Ambulance Victoria Winching Accident

[Rotorwork]

Aircraft was a Bell 412

 

Very sad RW

 

From ABC News

 

Ambulance Victoria has suspended the use of helicopter winches as it investigates how a patient fell to his death during a rescue operation this afternoon.

 

The man was bushwalking with a group at Macs Cove, near Mansfield, when he broke his ankle about 10:30am AEST.

 

The ambulance helicopter was sent in to rescue the man about midday because of the terrain.

 

Ambulance Victoria chief executive Greg Sassella says at about 12.30pm he fell approximately 30 metres to his death while he was being winched into the helicopter with a paramedic.

 

"I understand he was at the door of the helicopter and they were attempting to get him into the helicopter," he said.

 

"This is devastating for the crew, they spend their whole lives putting themselves at risk for patients and in this instance something's gone astray."

 

Mr Sassella says Ambulance Victoria has suspended all winch rescues while the equipment is tested and an investigation is completed.

 

"What we do know is the crews risk themselves to help the patient, they do everything they can for the patient and in this instance something has happened and the patient's deceased but helicopter operations are high risk," he said.

 

"We have a very good record here in Victoria but that's because we do learn and understand what goes wrong when it goes wrong."

 

Police, the Civil Aviation Safety Authority and Work Safe Victoria are also investigating.

 

Counselling has been offered to the paramedic and the flight crew involved.

 

 

[damkia]

Condolences to all concerned.

 

I've always wondered why they only use one winch/cable, when in all other modes of rescue they use two ropes (IRATA standards)? Surely two winch cables and two winches double caribeenered to a harness/rescue lifting hook would make more sense

 

 

[Guest Maj Millard]

Condolences to all concerned.I've always wondered why they only use one winch/cable, when in all other modes of rescue they use two ropes (IRATA standards)? Surely two winch cables and two winches double caribeenered to a harness/rescue lifting hook would make more sense

Condolences also, Hindsight is always 20/20, why should we use two cables when the rest of the world uses only one, that's just idealistic . When you look at the number of similar winches performed each year throughout the world, this would be a rare accident indeed. Generally at the door there would be two crewmen involved, to bring the injuried on board. One of those would be operating the winch.

 

This will either be an equipment failure or a communication mix-up, in all probability...........Maj...

 

 

[kaz3g]

Condolences also, Hindsight is always 20/20, why should we use two cables when the rest of the world uses only one, that's just idealistic . When you look at the number of similar winches performed each year throughout the world, this would be a rare accident indeed. Generally at the door there would be two crewmen involved, to bring the injuried on board. One of those would be operating the winch.This will either be an equipment failure or a communication mix-up, in all probability...........Maj...

Maj, I was winched out of the Wongungarra in the late 1980s by the National Safety Council's Hughie. I was on a fireline and the fie was above me on an extremely stereo gorge face. As the alpine grass burned rocks came bouncing down. One split my shin.

 

The doctor man came down on the winch in a 5 point harness with a helmet on. He hitched me into the hook and all I had was a sling under my arms. We were winched up about 100 FT thought the tree tops then the chopper moved out from the side of the mount and I was 3000 FT over the valley.

 

I didn't like it! If I had raised my arms at all I was gone!

 

Hope this poor fellow had something a bit more secure.

 

Kaz

 

 

[Greg Spiers]

Hi, Very sad this stuff but it is inevitable when operating in dangerous situations. The unexpected will always happen when humans are involved. The investigation will hopefully turn up something and prevent further occurrences for the same reasons.

 

I was involved in an incident in about 1981 when a National Parks employee in SA was dropped from a Jet Ranger in the Flinders. I had to attend cos I was the only guy on station (Wilpena) who had medical experience. He was dropped off a hook into bolder country on the side of range from about 20 feet off the ground, on the way up from clearing a helipad for a radio repeater, could have been a 1000 ft. Broke both his legs and I think an arm (can't remember, long time ago) he luckily survived. Couldn't land near him so observations had to happen from the air, very difficult. We winched a guy down, yep, on the broken hook (no choices out there at the time), with a radio, who reported his condition. Worst for the injured man was we had to lift him out on the same broken hook that dropped him, he wasn't told that at the time. We then had to fly him to flat ground a few hundred metres away, unaccompanied, in a stretcher (Stokes Litter) slung under the chopper, get him in the machine and fly him to Hawker Hospital 60 miles away. The hook had some how got twisted and (still unknown how it happened) managed to twist the locking tab inside out thus allowing the harness to slide off. The hook was still in one piece but no locking mechanism, it would have to have been twisted in the cable and hanging nearly inverted for this to happen, not sufficient checking is my guess. Wasn't one of my better days.

