I present the report of the Legal and Constitutional Affairs References Committee on the MRH-90 Taipan helicopter incident, together with accompanying documents. I move:

That the Senate take note of the report.

Inquiry into MRH-90 Taipan Helicopter incident

I begin by acknowledging the servicemen who lost their lives on the evening of 28 June 2023—Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class Two Joseph Laycock and Corporal Alexander Naggs. What happened to them was a tragedy. I pay tribute to their service, and they should never be forgotten.

I further thank the families of the servicemen who lost their lives for their courage in providing evidence to this inquiry.

Thank you also to my fellow committee members, the committee secretariat and all those who participated in this inquiry, mindful of the difficult and deeply sensitive nature of this inquiry.

Background

This was an inquiry into the tragic accident of the MRH-90 Taipan helicopter, callsign Bushman 83, while conducting a night-time training exercise during Exercise Talisman Sabre.

Importantly, the actions of the crew of Bushman 83 were not called into question. Retired Majors David Lamb and Ian Wilson, who are both highly experienced pilots, told the committee that the environment the pilot was operating in would challenge even the best pilot on the planet to recover.

The MRH-90 helicopter project had well-documented and reported issues.

Following the accident, the MRH-90 helicopter was decommissioned.

In conducting this inquiry, the committee sought to comprehend the regulatory framework that is designed to provide for the safety of military aviation operations. This is a comprehensive and complex regulatory area that involves:

While this is a complex web of regulation, complexity must not be used to obscure safety expectations and accountabilities.

TopOwl Helmet

This inquiry found that Defence could not articulate what authorised process was used, under the Defence Aviation Safety Regulation, to approve the TopOwl helmet mounted sight display version 5.10 into service.

As the committee discovered, AATES concluded that version 5.10 of the TopOwl helmet represented an unacceptable risk to flight safety as it implied a very high risk of pilot disorientation if used in poor conditions and the likely consequence was that disorientation at low levels could lead to multiple fatalities.

The fundamental concern with version 5.10 was that the altitude information presented was consistent with cockpit displays when the pilot was looking forward but reversed pitch and roll information when the pilot looked to the side.

This is particularly challenging for pilots when they are operating in a situation where they do not have full vision of the horizon and are more reliant on the symbology provided by the TopOwl helmet.

While Defence told the committee it had developed a range of procedures that were incorporated into training and guidance documents, the committee received contrary evidence that the gravity of the software's defects had not been adequately communicated to the aircrew.

No formal documentation outlining Defence's risk mitigation strategy to attempt to address the flight test concerns, and which are a requirement under workplace health and safety legislation, were provided to the committee.

In light of this evidence, the committee has made several recommendations, including:

The committee has recommended that the government establish an independent review of the DFSB investigation into this accident.

The committee has also made a range of recommendations relating to the management of fatigue and building a safety culture within the Australian Defence Force. This includes a review of the Army's aviation fatigue risk management procedures and promoting safer reporting pathways.

Recommendations have also been made regarding death and bereavement support for the families of ADF personnel.

The hardest part of this inquiry was hearing from the families of those who lost their lives.

I want to take the time now to read to the Senate some of their words as they reflected on their son, their husband, their partner and their brother.

In his testimony, Daniel Nugent, father of Lieutenant Nugent, stated that:

Max decided in year 11 that he wanted to become an Army officer. He began that journey in 2018 as a 19-year-old at the Royal Military College. By 21, he was an Army officer training to become a pilot. By 24, he had achieved his goal, becoming a special operations pilot with the 6th Aviation Regiment. On 28 July, he was exactly where he wanted to be, doing his job alongside his mates.

Chadine Whyte, Lieutenant Nugent's partner, said:

My hope moving forward is that institutions learn from Max and that they lead with the same integrity he demanded of himself. Anything less is an insult to his life and memory and to those who remain in service.

Lieutenant Nugent's sister, Samantha, told the committee:

If Max wasn't in the Army, he would have been at home with us. Just before he left to go to Talisman Sabre, we were planning our joint birthday dinner, to spend it as a family.

Sarah Loft, the partner of Corporal Naggs, said:

He was a proud soldier. One of the first things that we did together was the dawn service in the driveway, because it was the start of COVID. I had said to him, 'Hey, I'm doing the dawn service in the driveway tomorrow.' He goes, 'Well, yes, I will be, too.' We were two of only a few in the street in Toowoomba, freezing, listening to the neighbours' radio. The guy bled green.

David Naggs, father of Corporal Naggs, told the committee that he wasn't even informed by Defence that his son was missing. He said:

It got in my head that Alex was never coming home again when I was watching a Broncos and Cowboys football game on the telly the following Saturday. They had a minute's silence at the ground, and there was Alex's picture on the scoreboard with the rest of the boys. I thought: 'Wow. Okay.' And that's a hit, because there was no-one in uniform that came to the door.

Caitland Lyon, widow of Captain Lyon, stated:

Dan was 32 years old. He was our children's daddy. He was the light and laughter of our home. He trusted that the organisation that he served would keep him safe. That trust was catastrophically betrayed.

I encourage all senators to read or watch the testimony from the families of the victims, and I thank them for their strength. I again want to thank all of those who supported the work of the committee and provided evidence to the inquiry. May we never forget those who tragically perished: Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class 2 Joseph Laycock and Corporal Alexander Naggs.

I seek leave to continue my remarks later.

Leave granted.

I'd like to associate myself with the chair's remarks and comments. I won't repeat the detail of this report, but I will commend the report and the thoroughness of the report to all senators who are concerned about ensuring that defence personnel, as far as possible, are kept safe, respected and protected when they go about their work and their duties.

