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2. Search and Rescue Response...................................................................................................5

3. Post Mortem Investigations...................................................................................................13

4. Whyalla Airlines.....................................................................................................................23

5. VH-MZK................................................................................................................................36

6. Ben Mackiewicz – Pilot..........................................................................................................47

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7. Flights after final service before Flight 904.........................................................................51

8. Refuelling...............................................................................................................................56

9. The ATSB Investigation........................................................................................................63

10. Events in the Aircraft Industry 2000-2002..........................................................................86

11. Related Incidents....................................................................................................................97

12. The Scientific Investigation.................................................................................................111

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13. ATSB – Response and Further Investigation....................................................................152

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At 7:01:14pm on Wednesday 31 May 2000, a Mayday call was received at Adelaide Flight Information Service. The call came from Mr Ben Mackiewicz, the pilot of a Piper Navajo Chieftain Aircraft, registration number VH-MZK, owned by Whyalla Airlines. The aircraft was in the course of Flight 904 from Adelaide to Whyalla, South Australia, with eight persons on board. Mr Mackiewicz advised that they were ‘about one five miles off the coast of Whyalla on the Gibon-Whyalla track’. The last radio transmission from MZK was at 7:04:20pm. At about 7:06pm, the crew of another aircraft heard a signal from an Emergency Locator Transmitter which lasted for about 20 seconds.

A very substantial search and rescue effort commenced under the supervision of Australian Search and Rescue, with South Australia Police coordinating the surface search. A large number of aircraft, marine vessels and land-based vehicles were utilised during the search, including large numbers of volunteers. All searched tirelessly throughout the night.

At 12:41am, the body of Mrs Wendy Olsen was found floating in the water, and the body of her husband, Mr Peter Olsen, was found nearby at 12:51am. A third body, which I find was that of Mr Christopher Schuppan, was seen at around the same time, but it disappeared from view, and has never been recovered.

MZK was eventually located on Monday 5 June 2000, lying on the sea bed. The bodies of Mr Ben Mackiewicz, Mrs Joan Gibbons, Mrs Teresa Pawlik, Mr Neil Marshall and Mr Richard Deegan were recovered from the wreckage. Post mortem examinations established that Mr Mackiewicz, Mr Olsen, Mrs Olsen, Mrs Pawlik, Mr Marshall and Mr Deegan all died as a result of salt water drowning. Mrs Gibbons died as a result of ‘multiple injuries including flail chest’. I have not been able to determine the precise cause of Mr Schuppan’s death.

The substantial damage suffered by MZK when it impacted the water, the sudden inrush of cold water at high velocity, the sudden loss of visibility, the injuries suffered by some of the passengers, and the gasp reflex phenomenon known as ‘cold shock’ leading to aspiration of water or laryngeal spasm, would have collectively led to instant incapacitation and rapid drowning. It is very unlikely that any of the occupants of MZK, including Mr and Mrs Olsen and Mr Schuppan, survived the impact.

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On the basis that none of those on board MZK survived the impact, it was not necessary to assess the quality of the search and rescue operation except in the sense that it forms part of the surrounding circumstances. However, the evidence establishes that the operation was conducted with a high degree of professionalism and skill, and those involved should be commended for their efforts.

An examination of the wreckage by the Australian Transport Safety Bureau (ATSB) established that the left engine of MZK had suffered a total fracture of the crankshaft, and the right engine had suffered a holed No.6 piston due to melting of the piston material.

The final ATSB report, published on 19 December 2001, attributed the fractured crankshaft in the left engine to fatigue, initiated by thermal cracking due to failure of the No.6 connecting rod bearing insert causing rubbing on the journal surface of the crankshaft. This failure was attributed to ‘high bearing loads created by lead oxybromide deposit-induced preignition’, and ‘lowered bearing insert retention forces associated with the inclusion of an anti-galling compound between the bearing inserts and the bearings’.

The ATSB postulated that the bearings in the left engine began failing much earlier than 31 May 2000, so that at a time approximately 50 flights before that, thermal cracks began forming on the journal surface of the crankshaft, creating a weakness which led to the initiation of a fatigue crack which ‘grew’ over the next 50 flights, and eventually fractured the crankshaft completely at around 1837 or 1838 during Flight 904. It was suggested that the two pieces of the crankshaft remained ‘dogged’ together, allowing the engine to continue running until 1847:15 when the two sections parted and the engine ceased functioning.

The failure of the right engine was caused by a holed No.6 piston due to melting of the piston material. The ATSB postulated that when the left engine stopped at 1847:15, Mr Mackiewicz increased the engine power settings on the right engine to an inappropriate extent (‘overboosting the engine’) until, at about 1858 to 1900, detonation holed the piston and the right engine also failed.

To that extent, the ATSB argued that the two engine failures were ‘dependent’ in the sense that the failure of the left engine was causally linked to the failure of the right engine.