 

Greg

 

 

[Guest Maj Millard]

Freak accidents can happen when dealing with hooks and caribinas. I recall one years ago with a static line student parachutist, when the snap was attached to a seat stay on the pilots seat (best point for the day). The snap slid up hit another rail and unsnapped. Had the snap been hooked on the other direction, nothing would have occurred.

 

This one a sad event for all concerned...hope they learn something to make thing safer in the future........Maj...

 

 

[Teckair]

I see footage in movies and on TV etc where people appear to be on a helicopter next to an open door way and unrestrained and I think that looks so dangerous one slip and your gone, that's what it looks like anyway.

 

 

[damkia]

Normal operations in mines rescue (assumed civilian rescue also) and also for industrial rope access (ie high rise window washers/maintenance crews) is to have two lines on at all times.

 

I wonder if the patient slipped out of the basket as they were loading, or if the basket itself was left untethered as it was being manipulated off the winch line? Pretty basic mistake if it was the latter...

 

 

[Head in the clouds]

Normal operations in mines rescue (assumed civilian rescue also) and also for industrial rope access (ie high rise window washers/maintenance crews) is to have two lines on at all times.I wonder if the patient slipped out of the basket as they were loading, or if the basket itself was left untethered as it was being manipulated off the winch line?

I've never heard of a second line for helicopter operations, the risk to the helicopter of one cable getting snagged is high enough, let alone two.

 

A basket isn't generally used for these kinds of extractions, it is normally a padded loop (sling) that is attached to the end of the cable and you put it across your back and under your arms. Although it feels a little insecure at first in fact it takes a hell of a lot of deliberate effort to fall out of it (trying is sometimes part of HUET training). An unconscious person will never fall out of it, the weight of your arms is plenty to keep them down. An hysterical victim may need their arms restraining to a belt or crotch strap.

 

 

Given that all the Ambulance Victoria helicopters have been stood down from winch ops it is likely that it was a winch problem rather than a mishandling during transfer from the line to the helicopter cabin. The 'patient' is never removed from the sling or harness until they are secured in the cabin. Teckair - the crewmen hanging out may look a bit precarious but they wear harnesses and are clipped on to strongpoints in the cabin, sometimes the safety line is quite long to allow them to do their job but will arrest a fall. Same for news camera operators etc.

 

Quite some years ago (maybe late 1980s) there was a similar incident, or perhaps two. In one case a doctor was killed while being winched. The reason then was the cable-cutter mechanism operated without being commanded. The pilot has a push-button switch usually mounted on the end of the collective lever and it is armed whenever the winch is in use. Operation of the switch causes a guillotine to cut the cable. It is a last-resort system for use in the event of the cable becoming snagged and the helicopter being in dire risk. Cable entanglement is not uncommon when working close to rock faces in strong winds, or among thick timber in gusty conditions. Accidental operation of the switch by the pilot is also possible but you'd certainly hope it's not the case in this event. I know two pilots who have accidentally operated similar armed switches, fortunately without involving any injury because it was the switch for pneumatic floats for over-water ops. One was on the deck of a Greenpeace ship prior to take-off and so caused nothing more than a red face. The other was a Long-Ranger at about 90kts and they were lucky to survive it as the blades hit the tailboom when it pitched forward, max float inflation is placarded at 60kts and you should be in the flare at the time.

 

 

[turboplanner]

There's some more information on this link; doesn't look like equipment failure.

 

http://www.heraldsun.com.au/news/victoria/injured-bushwalker-dies-while-being-winched-to-safety-by-ambulance-officers-in-a-helicopter-near-mansfield/story-fni0fit3-1226708104914

 

 

[facthunter]

Actually one would have to give that report a tick for being reasonable. Sad outcome though . All been said before my comment. They do a great job. Nev

 

 

[Gnarly Gnu]

Perhaps the moral is don't put too much faith in the government, eventually it will let you down.

