AUSTRALIA'S air safety and crash investigation systems failed at almost every level when an innocent pilot was falsely blamed for a fatal Mary Valley plane crash, a Gympie Coroner has found.
Coroner Maxine Baldwin's findings, delivered in Maroochydore on Monday, were scathing of processes adopted by authorities ranging from Gympie police to the Civil Aviation Safety Authority.
Mrs Baldwin found too many people had accepted the word of the aircraft's manufacturer, who had lied about its weight to minimise registration costs.
Police had relied too heavily on investigations by others, the coroner found. Those others had not carried out good enough investigations.
One of those who accepted the manufacturer's advice was an engineer who had modified the aircraft's balance without knowing its true weight - about 200kg more than that shown on registration documents.
Contrary to earlier findings, Mrs Baldwin said the plane was malfunctioning at the time of the crash and "the pilot (Barry Joseph Uscinski) could not reasonably have recovered the aircraft at such low altitude in the circumstances".
Mrs Baldwin found Dr Uscinski died from multiple injuries when his craft, an 80% scale Spitfire replica, crashed on October 22, 2010, on approach to Gympie's Kybong aerodrome.
Mrs Baldwin was scathing about the evidence of aircraft manufacturing chief executive Michael O'Sullivan, of Supermarine Aircraft Pty Ltd.
She said he had covered up the aircraft's excessive weight with "knowingly falsified documents" so he could register the plane under the less stringent requirements of Recreational Aviation Australia (RA-Aus), which administered registrations of ultra light and light sports aircraft.
Mrs Baldwin recommended RA-Aus introduce a system of random checks on registration information and impose exemplary punishment on Mr O'Sullivan.
CASA should review its expectations of RA-Aus and conduct random audits. And police should improve procedures to ensure better security for exhibits, she also recommended.