Latest news with #LieutenantMaxwellNugent
ABC News
21-05-2025
- ABC News
Defence investigation finds Taipan pilot's actions possibly prevented further fatalities in crash
A defence investigation into an army helicopter crash that killed four soldiers has revealed more lives could have been lost, had the aircraft pilot not taken evasive action to avoid another collision. The Defence Flight Safety Bureau (DFSB) report — which made 196 findings or observations and 46 recommendations to the Australian Defence Force (ADF) — was today released publicly, after it was finalised last month. It concluded it was highly likely the crash, which claimed the lives of Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class 2 Joseph "Phillip" Laycock and Corporal Alexander Naggs in July 2023, was because of unrecognised spatial disorientation suffered by at least one of the aircraft's pilots. "This refers to a situation where a pilot is unaware of their actual orientation in relation to the earth's surface and the surrounding environment," defence said in a statement. The four men were on board an MRH-90 "Taipan" helicopter with the call sign "Bushman 83" as part of a defence training exercise in Queensland's Whitsunday region. The report identified that, after making a turn while flying in a four aircraft formation, Bushman 83 climbed over 100 feet, before rapidly descending and crashing into the ocean. It took all of 21 seconds for the pilots to lose their orientation, and crash. The report described how the conditions they flew in that night — low level, over water, using night vision devices in a degraded visual environment, while likely fatigued — increased the risk of a person experiencing spatial disorientation. The report stated the pilot, Captain Danniel Lyon, "almost certainly" lost sight of the aircraft ahead of him in formation — Bushman 82 — and tried to regain visual. It stated Captain Lyon likely didn't know Bushman 83 was facing nose down at the time and accelerated quickly "which, combined with a lack of recognition of the aircraft's increasing airspeed, resulted in a very high and unrecoverable rate of descent towards the water". The DFSB said it was more than likely that during this time, Captain Lyon regained sight of the other aircraft and realised he was closer than expected. It said he took evasive manoeuvres to "avoid a mid-air collision" by conducting a "controlled flight into terrain", therefore potentially saving the lives of those on board the other aircraft. The report also identified that the loss of spatial orientation was likely not because of night vision technology used by the pilots of Bushman 83, which had previously been deemed as posing an unacceptable risk. The helmet mounted visor, known as TopOwl 5.10, has been at the centre of bombshell evidence as part of a separate independent inquiry into the crash. The Inspector-General of the Australian Defence Force (IGADF) inquiry heard evidence that a defence testing organisation held grave concerns about the technology, as it had a tendency to display serious inconsistencies when compared with real readings. "Regardless [of the risks previously identified], the investigation determined that it was very unlikely the known hazards relating to the HMSD v5.10 contributed to the loss of spatial orientation," the report stated. The ADF described the aviation safety investigation as "one of the most complex conducted by defence in recent history", with the resulting report determining the crash was "not survivable". Defence has faced criticism from the family members and loved ones of the four men during the IGADF inquiry, for how long it took to inform them they were likely dead. It heard for three days, the families were "cruelly" led to believe their loved ones would be found alive, despite many believing very early on, there was next to no chance they would be. "[To tell us they were dead would have been] far less cruel than having us hoping and praying for a miracle that was actually impossible," Captain Danniel Lyon's wife, Caitland Lyon, told the inquiry last year. Corporal Alexander Naggs's partner, Sarah Loft also echoed the sentiment, saying "They knew hope was lost long before we were told hope was lost". Fatigue has been a major focus of the IGADF inquiry, and the DFSB report made findings in relation to the issue. It found Captain Lyon and Lieutenant Nugent were likely fatigued, as a result of disruptive work patterns, burnout and rough sleeping conditions during the defence training exercise. The IGADF inquiry heard the crew were sleeping next to an active fire station and operational airport, in hot tents, while trying to switch their body clocks to night-flying mode. The report found their levels of fatigue likely increased their risk of experiencing spatial disorientation. In its recommendations, the DFSB urged army aviation to review its fatigue management policy, and provide training to pilots about how to recognise spatial disorientation. All 46 recommendations have been accepted by defence, many of which are also being enacted. Hearings as part of the IGADF inquiry wrapped up this month, with its findings and recommendations to be handed down at a later date.