 

 

[Downunder]

From the comment "well over 100kg", could this have something to do with it?

 

In my industry/company triple lock carabiners are only allowed. Would this be the same for rescue ops?

 

 

[Rotorwork]

According to Ten News, the patient weighed more than 140kg and it took a SES Team over an hour and a half to get the body down to the nearest track. A winch may have been a challenge on the deceased's size alone.

 

Ambulance Victoria have resumed Limited Winching Operations according to ABC

 

 

[Old Koreelah]

According to Ten News, the patient weighed more than 140kg and it took a SES Team over an hour and a half to get the body down to the nearest track...

Much of the rich world has been upsizing, and standards have been slow to keep up. The average passenger weight used by airlines is probably an underestimate, and passengers seem to flout carry-on baggage limits with impunity. (One brave Pacific Island airline now charges airfares on a per kg basis.)

I know that we in the emergency services regularly have major problems with enormous humans.

 

 

[fly_tornado]

Perhaps the moral is don't put too much faith in the government, eventually it will let you down.

I'll take my chances getting winched out, you can walk out with your broken ankle

 

 

[icebob]

Hi,

 

I think you may find the SWL of winch wire is 600Kgs. That's what we use and it's an off the shelf product.

 

Bob.

 

 

[Sky Capt. Greybeard]

Well done to 'Head in the Clouds' for some facts on this issue. Single line winching is the Australian standard, and believe it or not Kaz3g, the rescue strop is the industry standard. If we look at this terrible incident, it appears the problem may have occurred when the patient was transferred from the door into the cabin. Unlike smaller aircraft such as the BK117, the 412 doesn't have a winch boom. This means that the distance of the winch cable from the door must be sufficient for the winch load to miss the skids. In the 412, it can seem a long way between the cable and the door when your hanging by your harness with a patient in distress in the rescue strop.

 

When the patient is winched to the door, careful coordination is required between the rescue crewman and winch operator to get the patient on board. A common technique is for the rescue crewman is to ascend with the patient in the strop, secured between the legs. This enables the legs of the crewman to grip the waist of the patient, and this helps the crewman maintain close contact. The crewman can then use one or both arms on the way up to keep the patients elbows down, ensuring they stay within the strop.

 

Once at the door, the crewman will grab a hand hold in the doorway and thrust with the hips, pushing the patient into the doorway. The winch operator will grab a handle on the back of the rescue strop, and together they will drag the patient on board and secure by seatbelt or wander lead prior to unhooking the winch cable.

 

It appears that in this tragic incident, a major fault has occurred in this procedure. There has been a lot of speculation in the professional fields, and my guess is that the size and injury to the patient have made the transition in the doorway more difficult.

 

The aim of the rescue crewman is to get the tailbone of the patient over the edge of the floor when the patient is thrust in with the hips. If the tailbone is on the floor, then the winch operator can slide the patient along the floor relatively easily. If the tailbone of the patient is below the edge of the helicopter floor, the lower half to the patient hangs outside and a great deal of effort is needed to correct this. This is due the curvature of the spine above the buttocks. If the patient has a broken ankle, then the patient is obviously in pain or on medication, and the crew cannot rely on the patient's assistance in the rescue.

 

I am waiting to see what the official investigation produces, and my thoughts are with the crews who have undoubtedly replayed this tragedy over and over again. My backseat second-guessing will be no help to anyone involved in the incident, but I am sure that the lessons learned will help the entire industry improve a practice that in inherently dangerous by necessity.

 

And to 'Gnarly Gnu', stay under you rock, you cretin. Hopefully Darwinian theory is at work and your pathological ignorance has prevented you from breeding.

 

 

[Sky Capt. Greybeard]

From today's Herald Sun;

 

A PARAMEDIC grabbed an injured hunter's shoulder in a vain attempt to stop him slipping to his death as the man was winched up to a helicopter.

 

Robert Davis, 68, slid out of the rescue harness and fell about 30 metres to his death during the August 31 rescue from dense bushland.