Evidence of material defects in crankshafts in Textron Lycoming engines, the type fitted to MZK, did not begin emerging until a Special Advisory Bulletin was issued on 9 November 2000, although similar failures had been noted in Teledyne Continental engines, the brand

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fitted to Cessna aircraft among others, as early as April 2000. The Civil Aviation Safety Authority (CASA) was advised that no Australian aircraft were affected by the 9 November 2000 Special Advisory Bulletin. On 1 February 2002, Textron Lycoming recalled about 400 engines, including one fitted to an identical aircraft to MZK, at around the same time the left engine was fitted to MZK. More extensive recalls were made on 16 August 2002 and 16 September 2002. Included among the approximately 3,000 engines on the 16 September 2002 list was the left engine in MZK. Each of these recalls was accompanied by a Mandatory Service Bulletin issued by Textron Lycoming which stated that the cause of the crankshaft failures was ‘material related’.

On 14 December 2001, only five days before the ATSB final report was published, the right engine in an aircraft identical to MZK failed. Upon inspection of the engine, it was established that the crankshaft had fractured, and the appearance of the fracture was strikingly similar to that of MZK’s left engine crankshaft. The ATSB did not examine the fracture in detail, so the aircraft owner commissioned an examination by an engineer who concluded that the failure was caused by a material flaw, and not by thermal cracking.

A scientific investigation conducted for this inquiry has thrown doubt on a number of ATSB conclusions:

• Professor King, an expert in chemical engineering and Dr Zockel, an expert in mechanical engineering, both agreed with the ATSB that the damage to the right engine was due to end gas detonation;

• Professor King concluded that there was considerable doubt about the ATSB conclusion that lead oxybromides were present in sufficient quantity to be a significant factor in the failure of the left engine;

• Dr Zockel concluded that the damage to the left crankshaft was not caused during the combustion stroke of the engine and so abnormal combustion was irrelevant anyway;

• Dr Zockel also concluded that the failure of the left crankshaft was not caused by bearing failure or thermal cracking as suggested by the ATSB;

• Dr Powell and Mr McLean, both experts in metallurgy, found iron oxide inclusions at the nearby No.5 journal of the left crankshaft of sufficient size to constitute a material defect capable of affecting the tensile and torsional strength of the crankshaft. Although similar inclusions were not found at the fracture site, they could have been lost during the fracture process;

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• Mr Braly, an aeronautical engineer, aviator and manufacturer of aircraft components, also disputed that lead oxybromides were relevant to the failure of MZK’s left engine, that the crankshaft could have remained ‘dogged’ as the ATSB suggested, that the aircraft could have maintained 167 knots groundspeed on one engine after 1847:15, and hence that the left engine failed first. He argued that the right engine suffered a partial loss of power at 1847:15, and that it was not until after 1858 or so that the left engine failed;

• Mr Braly also said that the mixture settings adopted by Whyalla Airlines for the climb phase of flight were too lean and these settings may have caused or exacerbated the damage to the right engine;

• Mr Hood, a metallurgist with McSwain Engineering Inc. in the United States of America also confirmed that the left engine crankshaft in MZK did not fail due to thermal cracking initiated fatigue fracture, that bearing failure was not relevant, and that the crankshaft failure was due to a ‘manufacturing-related material condition’. Like Dr Powell and Mr McLean, they were unable to identify an inclusion in the metal at the fracture site, but he found a ‘pocket’ there, from where an inclusion may have fallen during the fracture process.

On the basis of the evidence presented at the inquest, I reached the following conclusions about how this tragedy occurred:

• It is possible (but not capable of proof) that the No.6 piston in the right engine of MZK was damaged during the takeoff and climb of Flight 904. It is very unlikely that damage occurred during the cruise phase;

• The right engine began running roughly and showing signs of end gas detonation damage at around 1837:41. Mr Mackiewicz reduced power on that engine at 1847:15 to protect it, causing a yaw to the right and reduction in groundspeed to 167 knots. He increased the RPM on the left engine to 2,400 to compensate. This was not ‘overboosting’ the engine;

• The crankshaft in the left engine failed at 1858:30 causing immediate cessation of function;

• Mr Mackiewicz may have tried to increase power on the right engine again after the left engine failed completely, but this would have not produced enough power to maintain altitude;

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• The cause of the fracture of the left crankshaft was a fatigue crack, initiated from a subsurface defect in the steel as a result of a flaw in the manufacturing process, which created a point of weakness from which fatigue cracking radiated outwards over the ensuing 50 to 70 flights until it finally fractured through at around 1858:30 on 31 May 2000 causing immediate cessation of functioning;

• The cause of the failure of the right engine was end gas detonation damage to the No.6 piston, not due to ‘overboosting’ but possibly due to detonation during the ‘climb’ phase of Flight 904 when the mixture settings (specified in the Whyalla Airlines Operations Manual) were unduly lean and were likely to create unduly high peak cylinder pressures.

