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The ATSB is pleased that Coroner Hope has adopted much of the material in ATSB's final report on the tragic VH-SKC accident and stated that "ultimately it appears that the ATSB report was based on a substantial amount of scientific investigation and many issues were diligently pursued" (p21). The Coroner also cites (eg p6) the evidence of Dr Brock who was a consultant to the ATSB and part of the ATSB investigation team.

The Coroner concludes (p55) that: "It appears that the aircraft was unpressurised for a significant period of its climb and for the subsequent flight. While it is possible that the occupants died as a result of hypobaric hypoxia, I cannot exclude the possibility that some unknown and unidentified toxic fumes caused their incapacity and death".

The ATSB final report (p29) conclusion was very similar: "Due to the limited evidence available, it was not possible to draw definitive conclusions as to the factors leading to the incapacitation of the pilot and occupants of VH-SKC.� The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen."

ATSB reported that testing established that carbon monoxide and hydrogen cyanide were unlikely to have been factors - there was no evidence of another toxic substance.

The WA Coroner has also supported the safety recommendations that the ATSB had either already made or had proposed in submissions and that is very welcome.

While an investigation report into a remote 440km/h impact crash and subsequent fire which destroys much of the evidence is always open to criticism, based on its initial reading of the 75 page report, the ATSB does not accept the Coroner's criticisms concerning the ATSB.

The ATSB cannot prepare an investigation report that is suitable for an adversarial legal process because this is contrary to its 'no blame' legislation based on Annex 13 to the Chicago Convention. The proposal to share investigation information with those who may use it in blame proceedings also has limitations. The Coroner, police or regulators could have undertaken their own parallel inquiries for such purposes.

The ATSB investigation report was prepared to satisfy the Bureau's Commonwealth legislation (which it did), not to satisfy the WA Coroner or any other parties who may have had an agenda related to blame or litigation. The ATSB nevertheless provided extensive expertise at its expense to assist the Coroner during the Inquest.

The Coroner criticises the ATSB for deficiencies and delays with the forensic tests done in Brisbane - however, coroners not ATSB have control/powers with respect to autopsies and forensic testing. The ATSB relies on coroners to authorise the conduct of such testing and has no powers to do so itself. Improving cooperation with coroners in relation to sharing evidence is a key element of a memorandum of understanding currently under discussion with coroners across Australia. Coroner Hope's final remark (p75) that "The various Coronial jurisdictions clearly have a role to play in this context to ensure that sensible co-operation can take place." is welcome.

The Coroner's criticism (pp 9-10) of the letter written by the ATSB Executive Director to the Coroner on 26 March 2002 (copy attached) is noted. The letter was written and sent only after the Executive Director had obtained legal advice that it would be appropriate to do so given that the Inquest was in the nature of an inquiry.

The Bureau is deeply concerned at the personal criticism directed towards its senior Perth-based investigator (pp17ff). It does not agree that there is evidence to conclude that the investigator "demonstrated an unfortunate lack of compassion for grieving families who were searching for answers." The investigator had the difficult job of finalising the investigation report after several staff had resigned/retired from the Bureau and had to face aggressive cross-examination.

The Coroner refers to the Transport Safety Investigation Bill 2002 that is before the Commonwealth Parliament and suggests that this may need to be amended. This Bill has been extensively discussed with representatives of the Coroners and their suggestions have been incorporated. There is positive and helpful ongoing discussion with Coroners on draft regulations and a future memorandum of understanding.

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Last update 01 April 2011