6 fatalities

2017-12-31: De Havilland DHC-2 Beaver (VH-NOO) — Sydney Seaplanes — Cottage Point, Australia

Cottage Point, AustraliaFlight

On December 31, 2017, a De Havilland DHC-2 Beaver (registration VH-NOO) operated by Sydney Seaplanes was involved in an aviation accident near Cottage Point, Australia in flight. 6 people were killed. Investigators recorded the probable cause as: Contributing factors: - The aircraft entered Jerusalem Bay, a known confined area, below terrain height with a level or slightly descending flight path. There was no known operational need for the aircraft to be operating in the bay. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 1 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781191586Data APIEditorial standards
Aircraft registered VH-NOO
Aircraft registered VH-NOO. Photo: Phillip Capper from Wellington, New Zealand / CC BY 2.0, via Wikimedia Commons

On 31 December 2017, a de Havilland Canada DHC-2 Beaver floatplane crashed in Jerusalem Bay, NSW, killing the pilot and five passengers. The aircraft, operated by Sydney Seaplanes, stalled during a steep turn after entering a confined area.

Accident Overview

On 31 December 2017, a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO, operated by Sydney Seaplanes, crashed in Jerusalem Bay, New South Wales. The aircraft had departed Rose Bay for a charter flight to Cottage Point, then conducted additional flights. After a 27-minute taxi with the pilot's door ajar, it departed Cottage Point with five passengers at about 1511. Witnesses observed the aircraft flying level or slightly descending into Jerusalem Bay, then entering a steep right turn at low level. The nose dropped and the aircraft collided with water, coming to rest inverted and submerged. The pilot and five passengers received fatal injuries.

Contributing Factors

According to the official investigation, contributing factors included: The aircraft entered Jerusalem Bay, a known confined area, below terrain height with no operational need. During a steep turn, the aircraft likely aerodynamically stalled at low altitude. There were elevated carbon monoxide levels in the cabin, causing higher carboxyhaemoglobin in occupants. Pre-existing cracks in the exhaust collector ring likely released exhaust gas into the engine bay, which entered the cabin through holes in the main firewall where three bolts were missing. The extended taxi with the door ajar likely exacerbated the pilot's carbon monoxide exposure, degrading ability to safely operate the aircraft.

Safety Issues

The investigation noted that disposable chemical spot detectors for carbon monoxide can be unreliable; there was no regulatory requirement for active warning detectors. The effectiveness of the detector on the aircraft was likely reduced by sun bleaching. Sydney Seaplanes had no monitoring mechanism for detector serviceability. Bolts securing magneto access panels were worn and non-standard, increasing risk of loosening. The operator relied on volunteered passenger weights without allowances, risking overload. Standard passenger weight guidelines were outdated. Australian regulations did not mandate flight recorders for aircraft under 5,700 kg, hampering determination of factors in this and other accidents.

Probable cause

Contributing factors: - The aircraft entered Jerusalem Bay, a known confined area, below terrain height with a level or slightly descending flight path. There was no known operational need for the aircraft to be operating in the bay. - While conducting a steep turn in Jerusalem Bay, it was likely that the aircraft aerodynamically stalled at an altitude too low to effect a recovery before colliding with the water. - It was almost certain that there was elevated levels of carbon monoxide in the aircraft cabin, which resulted in the pilot and passengers having higher than normal levels of carboxyhaemoglobin in their blood. - 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. - A 27 minute taxi before the passengers boarded, with the pilot's door ajar likely exacerbated the pilot's elevated carboxyhaemoglobin level. - It was likely that the pilot's ability to safely operate the aircraft was significantly degraded by carbon monoxide exposure. - Disposable chemical spot detectors, commonly used in general aviation, can be unreliable at detecting carbon monoxide in the aircraft cabin. Further, they do not draw a pilot's attention to a hazardous condition, instead they rely on the pilot noticing the changing colour of the sensor. - There was no regulatory requirement from the Civil Aviation Safety Authority for piston-engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. (Safety issue)