Investigation number
AO-2009-068
Occurrence date
Location
Horn Island Aerodrome west 132 Km
State
Queensland
Report release date
Report status
Final
Investigation level
Systemic
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence category
Airframe - Other
Occurrence class
Accident
Highest injury level
Serious

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 6m 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 10m 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.

Aircraft Details
Manufacturer
Bell Helicopter Co
Model
412
Registration
VH-EMZ
Serial number
33001
Operation type
Medical Transport
Sector
Helicopter
Departure point
Horn Island, Qld
Destination
Horn Island, Qld