All language subtitles for M.2003-S23E07-Dream.Flight.Disaster.WEBDL-1080pEAC3.5.1h264-PiTBULL_track4_[eng]

(plane droning)
(rattling)

A New Year's Eve tragedy.

REPORTER (over TV):
A seaplane with six onboard lost control.

BOSWORTH:
This is big news.

NARRATOR: A multi-millionaire
and his family are killed.

Initial reports about the
crash site are puzzling.

He's not where he's supposed to be.

NARRATOR: Investigators quickly
gather witness statements...

WITNESS: It took off normally,
like any other flight.

(beeping)

NARRATOR:
And scrutinize the pilot's background.

This guy was a competent pilot.

NARRATOR: With no significant clues,
the team turns to recovered wreckage.

We had a completely functional
aircraft at the time of impact.

NARRATOR: But something
buried deep inside the plane

provides investigators
with their biggest lead.

CAMPBELL:
This was in the cabin.

I felt we may have an answer in our grasp.

(dramatic music)

PILOT (over radio):
Mayday, mayday!

GPWS:
Pull up!

(radio chatter)

NARRATOR: Five British tourists have
started celebrating New Year's Eve

at a waterside restaurant at
Cottage Point, Australia.

- And how was lunch?
- Oh. It was great.

NARRATOR:
Gareth Morgan is the pilot

for the 20-minute flight
back to Sydney Harbor.

Have you enjoyed
your Australian visit so far?

Very much.

Take the front seat. You'll get
some good shots from up there.

NARRATOR: A born athlete
raised in Vancouver, Canada,

Gareth Morgan has come to
Australia to fly floatplanes.

GARETH: My dad's friend, he owned
an airplane, got me hooked.

So, you know, I just thought,
hey, this looks like a great career.

Gareth did not like to be bored.

He liked to be challenged
and have variety in his life.

And a pilot's career,
particularly a pilot on float planes,

gave that to him in spades.

NARRATOR:
Richard Cousins is the CEO

of one of the largest food
companies in the UK.

He's on holiday with his fiancée,
her daughter, and his two sons.

Buckled in?

(engine starts)

NARRATOR: The trip to Cottage
Point attracts a high-end crowd:

celebrities, business tycoons, and even
close relatives of the Royal Family.

Seven months ago, Pippa Middleton, the
sister of the Duchess of Cambridge,

and her husband, James Matthews,

took the same trip during
their honeymoon in Australia.

(miked) Well, welcome back folks. Pleasure
having you on board with me again.

(engine rumbles)

NARRATOR: The flight is
operated by Sydney Seaplanes,

which runs a small
fleet of agile floatplanes.

Today, Gareth Morgan is
flying a de Havilland Beaver.

QUINN: It's a very gentle,
easy, relaxed airplane to fly.

I call it the big comfy couch.

You can take large payloads. You can
get into tight places, confined areas.

It's very versatile.
(plane drones)

NARRATOR: The Beaver is powered by a
single 450 horsepower radial engine.

The iconic aircraft is at
work all over the world.

We're about ready for takeoff here, folks.

I went over the safety regulations on the
way over. Does anyone need a refresher?

All good.

GARETH:
We'll have you back in Sydney in a flash.

NARRATOR: Morgan takes the plane
towards the designated take off area

in Cowan Creek.

You're deciding, "Okay, where are the
hazards? Where are my obstacles?"

"Which direction is the wind coming from?"
You're considering all those variables.

Cowan Creek Traffic, this is Float
Beaver November Oscar Oscar.

We are taxiing to the takeoff point for
a northeast departure to Rose Bay.

QUINN: Most locations where
a float plane is operating,

you're in uncontrolled airspace,
so you're not talking to a controller.

You are just making blind
calls on the radio

to tell other aircraft what your
intentions are in the area.

Any conflicting traffic, please
advise. November Oscar Oscar.

NARRATOR:
Traffic is clear. They can depart.

A takeoff on water is
executed in two stages.

You're gonna be
ploughing through the water

until it kind of crests over that bow wave
that you're creating with the floats.

(propeller rumbles)

(dramatic music)

Once you're on that step,
you're watching your attitude,

keeping your directional control
with your rudder and your ailerons.

NARRATOR:
Racing at 60 miles per hour,

the floatplane takes
only 15 seconds to lift off.

