Thursday 23 April 2020

COMPREHENSIVE PRESS INQUIRY OVERVIEW.

courtesy Trove



Daily Commercial News, 14 May, 1912.

KOOMBANA INQUIRY.
The Verdict.
At the inquiry into the loss of the
ill-fated steamer Koombana held at
Fremantle, Mr. E. P. Dowley presided,
and with him as assessors were 
Captains J. W. W. Yates and F. L. Parkes.
Mr. Frank Parker (Crown Prosecutor)
appeared on behalf of the Chief Harbor
Master, whilst Mr. M. L. Moss, K.C.,
watched the proceedings on behalf of
the Adelaide S.S. Company, owners of .
the Koombana.
After explaining that the usual Marine 
Court Inquiry was held to decide
some set out charge made by the Chief
Harbor Master against a captain and
or officers of a vessel and that at the
preliminary Inquiry held on the 22nd
April no such charges had been made,
Mr. Parker remarked that, in view of
the serious loss of life that had occur-
red through the loss of the Koombana
the Court had been called upon to
publicly investigate the loss of the ship,
and to decide whether any blame could
be attributed to any of the Company's
officials ashore.

Mr. Moss was alleged to have 'commended' Mr. Parker 'for bringing about a public investigation'. A devious move given that the emphasis on the public inquiry would be looking for fault with the owners, whom he represented. Mr. Moss, in effect hinted that the Adelaide Steamship Company would be exonerated; an outcome foretold.

Mr. Stevens, Acting Divisional Officer of 
the Commonwealth Weather Bureau from 
March 15th to 25th, during which time the 
Koombana disappeared, was the first witness 
examined.

He said that each morning he received
reports from Wyndham, Hall's Creek,
Broome, Derby, Cossack, Onslow, and
other places in' the North-West. Duplicate 
reports were sent to the Melbourne Bureau, 
and from that office the forecasts, based 
on barometer and thermometer readings, 
were issued at noon, Eastern time. 

These forecasts were received in Perth 
between 11.30 and 12 noon (Western time). 
If they were not received by noon each day 
the forecast was issued by the local bureau. 
If storms were approaching warnings
were issued to all stations in the vicinity 
of the storm centre. Later, on in the afternoon 
forecasts based upon more recent data were 
issued by the local bureau. 

No special forecast was issued from the 
Melbourne office of any storm from March 
16th to 21st, inclusive. On March 15th there 
was a monsoonal depression which had worked
S.S.W. to Port Darwin. By the 18th the storm 
had reached the neighbourhood of Derby, but 
in no cases were high winds recorded, and the 
lowest point the barometer recorded was 29.70.

This was an embarrassing admission given the scale of the Balla Balla blow.

Monday, 18 March, Captain Richardson of the steamer Paroo anchored at Depuch Island, noted that there was a heavy swell coming in from the NE, associated with an increase in ambient temperature and falling barometer readings. There could be no doubt in mariners' minds that a cyclone was brewing somewhere in the NE. Surely the data submitted from Cossack, 30 miles away, should have alerted the Bureau to the possibility of a storm developing?

A report from Port Hedland on the
20th stated that the wind force was
four miles an hour, with threatening
weather and smooth seas, and Cossack
reported a barometer of 29.69 with wind
each blowing at the rate of 19 miles an
hour. 

It is hard to reconcile the Port Hedland report with a half to full gale from the NE and a ground swell from the NW when Bullarra departed port, 20th March. 'Smooth seas' suggests misinformation or miscommunication. Either way the reporting system was flawed.

On the 20th at 1 p.m. Cossack
advised that a fresh gale was blowing,
with high seas and weather threatening. 
On the 21st, next morning, the barometer 
recorded 29.56, wind 37 miles an hour, 
and there were very heavy seas

So why then were 'no storm' warnings issued for this location and date, given the acknowledged data?

By the 21st, there was 'a howling hurricane' 30 miles away at Balla Balla.

The storm, from 15th to 21st March, 
went in a south-west direction,
and evidently struck the coast at Cossack 
and curved. The centre of the storm 
passed north of Cossack. There
was nothing to indicate that a cyclone
was approaching.

Captain Richardson of the Paroo reported otherwise. 

To Mr. Moss: The forecasts were thoroughly 
satisfactory, and the only delay in getting 
them from Melbourne was the time it took to
transmit the telegrams, which had precedence 
over all other matters. 

Pressed by Mr. Moss he admitted there would
be a saving of time if the reports were
made by the local bureau. 

This statement does not make sense. Time delay was minimal given the speed of telegram transmissions. The local bureaus were the agencies submitting the data in the first place. Perhaps the problem lay in collation of data and compiling forecasts?  

Very strange that the forecasting system was claimed to be 'thoroughly satisfactory' when a cyclone battered Balla Balla and surrounds and no storm was predicted or reported for this time period!

Continuing, he stated that apparently: the 
depression struck the coast somewhere 
near Cossack, and, being interrupted by the
coastline, and the width of the depression 
being narrowed, it resulted in a sudden storm. 
It would help if the various officers of the coast 
exchanged information direct, provided they 
understood what it conveyed. Postmasters, 
speaking generally, were very reliable in the 
matter of weather reports.

Postmasters were certainly better than the existing system which failed to forecast and acknowledge a full blown cyclone during the time period, 20 and 21 March. Referring to a 'sudden storm' does not correlate with the Paroo account; Moira and Bullarra logs.

