A coroner investigating the deaths of some 50 refugees killed in a shipwreck off Australia's remote west coast ruled Thursday that the people-smugglers and crew behind the trip were to blame.
Coroner Alastair Hope said the accident, which killed 50 refugees from Iran and Iraq when their rickety ship was dashed on rocks in wild seas in December 2010, was Australia's worst peacetime sea disaster in 115 years.
Hope commended the "exceptional" bravery of local residents and defence personnel, some of whom risked their lives in an against-the-odds battle to pluck 41 survivors from the ocean, and cleared them of fault in the rescue.
One person made it to shore on his own.
Hope laid the blame with the smugglers who arranged the passage of 89 refugees from Indonesia via a heavily-trafficked sea corridor to Christmas Island, some 2,600 kilometres (1,612 miles) off Australia's west coast.
"Those persons provided the passengers with a vessel which was not suitable for the journey across open seas in the monsoon season to Christmas Island," Hope said.
"They did not provide enough lifejackets or other emergency safety equipment. The boat was overloaded."
The captain abandoned ship partway through the journey and the remaining three crew "appear to have been inadequately trained or qualified for such a journey" -- some of the "many safety deficiencies" found at the inquest.
Hope said the passengers had been "lied to" about "the quality of the boat which was to be used, the number of lifejackets which would be available and other matters bearing on the hazards associated with the journey".
However, he stopped short of ruling that the accident had amounted to unlawful homicide.
The conditions at Christmas Island's Flying Fish Cove were extremely severe and the coroner said "all on board were in great peril and faced possible death" from the moment the crew turned the ship west.
"The decision to turn the boat to the west into the weather was a fatal one in the circumstances," Hope said, likening the cove's unpredictable ocean swells to a washing machine.
"Had the boat travelled to the east, it is possible that it would have reached the relatively sheltered waters near Ethel Beach and the disaster may not have happened."
Hope's findings also revealed the victims' identities for the first time. The 50 ranged in age from 53 years to just three months old, and 15 were children aged 10 years or younger.
Defence Minister Stephen Smith said it was a "terrible tragedy" and recommendations from a number of other inquiries into the incident had since been implemented, including trial of a land-based radar at the island.
"The government will now consider the coroner's report in detail," Smith said.