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

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Role of the special casualty access teamMinor safety issueThe increased capability of helicopters and rescue winches enabled the conduct ofcomplex winch rescues beyond the current level of winch training and proceduralsupport associated with the traditional special casualty access team clinical accessrole, leading to an increased risk that hazards associated with complex rescues werenot identified.Action taken by the Ambulance Service of New South WalesIn response to this accident ASNSW has:• through its Statewide Services Division, introduced a mission governanceprocedure to ensure appropriate resources are supplied to support helicopterrescue missions• through its Control Division, strengthened procedures to ensure supervisors andall appropriate agencies are notified, and dispatched, to missions involving ahelicopter rescue or SCAT response• undertaken an external review of its command and control procedures• arranged to present the safety issue to the New South Wales State Rescue Boardfor consideration.Night winching recency trainingMinor safety issueAmbulance rescue crewmen did not conduct any night winching recency training,resulting in an increased risk of unfamiliarity with night winching procedures andtheir associated hazards.Action taken by the Ambulance Service of New South WalesASNSW advised that, in response to this accident, a requirement was implementedon 13 August 2012 that SCAT paramedics, in their role as ambulance rescuecrewmen, comply with an annual night winching currency. In addition, ASNSWwill liaise with the operator to consider the requirement for more frequent currency,or alternate methods of maintaining night operations awareness.Action taken by the operatorThe helicopter operator advised that training for the operator’s crewmen andASNSW paramedics had been amended to include night winching and a supervisedtask requirement for air crewmen. In addition, a requirement has been implementedthat all new crew members undertake a familiarisation of possible difficult rescueareas in the mountains around Sydney prior to commencing operations.- 48 -
External lighting in the operator’s AW139 helicoptersMinor safety issueThe helicopter’s lighting set-up did not allow independent control of thesearchlights by the pilot using the switches on the flight controls, as required by theoperations manual and Civil Aviation Order 29.11, and increased the risk of loss ofhover reference and distraction in the case of a single light failure or switchmis-selection by a pilot.Action taken by the operatorThe helicopter operator advised that an engineering order will be developed tochange the wiring and switch methodology in the operator’s AW139 helicopters inorder to simplify the operation of the searchlights. The changes will be incorporatedduring scheduled heavy maintenance of the operator’s AW139 helicopters that iscarried out in 2013.Action taken by the ATSBIn response to this safety issue, the ATSB has commenced a safety issueinvestigation that will examine the control of helicopter external lighting in thecontext of the night winching requirements of Civil Aviation Order 29.11. Theresults of that investigation (AI-2013-080) will be published on the ATSB websitewww.atsb.gov.auOther safety actionAlthough no safety issues were identified in respect of the general conduct of crewtraining and risk assessment in support of the attempted rescue, the following safetyactions were reported by ASNSW and the helicopter operator.TrainingAction taken by the Ambulance Service of New South WalesASNSW advised that, together with the helicopter operator, the conduct of trainingand recertification of crews had been revised to involve more scenario-basedtraining. In addition, crew resource management training was expanded to includeparamedics, and the assessment of crew members will now consider theeffectiveness of the team as well as the performance of individuals. Finally, a winchsimulator is being constructed at the Bankstown base and will be used forscenario-based training from July 2013.Action taken by the operatorThe operator’s crew resource management training that previously only involvedthe operator’s flight crew has, as a result of this accident, been extended to includeASNSW paramedics. In addition, since the accident the operator has introduced anew operations and training manual that has been approved by the Civil AviationSafety Authority.- 49 -
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Helicopter winching accidentInsert
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Published by: Australian Transport
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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 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 60 and 61: Risk assessmentAction taken by the
Page 63: Australian Transport Safety Bureau2
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atsb final report released 16 may 2013 - Ambulance Service of NSW

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