Original subtitles

A New Year's Eve tragedy.

A seaplane with six on board lost control.

A seaplane with six on board lost control.

This is big news.

A multimillionaire and his family are killed.

A multimillionaire and his family are killed.

Initial reports about the crash site are puzzling.

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

Investigators quickly gather witness statements...

Investigators quickly gather witness statements...

They took off normally, like any other flight.

They took off normally, like any other flight.

...and scrutinized the pilot's background.

This guy was a competent pilot.

This guy was a competent pilot.

With no significant clues,

the team turns to recovered wreckage.

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

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

But something buried deep inside the plane

But something buried deep inside the plane

provides investigators with their biggest lead.

This was in the cabin.

I felt we may have an answer in our grasp.

I felt we may have an answer in our grasp.

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

We lost both engines.

Mayday.

Mayday.

Brace for impact!

He's gonna crash!

Five British tourists have started celebrating

New Year's Eve at a waterside restaurant

in Cottage Point, Australia.

in Cottage Point, Australia.

And how was lunch?

Oh, it was great.

Gareth Morgan is the pilot for the 20-minute flight

Gareth Morgan is the pilot for the 20-minute flight

back to Sydney Harbor.

Have you enjoyed your Australian visit so far?

Have you enjoyed your Australian visit so far?

Very much.

Take the front seat.

You'll get some good shots from up there.

A born athlete raised in Vancouver,

Canada, Gareth Morgan has come to Australia

Canada, Gareth Morgan has come to Australia

to fly float planes.

My dad's friend, he owned an airplane.

My dad's friend, he owned an airplane.

Got me hooked.

So, you know, I just thought, hey,

this looks like a great career.

this looks like a great career.

Gareth did not like to be bored.

Gareth did not like to be bored.

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

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.

on float planes, gave that to him in spades.

Richard Cousins is the CEO of one of the largest

Richard Cousins is the CEO of one of the largest

food companies in the UK.

He's on holiday with his fiancee,

her daughter, and his two sons.

her daughter, and his two sons.

Buckled in?

The trip to Cottage Point

attracts a high end crowd...

attracts a high end crowd...

celebrities, business tycoons, and even close

relatives of the royal family.

relatives of the royal family.

Seven months earlier, Pippa Middleton... the sister

of the Duchess of Cambridge... and her husband,

James Matthews, took the same trip during their honeymoon

James Matthews, took the same trip during their honeymoon

in Australia.

Welcome back, folks.

Welcome back, folks.

Pleasure having you on board with me again.

The flight is operated by Sydney

Seaplanes, which runs a small fleet of agile float planes.

Seaplanes, which runs a small fleet of agile float planes.

Today Gareth Morgan is flying a de Havilland Beaver.

Today Gareth Morgan is flying a de Havilland Beaver.

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

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

I call it the big comfy couch.

You can take large payloads.

You can take large payloads.

You can get into tight places, confined areas.

It's very versatile.

It's very versatile.

The Beaver is powered by a single

450-horsepower radial engine.

450-horsepower radial engine.

The iconic aircraft is at work all over the world.

We're about ready for takeoff here, folks.

We're about ready for takeoff here, folks.

I went over the safety regulations on the way over.

Does anyone need a refresher?

Does anyone need a refresher?

All good.

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

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

Morgan steers the plane toward the designated

Morgan steers the plane toward the designated

takeoff area in Cowan Creek.

You're deciding, OK, where are the hazards,

You're deciding, OK, where are the hazards,

where are my obstacles, which direction

is the wind coming from.

You're considering all those variables.

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

We are taxiing to the takeoff point for a northeast departure

to Rose Bay.

Most locations where a float plane is

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.

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

Any conflicting traffic, please advise.

November Oscar Oscar.

Traffic is clear.

They can depart.

A takeoff on water is executed in two stages.

You're gonna be plowing through the water

You're gonna be plowing through the water

until it kind of crests over that bow wave

that you're creating with the floats.

that you're creating with the floats.