In forming those conclusions, a number of issues were identified at the inquest and considered. They assisted me to reach these conclusions in the following way:

• It is very unlikely that MZK would have been capable of maintaining a groundspeed of 167 knots in those conditions after 1847:15 if, as the ATSB argued, one engine was completely inoperative;

• Even if the aircraft was so capable, to achieve that groundspeed in those conditions, would have required absolutely maximum power on one engine, which was completely unnecessary since the aircraft was quite capable of maintaining altitude at a lower groundspeed on one engine at lower power settings, without putting the engine at risk;

• If Mr Mackiewicz had overboosted the engine, it is more likely that it would have been operating at 2,575 RPM (maximum) rather than 2,400 RPM detected by the ATSB;

• It is very unlikely that Mr Mackiewicz would have commenced his descent into Whyalla at 1855:54, and advised Adelaide Flight Information Service that he was expecting to arrive on time, if he was operating on only one engine at absolutely maximum power and was worried about maintaining altitude;

• Mr Mackiewicz made a number of radio transmissions after 1847:15, and as late as 1856:03 he was reporting his position without apparent concern. It is almost inconceivable that he would not have issued a Pan (distress) call at that point if he had completely lost one engine and was worried about maintaining altitude;

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• It is highly unlikely that the bearings in the left engine failed long before 31 May 2000, to the extent that they could cause thermal cracks in the crankshaft and initiate the fatigue fracture 50 to 70 flights before Flight 904, and yet no sign of bearing damage, particularly metal particles in the oil, was noted in any of the services performed on the engine in the meantime;

• I have been informed that there have been a total of more than fifteen crankshaft failures in Textron Lycoming engines since this incident. Information about many of them is meagre, but a material defect has been confirmed by the United States authorities in seven cases, and suspected as the cause in the rest. This is the only case in which a different explanation for the crankshaft failure has been offered.

On the basis of these findings, I have made recommendations pursuant to section 25(2) of the Coroners Act, 1975, in the following areas:

• Pilot Operating Handbooks and Operators Manuals.

• International communication between regulators.

• On-Board Recorders.

• Self-deploying Emergency Locator Transmitters.

• Lifejackets.

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1.1. At 1901:14 (7:01:14pm) Central Standard Time, (incorrectly recorded in the ATSB report, Exhibit C97, as 1901:10) on Wednesday 31 May 2000, a radio message was received at the Adelaide Flight Information Service (‘FIS’):

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1.5. A basic outline of the journey is as follows:

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1.6. Radio transmissions subsequent to the Mayday call were as follows:

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2.1. Adelaide FIS contacted Australian Search and Rescue (AusSAR) in Canberra and notified them of the emergency at 7:02:14pm. AusSAR immediately took control of the air search, and contacted SA Police (SAPOL) in order that ‘surface assets’ could be deployed. As things transpired, AusSAR remained in an overall coordinating role, and SAPOL assumed responsibility for the land and sea search (T501).

2.2. AusSAR contacted Lloyds Helicopter Group (Adelaide) and ascertained that the Bell Helicopter ‘Rescue 51’ was available and would respond immediately. Another helicopter, ‘Rescue 52’, was also available but its capability in the prevailing weather conditions was less, so it was effectively placed on standby.

2.3. As Mr Dunning, counsel for AusSAR, pointed out, all these steps were taken before MZK had ditched.

2.4. Mr Williams, the pilot of FMC, states that around 7:06pm he heard an emission from an Emergency Locator Transmitter (‘ELT’). Unfortunately, the transmission only lasted for 10 - 20 seconds, not long enough for the ELT to be located using a ‘homing pattern’ (T419).

2.5. Mr Williams descended to 2000 feet. He noticed a flashing light, which was later identified as a navigation light at Yarraville Shoal (T417). He said that at 2000 feet, he was unable to see the surface of the water, although he could see the lights of Whyalla (T418). It was a moonless night and it was difficult to detect the horizon visually (T423).

2.6. Within minutes, as a result of an offer of assistance from the Royal Australian Air Force, a P3-C Orion (Mariner 85) commanded by Flight Lieutenant Paul Freeman was also dispatched to the scene.

2.7. It was recognised from the start that MZK did not carry lifejackets or a life-raft. The water temperature in the area was approximately 16°C, and hypothermia could have led to drowning within two to four hours if any survivors were not located quickly. From two to twelve hours after immersion at 15°C there is a 50% expectancy of death (National Search and Rescue Manual, Exhibit C114).

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2.8. There was some controversy about Mr Mackiewicz’s advice in the Mayday call at 7:01:14pm that they were ‘currently about one five miles off the coast of Whyalla on the Gibon Whyalla track’, and his call at 7:04:08 pm that ‘MZK is now currently 15 miles’.

2.9. An estimated splash point was established at approximately 11 miles south east of Whyalla on the Adelaide-Whyalla track. This was relayed to FMC, Mariner 85 and Rescue 51.

2.10. Some parts of Mr Mackiewicz’s radio transmissions were also heard on a private radio by Mr Ian Bull, who notified his friend Mrs Raelene Haynes, who is the radio operator for the Spencer Gulf and West Coast Prawn Fisheries Association, and also the Volunteer Search and Rescue Coordinator for the State Emergency Service and the Wallaroo section of the Australian Volunteer Coast Guard. On her own initiative, Mrs Haynes advised the prawning fleet by a broadcast on VHF channel 71 at 7:20pm. There were 39 prawn boats at sea that evening.

2.11. In addition to that, AusSAR issued a ‘Mayday’ distress alert to all ships in the vicinity and SAPOL did the same to volunteer agencies, port authorities and the fishing industry.

