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

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communications were controlled by the ACM via the winch operator’s controlpanel (Figure 10) and an ICS control panel (Figure 15).Figure 15: Winch operator ICS control panelSource: ATSBWith the switch located on the winch operator control panel set to ICS, the ACMwas able to use either a voice activated (VOX) microphone or a switch on the winchcontrol pendant to communicate via the ICS. With the winch operator control panelset to RADIO, the ACM could use the switch on the winch control pendant tocommunicate externally via the radio that was selected on the ICS control panel.Maintenance historyA review of the helicopter’s maintenance documentation identified that, at the timeof the accident, all of the required maintenance on the helicopter and its rescuewinch had been completed. In addition, all of the necessary servicing on the winchafter the accident, and in support of the 995 winch cycles carried out between thetime of the accident and 26 March 2013 were carried out with no faults found.During the course of the investigation, an Emergency Airworthiness Directive (AD)was issued by the European Aviation Safety Agency (EASA) in response to thefailure of a winch overload clutch assembly during a ‘maximum load cycle’ thatwas being carried out as part of a maintenance test flight. An unintended winchcable run out resulted.The winch that sustained a clutch failure and contributed to the development of theEASA Emergency AD was of the same type as that fitted to VH-SYZ. 17EASA determined that, if not detected and corrected, this condition could lead tofurther cases of in-flight loss of the hoist load, possibly resulting in injury topersons on the ground or that were being winched at the time. A one-time loadcheck test was stipulated, with varying compliance times depending on the nature ofthe intended winch and the date of the respective versions of the AD.On 26 March 2013, the operator complied with the winch load check testrequirements of the EASA AD on the winch that was installed in VH-SYZ on theday of the accident. No fault was found with the winch overload clutch assembly.17See http://ad.easa.europa.eu/ad/2013-0077R1- 20 -
The ACM recalled that the winch on VH-SYZ had operated normally throughoutthe operations on 24 December 2011. He advised being aware of the winchcharacteristics should the overload clutch activate, and did not believe that theclutch activated during the attempted winch retrieval of the duty paramedic andinjured canyoner.Meteorological informationThe Bureau of Meteorology conducted an analysis of the likely weather conditionsin the vicinity of the Bridal Veil Falls at the time of the accident. That analysisconcluded:Upon examining all the meteorological observation and analyses, it isconsidered that the weather conditions at the location at the time of theincident were of light winds, with no precipitation, significant low cloud orother visibility reducing phenomena present. The temperature was between20.5 and 22.5 degrees Celsius and the QNH [atmospheric pressure] wasbetween 1012 and 1013 hPa. From the upper wind and temperatureobservations it is also evident that there was no significant turbulence or icingpresent.The ACM reported that there was localised low cloud in the vicinity of the waterfallwhen the crew were on the ground at the staging area planning the recovery of theinjured canyoner. He recalled that it was still present when they returned to thewaterfall after refuelling; however, as the evening progressed the cloud dissipatedto a fine evening. The ACM’s observations were consistent with those of a localNational Parks and Wildlife Service (NPWS) field officer who assisted with theground recovery.Last light on the day of the accident was at 2040. 18 With regard to the determinationof last light, paragraph 1.2 of GEN 2.7 SUNRISE/SUNSET TABLES of theAeronautical Information Publication stated:...parameters used in compiling the Daylight and Darkness Graphs do notinclude the nature of the terrain surrounding a location, or the presence ofother than a cloudless sky and unlimited visibility at that location.Consequently, the presence of cloud cover, poor visibility or high terrain tothe west of an aerodrome will cause daylight to end at a time earlier than thatextracted from the appropriate graph.Site and equipment examinationOn-site examinationThe access sequence to the waterfall area in support of the ATSB’s investigation isdetailed in Table 1. The ATSB is aware of a number of other visits by variousparties to the top of the waterfall that were undertaken for purposes other thanassisting its investigation. However, the ATSB is satisfied that none of these partiesinterfered with or touched the equipment used by the canyoners or the dutyparamedic.18Last light was computed using the National Aeronautical Information Processing System.- 21 -
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 28 and 29: Figure 13: Winch-mounted lighting (
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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