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Response to Coroner’s findings – AO-2008-11

The ATSB notes that on 2 May 2013 the Deputy State Coroner, Magistrate P. A. McMahon, handed down his findings in the inquest into the deaths of the two occupants of a Cessna 152 aircraft, registered VH-FMG, following a midair collision with a Liberty XL2 aircraft, registered VH-XLY.

The Coroner’s findings were substantially in accordance with those of the ATSB. The Coroner did not make any recommendations arising out of his findings.

The factors identified in the report and the Coroner’s findings highlight the limitations with visual flight procedures and the need for vigilance at all times, particularly in the vicinity of other aircraft and in potentially high traffic areas.

Cooperation with Coroners

Australian Transport Safety Bureau (ATSB) investigations are conducted with the objective of providing findings that can be used to improve transport safety in the future. Coronial Inquests are a separate process to the ATSB investigation and they are usually supported by their own investigation and brief of evidence. However, as Inquests also have the objective of seeking to prevent a death occurring again, the ATSB provides cooperation through the explanation of the ATSB's findings in its report. 

The ATSB appreciates the interest of Coroners in working with the ATSB in the interests of improving safety. The Coroner formulated his findings and recommendations independently of the ATSB. However, the ATSB supports the coronial process and in the interests of ensuring that safety information is made available to the broadest audience the ATSB is making this publication.


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