Investigation number
AO-2013-136
Occurrence date
Location
Macs Cove, near Lake Eildon
State
Victoria
Report release date
Report status
Final
Investigation level
Systemic
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Miscellaneous - Other
Occurrence category
Accident
Highest injury level
Fatal

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.

Aircraft Details
Departure point
Essendon, Vic.
Model
412
Serial number
36504
Sector
Helicopter
Registration
VH-VAS
Operation type
Aerial Work
Damage
Nil
Manufacturer
Bell Helicopter Co