 


There had been cases of delay in issuing 
forecasts from Melbourne. He could not 
form any ideas as to the velocity of the 
cyclone which wrecked the Koombana.
The diameter, he thought, would extend 
from Port Hedland on the north and Cossack 
on the south, or about 90 miles north-east by .
south-west.



courtesy Google Earth

Captain Upjohn, who had charge of
s.s. Bullarra, one of the vessels that
had a trying time in the hurricane, was
next called. 

Examined by Mr. Parker, he stated his 
vessel arrived at Port. Hedland on the 
18th March, and the Koombana entered 
port next day. Both vessels left on the 20th. 
About 8 a.m. on the 20th Captain Allen 
boarded the Bullarra, and in the course 
of a general conversation, said 

'What do you think of the, weather?' 

He replied that it would be dirty; but he didn't 
know if there would be anything in it. He
expected similar weather, or even finer,
on the voyage. 

The 'dirty weather' reference is intriguing. Dirty weather, generally, refers to storm conditions. Captain Upjohn hedged his bets by claiming that he did not know if the anticipated storm would be severe - 'anything in it' - or not. Adding a gambling element to the statement he suggested that the weather could be better than anticipated, thus justifying departure. A passing squall is a possible explanation for weather improving, but does not account for the groundswell from the northwest.

My feeling is that both captains, given all the indicators, suspected there was a cyclone brewing along the coast, but where, how extensive and in what direction it was heading, were the unknown factors. Part of the cyclone-gamble equation must surely have included discussions whether it would be better to confront such a system in port or out at sea?

It is said that the trend was to 'evacuate' the port ahead of a cyclone, which makes sense in the context of a vessel being wrecked on shore, in port. However, and this is important, Captain Allen expressed reservations about departing, stating that 24 hours would not make much difference. He was disinclined to put out to sea and with good reason - lives vs. material ship.

It is interesting to note that rule 4 for captains employed by the Adelaide Steamship Company referred to not 'endangering the ship', which staying in port might imply. Nothing in said rule book about lives.

It is also interesting to note that Captain Upjohn could simply have acknowledged the indicators heralding a cyclone, but justified departure on the grounds that it would be safer to confront a cyclone at sea than in port. 

Why didn't he opt for the more accepted approach?

Koombana was inherently top heavy and vulnerable in storm (cyclone) conditions; far wiser to remain in port - they all knew it and Captain Upjohn did everything to mitigate responsibility for encouraging Captain Allen to depart.

He had no discussion on the question of 
leaving port or otherwise. 

In this one sentence Captain Upjohn defied common sense, the most important issue requiring discussion and in so doing, telegraphed to the Court that he was not going to give up the truth easily. 

The Koombana sailed between 20 and 30 
minutes earlier than the Bullarra. When the 
latter left port the Koombana was in sight 
and was to be observed for about two hours. 

This statement was confirmed by a cattleman on board Bullarra who claimed that the two steamers were 5 miles distant, stern on to each other, at midday and Bert Clarke who watched the steamer from a tower near the port entrance. This also confirms that Koombana must have been relatively stationary, bow heading into the gale, while tanks were being filled, for this scenario to have been fulfilled.

He noticed how well the Koombana
behaved, and either he or the chief officer, 
who was on the bridge with him, remarked 
that she appeared in good trim. The propeller 
was well submerged, and she did not roll at 
all in crossing the bar. 

Captain Upjohn made his position clear to the Court that he was willing to abandon the truth to protect the reputation of the owners' top heavy steamer. The upper limit of the propeller was 16.5 ft. (as per plans) and with a draft aft. of 16 ft. (Port Hedland Harbour Master's claim), the propeller could not have been fully submerged. 

Even if one generously uses the erroneous claim by Captain Upjohn that Koombana's aft. draft was 17 ft. and the incorrect figure quoted for the upper limit of the propeller, 18 ft. plus, one still gets an exposed blade. Either way the propeller could not have been fully submerged.

It would have been an impossibility for a top heavy steamer not to roll crossing the bar with a ground swell coming in from the NW and a gale from the NE.

When they parted the Koombana was 
proceeding on her ordinary course for 
Broome. Between 2 and 4 p.m. the wind 
changed from northeast to east-north-east. 

A cattleman on board Bullarra observed that the inky, dark cloud mass indicating the position of the cyclone lay on the western horizon, in which direction they were headed. What is interesting about the changing wind directions is that it strongly suggests Bullarra steamed into the inferior aspect of the cyclone tracking towards Balla Balla from the north-northwest. 

At 4.20 the engines were slowed, and at 5 p.m. 
he altered the Bullarra's course and stood out 
to sea. 

And in so doing steamed into the centre of the system.

At 6 a.m. the barometer had been at 
29.50, and it then began to fall gradually, 
though it did not flicker. Between 8 and 
10 p.m. a heavy gale was blowing and 
the sea running high. The ship began to 
labour heavily, and things were getting 
serious. He did not take, any particular 
notice of the barometer until about 10 p.m. 

He did not have to consult the barometer to know what was happening.

He had been chief officer of the Koombana
for about 12 months, and during that time 
had experienced some very heavy weather 
when she was lightly laden. She was a magnificent
ship, and a splendid seaboat. 

What is most interesting about this statement is protesting Koombana's virtues and stressing that 'when lightly laden' Koombana was stable in 'very heavy weather'. This, after all, was the very core of contention and the most likely cause of the disaster; an issue that this employee of the Adelaide Steamship Company was determined to protest and defend in order to avoid reparations.

