An "embedded culture" of shortcuts in maintenance practices in the Royal Australian Navy, combined with failures among commanders and other defense organizations, led to the April 2, 2005 crash of a Sikorsky Aircraft Sea King that killed nine people.
Those were among the findings of the Australian Defence Force board of inquiry into the crash on the island of Nias, Indonesia that killed nine Navy and Air Force members providing humanitarian aid following an earthquake on Nias.
The board found the primary cause was a failure of mechanical flight-control links on which mechanics had installed an incorrect nut and locking pin two months before the crash, said Vice Adm. Russ Shalders, chief of the Royal Australian Navy. But he said the board also found a series of errors and non-compliances with maintenance regulations contributed to the accident, including deficient maintenance practices in the Sea King detachment on the HMAS Kanimbla and in the parent 817 Sqdn. at Nowra.
The board found "an embedded culture of shortcuts in the 817 Sqdn.," said Australia’s defense chief, Air Chief Marshal Angus Houston. Other shortcomings included deficient support from the Navy and the wider defense organisation, Shalders said.