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

keeping your directional control with your rudder

and your ailerons.

and your ailerons.

Racing at 60 miles per hour,

Racing at 60 miles per hour,

the float plane takes only 15 seconds to lift off.

You'll see Cowan Point down there.

In the moments after takeoff,

the plane must gain altitude quickly.

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

What makes it different

for pilots flying these kind of aircraft

is just being open to constant changes.

is just being open to constant changes.

The variables are always changing.

Gareth Morgan has to decide the best way

to gain the altitude he needs to clear the surrounding hills.

to gain the altitude he needs to clear the surrounding hills.

He can continue forward, climbing along

He can continue forward, climbing along

the length of the channel.

He can also make a U-turn back over the waterway and the point

where he just took off.

where he just took off.

A pilot chooses their departure path

based on experience, knowledge of the area,

based on experience, knowledge of the area,

comfort level with the aircraft.

Typically, you want to go out into the most

Typically, you want to go out into the most

open area possible.

For the pilot, this is the eighth flight of a busy day

For the pilot, this is the eighth flight of a busy day

shuttling passengers.

That there is Cowan...

um, Comox Creek.

um, Comox Creek.

Say again.

There's Comox Creek.

Ah.

At just 130 feet, the float plane stops climbing.

At just 130 feet, the float plane stops climbing.

I got a...

I got a...

um...

Morgan needs to gain altitude.

Morgan needs to gain altitude.

He's headed toward a dead end.

You have to have a point of making a decision.

You have to have a point of making a decision.

Can I make it or can I not make it?

Can I make it or can I not make it?

And if you cannot make it, do you have space

to get out of that situation?

to get out of that situation?

Less than two minutes after taking

off from Cottage Point...

...the float plane crashes into Jerusalem Bay and sinks.

...the float plane crashes into Jerusalem Bay and sinks.

A New Year's Eve tragedy.

A New Year's Eve tragedy.

Six people, feared dead in a sea plane crash

on the Hawkesbury River.

By the time rescuers arrived on the scene,

By the time rescuers arrived on the scene,

the aircraft had disappeared under the water.

This is big news.

Investigators from the ATSB...

Investigators from the ATSB...

the Australian Transport Safety Bureau...

begin their first assignment of the new year.

I'll handle the press.

I'll handle the press.

Try to find some witnesses.

Someone must have seen this.

The media attention was huge.

It was on every television that I turned on.

It was on every television that I turned on.

The search for answers

intensifies as police dive on the crash site,

intensifies as police dive on the crash site,

joined on the surface by investigators

from the Australian Transport Safety Bureau.

from the Australian Transport Safety Bureau.

All five passengers, including

All five passengers, including

CEO Richard Cousins are dead.

So is the pilot, Gareth Morgan.

It was a day that drastically changed our lives.

It was a day that drastically changed our lives.

This was a devastating moment, and we

still live with it every day.

My first thought went to those who had just lost loved

My first thought went to those who had just lost loved

ones in such a tragic accident.

And then it was changed gears and went straight into

And then it was changed gears and went straight into

the business side of things...

what did we know, and how we were going

to approach the investigation.

OK, great.

OK, great.

How deep is the plane?

The ATSB begins its investigation

into the crash that took the lives of six people.

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.

It's right here, in Jerusalem Bay.

Recovering all the wreckage is crucial.

There was no radio contact with the pilot.

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.

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

aircraft, it is very unlikely that they will have some form

of recording device on board.

Until the wreckage can be recovered,

witness statements are all there is to go by.

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 consider witness interviews what

we call perishable evidence, in that we try to get

that done as soon as possible.

that done as soon as possible.

Well, it took off normally.

It just seemed like any other flight.

It just seemed like any other flight.

We utilize aircraft models so that they

can show us rather than tell us of what

can show us rather than tell us of what

their observations were.

And where were you?

Near the creek, here.

Near the creek, here.

We also use maps to try

and get a sense of what they saw and where they were positioned.

and get a sense of what they saw and where they were positioned.