(plane drones)

GARETH:
You'll see Cowan Point down there.

NARRATOR: In the moments after takeoff,
the plane must gain altitude quickly.

(plane drones)

The hills surrounding the bay
are more than 400 feet high.

QUINN: What makes it different for
pilots flying these kind of aircraft

is just being open to constant changes.

The variables are always changing.

NARRATOR: Gareth Morgan has to decide the
best way to gain the altitude he needs

to clear the surrounding hills.

He can continue forward, climbing
along the length of the channel.

He can also make a U-turn

and head back over the waterway
from where he just took off.

QUINN: A pilot chooses their departure
path based on experience,

knowledge of the area, comfort
level with the aircraft.

Typically, you want to go out into
the most open area possible.

NARRATOR:
For the pilot, this is the eighth flight

during a busy day shuttling passengers.

(plane drones)

GARETH:
That there's Cowan... um... Comox Creek.

Say again?

There's Comox Creek.

Oh.

(tense music)

NARRATOR: At just 130 feet,
the floatplane stops climbing.

GARETH:
I gotta... um...

NARRATOR: Morgan needs to gain altitude.
He's headed towards a dead end.

QUINN: You have to have a
point of making a decision.

(plane drones)

Can I make it or can I not make it?

And if you cannot make it, do you have
the space to get out of that situation?

(rattling)

(engine droning)

NARRATOR: Less than two minutes
after taking off from Cottage Point...

(plane drones)

The floatplane crashes into
Jerusalem Bay and sinks.

ANCHOR (over TV):
A New Year's Eve tragedy.

Six people feared dead in a seaplane
crash on the Hawkesbury River.

By the time rescuers arrived on scene, the
aircraft had disappeared under the water.

This is big news.

NARRATOR: Investigators from the ATSB,
the Australian Transport Safety Bureau,

begin their first assignment
of the new year.

I'll handle the press.
Try to find some witnesses.

Someone must have seen this.

(newscaster speaks indistinctly)

BOSWORTH:
The media attention was huge.

It was on every
television that I turned on.

REPORTER (over TV):
The search for answers intensifies

as police dive on the crash site,
joined on the surface by investigators

from the Australian
Transport Safety Bureau.

NARRATOR: All five passengers,
including CEO Richard Cousins, are dead.

So is the pilot, Gareth Morgan.

MORGAN: It was a day that
drastically changed our lives.

It was a devastating moment and
we still live with it every day.

HUGHES:
My first thoughts

went to those who had just lost loved
ones in such a tragic accident.

And then it was change gears, and went
straight into the business side of things;

what did we know, and how we were
going to approach the investigation.

HUGHES:
Okay. Great.

How deep is the plane?

NARRATOR: The ATSB begins
its investigation into the crash

that took the lives of six people.

Police are saying it's
probably under 14 meters.

It's right here, in Jerusalem Bay.

NARRATOR:
Recovering all the wreckage is crucial.

There was no radio contact with the pilot,
the flight wasn't tracked on radar,

and the plane didn't carry a key
source of information.

Unfortunately, we find with
accidents involving smaller aircraft

it is very unlikely that they will have
some form of recording device onboard.

NARRATOR:
Until the wreckage can be recovered,

witness statements are all
there is to go by.

Let's just walk through where
you were and what you saw.

We consider witness interviews
what we call perishable evidence,

in that we try to get
that done as soon as possible.

WITNESS:
Well, it took off normally.

It just seemed like any other flight.

HUGHES: We utilized aircraft
models so that they can show us,

rather than tell us,
what their observations were.

And where were you?

WITNESS:
Near the creek. Here.

HUGHES: We also use maps to try
and get a sense of what they saw,

and where they were positioned.

NARRATOR:
Investigators quickly discover that

although several people witnessed parts of
the fatal flight, no one saw all of it.

Thank you so much.

BOSWORTH: No smoke.
No one heard any unusual noises.

Witness A says he takes off normally
and flies down Cowan Creek.

Witness B sees him climbing.
No obvious issues.

BOSWORTH:
The initial witnesses we interviewed

described the flight path
of an aircraft steady,

no erratic movements on the southern
bank of Jerusalem Bay.

They then described the
aircraft doing a steep turn

before the nose dropped and
the aircraft impacted the river.

