Inquest into the deaths of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins & Gareth
Deceased
Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins, Gareth Morgan
Demographics
unknown
Date of death
2017-12-31
Finding date
2023-05-26
Cause of death
Multiple blunt force injuries and immersion secondary to seaplane crash caused by pilot impairment from carbon monoxide exposure
AI-generated summary
On 31 December 2017, a de Havilland DHC-2 Beaver seaplane crashed into Jerusalem Bay, Sydney, killing all six occupants. The coroner found the crash was caused by pilot impairment due to carbon monoxide (CO) exposure. Pre-existing cracks in the aircraft's exhaust manifold allowed CO to enter the cabin through breaches in the firewall (three missing AN3-3A bolts in magneto access panels and a misoriented panel). The pilot had a carboxyhaemoglobin level of 11%, which impaired his cognitive function and aircraft operation. Maintenance contractor Airag Aviation Services used non-standard bolts and parts without approval or testing, and failed to establish written safety policies or adequately supervise staff. A critical investigative delay occurred—toxicology was not tested for CO initially, only in March 2020 nearly two years after the crash. The coroner made eight recommendations to Airag, NSW Health Pathology, CASA, and the ATSB addressing maintenance procedures, pathology protocols, and aviation safety regulations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Pre-existing cracks in aircraft exhaust manifold
- Three missing AN3-3A bolts from magneto access panels
- Misoriented magneto access panel
- Use of non-standard and worn bolts
- Use of non-standard magneto cooling tubes without approval
- Inadequate maintenance procedures and inspection protocols
- Absence of written safety policies
- Inadequate supervision and guidance of maintenance staff
- Pilot door ajar during prolonged taxi exacerbating carbon monoxide ingress
- Delayed toxicological investigation—carbon monoxide testing not performed initially
Coroner's recommendations
- Airag to institute written policy requiring inspection for conformity and carbon monoxide testing when firewall access panels are removed and installed on DHC-2 aircraft prior to return to service
- Airag to institute written policy requiring carbon monoxide testing following maintenance work on engine exhaust systems of piston engine aircraft
- NSW Health Pathology to conduct carbon monoxide screening as part of standard toxicology testing in all deaths resulting from aviation incidents
- CASA to engage with ATSB to understand basis for carbon monoxide detector mandate recommendation and reconsider appropriateness of mandating detectors in piston engine aircraft
- CASA to develop and implement program for regularly promoting voluntary installation of electronic carbon monoxide detectors in piston engine aircraft
- CASA to engage with ATSB to understand whether cost-benefit analysis exists supporting mandatory fitment of on-board recording devices in aircraft under 5,700 kilograms
- CASA to engage with ATSB to devise program for promoting voluntary installation of on-board recording devices in small passenger-carrying aircraft under 5,700 kilograms
- ATSB to engage with CASA regarding whether on-board recording devices would demonstrate measurable improvement in investigation outcomes
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