Deceased
AA
Demographics
unknown
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2016-03-21
Finding date
2018-11-30
Cause of death
exact cause undetermined; death resulted from intentional crash of light aircraft into ocean
AI-generated summary
A pilot died by intentionally crashing a light aircraft into the ocean. The exact cause of death remains undetermined. The inquest revealed concerns about medical fitness assessment for pilots. Key clinical lessons include the importance of comprehensive health screening for safety-critical roles and the need for better information sharing between aviation authorities and health systems regarding medication use and mental health status. Recommendations focus on improving reporting mechanisms for medical fitness concerns and enabling CASA access to PBS/MBS prescribing data to identify potentially unfit pilots.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the disappearance and suspected death of AA Hearing dates: 22-24 October 2018 (Byron Bay Local Court) Date of findings: 30 November 2018 Place of findings: NSW State Coroner’s Court, Glebe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – missing person, manner and cause of death, self-inflicted death, death in light aircraft File numbers: 2016/00099433 Representation: Mr A Creagh (Sergeant) Advocate assisting the Coroner Mr M Lynch instructed by Mr J Vijayaraj, Avant Law for Dr G Pearson and Dr James Boyd Mr J Rule for the Civil Aviation Authority (CASA) Mr J Priestly SC instructed by Ms B Crane, Crane Paskins Law for the family Non Publication order The detailed reasons for these findings are subject to a non-publication order pursuant to section 75 of the Coroners Act 2009 (NSW).
Findings: The findings I make under section 81(1) of the Coroners Act 2009 (NSW) are: Identity The person who died was AA.
Date of death He died on March 21 2016.
Place of death He died in the Pacific Ocean, approximately 10-15 kilometres northeast of Cape Byron NSW.
Cause of death His exact cause of death remains undetermined.
Manner of death His death was intentionally self-inflicted. He died as a result of crashing a small aircraft into the ocean.
Recommendations pursuant to section 82 Coroners Act 2009 I make the following recommendations to the Civil Aviation Safety Authority (CASA).
That CASA give consideration to seeking an amendment of the indemnity currently provided in regulation 67.140 of the Civil Aviation Safety Regulations 1998 (CASR) to provide indemnification for a wider range of good faith reporting in relation medical fitness by a broader range of persons.
That CASA undertake to liaise with the Commonwealth Minister for Human Services to determine whether there is basis upon which it can appropriately share Pharmaceutical Benefits Scheme (PBS) prescribing information and Medical Benefits Scheme (MBS) information relating to persons who apply for the issue of a medicate certificate under Part 67 of the CASR.
Magistrate Harriet Grahame Deputy State Coroner 30 November 2018 NSW State Coroner’s Court, Glebe
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