It's all your fault (pilots) - We don't have enough serious and mysterious crashes to justify employing/$upporting more staff.
Nope, it seems... Here's 2 paragraphs lifted from the ATSB website. Note the timing... right at the end of things. Not only but also, they happened to pick a switched-on Consultant who made the suggestion...
“During the DRAFT review process for the investigation’s final report, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide toxicology testing be undertaken on blood samples of the aircraft occupants,” said ATSB Chief Commissioner Greg Hood.
The results of that testing, provided to the ATSB in March 2020, indicated that the pilot and two of the passengers, whose post-mortem examinations established received fatal injuries sustained as a result of the impact sequence, had elevated levels of carbon monoxide."
That got them going, and they '...con$ulted widely with medical experts to fully understand those results'
- Took me 30 seconds to google 'Effects of carbon monoxide on pilots' = Carbon Monoxide Poisoning - AviationKnowledge
Some people are VERY lucky with cracked heaters, https://www.faa.gov/pilots/safety/pi...Obroforweb.pdf
- in which there is a nice simple chart - to assist in their Understanding.
Apologies for ranting, but this was such a preventable fatality - and Probable Cause should have been discerned at the time of post-mortem. Two+ years ago.
My thoughts are for the Families.
Irrespective of ATSB requirements, I would have thought such testing would have been standard under the State Coronial Post Mortem requirements as these would take priority
Garry
Seaplane report prompts exhaust gas warning
Seaplane report prompts exhaust gas warning | Flight Safety Australia
Carbon monoxide poisoned the pilot of the tourist seaplane that crashed in Jerusalem Bay, north of Sydney, on New Year’s Eve 2017, the Australian Transport Safety Bureau (ATS has found.
The ATSB report, issued today, found the pilot and passengers on the aircraft all had elevated levels of carboxyhaemoglobin in their blood, indicating exposure to carbon monoxide, a colourless, odourless gas created by combustion in engines that, when breathed, displaces oxygen in the bloodstream.
In response, the ATSB has called for the operators and owners of piston-engine aircraft to install active-warning carbon monoxide (CO) detectors (as opposed to colour-changing detection strips) or for pilots to carry a phone-sized personal electronic CO detector. The ATSB has recommended that CASA consider making active-warning CO detectors in piston-engine aircraft mandatory, particularly in passenger-carrying aircraft.
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