Aviation safety issues and actions

Ambulance Service of NSW specialty casualty access team operating procedures

Issue number: AO-2011-166-SI-01
Who it affects: Ambulance Service of NSW specialty casualty access teams
Issue owner: Ambulance Service of NSW
Transport function: Aviation: Other
Background: Investigation Report AO-2011-166
Issue release date: 16 May 2013

Safety issue description

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.

Proactive Action

Action number: AO-2011-166-NSA-042
Action organisation: Ambulance Service of New South Wales
Date: 16 May 2013
Action status: Closed

The Ambulance Service of New South Wales (ASNSW) advised of the following action in response to this accident:

  • Flying staff instructions have been issued reinforcing that procedures must be in accordance with the operations manual, and equipment used for its intended purpose.
  • Winching procedures have been reviewed and revised procedures, particularly relating to the position of the aircraft before attaching to the winch, have been issued.
  • A mandatory winch review process has been introduced to ensure winching missions are conducted in accordance with procedures and to enable the detection of issues and potential scope creep.
  • Cameras are being installed on helicopter rescue winches to facilitate training and mission review.
  • A special casualty access team (SCAT) educator position has been created within the Special Operations Unit to focus on SCAT training development and certification.

Action taken by the operator

Immediately following the accident, the helicopter operator, with the agreement of ASNSW, verbally briefed all crews that ‘combined roping techniques’ were not to be carried out. That was followed by the issue of a flying staff instruction on 28 December 2011 that banned the use of such techniques. This ban remains in place and has been incorporated into the operator’s operations manual.

Last update 02 December 2019