The ATSB's final report into the tragic helicopter accident near Mackay that killed all three crewmembers found that spatial disorientation of the pilot was likely and includes a number of safety recommendations to prevent a recurrence.

The Bell 407 helicopter, operating under the night Visual Flight Rules (VFR), was en-route from Mackay to Hamilton Island, to pick up a patient, when it crashed into the sea.

The report found that the circumstances of the accident combined most of the risk factors known to be associated with helicopter Emergency Medical Services (EMS) accidents. These included pilot experience and training, organisational and operating environment issues.

While the ATSB could not conclusively determine why the helicopter departed controlled flight, it found that spatial disorientation of the pilot in dark night conditions over water was likely.

As a result of the investigation, safety improvements related to helicopter EMS operations, particularly operations at night, have been taken or are planned by the organisations involved in the operation and oversight of the flight.

These include:

  • a revision of standard operating procedures for helicopter emergencies and the requirement for pilots to hold a command instrument rating, have received crew resource management training
  • the establishment of centralised clinical coordination and tasking of aero-medical operations for Southern Queensland through a centre in Brisbane with a parallel system planned for North Queensland by July 2005.

The ATSB is bringing this report to the attention of the Australian Health Ministers' Advisory Council and copies of the report ( Aviation Safety Investigation Report 200304282) can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6478 or 1800 020 616.

Media contact: 1800 020 616
Last update 01 April 2011