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Sea King Board of Inquiry

Rear Admiral Davyd Thomas AM CSC RAN

Thank you Sir, and good afternoon Ladies and Gentlemen.

Before I explain a little more about the Board's recommendations and how they are being implemented, it is important for the public to understand that the Navy has not waited for the release of the Report to begin the process of improving safety practices.

In August 2005, I initiated a Navy Maintenance Reinvigoration Program to address safety issues and concerns within the Navy aviation community that required immediate attention.

The Program undertook an ambitious plan to change Navy's aviation maintenance culture by tackling head on the things that contributed to the Nias accident. In establishing the Program there were 72 action items targeted for improvement. 68 of these have now been implemented. The nature of these improvements included:

•  Adjusting Navy flying rates to match available resources and therefore better ensure safer flying operations

•  The introduction of education programs across Navy aviation squadrons including the human factors associated with maintenance of aircraft as well as maintenance error management

•  Adjusting squadron maintenance work structures to ensure more appropriate and increased levels of supervision

•  Commissioning a group of independent experts to provide advice on the best way forward to rebuild Squadron morale, focus and communication after the tragedy

As with all cultural change programs, the full effect of change takes time. Nevertheless, we have already started to see improvement and this will continue to be independently monitored over the next three years.

In June last year, Navy also engaged the Sea King helicopter manufacturer Agusta Westland to determine how we could make improvements to both the existing crashworthiness of the aircraft's fuel system and passenger safety. These modifications have all been approved and include the fitting of energy absorbing troop seats and improved five point harnesses as well as enhancements to the fuel system. These will be installed through a rolling program in all Sea King aircraft, completing in December this year.

As Chief of Defence Force and Chief of Navy have both indicated Defence has accepted all 256 recommendations from the Board's Report.

The process of accepting the recommendations involved comprehensive review by those authorities identified by the Board as being areas that could implement improvement.

The Board's recommendations have been allocated to 27 Implementing Authorities who will be responsible for giving effect to these reforms.

Their responses have led to the development of an implementation plan that, as Chief of the Australian Defence Force has stated, has also been agreed by the most senior officers in Defence.

The 256 recommendations can be broadly grouped into eight themes:

Firstly, Airworthiness. This is Defence's overarching system for governing flying safety. There were 35 recommendations to improve the Australian Defence Force's Airworthiness system. Importantly, the Chief of Air Force, as the Defence Airworthiness Authority, has already initiated a strategic review of the ADF Airworthiness Management System. This review will examine its structure, the effectiveness of its processes and the adequacy of the resources allocated to Airworthiness. The Board believes these recommendations will also assist the other Services with their safety management practices.

Second. Maintenance Management. Deficiencies in maintenance management were a significant contributing factor to the accident, and the Board of Inquiry made 13 recommendations to address these identified problems. This involves reviewing matters such as maintenance error management, supervision of work, procedures and management of the Squadron quality assurance organisation, and formal guidance on briefing processes between maintenance managers working on a common job.

Implementing these recommendations will help us achieve our goal of reducing the number of maintenance errors to a minimum, and improve our ability to detect errors earlier and more consistently. Work is already underway.

Third. Command, Control and Communications. The Board of Inquiry identified 37 recommendations to improve the processes and practices involved in the management of naval aviation. This includes activities such as reviewing management structures within the Navy in order to better support flights at sea, and reviewing essential information flow requirements within those organisations involved in the management of safety and airworthiness. I can attest that there is now more scrutiny over squadron and flight activity.

Fourth. Engineering and Logistics. There were 26 recommendations for improvements to Aviation Engineering and Logistics identified by the Board. Work in this area encompasses issues such as crashworthiness improvements, a review of the composition of flyaway stores and tool kits in support of flights at sea, improved management configuration control of stores items, and a review of planned servicing schedules and documentation.

Fifth. General Administration and Personnel. The Board made 45 recommendations regarding general administration and personnel support. These ranged from the need to review information flow by the Defence Community Organisation to other authorities and families, directing ADF members to advise family registration details prior to any deployment, through to setting guidelines to ensure the timely forwarding of management audits to Fleet Headquarters. Many of these recommendations cover activities across the ADF and will serve to improve administrative management and support to our personnel deployed overseas, and their families, both now and into the future.

Sixth. Operations. The Board made 45 recommendations to better manage flying operations. These recommendations include the management of cargo during contingency operations such as humanitarian aid flights; the need for greater rigor in managing risks during highly dynamic operations; improvements to communications procedures and systems when operating in remote areas, and improved preparation schedules for short notice operational response squadron detachments to ships. Again, I can say many of these are already in train.

Seventh. Safety and Safety Management Issues. 14 recommendations were made to address Safety and Safety Management issues. Work being undertaken within this area includes the conduct of safety climate and culture surveys in Navy aviation squadrons in order to better measure the effect of our improvements program and change in culture; the development of improved systems to audit safety trends and communicate operational hazards and improvements to personal protection equipment.

Finally, Aviation Training and Skills. Last but not least, the Board made 40 recommendations to improve aviation training and skill development for personnel involved in aviation, ranging from junior sailors to senior officers. Actions include a review of training in risk assessment, a review of the maintainer's training curriculum, development of competency improvement and continuation training programs and consideration of the need to link promotion and qualification to consolidation of experience. It is in this area that an enduring understanding of proper maintenance practices is being further developed and reinforced across ranks and throughout careers.

Let there be no misunderstanding of the determination of my command, Navy, and Defence, to ensure these recommendations are implemented.

As Chief of the Australian Defence Forces has said, the Chiefs of Service Committee, chaired by the Chief of Defence Force, will oversee the implementation of the Board's recommendations.

In doing so, a dedicated and independent team, comprising engineers, aviators and other specialists has been charged with verifying and ensuring the implementing authorities complete their undertakings as the Board intended.

To date some 80 recommendations have been reported as complete, with the number scheduled to increase to 140 by the end of June. Our objective is for 90% of the Board's recommendations to be completed by the end of the year.

In any event let me assure you the Board of Inquiry Implementation Team will remain in place until all recommendations have been addressed.

Like the conduct of the Board itself, this next phase of recommendation implementation will be a transparent process with Defence providing quarterly updates to the public, via the Internet.

This level of accountability will ensure demonstrable improvement to aviation safety and highlights the personal commitment of senior Navy and Defence leadership to this part of the process.

In closing let me say the Board's findings and recommendations represent a most comprehensive examination into Defence Aviation Safety.

When combined with the accountability and commitment of Defence to fully implement them, I believe they form the basis for best ensuring that the circumstances that led to this tragedy never occur again.