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Sydney Sea Plane crash (Anna Bay) Coronial inquest begins 

Via the SMH:

Role of carbon monoxide in seaplane crash was not considered until years later, inquest told

Georgina Mitchell
Updated October 17, 2022 — 6.59pmfirst published at 2.07pm

The possibility that carbon monoxide caused a seaplane pilot to become disoriented and crash was not investigated until two years after the tragedy, an inquest has heard, with the coroner urged to recommend routine testing for the toxic gas in the future.

Pilot Gareth Morgan and five British tourists were killed on December 31, 2017, when their scenic flight from Cottage Point in Sydney’s north to Rose Bay in Sydney Harbour crashed into Jerusalem Bay shortly after taking off.


Died in the crash: Pilot Gareth Morgan, Emma Bowden, her daughter Heather Bowden-Page, Richard Cousins, and his sons Edward and William.

Several witnesses who observed the crash tried to dive down to rescue the occupants before the plane sank, but the water was too murky and filled with jet fuel.

In an opening statement on Monday, counsel assisting Sophie Callan, SC, said Richard Cousins, his sons Edward and William, his fiancee Emma Bowden, and her daughter Heather had been on holiday in Australia ahead of Richard and Emma’s planned wedding in 2018.

On December 31, they travelled by seaplane to have lunch at the Cottage Point Inn and were flying home when the plane unexpectedly circled in a different direction and crashed at 3.14pm.

Callan said the pilot sustained significant injuries and was unlikely to have regained consciousness after the crash. The others on board died from a combination of their injuries and being submerged in the water.


An undated photo of the plane that later crashed into Jerusalem Bay, killing its occupants.CREDIT:AUSTRALIAN TRANSPORT SAFETY BUREAU

An investigation by the Australian Transport Safety Bureau (ATSB) concluded that elevated levels of carbon monoxide were present in the cabin of the plane, affecting the pilot’s ability to fly and most likely causing the crash.

Mechanical examinations suggested that the colourless, odourless gas leaked into the engine bay due to cracks in the exhaust system, then leaked into the cabin because three bolts were missing from the plane’s front instrument panel.

Callan said the gas could have passed through the holes from the missing bolts. The inquest is also expected to hear evidence that one part of the instrument panel was upside-down, potentially allowing further gas to escape.

The inquest heard carbon monoxide was only examined as a potential contributor to the crash in late 2019, two years later, when an aviation medical specialist examined a draft report and suggested investigators look at carbon monoxide poisoning.


The wreckage of the plane is recovered by police and transport safety authorities on January 4, 2018.CREDIT:WOLTER PEETERS

Callan said it appears that police and the ATSB wrongly assumed a chemical byproduct of carbon monoxide was routinely checked for in toxicology screening. Blood samples retained from the autopsies were examined, revealing all passengers had the chemical, carboxyhaemoglobin, in their systems.

Morgan had the chemical in his blood at a concentration of 11 per cent. Experts are expected to give evidence that a level of 10 per cent is sufficiently high to cause adverse physical and cognitive effects.

Callan said the delay in focusing on carbon monoxide meant 2½ years had passed between the crash and authorities being able to issue bulletins to remind plane operators of the dangers of the gas.

Detective Sergeant Michael O’Keefe, who led the police investigation, said he received the additional test results in March 2020. He said if carbon monoxide was routinely screened for in autopsies, it would have quickly become the focus of the investigation.


Police respond to the scene of the crash on December 31, 2017.CREDIT:JESSICA HROMAS

“We would have saved a lot of time, and it would have saved the relatives and family probably a lot of pain over the years,” he said.

He said the coroner should consider recommending routine testing be carried out for deaths involving vehicles that produce carbon monoxide, if a cause of death was not immediately obvious.

“We might be surprised with the number of positive results we might get,” O’Keefe said.

The inquest heard Morgan, 44, was a highly experienced pilot and a gifted athlete who had a devout Christian faith and had been on missions to Mexico and Mozambique.

Richard Cousins, 58, was remembered as the chief executive of catering company Compass and a lover of cricket, who had just attended the Boxing Day Test with William, 25, and Edward, 23.

William, a press officer and parliamentary speechwriter, had recently been commended for talking down a suicidal person on a bridge at the Thames. Edward, who previously taught at a refugee camp, had just passed his entrance exam to be a police officer.

Emma, 48, who worked at OK! Magazine, was a lover of travel, cinema, theatre and cycling. Heather, 11, had started a school newspaper and starred in a play. She had big dreams to study at Cambridge.

The inquest continues.

MTF...P2