2.12. At about 7:30pm Mr Barry Ellis, the master of the prawn boat Orao, responded to Mrs Haynes’ call, advising that he, and the skippers of the Seabelle, Roslyn Ann and Skandia had all pulled their nets and were on their way. They were 18 miles from the scene at that stage, and it would take them about two hours to get there (Exhibit C103, p2)

2.13. By 7:25pm, Mariner 85 was already in the area flying at 300 feet conducting what Flight Lieutenant Freeman described as a ‘creeping line ahead search’ along the track taken by MZK, using the Orion’s landing lights to illuminate the sea surface (Exhibit C108, p3). FMC had moved to a higher altitude and continued to orbit the area in order to assist with communications.

2.14. Rescue 51 arrived at the search area at 7:50pm and commenced searching at 500 feet. Rescue 51 was very well-equipped for the task, having excellent communications, a homing device to track ELT’s, Forward-Looking Infrared (FLIR) sensors, and a ‘nightsun’ light.

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2.15. Once Rescue 51 arrived, Mariner 85 climbed to a higher position to continue searching.

2.16. Many of the witnesses spoke of the difficulties faced by the searchers in finding any survivors in the water. It was a dark, moonless night, so much so that the pilots were unable to see the surface of the water. Only the head of a survivor would show above the water, so the chances of an aircraft finding such a person, even at low altitude, were very small (see the evidence of Mr Young at T463).

2.17. At about 8:15pm, the Whyalla Air Sea Rescue Squadron vessel ‘City of Whyalla’ departed Whyalla heading for the Yarraville Shoal area, arriving at about 9:15pm (Exhibit C62a). At around the same time, the State Emergency Service vessel ‘City of Port Pirie’ departed Port Pirie and proceeded to the search area (Exhibit C139).

2.18. The prawn boat Orao arrived at Yarraville Shoal at about 9:30pm (Exhibit C163a). The evidence of Inspector Kameniar indicates that by then, there were six vessels searching in a northerly direction, 100 metres apart at 10 knots, from Yarraville Shoal (Exhibit C119b). There were other vessels searching south of the Shoal as well.

2.19. At 9:56pm, the search fleet were directed to consolidate at the Yarraville Shoal light and a fully coordinated search pattern was then established.

2.20. By this time, searches of the coastline as far south as Cowell on the western side of Spencer Gulf and Port Broughton on the eastern side had also commenced.

2.21. As I have already mentioned, the search area was designated and this is illustrated by the diagrams appended to Inspector Kameniar’s statement (Exhibit C119b). The ‘splash point’ was estimated using information received from AusSAR about the movements of MZK, in particular its altitude, Mr Mackiewicz’s information in the radio transmissions, and estimates based on flying experience about the probable rate of descent of an aircraft operating without engines. From this information, it was calculated that the most appropriate search area was between 15 and 9 miles from Whyalla, on the Adelaide-Whyalla track (making due allowances for navigational discrepancies). It was also considered possible that the pilot may have turned the aircraft into the wind before ditching, or that he may have headed to the Yarraville Shoal being the only light in the area.

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2.22. At 10:59pm, a second RAAF P3C Orion, designated R251 was tasked to the area. This was far better equipped than the first Orion, having FLIR, illumination flares, and sophisticated electronic surveillance equipment. The RAAF also made a Blackhawk helicopter (Tester 913) available and it also took part in the search. The crew were equipped with ‘Night Vision’ goggles.

2.23. At 11:03pm, the crew of the prawn boat Nicole located an Emergency Position Indicating Radio Beacon (‘EPIRB’) in the water at a point about six miles south of the Yarraville Shoal light. It took some time to establish that the EPIRB was in fact a datum buoy dropped by a search aircraft some time earlier in order to ascertain tidal movements.

2.24. At 11:18pm, a can of Coca-Cola was also found by the crew of Nicole quite close to the point where the EPIRB was found. Nicole was still steaming north to Yarraville Shoal at the time.

2.25. As a result of these finds, the search vessels were formed into a line and searched south from Yarraville Shoal towards those positions.

2.26. At 11:41pm, a bag of netballs carrying the inscription ‘Wendy Olsen for Kay’ was located at a point north of where the Coca-Cola can was located. In fairly rapid succession, a piece of tan vinyl (12:14am), a piece of fibreglass (12:21am), a black leather folder containing airline tickets (12:33am), and a woollen seat cover (12:35am) were found in the same general area.

2.27. At 12:41am, the crew of the prawn boat Skandia found the body of a female person later identified as Mrs Wendy Olsen. The body was retrieved from the water.

2.28. At 12:51am, a male body, later identified as Mr Peter Olsen, was also located by the crew of the Skandia. This body was also retrieved.

2.29. Some of the crew of Skandia reported that they saw a third body in the water, but by the time Mr Olsen’s body was retrieved, the third body had disappeared. The skipper, Mr Keith Montgomery was unsure if he saw a third body (T971), since his position did not afford him as good an opportunity to observe the water as was available to his crewmen. His brother Mr Brian Montgomery was 100% sure (T988), and the other crewman, Mr Niki Mislov was 90% sure. His slight doubts were engendered by the

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conditions (T1002). I find on the balance of probabilities that there was a third body. I find that this was the body of Mr Christopher Schuppan. It has never been recovered.