 

A preliminary Australian Transport Safety Bureau report found Mr Davis was "limp and unresponsive" when being winched up to the chopper.

 

The bureau has issued a safety warning to rescue crews that a patient's size, weight and medical condition, and the potential to slip out of the harness, should be taken into consideration, and "may indicate that other recovery options offer reduced risk".

 

Air Ambulance Victoria is exploring alternatives to the current rescue strop.

 

The report said the paramedic on the ground and the aircrew could not get the portable radio to work and had to communicate using hand signals.

 

The Sydney man, who was believed to weigh more than 100kg, had been hunting in dense woodland at Macs Cove, near Lake Eildon, when he broke his ankle on August 31.

 

He was less than 1.5km from the nearest road but the terrain was steep, so the crew tried to winch him to safety.

 

In a winch rescue, the paramedic travels with the patient, wrapping his arms and legs around his charge.

 

The report said at 10-15 metres, the pair came too close to trees and the paramedic had to use both hands to fend off the branches.

 

When they were clear of the trees, the aircrew noticed the patient was moving or wriggling and his arms were not in the usual position in the strop.

 

The paramedic appeared to be shouting at him.

 

Mr Davis began to slip out of his harness.

 

The paramedic on the winch tried to pin him against the chopper's skid to stop him.

 

When he was within an arm's length the chopper crewman grabbed Mr Davis.

 

He was limp and unresponsive, but it remains unclear whether he suffered a medical problem during the rescue or whether this was related to how he was slipping from the harness.

 

The report said the patient fell to the ground, suffering fatal injuries.

 

The ATSB report found the aircraft, winch and equipment were working, there were no organisational or systemic problems, and the crew were qualified for the rescue.

 

It will now focus on the rescue strop design and its "potential limitations" for patients of some weights. It will also look at medical problems that could arise during winching.

 

AV chief executive Greg Sassella said equipment, including radios, had been checked and cleared and use of hand signals during winching was common.

 

He expressed his condolences to the family.

 

AV, the State Coroner and WorkSafe are each conducting separate inquiries.

 

[email protected]

 

 

[Sky Capt. Greybeard]

From the preliminary ATSB report, an extract;

 

"At 1224, the helicopter departed Macs Cove to return to the scene. On arrival the crew noted that some trees had been cleared to create a larger winching area and that the patient had been moved to this area. After about 5 minutes the paramedic signalled to the crew that he was ready to winch and the crew positioned the helicopter over the winching area in an approximately 80 ft hover, about 20 ft above the tree canopy.

 

Initially the winching procedure appeared to proceed normally. The aircrewman reported that the paramedic appeared to have his arms and legs wrapped around the patient, as is the normal procedure. When the paramedic and patient were approximately 30–40 ft above the ground, the aircrewman noticed that they had moved towards the edge of the winch area and close to the upper branches of the trees. The paramedic stated that he came in contact with the branches and had to use both hands to fend off as he came through the tree canopy. The helicopter was moved back and right about 5 ft and the winch continued.

 

The aircrewman reported that once the paramedic and patient were clear of the canopy, at about 15 ft below the aircraft, he noticed that the patient was moving or wriggling. The aircrewman stopped the winch for a control check, and shortly after resuming the winch noticed that the patient’s arms were not in the usual position in the strop and that the paramedic appeared to be shouting at the patient. The aircrewman elected to continue winching in, and informed the pilot that the patient was slipping.

 

As the paramedic and patient reached the height of the helicopter’s right skid-landing gear, the paramedic was facing the helicopter and the patient was facing outwards. The paramedic reported attempting to pin the patient against the skid in an attempt to stop him slipping. The aircrewman continued winching until the paramedic’s head was level with the middle of the door opening. At this stage the aircrewman informed the pilot that he could see the patient slipping further. He dropped the winch pendant and reached down, grabbing the patient’s shoulder in an attempt to stop his fall. The aircrewman stated that by this stage the patient appeared to be unresponsive and limp.

 

Despite the crew’s efforts, the patient slipped out of the strop and fell to the ground, sustaining fatal injuries.

 

Preliminary investigations indicate that the aircraft, winch and rescue equipment were serviceable at the time of the accident, and that the crew were qualified to carry out the task. "

 

Refer ATSB AO-2013-136