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

Risk assessmentThe helicopter operator advised that the procedures in the operations manual weredeveloped following an assessment of the risks involved in winching and the extentto which compliance with the operator’s procedures would mitigate those risks. Theoperator advised that in that context, a specific risk assessment was not requiredprior to commencing winching operations.The operator stated that there was an expectation that its crews would consider thepotential environmental risks both prior to, and during the conduct of a mission.This included the weather conditions and available ambient light. In addition, theoperator advised that, while the pilot in command had overall responsibility for thesafety of the aircraft, all members of the crew were expected to participate in theconsideration of the potential risks to a mission. The mission was only to proceed ifall crew members were satisfied that it was safe to do so.Checking and trainingThe operations manual specified winching-related recency requirements for pilots,air crewmen (ACM) and rescue crewmen (RCM) who were engaged in emergencymedical service roles and the operator’s pilots and ACM complied with thoserequirements. This included the conduct of one winch by day and night every90 days.The paramedics, in their role as ambulance rescue crewman (ARC), were requiredto comply with the operator’s day and night winching recency requirements asspecified for RCM. The operations manual allowed night recency to be varied aspart of individual contracts. The ASNSW’s contract with the operator included apersonnel and stretcher winch at 6-monthly intervals. The requirement for a nightwinch within those minimum standards was not stipulated in the contract.The lack of a night winching currency requirement in the contract was interpretedby the operator as a variation to the RCM currency requirements in the operationsmanual and that therefore there was no night winching currency requirement forASNSW personnel. The ASNSW reported being unaware of the night winchingcurrency requirements in the operations manual.The operations manual detailed a number of requirements in relation to thewinching area that could be used for the conduct of winch training. The areas weredefined with reference to CAO 29.11 and differed for the conduct of basic andadvanced winch training. Basic winch training was required to be conducted to anarea that was largely free of obstacles, whereas advanced winch training could beconducted to more confined areas.In addition to the requirements relating to the area used for winching, the operationsmanual contained a recommendation that, during personnel winching (livewinching) for training purposes:Persons carried on the winch shall be kept at a height above the surface wherein the event of separation from the cable the likelihood of injury is reduced.The recommended height above the surface for over land operations shall beno more than 15 ft [4.6 m].The operations manual also permitted advanced live winch training, in accordancewith CAO 29.11, to a maximum height of 50 ft (15.2 m). Prior to the conduct of- 31 -