Several weeks into the local investigation, the then Chief of Air Force (Air Marshal Errol McCormack) was approached with concerns that there were possibly problems, not only with the respray program, but with F-111 fuel tank maintenance programs dating back to the 1970s.
Given the magnitude of the possible implications, CAF decided to appoint a Board of Inquiry with wide-ranging Terms of Reference. The Board convened on 19 July 2000 and was provided with a budget of $7.2 million. Counsel assisting the Board interviewed some 700 people, searched through 1.5 millions pages of documents to build a data base for the public hearings. After several weeks of sittings the hearings were completed on 28 May 2001.
The Board’s principal finding is that the health symptoms that DSRS workers currently experience or demonstrate are reasonably attributable to their earlier exposure. It is on this basis that the Board estimates there to be in excess of 400 workers who have suffered long term damage to their health. The Board determined at the outset that it would be unnecessary and inappropriate to pursue individual cases of improper action, or inaction. This was particularly appropriate as these events occurred over a 27 year period and many persons had subsequently left the Service. The Board found that there were a number of systemic failures, described in the Report as the ‘causal pathways to the outcome’. The Air Force medical service was seen as failing, in particular by the low priority given to occupational medicine. A second factor identified as an immediate cause was the relative powerlessness of maintenance workers. Complaints were effectively ignored. At the level of immediate causes, exposure to toxic chemicals was the main focus of the Inquiry. Exposure was possible, the Board found, as the Air Force was relying totally on personal protective equipment (PPE) to protect its workers from the many hazards involved in working with toxic substances in confined spaces. Given the reliance on personal protective equipment, problems arose with the appropriateness of protective equipment for the tasks at hand, the availability and control of that equipment through the supply network, and the failure of some workers to wear the equipment, coupled with an inadequate compliance system. A final failure, and in some respects, most fundamental of all failures, was that the chain of command did not operate optimally. Senior Non Commissioned Officers (SNCOs) put up with a variety of inadequacies in PPE, equipment failures and ventilation problems without raising them through the chain of command because of the expectation that they resolve things. There was also a particular weak link in the chain of command between the SNCOs and junior engineering officers who had too broad a span of responsibilities. Senior officers were also suffering extreme work overload; in particular during the latest spray seal program, from conflicting priorities due to impending commercial support testing. As a consequence, senior officers had little understanding of what was occurring on the hangar floor. These weaknesses of the chain of command also stem from government policy decisions which have affected workforce numbers, and a reliance on contractor support.
There are 53 recommendations provided by the Board of Inquiry to rectify the problems uncovered. The Board’s intent, while addressing the F-111 specific issues, has also been to set the scene for Occupational Health and Safety for the next generation of the Defence Force. The recommendations have been accepted by all levels of Defence and the Minister, and are fully explained in Volume 1 and listed in Appendix 3 of the Report. To understand the underlying tenor and theme of each recommendation, it is important that it be read in context with the content of the report.
Implementing the Recommendations
As many of the areas
under scrutiny have been removed from within the Air Force Program and now
reside in Service Provider Programs, CAF has sought support from the Chief
of the Defence Force and Secretary to implement changes. This will result
in Defence-wide changes requiring a most comprehensive review of workplace
safety issues. A team of specialists, with expertise in workplace safety,
health, training and project management is forming a specific tri-Service
Defence Workplace Safety Project Office within Defence and is expected to
start activities in January 2002. In the meantime a number of initiatives
have already been started in anticipation of the Board’s recommendations.
Air Force has established a ground safety agency; an audit of ground safety
is to start shortly at a major Air Force Base; and an audit of toxic substances
used across Defence is under way. Defence and the Department of Veterans’
Affairs are working together closely to implement the Board’s recommendation
that health care is to be provided to those ex-service members whose health
has been affected by their work in the Deseal Reseal program. The Department
of Defence is funding a special scheme, administered by DVA on behalf of Defence,
where these workers will now be able to receive appropriate counselling and
free medical treatment for their specific ailments. Further information on
the F-111 DSRS
Health Care Scheme is available in this Information Package. To assist those who have been involved in fuel tank maintenance, a suitably qualified and experienced ‘advocate’,
or ‘airmen’s friend’, has been appointed to provide guidance to maintenance workers and link with the Department of Veterans’ Affairs to ensure these people have appropriate guidance and assistance in preparing claims and seeking assistance. The advocate also has direct access to the Chief of Air Force. Contact details for the advocate are contained in the Contact Sheet in this package. Information concerning the Inquiry will be passed to those involved and also the wider community through the media and via the BOI / Defence Website.