atsb final report released 16 may 2013 - Ambulance Service of NSW

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front right seat; an air crewman (ACM), who was seated in the front left seat; 5 and aSpecial Casualty Access Team (SCAT) (see the section titled Ambulance Service ofNew South Wales) duty paramedic and doctor, who were seated in the rear cabin.Based on the advised location of the beacon and the potential for difficult patientaccess, an additional SCAT support paramedic was also on board, and seated in therear cabin. Due to the additional weight of the support paramedic, the helicopterwas operated on the ground for 13 minutes in order to reduce the fuel load andensure the helicopter was below its maximum allowable weight prior to departure.The helicopter arrived at the advised beacon location at about 1735 and, shortlyafter, the crew identified a person at the top of the waterfall and a second,apparently injured person on a rock ledge near the bottom of the waterfall. The crewconducted an aerial reconnaissance of the area and assessed that, due to the terrainand vegetation, it would not be possible to winch personnel directly to the injuredcanyoner’s position and that a vertical winch retrieval would similarly not bepossible. The pilot elected to land and shut down the helicopter in a nearby stagingarea (Figure 2) while a plan was devised to access the patient.Figure 2: Operating areaSource: Google EarthThe plan for the recovery of the injured canyonerA plan was developed to winch the paramedics to the top of the waterfall, near theposition of the uninjured canyoner. The intention was that the duty paramedicwould then abseil down to assess the patient while the support paramedic remainedat the top of the waterfall. In addition to the rope used to abseil down to the patient,the plan involved the duty paramedic taking one end of a second, yellow rope(tag line) (see the section titled Role equipment) down with him, while the other endof the tag line remained with the support paramedic. The purpose of the tag line was5The ACM generally occupied the front left seat and relocated into the rear cabin when required tooperate the rescue winch.- 2 -
to facilitate delivery of the winch hook to the rock ledge. If the paramedic assessedthat the canyoner’s injuries permitted him to be winched, the patient and paramedicwould be winched together from the ledge. 6The delivery of the winch hook to the patient’s location was to be achieved by thepilot hovering the helicopter overhead the top of the waterfall and the ACMlowering the hook to the support paramedic, who would attach one end of thetag line to the hook (Figure 3). The pilot would then manoeuvre the helicopter to aposition adjacent to the waterfall, and the duty paramedic would pull the winchhook to his location using the tag line, while the ACM let out the winch cable.Figure 3: Winch hook delivery using the tag line 7Source: ATSBThe crew identified that, given the overhanging cliff and surrounding vegetation(Figure 3), a vertical lift from the patient’s position was not possible. A winch froma position laterally displaced from overhead the patient meant that, as the paramedicand patient were winched from the ledge, there would be a tendency for them toswing like a pendulum towards a position under the helicopter. In order to managethat pendulous tendency, it was planned that the duty paramedic would establish astabilising rope system to minimise any swing, until he and the patient were directlyunderneath the helicopter (Figure 4).The stabilising rope was never intended to support a significant component of thecombined weight of the patient and paramedic, as it was anticipated that the angleof the winch cable from vertical would be minimal when they were winched fromthe ledge. The intent was for the weight of the personnel and equipment to bealmost entirely supported by the winch cable, and that they would be winched fromthe ledge prior to the paramedic feeding out the stabilising rope to position the67Commonly termed a ‘double lift’, where two persons are winched simultaneously.The overhang above the ledge position is indicative only.- 3 -
Page 1: Helicopter winching accidentInsert
Page 4 and 5: Published by: Australian Transport
Page 6 and 7: CONTENTSSAFETY SUMMARY ............
Page 8 and 9: DOCUMENT RETRIEVAL INFORMATIONRepor
Page 10 and 11: TERMINOLOGY USED IN THIS REPORTOccu
Page 14 and 15: patient and himself directly undern
Page 16 and 17: paramedics, so the pilot elected to
Page 18 and 19: eported that he did not advise the
Page 20 and 21: advised the ACM to communicate usin
Page 22 and 23: The pilot contacted the ASNSW Medic
Page 24 and 25: and lighting systems. The ACM’s t
Page 26 and 27: 15° cable angle limit. This limit
Page 28 and 29: Figure 13: Winch-mounted lighting (
Page 30 and 31: communications were controlled by t
Page 32 and 33: The ATSB did not examine the accide
Page 34 and 35: Figure 17: Duty paramedic’s ropes
Page 36 and 37: The section of severed cable that h
Page 38 and 39: was night vision goggle (NVG)-capab
Page 40 and 41: ASNSW management and individual ARC
Page 42 and 43: winch training at increased height
Page 44 and 45: tag line was connected to the stret
Page 47 and 48: ANALYSISIntroductionThe ATSB identi
Page 49 and 50: It was also considered unlikely tha
Page 51 and 52: CommunicationDuring the course of t
Page 53: manual, increased the risk that ARC
Page 56 and 57: Other key findings• There was no
Page 58 and 59: Role of the special casualty access
Page 60 and 61: Risk assessmentAction taken by the
Page 63:
Australian Transport Safety Bureau2
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atsb final report released 16 may 2013 - Ambulance Service of NSW

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