Australian Sea King Board of Inquiry
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Australian Sea King Board of Inquiry
Suspect part blamed for Sea King tragedy
Simon Kearney and Annabelle McDonald
September 07, 2005
A SUSPECT piece of machinery that had been examined just two months before an Australian Sea King helicopter crashed in Indonesia in April has been blamed for the deaths of the nine crewmembers on board the aircraft.
A navy board of inquiry heard yesterday that the "bell crank" in the helicopter's flight control system had been reinstalled, not replaced, despite the objections of a technician.
Documents detailing the maintenance work on the part were now missing, said counsel assisting the inquiry, Captain Michael Slattery QC. "A bolt appears to have come out of that bell crank ... it was found some distance from the bell crank and buried in debris in a way inconsistent with the fire," he said.
Senior defence sources told The Australian last night they believed the bolt was not properly fitted nor checked before the aircraft was cleared to resume flying.
Captain Slattery also told the board the helicopter did not have enough helmets for its 11 passengers and crew and that the navy had refused to install new seating to improve its safety, after eight years considering the problem.
In his opening statement, Captain Slattery said a maintenance procedure on the part had been performed on February 3 after a junior seaman noticed that the bell crank had "lateral play" and reported it to his superiors.
The crank was removed while HMAS Kanimbla was at sea and Captain Slattery said it was later reinstalled, over the objections of the maintainer who had found the problem. Captain Slattery said the testimony of the maintenance supervisor was that the bell crank was "in the limits as specified by the documents".
However, the captain said documents - which should have been kept for the procedure - could not be found.
"There's no proper record of the removal of the bell crank and its reinstallation," he said.
Opposition defence spokesman Robert McClelland said the Defence Department should explain what went wrong.
Two reports by Defence Department investigators have now all but ruled out pilot error for the crash. "There is nothing that the pilots could have done by way of action or inaction to avoid the collision with the ground," Captain Slattery said.
The inquiry heard that on April 2, as Sea King Shark02 was coming in to land on earthquake-ravaged Nias, it suddenly nosedived into the ground from a height of 20m, sparking a large fire. Survivors Leading Seaman Shane Warburton and Corporal Scott Nichols had noticed nothing out of the ordinary until they both felt the tail of the helicopter kick upwards.
"The nose hit the ground somewhere near vertical," Captain Slattery said. "It hit first on the roof and then on the port side. Neither (survivor) can recall how they left the helicopter."
Indonesian witnesses saw one of the pair drag the other from the burning wreckage.
The two-month inquiry will focus on the missing bolt and the crashworthiness of the aircraft - which was put into service in the Royal Australian Navy in 1975 - in particular, the seating and the shortage of helmets.
Simon Kearney and Annabelle McDonald
September 07, 2005
A SUSPECT piece of machinery that had been examined just two months before an Australian Sea King helicopter crashed in Indonesia in April has been blamed for the deaths of the nine crewmembers on board the aircraft.
A navy board of inquiry heard yesterday that the "bell crank" in the helicopter's flight control system had been reinstalled, not replaced, despite the objections of a technician.
Documents detailing the maintenance work on the part were now missing, said counsel assisting the inquiry, Captain Michael Slattery QC. "A bolt appears to have come out of that bell crank ... it was found some distance from the bell crank and buried in debris in a way inconsistent with the fire," he said.
Senior defence sources told The Australian last night they believed the bolt was not properly fitted nor checked before the aircraft was cleared to resume flying.
Captain Slattery also told the board the helicopter did not have enough helmets for its 11 passengers and crew and that the navy had refused to install new seating to improve its safety, after eight years considering the problem.
In his opening statement, Captain Slattery said a maintenance procedure on the part had been performed on February 3 after a junior seaman noticed that the bell crank had "lateral play" and reported it to his superiors.
The crank was removed while HMAS Kanimbla was at sea and Captain Slattery said it was later reinstalled, over the objections of the maintainer who had found the problem. Captain Slattery said the testimony of the maintenance supervisor was that the bell crank was "in the limits as specified by the documents".
However, the captain said documents - which should have been kept for the procedure - could not be found.
"There's no proper record of the removal of the bell crank and its reinstallation," he said.
