[Peetwo]

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

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.”

Via the NSW Coroner's website: https://www.coroners.nsw.gov.au/coronial...archPage=1#

• Inquest into the deaths of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins & Gareth Morgan- external sitelaunch
  Decision of Deputy State Coroner 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,
  

Remember this 'update' from the ATSB FR: https://www.atsb.gov.au/publications/inv...o-2017-118

Update: 3 July 2020

During the draft investigation report review process, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide (CO) toxicology testing be undertaken on blood samples of the aircraft occupants that had been taken and suitably stored by the New South Wales State Coroner. This required testing at a specialised laboratory. With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.

The results of the testing were provided to the ATSB in March 2020, indicating that the pilot and two of the passengers had elevated levels of CO. The ATSB notes that post-mortem examinations established that the pilot and passengers received fatal injuries sustained as a result of the impact sequence.

Since receiving the toxicology results, the ATSB has:

• consulted with New South Wales Health pathology to confirm the integrity of the samples given the preservation method, storage temperature and duration
  
• consulted with NSW Health forensic toxicology to confirm the accuracy of testing given the technique used and sample preparation
  
• received independent advice from a forensic pharmacologist, and engaged an experienced independent forensic pathologist to advise on the testing and effects of the CO levels found in the occupants
  
• undertaken research on CO poisoning and detectors relating to aircraft operations.
  

From this, the ATSB considers the levels of CO detected were likely to have adversely affected the pilot’s ability to control the aircraft during the flight.

Having discounted other potential sources of CO exposure, the ATSB considers it likely that the pilot and passengers were exposed to CO inside the aircraft cabin. To identify the source of CO in the aircraft cabin, the ATSB has:

• conducted a further examination of the aircraft, in particular, the exhaust system and engine firewall, and identified a potential source of CO and path for exhaust gases to enter the aircraft cabin
  
• reviewed the aircraft’s maintenance records for scheduled/unscheduled maintenance and inspections carried out on relevant components
  
• attended the maintenance facility to examine an exemplar exhaust system in-situ, and to discuss relevant maintenance procedures
  
• undertaken ground testing on an exemplar DHC-2 aircraft to replicate the potential source of CO and ingress into the cabin
  
• consulted with the Civil Aviation Safety Authority regarding the release of an airworthiness bulletin providing advice on CO issues.
  

From the above activities, the ATSB found pre‑existing cracking of the engine exhaust collector-ring, which could lead to exhaust leakage into the engine bay. Further, the ATSB found a breach in the firewall from missing bolts used to secure magneto access panels in the firewall under the instrument panel in the cabin. Any breach in the firewall can allow the ingress of gases from the engine bay into the cabin. 

In order to communicate the significance of the above to the aviation industry, the ATSB has released the following two safety advisory notices, which:

• Remind aircraft maintainers of the importance of conducting thorough inspections of exhaust systems and firewalls, with consideration for potential CO exposure (AO-2017-118-SAN-001).
  
• Strongly encourage operators, owners and pilots of piston-engine aircraft to install or carry a carbon monoxide detector with an active warning to alert pilots of elevated levels of CO in the cabin (AO-2017-118-SAN-002).
  

Despite the inexcusable fact it took the ATSB the better part of 2 years to discover that there had been no toxicology testing for CO, the Deputy Coroner went easy on the ATSB but his findings and recommendations went to the issue with other directly involved government agencies: Ref from page 57






Read between the lines on the Deputy Coroner's observations on the regulator...










It continues on and IMO is well worth the read - top job that Coroner...

Much MTF??..P2 - 

PS: Reflect on this post from August 2019 - Hooded Canary not singing but still talking bollocks - and consider how things have improved in the nearly 4 years since - err NOT!