He had searched for the Koombana and 
found portion of a motor launch, etc., which
he was certain belonged to her. All the 
Bullarra's boats had been damaged.
The only explanation of the loss of the
Koombana he could offer was that she
was smashed up by the force of the
cyclone. He considered it impossible
for her to have 'turned turtle.' 

And there we have it. Impossible to 'turn turtle' was the very thing most likely to explain the steamer's loss. Using the word 'impossible' was ridiculous. The fact that Koombana steamed away from the cyclone, not into it, was neatly dodged by all participants of this farce.

It was the worst cyclone he had 
experienced, and it was a miracle that the
Bullarra lived through it.

But the ageing steamer had survived the cyclone.

Mr. Moss now handed in a telegram
sent from Port Hedland on March 20th,
and was signed 'Upjohn' and 'Allen.'
It referred to the painting of buoys,
the matter Captains Upjohn and Allen
had under discussion. Proceeding,
Captain Upjohn stated it was untrue
that he and Captain Allen had had a
conference about the weather. 

What was taboo about discussing the weather and changes already observed? It was the most likely topic of discussion, in addition to the buoys of course. Denying the obvious did not make sense and confirmed that Captain Upjohn was not a reliable witness.

He was sure Captain Allen did not state he
'would be lucky to get to Broome,'
which he was credited with saying.

Omitting the word 'by' Saturday, convenient to introduce an element of doubt in Hedland Advocate reporting. How could be be sure about a statement if he was not, at all times, in Captain Allen's company?

Going back to the question of the
search for the Koombana the witness
remarked that in latitude 19.11, longitude 
119.25, about 27 to 37 miles from
Bedout Island, one evening they saw
what looked like a portion of the deck
of a vessel, but it proved to be the
shape of a ship outlined by an oily
substance such as would rise from a
sunken vessel, floating on the sea. They
had taken the specimens produced in
court as this spot. An awning spar
and one of the planks exhibited in
Court had also been discovered in close
proximity. Other article were picked
up about 20 miles from that spot.

Extraordinary that the 'oily substance such as would rise from a sunken vessel' was never pursued then and now. 27 to 37 miles was an error - 27 to 28 miles.

Chief officer James Crossley, of the
Bullarra, corroborated Captain Upjohn's 
evidence, and to Mr. Parker stated that 
when the Koombana went on her course 
he didn't see her propeller rising out of the 
water. 

Closing ranks. 

Answering Mr. Moss, Crossley stated that
the light on Bedout Island was out
when he went there. 

An issue and implication which should have been fleshed out in cross-examination.

It was the worst storm he had experienced 
in 15 years at sea, and he should have, 
thought it impossible for any ship to live in such
weather.

Except an old steamer like the Bullarra...

J. F. Morrison, a pilot, then gave
evidence as to the Koombana's 
equipment. Her boats and appliances 
were examined in January, and were in
good order and condition. He had
known Captain Allen 25 years. He
was a sound and careful navigator,
who took-no risks. 

This character reference was crucial testimony. Captain Allen was experienced, good at what he did, and careful. He echoed this judgment when stating that he 'was disinclined to go out due to the glass' (barometer). We know that he adopted a very cautious approach to keeping ballast tanks full when crossing the bar - stability vs. bar strikes. He, therefore, must have been extremely unhappy about departing Port Hedland that day with all tanks empty; but if he were to depart, he had no choice. A damaging bar strike could have been catastrophic. 

Why was Captain Allen then coerced by Captain Upjohn to depart Port Hedland, 20 March, when it went against his better judgment? 

One can only surmise that there was a degree of schedule pressure, but perhaps more significantly, Captain Upjohn had challenged Captain Allen by claiming that Koombana was the far better steamer and he had decided to depart in the more inferior Bullarra. It was directly after this that Captain Allen decided to go:


Captain Allen Koombana: "I do
not like the look of the weather. 
Captain Upjohn; what do you intend 
doing?"
Captain Upjohn (Bullarra): "I have
made up my mind to go out and your
boat is a far better one than mine."

Captain Allen: "Well, if you intend
going out, I do not suppose it will do
for me to stop here."

On her first, trip from the North-West 
she came into port with a list. Speaking 
to Captain Rees, the then master, he 
learned that the cattle deck was filled with
cattle, and one of the tanks was
empty, the latter being due to the fact
that the engineers had not the proper
'hang' of the tanks. 

One could almost view this statement as breaking ranks and cheekily confirming that Koombana had top heaviness issues when all ballast tanks were not filled and weight concentrated high up in the hull - i.e. the cattle deck.

The Koombana was a well-built ship, 
and such weather might never be 
experienced again in a lifetime.

Cyclones / willy willies were well known on the Nor'West coast in the summer season. It was a bizarre implication that Koombana was not designed to survive significant cyclonic events - occurring  'once in a lifetime'.

M. J. Williams, Marine Superintendent 
for the Adelaide S.S. Company
in Western Australia, gave evidence
as to the loading of the Koombana,
and all particulars of cargo shipped.
He was of the opinion that the cargo
had not shifted.