ABC News
09-05-2025
- ABC News
Taipan inquiry exposes deep flaws within Australian Defence Force
It was designed to probe the devastating downing of an army helicopter that killed four people. But the Taipan inquiry became something so much more — exposing deep flaws within the Australian Defence Force and exploring the very core of its culture. On July 28, 2023, Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class 2 Joseph "Phillip" Laycock and Corporal Alexander Naggs were killed when the MRH-90 Taipan helicopter they were flying ditched and crashed into the ocean off the Queensland coast. The families of the four men have championed a phrase since the inquiry was in its early phases. After 15 months of evidence from dozens of witnesses across 48 days of hearings, it's not hard to understand why. Whether their fate was a devastating, unpreventable accident, or the culmination of a litany of failures, is something only the inquiry can answer. But no matter what presiding former judge Margaret McMurdo finds caused the crash, it would be hard to deny that defence has some hard truths to face. On that fateful July day, what was supposed to be a routine defence training exercise involving "Bushman 83" turned to tragedy. Children lost their fathers, women lost partners, and mates lost mates. Week two of the inquiry bared the grief of the four affected families as they took the stand. We saw it again on the final day of the inquiry this week. It showed the real people behind the devastation — the final words they spoke to their loved ones, the moment they were first informed of the crash, and the holes that have been left in the wake of their loss. All four men were described as passionate aviators — people who loved their jobs, their families and had a drive to do better. Captain Danniel Lyon's wife, Caitland, described her husband's desperate attempts to change the culture of 6th aviation regiment, based at Holsworthy in Sydney. She said he felt as though they didn't deem family as a priority — the job and the mission came first, always. In her evidence, she said her husband was working constantly, was home less and less, forced to miss school events for their children, and dealing with increasing and "relentless" piles of admin that resulted in less time in the air. Mr Lyon wasn't the only one — some told the inquiry that working 14-hour days became their new norm, alongside the need to answer phone calls at all hours of the day and night. A survey of the regiment the year before the crash highlighted a workforce under pressure, suffering from burnout, cumulative fatigue and stress. One witness, referred to as the pseudonym 'D-10', described the regiment as showing a "concerning level of fatigue and tempo", that "appeared to be a trend that was re-occurring since … [at least] 2014". Another witness said after a survey in 2015, defence members flagged with him that they were concerned fatigue was going to lead to a major safety event occurring. Simply put, aviators were reporting that they were being expected to do more with less, and it was having a significant impact on their everyday lives. During the exercise that claimed their lives, the four airmen were exhausted. Who wouldn't be when camped next to an operational fire station and a commercial airport, in hot conditions, trying to switch body clocks to night flying while their colleagues on opposite schedules were moving in and out of the tents. They were so exhausted — an expert equated it to driving while over the legal blood alcohol limit. Fatigue was a cornerstone of questioning as part of the inquiry — fatigue awareness is part of a pilot's basic training, and they're required to complete refresher courses every year and complete checks before every flight. But the inquiry heard individuals are the worst people to assess their own fatigue levels — pushing through to get the job done so their mates don't miss out on vital training, missions and qualifications. It isn't the first time fatigue has been raised as a defence issue — it was a focus of the Royal Commission into Veteran Suicide. It's findings, handed down last year, also recommended better fatigue management. Perhaps it's not a lack of process, but a problem with culture — checking boxes, not checking people. Arguably, some of the most explosive evidence of the inquiry came during the fifth round of hearings — if you've been following along, you'll know I'm referring to the TopOwl night vision goggles. One test pilot, Major Ian Wilson, staked his defence career and broke ranks to raise concerns about the helmet-mounted visors, which he said would lead to lives being lost. The army's test