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What happened

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.

Safety message

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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Safety issues

AO-2011-166-01 - AO-2011-166-02 - AO-2011-166-03 - AO-2011-166-04 -  

Ambulance Service of NSW specialty casualty access team operating procedures

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.

Issue number:AO-2011-166-01
Who it affects:Ambulance Service of NSW specialty casualty access teams


Role of the Ambulance Service of NSW specialty casualty access team

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.

Issue number:AO-2011-166-02
Who it affects:Ambulance Service of NSW specialty casualty access team


Night winching recency training

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.

Issue number:AO-2011-166-03
Who it affects:Special casualty access training


External lighting in the operator’s AW139 helicopters

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.

Issue number:AO-2011-166-04
Who it affects:The helicopter operator


General details

Date: 24 Dec 2011 Investigation status: Completed 
Time: 2039 ESuT Investigation type: Occurrence Investigation 
Location   (show map):16 km WSW of Wollongong Airport Occurrence type:Cabin injuries 
State: NSW Occurrence class: Operational 
Release date: 16 May 2013 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 

Aircraft details

Aircraft manufacturer: Agusta, S.p.A, Construzioni Aeronautiche 
Aircraft model: AW139 
Aircraft registration: VH-SYZ 
Serial number: 31155 
Type of operation: Aerial Work 
Damage to aircraft: Nil 
Departure point:Bankstown Airport, NSW
Destination:Sydney, NSW
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Last update 25 March 2014