Limited guidance was provided by the operator and Air Ambulance Victoria for to crews on the selection of the most appropriate winch rescue equipment given operational and medical considerations, and the conditions when various types of equipment should be considered.
The ATSB is satisfied that the relevant organisations have taken appropriate safety action to address this safety issue. In addition, safety advisory information has been issued to other organisations conducting similar activities.
Immediately after the accident the operator suspended all winching operations pending their initial investigations. Following that investigation and an associated risk assessment, winch operations were recommenced.
An interim investigation report was published by the operator with associated safety action. That action included reinforcing the need to critically assess a patient’s physical and medical state and any associated risks before committing to using the rescue strop without utilising the hypothermic strap.
On 5 September 2013, the operator issued an Immediate Safety Notification to its air crewmen, rescue crewmen and pilots. The notice promulgated an order of priority use of rescue equipment for application in overland winch operations. The order of priority, in decreasing priority of use was to use the harness, followed by the stretcher, rescue strop utilising the hypothermic strap with the chest strap connected and then the rescue strop with the chest strap connected.
On 12 November 2014, the operator provided further advice of safety action taken within their organisation. This included, in conjunction with Air Ambulance Victoria, enhancing the existing on-scene patient assessment for possible recovery by rescue strop to include:
Also in conjunction with Air Ambulance Victoria, the operator commenced the introduction of, and training for a Civil Aviation Safety Authority (CASA)-approved aviation rescue vest (seat-type harness).
In addition to the proactive safety action by the aircraft operator and Air Ambulance Victoria, the Australian Transport Safety Bureau (ATSB) released a Safety Advisory Notice (SAN) to other operators of rescue and other winch-fitted helicopters.
On 15 October 2013, CASA issued Airworthiness Bulletin (AWB) 25-025 to 'clarify use and application of Rescue/Retrieval Strops'. The AWB stated:
Rescue Strops were originally designed for retrieval of persons from the water in rescue situations. They were designed as an alternative to using 3 or 5 point harnesses which are problematic to don in a water environment. A separate version was developed to lift persons who may be suffering hypothermia.
A Rescue strop (excluding the Hypothermic version) requires the occupant to be conscious and compliant, and requires active participation from the occupant to ensure safe use. The occupant must follow directions correctly from a trained operator throughout the winch.
and recommended:
As a Rescue Strop requires active participation by an occupant who is not formally trained in its use and may likely be in a highly stressful situation, the following points should be considered prior to use of the strop:
1) whether life is at imminent risk;
2) the state of the person to be winched, particularly whether the rescuee will remain conscious and coherent during the winch process;
3) the potential for the person to remain compliant with winching brief;
4) alternative methods and devices to recover the person; and
5) whether the risk of falling from the device would not result in further serious injury or death.
The ATSB is satisfied that the relevant organisations have taken appropriate safety action to address this safety issue. In addition, safety advisory information has been issued to other organisations conducting similar activities.
Following the accident at Macs Cove, all winching operations involving Air Ambulance Victoria emergency medical service (EMS) helicopters were suspended. This suspension remained in place until the operator’s interim investigation report confirmed that an equipment fault did not contribute to the accident.
In addition, Air Ambulance Victoria, in conjunction with its EMS contractors, commenced a separate investigation that examined the availability of suitable alternatives to the current rescue/retrieval strop.
On 5 May 2014, Ambulance Victoria issued a Service Improvement System notice to its mobile intensive care ambulance Flight Paramedics. The notice provided guidance on the preparation and conduct of overland winch training and operations and an order of priority use of rescue equipment for application in overland winch operations. The notice also included the requirement for an ‘operational pause and reassessment’ to re-affirm the plan and necessity for the winch operation.
On 29 September 2014, Air Ambulance Victoria, in conjunction with Australian Helicopters, commenced the introduction of, and training for a CASA-approved aviation rescue vest (seat-type harness).
The ATSB is satisfied that the relevant organisations have taken appropriate safety action to address this safety issue. In addition, safety advisory information has been issued to other organisations conducting similar activities.
As part of its preliminary investigation report of 10 October 2013, the ATSB issued the following safety advisory notice to helicopter emergency medical service operators and other operators carrying out winching operations:
The Australian Transport Safety Bureau advises helicopter emergency medical service and other operators carrying out winching operations to note the circumstances of this accident and consider the implications for their operations of the risk of patients or other persons being winched to slip out of a rescue/retrieval strop. In this context the size, weight and medical condition of the person(s) being winched may indicate that other recovery options offer reduced risk.
The ATSB is satisfied that the relevant organisations have taken appropriate safety action to address this safety issue. In addition, safety advisory information has been issued to other organisations conducting similar activities.
