[Peetwo]

NSW Coroner drills a hole through the Sydney Seaplane crash Federal obfuscation??? 

Via the Oz:

Disturbing twist to Sydney Seaplane crash that claimed six lives



An aircraft maintenance company at the centre of a fatal Sydney Seaplane’s crash continues to operate with Civil Aviation Safety Authority approval, despite failing to address work practices that contributed to the tragedy.

Airag Aviation Services was found to have used non-standard bolts and other non-standard materials in its maintenance of the crash aircraft — a DHC-2 Beaver floatplane.

As a result it was believed three of the bolts securing a firewall had come out, allowing carbon monoxide fumes to enter the plane’s cockpit during a return trip between Rose Bay and Cottage Point on December 31, 2017.

The Australian Transport Safety Bureau found carbon monoxide poisoning most likely led to pilot Gareth Morgan becoming disoriented, and crashing into Jerusalem Bay.

The impact killed all six people on board, including Mr Morgan and British tourists Emma Bowden and daughter Heather, 11, Richard Cousins and sons William and Edward.

It wasn’t until two years after the crash that it occurred to the ATSB to test the victims for carbon monoxide, with the results showing all had elevated levels of the toxic gas in their blood.



Maintenance issues that led to the gas leak were identified in the final ATSB report released in January 2021 but no safety direction was made specifically for Airag.

Throughout the investigation and since, Airag has continued to work on commercial aircraft despite making little apparent effort to change its practices that allowed the use of non-standard parts such as bolts and pipes.

The situation was highlighted in a report by NSW deputy state coroner Derek Lee who confirmed the ATSB’s findings that carbon monoxide poisoning was the likely cause.

Magistrate Lee also noted remedial action taken by Airag since December 31, 2017 had been “extremely limited and in essence confined to oral instructions which are lacking in detail”.

“(These instructions) have not been reduced to writing or developed into any robust policy,” he wrote.

“The evidence suggests that the response by Airag is antiquated and not informed by contemporary practices. The response also does not demonstrate an attitude and approach to supervision and safety that is consistent with the expectations of the industry.”



The Civil Aviation Safety Authority indicated Airag was subject to surveillance and regular audits, like any other holder of a CASA-issued operator certificate.

“Following the publication of the coronial report, CASA is considering the Coroner’s reasons, including any new information disclosed as a result of the coronial process, and will evaluate if further regulatory action is warranted,” said a CASA spokesman.

“Any safety findings raised must be followed up and satisfactorily addressed by operators.”

Airag Aviation CEO David Pyett did not respond to calls from The Australian.

Sydney Seaplanes sued Airag Aviation following the release of the ATSB report and the case was settled out of court last year.

Managing director of Sydney Seaplanes Aaron Shaw said they remained “very, very angry” about what had happened on New Year’s Eve in 2017.

“It’s resulted in the death of a dear colleague of ours and caused untold grief for many other families,” Mr Shaw said.

“We are also victims of this accident. It’s caused us reputational damage, financial damage and for there to be effectively no consequences or actions (for Airag) beggars belief.”

He said the tragic matter also called into question the role of the aviation safety regulator.

“I don’t think expectations are being met by the lack of action being taken, from what we can see,” said Mr Shaw.

“I think the community would expect a more proactive response to the various reports made about this accident.”

MTF...P2