- A.N. Other
- Naval Aviation
- RAN Ships
- HMAS Kanimbla II
- December 2022 edition of the Naval Historical Review (all rights reserved)
By MIDN T.D. Craig
This well researched essay providing a critical analysis of serious problems within the Fleet Air Arm was a runner up to the Naval Historical Society history prize at the NEOC 66 graduation. It is worthy of attention.
Tristan Craig comes from a family with a strong service background, with his father, two brothers and uncle all serving in the RAN and his mother and third brother serving in the RAAF and army respectively. He grew up mainly in Nowra attending the local Anglican College but due to his parents’ service postings also attended St Edmund’s College, Canberra. He completed a Batchelor of Pre Medicine, Science and Health at the University of Wollongong and worked part-time in various jobs while waiting to join the RAN. After completion of NEOC he is currently posted to HMAS Sydney as an Assistance Maritime Logistics Officer and looks forward to a long career in the RAN.
Those who fail to learn from history are doomed to repeat it.
Churchill to the Commons 1948, from George Santayana 1905 The Life of Reason.
On 28 March 2005 an 8.6 magnitude earthquake struck Indonesia. The island of Nias was most affected, with hundreds of fatalities. After recently completing Op Sumatra Assist, HMAS Kanimbla was alongside in Singapore. Kanimbla, with two detached Sea Kings from 817 Squadron (Shark 02 & 21), sailed to the island of Nias at short notice (Purcell, 2007). On 02 April 2005 Shark 02 was transporting a medical team when the pilots lost control of the aircraft and nosedived, impacting the ground. Nine Australian Defence Force members were killed and a further two were seriously injured. The Sea King Board of Inquiry (SKBOI) determined that a single split pin missing from a castellated nut caused the devastating crash and that systemic failures in the RAN Airworthiness system and Navy’s safety culture were to blame (DoD, 2007a).
The aim of this essay is to critically analyse the 2005 Nias Island Sea King Crash and investigate what lessons have been learnt from the tragedy and how this influenced the Royal Australian Navy today. It will evaluate whether those lessons learnt were appropriately addressed and how the RAN might better identify mistakes and evaluate their own actions.
The scope of this essay will not allow for an in-depth analysis but will instead cover four key lessons learnt from the crash and whether or not the RAN addressed them appropriately. Further, it will briefly examine how the incident has influenced the RAN today and how to better identify mistakes and evaluate actions.
The Sea King Board of Inquiry (SKBOI) and Aircraft Accident Investigation Team revealed a number of causal factors that contributed to the fatal accident. These interrelated factors meant that the Fleet Air Arm (FAA) motto of ‘Mission First, Safety Always’ was not upheld. Firstly, unclear mission and purpose for individuals at all levels of 817 Squadron and arguably across the FAA resulted in losing sight of the key organisational priorities of safety and airworthiness (DoD, 2007a). Secondly, inadequate communication, information and reporting systems across the FAA meant that for 57 days the missing split pin which ultimately caused the crash of Shark-02 went undetected. The third key lesson learnt from the incident was that the FAA as a whole had impotent safety and quality management systems. The SKBOI highlighted this, finding that the crash was in fact partially survivable if not for inadequate and unsafe seating restraint systems causing extensive fatal injuries to passengers, the configuration of the aircraft which restricted egress, poor security and stowage of medical stores and potentially most significant finding was the inappropriate carriage of explosive cargo (DoD, 2007a). The final factor examined is the failure to learn from previous incidents.
The lessons learnt from the Nias Island crash, as a result of the SKBOI have significantly influenced the modern RAN. The Navy itself has changed its Command and Control structure, implementing a change in responsibility for operational command and airworthiness (to Commander Fleet Air Arm). There is a greater focus on implementing and maintaining safety management systems to avoid future incidents. The FAA and wider RAN no longer operates ageing equipment which poses a safety risk to its people, instead focusing government spending on safer, more technologically advanced equipment (DoD, 2007b). Finally, potentially most significant is the development of a new culture within the entire RAN, initiated with the introduction of New Generation Navy and subsequently Next Generation Navy (RAN, 2020). This culture focuses on developing agile, modern leaders across all levels and platforms to maintain safety and professionalism in order to achieve Navy’s mission, to ‘fight and win at sea’.
How Lessons Were Addressed
Immediately following the crash, the RAN Sea Kings were grounded to establish the causes of the accident and the systemic failures that it exposed throughout the FAA. The SKBOI found that there were significant organisational failures across 817 SQN and the FAA. The factors relating to the accident were evaluated and a plan to effect systematic change across the FAA’s safety and organisational culture was developed (Debrincat et al., 2010). This set out a path which inevitably changed the face of the FAA for the better. The most pertinent lesson that was addressed by the FAA was the archaic safety culture of 817 SQN and the entirety of the FAA. Inadequate communication of operational priorities meant that the maintenance team understood that the mission came first always. In this environment, a culture of workarounds and short cuts to get the job done developed. Maintenance work was often signed off without ever having been carried out. Ironically the Squadron won the safety award two years running prior to the accident, proving that there was no tracking or oversight of safety matters (Debrincat et al, 2010).