Investigators quickly discover

that although several people witnessed

that although several people witnessed

parts of the fatal flight, no one saw all of it.

Thank you so much.

Thank you so much.

No smoke.

No one heard any unusual noises.

No one heard any unusual noises.

Witness A says it takes off normally

and flies down Cowan Creek.

and flies down Cowan Creek.

Witness B sees him climbing, no obvious issues.

Witness B sees him climbing, no obvious issues.

The initial witnesses

we interviewed described the flight path of an aircraft

steady, no erratic movements on the southern bank of Jerusalem

steady, no erratic movements on the southern bank of Jerusalem

Bay.

They then described the aircraft doing

They then described the aircraft doing

a steep turn before the nose dropped and the aircraft

impacted the river.

impacted the river.

We got a gap in the flight path.

He starts off here and somehow ends up here.

He starts off here and somehow ends up here.

Investigators can't confirm

the plane's entire flight path.

the plane's entire flight path.

The more we spoke to the witnesses,

the more questions it did raise.

the more questions it did raise.

Do you have the flight chart?

As investigators review the flight chart,

they make a key discovery.

they make a key discovery.

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

The plane ended up in Jerusalem

The plane ended up in Jerusalem

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

We established that there was no operational reason

We established that there was no operational reason

for the aircraft to be operating in Jerusalem Bay.

With little to go on, the biggest piece of evidence

With little to go on, the biggest piece of evidence

is on the bottom of the bay.

Investigators will have to retrieve it.

Investigators will have to retrieve it.

The lift of the wreckage was quite a nerve

racking event for my team.

We had the area cordoned off to vessels

We had the area cordoned off to vessels

except for emergency services.

The police divers first went down

The police divers first went down

and secured the main fuselage.

The team delicately lifts

The team delicately lifts

the aircraft to the surface.

We were very careful,

especially with the main fuselage

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.

the water from it before we lifted it onto the barge.

The full recovery of the wreckage

of the Beaver seaplane provides hope for the investigation.

of the Beaver seaplane provides hope for the investigation.

Well, they got everything.

ATSB investigator Lian Campbell

ATSB investigator Lian Campbell

is tasked with dissecting what's left of the plane

and searching for signs of mechanical failure.

and searching for signs of mechanical failure.

The nose is creased.

Let's check the flight controls.

Let's check the flight controls.

The aircraft was delivered

to the hangar inverted, and we decided to keep it

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.

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

Did the plane crash because of an engine failure?

Well, the blade is damaged.

Well, the blade is damaged.

We are looking for signatures if it

was providing power at impact with the terrain or water.

was providing power at impact with the terrain or water.

Slope forward bending here.

There's a mid-span bend too.

There's a mid-span bend too.

That's a double bend.

Investigators find a pattern they recognize.

So the propeller was turning normally.

So the propeller was turning normally.

The engine was working.

The wreckage examination determined

The wreckage examination determined

that we had a completely functional

aircraft during the flight.

And at the time of impact, everything appeared normal.

And at the time of impact, everything appeared normal.

Still without any answers,

Still without any answers,

investigators scour every inch of the plane,

inside and out, looking for clues.

inside and out, looking for clues.

We noted that the forward cabin

roof area was filled with mud.

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.

I had the unenviable task of going through this mud.

Duncan.

This was in the cabin.

Wow.

Great job.

Great job.

They find something completely unexpected.

The discovery of a camera could change the course

of the investigation.

The camera was a crucial piece of evidence

The camera was a crucial piece of evidence

that we could hopefully gain some more insights as to what

occurred during the flight.

occurred during the flight.

Maybe there's something valuable on the memory card.

But the camera was underwater for four days.

The compact flash card was damaged.

We treated this card just like we

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.

is fairly significant.

Agreed.

While work begins on the data card,

investigators turn their focus back to the wreckage.

investigators turn their focus back to the wreckage.