2.30. By the time the bodies of Mr and Mrs Olsen were located, there were more than 50 vessels, seven helicopters and two fixed wing aircraft engaged in the search. Even so, the conditions were extraordinarily difficult. Mr Keith Montgomery said that it was so dark that without lights, they would have been unable to see the surface of the water (T984). He said that had the bodies been 10 or 15 metres further away from the boat, he doubted that he would have seen them (T983).

2.31. In those circumstances, it was due to the alertness and professionalism of the searchers that they were able to find anything at all, let alone as much as they did. It is a credit to all involved that so much was achieved.

2.32. After the two bodies were recovered, the search continued and more pieces of wreckage were found. The boats continued performing line searches throughout the night and for the next several days.

2.33. An analysis of the maps and diagrams tendered (Exhibits C119a&b, C115) discloses that on several occasions the search vessels passed over the site where the wreckage was eventually discovered, but no sign of it was found, and no further bodies were found in the water. On the next page is a map (Exhibit C115, slide 14) which illustrates the many different search areas covered:

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2.34. The air and surface searches continued throughout 1 June 2000. The AusSAR-directed air search was terminated at around 5:00pm that day. It was generally agreed that there was very little likelihood that there would be any survivors, and the prospects of making further significant sightings were also poor.

2.35. Responsibility for the ongoing search was transferred from AusSAR to SAPOL and accepted by SAPOL at 5:35pm on 1 June 2000.

2.36. On Friday 2 June 2000, the surface search continued on both sides of Spencer Gulf and at sea, looking mainly for oil slicks. This was continued on Saturday, and on Sunday 4 June, a crew from New South Wales Police arrived bringing side-scanning sonar equipment with them to assist with the search. This was fitted to the Fisheries SA vessel ‘Tucana’ and searching began that afternoon.

2.37. At about 2:30pm on Monday 5 June 2000, the Chief Pilot of Whyalla Airlines, Mr Kym Brougham was flying an aircraft over the search area and spotted what was later identified as an oil slick. He said that the sea surface was quite calm, as it often was at that time of day. He acknowledged the fact that the oil slick may not have been visible on previous days when the weather was rougher (T2574).

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2.38. This information was passed on to SAPOL, and the Tucana was directed to the coordinates provided by Mr Brougham. The side-scanning sonar was deployed and the wreckage was identified (see the statement of Mr Gryczeswski Exhibit C184a).

2.39. Divers from SAPOL Water Response Unit recovered five further bodies from the wreckage on 6 June 2000. The bodies were later identified as the pilot Ben Mackiewicz, and passengers Joan Gibbons, Teresa Pawlik, Neil Marshall and Richard Deegan. As I have said, no trace of Christopher Schuppan has ever been found.

2.40. The pilot Ben Mackiewicz was located in the pilot’s seat, which is the front seat on the left hand side of the plane, with the seatbelt fastened. Joan Gibbons was located in her seat, in the fourth row from the front, on the right hand side of the aircraft, with the seatbelt still fastened. Teresa Pawlik was located floating against the roof of the fuselage, towards the front of the aircraft. Neil Marshall was located in his seat, second from the front on the right side, with the seatbelt still fastened. Richard Deegan was located on his hands and knees on the floor of the aircraft, at the rear of the cabin, facing the tail section (Exhibit C162a).

2.41. The wreckage was identified and mapped over the ensuing days until, on 9 June 2000, the wreckage was lifted onto the salvage vessel ‘Andrew Wilson’. The remains of the aircraft were then handed over to the ATSB for scientific analysis.

2.43. Was there any confusion about the location of the ‘splash point’ as a result of Mr Mackiewicz’s radio transmissions? Did any such confusion hamper the search and rescue effort?

2.44. Mr Dunning, counsel for AusSAR submitted that the officials in charge of the air search correctly concluded that the initial call made by Mr Mackiewicz referred to the distance between the location of the aircraft and the coast of Whyalla, and that his second transmission referred to the distance to the Whyalla airport. Mr Kym Brougham submitted that in the second transmission Mr Mackiewicz was advising that the ‘splash point’ was 15 miles from Whyalla, and that he was not then advising them of his current location (T2569-2573).

2.45. It is clear from the evidence that there was an apparent inconsistency between the two transmissions made by Mr Mackiewicz. However, I do not consider that anything

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turns on the issue. It is apparent that the search was concentrated along the Adelaide-Whyalla track at a distance between 9 and 15 miles from Whyalla, which would have covered either interpretation of Mr Mackiewicz’s transmissions, and due allowance was made for drifting with the current. It is also clear from the evidence that the search areas covered the actual splash point. In those circumstances, I do not consider that the radio transmissions made by Mr Mackiewicz hampered the search and rescue effort.

2.46. Was the search and rescue operation timely, appropriately targeted and conducted with due professionalism and skill?

