Final Court of Inquiry into HMNZS Manawanui grounding and sinking in Samoa released

Royal New Zealand Navy ship HMNZS Manawanui ran aground with 75 people on board in Samoa whilst conducting a hydrographic survey of a reef on Saturday 5 October 2024. The ship sank on Sunday 6 October. 

An interim Court of Inquiry, released less than two months following the incident, found the direct causes and some contributing factors of the grounding and sinking related to a series of human errors.

In the final Court of Inquiry report, made public today, the Court found 12 factors that contributed to the grounding and sinking, making it more likely to occur.

In presenting the findings, Court of Inquiry president Commodore Melissa Ross, said the 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.”

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.

“This means investing in new technologies, streamlining ways of working, reviewing and adapting training and making sure our people are set up to succeed in their roles. Our people are working really, really hard; they are out there around the globe right now doing what they signed up to do – serve our country and protect New Zealand’s interests.”

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.” 

Access to the Court of Inquiry report:

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(external link)