On 2 April 2005 a Royal Australian Navy Sea King helicopter Shark 02 crashed on the island of Nias , Indonesia , while participating in an Australian Defence Force (ADF) humanitarian aid Operation Sumatra Assist II. This accident resulted in the tragic deaths of nine ADF members and serious injuries to a further two.
The Maritime Commander Australia (now the Fleet Commander) Rear Admiral Davyd Thomas AM, CSC, RAN appointed a Board of Inquiry to determine the factors contributing to the accident and make recommendations for preventing a similar tragedy. The Board consisted of five people with expertise in ADF operations, aviation, engineering and psychology.
The Inquiry considered 44 Terms of Reference and was conducted in an open and transparent manner with public hearings and the hearing transcript published on the Internet. The Board deliberated for almost 20 months, considered evidence from more than 160 witnesses, reviewed 560 exhibits, conducted hearings over 111 days and produced approximately 10,000 pages of transcript.
The Board's Report was submitted to the Fleet Commander as the Appointing Authority on 18 December 2006 . The Board was officially dissolved by RADM Thomas on 11 April 07. It is approximately 1,700 pages long and consists of 759 Findings and 256 Recommendations for improving aviation safety.
Navy accepts that the accident should not have happened and takes full responsibility. Navy and Defence will fix the safety problems identified in the Report by implementing all of the Board's recommendations in full. Navy did not wait however, for the Report's release before beginning to rectify aviation safety problems.
Upon receipt of the Report, a Board of Inquiry Implementation Team distributed the Recommendations and Findings to 27 Implementing Authorities who assessed how the Recommendations could be enacted, their resource implications and what the estimated completion date would be.
In the period between the receipt of the Board's Report 18 December 2006 and the dissolution of the Board on 11 April 2007 the Board further reviewed the Report and directed that a number of changes be made. Some of these changes were made in the light of an independent legal review undertaken to ensure that the Report adequately addressed the Terms of Reference and that the conclusions were supported by evidence. Also, in preparing the Report for release minor corrections have been included where they do not make substantive change to the Report.
Further, some paragraphs and sentences are not published. Some of these are not published due to issues of jurisdiction of the Board and procedural fairness. These matters have been the subject of legal advice from senior counsel. In addition, some material has not been published because publication would be an unreasonable disclosure of personal information of the deceased or because of operational security. Details regarding the changes and the material which is not published are set out in a Preface and a Table of Amendments.
An Implementation Plan is being released along with the Report. Subject to independent verification, 30 per cent of recommendations have already been completed and a further 60 percent will be fully implemented by December 2007.By improving aviation safety, Navy and Defence will demonstrate that it has learnt from this tragedy.
Information current at 13 June 2007