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

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 -