We've got a gap in the flight path. He
starts off here and somehow ends up here.

NARRATOR: Investigators can't
confirm the plane's entire flight path.

The more we spoke to the witnesses,
the more questions it did raise.

Do you have the flight chart?

NARRATOR: As investigators review the
flight chart, they make a key discovery.

He's not where he's supposed to be.

NARRATOR:
The plane ended up in Jerusalem Bay,

a narrow, dead-end body of water
west of the takeoff area.

HUGHES: We established that
there was no operational reason

for the aircraft to be
operating in Jerusalem Bay.

NARRATOR:
With little to go on,

the biggest piece of evidence
is on the bottom of the bay.

Investigators will have to retrieve it.

BOSWORTH: The lift of the wreckage was
quite a nerve-wracking event for my team.

We had the area cordoned off to
vessels, except for emergency services.

The police divers first went down
and secured the main fuselage.

NARRATOR: The team delicately
lifts the aircraft to the surface.

BOSWORTH: We were very careful,
especially with the main fuselage,

which carries a lot of water.

We needed to be patient to
drain the water from it

before we lifted it onto the barge.

NARRATOR: The full recovery
of the wreckage of the Beaver Seaplane

provides hope for the investigation.

CAMPBELL (hums):
Well, they got everything.

NARRATOR:
ATSB investigator Lian Campbell is tasked

with dissecting what's left of the plane

and searching for signs
of mechanical failure.

The nose is creased.

BOSWORTH:
Let's check the flight controls.

CAMPBELL: The aircraft was
delivered to the hangar inverted,

and we decided to
keep it in that orientation,

one, for safety because it
was quite stable,

and also it afforded us good
access to the flight controls.

NARRATOR: Did the plane crash
because of an engine failure?

Well, the blade is damaged.

CAMPBELL:
We are looking for signatures

if it was providing power at
impact with the terrain or water.

Slight forward bending here.
There's a midspan bend too.

It's a double bend.

NARRATOR: Investigators
find a pattern they recognize.

So the propeller was turning
normally. The engine was working.

The wreckage examination determined

that we had a completely
functional aircraft during the flight,

and at the time of impact
everything appeared normal.

NARRATOR:
Still without any answers,

investigators scour every inch of the
plane, inside and out, looking for clues.

CAMPBELL: We noted that the forward
cabin roof area was filled with mud.

To ensure that we're not
missing any vital evidence,

I had the unenviable task
of going through this mud.

Duncan.

This was in the cabin.

Wow. Great job.

NARRATOR:
They find something completely unexpected.

The discovery of a camera could
change the course of the investigation.

HUGHES: The camera was a crucial piece
of evidence that we could, hopefully,

gain some more insights as to
what occurred during the flight.

Maybe there's something
valuable on the memory card.

NARRATOR: But the camera
was under water for four days.

BOSWORTH:
The compact flash card was damaged.

We treated this card just like
we treat the memory

from a flight data
recorder that is damaged.

The creasing damage on the nose
and the fuselage is fairly significant.

Agreed.

NARRATOR:
While work begins on the data card,

investigators turn their
focus back to the wreckage.

Deformation and creasing
of the fuselage and the pontoons

can give us an indication of the speed,

orientation, and angle
of entry into the water.

NARRATOR: Investigators measure how much
the force of impact bent the plane's nose.

Deformation angle is 25 degrees upward.

Normally, it's only 12.

So the impact bent
the nose upward 13 degrees.

- Correct.
- So maybe we're looking at a stall.

It's possible.

NARRATOR:
With the engine operating,

and eyewitnesses reporting
the plane in a steep right turn,

investigators consider whether the
pilot lost lift over the wings,

stalled the plane, and fell from the sky.

Stalls at low altitude are dangerous
because there's no time to recover.

BOSWORTH:
It says here that the angle for a stall

is 12 degrees or more if the
flaps were set to climb mode.

HUGHES:
The flap actuator was extended.

So the flaps were set to climb.

NARRATOR: Investigators conclude the float
plane stalled before hitting the water.

(plane drones)

BOSWORTH: We had a pilot who
was in Jerusalem Bay at low altitude,

conducting a steep turn.

This raised questions
with the investigation team

on what was happening in the cockpit.

HUGHES: So why would a
professional floatplane pilot

go into a dead end and
then stall the plane?