Defamation increasing of the fuselage and the pontoons

Defamation increasing of the fuselage and the pontoons

can give us an indication of the speed, orientation, and angle

of entry into the water.

of entry into the water.

Investigators measure how much the force of impact

bent the plane's nose.

Deformation angle is 25 degrees upward.

Deformation angle is 25 degrees upward.

Normally, it's only 12.

Normally, it's only 12.

So the impact bent the nose upward 13 degrees.

So the impact bent the nose upward 13 degrees.

Correct.

So maybe we're looking at a stall.

It's possible.

It's possible.

With the engine operating and eyewitnesses

reporting the plane in a steep right turn,

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.

and fell from the sky.

Stalls at low altitude are dangerous because there's

no time to recover.

no time to recover.

It says here that the angle for a stall

It says here that the angle for a stall

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

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

The flip actuator was extended,

The flip actuator was extended,

so the flaps were set to climb.

Investigators conclude the float plane stalled

Investigators conclude the float plane stalled

before hitting the water.

We had a pilot who was in Jerusalem Bay

We had a pilot who was in Jerusalem Bay

at low altitude conducting a steep turn.

at low altitude conducting a steep turn.

This raised questions with the investigation team

on what was happening in the cockpit.

on what was happening in the cockpit.

So why would a professional float

plane pilot go into a dead end and then stall the plane?

plane pilot go into a dead end and then stall the plane?

Good question.

Investigators want to know more

about the pilot who crashed the float plane

about the pilot who crashed the float plane

into Jerusalem Bay, Australia.

The majority of his time is on float planes.

The majority of his time is on float planes.

More than 9,000 hours.

He was very experienced.

- ACTOR AS GARETH - This is Float

Beaver November Oscar Oscar.

Looks like he started with Sydney Seaplanes

Looks like he started with Sydney Seaplanes

in May of 2017.

in May of 2017.

He also had a stint with them between December

2011 and April 2014...

2011 and April 2014...

535 hours in the plane that crashed.

So he knew that plane.

So he knew that plane.

Hey, look here.

Hey, look here.

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

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 float plane.

while he was flying a Cessna 208 float plane.

Was it his fault?

No, I don't think so.

It's just a rough landing in Rose Bay.

It's just a rough landing in Rose Bay.

Traffic was busy and waves were high.

The event was essentially a bad luck event

The event was essentially a bad luck event

beyond the control of the pilot.

This guy was a competent pilot.

This guy was a competent pilot.

So what are we missing here?

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?

Was he celebrating a bit early?

Is it possible the pilot was impaired?

Is it possible the pilot was impaired?

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

I'll make some calls.

One of the things that we do look at

is whether there was the use of any substances

is whether there was the use of any substances

such as alcohol or any other medications

they may have been taking.

Can you think back?

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

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

He had a lunch break at the cafe

He had a lunch break at the cafe

at Cottage Point.

Happy New Year, my friend.

Happy New Year, my friend.

We are aware that the pilot had been

required to move his Beaver while another aircraft entered

required to move his Beaver while another aircraft entered

the area to onboard passengers.

I got to go.

I got to go.

I got to move my plane.

OK.

Did Gareth Morgan have a drink between flights?

Did Gareth Morgan have a drink between flights?

All right.

All right.

Thank you.

Thank you.

No one saw Gareth having a drink.

Toxicology report confirms that, as well.

Toxicology report confirms that, as well.

We knew his integrity.

We knew that he would have had the well-being

We knew that he would have had the well-being

of his passengers first and foremost

in his mind at all times.

A month into the investigation, and the ATSB

can't find any problems with the pilot or the plane involved

can't find any problems with the pilot or the plane involved

in the crash at Jerusalem Bay.

Nobody knew what had happened.

Nobody knew what had happened.

Something went terribly wrong in that cockpit,

Something went terribly wrong in that cockpit,

and we do not know what.

Investigators placed their hopes

on the camera found in the wreckage and the data

on the camera found in the wreckage and the data

on the memory card inside.

This was meticulous work.

