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

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Figure 17: Duty paramedic’s ropesRope bagcontaining theremainder ofthe abseilingropeCoiled redsafety lineDuty paramedic’sabseiling ropeSource: New South Wales National Parks and Wildlife ServiceHelicopter and role equipment examinationThe helicopter was examined by the ATSB at the operator’s Wollongong base on26 December 2011. The condition of the end of the exposed winch cable wasconsistent with its being severed with manual cutters (Figure 18).The severed winch cable and hook were visually examined and, having identifiedthat the winch hook was not defective or damaged, the ATSB returned it to thehelicopter operator (Figure 19). The winch cable was retained for furtherexamination.The helicopter’s multi-purpose flight recorder (MPFR) was also retained for furtherexamination.Figure 18: Severed end of winch cableSource: ATSB- 24 -
Figure 19: Severed winch cable and hookSource: ATSBThe duty paramedic’s equipment that was retrieved from the accident site by therescue party was also examined by the ATSB. The tag line that had been used todeliver the winch hook, together with a number of other roping-related componentsused by the duty paramedic, was also retained for further examination.Examination of recovered componentsAll of the retained helicopter and roping-related components were examined at theATSB’s technical facility in Canberra. The results of those examinations areoutlined in the following paragraphs.Multi-purpose flight recorderThe recorded audio and flight data from the accident flight were successfullydownloaded from the helicopter’s MPFR. Elements of those recordings wereparticularly important in understanding the conduct of the flight and the interactionbetween the flight crew and paramedical officers.Relevant extracts of the audio recordings and recorded flight data are referencedthroughout this report.Rescue winch cableThe surfaces of both ends of the severed winch cable were compared to the surfacefrom a sample of cable that was severed by the ATSB using the helicopter’s manualcable cutters. Magnified visual comparison of the cut surfaces confirmed that thewinch cable was severed on the day of the accident using manual cutters.- 25 -
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 30 and 31: communications were controlled by t
Page 32 and 33: The ATSB did not examine the accide
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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