In preparing the aircraft for the next flight, the pilot turned on the valve for the medical oxygen system. Witnesses then heard a loud bang and gas escaping as the pilot was thrown clear of the aircraft, which caught fire and burned. The pilot received significant ear and chest injuries in the blast.
The Bureau recommends that the Civil Aviation Safety Authority:
(i) conduct an audit of all emergency medical service oxygen-equipped aircraft to determine the equipment standards in Australian registered aircraft;
(ii) issue design standards for emergency medical service oxygen equipment installations;
(iii) issue maintenance requirements for emergency medical service oxygen equipment;
(iv) provide surveillance requirements for emergency medical service oxygen equipment in the Aviation Safety Surveillance Program;
(v) ensure flight crew are provided with appropriate instructions in the use of emergency medical service oxygen equipment in aircraft flight manuals or company operations manuals; and
(vi) provide educational material to the aviation industry on the installation, operation and maintenance requirements of emergency medical service oxygen systems.'