Media Room: Defence Speech

 

REPORT OF THE BOARD OF INQUIRY INTO THE CRASH OF BLACK HAWK 221 RELEASED

 

Media Briefing held by Chief of the Defence Force,

Air Chief Marshal Angus Houston AC AFC, and the

Chief of Army, Lieutenant General Ken Gillespie AO DSC CSM

Tuesday, 15 July 2008

 

E&OE

 

ANGUS HOUSTON:           

Well, first of all, this is a sad day for the Australian Defence Force. I'm going to report to you on the outcome of the Black Hawk Board of Inquiry. And, of course, later today Chief of Army and I will go to Amberley to participate in the ramp ceremony for the return of Signaller McCarthy from Afghanistan. So, thank you all for being here this morning.

 

In late 2006, elements of the Australian Defence Force were deployed to the southern Pacific Ocean as part of Operation Quickstep. Our forces were on standby to possibly evacuate Australians from Fiji in the lead up to the military coup. The ADF task group comprised the frigate Newcastle, together with Kanimbla and Success. The ships carried evacuation handling teams, medical staff and a Special Forces contingent supported by a Black Hawk helicopter detachment from 171 Aviation Squadron. 

 

While deployed, the helicopters were routinely conducting flying training to maintain air crew and passenger currency. Some of this training involved performing special operations assaults. The aim of the special operations assaults that were flown was to deliver Special Forces troops on to a specific target area quickly and at the first attempt in order to maximise surprise and minimise exposure to threat. 

 

On the twenty-ninth of November 2006, after 25 days at sea, an Australian Army Black Hawk helicopter was conducting a training flight when it crashed onto the aft flight deck of HMAS Kanimbla and fell into the sea. Nine of the ten service personnel were rescued from the water. One of these nine personnel, Captain Mark Bingley, the pilot, later died from his injuries. Trooper Joshua Porter, a passenger, was unaccounted for and presumed dead. His body was recovered from the seabed on the fifth of March 2007. 

 

As you are aware, I commissioned a Board of Inquiry to determine the cause of the crash. Boards, or Commissions of Inquiry provide commanders with information on incidents that affect our people, assets, training and policy. For the first time an open Board of Inquiry into a military aircraft accident was presided over by an independent civilian, the Honourable Mr David Levine, a retired New South Wales Supreme Court Justice.

 

His approach ensured a rigorous examination as to what happened, why it happened and what was required to prevent a similar occurrence in the future. Everyone involved was placed under the microscope by the board.

 

The principal and overarching finding of the Board of Inquiry was that the cause of the crash of Black Hawk 221 was pilot error by the aircraft captain. Justice Levine made it clear, however, that this principal finding would not be viewed in isolation, nor blame attributed to a highly experienced, dedicated and very well respected Black Hawk pilot.

 

As is often the case, the accident was the result of a combination of factors. The board found that pilots in 171 Squadron had progressively adopted more demanding flying profiles in support of Special Operations. The pilots were flying on, or close to the limits of the aircraft, thereby reducing or eliminating their margin for error. The board stated those involved genuinely believed what they were doing was authorised and the risk properly managed.

 

Special Operations missions are inherently dangerous and carry significant risk. These

operations require a very fine balance between safety and achieving the mission. The Squadron's can-do attitude meant that they were taking greater risks to achieve their missions. This led to an erosion of their safety standards.

 

I want to be absolutely clear that the President, the Honourable David Levine, and his board recommended that no administrative or disciplinary action be taken against any one individual. This tragic accident was the culmination of a number of factors. In addition to the gradual adoption of approach profiles on the limits of the aircraft, these factors included a can-do culture, inadequate supervision, the pressure of preparing for operations, the relocation of the Squadron to Sydney and a high operational tempo.

 

The Board of Inquiry into the crash of Black Hawk 221 made 58 recommendations to reduce the risk of further incidents of this nature occurring again. I have agreed to 56 of these recommendations, all aimed at making Special Operations flying safer. These recommendations include external auditing of the Squadron and redesigning the Special Operations approach.

