The long-awaited report into the death of Australian soldier Marcus Case in a helicopter crash in Afghanistan has found that the military aircraft he was travelling in was susceptible to dangerous pitch oscillations.
The former chief of the defence force General David Hurley appointed a commission of inquiry into the lieutenant’s May 2011 death. It concluded in March 2013, but the report was not released until Thursday.
The report found that the CH-47D Chinook helicopter had a propensity to oscillate violently, or “porpoise”. Case was thrown from the helicopter when it swayed unpredictably, at one point tilting nose down to more than 90 degrees.
Case was riding on the open rear ramp and was tethered by a harness that became fully extended, leaving him dangling more than four metres from the aircraft. His skull was crushed when the ramp of the helicopter landed on him, killing him instantly. The aircraft then crashed and caught fire, but all other crew members survived.
The report found that the pilots flying the Chinook received no formal advice or training in how to handle the porpoising and “responded incorrectly to the uncommanded pitch oscillations”.
The report criticised the decision to allow Case to be seated on the ramp, saying the practice of “ramp riding” had been prohibited in the months before his death.
“The commission considers that, despite the lack of formal training dedicated to dealing with pitch oscillations on the CH-47D, pilots should have the basic skills to avoid the onset of pitch oscillation by using correct flying techniques, as taught in initial flying training and to recover the aircraft should a pitch oscillation occur,” the report said.
The report acknowledged that there were 11 instances of porpoising in Afghanistan before Case’s death.
“The commission noted the apparent increase in the frequency and number of Chinook oscillatory incidents, particularly in the few months preceding the accident,” it said.
“All the reported pitch oscillation incidents occurred with a less experienced pilot [at the time of the incident] flying the aircraft.”
The pilot and co-pilot acted according to protocol when the oscillations began, waiting for the flight’s electronic control system to correct itself. When that did not occur, the captain took over and levelled the plane before it crashed.
Members of Case’s family, who had seen parts of the report, told Fairfax Media this month they were unhappy with the commission and its findings.
“The report fails to explain coherently what caused Marcus’s death,” a statement from Case’s siblings said. “It practically takes the helicopter out of a helicopter crash.”
They said it was inadequate.
“You can’t trust someone who is writing their own investigation. Imagine writing your own performance review, or a student marking their own exam. The attempt is worse than meaningless.
“The employer duty of care obligation to Marcus is a different issue altogether.”
Defence has agreed to adopt 19 of the largely procedural recommendations outlined in the 250-page report.
