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Key points
Pilot’s ability to control the aircraft likely significantly degraded due to carbon monoxide exposure;
Cracks in aircraft exhaust and holes in firewall very likely allowed carbon monoxide to enter the aircraft cabin;
ATSB recommends mandated fitment of recording devices in smaller passenger aircraft, active CO detectors in piston aircraft.
Carbon monoxide exposure likely significantly degraded the ability of the pilot of a Beaver floatplane to safely operate the aircraft before it collided with water in Jerusalem Bay on the Hawkesbury north of Sydney in December 2017, fatally injuring all six people on board, the final report from Australian Transport Safety Bureau investigation into the accident has found.
CO Poisoning led to Beaver Crash: ATSB 29 January 2021
The Australian Transport Safety Bureau (ATSB) has determined that a carbon monoxide (CO) leak into the cabin of a de Havilland Beaver floatplane contributed to a fatal crash on the Hawkesbury River, killing all five on board.
Beaver VH-NOO had just taken off from Cottage Point with four passengers on board on New Year s Eve 2017 when it circled back from Cowan Water into the narrow Jerusalem Bay. During an attempt to perform a high bank-angle low-level 180-degree turn, the pilot stalled the aircraft into the water.
In the investigation report released today, the ATSB found that cracks in the exhaust collector ring on the engine allowed CO gas to escape into the cabin via holes in the main firewall where three bolts were missing.