A report into a fatal light plane crash that killed five tourists and the pilot three years ago has recommended mandating the use of active warning carbon monoxide detectors in passenger-carrying aircraft.
On December 31, 2017, pilot Gareth Morgan and five passengers – British tycoon Richard Cousins, 58, his sons William, 25, and Edward, 23, his fiancee Emma Bowden, 48, her daughter Heather, 11 – boarded a Sydney Seaplanes aircraft for a flight from Cottage Point on Sydney’s northern beaches to Rose Bay.
Shortly after takeoff, the aircraft entered Jerusalem Bay, when its nose dropped and the plane crashed into the water, killing everyone on board.
Following a four-year investigation, the Australian Transport Safety Bureau released its final report on Friday, finding carbon monoxide exposure affected Mr Morgan’s ability to operate the aircraft.
The report also found several pre-existing cracks in the aircraft engine’s exhaust collector ring likely released exhaust gas into the engine or accessory bay, which likely entered the cabin through holes in the main firewall where three bolts were missing.
The report also noted 27 minutes of taxiing time prior to takeoff, with the pilot’s door ajar, before the passengers boarded likely exacerbated the pilot’s elevated carboxyhemoglobin level.
“Toxicology results identified that the pilot and passengers had higher than normal levels of carboxyhemoglobin in their blood,” the report notes. “This was almost certainly due to elevated levels of carbon monoxide in the aircraft cabin.”
ATSB chief commissioner Greg Hood said Mr Morgan would have “almost certainly experienced effects such as confusion, visual disturbance and disorientation”.
He added the incident highlighted the dangers of carbon monoxide exposure to aircraft occupants.
As a result, the agency has recommended the International Civil Aviation Organisation and Civil Aviation Safety Authority (CASA) consider mandating the carriage of active warning carbon monoxide detectors and the fitment of lightweight recording devices, such as a cockpit voice recorder or a flight data recorder, to smaller passenger-carrying aircraft.
At the time of the incident, the plane was carrying a disposable carbon monoxide chemical spot detector, but it was “likely not effective on the accident flight due to sun bleaching,” the report notes.
A spokesperson for Sydney Seaplanes said the company’s thoughts were with the families of those who had died.
The 157-page final report made several recommendations and in July 2020 issued a safety advisory notice to aircraft maintainers about the importance of conducting detailed inspections of exhaust systems and firewalls.
It also issued a notice to owners and operators encouraging them to install carbon monoxide detectors with an active warning.
Since the incident, Sydney Seaplanes has installed carbon monoxide warning systems on its aircraft and introduced additional safety procedures.
A spokesperson for CASA said it was considering the recommendations.
“If we determine regulatory change is required we will consult widely with the aviation industry. These are important safety issues and very worthwhile looking at,” the spokesperson said.
The International Civil Aviation Organisation has been contacted for comment.
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Laura is a crime reporter for The Sydney Morning Herald.
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2021-01-29 09:48:00Z
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