Opposition defence spokesman Robert McClelland said the Defence Department should explain what went wrong.
Two reports by Defence Department investigators have now all but ruled out pilot error for the crash. "There is nothing that the pilots could have done by way of action or inaction to avoid the collision with the ground," Captain Slattery said.
The inquiry heard that on April 2, as Sea King Shark02 was coming in to land on earthquake-ravaged Nias, it suddenly nosedived into the ground from a height of 20m, sparking a large fire. Survivors Leading Seaman Shane Warburton and Corporal Scott Nichols had noticed nothing out of the ordinary until they both felt the tail of the helicopter kick upwards.
"The nose hit the ground somewhere near vertical," Captain Slattery said. "It hit first on the roof and then on the port side. Neither (survivor) can recall how they left the helicopter."
Indonesian witnesses saw one of the pair drag the other from the burning wreckage.
The two-month inquiry will focus on the missing bolt and the crashworthiness of the aircraft - which was put into service in the Royal Australian Navy in 1975 - in particular, the seating and the shortage of helmets.
The way I read these media reports, the bellcrank has nothing to do with the accident, but the bolt that came out of the mixing unit had everything to do with it.
Documents detailing the maintenance work on the part were now missing, said counsel assisting the inquiry, Captain Michael Slattery QC. "A bolt appears to have come out of that bell crank ... it was found some distance from the bell crank and buried in debris in a way inconsistent with the fire," he said.
With all respect to those who died and were injured in this accident, I am not sure that I understand the point of this inquiry and the dance around the cause. The investigation has been thorough and complete, now it is time to examine and deal with the root cause. If you have a bolt disconnect (or a control rod failure!) in the mixing unit in an Sea King/S61 you will lose control of the machine. The cause of this accident has nothing to do with the capability of the crew, the way it was operated, or the age of the helicopter.
It has everything to do with fundamental, elementary, maintenance safety practices and inspection systems . This is not the first accident of this nature, nor will it be the last. This type of accident occurs every year in all kinds of equipment, yet should never occur in the first place.
Fatal Australian helicopter crash caused by disconnected bolt, inquiry told
SYDNEY (AP): A bolt that disconnected from an Australian navy helicopter caused a crash which killed nine military personnel while on a mercy mission in Indonesia, an investigator said on Wednesday.
Another two Australians were also injured when the Sea King helicopter crashed on April 2 on the island of Nias where they were retrieving Indonesians injured by a magnitude-8.7 earthquake that struck nearby on March 28.
Wing Commander Pierre Blais, who headed the accident investigation, told a defense board inquiry on Wednesday that a five-centimeter bolt linking two crucial components of the unit which controls the Sea King's movement had become disconnected from its normal position before the crash.
The inquiry, which is investigating the tragedy, had earlier been told that maintenance workers had removed the bolt eight weeks before the crash because a bearing in the flight control mechanism was worn.
The inquiry was also told the worn unit was reinstalled because no spare part could be found.
"The evidence was telling us ... the nut and bolt had come apart, causing the system to fail and the helicopter to crash," Blais said.
He dismissed sabotage, gunfire from the ground and weather as possible causes. Problems with the rotor blades, fuel system, auto pilot, aircraft weight and engine performance were among the 20 other possibilities ruled out.
The helicopter crew had been involved in relief work in nearby Aceh province following the Dec. 26 tsunami and were headed home when their navy ship was diverted from Singapore to offer assistance following the massive quake.
It has everything to do with fundamental, elementary, maintenance safety practices and inspection systems . This is not the first accident of this nature, nor will it be the last. This type of accident occurs every year in all kinds of equipment, yet should never occur in the first place.
Fatal Australian helicopter crash caused by disconnected bolt, inquiry told
SYDNEY (AP): A bolt that disconnected from an Australian navy helicopter caused a crash which killed nine military personnel while on a mercy mission in Indonesia, an investigator said on Wednesday.
Another two Australians were also injured when the Sea King helicopter crashed on April 2 on the island of Nias where they were retrieving Indonesians injured by a magnitude-8.7 earthquake that struck nearby on March 28.
