On 31 December 2017 at about 3:15 pm AEDT (UTC+11:00), a de Havilland Canada DHC-2 Beaver configured as a floatplane crashed into Jerusalem Bay off Cowan Creek,[1] on the northern outskirts of Sydney, Australia. The aircraft, operated by Sydney Seaplanes, was carrying five passengers and a pilot, all of whom were killed in the crash. It was returning diners from Cottage Point Inn restaurant to Rose Bay Water Airport.[2][3] The ATSB believes it probable that the pilot's performance was adversely affected by carbon monoxide poisoning. Post mortem tests on the bodies of the victims showed raised levels of CO in the blood, and a crack in the exhaust system was seen as the likely source of the gas.[4][5]

2017 Sydney Seaplanes DHC-2 crash

VH-NOO, the aircraft involved in the accident, seen here in January 2017
Accident
Date	31 December 2017 (2017-12-31)
Summary	Crashed following pilot incapacitation due to carbon monoxide poisoning
Site	Cowan Creek
Aircraft
Aircraft type	de Havilland Canada DHC-2 Beaver
Operator	Sydney Seaplanes
Registration	VH-NOO
Flight origin	Cottage Point, New South Wales
Destination	Rose Bay Water Airport
Occupants	6
Passengers	5
Crew	1
Fatalities	6
Survivors	0

Aircraft

The aircraft was a 54-year-old de Havilland Canada DHC-2 Beaver, originally built in 1963 and registered in Australia since February 1964; it was powered by a single Pratt & Whitney R-985 Wasp Junior engine.[6]

In 1996, the aircraft was destroyed in a crash while working as a crop duster near Armidale, New South Wales, killing the pilot. The aircraft was then completely rebuilt; the Civil Aviation Safety Authority confirmed that it had been repaired according to industry requirements.[7]

Victims

The Canadian-Australian pilot[8] and five British tourists – Richard Cousins, 58, CEO of British foodservice company Compass Group, his two sons, his fiancée[9] and her daughter – were killed in the crash.[10][11]

Investigation

The Australian Transport Safety Bureau (ATSB) opened an investigation into the accident. Most of the wreckage of the aircraft was raised on 4 January 2018.[12] The intermediate report, published on 31 January 2018, indicated that the aircraft was found to have followed a differing flight path from the usual, and had failed to climb to the necessary altitude needed to fly over the surrounding terrain. It also indicated that the preliminary examination of aircraft flight control surfaces and controls seemed in sound order and expected positions, and that the engine sounded normal to witnesses on the ground. The aircraft landed inverted and all six on board suffered fatal injuries.[5]

On 28 January 2021, the ATSB released a final report to the accident, which concluded that the pilot and passengers had higher than normal levels of carboxyhaemoglobin in their blood and that several pre-existing cracks in the exhaust collector ring, very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main firewall where three bolts were missing from the magneto access panels. The aircraft was fitted with a disposable CO detector, but CO detectors of its kind have been widely deemed unreliable.[5]

The operators of the aircraft have implemented changes to the aircraft's system of maintenance, which include:

• The aircraft being fitted with active electronic CO detectors.
• The check of the serviceability of the CO detectors has been incorporated into the monthly emergency equipment checklist.
• Directing its new maintenance provider that the removal and installation of the main firewall access panels must be classified as a critical maintenance operation task, and will require certification by a licensed aircraft maintenance engineer and a conformity inspection.
• Directing its new maintenance provider that following maintenance activities on the engine exhaust system or use of the main firewall access panels, the test for the presence of CO must be conducted.
• An inspection of the magneto access panels and CO testing has been incorporated into the 100-hourly 'B' check inspection.[5]

Dramatization

This accident will be featured in Season 23 of Canadian Documentary Series Mayday.[13]^{[needs update]}

See also

• 2019 English Channel Piper PA-46 crash - another light aircraft crash where carbon monoxide poisoning was a significant cause

References