2.47. On the totality of the evidence before me, I find that the search and rescue operation was indeed timely and appropriately targeted. As I have already pointed out, the search patterns adopted, as is illustrated by the maps and diagrams before me, passed over the actual splash point, where the wreckage was eventually located. Despite the fact that the conditions for search and rescue were extremely adverse, the location of articles from MZK, and then the location of the bodies of Mr and Mrs Olsen, occurred within hours. This was an extraordinary achievement, in my opinion, having regard to the evidence that it was so dark that, without lights, the searchers would have been unable to see the surface of the water from their boats.

2.48. It is necessary to mention that it is a matter of great credit to all of the volunteers that they went into action so quickly, as soon as the ditching became known. The prawn fishermen, in particular, immediately ceased their fishing activities and began steaming north to the search area. All participants, both volunteers and salaried personnel, should be commended for the dedication and professionalism shown throughout the search and rescue effort.

2.49. The search and rescue was a very extensive one, involving multiple resources in relation to air, sea and land searching. The deployment of a wide variety of resources in an urgent situation, particularly where civilian resources are involved, must inevitably involve some confusion and miscommunication. However, on the evidence before me, it seems that any such difficulties were kept to a minimum, and that the search and rescue coordinators from both AusSAR and SAPOL did a remarkable job in adverse conditions. I find that the search and rescue operation was conducted with a high degree of professionalism and skill.

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3.1.1. Dr J D Gilbert, Forensic Pathologist, performed a post-mortem examination on the body of Ben Mackiewicz at the Forensic Science Centre on 7 June 2000. Mr Mackiewicz was identified by Forensic Odontologist Dr Jane Taylor (Exhibit C4a). Dr Gilbert attributed Mr Mackiewicz’s death to salt water drowning (Exhibit C164, p1).

3.1.2. Dr Gilbert noted a compound dislocation of the metatarso-phalangeal joint of Mr Mackiewicz’s left big toe, the main joint at the base of the big toe (T1141). Dr Gilbert speculated that Mr Mackiewicz may have been exerting pressure on the left rudder pedal of the aircraft at the time of impact (T1141), although he was by no means sure of that suggestion in view of further cross-examination (T1157).

3.1.3. There is no suggestion that Mr Mackiewicz was affected by drugs or alcohol at the time of the ditching (Exhibit C164, p5).

3.2.1. Dr Gilbert also performed a post-mortem examination on the body of Neil Marshall at the Forensic Science Centre on 7 June 2000. Dr Jane Taylor also identified Mr Marshall odontologically (Exhibit C6a). Dr Gilbert attributed Mr Marshall’s death to salt water drowning (Exhibit C164a, p1).

3.2.2. Dr Gilbert noted multiple fractures of Mr Marshall’s ribs on both sides, fractures of the tibia and fibula on both sides and minor bruising on the right side of the scalp. He commented that none of these injuries would have been fatal, but would have prevented Mr Marshall from exiting the aircraft (Ex C164a, p4). He added that the head injury may have rendered Mr Marshall unconscious (T1145).

3.3.1. Dr R A James, Chief Forensic Pathologist, performed a post-mortem examination on the body of Richard Deegan at the Forensic Science Centre on 7 June 2000. Dr Taylor identified Mr Deegan odontologically (Exhibit C1a). Dr James attributed Mr Deegan’s death to salt water drowning (Exhibit C167, p2).

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3.3.2. Dr James noted an abrasion on the point of the chin, and bruising to the lower left neck and below the right groin (Exhibit C167, p3). There were no fractured bones, and no damaged internal organs.

3.3.3. Dr James noted contusions (bruising) of the left temporal lobe of the brain, and evidence of haemorrhage in the region of the left basal nuclei. He commented that he did not believe that these injuries would have been fatal, but quite probably rendered Mr Deegan unconscious at the time of impact (T1183-84).

3.4.1. Dr James performed a post-mortem examination on the body of Joan Gibbons at the Forensic Science Centre on 7 June 2000. Dr Taylor identified Mrs Gibbons odontologically (Exhibit C225a). Dr James diagnosed the cause of Mrs Gibbons’ death as ‘multiple injuries including flail chest’ (Exhibit C167b, p2).

3.4.2. Dr James noted lacerations above the left eyebrow, bruising of the left cheek, lacerations down the midline of the chin, extensive bruising on the left side of the neck, on the lower abdomen and the left calf. All ribs were fractured on both sides both parasternally and laterally (flail chest), and the lungs had collapsed. There was no water in the airways.

3.4.3. Additionally, Mrs Gibbons had a fractured spine, pelvis, right tibia and fibula, left hand, left upper arm and larynx.

3.4.4. There were contusions to the lateral aspect of the left temporal lobe and the interior aspect of the left frontal lobe. Dr James said that these injuries would have been sufficient to render Mrs Gibbons unconscious upon impact. The chest injuries would have been fatal (T1186).

3.5.1. Dr James performed a post-mortem examination on the body of Teresa Pawlik at the Forensic Science Centre on 8 June 2000. Mrs Pawlik was identified odontologically by Dr Taylor (Exhibit C17a). Dr James attributed Mrs Pawlik’s death to salt water drowning (Exhibit C167d, p1).

