EXECUTIVE SUMMARY
On the evening of 17 October 2003, an air ambulance Bell 407
helicopter, registered VH-HTD (HTD), being operated under the
'Aerial Work' category, was tasked with a patient transfer from
Hamilton Island to Mackay, Queensland. The crew consisted of a
pilot, a paramedic and a crewman. Approximately 35 minutes after
the departure of the helicopter from Mackay, the personnel waiting
for the helicopter on the island contacted the Ambulance
Coordination Centre (ACC) to ask about its status. ACC personnel
then made repeated unsuccessful attempts to contact the helicopter
before notifying Australian Search and Rescue (AusSAR), who
initiated a search for the helicopter. AusSAR dispatched a BK117
helicopter from Hamilton Island to investigate. The crew of the
BK117 located floating wreckage, that was later confirmed to be
from HTD, at a location approximately 3.2 nautical miles (NM) east
of Cape Hillsborough, Queensland. There were no survivors.
Following 12 days of side scan array sonar searches, underwater
diving and trawling, the main impact point and location of heavy
items of wreckage were located. The wreckage was recovered and
examined at a secure on-shore location.
Although the forecast weather conditions did not necessarily
preclude flight under the night Visual Flight Rules (VFR), the
circumstances of the accident were consistent with pilot
disorientation and loss of control during flight in dark night
conditions. The effect of cloud on any available celestial
lighting, lack of a visible horizon and surface/ground-based
lighting, and the pilot's limited instrument flying experience, may
have contributed to this accident. Although not able to determine
with certainty what factors led to the helicopter departing
controlled flight, the investigation determined that mechanical
failure was unlikely.
The circumstances of the accident combined most of the risk
factors known for many years to be associated with helicopter
Emergency Medical Services (EMS) accidents, such as:
Pilot factors
- the pilot was inexperienced with regards to long distance over
water night operations out of sight of land and in the helicopter
type
- the pilot did not hold an instrument rating and had limited
instrument flying experience
- the pilot was new to the organisation and EMS operations.
Operating environment factors
- the accident occurred on a dark night with no celestial or
surface/ground-based lighting
- the flight path was over water with no fixed surface lit
features
- forecast weather in the area of the helicopter flight path
included the possibility of cloud at the altitude flown.
Organisational factors
- a number of different organisations were involved in providing
the service
- the operation was from a base remote from the operator's main
base
- actual or perceived pressures may have existed to not reject
missions due to weather or other reasons
- an apparent lack of awareness of helicopter EMS safety issues
and helicopter night VFR limitations
- divided and diminished oversight for ensuring safety
- no single organisation with expertise in aviation having
overall oversight for operational safety.
As a result of the investigation, safety recommendations were
issued to the Civil Aviation Safety Authority recommending: a
review of the night VFR requirements, an assessment of the benefits
of additional flight equipment for helicopters operating under
night VFR and a review of the operator classification and/or
minimum safety standards for helicopter EMS operations.
Following the accident, the Queensland Department of Emergency
Services took initiatives to implement:
- increased safety standards in the Generic Service Agreements to
Community Helicopter Providers (CHP) to include increased pilot
recency and training requirements, a pilot requirement for a
Command Instrument Rating, crew resource management training, a
Safety Management System and a Safety Officer
- the recommendations of the reviews associated with the
aeromedical system/network
- the establishment of a centralised clinical coordination and
tasking of aeromedical aircraft and helicopters for Southern
Queensland, including all CHP state-wide through a centre in
Brisbane, with a parallel system planned for all Northern
Queensland by July 2005
- the establishment of a requirement for a safe arrival broadcast
for flights of less than 30 minutes duration and the nomination of
a SARTIME for all flights
- the revision of the standard operating procedures for
helicopter emergencies to attempt to establish communication with
an aircraft when lost for a maximum 5 minute period, then
immediately contacting AusSAR
- the establishment of a requirement for CHP to provide updated
contact/aircraft details on a bi-annual basis and amend the
standard operating procedures containing this information
accordingly
- a requirement for CHP operations to ensure sufficient celestial
lighting exists for night VFR flights to maintain reference to the
horizon.
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