Good question.

NARRATOR: Investigators want
to know more about the pilot

who crashed the floatplane
into Jerusalem Bay, Australia.

BOSWORTH: The majority of
his time is on float planes.

- More than 9,000 hours.
- He was very experienced.

(engine drones)

GARETH: This is Float Beaver
November Oscar Oscar.

HUGHES: It looks like he started with
Sydney Seaplanes in May of 2017.

He also had a stint with them

between December 2011 and April 2014.

- 535 hours on the plane that crashed.
- So he knew that plane.

Hey, look here.

He had an incident only a
few days before the crash.

The pilot was involved in an incident

while he was flying
a Cessna 208 floatplane.

- Was it his fault?
- No, I don't think so.

It's just a rough landing in Rose Bay.
Traffic was busy and waves were high.

HUGHES: The event was
essentially a bad luck event

beyond the control of the pilot.

This guy was a competent pilot.

(Bosworth sighs)

So what are we missing here?

It was New Year's Eve.

- Not a normal day.
- What are you getting at?

Was he celebrating a bit early?

NARRATOR:
Is it possible the pilot was impaired?

I'll check on the status
of the toxicology report.

I'll make some calls.

HUGHES:
One of the things that we do look at

is whether there was the use of any
substances such as alcohol,

or any other medications they
may have been taking.

BOSWORTH:
Can you think back?

What was he up to while the
passengers were having lunch?

(Gareth laughs)

BOSWORTH: He had a lunch
break at the café at Cottage Point.

Happy New Year, my friend.

BOSWORTH: We were aware that the pilot
had been required to move his Beaver

while another aircraft entered
the area to onboard passengers.

I gotta go. I gotta move my plane.

Okay.

NARRATOR: Did Gareth Morgan
have a drink between flights?

All right. Right. Thank you.

- No one saw Gareth having a drink.
- Toxicology report confirms that as well.

MORGAN:
We knew his integrity.

We knew that he would have
had the wellbeing of his passengers

first and foremost
in his mind at all times.

NARRATOR:
A month into the investigation,

and the ATSB can't find any
problems with the pilot or the plane

involved in the crash at Jerusalem Bay.

MORGAN:
Nobody knew what had happened.

Something went terribly wrong in that
cockpit and we did not know what.

NARRATOR: Investigators place their hopes
on the camera found in the wreckage,

and the data on the memory card inside.

BOSWORTH:
This was meticulous work.

The controller chip contained
144 solder points,

which needed to be reconnected
under the microscope.

Thank you. It looks like we got something.
The lab is sending the images now.

We were successful in recovering over 350
images from the compact flash card.

NARRATOR:
Investigators analyze the pictures,

hoping they see something that
might help them solve the case.

It looks like they're taxiing.

(plane drones)

HUGHES: Oh, it's taken from the
passenger's side next to the pilot.

NARRATOR: The next 22 pictures were
taken during the taxi, takeoff, and climb.

Nine were taken while
the plane was airborne.

Taken over 39 seconds.

That's the last one.

(sighs) Too bad that's all there is.

I think there's more we can do with these.

When we had the photos
from the accident flight,

we decided to see if we could
rebuild the flight path of the aircraft

using these images.

Time: 15:11:45. Direction: forward.

Estimated altitude: 98 feet.

NARRATOR: They compile data from the
photographs about the plane's position,

the camera angle, and the time of day.

BOSWORTH: Okay, that's all
of them. Let's process this.

So? How's it going?

NARRATOR: Strung together, the
images provide investigators

with a key portion of
the plane's flight path.

HUGHES:
Using camera tracking software,

we were able to get a better
idea of the aircraft's flight path,

but also have a more
accurate understanding

of the altitude of the aircraft.

(simulation plane drones)

BOSWORTH:
The plane is at 98 feet and turning right

and it stops climbing for some reason.

HUGHES:
That's odd.

BOSWORTH: We could see that
the aircraft was in a bank turn,

but despite being in the climb flap
setting, the aircraft was losing altitude.

NARRATOR:
The photo analysis tells investigators

that the plane was descending,

but the complete flight path
remains an educated guess.

Well, the good news is that matches
the flight path from our eyewitnesses.

But it doesn't go much beyond that.

