Sea King Board of Inquiry
PREFACE
EXECUTIVE SUMMARY
TABLE OF CONTENTS
CHAPTER 1: Conduct of the Board of Inquiry
CHAPTER 2: Biographies of the deceased members and the survivors
CHAPTER 3: Background to the accident
CHAPTER 4: A Discussion on responsibility and accountability
CHAPTER 5: The final flight of Shark 02 and the rescue of the survivors
CHAPTER 6: The primary cause of the accident and associated issues
CHAPTER 7: Immediate contributory causes of the accident
CHAPTER 8: Analysis of the maintenance activities
CHAPTER 9: Non-compliant maintenance practices within the 817 Squadron
CHAPTER 10: Management of noncompliant practices by CO 817 Squadron
CHAPTER 11: Naval Aviation FEG HQ Support of 817 Squadron
CHAPTER 12: Maritime Headquarters Support to 817 Squadron
CHAPTER 13: The Defence and Navy safety system
CHAPTER 14: ADF Airworthiness management system structure
CHAPTER 15: Naval Aviation maintenance training continuum
CHAPTER 16: Logistics support system analysis
CHAPTER 17: Previous Australian Defence Force Boards of Inquiry and investigation recommendations
CHAPTER 18: The manner and cause of death
CHAPTER 19: Non causal issues
CHAPTER 20: Compensation and remediation
CHAPTER 21: Conclusion