Wing Commander Pierre Blais, who headed the accident investigation, told a defense board inquiry on Wednesday that a five-centimeter bolt linking two crucial components of the unit which controls the Sea King's movement had become disconnected from its normal position before the crash.
The inquiry, which is investigating the tragedy, had earlier been told that maintenance workers had removed the bolt eight weeks before the crash because a bearing in the flight control mechanism was worn.
The inquiry was also told the worn unit was reinstalled because no spare part could be found.
"The evidence was telling us ... the nut and bolt had come apart, causing the system to fail and the helicopter to crash," Blais said.
He dismissed sabotage, gunfire from the ground and weather as possible causes. Problems with the rotor blades, fuel system, auto pilot, aircraft weight and engine performance were among the 20 other possibilities ruled out.
The helicopter crew had been involved in relief work in nearby Aceh province following the Dec. 26 tsunami and were headed home when their navy ship was diverted from Singapore to offer assistance following the massive quake.
Email warned of helicopter disaster
By Cynthia Banham Defence Reporter
December 1, 2005
THE navy's aviation commander sent a chilling email to his superior six days before a fatal Sea King helicopter crash warning of a possible disaster because he was being kept in the dark on maintenance problems - but he was told to "sit on" the problem.
In an email dated March 28, Commodore Geoff Ledger told the then maritime commander, Rear Admiral Rowan Moffitt, that under the navy's command and control structure, he was not being told, or not told until "the very last moment", about serious incidents.
He offered to discuss the problem, saying: "I am very happy to raise a couple of recent issues in particular that I believe that you will agree was unacceptable."
However, he ended the email with this warning: if something serious happened in naval aviation, it would most likely be him who had to explain to the defence chiefs or the Defence Minister why.
Rear Admiral Moffitt replied on March 31: "Geoff, I suggest that you sit on the idea until the last few months of your tenure, there is little receptiveness or capacity for taking on such work (examining the organisation that is) at the moment with the focus firmly on sea change, but by new year with a new regime settling in, the timing might be better." Two days later, Sea King Shark 02 of the navy's 817 Squadron crashed on the Indonesian island of Nias, killing nine and injuring two others.
An inquiry into the crash has already heard allegations there were serious maintenance issues within 817 Squadron, that it had "an embedded culture of unauthorised shortcuts" and a lack of supervisors.
Yesterday the counsel assisting the board of inquiry challenged Commodore Ledger on how much he knew of the squadron's maintenance problems.
Captain Michael Slattery, QC, asked Commodore Ledger why last month he had changed his initial statement to the inquiry.
In his September statement Commodore Ledger, who was made commander of Australian troops in the Middle East in May, said he had seen in April 2003 a damning audit report which said there were major deficiencies in the squadron's maintenance processes that could "compromise the integrity of technical airworthiness".
When he returned from the Gulf last month, he said he had never seen the report or an attached minute.
"I only had a short time to look at the document when I came back in September … since coming back, in the cold light of day, I've had a chance to reflect and made the amendment," he said.
'Sir, at the end of the day, if something serious happened in naval aviation it would be most likely [me] explaining … why it happened.'
By Cynthia Banham Defence Reporter
December 1, 2005
THE navy's aviation commander sent a chilling email to his superior six days before a fatal Sea King helicopter crash warning of a possible disaster because he was being kept in the dark on maintenance problems - but he was told to "sit on" the problem.
In an email dated March 28, Commodore Geoff Ledger told the then maritime commander, Rear Admiral Rowan Moffitt, that under the navy's command and control structure, he was not being told, or not told until "the very last moment", about serious incidents.
He offered to discuss the problem, saying: "I am very happy to raise a couple of recent issues in particular that I believe that you will agree was unacceptable."
However, he ended the email with this warning: if something serious happened in naval aviation, it would most likely be him who had to explain to the defence chiefs or the Defence Minister why.
Rear Admiral Moffitt replied on March 31: "Geoff, I suggest that you sit on the idea until the last few months of your tenure, there is little receptiveness or capacity for taking on such work (examining the organisation that is) at the moment with the focus firmly on sea change, but by new year with a new regime settling in, the timing might be better." Two days later, Sea King Shark 02 of the navy's 817 Squadron crashed on the Indonesian island of Nias, killing nine and injuring two others.