BOSWORTH: You're right. We need to
come at this from a different perspective.

HUGHES:
At that point,

because we had no obvious reason
as to why the accident occurred,

we were looking at all the
other possible hypotheses.

Maybe he had a seizure.

Or heart failure.

Well, that's a possibility.

His medical records indicate no history
of headaches, blackouts, dizziness.

I'm not seeing anything.

NARRATOR: Investigators shift their
focus back to the pilot, Gareth Morgan.

What about the cardiology?

This isn't normal.

Some of the ECGs had signs
of sinus bradycardia,

which is a slower than normal heart rate.

His resting heart rate is 50 bpm.

He's like a trained athlete.

BOSWORTH: Yeah, it's an
abnormality. But it's not a problem.

He was a very fit individual and there
was nothing in his medical history

that could have
led to medical incapacitation.

I thought we'd have more answers by now.

NARRATOR:
Almost two years into the investigation,

the ATSB prepares a final report

without any firm conclusions
about what caused the crash.

BOSWORTH:
The investigation team were disappointed

and frustrated that they could not
provide an answer to the families.

(phone ringing)

Duncan Bosworth.

Yeah, well, incapacitation
was always a possibility.

We went pretty far down that
road. We came up empty.

While the report was being prepared,
we have an internal review.

This included our
aviation medical specialist.

No, we must have tested for that.

I'll get back to you, all right?

The aviation specialist
raised the fact that

carbon monoxide could have been
an issue during this accident.

(plane drones)

NARRATOR:
When aviation fuel is burned,

exhaust from the engines contains a highly
poisonous carbon monoxide gas,

which can cause short-term symptoms.

Long term exposure can have a severe
impact on health, and can be fatal.

They tested for carbon monoxide, right?

Here's the pathologist's report.

BOSWORTH: I said, "I thought
it must have been examined,"

because we had the toxicology report

and nothing had been
raised about carbon monoxide.

Kerri?

It's not here.

I could not find evidence of carbon
monoxide testing during the autopsy.

I have a few questions for you.

NARRATOR: Investigators contact
the state's health pathologist.

Is there any reason you didn't
test for carbon monoxide poisoning?

NARRATOR:
The team learns that pathologists

do not test for carbon monoxide
unless there's evidence of a fire.

Any chance you still
have the original samples?

I see. Oh, you do.

Oh, that's great.

HUGHES: That's when they went
off and did the additional testing

to assess whether carbon
monoxide was an issue or not.

NARRATOR:
26 months after the crash,

Gareth Morgan's blood sample
is tested for carbon monoxide.

Look at this.

NARRATOR: The results provide
investigators with their biggest lead yet.

I felt we may have an answer in our grasp.

Morgan's carbon
monoxide levels were at 11%.

Some of the passengers also tested
positive for CO poisoning.

(heavy breath)

NARRATOR:
Toxicology results confirm

that the pilot and two passengers
of the ill-fated floatplane

had higher than normal levels of
carbon monoxide in their blood.

(plane drones)

HUGHES:
We were re-energized

because we may have found
that missing piece of evidence.

According to this study, the pilot
would have been suffering

from neurobehavioral and
cognitive side effects.

We did a lot of research to see what
that 11%, in particular for the pilot,

how that would have
affected his performance.

You'll see Cowan...

um...

Comox Creek.

NARRATOR: Was Gareth Morgan's
carbon monoxide level high enough

to incapacitate him and
cause him to crash the plane?

BOSWORTH: At 11%, he would
have had feelings of nausea,

dizziness, possibly a headache.

HUGHES: It's hard to know
with those symptoms

if it's carbon monoxide
poisoning or something else.

NARRATOR: The side effects of 11% carbon
monoxide poisoning are so insidious,

it would have been hard for Gareth Morgan
to be aware of what was happening to him.

HUGHES: Quite often the cognitive
effects can be quite subtle,

and they may often be overlooked
or even dismissed by the pilot.

How much carbon monoxide does
he need to breathe in to reach 11%?

The safety literature
says there would have to be

a concentration of 80 parts per million
in the cabin for a sustained period.

That's an awful lot of
carbon monoxide in the aircraft.

- So, what's the source?
- And how did it get into the cabin?

BOSWORTH: We knew the source of
carbon monoxide in an aircraft

would be the exhaust system
or a heater in the aircraft.

