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

CONTENTSSAFETY SUMMARY ........................................................................................... iiiTHE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ viiTERMINOLOGY USED IN THIS REPORT ................................................... viiiFACTUAL INFORMATION ................................................................................ 1History of the flight ........................................................................................... 1The plan for the recovery of the injured canyoner ............................... 2Preparation for the recovery ................................................................. 5The attempted recovery ........................................................................ 7Personnel information ..................................................................................... 13Pilot ................................................................................................. 13Air crewman ....................................................................................... 13Duty paramedic .................................................................................. 14Support paramedic .............................................................................. 14Aircraft information ........................................................................................ 15Aircraft specifications ........................................................................ 15Maintenance history ........................................................................... 20Meteorological information ............................................................................ 21Site and equipment examination ..................................................................... 21On-site examination............................................................................ 21Helicopter and role equipment examination ....................................... 24Examination of recovered components .............................................. 25Medical and pathological information ............................................................ 26Organisational and management information ................................................. 27Helicopter operator ............................................................................. 27Ambulance Service of New South Wales........................................... 32Additional information.................................................................................... 33Role equipment ................................................................................... 33‘Pause point’ risk assessment ............................................................. 35ANALYSIS ............................................................................................................ 37Introduction ..................................................................................................... 37Development of the accident .......................................................................... 37Rope stabilising system................................................................................... 38- iv -