue vessel in adverse conditions
  8. Commonwealth to liaise closely with representatives of Christmas Island VMRS prior to purchasing or replacing any vessels for VMRS in future
  9. Christmas Island VMRS be given autonomy to maintain operational readiness for VMRS rescue vessel(s) with appropriate budget provided
  10. Arrangements be put in place to remove requirement for Masters of Volunteer Marine Rescue vessels to hold commercial certificate of competency; operators to be qualified through FESA pathway as skippers and crew
  11. Border Protection Command to establish onshore presence at Christmas Island including Military Liaison Officer and facilities for shore party
  12. Commonwealth to ensure there is mooring buoy enabling mooring of SIEVs to free up Christmas Island response vessel for ongoing surveillance duties
  13. Commonwealth to prioritise completion of hydrographic survey of Christmas Island in near future
  14. RHIB jet intake protection to be allocated high priority with ongoing investigation of possible solutions to reduce blockage problem
Full text
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