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 highlighted that the RAN and Australian Defence Industries (ADI) contractor did not adequately assess their actions, resulting in inadequate training and qualifications among key personnel. The inquiry also found that the hoses were poorly designed and unsuitable for their intended purpose. In 2005, ADI was penalized $75,000 for neglecting to provide a secure work environment.