An inquiry into the crash has already heard allegations there were serious maintenance issues within 817 Squadron, that it had "an embedded culture of unauthorised shortcuts" and a lack of supervisors.
Yesterday the counsel assisting the board of inquiry challenged Commodore Ledger on how much he knew of the squadron's maintenance problems.
Captain Michael Slattery, QC, asked Commodore Ledger why last month he had changed his initial statement to the inquiry.
In his September statement Commodore Ledger, who was made commander of Australian troops in the Middle East in May, said he had seen in April 2003 a damning audit report which said there were major deficiencies in the squadron's maintenance processes that could "compromise the integrity of technical airworthiness".
When he returned from the Gulf last month, he said he had never seen the report or an attached minute.
"I only had a short time to look at the document when I came back in September … since coming back, in the cold light of day, I've had a chance to reflect and made the amendment," he said.
'Sir, at the end of the day, if something serious happened in naval aviation it would be most likely [me] explaining … why it happened.'
Navy's helicopter time bomb
December 10, 2005
The navy's aviation squadrons are plagued by lack of experience and supervision, a culture of blame and an attitude that airworthiness manuals are for the "strict adherence of fools", a survey of sailors has found.
The problems are so rife a maintenance worker warns they are "a time bomb waiting to go off".
The Herald has obtained a copy of the survey of all personnel in the navy's fleet aviation engineering unit, carried out in August during a week-long safety grounding off all navy aircraft.
Five months earlier, a Sea King helicopter crashed in Indonesia, killing nine people. The subsequent inquiry, which brought the survey's existence to light, has heard extensive evidence of an unhealthy maintenance culture in 817 Squadron, home of the Sea Kings.
One survey respondent said "arrogance" was widespread, and that sailors believed they could ignore airworthiness manuals "at will" because of a "perceived greater knowledge and experience than most".
Another said maintenance staff were blase: "It should be stressed to them regularly that mistakes and errors at their level can lead to deaths."
In some instances, one sailor said, junior sailors who referred to manuals while carrying out maintenance work were told by their superiors to "just get on with it", leading to mistakes. Another said: "If a senior sailor persistently raises concerns about maintenance practices and overall safety, then he will find himself posted off the squadron very quickly."
The survey was carried out by Lieutenant Commander Bradley Hock, who was responsible for monitoring safety standards in the aviation fleet at the time of the Sea King crash.
It reveals deep concerns among staff about maintenance practices and standards across all squadrons, not just 817.
One respondent said most leading seaman and petty officers were being "promoted in minimum time", leading to a lack of experience among those ranks, while another said personnel who had "failed up to 30 exams" were being "pushed" through the system.
The survey also includes comments that the squadrons are undermanned and overworked.
"Although the squadron hierarchy say 'take the time and do the job safely and do it right', in the next breath they want to know why isn't the aircraft 'S' [ready to fly]," a respondent said.
Another said discipline "has swung too far to the non-punitive side", meaning there was "no accountability, just a smack on the wrist".
Compounding this was a "no blame culture". One respondent noted: "There seems to be an attitude of 'it's not my fault' or 'it must be someone else's fault'."
Lieutenant Hock told the Sea King inquiry he decided to conduct the survey off his own bat during the naval aircraft grounding. He asked personnel, from petty officer to lieutenant rank, to give "their thoughts on what was actually happening out there with the naval aviation squadrons".
The navy ordered another grounding of the Sea Kings over a maintenance incident last month.
One of the survey's most damning comments was directed at senior officers: "I think the question should be asked after the worst air disaster … Why didn't we have an FAEO [Fleet Aviation Engineering Officer] and commodore leading/showing us a way ahead? … I can't answer this but someone should."
December 10, 2005
The navy's aviation squadrons are plagued by lack of experience and supervision, a culture of blame and an attitude that airworthiness manuals are for the "strict adherence of fools", a survey of sailors has found.
The problems are so rife a maintenance worker warns they are "a time bomb waiting to go off".
The Herald has obtained a copy of the survey of all personnel in the navy's fleet aviation engineering unit, carried out in August during a week-long safety grounding off all navy aircraft.
