Immigration officers Wilfred Baira, 38, Ted Cyril Harry, 54, and passengers Valerie Saub, 34, Flora Enosa 34 and her daughter, Ethena Enosa, 5, died on October 15, 2005, when their poorly equipped and shoddily built government boat, the Malu Sara, sank en route between Saibai and Badu islands.

Family members wept in the Thursday Island Court House last week as State Coroner Michael Barnes said none of those on board were at fault, and were the victims of shocking and incompetent mistakes made by police, boat builders and the Department of Immigration.

Mr Barnes said their deaths were a "totally avoidable" disaster that would not have happened "if any one of a number of those involved in purchasing, building, operating or searching for the vessel had faithfully and diligently discharged his duties".

Mr Barnes recommended disciplinary action be taken against Garry Chaston, the Department of Immigration’s regional manager, and Sergeant Warren Flegg, the officer-in-charge of the search who did not believe the vessel was sinking and who failed to report the information to rescue co-ordinators in Canberra.

"When no help came and the engines failed and water leaked into the supposedly watertight bilge faster than it could be pumped out, it is likely the boat capsized and soon sank," State Coroner Michael Barnes said.

"The wretched dread of a mother seeking to cling to her terrified child as they were dumped into the dark and wild sea is too terrible to contemplate."

The ship’s captain, Wilfred Baira, began making distress calls more than 12 hours before when the vessel became lost in fog in the early evening of October 14.

Mr Barnes said Mr Baira was an experienced seaman who did not contribute to the disaster and had acted bravely on the night, even while he was being mocked by police and rescuers who did not believe his distress calls.

"The people lost when the Malu Sara sunk didn’t die because some unforeseeable, freak accident swept them away before anything could be done to save them. Rather, they died because several people dismally failed to do their duty over many months," Mr Barnes found.

"When the incident was reported to police and the national search and rescue authority, the danger to the people on the Malu Sara was continually trivialised, and reports of their worsening predicament were disbelieved, ignored and even mocked."

Mr Barnes was especially critical of Mr Chaston (pictured below), who, he said, had overseen the construction of the unseaworthy boats, did not fit them with vital safety equipment, such as GPS, and left the rescue operation in the hands of junior DIMIA officer Jerry Stephen.

Mr Barnes described Chaston as "incompetent and indolent" and said the former AFP officer had an abrasive reputation who had been dismissive of Torres Strait Islander staff.

"Mr Chaston said words to the effect; "the MMOs are two generations behind and would not be able to handle that type of equipment".

Mr Chaston said he couldn’t recall the conversation… but he offered the opinion that "quite a number of MMOs were not ‘technically minded’".

"I find Mr Chaston did make those comments and I reject the sentiment they reflect," Mr Barnes said.

Mr Barnes said Mr Chaston "wilfully, recklessly or negligently" did not tell the boat builder the vessels would operate in open waters, failed to test the vessels for seaworthiness, failed to fit appropriate safety equipment, failed to train crew and wilfully provided regulators with false information about the vessels’ use.

Mr Barnes said Chaston also allowed the Malu Sara to go on its ill-fated voyage in heavy weather despite knowing the vessel had been taking water.

"The boat’s builder failed to meet the most-basic standards of workmanship, and concealed his defective work with false certificates of compliance.

"The hidden danger he created would have been detected and defused had the regional manager checked the boat complied with the terms of the contract for its supply, and ensured it had the necessary safety and navigation equipment.

"Instead, (Mr Chaston) rushed the defective vessels into service without ensuring those who were to cross miles of open ocean in them had been trained in their use."

Sergeant Flegg was also criticised, especially after he falsely tried to blame his failure to tell rescuers the Malu Sara on Mr Stephen, claiming it was the junior DIMIA officer who had failed to pass the information on.

"(Sergeant Flegg’s) attempt to manufacture an excuse for his failure to take appropriate action on being told the boat was sinking by seeking to shift the blame to Mr Stephen is reprehensible. The injustice and unwarranted recriminations that would have ensued had his despicable attempt not been thwarted are alarming to contemplate," Mr Barnes said.

Although Mr Barnes said he believed he did not have the power to lay criminal charges, it is believed charges may still be laid as a result of the scathing findings.

John Saub, whose daughter Valerie died in the disaster, said he welcomed the findings but he was still a long way from getting justice.

"There were so many mistakes made, that should not have been made. My daughter died because nobody cared about the boats, nobody cared how they used, nobody cared when they got lost," said John Saub, 52-year-old the father of Valerie Saub who now cares for her four children. "I’m so sad.

"The children have no mother, and Sergeant Flegg and Mr Chaston have never been punished. They should be locked up."

Wilfred Baira sister, Lily-Jane Shibasaki, said racism on the part of officials had played a part in the tragedy.

"I hope the government acts on all of the recommendations," Ms Shibasaki said.

Fred Joe, whose partner Flora and daughter Ethena died in the tragedy, also hoped criminal charges would flow from the findings.

"My daughter Rona was so young when she lost her mother and sister. All this could have been avoided," said Mr Joe, who was studying a science degree in Perth when the tragedy occurred.

"Flora was a kind and caring person. She liked fishing. She loved her community. She should not have died like this."

The families are preparing civil action against those involved in the disaster.

Mr Chaston was not present at the hearings at the Thursday Island Court House. It is understood he is on leave from the Department.