The coronial inquest into the fatal explosion onboard a boat carrying Afghan asylum seekers in April 2009 began on January 25. Five people died and many were injured.
Evidence has revealed the navy did not fit asylum seekers with life jackets. It misled them about where they were being taken. When the drowning and injured tried to climb into navy lifeboats, they were pushed — even kicked — back into the sea. All of these facts finally came to light.
But the blame remained pointed squarely at the refugees.
The inquest is being held in Darwin by Northern Territory coroner Greg Cavanagh. It opened with a "summarising statement" given by Stephen Walsh, who was assisting the coroner, which said: "It is possible in fact probable that the engine was sabotaged and that petrol was poured or deliberately leaked into the bilge and subsequently ignited by a lighter or match."
But the inquest has also exposed navy conduct that challenges its role in so-called border security.
The boat known as SIEV 36 was carrying 47 Afghan men and two Indonesian crew when it was intercepted by the navy on April 15. It was being taken to Christmas Island when it exploded without warning. The inquest heard that when navy personnel boarded the vessel and began towing it, nobody told the passengers where they were going.
Walsh's submission said the government had announced the boat would be taken to Christmas Island, but "CO [Commanding Officer Brett] Westcott said that he had not been informed of this policy."
Instead, a note to the crew, which was discovered by the passengers, said: "You should now consider immediately returning to Indonesia with your passengers and not enter Australian territory."
The asylum seekers feared the boat was being taken back to Indonesia and became distressed and agitated.
When the boat was ripped apart by the explosion, almost everyone on board was thrown into the sea.
Walsh said evidence suggested lives could have been saved, but the navy rescued its own crew and even kicked refugees away from lifeboats.
Video footage of the explosion, which had been kept confidential, was finally presented to the inquest. The January 26 Age said it showed "navy rescuers in four inflatable vessels bypassing asylum seekers struggling in the area in the minutes after the explosion".
Many of the refugees could not swim and were badly injured. Life jackets that had not been used floated in the water nearby.
The coroner heard on January 25 that navy lifeboats rescued their own crew first. Walsh said: "Some [asylum seekers] may have lost their lives because of the delay."
The inquest heard on January 28 that a navy officer forced two struggling refugees away from a lifeboat in favour of rescuing another officer.
In her testimony to the inquest, Corporal Sharon Jager said: "I saw him raise one of his feet and connect with the asylum seekers. From what I saw it was the head."
The allegation of abuse of refugees after the explosion was made by survivors and widely reported by the media in September. At the time, defence minister John Faulkner was under pressure to publicly release the footage in question, which was taken during and after the blast.
Yet the coroner blocked its release, along with any internal defence investigations, because it would "prejudice due process", reported the Australian on September 11.
Soon after, the NT police accused at least one passenger aboard SIEV 36 of deliberately setting fire to the boat. The police said fuel in the bilge pump had been intentionally set alight, but survivors said it had been an accident from someone smoking.
The police "conclusion" followed five months of unfounded and pre-emptive accusations from politicians and the media.
The coroner is yet to release the rest of the footage — including what happened in the lead up to, and after, the explosion.
Before the inquiry began, on January 21, Cavanagh also held up an application from the navy to keep some evidence from publication. ABC Online said it included aspects of the navy's "border security procedures", such as its use of force, the maximum speed of patrol boats and Australian fishing zone surveillance.
The gag was supposedly in the interests of "national security".
An inquiry by the defence department, which was submitted to the coroner's inquest, found "failings" in Australia's "border protection".
Officers like Jager were put in a situation for which they had little or no training, it said. Defence personnel were ill-equipped for the "job" of preventing refugees from reaching the Australian mainland.
The burnt and injured had not even made it to hospital before politicians and media accused them of deliberately starting the blaze that led to the explosion. Whether it was an accident or the actions of desperate and traumatised people was lost to fearmongering and demonisation of the asylum seekers.
Yet, all evidence suggests the tragedy could have been avoided and five lives could have been saved if defence had acted differently.
But the role of the defence force in the government's anti-refugee policy is what needs to be investigated — and its practice abandoned.
This horrific event shows what can happen every time a boat is intercepted.
It is always distressing for the people on board.
It is always dangerous.
The inquest will continue for several weeks, but there will be no justice if refugees risking their lives on dangerous sea journeys continue to be subject to such treatment.