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Release of Shark 02 report
Volume 49, No. 11, June 28, 2007 |
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SHARK 02: The Navy Sea King which crashed on Nias Island, Indonesia, on April 2, 2005. Recommendations from the Board of Inquiry into the accident will be implemented by the ADF.
Photo by PO Kaye Adams |
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CAF AIRMSHL Geoff Shepherd has confirmed his commitment to implementing all relevant recommendations from the Sea King Board of Inquiry (BOI) report, which was publicly released on June 21.
The BOI made 35 recommendations to further improve the ADF’s airworthiness management system.
CAF, as the ADF Airworthiness Authority, has confirmed all the recommendations are being implemented.
“There has been a significant reduction in ADF aviation accidents since a single airworthiness management system was created in the 1990s,” AIRMSHL Shepherd said.
“However, any system, no matter how robust can always be further improved. We must learn from the Sea King tragedy and make the airworthiness management system even stronger.”
Navy Sea King ‘Shark 02’ crashed on Nias Island in Indonesia on April 2, 2005.
Three Air Force members, SQNLDR Paul McCarthy, FLTLT Lynne Rowbottom and SGT Wendy Jones, died in the accident, which also took the lives of six Navy personnel and seriously injured two others. It was the worst Australian naval aviation disaster of modern times.
The BOI found that the primary cause of the 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 Sea King some two months before the crash. This separation was the result of a series of errors and non-compliances with the Maintenance Regulations.
There were several contributory causes of the accident, including: deficient maintenance practices in both the Sea King detachment and 817 Squadron; errors made by the Naval command and management systems; and deficiencies in the level of support provided by Navy and the Defence Organisation’s safety, airworthiness, training and logistics management systems.
The report’s 256 recommendations are broadly grouped into eight different areas: airworthiness; maintenance management; command, control and communications; engineering and logistics; administration and personnel; operations; safety and safety management and aviation training and skills.
CDF ACM Angus Houston said he fully supports the report outcomes and has directed a five-point strategy for the implementation of its recommendations.
A specialist implementation team, headed by CDRE Tim Barter, has been established to verify the recommendations are fully implemented. An implementation plan has been prepared, and to ensure the highest level of oversight, CDF has directed the team report quarterly to the Chiefs of Service Committee.
AVM Neil Smith has begun a wide ranging review of the airworthiness management system, which focuses on how the BOI’s key airworthiness recommendations can be actioned.
This review is examining:
- The current airworthiness management system structure;
- How airworthiness management system processes, such as audit, compliance and intervention processes, can be further strengthened; and
- What further resources the system needs.
In line with the policy of openness and transparency maintained throughout the BOI, there will be public updates on the progress of implementing the recommendations. This will include updates in the Defence Annual Report.
CDF has also directed that the survivors and families of the victims will be kept fully informed of progress.
The Sea King Board of Inquiry report is available at www.defence.gov.au/sea_king_boi/
| Board of Inquiry results |
- The Sea King Board of Inquiry (BOI) has made 35 recommendations to improve the ADF’s airworthiness management system.
- A review to focus on how the recommendations can be actioned has begun.
- The review will examine the airworthiness management system structure, how processes can be strengthened and what further resources are required.
- There will be public updates on the progress of implementing the recommendations. |
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