 

Two recommendations were not accepted. Recommendation 7G related to developing generic ship-helicopter operating limits for deploying Special Forces to non-naval vessels. The recommendation was not agreed to as the Australian book of reference, Ship-Helicopter Operations Manual, already provides guidance to approaches for non-naval vessels. Recommendation 9B referred to the carriage of passengers and was not agreed because this was already covered in recommendation 9A.

 

While the board was in session a Black Hawk helicopter experienced a heavy landing in East Timor in June last year. On receiving the board's report, which included reference to the East Timor incident, I ordered a safety audit of all rotary wing aircraft in the Australian Defence Force. I have just received a copy of this audit report. I am pleased to say this report found there is a high degree of safety system compliance within Navy and Army aviation units, both at home and on deployment in Afghanistan and Timor.

 

However, the audit report does identify that our helicopter Squadrons are working very hard and we face competition to retain our pilots. I will closer monitor these issues along with the Chief of Navy and the Chief of the Army. The audit report has also found that 171 Squadron is now operating with appropriate safety margins and is being adequately supervised.

 

Army has already put into place a number of initiatives to improve safety in the Squadron. Army issued its new risk management policy in October of 2007. It provides commanders with clear instructions on how to conduct risk management on operations and training. This means that units conducting high risk activities are now required to have higher authorisation and more detailed planning. 

 

The Special Operations approach has been reviewed by test pilots from the Aircraft Research and Development Unit. They have developed a procedure that provides pilots with clear instructions on how to conduct Special Operations approaches whilst maintaining appropriate safety margins. Army has fully incorporated these instructions into the orders and manuals that all pilots are required to adhere to. 

 

Furthermore, a new headquarters known as 6 Aviation Regiment was established in March this year. 6 Aviation Regiment now commands 171 Squadron and is providing strong and experienced leadership. 

 

In conclusion, the Australian Defence Force remains committed to continuing to have one of the most capable counter-terrorism and hostage rescue forces in the world for the protection of all Australians. To ensure we maintain this capability, the training that our counter-terrorism forces conduct must be as demanding and realistic as is possible. However, this board of inquiry report highlights that this training must strike the right balance between safety and achieving the mission.

 

A copy of this comprehensive board of inquiry report is available on the Department of Defence website. Copies of this report have been given to the families of Captain Bingley and Trooper Porter and we have also briefed the other Defence members and units involved in this incident of the inquiry outcomes. 

 

Of course our thoughts today are with the families of Captain Bingley and Trooper Porter. I hope this report answers some of the questions they may have about this tragic accident and the circumstances surrounding the loss of their loved ones. At the express request of Mrs Bingley and Mrs Porter, I ask that members of the media respect their privacy at this difficult time.

 

I would like to thank all those involved in the recovery of Trooper Porter. This was an extremely challenging task. It was, however, very important for us to bring this soldier home and for his family to properly lay him to rest. I would also like to thank the Special Forces personnel and members of Kanimbla for their efforts and bravery in helping to rescue and treat the crew and passengers of Black Hawk 221.

 

The Chief of Army and I will now take your questions. Thank you.

 

 

QUESTION: 

So your description of the safety audit sounds rather sanguine in its findings compared to the litany of failures and inherent systemic and cultural problems identified in the board's report. Are you saying that all of those have been eliminated between October last year and today? That that culture has been turned around?

 

ANGUS HOUSTON:

Yes, essentially I am. I think if we reduce this to the bare essentials, the problem was in how the Squadron was conducting special operations approaches. Over a period of time, some years, they had gradually started to conduct the approaches so they got faster and faster and faster. This was obviously to achieve their mission, which was to maximise surprise and minimise vulnerability to potential ground fire from terrorists or whoever they were going against.