This was a pretty tough inquiry to sit on. It was tough to come to terms with the complexity of the material, but I think the hardest thing was to hear from the families of the four defence personnel who lost their lives on the night of 28 July in 2023. I'll say their names: Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class 2 Joseph Laycock and Corporal Alexander Naggs. They all lost their lives instantly when the Taipan helicopter they were in crashed at speed, on a dark night in a dangerous exercise, into the waters off the Whitsundays in Queensland.

There had been so many warnings about the dangers, particularly of what was happening that night. A very loud warning had been delivered in March of 2023, when 10 ADF personnel, including special forces soldiers who were hanging off the back of a Taipan helicopter on a rope ladder, were forced to ditch into Jervis Bay. Eyewitnesses said they saw sparks at the top of the rotor blades and an explosion before the helicopter went, in a somewhat controlled emergency ditch, into Jervis Bay. The special forces team, who were hanging off the back on their rope ladder, came within a whisker of losing their lives and being dragged under and killed. That was in March of 2023.

It turns out that, in the 12 months before and the 12 months that followed—throughout that whole period and, indeed, even before that—a whole series of people inside Defence and Army Aviation, who are the experts that you rely upon to keep platforms and any additions on platforms safe, had been ringing alarm bells with Defence about the Taipan helicopter. This was not about the core helicopter itself but about a bunch of mod cons that Defence had added to it—the TopOwl system—concerning the images that were being fed to the pilot and the co-pilot, particularly during low-light scenarios.

What the experts, the ones who tested the equipment, said was that, particularly in low-light situations where you're relying entirely on the visual because you can't see what's in front of you, the information that's fed to the pilot through the TopOwl could totally flip your orientation. Up might be down and down might be up. They highlighted that this equipment shouldn't be on the Taipans. You shouldn't put on equipment that, in the most stressful moments—the moments you most need to be relying upon the instrumentation—is potentially flipping it upside down. What they said was that, if Defence proceeded to allow this equipment in and allow it to be used—particularly in low-light situations, in stressful situations like that—it could lead to multiple deaths in a controlled flight into terrain. Then, on 28 July 2023, that's exactly what happened. Bushman 83, with those four defence personnel and an incredibly experienced pilot was in a low-light situation where we know they'd have been relying on looking at their instrumentation. We know it was instrumentation that, particularly when looking out left or right, could be flipping everything upside down. Tragically, they went into the water at speed in a controlled flight. They hit it like hitting concrete, and their lives were lost instantly.

As we started unpicking what Defence knew, when they knew it and how they responded to the reports, the story just got worse and worse. Warnings were not heeded. Once the warnings were in place and it looked like there might be significant restrictions on the Taipan, particularly when they were engaged in joint exercises with the United States, where Australia wanted to show off its stuff and its ability to insert special forces—those situations where they wanted that to happen—people inside Army aviation tried multiple workarounds to get around these safety complaints and reports about how dangerous it was. They brought in individuals and experts. They looked at German reports. they did this and that and whatever. They said, 'Keep flying. Keep doing it'—even in these dangerous situations. And we know what happened.

I particularly want to thank some of those really brave people inside Defence who put their careers and their professional experience on the line to try and make that safety call. I'm particularly thinking here of retired majors David Lamb and Ian Wilson, people of genuine integrity and enormous experience. If only they'd been listened to and heard.

I won't repeat every one of the recommendations. There are 15 recommendations in this committee report. They go to questioning whether or not Army aviation should operate as it does. They recommend that the Defence Aviation Safety Authority review Army aviation's compliance with the Defence Aviation Safety Regulation and related Defence safety standards. The recommendations proposed that the Department of Defence conduct an urgent review to consider placing the Army Aviation Test and Evaluation Section outside the Army and under the command of the Air Force, where the best flight experience exists. I've got to tell you that that recommendation alone to not let Army aviation be judge, jury and executioner but to actually ensure that the best airworthiness experts—the best experts in the space, who are, it won't surprise you, within the Air Force—have some kind of direct oversight is critical.

Recommendation 7 says:

The committee recommends that the Department of Defence strengthen the Australian Defence Force's internal policies and procedures to:

That's essential. I said before that incredibly experienced test pilots, people with enormous experience and integrity, kept blowing the whistle and kept being ignored, and Defence kept looking for workarounds.

Recommendation 9 recommends:

… the Australian Government examine the effectiveness of the framework designed to ensure the Defence Flight Safety Bureau's independence from the military's chain of command and reconsider the appropriateness of situating the Defence Flight Safety Bureau within the department that it is tasked with independently investigating.

The evidence I heard had a very disturbing taint to it, where those in the chain of command who just wanted this platform to keep operating and wanted it to operate in the very conditions in which these fatalities happened seemed to have some kind of power over the notionally independent safety experts—the people setting the standards and doing the testing. They need to be completely separated.

Then there is a series of recommendations—11, 12, 13, 14 and 15—which go to providing things like an acute support package to the families of veterans who lose their lives in situations like this and making sure that no-one's widow has to beg just to have the rent paid, that there's actually leniency there and that you understand the incredible loss and provide support, because we did hear about that. We heard about widows that, whilst they had some extensions and whilst there's been gradual improvement in some of this, were literally begging to get the support so that they could keep a roof over their heads of their kids, who've lost their dad. That shouldn't happen.

The final recommendation I'll reference is recommendation 15. This recommends the Department of Defence and the Australian War Memorial continue to consider the eligibility of Captain Daniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class Two Joseph Laycock and Corporal Alexander Naggs for the roll of honour at the Australian War Memorial. If, for some bureaucratic reason I can't comprehend, that can't happen, then the committee recommends a dedicated memorial be created along Anzac Parade to honour their and other training deaths, because they died in service, and there should be some place to honour and respect that. I seek leave to continue my remarks later.

Leave granted; debate adjourned.