Chief of Navy, Vice Admiral Russ Shalders AO, CSC, RAN, today released the Board of Inquiry (BOI) Report into the loss of Navy helicopter 'SHARK 02' , which crashed on Nias, Indonesia on 2 April 2005.
Nine Navy and Air Force members were killed and two seriously injured in the accident. The flight crew and medical personnel were providing humanitarian aid as part of Operation SUMATRA ASSIST II following the Nias earthquake.
Under the wide ranging Terms of Reference, the Navy Appointing Authority empowered the BOI to not only examine the factors that directly contributed to this tragic accident, but to also critically examine many other associated areas including operations, flight safety, logistics support and personnel management.
"After a meticulous examination of the evidence presented during the inquiry, the Board concluded that the primary cause of the accident was a failure of the flight control system. A key component of the flight control system was not properly secured during maintenance, which resulted in the pilots losing ability to control the aircraft. This was the result of a series of errors and non-compliances with Maintenance Regulations" Admiral Shalders said.
"In the opinion of the Board change is required to improve aviation safety. I agree with this conclusion and the ADF views the recommendations as an opportunity to further improve Defence's current high standards of operational performance and safety.
"The loss of nine Navy and Air Force personnel is deeply felt. This accident was a tragedy and only by learning from our mistakes can we demonstrate that they did not die in vain. We will honour their memories by making flying safer," Admiral Shalders said.
The report includes several far-reaching recommendations for cultural and organisational change to improve Navy Aviation safety performance and to make improvements in some areas of ADF aviation that will require the engagement and commitment of senior leaders.
Chief of the Defence Force, Air Chief Marshal Angus Houston AO, AFC, said he was personally committed to ensuring the implementation of all the Board's recommendations.
"I have established a dedicated Implementation Team headed by a Senior Officer to ensure that the recommendations are properly implemented. I have also directed that the Implementation Team provide a quarterly report on their progress to the Chiefs of Service Committee, the most senior management group in the ADF.
"Defence will continue the policy of openness and transparency that it has maintained throughout the BOI period by providing routine public updates on its progress in implementing the Board's recommendations. This progress will also be detailed in subsequent Defence Annual Reports.
"In order to ensure the survivors and families of the victims are kept fully informed of our progress in implementing the recommendations, I have also directed the Implementation Team offer to brief them on a quarterly basis.
"The ADF Airworthiness System is a robust system but we must learn from the mistakes of the Sea King tragedy.
"A review of the airworthiness system is currently underway. The review is wide ranging and will look at, among other things, the need to improve and strengthen the auditing, compliance and intervention aspects of the system," Air Chief Marshal Houston said.
Navy has not waited for the release of the report to begin the process of improving safety practices. A Maintenance Reinvigoration Program was launched in 2005 with seventy two specific aims for improving aviation safety. By 30 June 2007 , all but four of the tasks will have been implemented.
Subject to independent verification by the implementation team, 30 per cent of recommendations made by the Sea King Board of Inquiry have been completed and further 60 per cent will be complete by December 2007.
Improvements to date include adjusting Navy flying rates to ensure safe operations; the institution of programs to educate Navy staff about human factors in maintenance and correct maintenance practices; and the alteration of Navy Squadron maintenance structures to ensure appropriate levels of supervision.
The Sea King's manufacturer Westland Helicopters, has also been commissioned to improve fuel system components and install new crashworthy seats into Sea King aircraft by December 2007.
Next of Kin and the NSW Coroner have been briefed on the Board's findings and recommendations. The Defence Community Organisation will continue to offer ongoing support to the families of those who were killed and also to the survivors of the accident.
Defence Public Affairs
02 6265 3343
Information current at 15 June 2007