The enquiry found that the RAN and the contractor Australian Defence Industries (ADI) did not critically examine their course of action and that key personnel in both the RAN and the contractor were insufficiently trained and qualified. The inquiry also found that the hoses were not properly designed and were unfit for the intended purpose. In 2005, ADI was fined $75,000 for failing to provide a safe workplace.
The investigation revealed that the RAN and the contractor Australian Defence Industries (ADI) did not thoroughly assess their actions, and key personnel in both organizations lacked sufficient training and qualifications. The inquiry also uncovered that the hoses were inadequately designed and unsuitable for their intended use. In 2005, ADI was penalized $75,000 for failing to provide a secure work environment.