 

As they gradually got faster and more mission focused, their margin for error gradually reduced - their safety margin was reduced. And as a consequence, we ended up with a set of circumstances where one mistake was going to end up in an incident or at worst an accident, as happened on this occasion.

 

Now, what has happened since is that we really focused on that part of the flying activity, we've made it much safer by getting the Aircraft Research and Development Unit involved to design a new approach. We're insisting that all the pilots fly that approach. It's slower than the old approach but it's much safer than the old approach, and the Squadron will be audited every six months to make sure that pilots are adhering to the required standards. Those standards have also been published in all the documentation that guides flying activity.

 

Now, what I have to say is one of the things that the board found was that in just about every other respect the Squadron was doing okay. They were very safety focused, they were very focused on being professional in everything they did. What happened here was a bunch of young, highly motivated, can-do pilots who wanted to perfect the mission so that they achieved the mission results in a way that satisfied the requirements of the Special Forces, in getting them in quickly with maximum surprise, minimal vulnerability to anybody who might be opposing them, and they were really captured by this requirement and they essentially degraded their margin for error.

 

That's what happened on this occasion. So when you introduce a tail wind, a large tail wind, you end up with the circumstances that happened on that day.

 

QUESTION: 

Just to clarify, did it say they were safe or that they believed, honestly believed, they were safe? 

 

ANGUS HOUSTON:

They honestly believed - this was a point brought out by the board. They honestly believed that they were operating safely. And it really needed somebody to point out, hey, this mission focus is going to get you into trouble at some stage in the future and, as we saw, it did, on that occasion and again in East Timor shortly afterwards.

 

QUESTION: 

Air Chief Marshal, you say the problem was confined to this Squadron, yet this report says, quote, it's due to the systematic failures within Army Aviation. Which is it? 

 

ANGUS HOUSTON:

Well, the accident was due to a multiplicity of factors, but the accident happened in that critical phase, the Special Operations approach. We bring out - in fact, the report brings out the can-do attitude as a factor, it brings out poor supervision as a factor, it brings out the fact that the Squadron was or had been relocated from Townsville to Sydney and it also brings out the demands of a very high level of operational tempo.

 

Fundamentally, Army Aviation, the Black Hawks, had been on operations almost continuously for the last 10, 15 years. They had to deploy overseas, Timor, they operated for a while in the Solomon Islands and, of course, they're currently operating in Afghanistan. And while all this was going on, there were countless disaster relief operations, they provided forces to the tsunami relief, they went into New Guinea last year to do operations. And, of course, while all of this is happening they had to maintain that vital counter-terrorism capability back here in Australia, to handle a terrorist incident should it arise here in Australia.

 

QUESTION: 

CDF, the report's findings state that the Black Hawk helicopter engines are susceptible to significant main rotor droop if mishandled by the pilot, whilst unsatisfactory characteristic main rotor droop can be avoided if flight manual limitations and recommendations are adhered to. Given the nature of the flying operations conducted by 171 Squadron personnel, are you saying that this was an accident waiting to happen for years?

 

ANGUS HOUSTON:

What I'm saying is that they - they eventually got to a situation where they were flying on the absolute limit, okay? Look, military aviation is different from civil aviation. We have to fly in a way to conduct a mission, but we've got to fly it safely. They went past the balance, the right balance between safety and mission achievement. So they were going for - going for the best possible outcomes to satisfy the mission and at the same time as that was happening, over a period of years, the safety margin gradually reduced until they were flying on the absolute limit.

 

What happens then if you make a mistake? Well, there's no margin to look after you. You're going to have an incident and at worst an accident and, that's what happened in these circumstances. Now just to get to the rotor droop, the rotor droop is something that happens when you fly the aircraft very aggressively at the end of the approach, when you put very, very quick and very high demands on the engines and the engines have to spool up very quickly. And, if you're demanding the engines to spool up very rapidly to arrest descent, to slow down, you're going to get rotor droop. And again, that's what happened in these circumstances.

