Date:	Sunday 31 December 2017
Time:	15:15 LT
Type:	de Havilland Canada DHC-2 Beaver
Owner/operator:	Sydney Seaplanes
Registration:	VH-NOO
MSN:	1535
Fatalities:	Fatalities: 6 / Occupants: 6
Other fatalities:	0
Aircraft damage:	Destroyed
Category:	Accident
Location:	off Cottage Point, Jerusalem Bay, NSW -   Australia
Phase:	Initial climb
Nature:	Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:	Cottage Point Inn, NSW
Destination airport:	Rose Bay, NSW (RSE/YRAY)
Investigating agency:	ATSB
Confidence Rating:	Information verified through data from accident investigation authorities

Narrative:
On 31 December 2017, at about 10:45, five passengers arrived via water-taxi at the Sydney Seaplanes terminal, Rose Bay, Australia, for a charter fly-and-dine experience to a restaurant at Cottage Point on the Hawkesbury River. Cottage Point is about 26 km north of Sydney Harbour in the Ku-ring-gai Chase National Park, a 20 minute floatplane flight from Rose Bay.
At about 11:35, the pilot and five passengers departed the Rose Bay terminal for the flight to Cottage Point via the northern beaches coastal route, in a float-equipped de Havilland Canada DHC-2 Beaver, registered VH-NOO and operated by Sydney Seaplanes. The flight arrived at Cottage Point just before midday and the passengers disembarked. The pilot then conducted another four flights in VH-NOO between Cottage Point and Rose Bay.
The pilot arrived at Cottage Point at about 13:53. After securing the aircraft at the pontoon and disembarking passengers from that flight, the pilot walked to a kiosk at Cottage Point for a drink and food. At about 14:15, the pilot received a phone call from the operator via the kiosk, asking the pilot to move the aircraft off the pontoon, which could only accommodate one aircraft at a time. This was to allow the pilot of the operator’s other DHC-2 aircraft (VH-AAM) to pick-up other restaurant passengers. The pilot of VH-NOO immediately returned to the aircraft and taxied away from the pontoon into Cowan Creek. The operator’s records indicated that VH-AAM arrived at the pontoon and shut down the engine at about 14:19, and subsequently departed at about 14:46. The pilot of VH-NOO returned to the pontoon after having taxied in Cowan Creek with the engine running for up to 27 minutes, while waiting for the other aircraft.
After shutting down the aircraft, the pilot briefly went into the restaurant to see if the passengers were ready to leave, and then returned to the aircraft.
The return flight to Rose Bay, scheduled to depart at 15:00.
At about 14:57, the passengers commenced boarding the aircraft and at around 15:04, the aircraft had commenced taxiing toward the designated take-off area in Cowan Creek. At about 15:11, the aircraft took off towards the north-north-east in Cowan Creek, becoming airborne shortly before passing Cowan Point.
The aircraft climbed straight ahead before commencing a right turn into Cowan Water. A witness photographed the aircraft passing over a location known as ‘Hole in the wall’. These photographs indicated that the aircraft was turning to the right with a bank angle of 15-20°. Witnesses observed the right turn continue above Little Shark Rock Point and Cowan Water.
The last photograph taken by the passenger was when the aircraft was heading in a southerly direction towards Cowan Bay. At that time, the aircraft was estimated to be at an altitude of about 30 m (98 ft).
Shortly after the turn in Cowan Water, several witnesses observed the aircraft heading directly towards and entering Jerusalem Bay flying level or slightly descending, below the height of the surrounding terrain. Witnesses also reported hearing the aircraft’s engine and stated that the sound was constant and appeared normal.
About 1.1 km after entering Jerusalem Bay, near the entrance to Pinta Bay, multiple witnesses reported seeing the aircraft flying along the southern shoreline before it suddenly entered a steep right turn at low-level. Part-way through the turn, the aircraft’s nose suddenly dropped before the aircraft collided with the water, about 95 m from the northern shore and 1.2 km from the end of Jerusalem Bay. The aircraft came to rest inverted and with the cabin submerged. A number of people on watercraft who heard or observed the impact, responded to render assistance. Those people could not access the (underwater) aircraft cabin. The entire tail section and parts of both floats were initially above the waterline, but about 10 minutes later had completely submerged. The pilot and five passengers received fatal injuries.

