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By Online parliamentary correspondent Emma Rodgers
The inquiry into the crash, presided over by retired NSW Supreme
Court justice David Lavine, also found that the main cause of the crash
was pilot error, but that this could not be viewed in isolation with
other factors and no individual blame should be placed on the captain.
The report's findings were released today by the Chief of the
Defence Force, Air Chief Marshal Angus Houston, who was given the
report over six months ago.
"As is often the case the accident was a result of a culmination of factors," he said.
The Black Hawk crashed while attempting to land on HMAS Kanimbla
during a special operations assault exercise on November 29, 2006,
which was designed to get troops to a specific area quickly.
The crash killed pilot Captain Mark Bingley and Special Air Service
Trooper Joshua Porter after the Black Hawk slammed into the aft deck of
the ship and plunged into the sea.
Captain Bingley was rescued from the water and later died, While SAS
Trooper Porter's body was recovered from the seabed in March.
The report has made 56 recommendations to reduce risk during special
operations, of which Air Chief Marshal Houston says 56 have been agreed
to, one of which is that the squadron's flying standards be externally
audited.
The approach procedures of how aircraft approach their landings
during special operations has also been changed after a review from
test pilots in the Aircraft Research and Development Unit.
"These operations require a very fine balance between safety and achieving the mission," he said.
"The squadron's 'can-do' attitude meant they were taking greater
risks to achieve their missions. This led to an erosion of their safety
standards."
The board of inquiry found that pilots of 171 Squadron had
progressively become more aggressive in their flying during operations,
virtually eliminating any margin of error.
The progressive change toward riskier flying behaviour was also
combined with a lack of supervision, the pressure of preparing for
operations, the relocation of the squadron of Sydney and the high
pressure involved in special operations to decrease the safety of
operations.
Air Chief Marshal Houston said over several years the pilots'
approach to landing became faster and faster, in order to achieve the
mission outcome of maximising surprise and minimising vulnerability.
"As a consequence we ended up with a set of circumstances where one
mistake was going to end up with an incident or at worse an accident as
happened on this occasion," he said.
However the said the pilots believed that their actions were authorised and that they were flying safely.
"They eventually got to a situation where they were flying on the
absolute limit ... they went past the right balance of safety and
mission achievement," Air Chief Marshal Houston said.
However, Air Chief Marshal Houston said no disciplinary action would be taken against anyone.
He also confirmed that a Black Hawk was involved in a "heavy
landing" during an exercise in East Timor, in June last year, while the
inquiry was sitting.
In the wake of the crash in East Timor an audit of all rotary wing
aircraft took place and found there was a high degree of safety
compliance and that 171 Squadron was now better supervised and
operating within safety margins.
Air Chief Marshal Houston says the Defence Force remains committed
to counter-terrorism exercises that are realistic and demanding but
admits that training must also be safe.
"This board of inquiry report highlights that this training must
strike the right balance between safety and achieving the mission," he
said.
A copy of the report has been given to the families of Captain Bingley and SAS Trooper Joshua Porter.
It is the first time a board of inquiry for the Defence Force has
been presided over by a civilian, Air Chief Marshal Houston said.
Video footage of the accident can be found HERE
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