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

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Figure 13: Winch-mounted lighting (looking out from the rear cabin)ForwardWinch-mountedlightsSource: ATSBFigure 14: Handheld searchlightSource: ATSBMovement of the Nightsun was achieved through the use of multi–position switchesmounted on the collectives for use by the front seat occupants, or via amulti-position switch located on a pendant control box that could be used by thewinch operator in the rear cabin (Figure 9). Movement of the secondary searchlight- 18 -
could only be achieved via the collective-mounted switches. As there was only oneswitch on each collective, the controlling pilot was unable to move bothsearchlights simultaneously. The assignment of either searchlight to themulti-position switch on the collective was achieved using a controller mounted ona panel between the two front seats. The requirement to use a separate lightingswitch to move between lights, rather than controlling both from the collective, wasnot unique to the AW139 and the ATSB is aware of other helicopter types withsimilar lighting control configurations.Due to the Nightsun/secondary searchlight switch arrangement, it was possible toinadvertently extinguish the Nightsun when assigning control of the secondarysearchlight to the multi-position switch on the collectives.In order to prevent the accidental extinguishing of the Nightsun, the master switcheson the pendant and panel-mounted controllers were required to be in the sameposition prior to selecting control of the secondary searchlight. This requirementwas included as a note in the Nightsun searchlight supplement to the AW139 RFM.An operator flying staff instruction also explained the correct use of the Nightsunmaster switches.The pilot stated that on the night, he was aware that the controller switches were notaligned and as a result there was a risk of the Nightsun being inadvertentlyextinguished. He further advised that he did not want to risk moving his (left) handfrom the collective to activate the pedestal-mounted controller while hovering inclose proximity to obstacles associated with the waterfall.The operator advised that the Nightsun and secondary searchlight providedredundant sources of illumination for pilots to ensure adequate hover referenceduring night winching. They were not intended to illuminate the winching area.Radio communication systemThe helicopter was equipped with four radios (designated COM 1 to 4) and anonboard telephone. COM 1 and COM 2 were very high frequency (VHF) radiosused by the pilot for communication with air traffic. COM 3 was a marine bandVHF radio and was the primary means of radio communication between the flightcrew and the paramedics on the ground. COM 4 was an ultra high frequency (UHF)radio that was available as an alternative means of radio communication betweenthe flight crew and personnel on the ground.The duty paramedic had portable radios that enabled him to communicate viaCOM 3 (marine band VHF) and COM 4 (UHF), and an ASNSW-issued mobiletelephone. The support paramedic had a radio that enabled him to communicate viaCOM 3, a satellite telephone and a mobile telephone. The support paramedicreported that the satellite telephone ceased functioning during the mission due to itsbeing accidentally immersed in water.The paramedics were also able to connect a portable radio to their flight helmet;however, during operations on the ground, they used a different helmet that had noprovision to connect to this radio. The resulting need to hold the radio near theoperator’s exposed ear meant that any ambient noise, including from the helicopter,would hamper communication between the paramedics and helicopter.The air crewman (ACM) could talk on the helicopter’s internal communicationsystem (ICS) or transmit externally via the installed radios. ICS and radio- 19 -
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 12 and 13: front right seat; an air crewman (A
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 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

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

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