ATSB Response to Findings
On 16 September 2014, NSW Deputy State Coroner Forbes released findings into the fatal helicopter winching accident involving an Agusta Westland AW139 Helicopter (VH-SYZ) 16km WSW of Wollongong airport which occurred on 24 December 2011. The accident was the subject of ATSB Investigation AO-2011-166.
The ATSB summary explains that a paramedic died during the retrieval operation for an injured person at the base of waterfall. The paramedic and the injured person swung into rocks after coming off a ledge during the retrieval.
With respect to findings of fact, the Coroner was unable to make a finding as to how the paramedic and injured person came off the ledge, with some uncertainty as to the evidence at the inquest. For the reasons set out in its report, the ATSB found that the paramedic and injured person were accidentally pulled from the ledge in low light conditions.
There were no significant differences in views between the findings of the Coroner and the findings of the ATSB with respect to the manner in which safety could be improved. This included the ATSB’s key safety message that dangers associated with modifying established procedures in order to complete a difficult, and potentially not previously experienced, rescue task. Specifically, the use of procedures that are neither documented nor trained for by crews makes it difficult to identify hazards and manage the related risks.
The Coroner canvassed additional recommendations relating to the coordination and planning of the rescue which can be reviewed in the Coroner’s findings.
ATSB investigations and coronial investigations
Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident involving VH-SYZ.
The ATSB's report can be downloaded by clicking on the link: Final Report.
The Coroner’s findings can be downloaded from the NSW Coroner’s Court website.
On 24 December 2011 an Agusta Westland AW139 helicopter departed Bankstown Airport in response to an emergency personal locator beacon in the Budderoo National Park, about 16 km west-south-west of Wollongong Airport, New South Wales. On board the helicopter were a pilot, an air crewman, two paramedics and a doctor.
On locating the emergency beacon, the crew identified a seriously injured person on a rock ledge near the bottom of a waterfall. They assessed that it would not be possible to winch emergency personnel directly to the patient. In response, the crew landed at a nearby clear area and devised a plan to access and retrieve the patient. During the retrieval, the patient and one of the paramedics hit rocks at the base of the waterfall. The paramedic died from the impact. The patient was subsequently transported to hospital for treatment.
What the ATSB found
The Australian Transport Safety Bureau (ATSB) identified that, due to reduced light, the paramedic and patient were accidentally pulled from the rock ledge as the helicopter was manoeuvred in preparation to lift them out using its winch.
The ATSB also identified several safety issues relating to training and use of the helicopter’s lighting and radios. A number of organisational issues that could adversely influence the way crews act in similar circumstances were also identified.
What has been done as a result
In response to this accident, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training. Finally, proactive safety action was taken by these parties in the areas of general crew training and operational risk assessment.
This accident highlights the dangers associated with modifying established procedures in order to complete a difficult, and potentially not previously experienced, rescue task. Specifically, the use of procedures that are neither documented nor trained for by crews makes it difficult to identify hazards and manage the related risks.
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The accepted use of procedural adaptation by special casualty access team paramedics, and the past success of rescues that involved adapted techniques, probably led to the retrieval procedure that was used on the night.
|Who it affects:||Ambulance Service of NSW specialty casualty access teams|
The increased capability of helicopters and rescue winches enabled the conduct of complex winch rescues beyond the current level of winch training and procedural support associated with the traditional special casualty access team clinical access role, leading to an increased risk that hazards associated with complex rescues were not identified.
|Who it affects:||Ambulance Service of NSW specialty casualty access team|
Ambulance rescue crewmen did not conduct any night winching recency training, resulting in an increased risk of unfamiliarity with night winching procedures and their associated hazards.
|Who it affects:||Special casualty access training|
The helicopter’s lighting set-up did not allow independent control of the searchlights by the pilot using the switches on the flight controls, as required by the operations manual and Civil Aviation Order 29.11, and increased the risk of loss of hover reference and distraction in the case of a single light failure or switch mis‑selection by a pilot.
|Who it affects:||The helicopter operator|
|Date:||24 December 2011||Investigation status:||Completed|
|Time:||2039 ESuT||Investigation level:||Systemic - click for an explanation of investigation levels|
|Location:||16 km WSW of Wollongong Airport|
|State:||New South Wales||Occurrence type:||Cabin injuries|
|Release date:||16 May 2013||Occurrence category:||Accident|
|Report status:||Final||Highest injury level:||Fatal|
|Aircraft manufacturer||Agusta, S.p.A, Construzioni Aeronautiche|
|Type of operation||Aerial Work|
|Damage to aircraft||Nil|
|Departure point||Bankstown Airport, NSW|