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

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ATSB TRANSPORT SAFETY REPORTAviation Occurrence InvestigationAO-2011-166FinalHelicopter winching accident involving anAgusta Westland AW139 helicopter, VH-SYZ,16 km WSW of Wollongong Airport,New South Waleson 24 December 2011Released in accordance with section 25 of the Transport Safety Investigation Act 2003- i -
Page 1: Helicopter winching accidentInsert
Page 5 and 6: SAFETY SUMMARYWhat happenedOn 24 De
Page 7 and 8: Use of the helicopter’s lighting
Page 9 and 10: THE AUSTRALIAN TRANSPORT SAFETY BUR
Page 11 and 12: FACTUAL INFORMATIONHistory of the f
Page 13 and 14: to facilitate delivery of the winch
Page 15 and 16: the ACM’s query of the intended w
Page 17 and 18: specifications). The pilot reported
Page 19 and 20: Figure 6: Position of the helicopte
Page 21 and 22: Figure 7: Rock ledgeCanyoner’s in
Page 23 and 24: The injured canyoner was subsequent
Page 25 and 26: ARC flight review was conducted in
Page 27 and 28: Figure 11: Manual winch cable cutte
Page 29 and 30: could only be achieved via the coll
Page 31 and 32: The ACM recalled that the winch on
Page 33 and 34: Figure 16: Tag lineTag lineKarabine
Page 35 and 36: Figure 19: Severed winch cable and
Page 37 and 38: The surgeon concluded that the caus
Page 39 and 40: Night winchingThe operations manual
Page 41 and 42: Risk assessmentThe helicopter opera
Page 43 and 44: expected level of innovation. No gu
Page 45: ‘Pause point’ risk assessmentTh
Page 48 and 49: from the rock ledge after connectin
Page 50 and 51: the combination of which required t
Page 52 and 53:
access the injured canyoner. Althou
Page 55 and 56:
FINDINGSFrom the evidence available
Page 57 and 58:
SAFETY ACTIONThe safety issues iden
Page 59 and 60:
External lighting in the operator
Page 61:
APPENDIX A: SOURCES AND SUBMISSIONS
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atsb final report released 16 may 2013 - Ambulance Service of NSW

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