There was no heater, so our focus
was on the engine exhaust system.

Well this piece seems okay.

NARRATOR:
When an engine burns fuel,

the hot gases are directed through the
exhaust manifold and out of the tailpipe,

preventing them from
entering the plane's cabin.

Take a look at this.

See those cracks?

NARRATOR: Investigators take a closer
look at pieces of the cracked manifold,

to determine if the damage
occurred before or after the crash.

(tense music)

There's some oxidation here.

NARRATOR: Rust on the
fractures in the exhaust manifold

tells investigators that the crack
developed prior to the accident.

We found the leak.

After we discovered there
was an exhaust leak,

we had to determine how the carbon
monoxide got into the cabin

to affect the occupants.

What's the most likely point of entry?

HUGHES:
Right here, the firewall.

NARRATOR:
Investigators try to determine

how carbon monoxide entered
the floatplane's cockpit,

incapacitating the pilot.

The firewall exists between the
engine accessory bay and the cabin

to prevent fumes getting into the cabin.

Zoom in.

NARRATOR: The team
examines the plane's firewall.

It's pretty banged up.

NARRATOR:
They focus on two panels,

which allow access to the
engine for maintenance.

Here's what we found.

NARRATOR:
They discover the left access panel

is missing one of its four required bolts.

The right panel is missing two.

BOSWORTH: That means there
were three holes in the main firewall

on the day of the flight.

(Hughes hums)

NARRATOR: It's a pathway for
exhaust to travel from the engine bay

into the cabin of the Beaver.

(heavy breath)

Several pre-existing cracks
in the exhaust system

released the poisonous gas
into the engine bay.

Tiny bolt holes allowed the gas to leak
into the cabin through the main firewall.

BOSWORTH: So we have the
source and the point of entry.

NARRATOR: The discovery leaves
investigators with a burning question.

How long has the
dangerous problem existed?

(plane drones)

The last work performed on the
parts was done in early 2017.

NARRATOR: Maintenance records show
when the access panels were last modified.

That's months before the accident.

HUGHES:
That means Sydney Seaplanes' pilots

have flown the same Beaver
floatplane hundreds of times

without being affected by the
carbon monoxide leak.

And it also means Gareth Morgan
flew the plane dozens of times himself

without a problem.

So why did it affect him this time?

One of the key questions we
were asking ourselves was:

Why did the accident
happen on this flight?

NARRATOR: ATSB investigators
examine pilot logbooks to understand

what made the fatal flight of a Sydney
Seaplane different from others.

He's flying the same plane day after day.

It has the same problem.

But nothing happens until New Year's Eve?

I can't figure it out.

What was his schedule
on the day of the crash?

Well, he's making flights all day long.

So the carbon monoxide is
gonna build up in his system.

HUGHES: An individual's carbon monoxide
levels will increase with intensity,

depending on the duration.

We had a pilot who was conducting
multiple flights throughout the day

with only short intervals
between each flight.

There's something else.

NARRATOR: As investigators
reconstruct Gareth Morgan's schedule,

they remember they have to add
one more piece to the puzzle.

BOSWORTH: An hour before
he took off from Cottage Point,

Gareth Morgan was asked to move
his plane off the dock

- to make room for another plane.
- I gotta go. I gotta move my plane.

HUGHES:
Maybe Morgan was exposed

to even more carbon monoxide
gases while he moved the plane.

Exactly.

How long did that take?

27 minutes.

That's almost as much as an extra flight.

That's a lot more time in a plane.

NARRATOR: Morgan had to maneuver his plane
away from the dock and around the bay

while another plane picked up passengers.

There's still a missing link.

These holes don't seem big
enough to let in enough exhaust.

Why is that exhaust
flowing into the cabin?

Maybe he had the windows
open during the flight?

Good point.

That would create enough suction
for the carbon monoxide to flow in.

(heavy breath)

BOSWORTH:
Most pilots have their windows down

to get some ventilation into the cabin.

NARRATOR: Investigators revisit pictures
they collected from witnesses.

BOSWORTH:
This was taken earlier in the day.

It looks like he cracked the door

during the taxi into Cottage
Point to get some air.

NARRATOR:
The open door could have created a draft

that sucked the exhaust into the
cabin through holes in the firewall.

