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Defence Publications

Sea King Board of Inquiry

Implementation Plan


The Defence implementation strategy details the steps Defence will take to achieve the aims of the 256 individual recommendations of the Sea King Board of Inquiry (BOI) and how we will address the underlying issues highlighted in the report.

Under the wide ranging Terms of Reference, Defence 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.

Defence welcomes the report and views the recommendations as an opportunity to further improve Defence's current high standards of operational performance and safety.

The Report includes many far ranging recommendations for cultural and organisational change to improve Navy Aviation safety performance and to make improvements in some areas of the Australian Defence Force (ADF) aviation that will require the engagement and commitment of senior Defence leaders.  To ensure these changes are implemented, the Chief of the Defence Force (CDF) has directed that the following five step strategy be adopted;

1.      A specialist Implementation Team headed by a Senior Officer has been established to ensure adequate governance and that the recommendations are properly implemented.

2.      The Implementation Team will develop implementation strategies for each recommendation including milestones for achievement and measures of success.

3 To ensure the highest level of oversight, the CDF has directed that this Implementation Team report to the Chiefs of Service Committee, the most senior management group in ADF quarterly.

4.      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 Report's recommendations.  Additionally, achievements against the recommendations will be detailed in future Defence Annual Reports.

5.      In order to ensure the survivors and families of the victims are kept fully informed of our progress in implementing the recommendations, CDF has directed the Implementation Team offer to brief them on a quarterly basis.

Recommendation themes

Defence has accepted all 256 recommendations of the report which can be broadly grouped into the following eight themes:


•  There are 35 recommendations to improve the ADF Airworthiness system. Significantly the Chief of Air Force, as the ADF Airworthiness Authority, has initiated a strategic review of the ADF Airworthiness Management System that will consider the structure of the organisation that manages airworthiness, the effectiveness of current airworthiness processes and the adequacy of resource allocations to a number of significant airworthiness areas.

Command, Control and Communication

•  The BOI identified a number of areas for improvements in the Command, Control and Communications during its examination and made 37 recommendations in this area that range from the command and control arrangements for flights and detachments to the overall management of Aviation within Navy.

Engineering and Logistics

•  26 recommendations for improvements in Engineering and Logistics areas were identified by the BOI. Improved crashworthy seats are being installed along with improvements to Sea King fuel systems. Support documentation is being reviewed and deficiencies corrected.

General Administration and Personnel

  • The BOI made 45 recommendations after examining areas of general administration and personnel support, including support to survivors and families of deceased ADF personnel.

Maintenance Management

•  Deficiencies in maintenance management were a significant contributing factor to the accident and the BOI made 13 recommendations to address the identified problems. Navy initiated a Maintenance Reinvigoration Program in 2005 that has already achieved 68 of the 72 action items targeted for improvement. These include enhancements to improve maintenance safety and culture, and altering squadron maintenance structures to ensure appropriate levels of supervision. A program has also been established to educate staff about human factors in maintenance and correct maintenance practice.


•  There are 45 recommendations for better management of ADF operations. Recommendations include: the management of cargo during contingency operations such as humanitarian aid flights; the need for greater intellectual rigour in managing risks during highly dynamic operations; and improvements to communications procedures and systems when operating in remote areas.

Safety and Safety Management

•  There are 14 recommendations to address Safety and Safety Management issues. Defence has already implemented significant improvements to its safety management systems since this accident occurred. Navy has already introduced improved safety climate and culture surveys in Navy aviation squadrons, improvement to personal protection equipment is being examined, and better systems to audit safety trends and communicate operational hazards are being developed.

Aviation Training and Skills

•  There are 40 recommendations to improve Aviation Training and Skills of personnel ranging from junior sailors to senior officers involved in aviation management. Recommendations include education and competency improvement programs, and continuation training programs at the aviation squadrons.