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3.5.2. Dr James noted a laceration on Mrs Pawlik’s right shin, bruising on both shins, across the upper left thigh and on the left wrist. There was a fractured sternum but no other fractures. He noted obvious bruising of the left temple region, and this, coupled with the absence of swallowed water in the stomach, led him to suggest that Mrs Pawlik may have been unconscious upon impact (T1187).

3.6.1. Professor RW Byard, Forensic Pathologist, performed a post-mortem examination on the body of Peter Olsen at the Forensic Science Centre on 2 June 2000. Mr Olsen was identified visually by a near relative (Exhibit C12a, p1). Professor Byard diagnosed the cause of Mr Olsen’s death as salt water drowning (Exhibit C9a, p2).

3.6.2. Professor Byard found ‘minor’ bruising of the face, scalp and forearm, fracture of the right arm (ulna), right femur and right ribs, fractures of the right orbit with subarachnoid haemorrhage of the brain, congestion and oedema of the lungs with bilateral pleural effusions and bone marrow and fat emboli. He also found white foam in the mouth and upper airway (Ex C9a p2).

3.6.3. Professor Byard commented in his report:

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3.7.2. Dr Gilbert found scattered bruising and abrasions of the head, right arm, upper left thigh and back, left leg and right leg. There were multiple fractures of the left ribs both anti-laterally and posteriorly, and a compound fracture of the right tibia. He found white froth at the lips consistent with inhalation of seawater. He also found ‘widespread sloughing’ of the skin of the upper body which he suggested may have been caused by contact with aviation fuel (Exhibit C164b, p2), hydraulic fluid or brake fluid (T1166).

3.7.3. Dr Gilbert said that the injuries sustained by Mrs Olsen were ‘relatively minor and survivable’ (T1148). However, her ability to swim or tread water would have been impaired by the rib and leg fractures.

3.7.4. Dr Gilbert had some difficulty explaining the fact that Mrs Olsen’s jeans were found by the SAPOL divers attached to the right wing of the aircraft on the seabed (see the statement of Constable Brownridge, Exhibit C58a, p3). The jeans were relatively undamaged. There was some damage to the knee and shin areas, which would correspond with Mrs Olsen’s leg injuries (Exhibit C164c). Dr Gilbert thought it was unlikely that Mrs Olsen would have removed the jeans manually after impact, in view of the leg injuries and other difficulties, and the lack of damage made it unlikely that they were torn off during impact (T1150). The issue remains a mystery.

3.7.5. Dr Gilbert thought that the bruising to Mrs Olsen’s scalp (front and rear) was ‘very minor’. He said that a loss of consciousness upon impact was ‘possible but by no means certain’ (T1153).

3.8.1. I have already mentioned that Mr Schuppan’s body has never been recovered. Two of the crewmen of the Skandia saw a third body in the water, and I have found that this was the body of Mr Schuppan. No specific injuries were noticed at that time.

3.8.2. It is not possible to find the precise cause of Mr Schuppan’s death in view of that. In particular, it is not possible to find whether he survived the impact or not.

3.8.3. In those circumstances, I find that Mr Schuppan died from undetermined causes.

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3.9. Survivability of Impact I heard evidence from Dr Jeffrey Brock, who is a Consultant and Specialist Adviser in Aviation Medicine to the Australian Defence Force. He formerly served in the Australian Army, and holds the rank of Colonel. From 1995 to 1998 he was the Acting Director of Aviation Medicine for the Civil Aviation Safety Authority (‘CASA’). Dr Brock has been trained in altitude medicine, extreme weather survival, aviation underwater escape, and has been an instructor in survival techniques on land and in the ocean. He has participated in numerous helicopter rescues at sea and subsequent resuscitation of survivors. He holds numerous specialist medical qualifications, and is a qualified Army pilot in both fixed wing and helicopter aircraft. Dr Brock is uniquely qualified to explain what happened when MZK ditched in Spencer Gulf on 31 May 2000.

3.10. Dr Brock said that it would have been ‘exceptionally difficult’ for the pilot of MZK to have ditched the aircraft in a completely level altitude, having regard to the darkness of the night, the lack of a visible horizon, the emergency situation, and the low speed which would have made the aircraft more difficult to handle (T1202). The ATSB examination of the wreckage indicated that the right wing struck the sea surface first. At that time, the aircraft was slightly nose-down, and wings-level or banked slightly right. The impact tore off the right wing and left a large hole in the right side of the fuselage. The aircraft would have slewed violently to the right, and when the front hit the water, it was severely deformed inwards. The cabin would have instantly filled with water. The impact, and the inrushing water, forced the doors, most windows, and the emergency escape hatch out of their frames. Both engines were torn off (Exhibit C97, p22).

3.11. The report of the ATSB (Exhibit C97) contains information about 13 instances where Piper Navajo and Piper Chieftain aircraft have ditched into water since 1984 (p128-9). Remarkably, in 10 of these instances, all on board survived. As to the other three, in one instance a passenger had a cardiac arrest, in the second instance, seven of the eight people on board were able to exit. In a third instance, the aircraft was substantially damaged, and the pilot, as here, was found deceased, still strapped in his seat.