 

QUESTION: 

The incident in East Timor, was that a repeat of this?

 

ANGUS HOUSTON:           

The incident in East Timor was a Special Operations approach. It was completely different in that it happened at night, and the target that was being used for the special operations approach was the middle of the airfield at Dili; it was a big flat open area. So, the pilot on this occasion, he did rehearsals during the day time, he essentially flew the approaches in the day time, he planned meticulously, he then went up on night vision goggles and flew the approach on night vision goggles.

 

Now, flying under night vision goggles is more demanding than flying during the day time, or indeed flying when you've got good peripheral vision. It's a demanding activity. During the approach he probably failed to detect about a nine knot tailwind and, again, he came in, he was flying close to the limits with a tailwind, that took him over it and he landed heavily.

 

So, to that extent, it's similar to what happened on Kanimbla. I might add that this pilot, in order to maintain his proficiency in Special Operations approaches, had flown to that spot 40 times in his deployment to Timor.

 

QUESTION: 

Air Chief Marshal, can you tell us when all these recommendations are going to be implemented and give us a feeling of how much has already been done?

 

ANGUS HOUSTON:

Well, a lot of the - some have been completed already, but most of them are in-train. And the Chief of Army is deeply committed to completing them as quickly as possible. Now that's obviously going to take a period of time, but we would like to see almost all of them complete within 12 months, and most of them will be done, I think the vast majority will be done within six months. 

 

QUESTION: 

Sir, there are a couple of recommendations in the 15 range which, if adopted, would carry considerable expense, and that is fitting flotation devices and something you might explain, a DECU compatible engine. 

 

ANGUS HOUSTON:

Yeah.

 

QUESTION: 

Is that something that has been considered and is Defence predisposed to investing in that?

 

ANGUS HOUSTON:

The DECU is a digital engine control unit. At the moment it, it's an analogue system. A digital system will be more responsive in terms of rotor droop and so on. In terms of the flotation, there is a recommendation that we have another look at that. We'll be having another look at it. But as the - as the board brings out, Black Hawks only spend about three per cent of their time over water, and there are substantial penalties associated, in capability terms, if we fit the flotation gear.

 

And with the replacement of the Black Hawk with the MRH 90 just round the corner, we'll have to have a good close look at that. So we'll review it, and, I'd have to say, I'd be very surprised if we end up fitting the flotation gear, because of the factors that I've mentioned to you.

 

QUESTION: 

Sir, were you surprised that this can-do attitude developed on your watch?

 

ANGUS HOUSTON:

I think that one thing you've got to understand about people in the ADF, they always, they always say can-do. What's important here is can-do safely. I want people to have a can-do attitude, that's why we do so well in environments like Afghanistan, Iraq, Timor, the Solomon Islands. What's important in all environments that is can-do safely, and that we assess the risk associated with any activity that we do and we manage and mitigate those risks so that we can-do safely.

 

QUESTION:

Is there an attitude that, like, safety's for sissies?

 

ANGUS HOUSTON:           

Sorry?

 

QUESTION:

Is there an attitude that safety is for sissies? You know [indistinct]?

 

ANGUS HOUSTON:

No. No. Not at all. I think that, as I, as I said earlier on, it's about getting the right balance between achieving the mission and doing it safely. And that's one of the reasons that the rotor wing audit went to Afghanistan, went to the ship out in the Northern Gulf and went to Timor. What we need to have while we're conducting operations is that right balance, because if you over-focus on the mission and you forget about safety, you end up losing people and you end up losing equipment. And we don't want that.

 

So it's, it's a very fine balance, because a lot of what we do, particularly in the operational environment - and bear in mind these people were preparing for operations, it's high risk, and it's all about finding the best way to manage that risk so that we have the appropriate margin for error, the appropriate safety margin.

 

QUESTION:

Sir, and how have the families responded to the report?

