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Series of errors in Sea King crash
By CMDR Philip Machin
Volume 50, No. 11, June 28, 2007 |
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INQUIRY: Sea King SHARK 02 which crashed on Nias island.
Photo: PO Kaye Adams |
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The primary cause of the SHARK 02 Navy Sea King helicopter accident was a failure of mechanical linkages within the flight control system.
This occurred following the incorrect re-fitting of a nut and split pin during maintenance performed on the aircraft some two months before the crash.
The resulting separation of parts was a result of a series of errors and non-compliances with the maintenance regulations.
These were the main findings of the Sea King Board of Inquiry report released in a media conference at HMAS Kuttabul on June 21 in which the Chief of the Defence Force, ACM Angus Houston, the Chief of Navy, VADM Russ Shalders, AO CSC RAN; and Fleet Commander RADM Davyd Thomas participated.
VADM Shalders said that while the primary cause of the accident was the failure of mechanical linkages, there were also contributory causes including:
- Deficiencies in maintenance practices in both the Sea King detachment and 817 Squadron;
- Errors made by the Naval command and management systems; and
- Deficiencies in the levels of support provided by Navy and the Defence organisation’s safety, airworthiness, training and logistics management systems.
ACM Houston outlined measures adopted to prevent a recurrence of the accident – measures which RADM Thomas said were already being implemented.
“I fully support the report outcomes and have directed a five-point strategy for the implementation of its recommendations,” ACM Houston said. “A specialist implementation team has been established to verify that the recommendations are fully implemented.
“An implementation plan has been prepared and, to ensure the highest level of oversight, I have directed the implementation team to report quarterly to the ADF’s most senior management group, the Chiefs of Staff Committee.
“In addition, to continue the policy of openness and transparency maintained throughout the Board of Inquiry, public updates on the progress of implementing the recommendations will be given.
“Finally, I have also directed that the survivors and families of victims are to be kept fully informed of the progress in implementing the recommendations.”
RADM Thomas said the Navy had not waited for the release of the report to begin the process of improving safety practices.
“In August 2005, I initiated a Navy Maintenance Invigoration Program to address safety issues and concerns within the naval aviation community that required immediate attention,” he said. “Seventy-two action items were targeted for improvement and 68 of these have been implemented.”
The BOI report makes a total of 256 recommendations that can be broadly grouped into the fields of airworthiness; maintenance management; command, control and communications; engineering and logistics; administration and personnel; operations; safety and safety management; and aviation training and skills.
VADM Shalders said, “We will learn from the painful mistakes of the past, and we will do that by tirelessly improving our operational competence, risk management procedures, leadership and safety culture.
“The Board of Inquiry report has provided us with vital recommendations for improving all areas where we have been revealed as deficient.
“Above all, what this accident has taught us is that we must move forward from a CAN DO mentality to a CAN DO SAFELY attitude.
“The Australian Defence Force has a justifiably high reputation for its operational excellence.
“It is self-evident that our operational performance is built, in part, on ensuring safety of our personnel and we are determined to prevent accidents like this happening again.”
The report can be found at http://www.defence.gov.au/sea_king_boi/
| The SHARK 02 crash occurred on April 2, 2005, while the aircraft was carrying out humanitarian aid operations in response to tsunami and earthquake disasters on the Indonesian island of Nias. The aircraft was operating from HMAS Kanimbla at the time. Nine Navy and Air Force personnel were killed. Two survived but were seriously injured.
Those who died were:
LEUT Matthew Davey
LEUT Matthew Goodall
LEUT Paul Kimlin
LEUT Jonathan King
PO Stephen Slattery
LS Scott Bennet
SQNLDR Paul McCarthy
FLTLT Lynne Rowbottom
SGT Wendy Jones
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