H. J. Clarke, one of the Company's
wharf managers at Fremantle, in 
answer to Mr. Parker, stated that for
fifteen months he occupied the position 
of chief officer of the Koombana.
He came out from Glasgow with her,
and had gone in her from Fremantle
to Geraldton in the teeth of a howling
gale, and she behaved very well indeed. 
He had also been in her on the New 
South Wales coast when the wind
was right on her beam, and only her
ballast tanks were full. They drove
right through it, but it was blowing
so hard that they could not go up to
the wharf and had to lay in stream at
Watson's Bay with both anchors down.
As to her end, he was pf the belief that
she had been battered to pieces. He
believed that she went through the
storm but was so knocked about that
she foundered. He didn't think it was
possible for the vessel to be blown 
absolutely over. 

A common theme among Adelaide Steamship Company employees denying the obvious and protesting the steamer's virtues.

Answering Mr. Moss, witness said the 
stability and trim indicator in Court was 
the invention of Mr. Ralston, the head 
draughtsman at the yards where the 
Koombana was built, and a man with 
one of the best reputations in such 
matters in the United Kingdom.

Praising a designer and design which was not present on board when Koombana departed Port Hedland for the last time. Irrelevant to the case.

To Mr. Parker: Sometimes he had
been asked to empty one of the tanks
so as to produce a list in order that
that coaling could be facilitated.

And in this one statement the truth revealed. The inherently top heavy steamer could be induced into a list by the simple act of emptying just one of her tanks. There you have it!

Chief Engineer Craig, of the s.s.
Bullarra, under cross-examination by
Mr. Moss, stated the Koombana's 
propeller was under water fully six or
eight inches at Port Hedland, and he
had heard nothing about the propeller
'flogging the air.'

A pointless exercise interviewing biased employees. In this case one can deduce that the Chief Engineer was referring to a draft aft. of 17 ft. or marginally greater - which was the incorrect figure supplied by Captain Upjohn.  Note that this would not have applied to the erroneous propeller figure of 18 inches.

 

Captain Upjohn and Mr. Crossley,
of the Bullarra, were now recalled to
explain a statement of the former 
regarding the barometer reading at noon
on March 21st. The Captain had said
the reading was 29.80, while the entry
in the log was 28.83. It was explained
that the latter reading was from the
chart-room glass, which was a low-set
instrument, with a 'fine weather' reading 
of 28.90, and the captain's reading
was taken from the commander's
glass, which was hung in his own
cabin. 

In reply to a question by Mr. Dowley, 
he said he did not know if the light 
on Bedout Island had failed prior
to the cyclone.

The Bedout Light was out from a week prior to the disaster. To say that these men did not know about it either speaks of gross negligence on the part of the Port Hedland port authority not notifying such; or a lapse in the chain of communication between Mr. Moxon, Adelaide Steamship Co, who acknowledged he had received the notification 1 week prior, and the Chief Harbour Master at Fremantle, Captain Irvine, who was then in turn obligated to issue a warning to all shipping in the region.

In fact Captain Irvine was disingenuous as regards the Bedout light and published this statement in the March Gazette:

 'Western Australia—North-West Coast. NOTICE is hereby given that the hurricane which passed over Bedout Island—lat. 19.35 S. 119.6 E.—on the 22nd inst., extinguished the unattended light established on this island in December, 1909. Further notice will be issued as soon as the lamp has been re-lighted. Charts affected. No. 1055—Bedout Island to Cape Cuvier. No. 1048—Buccaneer Archipelago to Bedout. C. J. IRVINE, Chief Harbour Master. Harbour and Light Department, Fremantle, 30th March, 1912.'  

The cyclone was NOT responsible for extinguishing the light!

Mr. Clark was now recalled and
questioned by Mr. Parker regarding
rumours 'prevalent in Fremantle.' and
deposed that no rails had been put
into the vessel as ballast, a reply which
elicited from Mr. Moss: ''Another
pavement expert's opinion exploded.'

In February 1910 Koombana heeled over to an alarming degree in a squall and took a long time to straighten up. Captain Rees decided that he would keep 150 tons of rails in the hold to assist ballasting and stability. These rails were not 'put in' but rather 'kept in'. Semantics exploited by the dramatic Mr. Moss.

The Court now had the evidence
given at the preliminary inquiry by
R. H. Arundel, Surveyor to Lloyd's
Register and the Marine Underwriters,
read. In effect the witness had come
to the conclusion that after leaving
Port Hedland making for Bedout, the
captain of the Koombana met the wind
northerly so strong that it prevented
him from getting to the north to go
round about; then finding it impossible 
to heave-to on his port tack, which was 
the proper tack, he must have adopted 
one of two courses: either to heave-to 
on the starboard tack or attempt to run 
across to the open water to the westward 
in the face of the disturbance. Witness was
of opinion that the disturbance came
over from a S.S.E. direction, and that
the Koombana before she reached 
Bedout, experiencing a wind direction N.
and E., was obliged to heave-to on
the starboard tack on the westward,
and in running west would get into the
centre of the cyclone. The finding of
wreckage to the westward confirmed
his opinion that she ran out to westward. 

A large portion of wreckage was found to the north of Bedout Island, not to the west. The cyclone coming in from the SSE was a crazy claim. The entire statement was intensely flawed.

He had formed the opinion the
Koombana was a 'tender' ship when
light, but perfectly seaworthy. 

At least one of the 'experts' had the decency to state the obvious. 'Perfectly seaworthy' was pushing it, though.

On the question of top-hamper he thought if
cargo was properly stowed and distributed it 
would not interfere with a vessel's stability.

