Aviation safety investigations & reports

Operational event - Bell Helicopter 412, VH EMZ, 132 km west of Horn Island, Qld, 9 November 2009

Investigation number:
Status: Completed
Investigation completed


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At about 1500 Eastern Standard Time on 9 November 2009, a Bell Helicopter Company 412 helicopter, registered VH‑EMZ and operating as call sign 'Rescue 700', departed Horn Island Aerodrome, Queensland to rendezvous with a container ship located about 132 km to the west of Horn Island. The purpose of the flight was to evacuate an ill crew member and transfer him to hospital.

Prior to arrival, the flight crew had been advised that the patient would need to be recovered via rescue winch from the ship's forecastle. Approaching overhead the winching area, with the rescue crew officer (RCO) and paramedic being lowered by the winch and about 6 m above the deck, the pilot lost sight of the ship. Shortly after, the helicopter began drifting back towards a mast that was located on the forecastle. Despite assistance from the winch operator to re-establish the hover, the pilot was unable to arrest the helicopter's movement and the winch cable became fouled on the foremast while the helicopter continued to drift rearwards. The winch cable separated and the paramedic and RCO fell about 10 m to the ship's deck, seriously injuring both personnel.

The investigation identified that the requirement to confirm adequate hover reference existed overhead an intended winch area, before deploying personnel on the winch, was left to the pilot's discretion. In this instance the pilot, despite his extensive experience, did not identify the possibility of losing sight of the ship, and therefore the necessary hover reference.

Following the occurrence, the helicopter operator issued an instruction to aircrew emphasising the importance of ensuring that adequate hover reference exists during winching operations. The helicopter operator also commenced a review of its operations manual to ensure that it provides sufficient procedural guidance for winching operations and commenced the development of company-wide aviation risk management training that will commence in early 2011.

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Safety Issues

Go to AO-2009-068-SI-01 - Go to AO-2009-068-SI-02 -

Requirement to confirm hover reference

The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.

Safety issue details
Issue number: AO-2009-068-SI-01
Who it affects: Helicopter operator
Status: Adequately addressed

Lack of formal task risk management

There was no formal risk assessment process in use at the operator’s Horn Island base.

Safety issue details
Issue number: AO-2009-068-SI-02
Who it affects: Helicopter operator
Status: Adequately addressed
General details
Date: 09 November 2009   Investigation status: Completed  
Time: 1550 EST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Horn Island Aerodrome west 132 Km    
State: Queensland   Occurrence type: Airframe - Other  
Release date: 21 January 2011   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Bell Helicopter Co  
Aircraft model 412  
Aircraft registration VH-EMZ  
Serial number 33001  
Type of operation Medical Transport  
Sector Helicopter  
Damage to aircraft 406  
Departure point Horn Island, Qld  
Destination Horn Island, Qld  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 2176.6 8125
  Crew Passenger Ground Total
Serious: 2 0 0 2
Total: 2 0 0 2
Last update 03 April 2020