View the report as separate downloadable parts:
Members
Abbreviations
List of Recommendations
Executive Summary
Headcounts in relation to the death of Mr Mills
The investigation and scope for prosecution in relation to the death of Mr Mills
Areas for review and reform
Chapter 1—Introduction and Background
Referral of inquiry
Conduct of inquiry
Structure of Report
Background
Acknowledgements
Notes to references
Chapter 2—The maritime legislative framework
Background
The role of AMSA
Application of the National Law
Purpose of the National Law
Compliance and enforcement under the National Law
Changes to service delivery
National System Statement of Regulatory Approach
Marine Orders
Marine Safety (Domestic Commercial Vessel) National Law (Consequential Amendments) Act 2012
Chapter 3—Passenger headcounts as a safety measure
Coronial findings
Coroner's comments on public safety
AMSA's evidence on headcounts
Suggested changes to headcount requirements
Headcount method and prescription
AMSA's response to the coronial inquiry
AMSA's actions since 2014
Marine Order 504 and headcounts
Chapter 4—Investigations and scope for prosecution under the National Law
Western Australia Police investigation into the death of Mr Mills
AMSA response to WA Police regarding headcount requirements
AMSA response to WA Police recommendation regarding crew induction
Regular inspection and issue of direction notice – 2 November 2014
Suspension of the certificate of operation – 13 November 2014
DoT report to AMSA – 21 December 2014 – 29 May 2015
Investigation into alleged fraudulent certificates
Committee view
Findings and fallout between AMSA and DoT
Chapter 5—Coronial inquiries and the performance of AMSA
Inquest into the death of Ryan Harry Donoghue – Northern Territory Coroner's Court
Inquest into the death of Murray Allan Turner, Mason Laurence Carter and Chad Alan Fairley – Coroner's Court of Western Australia
Inquest into the death of Mr Daniel Thomas Bradshaw
Committee view
Chapter 6—Grandfathering arrangements and other areas for reform
Grandfathering arrangements
Committee view
Increased red tape, centralisation and complexity
AMSA's regulatory approach
Committee view
Labor Senators' Additional Comments
Appendix 1—Submissions and additional information
Appendix 2—Public hearing and witnesses