Captain J. A. Rankin, Acting Marine
Superintendent for the Adelaide S.S.
Company, deposed he was stationed at
Adelaide, and referring to the Ralston
stability and trim indicator in Court,
he said it was used for, among other
things, determining the 'G.M.' the
generally accepted term for denoting
the stability of a vessel. The instrument 
could only be used for the vessel
it was designed for, and he had, when
he received it, tested the Koombana
on information supplied by Captain
Rees, when the vessel was in the lightest 
possible condition. The test gave
a result of plus 1ft. 6in., which was 
exceptionally good. If the vessel were
fully loaded with cargo, and coal and
all tanks were full, she could heel over
to an angle of 90 per cent, and even
then have a margin for recovery. 

Like the cyclone coming in from the SSE, there is an element of fantasy. 1 ft. 6 inches was simply not possible in the 'lightest condition possible'.

Before Captain Allen's departure from
Fremantle on his last trip he had sent
him (witness) a report showing the
distribution of a load of 712 tons, and
showing also particulars of draught
and trim. He asked the Court to make
the test from these particulars on the
stability and trim indicator in Court.
Captain Rankin then gave a 
demonstration with the indicator, which 
was closely watched by the Court and 
Counsel. He distributed the weights over
the plan in the indicator. The 'G.M.'
was plus 2ft. 1 1/2 in., and the result of
the second process almost exactly
agreed with the late captain's figures
for the draught and trim arrived at
by ordinary means. 

Answering Mr. Moss, the witness stated 
the Koombana was in many respects in 
excess of British requirements.

No other experts called to challenge the wildly optimistic GM figure.

Mr. A. C. Butcher, engineer for
harbour and lights in Western Australia, 
was next examined, and he said
that, in conjunction with Captain Rankin, 
he carried out tests, and the
curves of stability were particularly
good. The stability curves supplied
by the builders did not show such 
severe tests as those carried out by 
witness.

These curves should have been submitted to the Court as evidence as was done at the Inquiry into the loss of the Waratah and which could have been open to scrutiny.

 

The President of the Court then 
announced that he would be pleased to
take any evidence anybody might wish
to bring forward. Mr. Moss thereupon
remarked the Company was pleased at
the general invitation extended to the
public, as it would give any person who
had been circulating rumours concerning 
the ship a chance to show just what they 
knew of the matter.

Mr. Moss was a shrewd operator. Potential witnesses presented as 'circulating rumours' rather than making valid contributions; and 'showing just what they knew of the matter' implying that it was not likely to amount to much once he was done with them. The residents of Port Hedland must have been incensed at his attitude, and rightly so.

Before the proceedings commenced
on the second day Mr. Moss drew 
attention to the fact that Captain 
Upjohn had, in his evidence, stated the
Koombana's propeller was well 
submerged when leaving Port Hedland,
instead of 'not' submerged, as had
been reported and published.

A Freudian slip?

Mr. W. E. Moxon, Manager in Western 
Australia for the Adelaide S.S. Company, 
was then examined by Mr. Moss. He said 
the Koombana came under his supervision, 
and no special instructions were given to 
the late Captain Allen to push on, as the 
vessel ran on a time-table. 

Referring to the previous post was not Mr. Moxon embarrassed to make this statement to the Court? The 'time-table' was grueling and tide-dependent. Any delays had serious knock-on effects.

She carried a particularly small cargo up 
to Port Hedland, and the captain had plenty
of time to discharge cargo and do any other 
work necessary. 

A 'particularly small cargo' and empty ballast tanks reinforces the fact that Koombana departed Port Hedland, 20 March, in very light condition, drawing 16 ft. aft and 11 ft. forward. What 'other work' did Mr. Moxon have in mind? 

In the North-West trade the captains were 
'peculiarly responsible,' the company left
matters very largely in their hands.

In other words, Mr. Moxon washed his hands of any direct responsibility for decisions, good or bad, taken by Captain Allen.

 

His company's rule No. 4 stated that
'No order will be held to excuse the
endangering of the ship.'  

Again distancing himself from any form of culpability. Because the ship had disappeared without trace and known cause, a catch-22 situation was created. Neither Captain Allen posthumously nor the Company could be held accountable for the disaster. No reparations. 

If Koombana had been wrecked in Port Hedland due to a direct hit by the cyclone, there would have been no 'excuse' and the main reason why Captain Allen decided to go out. Damned either way but honouring his commitment to the Company rules.

Everything humanly possible had been 
done, by the company to find traces of 
the vessel and for succouring of any 
possible survivors. 

An empty echo of humanitarianism.

With reference to the report
published - in the 'West Australian'
from its Port Hedland correspondent
on April 4, he had received a letter
from the company's manager denying
that the ship rolled as she crossed the
bar, that the propeller was out of the
water, and that Captain Allen had said
he would ' be lucky if he got to
Broome.'   ...by Saturday.

Given the employees' collective testimony, the Company manager would say that, wouldn't he. 

He (the local manager) was
on board the Koombana in the last
hour before she left Port Hedland, and
he was not aware that Captains Upjohn 
and Allen had any conversation
with reference to the weather. The
glass was not more than 10 points 
below normal. 

A fortnight before there had been a fall 
of 60 points and nothing followed. 

Captain Allen wrote a letter home, a date coinciding with the above statement:

"It was dated March 8, and in it Captain Allen
said that he had got through the worst of
the season as far as the climate was concerned. 
"I just kept clear of a blow last trip,"
he added, "but as soon as I got round the
North-West Cape it started, so my luck was
in that time."

