PREFACE [PDF 249 KB]
EXECUTIVE SUMMARY [PDF 5.11 MB]
TABLE OF CONTENTS [PDF 518 KB]
CHAPTER 1: [PDF 4.30 MB] Conduct of the Board of Inquiry
CHAPTER 2: [PDF 448 KB] Biographies of the deceased members and the survivors
CHAPTER 3: [PDF 2.76 MB] Background to the accident
CHAPTER 4: [PDF 723 KB] A Discussion on responsibility and accountability
CHAPTER 5: [PDF 7.78 MB] The final flight of Shark 02 and the rescue of the survivors
CHAPTER 6: [PDF 6.45 MB] The primary cause of the accident and associated issues
CHAPTER 7: [PDF 6.81 MB] Immediate contributory causes of the accident
CHAPTER 8: [PDF 2.18 MB] Analysis of the maintenance activities
CHAPTER 9: [PDF 2.90 MB] Non-compliant maintenance practices within the 817 Squadron
CHAPTER 10: [PDF 2.80 MB] Management of noncompliant practices by CO 817 Squadron
CHAPTER 11: [PDF 5.31 MB] Naval Aviation FEG HQ Support of 817 Squadron
CHAPTER 12: [PDF 2.54 MB] Maritime Headquarters Support to 817 Squadron
CHAPTER 13: [PDF 1.77 MB] The Defence and Navy safety system
CHAPTER 14: [PDF 4.95 MB] ADF Airworthiness management system structure
CHAPTER 15: [PDF 1.09 MB] Naval Aviation maintenance training continuum
CHAPTER 16: [PDF 2.54 MB] Logistics support system analysis
CHAPTER 17: [PDF 1.61 MB] Previous Australian Defence Force Boards of Inquiry and investigation recommendations
CHAPTER 18: [PDF 2.16 MB] The manner and cause of death
CHAPTER 19: [PDF 3.30 MB] Non causal issues
CHAPTER 20: [PDF 1.04 MB] Compensation and remediation
CHAPTER 21: [PDF 5.08 MB] Conclusion
Abbreviations [PDF 478 KB]
