Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On the morning of 26 March 2019, a Sikorsky S92 crew was conducting a search-and-rescue/medevac training sortie in conjunction with a contracted training vessel. On arrival at the rendezvous location, the crew established themselves in a stable hover over the vessel that was underway in relatively calm conditions. At approximately 0900 Western Standard Time, the crew commenced a winching operation to lower an Intensive Care Paramedic (ICP) onto a clear exposed area of the deck. As the ICP came over the intended landing area he was slightly spinning, which is normal in winching operations. The ICP’s foot contacted a fitting on the boat and with the momentum of the spin his knee struck a hatch cover causing a serious knee injury. After some consideration of the situation, the crew recovered the ICP and transported him to Broome for medical assistance.
The ICP’s knee injury required admission to hospital for surgery.
The operator conducted a review, identifying and confirming that all controls in place for this exercise are effective. No causal human factor has been identified that would contribute to, or instigate, an injury to the ICP, and no shortfall or omission in any existing formal documentation, training, competencies or operator processes could indicate a root cause.
The company has established policy, procedures and training for conducting winch operations. This crew had seemingly done everything to conduct the training correctly. Weather and sea conditions were suitable to carry out the winching practice. So what can be learnt?
This occurrence is a first for this operator and from the collective prior experiences of aircrew staff members, it was noted that bump/impact injuries are not uncommon, and have occurred with most operators in similar roles. The occurrence of injury has been as low as reasonably practicable and the likelihood of a re-occurrence, whilst it is considered possible, is remote. This brief indicates that there were no faults in the performance of the crews during the training exercise, and despite all conditions being suitable, it still resulted in an accidental serious injury. Although this incident is comparable to a slip/trip/fall in the workplace environment with causal factors that are unlikely to be able to be ‘trained’ for, it is the recognition and understanding that winching operations are inherently hazardous.
This incident therefore provides a reminder to operators and crews to ensure all organisational policy, procedures and training mediums are current and comprehensive. For all crews undertaking any complex exercises, it is important to review, understand, and brief the hazards involved and recovery actions to follow in the event of an unplanned incident.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
|Date:||26 March 2019||Investigation status:||Completed|
|Release Date:||03 May 2019||Occurrence category:||Accident|
|Report status:||Final||Highest injury level:||Serious|
|Aircraft manufacturer||Sikorsky Aircraft|
|Type of operation||Aerial Work|
|Damage to aircraft||Nil|
|Departure point||Broome, WA|