'Nothing followed' is not consistent with 'kept clear of a blow' (blow = storm)

They had discussed the question of the vessel 
leaving port on the top of the equinoctial 
spring tides, but the question of 'willy willies' 
did not arise during the conversation. 

This was the very crux of the Koombana dilemma. She was too large for ready access to Port Hedland; unless during the narrow window of opportunity provided by high water springs.

Captain Allen had remarked that with 
the stiff head wind blowing he would 
have no hope of reaching Broome in 
time to catch the following day's tide, 
and he would not be surprised if he 
were a day late, as he was not 
particularly keen on going into Broome 
at night time. 

What a gem. Finally we have a senior employee of the Adelaide Steamship Company admitting to the Court that Captain Allen did not believe that he would make Broome by the next day for no other reason than weather-related conditions - 'a stiff head wind'. Koombana was a very powerful steamer and capable of more than 14 knots. This statement acknowledged that she would not be making 10 knots or less.

Why?

Because the headwind in question was a gale not a 'fresh breeze', as claimed by Captain Upjohn at this Inquiry; a gale buffeting the significant top hamper (resistance) of a top heavy steamer; a gale from the NE associated with a groundswell from the northwest, signaling the presence of a cyclone.

Proof acknowledged!

Reference to a 'day late' refers back to the pressure of the tight tide-dependent schedule and a narrow window of access to these ports.

'Not particularly keen on going into Broome at night time' confirms that Captain Allen was cautious and not a risk taker. There should have been port pilots in ideal circumstances which the Nor-West certainly was not!  

The pearling luggers had come into port, 
but only on account of the dirty water caused
by the north-easterly blowing. 

Disingenuous and flouting the truth and risk presented. If it were simply a matter of dirty water surely some would have remained at sea until the sea cleared?

The pearlers said that by doing so they
had escaped the greatest disaster in
their history, as they did not expect
any hurricane. 

The man was shameless in his misrepresentations of the truth.

Captain Challoner, a pearler in the 
North-West, had reported that on March 
19 he was six miles from Bezout in a 
dead calm sea and glorious sunshine.

Bezout is not Bedout; two islands a considerable distance apart - 124 n miles. Again, taking the Court for fools.

From midnight the wind increased, and 
at 5 a.m. there was a big sea. From 2.30 
to 6 p.m. on the 21st there was a fierce 
hurricane, which was worse than the 'willy 
willies' of 1908 and 1910. From other 
reports received from the North-West
witness continued, it appeared that the
hurricane was one of the worst that had
ever been experienced. 

And yet it escaped the attention of the Meteorological Bureau.

Captain Dingle made a special trip in 
the Koombana in connection with his 
duties as marine superintendent, and 
said to witness on his return that he 
never wished to step on a better 
seaboat in his life, and he (Captain Dingle) 
considered on that trip she had been 
tested up to an extreme limit. 

The biased protests became quite boring in the scheme of things... How could Koombana have been tested to the 'extreme limit' if an extreme weather event was not encountered on that particular voyage?

The company had received a report 
from a magistrate at Broome that a 
statement had been made by a drover 
named Olive, that on the night of March 
20, when he was at Boyer's Camp, 
30 miles north of Condon, at about 
8 or 9 p.m. he saw two rockets go up 
in the direction of N.W. There was a 
hurricane blowing at the time. 

This was 82 miles to the northeast of Port Hedland which did not sustain any hurricane-force damage; the cyclone targeting Balla Balla 60 miles further to the southwest. Therefore it was unlikely that a 'hurricane was blowing'. It is an interesting report, though, and one that strongly suggested, if true, that either the disaster took place between Bedout Island and the coast or a lifeboat made it to this location. 

A report had also been received from 
a cattle station near Condon that copper 
air chambers had been picked up on the 
beach at Solitary Island.

These were from one of the lifeboats and Solitary Island is near Condon.

When a ship went to the North-West she 
generally took a very large supply of fresh 
water in her tanks, as well as salt water, as 
the former was very expensive at ports.

By deduction one can assume that this factor could have contributed to a free surface effect in incompletely filled fresh water tanks; in turn contributing to a 'dangerous' list.

 

The Koombana was last spoken to by
wireless on the night of March 19.

Actually it was the morning of 20 March, and the communication was with the Gneisenau, some 800 miles distant. This implies that had the communication system and operator been functional during the disaster, a distress call could theoretically have been picked up by the Gneisenau. This not being the case, points strongly to a sudden catastrophic event.

So far as he knew none of the internal
fittings had been found. All the wreckage 
found so far had been from the upper 
deck, and debris of boats. 

The surprising thing is that no cargo was discovered. If the ship had been battered to pieces as had Yongala a year before, one would expect contents from the holds to have formed part of the wreckage discovered.

The ship would be reported 'missing' by
Lloyd's. He would not like to express
any opinion as to whether there was
any material difference in the construction 
of the Bullarra, and Koombana.

Naturally he wouldn't. The new one foundered and the old workhorse survived. Bullarra did not have towering superstructure and ballast issues accessing Port Hedland.

Witness then referred to the importance 
of an efficient system of signalling being 
instituted on the Nor'-West coast, and was 
of the opinion that postmasters should 
exchange information every morning, and 
it should be available for shipmasters. 

A sensible suggestion, given the failings of the centralised meteorological bureau. 

