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Case Number: 2018/1389; 2018/1393; 2018/1398; 2018/1399; 2018/1401; 2018/1404
Findings Date: 26 May 2023
Magistrate: Derek Lee
CORONIAL LAW | cause and manner of death; aviation fatality; de Havilland Canada DHC-2; Jerusalem Bay; Sydney Seaplanes; Airag Aviation Services; floatplane; engine exhaust system; magneto access panels; magneto cooling tubes; firewall breach; AN3-3A bolt; carbon monoxide exposure; ingress of carbon monoxide into aircraft cabin; chemical spot detectors; on board recording devices; recorded flight data; Australian Transport Safety Bureau; Civil Aviation Safety Authority
| Recommendations to | Response |
|---|---|
| Chief Commissioner Australian Transport Safety Bureau | Awaited |
| Chief Executive NSW Health Pathology | Awaited |
| Chief Executive Officer Airag Aviation Services Pty Ltd | Awaited |
| Chief Executive Officer Civil Aviation Safety Authority | Awaited |
1. I recommend that the Chief Executive Airage Aviation Services Pty Ltd (Airag) institute a written policy for its staff, requiring removal and installation of firewall access panels on DHC-2 aircraft to be inspected for conformity by its Chief Engineer, and a test for the presence of carbon monoxide to be conducted prior to the aircraft being returned to service.
2. I recommend that Airag institute a written policy for its staff requiring that following maintenance work being conducted on the engine exhaust system of a piston engine aircraft, whether scheduled or unscheduled, a test for the presence of carbon monoxide is conducted.
3. I recommend that carbon monoxide screening be conducted as part of standard toxicology testing by the NSW Health Pathology Forensic and Analytical Science Service in all deaths resulting from aviation incidents, subject to an appropriate biological sample from the deceased person(s) being available.
4. I recommend that further engagement occur with the Australian Transport Safety Bureau to better understand the basis for the ATSB recommendation that carbon monoxide detectors in piston engine aircraft, particularly for commercial passenger carrying operations, be mandated. Such engagement should give rise to further consideration being given by the Chief Executive Civil Aviation Safety Authority (CASA) as to the appropriateness of such mandatory action, including monitoring study data to determine what types of carbon monoxide detectors function most reliably in piston engine aircraft cabins.
5. I recommend that pending reconsideration mandating the installation of carbon monoxide detectors, CASA develop and implement a specific program for regularly promoting the voluntary installation of electronic carbon monoxide detectors in piston engine aircraft, involving regular and appropriate communication to aircraft owners and maintainers.
6. I recommend that further engagement occur with the Australian Transport Safety Bureau to better understand whether a cost benefit analysis exists to support mandating the fitment of on-board recording devices in commercial passenger-carrying aircraft with a maximum take-off weight of less than 5,700 kilograms. Such engagement should give rise to further consideration being given by CASA as to the appropriateness of such mandatory action.
7. I recommend that pending further consideration by CASA of mandating the fitment of on-board recording devices in small passenger-carrying aircraft under 5,700 kilograms, further engagement occur with the Australian Transport Safety Bureau to devise a program for promoting the voluntary installation of such devices in such aircraft.
8. I recommend that the Chief Commissioner Australian Transport Safety Bureau (ATSB) engage with CASA to address the issue of whether fitment of on-board recording devices in small passenger-carrying aircraft under 5,700 kilograms will demonstrate a measurable improvement in the outcome of investigations conducted by the ATSB, particularly in relation to whether the absence of such devices has resulted in the non-identification of safety issues which continue to present a hazard to current and future passenger carrying operations.
20 Apr 2024