Operator’s emergency procedures and cabin safety
Date issue released
Safety Issue Description

The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included:

  • insufficient information provided during pre-flight demonstrations and the passenger safety brief card to demonstrate how to use a life jacket
  • limited procedures and guidance regarding the relative roles, responsibilities and required actions of flight crew and medical personnel during emergencies, particularly with regard to the evacuation of a patient
  • no practical training or demonstrations for medical personnel on how to use the safety equipment on board the aircraft
  • no designated location for a stretchered patient’s life jacket
  • no formal, specific procedures and limited training on how to secure life rafts in an appropriate, readily accessible location prior to a ditching.
Issue number
Transport Function
Aviation: Air transport
Issue Owner
Pel-Air Aviation
Mode of Transport
Issue Status Justification

The ATSB notes the safety action undertaken by the operator to improve its emergency procedures following the November 2009 accident reduced the risk of this safety issue. The ATSB also acknowledges that the air ambulance provider also took safety action to reduce the risk of this safety issue.

Proactive action
Action number
Pel-Air Aviation
Action date
Action Status
Action description

In December 2009, the operator issued a formal notice to Westwind flight crew to state that prior to the commencement of an air ambulance flight, the captain had to brief the medical personnel about each person’s role for that flight. The briefing should include:

  • use of life rafts, life jackets and emergency exits
  • any flight crew requirements regarding the patient’s condition (for example, sea level cabin)
  • information for the medical crew regarding the nature of the flight (including flight times, weather, likelihood of diversions, use of electronic equipment).

The notice also clearly stated to flight crew that aviation safety was the primary consideration regarding flight continuation, and the condition of the patient was a secondary consideration.

In December 2009, all Westwind flight crew completed another wet drills training course (delivered by an external specialist).

In October 2017, the operator advised the ATSB:

Since the accident in 2009 new and comprehensive Safety Equipment and Emergency Procedures (SEEP) manuals were developed and published for the Westwind and Learjet aircraft.

In relation to the Life Raft prior to a ditching, there is no advice given to crew, or briefed passengers, that the life raft should be removed from its secure location prior to ditching. In fact it is made clear that under no circumstances is the life raft, or survival kit, to be removed from stowage and placed unsecured on the floor for landing.

The stowed location of the life raft is clearly explained and all advice to crew is that it is only to be removed after ditching…

In relation to safety equipment and passenger briefings, more broadly it should also be noted that amendments were made to Part A of the Operations Manual and included, for example, a change to the brief to include shoulder harnesses that previously were not mentioned.

This also led to an amendment of the Safety On Board cards…

Additionally, every aircraft in the fleet was issued with a “DEMO” bag to ensure the full demonstration of the life jacket with all its safety features, a seat belt for buckle demo and an oxygen mask. Any medical crew today are briefed along with the passengers prior to flight…

Proactive action
Action number
Action date
Action Status
Action description

Following the accident, the air ambulance provider introduced a number of changes to its international operations. These included:

  • adding life jackets to the medical equipment carried on all missions at each base (so that medical crew had rapid access to life jackets at all times)
  • adding individual EPIRBs to the medical equipment carried on all missions, so that medical crew had rapid access to EPIRBs at all times
  • changed uniforms to include cargo style pants with extra pockets to facilitate the medical personnel carrying the life jackets and EPIRBs at all times.

CareFlight also advised it offered HUET training to all medical personnel engaged in air ambulance flights.