He then stated that the Company had 
been informed that the Bedout light was 
extinguished on March 13, and was 
observed to be still extinguished on the 
14th and 15th. It was hard to say what 
bearing the absence of this light would 
have on the disaster. Their experience was that
self-attended lights were not to be
depended on.

Extraordinary statement! 'Bearing'? The ship striking the reef at night, which jutted 3 miles out from the island, for starters...Koombana would have to have averaged more than 10 knots to clear Bedout by dusk. With the headwind described this might not have been possible.

The Chief Harbormaster (Captain
Irvine) said inquiries had been made
in England and America as to the best
unattended light available, and eventually 
a Birmingham firm supplied the Bedout 
light, which was arranged to burn for 
12 months without attention, compressed 
acetylene being used. It started on December 
10, 1909, and up to the time of the recent failure 
had given entire satisfaction. It had never
been left for 12 months without attention, 
and when visited was always
found to be burning satisfactorily. The
first intimation he had of its failure
was on March 26, and telegrams were
sent to all ports advising them that
the light was out. 

As I have remarked, Moxon knew of the light being out from 13 March, but Captain Irvine only heard of it a fortnight later? Not likely. As I see it the problem was not with the unattended light but the monitoring of such. 

The notices to ship masters stated that 
the light was unwatched, and they were 
warned not to place too much reliance upon 
it. 

Then why bother to have it there in the first place if masters couldn't rely upon it? Ridiculous!

Continuing, Mr. Moxon said that in
his opinion the vessel did not strike
Bedout Island, as, if she did, wreckage
would be found. It was possible that
she struck it and foundered elsewhere.
I agree with this statement.

Mr. Parker hereupon asked for an
adjournment in order to secure a 
witness from Port Hedland. After some
discussion, during which Mr. Moss 
referred to the necessity for a limitation
being placed on the adjournments; but
stated the Company was not desirous
of shutting out any material facts, Mr.
Dowley adjourned the Court till the
following afternoon.

Nice try Mr. Moxon. If there was nothing to fear and the alleged 'busybodies' just that, there should have been no objection at all.

When the inquiry was resumed Mr.
Moxon; who was recalled by Mr. Moss,
read extracts from Interviews with
Messrs. McDonald and Fisher. Mr. Mc
Donald was for a time the chief engineer 
of the Koombana, and was sent to 
England to superintend the erection
of her engines, after which he came to
Australia in her, and Mr. Fisher was
for a time her third officer. Both gentlemen 
referred to her stability in laudatory terms. 
Mr. Moxon handed in to the Court a chart 
showing the location of the wreckage from 
the Koombana picked up by steamers and 
luggers.

Parading Company 'yes' men.

 

The witness from Port Hedland, William 
Patrick, clerk in holy orders, and
a member of the Church of England,
was then called by Mr. Parker. Witness 
stated that he was at Port Hedland from 
March 18 to March 25. He saw the 
Koombana arrive in Port Hedland on 
March 19, which was a very clear day 
and exceptionally hot. He saw the 
vessel leave Port Hedland on the 20th, 
but did not take particular notice of her 
propeller. The sky was very cloudy, the 
clouds were low, and there was a fairly 
strong breeze blowing. It was an easterly 
wind blowing, just a little stronger than 
usual. At the post office he heard people 
remark that the glass was steady and not 
too low. He had a conversation with Captain 
Pearson, who was a passenger for
Derby, and who did not expect any
thing in the shape of abnormal weather.
Witness did not think there was the
slightest truth in the statement that
Captain Allen had discussed the weather. 

Was the clerk of the church psychic as well? How could he attest to the fact that 'there was not the slightest truth in the statement that Captain Allen had discussed the weather'? He proved, without a fraction of doubt, that he was biased in favour of the Company, for whatever reason. But he did give important clues in the form of notable heat and wind from the east.

Captain Allen appeared to be a
little anxious, and seemed unwell, as
he was suffering from the heat.

Again, the clerk was not a doctor. How could he know if Captain Allen's anxiety and look of 'unwell' was heat or other related?

Witness regarded Mr. Gardener, Manager 
of the Adelaide S.S. Company at Port Hedland, 
as a very honourable man, whose reports 
could be thoroughly relied upon.

Again, bias confirmed and strengthened.

 

Mr. Moss then addressed the Court. 
He said that it had been shown
that the Koombana left Port Hedland
at half-past ten in the morning on the
top of the equinoxial spring tides. She
had her loading of 1,671 tons well 
distributed, a fact which had been well
proved.

What proof?

The evidence showed that she
was in good trim, and that the propeller 
was submerged. 

There was no 'evidence' to this effect.

It had also been clearly demonstrated 
that there was neither coal nor cattle on 
deck, 

Again, what evidence....

Chief officer Crossley, of the s.s. Bullarra
had said that, from the barometer,
there was no indication of a storm 
until it was upon them. 

Not likely.

Towards midnight the cyclonic conditions 
developed, the Bullarra then being on the 
way to Balla Balla. 

Balla Balla was a mere 55 miles from Port Hedland. Bullarra was 22 miles from Balla Balla at 4.30 p.m., 20 March. Midnight was another 7 1/2 hours later. What was this man thinking! I know what he was trying to suggest, though.

Mr. Crossley had expressed the opinion 
that it was a miracle that the 
Bullarra had come though at all, but 
then the Bullarra did not experience the 
same force of the cyclone as the 
Koombana must have encountered. 

Bullarra went through the blooming middle of the cyclone; how much more force was he talking about? Koombana was steaming away from the cyclone. There were no limits to the extremes this man was prepared to go to protect the Company.

