Originally Posted by
Squawk7700
Do you mean that they reviewed the autopsy reports?
No, it was a bit more than that.
“During the draft investigation report review process, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide (CO) toxicology testing be undertaken on blood samples of the aircraft occupants that had been taken and suitably stored by the New South Wales State Coroner. This required testing at a specialised laboratory. With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.
The results of the testing were provided to the ATSB in March 2020, indicating that the pilot and two of the passengers had elevated levels of CO. The ATSB notes that post-mortem examinations established that the pilot and passengers received fatal injuries sustained as a result of the impact sequence.
Since receiving the toxicology results, the ATSB has:
- consulted with New South Wales Health pathology to confirm the integrity of the samples given the preservation method, storage temperature and duration
- consulted with NSW Health forensic toxicology to confirm the accuracy of testing given the technique used and sample preparation
- received independent advice from a forensic pharmacologist, and engaged an experienced independent forensic pathologist to advise on the testing and effects of the CO levels found in the occupants
- undertaken research on CO poisoning and detectors relating to aircraft operations.
From this, the ATSB considers the levels of CO detected were likely to have adversely affected the pilot’s ability to control the aircraft during the flight.“