The controller chip contained 144

The controller chip contained 144

solder points, which needed to be reconnected

under the microscope.

Thank you.

Looks like we got something.

The lab is sending the images now.

The lab is sending the images now.

We were successful in recovering over 350 images

We were successful in recovering over 350 images

from the compact flash card.

from the compact flash card.

Investigators analyze the pictures,

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

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

It looks like they're taxiing.

Oh, it's taken from the passenger side,

next to the pilot.

The next 22 pictures were taken during the taxi,

The next 22 pictures were taken during the taxi,

take-off, and climb.

Nine were taken while the plane was airborne,

taken over 39 seconds.

taken over 39 seconds.

That's the last one.

That's the last one.

Too bad that's all there is.

Too bad that's all there is.

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

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

When we had the photos from the accident

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.

rebuild the flight path of the aircraft using these images.

Time, 15:11:45.

Time, 15:11:45.

Direction, forward.

Estimated altitude, 98 feet.

Estimated altitude, 98 feet.

They compiled data from the photographs

about the plane's position, the camera

angle, and the time of day.

angle, and the time of day.

OK.

That's all of them.

Let's process this.

So how's it going?

So how's it going?

Strung together, the images

provide investigators with a key portion

provide investigators with a key portion

of the plane's flight path.

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

path, but also have a more accurate understanding of

the altitude of the aircraft.

The plane is at 98 feet and turning right.

The plane is at 98 feet and turning right.

Then it stops climbing for some reason.

Then it stops climbing for some reason.

That's odd.

We could see that the aircraft

was in a bank turn.

was in a bank turn.

But despite being in the climb flap setting,

the aircraft was losing altitude.

the aircraft was losing altitude.

The photo analysis tells investigators

that the plane was descending.

that the plane was descending.

But the complete flight path remains an educated guess.

Well, the good news is that matches the flight

Well, the good news is that matches the flight

path from our eyewitnesses.

But it doesn't go much beyond that.

But it doesn't go much beyond that.

You're right.

We need to come at this from a different perspective.

At that point, because we had

no obvious reason as to why the accident occurred,

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.

Maybe he had a seizure or heart failure.

Well, that's a possibility.

Well, that's a possibility.

His medical records indicate no history of headaches,

His medical records indicate no history of headaches,

blackouts, dizziness.

I'm not seeing anything.

I'm not seeing anything.

Investigators shift their focus back

to the pilot, Gareth Morgan.

to the pilot, Gareth Morgan.

What about the cardiology?

This isn't normal.

Some of the ECG, he's

had signs of sinus bradycardia, which is a slower

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.

He's like a trained athlete.

It's an abnormality, but it's not a problem.

He was a very fit individual,

and there was nothing in his medical history

and there was nothing in his medical history

that could have led to medical incapacitation.

I thought we'd have more answers by now.

Almost two years into the investigation,

Almost two years into the investigation,

the ATSB prepares a final report without any firm conclusions

about what caused the crash.

about what caused the crash.

The investigation team

were disappointed and frustrated that they could not provide

were disappointed and frustrated that they could not provide

an answer to the families.

Duncan Bosworth.

Yeah, well, incapacitation was always a possibility.

Yeah, well, incapacitation was always a possibility.

Went pretty far down that road, came up empty.

While the report was being prepared,

we have an internal review.

we have an internal review.

This included our aviation medical specialists.

No, we must have tested for that.

No, we must have tested for that.

I'll get back to you.

All right?

The aviation specialists raise the fact

The aviation specialists raise the fact

that carbon monoxide could have been

an issue during this accident.

an issue during this accident.

When aviation fuel is burned,

exhaust from the engines contains

a highly poisonous carbon monoxide gas, which

a highly poisonous carbon monoxide gas, which

can cause short-term symptoms.

Long-term exposure can have a severe impact on health

Long-term exposure can have a severe impact on health

and can be fatal.

They tested for carbon monoxide.

They tested for carbon monoxide.

Right?

Here's the pathologist report.

