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

More documents

Recommendations

Info

access the injured canyoner. Although ASNSW management advised that thatparticular mission was extensively planned and risk managed, and included the useof a command and control system under the supervision of an accredited rescueagency, it created a high-profile precedent for SCAT personnel in the case ofcomplex rescues that involved the adaptation of established skills and procedures.This was consistent with the reported description of the retrieval plan by the dutyparamedic with reference to an adapted technique that had been employed on aprevious high profile helicopter rescue. The ATSB concluded that the accepted useof adaptation and the past successful use of adapted techniques probably led to thespecific technique that was developed to retrieve the injured canyoner.ASNSW management acknowledged that a degree of adaptation was sometimesrequired in order to complete missions. However, no guidance was provided onhow much variation from established procedures was acceptable. Although thedefinition of such a limit is inherently difficult, adaptation can result in the use oftechniques with which crews have little specific familiarity. Such situations makean accurate assessment of the associated risk difficult.Management representatives from ASNSW advised that the rescue capabilityavailable from the use of helicopters and rescue winches means that helicoptercrews are often responding to rescue situations without the support of accreditedground rescue agencies. This can result in situations where patient retrieval can onlybe achieved using complex winch rescues. These recoveries can go beyond thecurrent level of winch training and procedural support provided for the traditionalSCAT clinical access role.In this context, when SCAT personnel are performing the ambulance rescuecrewman (ARC) role, for which they are trained, they are often conducting lesscomplex rescues that are within their capability to perform. This formal training inthe rescue role, when combined with the skills obtained from SCAT training, mayincrease the likelihood that complex rescues will be attempted.The increased rescue capability, coupled with the support for innovation, training inthe ARC role and the success of previous innovative rescues, increased thelikelihood that complex rescues would be attempted without specialist groundsupport. This in turn increased the risk that crews would not have the skills orknowledge to identify the hazards associated with the proposed rescue.TrainingThe majority of land day and night winch training that was routinely conducted bythe operator involved vertical winches from low heights and within areas that wererelatively free of obstacles. While these conditions did not replicate the offsetwinching technique used on the night, they were designed to reduce the overall riskto the involved personnel while also providing a level of familiarity and skill withwinching procedures.The conduct of recency training was designed to supplement operational experienceand ensure that role-related skills, including winching, were maintained. Based onthe winching experience of the duty and support paramedics in their role asambulance rescue crewman (ARC), there appeared to be significantly moreoperational day winching conducted by ASNSW personnel compared to at night. Inthat context, not conducting night winching recency training, although interpretedby the operator as being permitted by the contract variation clause in the operations- 42 -
manual, increased the risk that ARCs may be unfamiliar with night winchingprocedures and their associated hazards.- 43 -
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 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: CommunicationDuring the course of t
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

Create successful ePaper yourself

Delete template?

Save as template?