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

The section of severed cable that had been attached to the winch hook was 25.1 mlong. That length of cable was probably not representative of the amount of cabledeployed at the time of the fall as the MPFR recorded the ACM verbalising that hewas winching the cable in and then out after the fall, but prior to cutting the cable.A number of kinks were observed in a section of the severed cable that was attachedto the winch hook. The circumstances surrounding the kinking of the cable couldnot be identified.Tag lineExamination of the tag line (see the section titled Role equipment) identified that itwas cut into two lengths of 49 m and 64 m respectively. The support paramedicadvised that he cut the tag line while removing equipment that had entangled theduty paramedic.Magnified visual inspection of the tag line identified evidence of abrasionconsistent with previous use; however, with the exception of the reported deliberatecut of the line by the support paramedic, there was no evidence that the tag line hadfailed. The weak link in the tag line was intact and attached to one end of the longerof the cut lengths.Two knots were also identified in the longest section of the tag line. The first knot,located about 30 m from the weak link, was a figure eight knot. A second, loop knotwas identified about 62 m from the weak link.Spring-loaded camming devicesSix spring-loaded camming devices (see the section titled Role equipment) thatwere carried by the duty paramedic were examined for defects and/or damage.Although all of the devices showed signs of normal wear, there was no evidence oftheir being forcibly removed from a rock fissure, or that any of the devices hadfailed.Medical and pathological informationThe examining pathologist identified that the fatal injuries sustained by the dutyparamedic were the consequence of blunt trauma injury. In addition to the autopsyreport, the ATSB sought the expertise of a trauma surgeon to provide an assessmentof a number of survivability-related aspects relating to the death of the dutyparamedic. The surgeon’s assessment was based on the review by the surgeon ofthe autopsy report and a number of associated x-ray and photographic images.Additional details of the accident were provided to the surgeon by the ATSB.- 26 -