Here's the pathologist report.

I said, I thought

it must have been examined because we

it must have been examined because we

had the toxicology report.

And nothing had been raised about carbon monoxide.

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.

I have a few questions for you.

Investigators contact the state's health pathologist.

Is there any reason you didn't test

Is there any reason you didn't test

for carbon monoxide poisoning?

The team learns that pathologists

do not test for carbon monoxide unless there's

do not test for carbon monoxide unless there's

evidence of a fire.

Any chance you still have the original samples?

Any chance you still have the original samples?

I see.

Oh, you do?

Oh, that's great.

Oh, that's great.

That's when they went off and did

the additional testing to assess whether carbon

the additional testing to assess whether carbon

monoxide was an issue or not.

26 months after the crash,

26 months after the crash,

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

Look at this.

Look at this.

The results provide investigators

with their biggest lead yet.

I felt we may have an answer in our grasp.

I felt we may have an answer in our grasp.

Morgan's carbon monoxide levels were at 11%.

Morgan's carbon monoxide levels were at 11%.

Some of the passengers also tested

positive for CO poisoning.

positive for CO poisoning.

Toxicology results confirm that the pilot and two

passengers of the ill-fated float plane

passengers of the ill-fated float plane

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

We were re-energized because we may have found

We were re-energized because we may have found

that missing piece of evidence.

According to this study, the pilot

According to this study, the pilot

would have been suffering from neurobehavioral and cognitive

side effects.

side effects.

We did a lot of research to see what that 11%

We did a lot of research to see what that 11%

in particular for the pilot... how that would

have affected his performance.

have affected his performance.

You'll see Cowan...

um, Comox Creek.

um, Comox Creek.

Was Gareth Morgan's carbon monoxide level

high enough to incapacitate him and cause

high enough to incapacitate him and cause

him to crash the plane?

At 11% he would had feelings of nausea,

At 11% he would had feelings of nausea,

dizziness, possibly headache.

It's hard to know what those symptoms

It's hard to know what those symptoms

if it's carbon monoxide poisoning or something else.

The side effects of 11% carbon monoxide poisoning

The side effects of 11% carbon monoxide poisoning

are so insidious, it would have been hard for Gareth Morgan

are so insidious, it would have been hard for Gareth Morgan

to be aware of what was happening to him.

Quite often, the cognitive effects

Quite often, the cognitive effects

can be quite subtle.

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

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

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.

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

So what's the source?

And how did it get into the cabin?

We knew the source of carbon monoxide

in an aircraft would be the exhaust system

in an aircraft would be the exhaust system

or a heater in the aircraft.

There was no heater.

There was no heater.

So our focus was on the engine exhaust system.

Well, this piece seems OK.

Well, this piece seems OK.

When an engine burns fuel,

the hot gases are directed through the exhaust

manifold and out of the tailpipe,

manifold and out of the tailpipe,

preventing them from entering the plane's cabin.

Take a look at this.

See those cracks?

See those cracks?

Investigators take a closer look

at pieces of the cracked manifold

to determine if the damage occurred

to determine if the damage occurred

before or after the crash.

There's some oxidation here.

Rust on the fractures in the exhaust manifold

Rust on the fractures in the exhaust manifold

tells investigators that the crack developed

prior to the accident.

We've found the leak.

We've found the leak.

After we discovered there was

an exhaust leak, we had to determine

how the carbon monoxide got into the cabin

how the carbon monoxide got into the cabin

to affect the occupants.

to affect the occupants.

What's the most likely point of entry?

Right here, the firewall.

Right here, the firewall.

Investigators tried to determine how carbon

monoxide entered the float plane's cockpit,

monoxide entered the float plane's cockpit,

incapacitating the pilot.

The firewall exists between the engine

The firewall exists between the engine

accessory bay and the cabin to prevent

fumes getting into the cabin.

fumes getting into the cabin.

Zoom in.

The team examines the plane's firewall.

The team examines the plane's firewall.

It's pretty banged up.

