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

ASNSW management and individual ARCs advised that they were not aware of thesignificance of the ACM extinguishing the winch lights, which indicated the needby the ACM to revert to the use of hand signals. Examination of the helicopteroperator’s ambulance rescue crewman training notes, which supported the trainingprovided to ASNSW personnel by the operator, identified that the notes did notcontain the additional night hand signal guidance.The operator advised that, unlike the operations manual, the training notes were notsubject to amendment action and were intended to summarise and draw thetrainees’ attention to the relevant contents in the operations manual. The operatoradvised that the training notes were developed prior to September 2009 and had notbeen revised since.The MPFR-recorded communication between the pilot and ACM did not indicatethat the winch lights were extinguished after the pilot instructed the ACM to usehand signals. This action was suggested by the pilot once radio contact could not beestablished with the duty paramedic (see the earlier section titled History of theflight).Figure 20: ‘Ready to be winched’ hand signalSource: Helicopter operatorThe operations manual listed a number of specific commands that were to be usedduring winching (Table 2). Neither the ‘Up gently’ nor ‘Taking the weight’commands were recorded on the MPFR prior to the fall.Table 2: Winching commandsCommand‘Clear to winch’‘Winching in the slack’‘Up gently’‘Taking the weight’MeaningRequest from the winch operator tocommence winching IN/OUT.This call warns the pilot that the winchoperator is winching in the slack cable.Instruction to start a gentle climb or to liftthe load clear of the ground, water ordeck...The winch operator is about to lift thesurvivor with the winch.- 30 -