Five months earlier, a Sea King helicopter crashed in Indonesia, killing nine people. The subsequent inquiry, which brought the survey's existence to light, has heard extensive evidence of an unhealthy maintenance culture in 817 Squadron, home of the Sea Kings.
One survey respondent said "arrogance" was widespread, and that sailors believed they could ignore airworthiness manuals "at will" because of a "perceived greater knowledge and experience than most".
Another said maintenance staff were blase: "It should be stressed to them regularly that mistakes and errors at their level can lead to deaths."
In some instances, one sailor said, junior sailors who referred to manuals while carrying out maintenance work were told by their superiors to "just get on with it", leading to mistakes. Another said: "If a senior sailor persistently raises concerns about maintenance practices and overall safety, then he will find himself posted off the squadron very quickly."
The survey was carried out by Lieutenant Commander Bradley Hock, who was responsible for monitoring safety standards in the aviation fleet at the time of the Sea King crash.
It reveals deep concerns among staff about maintenance practices and standards across all squadrons, not just 817.
One respondent said most leading seaman and petty officers were being "promoted in minimum time", leading to a lack of experience among those ranks, while another said personnel who had "failed up to 30 exams" were being "pushed" through the system.
The survey also includes comments that the squadrons are undermanned and overworked.
"Although the squadron hierarchy say 'take the time and do the job safely and do it right', in the next breath they want to know why isn't the aircraft 'S' [ready to fly]," a respondent said.
Another said discipline "has swung too far to the non-punitive side", meaning there was "no accountability, just a smack on the wrist".
Compounding this was a "no blame culture". One respondent noted: "There seems to be an attitude of 'it's not my fault' or 'it must be someone else's fault'."
Lieutenant Hock told the Sea King inquiry he decided to conduct the survey off his own bat during the naval aircraft grounding. He asked personnel, from petty officer to lieutenant rank, to give "their thoughts on what was actually happening out there with the naval aviation squadrons".
The navy ordered another grounding of the Sea Kings over a maintenance incident last month.
One of the survey's most damning comments was directed at senior officers: "I think the question should be asked after the worst air disaster … Why didn't we have an FAEO [Fleet Aviation Engineering Officer] and commodore leading/showing us a way ahead? … I can't answer this but someone should."
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Accountability?
It makes you wonder why we bother having AWB’s. If apparent failings such as that highlighted above can bypass the AWB process, what purpose does the Board serve?
The other issue of course is accountability. Who is accountable? The AA? Commodore Ledger? The unit CO? The engineering officer? Is it an issue of command or tech airworthiness, or are they one and the same thing?
I totally disagree with the “blameless culture” stuff. Genuine errors of judgment or mistakes are one thing. A failure, through a conscious act, to apply documented procedures is called negligence and should be treated accordingly.
The other issue of course is accountability. Who is accountable? The AA? Commodore Ledger? The unit CO? The engineering officer? Is it an issue of command or tech airworthiness, or are they one and the same thing?
I totally disagree with the “blameless culture” stuff. Genuine errors of judgment or mistakes are one thing. A failure, through a conscious act, to apply documented procedures is called negligence and should be treated accordingly.
I'm with you griffinblack - we have the same problem in UK - 'no blame-no sue' I think is probably the real reason and it means that senior commanders never have to face the realities of their 'cost saving' and 'efficiency measures'.
Despite constant urging from above to improve Flight Safety, as soon as a problem is identified which will cost money to solve, it suddenly becomes 'manageable' instead of dangerous.
Despite constant urging from above to improve Flight Safety, as soon as a problem is identified which will cost money to solve, it suddenly becomes 'manageable' instead of dangerous.
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Just watch this space for the announcement that the RAN has outsourced its maintenance. That saves heaps of $s out of the Defence buckets with bigger heaps coming out of someone else's bucket. Bet I didn't think of it first!!
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It is entirely possible that the maintenance concern for the safety of the bellcrank lead to the accident, if it had been left alone, the bolt would not have been disturbed.
The safest human process is the one we don't have to perform.
The safest human process is the one we don't have to perform.
