Australian Defence Force Academy recruits injured in a bus crash near Goulburn were travelling without adequate first aid supplies, water or satellite phones at the time of the November 2015 accident, with a passing property owner the only person able to raise the alarm.
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A review of the crash and emergency response by the Defence Department shows the three people seriously injured were initially treated with optional first aid kits carried by some of the cadets and passersby, while no water or passenger manifest was on-board the four bus convoy.
The scathing report, released under freedom of information rules, shows the only shade available to the injured passengers in the immediate aftermath came from uninjured cadets holding up ground sheets to block the sun in 24 degree conditions.
The bus crashed about 9.55am on November 21, 2015, while carrying 57 passengers on Sandy Point Road, Windellama, about 50km south-east of Goulburn.
Three passengers were seriously injured, later airlifted to Canberra and Sydney. A further nine passengers were taken by road to Goulburn.
The cadets and midshipmen were returning from a training exercise at HMAS Creswell at Jervis Bay, passengers in the lead bus in a four vehicle convoy.
The nearby property owner, an Air Force warrant officer who had just arrived home, called 000 about four minutes after the crash.
Emergency services arrived on site about 50 minutes later, with police, fire and ambulance crews working to free a trapped recruit after an hour and 20 minutes.
The report notes satellite phones used during the training exercise were not on-board the buses and the only mobile phone coverage in the area was from on top of a hill about 650 metres away.
Further analysis by Defence found mobile phone signal was not available for more than 20 kilometres in either direction from the accident site.
Had the local resident not been passing by the crash site, "one of the remaining buses would have been required to search for a location where a mobile phone signal was available".
A registered nurse and a State Emergency Service volunteer who both passed by the accident site within half an hour of the crash provided additional first aid.
"Had the property owner... not arrived at his property immediately prior to the accident and immediately contacted the emergency services, there would have been a significant delay to the arrival of these services," the report says.
"The property owner had food, ice and water with him for the weekend at the property and made these available to the ADFA staff and uninjured cadets; no other supplies were available."
In April 2016 the driver of the bus was charged with three counts of dangerous driving occasioning grievous bodily harm and negligent driving occasioning grievous bodily harm. He has pleaded not guilty and will face court in Sydney in October.
The report found effective planning for the exercise but significant shortfalls in the transport phase. A number of risk management strategies had not been implemented.
Academy staff members who attended the most seriously injured passengers had all previously received battlefield first aid training, which the report says was of "enormous benefit at the accident site."
"The early call made to the emergency services, by the property, coupled with the immediate reaction and response by all the ADFA cadets and staff involved in this incident, limited the severity and consequences to those members that suffered injuries," the report says.
"Their actions brought credit to ADFA and the Defence Force."
The report's seven recommendations include calls for first aid kits, water, adequate shade provisions and passenger manifests to be carried on future exercises, as well as for more effective command and control measures to be in place.
Defence has been contacted for further comment.