 

ANGUS HOUSTON:

Well, General Gillespie and I spoke to Mrs Bingley last night and also Mrs Porter last night. They're very pleased that we're doing this today. And they had no particular issues with the report. They're just very pleased that it's being, it's going out to the people of Australia today.

 

QUESTION: 

Do they accept the findings?

 

ANGUS HOUSTON:

They didn't have any - any particular issues. And I would just reiterate again, they both said to me and to the General that they would appreciate being left alone at this difficult time. They want to - they want to sort of reflect on the report, they both got a copy of the report and, I guess, over the coming days they'll - they'll read it in its entirety and they don't want to be taking questions. They just want to get on with the rest of their lives. 

 

QUESTION: 

[Indistinct] elaborate on the respect and the [indistinct] experience of Captain Bingley?

 

ANGUS HOUSTON:

Captain Bingley was a very, very experienced pilot. He was very highly respected and he'd performed very well over a number of years. Let me just say that, you know, I'm a pilot myself. All pilots will make errors from time to time, and I guess the trick is to avoid the error at a critical time.

 

QUESTION:

…quite technical terms in the report. For someone who doesn't understand those terms, could you just clarify exactly what happened when the helicopter [indistinct]?

 

ANGUS HOUSTON:

Well, the helicopter was, was essentially first of all it was, it was over the sea and an approach was being flown to HMAS Kanimbla. The captain was sitting in the left seat and he turned left to position for an approach to the ship. He approached the ship with a 10 to 15 knot tailwind and he flew the approach quite fast and with the tailwind was unable to arrest the rate of descent and the speed of the helicopter. And as you've seen in the video, he hit the deck with a fair bit of forward speed and a fairly high rate of descent. So that's fundamentally what happened.

 

QUESTION: 

Air Chief Marshal, the report is very strongly worded when it talks about systematic failures within the Army, as well - in the Army Aviation, as well as unacceptable level of complacency. How do you personally describe this report? 

 

ANGUS HOUSTON:

Well, I think it's a good report. You've got the executive summary. I'd invite you to go through the report in its entirety and, in terms of the reference to complacency, that was in relation to the acceptance of tail wind. That was the specific against which that term was used. So again, we come back to - most of this was focused on the way they were conducting these Special Operations approaches. 

 

QUESTION:

In finding Captain Bingley primarily in error, are you not passing the buck a little bit given that the report also said that inadequate supervision and eroding of standards and this sense of complacency. Surely, someone higher up the food chain has to take that [indistinct].

 

ANGUS HOUSTON:

Well, if you have a look at the report, and you - I presume you've got it there, it says that the prime cause of the accident was pilot error by the Captain, but it was very quick then to point out that there was a multiplicity of factors that were at play here. And they included this can do attitude, this lack of supervision, this movement of the Squadron from one location to another, and the operational tempo. So that is covered in a lot of detail in the full report and, again, I'd invite you to have a look at that.

 

In terms of where we go from here, the Chief of Army and I, our responsibility is to fix the problem. We've accepted all the recommendations bar two, and as I said, the reason we're not accepting the two is because they're actually already covered elsewhere.

 

We've conducted a rotary wing audit right across the ADF - every single unit in the ADF - to make sure that we've got compliance with safety standards, and we are approaching the business of flying our missions with safety in mind and doing it in the safest possible way. The Chief of Army back in 2007 completely revamped Army's approach to risk management, not only for helicopter operations but right across the board in Army, and they now have a very robust risk management framework which will stand Army in good stead into the future.

 

The Defence Air Safety Manual has also been completely revamped. That's a manual that has policy, authorisation and procedures that relate to safety and all of the - all of that policy, all of those procedures are pooled into the one manual. That was issued by the Chief of Air Force on the seventeenth of March this year.

