ATSB Response to Findings

On 4 September 2015, Coroner Stella Struthridge of the Coroner’s Court of Victoria, without holding an inquest, released findings into the 2013 fatal helicopter winching accident involving a Bell Helicopter Co. 412EP. The accident was the subject of ATSB Investigation AO-2013-136.

The ATSB summary explains that a patient died during a retrieval operation for the patient after the patient had become injured in a fall.  The patient slipped out of the rescue strop and fell to the ground.

The Coroner referenced the ATSB investigation and noted the ATSB findings that the use of a rescue strop, without employing an integral hypothermic strap was not suitable for the patient’s size and medical condition.  The Coroner also noted the ATSB safety issue identified that there was limited guidance for rescue personnel regarding the selection of the most appropriate rescue equipment and the conditions when various types of equipment should be considered.

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 when undertaking a winching operation the implications for the operation of the risk of patients or other persons being winched slipping out of the rescue/retrieval strop.

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-VAS.

The ATSB's report can be downloaded by clicking on the link: Final report

The Coroner’s findings can be downloaded from the Victorian Coroners Court website.