It was stated that neither Captain Upjohn 
nor Mr. Crossley had experienced in the 
course of their lives such a gale. He thought 
that, in the interests of the public, something
should be said regarding the system of
forecasting the weather. It could be
improved on in a simple and inexpensive 
way. What was the use of sending out 
messages of warning to ship masters who 
had sailed the previous day? He would 
agree, however, that it was quite probable 
that it would have been impossible to send 
out warning on this particular occasion, 
because the storm broke so soon. It 
developed suddenly with an altogether
unexpected energy. 

A useful suggestion spoiled by references to a storm 'which developed suddenly with an altogether unexpected energy.' There were plenty of indicators.

He ventured to say that there could be 
no doubt in the mind of the Court but that 
the Koombana was a strongly-built ship.
The evidence showed that she was
superstrong. The Koombana had been
subjected to seven severe tests, and it
had been demonstrated that, had she
heeled over to an angle of 90 degrees,
she must have righted herself (water 
pouring in via every orifice). The
tests proved that even in extraordinary 
weather she was a vessel as stable
as any that had been built. They had
had evidence to the effect that it was
impossible to capsize the vessel. There
was the testimony of the witnesses 
Upjohn, Crosley, Clarke, Rankin, Craig,
and Butcher. He wished to direct special
attention to the evidence of Mr. Clarke,
who had travelled from Glasgow in the
Koombana and who was free from all .
bias. 

'Free from all bias' says two things; he was aware of the accusation and that there was in fact bias. 'Impossible to capsize the vessel' says it all - whitewash!

Mr. Clarke had said that he was
on board the steamer during a trip to
Geraldton in the teeth of a strong
north-westerly gale. She behaved
splendidly. What caused the disaster? 
In his opinion, the cause of the disaster
would be as great a mystery at the end
of the inquiry as it was at the beginning. 

Convenient.

There were many surmises which 
might be put forward, such as, Did she
graze Bedout Island or strike some hidden 
danger? In this connection, he would 
direct attention to the fact that the chart 
was not reliable, because that part of the 
coast had been imperfectly surveyed. 

Clutching at excuses.

He contended that the wreckage found 
negatived the idea that the
Koombana had been suddenly over
whelmed, but it did suggest that the
vessel had been subjected to a fearful
battering. 

Devoid of common sense.

It was also stated in the evidence that 
the Bedout light was out from March 13, 
and the question that suggested itself 
was that, in view of the condition of the 
coast, should an unattended light be so 
far from supervision? He cast no reflection 
on the Harbour and Lights Department, 
but were the port authorities satisfied that
the unattended light at Bedout was
safe? Should it not be attended to
more frequently?

Brave criticizing his strongest ally in this farce, Captain Irvine. 

The firm who supplied the light said that it 
was necessary.  It was possible that the vessel 
might have lost her rudder or propeller; but he 
was not inclined to that belief, seeing that evidence 
disclosed that they were 20 per cent, above 
requirements. 

Had a breakdown occurred in the engine-room, 
then there would have been very little chance of
the vessel surviving such terrible conditions as 
the Koombana must have experienced. 

It was the duty of the Court, from a public point 
of view, to see whether all that was possible had
been done by those directly concerned to trace 
any wreckage and succour any people who 
might be out on the sea.

It was the 'duty of the Court, from a public point of view' to establish that Koombana needed to be in too tender a condition to clear the bar at Port Hedland that day and that filling tanks at sea in gale force conditions was less than ideal, verging on dangerous.

 

He did not think such a charge could
be made against the Adelaide S S
Company. They had made almost superhuman 
efforts, and the Government was deserving 
of the greatest commendation for the part 
it had taken in the search for the missing 
vessel, and in which not only the Bullarra, 
but the Una, Gorgon, Moonta, Minderoo, and
four luggers were engaged. He did not
know what the finding would be, but
his suggestion was that the Koombana was
a steamer of the highest class and of
proved stability, encountered a hurricane of 
phenomenal violence, of which no warning 
was given, in a dangerous position, and was 
totally lost. The Admiralty said that no reliance 
was to be placed on the chart, and, in the 
circumstances, it was impossible to say
what caused the loss of the vessel.

Self congratulation on a scale such as this surely could not have gone down well with those who had lost loved ones with the ship.

On Friday, the Court delivered its
finding, which stated, inter alia with
regard to the personnel of the vessel,
that it was of the highest quality, and
both Captain Allen and the chief officer 
held extra masters' certificates, and
both were men of great experience on
the Australian cost. The Court was
satisfied that the Koombana in 
construction, stability, and seaworthiness
was equal to any vessel of her class in 
the Australian coastal trade.
The Court thinks it desirable that
telegrams regarding the weather should
be exchanged every day between stations 
while observations are made along the 
north-west coast; that information so 
obtained should be posted for general 
information; and that storm signals should 
be shown at all ports.

The Court simply finds, without indulging 
in useless speculation, that the stability 
and seaworthiness of the s.s. Koombana
were unassailable, and the
competency and carefulness of her master 
(Capt. Allen) beyond question; that after 
being lost sight of at sea on March 20, 
1912, her fate passes beyond human 
knowledge, and remains a mystery of
the sea.

Whitewash complete!!


courtesy Trove and
https://www.slp.wa.gov.au/gazette/gazette.nsf/gazlist/6205E4E859C7A3E548257C1D0015457F/$file/gg023.pdf

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