 

And finally, in terms of supervision and leadership, what we've done is we've created a new aviation regiment, 6 Aviation Regiment, with a very strong commander. A commander who will, basically, insist on the highest standards of airmanship, the highest standards of safety and, I believe, will guide the Squadron in getting the right balance between achieving the mission and maintaining appropriate safety margins.

 

And then, finally, we have got the aircraft research and development unit to design an approach which will give those safety margins. Unfortunately, if you have a look at the report, it talks about an exclusive reliance on pilot judgement. Up until now, those approaches were really flown on the basis of relying on the pilot to judge the approach properly in all circumstances. What we've got now with this new approach that Army has embraced is a series of matrix and check points during the approach where the pilot can check how he's going against the parameters that have been laid down by the test pilots from the aircraft research and development unit.

 

QUESTION: 

So - so doesn't this incident make a case for the Special Operations Command to have their own dedicated helicopter support? Given the special training that's involved?

 

ANGUS HOUSTON:

No, I don't think it does. I think that what's important is that we have a robust command system, and I think that's been put in place with the creation of 6 Aviation Regiment, and I think what's vitally important here is that, sure, there should be some sort of relationship with the Special Operations Command, but I think it's very important that the command chain go through probably the Commander, 16 Brigade to the Chief of Army, probably through the Land Commander to the Chief of Army. And I think that's the vital link.

 

QUESTION:

Sir, just one…

 

ANGUS HOUSTON:

I'll take after that one more question.

 

QUESTION:

You're off to Amberley today.

ANGUS HOUSTON:

Yeah.

 

QUESTION: 

As you mentioned, the US has had its heaviest loss there in a 24-hour period. Has there been any change in the last 72 hours or so to Australia's Force protection or disposition in Oruzgan that takes account of those developments, coupled with the Signalman McCarthy incident?

 

ANGUS HOUSTON:           

Well, I have to tell you, I think that our Force protection is very robust. If you have a look at it, we have the Reconstruction Task Force, which is built around two engineering teams. About 18 months ago, we put in an infantry company to support them. So that's organic to the Reconstruction Task Force and those infantry go out there and do assertive patrolling in the areas where the Reconstruction Task Force is working. And that is proving to be a very successful mission, in that we're engaging the people, we're winning the hearts and minds of the people that we're working with.

 

Now, while they're working, we then have the Special Operations Task Group which work around - more broadly around the area where the Reconstruction Task Force is working. Their operations are intelligence led. They're targeting the Taliban, the leadership, the bomb makers and they're keeping them well and truly on the back foot.

 

And what we're seeing is that, from time to time, Improvised Explosive Devices will be laid, and, unfortunately, that's just a reality of the environment that we're in. But I think we're holding the initiative and we're well and truly keeping the Taliban on the back foot in our province. And, I think, if you have a look at the recent history of our deployment, they generally come off second best in any engagement we have, and they're resorting to the bomb attacks, rather than taking us on face to face.

Last question, thanks.

 

QUESTION: 

Is there any further comment on Signalman McCarthy and will you be attending his funeral on Friday?

 

ANGUS HOUSTON:

Well, both of us are going to the ceremony this afternoon, and the Vice Chief of the Defence Force will represent me at the funeral on Friday. Of course, the Chief of Army will be at both ceremonies and will essentially host both ceremonies.

 

QUESTION: 

Got anything to say about Signalman McCarthy?

 

ANGUS HOUSTON:           

Well absolutely. He is a first class soldier. As I said here about a week ago, a very professional soldier. A soldier that was doing extremely well in his chosen specialty of being a Signaller, and as I mentioned last time, he was commended for his performance under fire in very demanding circumstances. He maintained a situational awareness, and conducted himself with great skill and great courage in demanding circumstances. We've lost a very fine young man. I feel his loss and, at this time, my heart goes out to his family who will have a very difficult day today.

 

The Chief of Army and I are going up to support the family at Amberley later today. I might add, both of us have spoken to his father, David McCarthy, and we will - we'll look forward to meeting him later today.

 

Thank you.

 

 

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