organisation found the latest software update for the TopOwl 5.10 was notorious for issues that could cause pilots to become spatially disoriented. It would display serious inconsistencies between the pitch, roll, bank and attitude when compared with actual readings. Despite it being deemed an unacceptable risk to safety, the technology was accepted into the service after more testing because the pros outweighed the cons. Some evidence suggested this was because it had already been paid for, at least partly. An expert in spatial disorientation, Dr Braden McGrath, said research had shown using helmet-mounted display system and night vision devices increased the probability of pilots becoming disorientated. Fatigue, poor weather, flying in formation and low-altitude missions — all things the pilots were experiencing on the night of the fatal flight — can increase the likelihood of spatial disorientation. The ABC understands defence's aircraft crash investigation wing, the Defence Flight Safety Bureau (DFSB), found spatial disorientation was a key factor in the crash, but admitted it did not investigate whether TopOwl 5.10 should be in use. DFSB director, Group Captain David Smith, said it was not within the scope of the investigation. Its report found it was functioning correctly, but didn't investigate whether the system was safe or ought to have been in use. One of the measures that can help pilots identify and recover from spatial disorientation is the help of their air crew — the men in the back of the aircraft. In this case, Corporal Naggs and Warrant Officer Laycock. With the doors of the aircraft open, they'll often have sight of other aircraft in formation, or visual cues like the ground. But in this case, it is understood the doors may have been closed due to the cool weather. The inquiry heard air crewmen — and especially Warrant Officer Class 2 Josheph "Phil" Laycock – had been fighting for warmer flying gear for years leading up to the crash, which they were denied. It wasn't until a year after the crash, when the head of army aviation command Major General Stephen Jobson stepped in, that change actually occurred. "[The air crewmen] were very clear in 2020 with their concerns about the equipment and unfortunately in that instance, we didn't see the outcome that we need for our people," he said. To say the MRH-90 aircraft were problem-plagued would probably be an understatement — they were in constant need of maintenance and have been described as immature and underperforming. In the decade leading up to the crash, the aircraft was assessed as having a "medium" risk level — or an elevated risk of a catastrophic event (death or serious injury) occurring. The aircraft was at the centre of two safety incidents in the year before the crash — a near-miss in Townsville in 2020 and a ditching at Jervis Bay months before the fatal crash. One witness who oversaw the helicopter's acquisition told the inquiry he felt it needed to fail several times before "there was the political will to retire them". To take what Lieutenant Maxwell Nugent's parents, Daniel and Marianna Nugent said in a statement at the final hearing day, "every decision matters." "Throughout the days of evidence, one thing that has constantly come to the forefront is that decisions matter," they said. "The decisions that you may make may not matter today, they may not matter tomorrow, but in the moment when things go wrong, these decisions matter. "People are your greatest asset. They're not just numbers on a page; they're people with families and lives to live." Major General Jobson said lessons had been learned from the acquisition of the Taipan. It's a sentiment defence has echoed when it comes to fatigue awareness. The DFSB's Group Captain David Smith conceded "there's more work to be done across the whole defence aviation safety program". When it comes to fatigue management, Major General Jobson said the army was "continuously updating and improving" its policy. To its credit, the ADF has implemented change even before the findings and recommendations from this inquiry have been handed down. Beds have been installed at 6th aviation regiment so pilots can nap, sleep studies have been green lit for flying units, and more fatigue checks have been made mandatory. Fatigue awareness has also been elevated as a priority heading into the next Talisman Sabre exercise. As its departure date rapidly approaches, loved ones of current serving members are undoubtedly hopeful lessons have been hard learned. The families of the fallen have put it well — let the legacy of those on-board Bushman 83 be change. "We cannot change what happened," Ms Whyte said on Friday.