The SKBOI found that this led to a toxic cycle of unsafe maintenance, insufficient training consolidation and competency development. This compounded poor leadership, with authoritative supervisory leadership being diluted by quick promotions. Despite enduring a series of near-miss incidents and significant aircraft crashes in its history, the FAA had failed to learn the lessons from these incidents. Ultimately this led to a mission focused culture, a disregard for basic safety reporting procedures, and poor communication both across the FAA and to the wider Navy (Debrincat et al., 2013). The SKBOI found that recommendations from previous inquiries were not implemented and that there was a failure at all levels to identify systemic flaws in FAA practices.
The FAA and the RAN have successfully addressed the majority of issues raised in the SKBOI. Importantly, all recommendations from the BOI were appropriately closed out but ongoing effort is required by leadership at all levels to guard against complacency (DoD, 2007b). With hindsight, it is clear that the Sea King had become an aged and unsafe airframe toward the end of its commission and has since been decommissioned. A just safety culture was adopted to encourage identification and rectification of unsafe practices (Hudson, 2003). Potentially the most concerning issue raised at the SKBOI was the fact that multiple incidents had occurred in the FAA but were never properly addressed. In 1995 a Sea King crashed in Bamaga, Northern QLD whilst on a night landing approach. The subsequent inquiry found that the seating and restraints in the Sea King were unsafe and had potential to cause injury to passengers (MCA, 1996). Yet the Nias accident was found to be at least partially survivable if not for the same inadequate seating and restraints (DoD, 2007a). The failure to deal with previous accident recommendations was a key leadership failure in Navy.
The Nias Island crash can be seen as a pivotal point for the FAA. It precipitated a series of phased changes in culture, attitude and organisational safety management. Fast forward to the present day and the ‘workaround attitude’ has been quashed (DoD, 2007b). The focus has returned to ‘Mission First, Safety Always.’ There is a better understanding throughout the RAN of dangers of aging equipment and the FAA focuses on leadership development across the entire squadron, manages air worthiness effectively and most significantly, lives by an organisational culture set by Next Generation Navy (NGN) that is inherently safe.
The RAN generally and the FAA specifically can better identify potential issues and avoid catastrophic accidents like Shark 02 with greater emphasis on leadership development. Previously, as identified by SKBOI, the FAA lacked effective leadership and training in this area was inadequate (DoD, 2007a). Generally speaking, a good manager has the ability to deal with outcomes and systematic processes, but the Navy must seek to develop strong and agile leaders who have the ability and attributes to deal with causal factors, anticipating problems before they evolve into catastrophic accidents. Hindsight clearly shows that the trends and causal factors for the 2005 Nias Island Sea King crash were plain for many to see, but a lack of effective leadership meant that no individual felt confident to challenge the organisation or its outcome driven culture. Holding true to FAA’s motto ‘Mission First, Safety Always’ supports the Navy in meeting its mission to ‘Fight and Win at Sea.’
The aim of this essay was to critically analyse the 2005 Nias Island Sea King Crash and investigate what lessons have been learnt from the tragedy, how this influenced the Royal Australian Navy today and evaluate whether those lessons were appropriately addressed. The SKBOI identified an unsafe culture, poor communication, reporting and leadership and a failure to learn lessons from previous incidents led to the crash (DoD, 2007a). It is clear that Nias was a critical turning point for the FAA. It has successfully improved its communication, leadership and safety focus and learned the lessons this accident brought into stark relief (DoD, 2007b). The natural progression from this is to develop agile leaders who can identify and address issues before they cause incidents. This is perhaps the greatest lesson that could come from this tragedy and one today’s Navy must adopt to better identify mistakes and evaluate actions.
Bushell, E., 2007. The Never-Ending Story of Airworthiness versus Murphy’s Law. Air Power Australia Analyses, 4(4), p.1.
Debrincat, J., Bil, C. and Clark, G., 2010, September. Assessing organisational factors in aircraft accidents: methodologies and limitations. In: Proc. 27th Congress of the International Council of the Aeronautical Sciences, Nice, France.
Debrincat, J., Bil, C. and Clark, G., 2013. Assessing organisational factors in aircraft accidents using a hybrid Reason and AcciMap model. Engineering Failure Analysis, 27, pp.52-60.
Department of Defence 2007a, Sea King Board of Inquiry, Defence Publications, viewed 01 April 2022, https://defence.gov.au/Publications/BOI/SeaKing/Chapters.asp>
Department of Defence 2007b, Sea King Board of Inquiry Implementation Plan, Defence Publications, viewed 02 April 2022, <https://defence.gov.au/ Publications/BOI/SeaKing/ImplementationPlan.asp
Hudson, P., 2003. Achieving a safety culture for aviation. Journal of Aviation Management, 3(1), pp.27-47.
Maritime Commander Australia, 1996. Board of Inquiry into the Crash of Sea King N16-124 on Cape York. pp 32-39.
Purcell, F., 2007. Operation Sumatra Assist Two. Journal of Military and Veterans Health, 16(1), pp.32-34.
Royal Australian Navy 2020, Next Generation Navy, Directorate of Navy Culture, viewed 03 April 2022, < http://drnet.defence.gov.au/navy/DNC/NGN/Pages/NGN.aspx>
Sea King, B.O.I., 2005. Transcript of Proceedings of the ADF Board of Inquiry into the Crash of Sea King Helicopter Shark 02 on 2 April 2005. National Transcription Services Pty Ltd, Level, 6, p.221.