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

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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 -
Use of the helicopter’s lighting ....................................................................... 39Survivability .................................................................................................... 40Communication ............................................................................................... 41Organisational influence ................................................................................. 41Training ........................................................................................................... 42FINDINGS ............................................................................................................. 45Contributing safety factors .............................................................................. 45Other safety factors ......................................................................................... 45Other key findings........................................................................................... 46SAFETY ACTION ............................................................................................... 47Special casualty access team operating procedures ........................................ 47Role of the special casualty access team ......................................................... 48Night winching recency training ..................................................................... 48External lighting in the operator’s AW139 helicopters .................................. 49Other safety action .......................................................................................... 49Training .............................................................................................. 49Risk assessment .................................................................................. 50APPENDIX A: SOURCES AND SUBMISSIONS ............................................. 51- v -
Page 1: Helicopter winching accidentInsert
Page 4 and 5: Published by: Australian Transport
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 58 and 59:
Role of the special casualty access
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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