They focus on two panels, which allow access

to the engine for maintenance.

to the engine for maintenance.

Here's what we found.

They discover the left access panel is missing

They discover the left access panel is missing

one of its four required bolts.

The right panel is missing two.

The right panel is missing two.

That means there were three holes in the main firewall

on the day of the flight.

Mm-hmm.

Mm-hmm.

It's a pathway for exhaust

to travel from the engine bay into the cabin of the Beaver.

Several pre-existing cracks in the exhaust system

released the poisonous gas into the engine bay.

released the poisonous gas into the engine bay.

Tiny bolt holes allowed the gas to leak into the cabin

Tiny bolt holes allowed the gas to leak into the cabin

through the main firewall.

So we have the source and the point of entry.

So we have the source and the point of entry.

The discovery leaves investigators

with a burning question.

with a burning question.

How long did the dangerous problem exist?

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

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

Maintenance records show when the access

panels were last modified.

That's months before the accident.

That's months before the accident.

That means Sydney Seaplanes pilots have flown

the same Beaver float plane hundreds of times

the same Beaver float plane 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.

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

One of the key questions we were asking ourselves

was why did the accident happen on this flight.

ATSB investigators examine pilot logbooks

ATSB investigators examine pilot logbooks

to understand what made this fatal flight of a Sydney

Seaplane different from others.

Seaplane different from others.

He's flying the same plane day after day.

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.

I can't figure it out.

What was his schedule on the day of the crash?

Well, he's making flights all day long.

Well, he's making flights all day long.

So the carbon monoxides can be built up in his system.

So the carbon monoxides can be built up in his system.

An individual's carbon monoxide

levels will increase with intensity

depending on the duration.

depending on the duration.

We had a pilot who was conducting multiple flights

throughout the day with only short intervals

throughout the day with only short intervals

between each flight.

There's something else.

There's something else.

As investigators reconstruct Gareth Morgan's

schedule, they remember they have to add

one more piece to the puzzle.

one more piece to the puzzle.

An hour before he took off from Cottage Point,

Gareth Morgan was asked to move his plane off the dock

Gareth Morgan was asked to move his plane off the dock

to make room for another plane.

I got to go.

I got to move my plane.

I got to move my plane.

Maybe Morgan was exposed to even more carbon monoxide

gases while moving the plane.

Exactly.

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.

Morgan had to maneuver his plane away from the dock,

Morgan had to maneuver his plane away from the dock,

and around the bay, while another plane picked up

passengers.

passengers.

There's still a missing link.

These holes don't seem big enough

These holes don't seem big enough

to let in enough exhaust.

Why is that exhaust flowing into the cabin?

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

That would create enough suction for the carbon monoxide

to flow in.

Most pilots have their windows down to get some ventilation

into the cabin.

Investigators revisit pictures

Investigators revisit pictures

they collected from witnesses.

This was taken earlier in the day.

Looks like he cracked the door during the taxi

into Cottage Point to get some air.

into Cottage Point to get some air.

The open door could have created a draft that

sucked the exhaust into the cabin

sucked the exhaust into the cabin

through holes in the firewall.

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

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

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.

But check out the door.

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

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

that likely elevated the level of carbon monoxide

that likely elevated the level of carbon monoxide

in the pilot's system.

The investigation team

had an hypothesis about how the door ajar may have exacerbated

had an hypothesis about how the door ajar may have exacerbated

the passage of carbon monoxide.

We needed to test this theory.

OK.

Initiating test number one with the door closed.

Initiating test number one with the door closed.

Investigators recreate the conditions of Gareth

Investigators recreate the conditions of Gareth

Morgan's plane to see if concentrations

of carbon monoxide were high enough to incapacitate him.

of carbon monoxide were high enough to incapacitate him.

We needed to use an exemplar Beaver aircraft

with a simulated exhaust leak, and excess panel bolts removed,

to test our hypotheses.

to test our hypotheses.

They begin the test with the windows and doors

closed.

