THE FINAL Court of Inquiry report into the loss of the HMNZS Manawanui off Samoa on 5 October 2024 has confirmed the principal cause was the failure to disconnect the vessel’s autopilot, as per the interim report released two months later.
But Court of Inquiry president Commodore Melissa Ross, who made the full, final report public today [4 April] found 12 factors that contributed to the grounding and sinking, making it more likely to occur.
The ship was conducting a hydrographic survey south of Upolu, Samoa ahead of the upcoming Commonwealth Heads of Government meeting in Apia later that month. At around 6.15pm (local time), the ship was around half a nautical mile south of the Sinalei Reef, heading north toward the reef at a speed of 6 knots. Manawanui crew prepared for a turn to starboard, however when they attempted the move, the ship did not turn. The officer on watch made an order that they believed would stop the ship, applying full power astern. However, instead of the ship stopping, it began to accelerate forward. The ship grounded on the reef around 6.18pm at a speed of around 10.7 knots.
Twelve minutes later, at 6.27pm, autopilot was disengaged. But the ship was aground and could not be moved. The 75 souls on board abandoned ship and were rescued without serious injury, with Manawanui subsequently catching fire and rolling off the reef the following morning.
Commodore Ross today said the 12 contributing factors were: training and experience, military hydrographic planning, orders, instructions and procedures, operational risk matrix, force generation, operational release, supervision, violations, haste, leadership, distraction/interruption and hollowness.
“The Court found deficiencies in the training and qualifications of key ship’s personnel involved in the incident, risks related to the survey task were not sufficiently identified, discussed and mitigated, and instructions or procedures were lacking,” she said.
The Court also found leadership was inadequate in some areas, supervision was not at expected levels and time pressure influenced the way the survey task was conducted.
The report also made nine recommendations relating to: Risk management; Orders, instructions, procedures and information management; Force generation; Seaworthiness and Operational release; Training and experience;
Hydrographic capability; Lifesaving equipment and orders, instructions and procedures; and Hollowness.
Commodore Ross acknowledged those on board the ship for their role in the investigation.
“It was a difficult and stressful experience for some and I want to acknowledge your courage, commitment, comradeship and integrity,” she said. “We would not have been able to complete the report without your evidence, and the lessons and recommendations could not have been developed without your input to ensure an incident like this is not repeated.”
Chief of the Navy Rear Admiral Garin Golding said the report highlighted a gap between work as imagined and work as done. This contributed to the incident, with a series of issues compounding the direct cause of the incident, he said.
Several immediate actions were recommended before the release of the preliminary findings of the Court of Inquiry report and Rear Admiral Golding said all of them had been addressed.
“We have not waited until the report was finished to get after what we knew we could start to improve on. With the assistance of external sources, we have completed reviews of areas such as risk management, oversight and documentation, as well as audits on the state of training, among other areas,” he said.
“We have updated our critical incident management procedures, made changes to some of our tools that assist with risk, and stood up a project team specifically to ensure quality and consistency of our plans and procedures.”
Rear Admiral Golding said while some of the recommendations were already underway, others would take longer to resolve.
“Ultimately, there are a range of issues, including the lack of commonality across the fleet, which means our people need to constantly adapt to new procedures each time they change ships.”
To counter this, Rear Admiral Golding said the Navy would be embarking on a transformation programme that seeks to reform the approach to operating the Navy.
“Fundamentally we need to do things differently. We need to adapt to new technologies, change the way we approach what we do, and find new ways to continue to deliver on what is expected of us,” he said.
Rear Admiral Golding said the decision to proactively release the Court of Inquiry report in its fullest capacity was an acknowledgement of the warranted public interest in the incident.
“The sinking of a Navy ship is an incredibly serious situation, and it is important that the public have a full understanding of how serious our investigation has been, and we owe it to them to be transparent about the causes so that we can avoid future issues.”
The final Court of Inquiry report, which underwent an independent external review by a King’s Counsel, can be found at nzdf.mil.nz/court-of-inquiry-hmnzs-manawanui
The court is not a disciplinary body and cannot make findings of guilt, the report said. However, NZ media reports the court has recommended a separate inquiry be made into possible offences. The possible offence, or offences, have been redacted from the report.
