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Sea King Board of Inquiry

Vice Admiral Russ Shalders AO CSC RAN

At the outset, let me publicly and clearly acknowledge that Navy accepts full responsibility for this terrible accident. Nothing that I can say will bring back the nine young lives that were lost.

I commit to their families, to do everything within my power to rectify the problems we have discovered. We owe it to their memories to do nothing less.

Board of Inquiry

The tragic nature of this accident demanded a formal and comprehensive investigation into the cause of the crash, and all factors which contributed to it.

A Board of Inquiry was promptly established and it was mandated that the proceedings be open and transparent.

A number of you have followed the Inquiry, which was open to the public. Reporting on its proceedings has been extensive.

The Board was given wide Terms of Reference to ensure that their inquiry was not constrained in any way.

The Board was empowered to not only examine the factors that directly contributed to the accident, but to also critically examine all associated areas. These included operations, flight safety, logistics support and personnel management.

The Board deliberated for almost 20 months, considering evidence from more than 160 witnesses. It reviewed 560 exhibits and produced approximately 10,000 pages of transcript, all of which has been made available on the Internet.

The result of what was a meticulous examination is a 1700 page Report, which makes 759 findings and 256 recommendations.


When reading the Report, you will notice that a small number of paragraphs have not been released in the public version.

The changes were necessary for three reasons. Firstly, they were made in light of an independent legal review, secondly to protect private information relating to those who died and, finally, to limit release of operationally sensitive information.

The deletions do not affect the integrity of the Board's Recommendations. An explanation of what has not been released, and why, is provided in a Preface to the report.


The Board of Inquiry 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.

The Board found that there were a series of errors and non-compliance with internal defence maintenance regulations. These included:

•  Deficient maintenance practices in the Sea King Detachment deployed in HMAS KANIMBLA;

•  Deficient maintenance practices in the parent 817 Squadron at Nowra;

•  Aspects of support provided to the Squadron from the wider Naval command and management systems; and

•  Deficiencies in the level of support provided by Navy and the wider Defence Organisation's Safety, Airworthiness, Training and Logistics management systems.


Every one of the 256 Recommendations made by the Board has been accepted. We are now working to implement these recommendations.

The Board's Recommendations provide an opportunity to further improve Navy's operational performance and safety. Admiral Thomas will shortly detail how this is being achieved.


As Chief of Navy, it is my responsibility to ensure that the correct measures are taken to address the cause of the accident, and to ensure the safety of all our people who fly naval aircraft.

I take personal responsibility for this. I take personal responsibility for delivering the necessary actions demanded by the Inquiry.

Administrative Actions

The Board has made adverse findings against some current and former Defence personnel. Those men will be called to account, and that process has started.

I will use the powers of the Defence Force Discipline Act and the provisions of the relevant Defence Regulations to take the necessary action where warranted.

Action has already commenced against a number of those named, who range from junior sailors to senior officers.

The Inquiry was not a trial, and you will appreciate that I cannot publicly discuss the proceedings currently in train. That could prejudice the legal process and may deny natural justice and fair treatment for those against whom action is being taken.

I am able to advise that, if any person is found to have breached either the Defence Force Discipline Act or not met the standards expected of members of the Australian Defence Force, the sanctions can be severe, up to and including reduction in rank or termination of service.

I would also note that the Board has made it clear that, whatever the errors, omissions or deficiencies identified; they did not find any evidence of malicious intent on the part of those named.

Future Action

Navy has co-operated throughout the inquiry with the NSW Coroner and COMCARE, and both these organisations have made significant contributions to the Board outcomes. The NSW Coroner's Office has received a full copy of the Board of Inquiry Report.

Any decision concerning a future coronial inquest into the death of the Navy and Air Force members remains a matter for the Coroner.

In the course of the Inquiry, the Board found that the aftermath of the crash was compounded by explosions and a major fire which spread rapidly through the aircraft wreckage. This fire was fuelled either by engine oil or, butane gas cylinders which had been improperly placed on the aircraft. The carriage of butane on aircraft is prohibited.

The Board has identified that a civilian aid worker may have been responsible for placing these cylinders on the Sea King. As a result, this matter was referred to the Australian Federal Police, who continue to investigate this issue.


Navy has learnt, and will continue to learn, from the painful and fatal mistakes of the past. We will be tireless in focussing on improving our operational competence, our risk management procedures, our leadership and our 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 else, 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 the safety of our personnel and we are determined to do all we can to prevent accidents like this happening again.

Let me now introduce the Fleet Commander, Rear Admiral Davyd Thomas to explain how this will be achieved.