He had been able to recover from the first but overcorrected on the second and hit the ground three seconds later. He was flying at only about 178 feet and 65 knots when he lost control for the second and fatal time.
"In the opinion of the court, once the second departure commenced the situation was unrecoverable and the accident inevitable, given the height of the aircraft,'' the inquiry's report into the crash, released today, said.
"Squadron Leader Cree was flying the Fishtail Pass in an unstable and inconsistent manner due to a lack of specific training in how to fly the manoeuvre,'' it said.
"Guidance in Red Checkers' standard operating procedures was limited and ambiguous, and did not provide sufficient guidance to ensure the use of appropriate techniques to fly the Fishtail Pass.
"Squadron Leader Cree had not discussed the manoeuvre with any other pilot, nor had he advised of the fact that he was regularly departing from controlled flight during the Fishtail Pass.''
He persevered with the manoeuvre after the first departure because he did not realise the danger of continuing, and the second departure probably took him by surprise.
That may have been due to a perception among Red Checkers pilots that the Fishtail Pass was a "benign manoeuvre'' and malaise due to the fact he had recovered from departures when he had previously performed it.
Other pilots and supervisors had not noticed anything amiss with the way Mr Cree carried out the manoeuvre previously as there were no formal supervisory or informal monitoring systems in place.
However, his FDR led the inquiry to conclude his previous performances of it were "unstable and dangerous''.
Mr Cree had previously been involved in two other incidents; in one, a policeman was injured when he was told to jump out of an Iroquois helicopter over water at a higher than normal height and speed, and in the other he crash-landed a Tiger Moth in a paddock when it stalled during a manoeuvre.
The inquiry team did not believe either event had any relevance to the January 14 crash.
Air Commodore Kevin Short, in his response to the report, said it had occurred because Mr Cree chose to fly the manoeuvre the way he did, despite his extensive training background.
"He appears to have underestimated the fundamental dangers inherent in departure from controlled flight at low level.''
Mr Short accepted 18 of the court's recommendations but did not accept that the flight's wreckage should be available for teaching purposes.