Jump to Content

Inquest

Summary

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.

 
Share this page Comment