3.12. Dr Brock said that the most significant factor which enabled survival in the other 10 cases was that the aircraft was ditched at the slowest possible speed, and was basically

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undamaged after ditching, thereby allowing it to float for a short period giving the occupants the opportunity to escape.

3.13. Once MZK was in the water, the visibility would have been zero, in other words, the occupants would not have been able to see a finger a few inches from their eyes. This, combined with the impact of the water swirling around, the cold temperature, and the loss of orientation due to interference with the vestibular mechanism in the inner ear, would have rendered the passengers almost helpless (T1202).

3.14. Dr Brock explained that the force of impact with the water would have been ‘very significant’. The forces involved caused significant injuries as the passengers ‘flailed’ about inside the cabin. Several had multiple rib fractures, which would have hindered them from holding their breath and extracting themselves. Similarly, the passengers with leg and pelvic fractures would have been impeded from escaping (T1203-4).

3.15. Dr Brock thought that all of the passengers would have suffered ‘concussion’, in other words their senses would have been stunned, and they probably suffered at least partial loss of consciousness, and total unconsciousness in several cases. In that case, they would have been unable to protect their airway, and drowning would have quickly ensued (Exhibit C168, p4).

3.16. ‘Cold Shock’ Dr Brock said:

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3.19. In relation to Mrs Olsen’s jeans, Dr Brock said that it is most probable that they were removed forcibly due to fouling with the fuselage. He said that it is a ‘fascinating phenomenon’ in aircraft accidents for people to involuntarily lose their clothing. He thought it was improbable that Mrs Olsen removed them voluntarily either before or after the impact (T1223).

3.20. Dr Brock said that lifejackets are potentially valuable in aircraft accidents where passengers survive the ditching, but their availability in this case was unlikely to have changed the outcome in view of the injuries, the difficulties involved in putting them on, and the fact that they may have made egress from the aircraft even more difficult (T1224).

3.21. Dr Brock’s conclusions were as follows:

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3.25. Did any of the occupants of MZK survive the impact with the water?

3.26. I accept the evidence of Dr Brock, and find, on the balance of probabilities, that:

• All of the occupants of MZK died ‘very quickly’ when the aircraft impacted with the water;

• If any of the deceased did not die instantly, they were rendered unconscious or completely incapacitated either through cerebral concussion, ‘cold shock’ or both, to the extent that they were unable to protect their airway and died quickly through drowning;

• The serious injuries sustained by a number of the deceased would have substantially reduced their ability to escape from the wreckage, even if they did survive the impact.

3.27. Would their chances of survival have been enhanced if they had been wearing lifejackets, or there were other floatation aids including a life-raft, available?

3.28. Having regard to the conclusions outlined above, I do not consider that the wearing of lifejackets, or the presence of other floatation aids including a life-raft, would have materially improved the chances of survival for any of the occupants of MZK.

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4.1. According to the final ATSB report, Exhibit C97, Whyalla Airlines Pty Ltd was incorporated in South Australia on 22 October 1987, and was issued with an Air Operators Certificate (AOC) on 24 January 1990. The AOC permitted regular passenger transport (RPT) services over various routes, including Adelaide to Whyalla, as well as charter operations.

4.2. On 27 March 1995, Whyalla Airlines was issued with a Certificate of Registration for VH-MZK. The aircraft had originally been built in the United States of America in 1981, and a Certificate of Airworthiness, which is normally issued around the time an aircraft is imported into Australia, was issued on 2 June 1988.

4.3. By 31 May 2000, Whyalla Airlines owned four Piper Chieftains and several other aircraft. It employed six pilots, including the Chief Pilot and one of the Founding Directors of the Company, Mr Kym Brougham. The other Founding Director was his brother, Mr Chris Brougham.

4.4. Mr Kym Brougham is a highly qualified and experienced pilot. He had accumulated approximately 10,000 hours flying experience by 31 May 2000. He has participated in national and international air races, and he is qualified as an aerobatics pilot as well. In 1995, CASA approved him as a ‘Check and Training Pilot’.

4.5. Whyalla Airlines has had a troubled relationship with CASA over the years. A brief chronology of some of the relevant events is as follows:

• On 29 June 1997, MZK was landed in a paddock near Wudinna after running short of fuel. The pilot’s licence was suspended and subsequently reinstated after an examination;

• After that incident CASA audited Whyalla Airlines and identified a substantial number of issues of concern;

• On 6 September 1997, Mr Kym Brougham was involved in an incident in which it was alleged that he failed to comply with Air Traffic Control instructions. CASA suspended his Check and Training Pilot approval and his Command Instrument Rating on 12 September 1997;

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• On 27 October 1997, a report to the CASA Board identified a number of difficulties with Mr Kym Brougham, most of them related to his uncooperative and recalcitrant attitude. However, the ATSB report noted:

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• On 12 April 2000, the employment of Mr David Usher was terminated. Mr Usher had worked at Whyalla Airlines since its inception in 1990. Upon his termination, Mr Brougham resumed his position as Chief Pilot;

• Exhibit C97 further notes: