KEY POINTS:
Byron Solomon's death on the shiny new HMNZS Canterbury was an accident waiting to happen.
You won't read that finding in the Court of Inquiry into the death of the Able Hydrographic Systems Operator, who drowned in October 2007 in calm seas off Cape Reinga when a seaboat launch went wrong and he became trapped underneath the upturned vessel.
Nor will you find it in the Coles Review - a little known but revealing top-level Defence review - into the Canterbury's raft of design flaws. But read the two documents together and you can join the dots.
Solomon was killed after a shackle failed while the boat was being lowered, releasing the boat rope early. A wire connected from the back of the boat to its crane could not be released because an incorrect part had been fitted. The boat was swamped, overturned and the 22-year-old was caught in the lifting strops. Attempts to activate the self-righting gear failed.
The Court of Inquiry report found the system lacked an approved and documented design and linked the accident to "a can-do attitude which focuses more on a functional rather than a safety outcome". The Gibb shackle had been accepted despite a history of failures and an inappropriate part added.
What the Coles Review confirms is that the Ministry of Defence project team lacked the expertise and oversight to recognise such defects in the making.
Its release last September was largely overlooked by the news media as the Winston Peters allegations peaked in the run-up to the election. The report is astonishing and points to the challenge ahead for incoming Defence Minister Wayne Mapp if he is to restore public faith in a Defence Force hamstrung by equipment and personnel issues across all three services - Army, Navy and Air Force.
The technically complex projects to upgrade the Air Force's ageing Orions and Hercules are behind schedule; the Army is overstretched and has yet to find an operational need for its light armoured vehicles, which cost taxpayers $650 million and $50 million a year to run. But rescuing the Canterbury is the clear and present danger facing Mapp.
The multi-purpose transporter was the first of seven new boats for the Navy under Project Protector, the $500 million spend-up to rebuild naval capability. Its defects are now the subject of delicate negotiations with the ship's builders, BEA Systems Australia, formerly Tenix (builders of the Anzac frigates). The flawed seaboat launching system is common to all seven ships and holding up their delivery.
The two offshore patrol vessels, Otago and Wellington, have been held up by arguments over their weight while the smaller inshore patrol vessels failed initial safety tests. Crews for the offshore ships were stood down last October.
It seems almost routine for new defence equipment to be dogged by delays and budget blowouts. Then when it arrives it doesn't do what it was touted to do. The Labour Government jettisoned the Canterbury's forerunner, the Charles Upham, rather than spend $35 million to fix stability and other problems. In 2005, Hercules breakdowns marred our tsunami relief effort and embarrassed the Government. Late last year, the Air Force's two new Boeing 757s were both in for repairs when they were needed.
How much this matters depends on where you stand on defence spending.
In an era of no obvious threat to our shores, opinion ranges from "why bother" to hawks who claim we are freeloading on Australia while living in a fool's paradise. The embarrassments hand ammunition to both camps but even neutral observers might be concerned at the taxpayer dollars squandered in bungled defence contracts.
The Coles Review suggests a common thread in the problems plaguing all three services is the Ministry of Defence's handling of major acquisitions and its dysfunctional relationship with the New Zealand Defence Force.
What should be worrying Mapp is the sense of deja vu - the same problems have been highlighted in three inquiries by the Auditor-General since 2001, a 2004 report by former State Services Commissioner Don Hunn and successive select committee reports.
Together, the reports conjure a civil-military cocktail of considerable self-destructive capacity, yet it seems no one has been held accountable and lessons haven't been learned.
The Audit Office set out last year to audit 10 major acquisitions subject to cost and delivery overruns but had to give up because of the two agencies' poor information and reporting systems. "In our view, the defence agencies must improve the transparency of reporting so that readers of the reports can have confidence that [they] are appropriately managing the acquisition process."
Explaining the cost variations, the agencies disclosed that costings on projects sent for Cabinet approval were "intelligent guesses". Auditor-General Kevin Brady said they should be robust.
Just how badly bureaucratic failings and mistrust can affect operational outcomes is perfectly captured in the Coles Review into the Canterbury's safety and functionality. The $177 million vessel, the Navy's biggest ship, was welcomed to Lyttelton in June 2007 with much fanfare.
The multi-role vessel is supposed to provide "sealift" capability - to transport troops and equipment including the Army's light armoured vehicles (LAVs) and to transfer equipment and personnel at sea using its two landing craft - both for military operations and disaster relief. Its smaller seaboats (rigid hull inflatables) provide fast sea rescue capability, while it can carry four helicopters for relief or military operations. Built in the Netherlands and equipped
in Melbourne, the ship is a modified version of a roll-on, roll-off ferry which operates in the Irish Sea.
Even on the way from Rotterdam to Australia, its suitability for stormy southern ocean conditions was exposed. The ship was prone to bow slamming and, in moderate seas, its starboard inflatable - housed in an alcove 3m above the waterline - was swamped by waves and the alcove door forced open, allowing water to enter the cargo deck.
On the delivery voyage from Melbourne to Lyttelton in June 2007, the starboard alcove door was again opened and the inflatable's engine damaged when the ship rolled 21 degrees.
The next month, on its way to Devonport from Wellington in a fierce storm, the portside inflatable was ripped out and destroyed by waves and the starboard inflatable damaged during a 28 degree roll. The ship lost 50 per cent of propulsive and electrical power as the large roll buried the starboard propeller deep in the water.
A court of inquiry found that on each occasion the ship had travelled in open ocean in southern latitudes, one or both of the rescue boats had been damaged or lost. The risk had been known for some time to the Navy, the acquisition authority and the prime contractor. But the need to manage two other risks - propeller emergence and bow slamming - limited the commanding officer's options.
The Coles Review - which followed a second court of inquiry, into the death of Byron Solomon when the seaboat launch went wrong - was led by John Coles, formerly head of the British Ministry of Defence warship support agency and Royal Navy's ships support agency, with experience in ship acquisitions and design.
His report links the Canterbury's seakeeping and operational issues (see accompanying story) to the ministry's acquisitions capability and governance.
"Acquisition has been constrained by the initial choice of design, it has been managed to get the ship into service as soon as possible and characterised by shortcomings in project management and governance and collective wishful thinking. [The ship] is unlikely to meet all the requirements of the contract."
Coles found the Canterbury is "intrinsically safe but remedial work will be required to perform military functions
and some operating limitations will have to be accepted. Seakeeping performance is likely to be poor in higher seas".
"The project team lacked the size and range of skills to manage a project of this complexity.
"[There were] significant shortcomings in governance of the acquisition, exacerbated by some strained relationships between the MoD and NZDF. Reporting of project performance has been generally inadequate."
Coles also found it "very surprising" that nothing was done to move the location of the seaboats during design development.
Soon after the contract was awarded in 2004, concerns grew within the ministry about the stability issues in high seas. It commissioned a report which identified "high-level risks" covering seakeeping, stability, power security and structural integrity.
The contract was suspended over the stability concerns in March 2005 but the Secretary of Defence was not told. The suspension was lifted in May after BEA accepted remedial plans but some seakeeping issues were unresolved.
The report says the basics of good project governance were fundamentally lacking - "there was no effective review or challenge to either the project director or to the deputy secretary (acquisitions) and patchy stakeholder management".
"We found the culture of the project team more akin to that of a military command than a team managing a significant contract and sum of taxpayers' money.
"We detected personal antipathies. We would like to have found evidence of more open debate...
"The project director was not subject to routine formal review. ... Reports from the deputy secretary (acquisitions) to the secretary of defence varied considerably in quality and breadth. There is little information on schedule and risks ... There was no specific monitoring of the Canterbury's costs against the [notional budget]."
Discussions within the executive capability board (the key joint governance body) "can be best characterised by the acquisition division seeking to demonstrate that all issues were being adequately addressed and the Navy seeking to ensure that vessels were accepted into service as soon as possible".
The report suggests that relations between the ministry and Defence Force have not improved since 2001, when the Audit Office termed it dysfunctional.
Coles says: "It has been suggested the atmosphere started to deteriorate with the reluctance of the acquisition division to explain its selection decision to other government agencies, exacerbated by leaks early in the programme. Relationships subsequently soured with the creation of the Naval Authority, which seemed to lack independence from the Navy ... and undertook work which seemed to cut across the project team.
"Some of the friction with the acquisition division stemmed from a perception that the Navy could not split the role of Naval Authority from its interest in getting a ship that met their concept of capability.
"The Naval Authority should be independent of the Chief of the Navy."
A fundamental problem was the staffing of the project team, which lacked the size and range of skills required. The team lacked an embedded naval architect and commercial and financial experts. Manpower shortages meant the project team was way behind on verification when the ship was accepted and a large number of contract deliverables were accepted without the necessary rigour.
"From the outset there was insufficient appreciation of the constraints imposed by the roll-on, roll-off ferry design. The programme was managed with relentless determination to deliver to time despite evidence of likely performance shortfalls."
Coles made 10 recommendations addressing the planning and governance of acquisitions, as well as a "Get Well Programme" to fix the Canterbury. But he said some operating limitations would have to be accepted and seakeeping performance was likely to be poor in higher sea states.
The Secretary of Defence, John McKinnon and Defence Force head Jerry Mateparae are overseeing implementation of the recommendations and negotiations with BEA to fix the Canterbury's defects.
The vessel has been fitted with new Zodiac seaboats and is again operational, but under restrictions including storm avoidance. She will perform guardship duties on Waitangi Day before deploying to Townsville for exercises with the Australians. The seaboat launch system has been changed for the entire fleet.
The cost of remedial work has been put at $20 million but who carries the can remains subject to warranty negotiations.
Some defence insiders believe the Canterbury's capabilities were over-hyped but Mapp blames the previous Government's penny-pinching for the choice of ship in the face of proven alternatives and a "rigid approach to costs" for some defects.
"The basic lesson in all of this is New Zealand should never be buying one-off stuff. We're too small for that."
He says the problems can largely be fixed - ballasting will improve stability, for instance - but there will always be limitations on loading and unloading at sea, which is supposed to be possible in conditions up to sea state 3 (on a 1-9 scale). Another safety concern is control of the landing craft while being moved by its crane on the top deck.
But, says Mapp: "The ship will be able to do the majority of things we ask of it."
He says the fleet of seven vessels represents a substantial boost to the Navy's capability and the Canterbury will be an asset to the region as a whole.
As for the ministry's acquisitions management, he says improvements are under way. Relations between the ministry and Defence Force were "much better" under Defence Secretary McKinnon, appointed 18 months ago. The ministry had a new deputy secretary of acquisitions in industry, veteran Des Ashton, while a new deputy secretary of policy had been appointed.
Asked whether anyone has been held accountable for the Canterbury's problems, Mapp says: "I'm more focused on fixing the issues and ensuring we get a good ship fit for purpose."
But he says the defence agencies' handling of acquisitions will be examined in a white paper.
Review points to myriad safety queries
The Canterbury's status has disturbing echoes of the 1990s' acquisition of the troop carrier Charles Upham, a converted roll-on, roll-off ferry which earned the nickname Chuck Upham because of stability problems. The Canterbury is also a modified "ro-ro", based on the Dutch-designed Ben my Chree, which plies the Irish Sea. The Coles Review describes the Ben my Chree as "a short/fat ship designed for short sea crossings".
It says: "Even a cursory examination of the Ben my Chree's design and operating profile should have raised questions over her suitability for long operational patrols in the southern oceans."
It is vulnerable to extreme pitching and heeling when headed directly into heavy seas (above 45 knots and waves 7-10 metres), causing bow slamming and propeller emergence. The report says this could lead to engine and electrical failure, possibly causing the ship to broach. The design is also subject to excessive rolling in heavy seas.
The ship's builders maintain the stability problems can be improved by higher ballasting - the same remedy touted for the Charles Upham but rejected by the Labour Government.
But the Coles Review says even after remedial work, the Canterbury's seakeeping performance is likely to be poor in higher seas and some operating limitations will have to be accepted. The ship was safe to operate "in the same manner as a commercial roll-on, roll-off ferry".
It recommended that further advice on handling and propulsion in extreme seas be obtained from the ship's designers, including machinery configuration and preferred headings. "It would be prudent to seek shelter and or change course in the higher sea states and avoid Beaufort scale 9 and above entirely."
The review also raises concerns about the transfer-at-sea capability, which involves lowering the rear ramp to load landing craft which are lowered by crane from the top deck. The system had "yet to be demonstrated to be safe" and queries include the loadings that could be experienced on the rear door. "Operational procedure should be critically re-examined as the consequences of inadvertently flooding the cargo deck are potentially disastrous."
Keeping the landing craft aligned with the ship's ramp in any sort of sea could also prove problematic.
Moving the landing craft on the top deck raised further safety concerns. "Control of any lateral movement of the landing craft once suspended on the crane hook is practically zero. The proximity of a swinging crane hook to the coxswain's wheel house is potentially dangerous, as is manual engagement of lifting strops to the crane hook."
The seaboats' vulnerability to wave damage related to their location in alcoves 3m above the waterline and too close to the stern. Potential remedies include fitting doors or relocating the boats - either of which could compromise their fast rescue capability.
"Our overall view is that the functionality required will be achieved and that following remedial work the Canterbury will be able to discharge all her operational roles. The ship will exhibit poor seakeeping qualities for ocean patrolling in higher sea states but over time the Navy should be able to develop practices and procedures to accommodate the seakeeping performance. Some of the deliverables required under the contract may never be delivered."
