A pilot flying at night without the required equipment or training became disorientated and crashed a helicopter into the sea, killing five people, a NSW inquest has concluded.
Coroner Carolyn Huntsman probed the circumstances that led to the "Huey" helicopter disappearing near Newcastle about 6.30pm on September 6, 2019.
Queenslanders Jamie Ogden and Grant Kuhnemann, NSW couple Jocelyn Villanueva and Gregory Miller, and pilot David Kerr were all believed to have been killed upon impact.
Only two bodies - those of Mr Kuhnemann and Mr Miller - were recovered.
In findings released on Wednesday, Ms Huntsman ruled pilot error and misadventure caused the fatal crash.
Mr Kerr was piloting the aircraft from Archerfield Airport in Brisbane to relocate it to Sydney for new part-owners Mr Miller and Ms Villanueva.
Mr Ogden and Mr Kuhnemann were just along for the ride.
The coroner found the flight - originally planned to take off mid-morning - had been delayed by several hours and took off around 2.30pm, only three-and-a-half hours before last light.
The weather was also becoming increasingly unfavourable - windy and smoky.
"Others recognised how windy the weather was and were 'shocked' that an aircraft would be flying in those conditions," Ms Huntsman wrote in her findings.
"A reasonable and prudent course would have been to have suspended the flight and continued the next day.
"However, it may have been that David Kerr was experiencing 'Plan Continuation Bias'."
A friend of Mr Miller, who was texting him throughout the flight, in the late afternoon raised concern that twilight was approaching.
Then asked if the pilot was night visual rules qualified, Mr Miller replied "David is".
He wasn't.
Within 10 minutes of last light he appeared to lose control of the aircraft and it disappeared from the radar.
"The manner of death was pilot error due to the pilot flying at night when not trained or qualified to do so, and in weather that was increasingly unfavourable for flying and particularly night flying," Ms Hunstman ruled.
"The cause of the crash was the spatial disorientation experienced by the pilot when he proceeded with the flight after last light."
The inquest also raised issues in relation to the mental health of the pilot and non-disclosure by Mr Kerr of medical conditions and medications, but Ms Huntsman said there was no evidence they played any role in the crash.
She declined a suggestion she formally recommend the implementation of mandatory reporting obligations for doctors treating commercial pilots with notifiable drugs or for conditions that may affect their ability to manage an aircraft.
At the inquest on Tuesday, the families of the four passengers killed were scathing of Mr Kerr.
Gregory Miller's mother said she was seeking legal advice as to whether Mr Kerr had sufficiently discharged his responsibilities as pilot.
The family of Mr Miller's partner - Jocelyn Villanueva - similarly called Mr Kerr reckless.
"Joc and Greg tragically trusted the ability of a pilot ... who did not put the safety of his passengers first and foremost," they said in a statement read to the court.