First we had to set a baseline level

First we had to set a baseline level

with the engine running.

We then removed the excess panel bolts,

We then removed the excess panel bolts,

and simulated an exhaust leak by feeding

the exhaust from the engine directly into the engine bay.

the exhaust from the engine directly into the engine bay.

55 parts per million.

There was no dangerous level of carbon monoxide

There was no dangerous level of carbon monoxide

in the cabin at that stage.

OK.

Let's clear the cabin and start again.

Let's clear the cabin and start again.

To protect against carbon monoxide poisoning,

investigators agree to stop the test if the levels

investigators agree to stop the test if the levels

reach 120 parts per million.

We then tested with the door ajar.

We then tested with the door ajar.

It has to get to 70 parts per million.

It has to get to 70 parts per million.

And we saw that the levels increased.

And we saw that the levels increased.

Within minutes, carbon monoxide in the cabin

climbs to deadly levels.

climbs to deadly levels.

We're at 144 PPM in here, way too high.

Let's shut it down.

Prolonged exposure to carbon monoxide levels

Prolonged exposure to carbon monoxide levels

greater than 144 parts per million

is dangerous to the occupants.

is dangerous to the occupants.

The tests are conclusive.

The tests are conclusive.

We did it.

It was a relief to see that our theory may have

been proved and confirmed that carbon

been proved and confirmed that carbon

monoxide could enter the cabin.

Investigators worry the same thing

Investigators worry the same thing

could happen again.

They tracked down other Beaver float planes that were serviced

They tracked down other Beaver float planes that were serviced

by the same company that maintained

the Sydney Seaplanes' fleet.

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

And we were surprised to find that there was one bolt missing

from each of those panels.

It's unbelievable.

It's unbelievable.

It was the same in every one of them.

They have to be fixed immediately.

They have to be fixed immediately.

Bolts are replaced in all the planes

where they're missing.

where they're missing.

As investigators try to determine how the accident

As investigators try to determine how the accident

could have been prevented, they're

left with one last question.

Was this thing even working?

Was this thing even working?

Carbon monoxide detectors provide pilots

with the opportunity to detect exposure

with the opportunity to detect exposure

before they become incapacitated.

Was the carbon monoxide detecting equipment on the

Beaver float plane functioning?

Beaver float plane functioning?

So how does this one work?

Well, it's supposed to turn a different color when

carbon monoxide is present.

carbon monoxide is present.

It's sun bleached.

There's no way it was working.

There's no way it was working.

When we examined the carbon monoxide

detector from this aircraft it was a beige color, which meant

detector from this aircraft it was a beige color, which meant

it was unserviceable and not capable

of detecting carbon monoxide.

of detecting carbon monoxide.

You know, the detectors aren't even mandatory.

Not in Australia.

Not in Australia.

Not anywhere.

The ATSB's final report

highlights the critical importance of audible carbon

highlights the critical importance of audible carbon

monoxide detectors.

As a pilot myself, I strongly encourage all pilots

As a pilot myself, I strongly encourage all pilots

to carry active carbon monoxide detectors

every time they go out flying.

every time they go out flying.

I have carbon monoxide detectors in my home.

I have carbon monoxide detectors in my home.

They're very loud.

And they're not expensive.

This should be mandatory in all small planes.

This should be mandatory in all small planes.

The crash at Jerusalem Bay

raises awareness of the deadly threat carbon monoxide

raises awareness of the deadly threat carbon monoxide

poses to aviators.

It was fulfilling to be able to identify

important safety issues in the hope

important safety issues in the hope

that we can prevent such a tragic accident from occurring

again in the future.

again in the future.

But it was also rewarding to provide the family and friends

some degree of resolution.

some degree of resolution.

I've had many people, particularly

I've had many people, particularly

after his death, say the marvelous experiences they had

as passengers with Gareth, he really touched

as passengers with Gareth, he really touched

people with his humbleness and his sense of dedication

people with his humbleness and his sense of dedication

to his profession.

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

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