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)

https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-118/
https://www.9news.com.au/national/2017/12/31/15/54/light-plane-crash-into-hawkesbury-river-new-years-eve
https://www.facebook.com/atsbgovau/photos/a.1655527014665323.1073741829.1638364093048282/2011095122441842/?type=3&theater
https://www.sbs.com.au/news/british-family-including-young-girl-named-as-hawkesbury-river-seaplane-crash-victims
https://www.theguardian.com/australia-news/2018/jan/02/sydney-seaplane-crash-investigators-say-type-of-plane-considered-reliable
http://www.news.com.au/travel/travel-updates/incidents/report-sheds-light-on-seaplanes-final-moments/news-story/367167abe4323af71d48199fd099a3e8
http://www.bbc.co.uk/news/world-australia-42561706
https://beta.theglobeandmail.com/canada/british-columbia/article-plane-may-have-crashed-in-australia-after-canadian-pilot-accidentally/
DEC-2018 : https://www.dailymail.co.uk/news/article-6514421/Chilling-pictures-camera-reveal-doomed-seaplanes-final-moments-crashed.html
________________________
https://www.jetphotos.com/photo/8521969

Other occurrences involving this aircraft


15 November 1996

VH-IDI

Private

1

7km W Point Lookout, NSW

w/o

Photo: ATSB

ATSB

#Beaver #VHNOO #Cousins - Chilling pictures taken on a passenger's camera have revealed a seaplane's final moments before it crashed into a river in Australia killing all six people on board. https://t.co/lHTqbndwTn pic.twitter.com/RaFzGF7GEO

— PLANES OF LEGEND (@PlanesOfLegend) 27 décembre 2018

Date/time	Contributor	Updates
31-Dec-2017 07:34	Pineapple	Added
31-Dec-2017 07:38	harro	Updated [Aircraft type, Location, Source, Narrative, ]
31-Dec-2017 07:43	harro	Updated [Total fatalities, Damage, Narrative, ]
31-Dec-2017 13:40	Iceman 29	Updated [Embed code, ]
31-Dec-2017 14:15	Iceman 29	Updated [Time, Phase, Destination airport, Source, Embed code, ]
31-Dec-2017 14:21	Iceman 29	Updated [Phase, Embed code, Photo, ]
01-Jan-2018 06:59	Iceman 29	Updated [Destination airport, Source, Embed code, Narrative, ]
01-Jan-2018 10:44	Anon.	Updated [Narrative, ]
02-Jan-2018 09:21	Iceman 29	Updated [Phase, Departure airport, Destination airport, Source, Embed code, Narrative, ]
02-Jan-2018 09:23	Iceman 29	Updated [Embed code, Narrative, ]
03-Jan-2018 09:18	Anon.	Updated [Destination airport, ]
03-Jan-2018 09:20	harro	Updated [Source, Narrative, ]
04-Jan-2018 16:52	Iceman 29	Updated [Embed code, ]
04-Jan-2018 20:39	Aerossurance	Updated [Source, Narrative, ]
05-Jan-2018 11:26	Iceman 29	Updated [Embed code, ]
18-Jan-2018 18:18	Anon.	Updated [Source, Narrative, ]
31-Jan-2018 07:04	harro	Updated [Photo, ]
31-Jan-2018 07:07	harro	Updated [Departure airport, Destination airport, Narrative, Photo, ]
31-Jan-2018 07:09	harro	Updated [Embed code, ]
31-Jan-2018 07:14	harro	Updated [Source, Narrative, ]
02-Feb-2018 15:31	Anon.	Updated [Source, Narrative, ]
16-Oct-2018 04:19	Iceman 29	Updated [Source, Narrative, ]
16-Oct-2018 14:10	Iceman 29	Updated [Narrative, ]
27-Dec-2018 18:45	Iceman 29	Updated [Source, ]
27-Dec-2018 18:45	Iceman 29	Updated [Embed code, ]
29-Jan-2021 09:55	harro	Updated [Embed code, Narrative, Accident report, ]