But is a short taxi really
long enough to be dangerous?

Hard to say.

Here's a short video
from one of the witnesses

during the time the pilot moved the plane.

The windows are closed.

But check out the door.

An extra 27 minutes in the
plane, with the door ajar.

That likely elevated the level of carbon
monoxide in the pilot's system.

BOSWORTH: The investigation team
had an hypothesis about how the door ajar

may have exacerbated
the passage of carbon monoxide.

We needed to test this theory.

(clears throat)

(engine rumbling)

Okay. Initiating test number
one, with the door closed.

(clacking)

NARRATOR: Investigators recreate the
conditions of Gareth Morgan's plane

to see if concentrations
of carbon monoxide

were high enough to incapacitate him.

We needed to use an exemplar Beaver
aircraft with a simulated exhaust leak

and access panel bolts
removed to test our hypothesis.

NARRATOR: They begin the
test with the windows and doors closed.

BOSWORTH: First, we had to set a
baseline level with the engine running.

We then removed the access panel
bolts and simulated an exhaust leak

by feeding the exhaust from the
engine directly into the engine bay.

55 parts per million.

There was no dangerous level of carbon
monoxide in the cabin at that stage.

Okay. Let's clear the
cabin and start again.

NARRATOR: To protect against
carbon monoxide poisoning,

investigators agree to stop the test if
the levels reach 120 parts per million.

BOSWORTH:
We then tested with the door ajar.

It has to get to 70 parts per million.

And we saw that the levels increased.

(beeping)

NARRATOR: Within minutes, carbon monoxide
in the cabin climbs to deadly levels.

BOSWORTH: We're at 144 PPM in
here. Way too high. Let's shut it down.

Prolonged exposure to carbon monoxide
levels greater than 144 parts per million

is dangerous to the occupants.

(engine quiets, shuts down)

NARRATOR:
The tests are conclusive.

(exhales)

We did it.

It was a relief to see that our
theory may have been proved

and confirmed that carbon
monoxide could enter the cabin.

(plane drones)

NARRATOR: Investigators worry the
same thing could happen again.

They track down other Beaver floatplanes
that were serviced by the same company

that maintained the
Sydney Seaplanes' fleet.

There's more than one
plane with the same problem.

We inspected the access
panels on three other Beaver aircraft,

and we were surprised to find

that there was one bolt missing
from each of those panels.

BOSWORTH: It's unbelievable.
It was the same in every one of them.

HUGHES:
They have to be fixed. Immediately.

NARRATOR: The missing bolts are replaced
in all the planes where they're missing.

As investigators try to determine how the
accident could have been prevented,

- they're left with one last question.
- Was this thing even working?

NARRATOR: Carbon monoxide detectors
provide pilots with the opportunity

to detect exposure before
they become incapacitated.

(heavy breath)

Was the carbon monoxide
detecting equipment

- on the Beaver floatplane functioning?
- Um.

So how does this one work?

Well it's supposed to turn a different
color when carbon monoxide is present.

It's sun-bleached. There's
no way it was working.

BOSWORTH: When we examined the carbon
monoxide detector from this aircraft,

it was a beige color,

which meant it was unserviceable and not
capable of detecting carbon monoxide.

You know, the detectors
aren't even mandatory.

Not in Australia.

Not anywhere.

NARRATOR: The ATSB's final
report highlights the critical importance

of audible carbon monoxide detectors.

HUGHES: As a pilot myself, I
strongly encourage all pilots

to carry active carbon monoxide
detectors every time they go out flying.

MORGAN: I have carbon
monoxide detectors in my home.

They're very loud and
they're not expensive.

(plane drones)

This should be
mandatory in all small planes.

(heavy breath)

NARRATOR:
The crash at Jerusalem Bay

raises awareness of the deadly threat
carbon monoxide poses to aviators.

(heavy breath)

HUGHES: It was fulfilling to be able
to identify important safety issues

in the hope that we can
prevent such a tragic accident

from occurring again in the future.

But it was also rewarding to
provide the family and friends

- some degree of resolution.
- GARETH: Watch your step.

MORGAN: I've had many people,
particularly after his death,

say the marvelous experiences they
had as passengers with Gareth.

He really touched people
with his humbleness

and his sense of dedication
to his profession.

And that's very much the
human being that Gareth was.