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

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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 -
The surgeon concluded that the cause of death was hypovolaemic shock (bloodloss) secondary to internal bleeding due to fractures of the pelvis and that theinjuries were consistent with a fall from height. Based on these injuries, the surgeonconcluded that:...the only prospects of survival for the deceased would have been institutingdefinitive medical care at a major trauma centre within approximately60 minutes from the time of injury. It should be noted that even if the patientwas able to be evacuated to a major trauma centre within this time-frame,there would still be a moderate to high risk of death from injuries of thisseverity.A supplementary assessment of the injuries sustained by the duty paramedic wasundertaken by the surgeon using the Injury Severity Score (ISS) 20 . This assessmentidentified a high to very high risk of death, even with definitive medical treatmentavailable. The surgeon advised that use of the available medical equipment andexpertise at the site may have extended the timeframe before having to commencedefinitive medical care at a trauma centre by no more than about 4 hours.In respect of the potential adverse effects of winching the injured paramedic in aharness, the surgeon stated that:It is well known that internal bleeding as a result of severe and unstable pelvicfractures may be worsened by movement of the fracture site. In this way, it ispossible that the deceased’s injuries may have been aggravated by winchingin a harness. The correct method of extrication of a patient sustaining unstablefractures of the pelvis such as that sustained by the deceased is with thepatient lying supine (flat on their back) on a spinal board or within a rigidlitter, and with the pelvis supported by a pelvic binder. This is in order toreduce movement of the fracture site that could accelerate any internalbleeding from the injury.Toxicological analysis detected a ‘clinically insignificant’ level of alcohol in theparamedic’s blood. The examining pathologist concluded this was most likely dueto natural post-mortem generation of alcohol rather than the result of consumption.The injured canyoner’s most significant injury was a fractured lumbar vertebra.Organisational and management informationHelicopter operatorThe helicopter operator was contracted to provide emergency medical rotary wingtransport services in the greater Sydney area for the ASNSW. Specifically theoperator provided the helicopters, pilots, air crewman (ACM) and maintenancepersonnel as well as training for ASNSW paramedics in their role as ambulancerescue crewmen.The contract required an AW139 helicopter and a Eurocopter EC145 helicopter tobe based at Bankstown, with a second AW139 at Wollongong and a secondEC145 at Orange. At the time of the accident the EC145 helicopter at Bankstown20The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score forpatients with multiple injuries.- 27 -
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 34 and 35: Figure 17: Duty paramedic’s ropes
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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