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Final ATSB report released on QLD Oct03 crash, 3 fatalities

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Final ATSB report released on QLD Oct03 crash, 3 fatalities

Old 14th Mar 2005, 23:29
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Final ATSB report released on QLD Oct03 crash, 3 fatalities

The final ATSB report on the Bell 407 which crashed in Queensland near Mackay in October 2003, killing 3, has been released.



On the evening of 17 October 2003, an air ambulance Bell 407 helicopter, registered VH-HTD (HTD), being operated under the ‘Aerial Work’ category, was tasked with a patient transfer from Hamilton Island to Mackay, Queensland. The crew consisted of a pilot, a paramedic and a crewman. Approximately 35 minutes after the departure of the helicopter from Mackay, the personnel waiting for the helicopter on the island contacted the Ambulance Coordination Centre (ACC) to ask about its status. ACC personnel then made repeated unsuccessful attempts to contact the helicopter before notifying Australian Search and Rescue (AusSAR), who initiated a search for the helicopter. AusSAR dispatched a BK117 helicopter from Hamilton Island to investigate. The crew of the BK117 located floating wreckage, that was later confirmed to be from HTD, at a location approximately 3.2 nautical miles (NM) east of Cape Hillsborough, Queensland. There were no survivors.

Following 12 days of side scan array sonar searches, underwater diving and trawling, the main impact point and location of heavy items of wreckage were located. The wreckage was recovered and examined at a secure on-shore location.

Although the forecast weather conditions did not necessarily preclude flight under the night Visual Flight Rules (VFR), the circumstances of the accident were consistent with pilot disorientation and loss of control during flight in dark night conditions. The effect of cloud on any available celestial lighting, lack of a visible horizon and surface/ground-based lighting, and the pilot’s limited instrument flying experience, may have contributed to this accident. Although not able to determine with certainty what factors led to the helicopter departing controlled flight, the investigation determined that mechanical failure was unlikely.

The circumstances of the accident combined most of the risk factors known for many years to be associated with helicopter Emergency Medical Services (EMS) accidents, such as:

Pilot factors

the pilot was inexperienced with regards to long distance over water night operations out of sight of land and in the helicopter type
the pilot did not hold an instrument rating and had limited instrument flying experience
the pilot was new to the organisation and EMS operations.
Operating environment factors

the accident occurred on a dark night with no celestial or surface/ground-based lighting
the flight path was over water with no fixed surface lit features
forecast weather in the area of the helicopter flight path included the possibility of cloud at the altitude flown.
Organisational factors

a number of different organisations were involved in providing the service
the operation was from a base remote from the operator’s main base
actual or perceived pressures may have existed to not reject missions due to weather or other reasons
an apparent lack of awareness of helicopter EMS safety issues and helicopter night VFR limitations
divided and diminished oversight for ensuring safety
no single organisation with expertise in aviation having overall oversight for operational safety.
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS operations.

Following the accident, the Queensland Department of Emergency Services took initiatives to implement:

increased safety standards in the Generic Service Agreements to Community Helicopter Providers (CHP) to include increased pilot recency and training requirements, a pilot requirement for a Command Instrument Rating, crew resource management training, a Safety Management System and a Safety Officer
the recommendations of the reviews associated with the aeromedical system/network
the establishment of a centralised clinical coordination and tasking of aeromedical aircraft and helicopters for Southern Queensland1, including all CHP state-wide through a centre in Brisbane, with a parallel system planned for all Northern Queensland by July 2005
the establishment of a requirement for a safe arrival broadcast for flights of less than 30 minutes duration and the nomination of a SARTIME for all flights
the revision of the standard operating procedures for helicopter emergencies to attempt to establish communication with an aircraft when lost for a maximum 5 minute period, then immediately contacting AusSAR
the establishment of a requirement for CHP to provide updated contact/aircraft details on a bi-annual basis and amend the standard operating procedures containing this information accordingly
a requirement for CHP operations to ensure sufficient celestial lighting exists for night VFR flights to maintain reference to the horizon.
full report
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Old 15th Mar 2005, 00:06
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Am I alone in feeling someone needs to be in jail over this?

So many questions arise as to why that crew could not have done a lot of other things than what they did.

One quick look at the map shows they could have followed the road....granted it may have been awfully dark there as well but maybe some traffic or surface lights would have been visible and the overwater leg would have been just a few short minutes instead of almost 30 minutes. That one change alone could have saved their lives.

Why ever on this earth was a non-instrument rated, current, and proficient pilot flying that trip? Why was he assigned to that base knowing he might be exposed to such a trip? Why did he not refuse to go? Why did his bosses not find themselves in jail for allowing that to happen?

Any of you folks in Oz want to explain to the rest of us why this is a proper way of doing business down there?

Reading the accident report ruined a good dinner.

If this is typical of the EMS business in Oz....we in the USA do not have a problem compared to down under.

I can hear a guy named Denny saying...."Ah, but it is not IFR, the weather is VMC." Explaining why his outift's Bell 212's did not need SAS(STAB) to fly night offshore. That attitude impressed me enough to create my room name. Similar attitude down under it seems.
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Old 15th Mar 2005, 01:07
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SASless, I'm not sure jail is the answer because as soon as the legal 'experts' get involved, attempts to improve safety often fly out the window along with common sense.

I think it would be fair to say that it was a surprising accident considering the operator and, it could be argued, there were responsibilities for various aspects of the operation that were held within several organisations.

Some members of the EMS industry in Australia are banding to gether to improve their safety systems; however others think they 'do it right' and don't need to be involved. (that attitude worries me sometimes) But at least there is some movement to improve things.

Night VFR is another issue though...it needs some sensible addressing by the industry and by CASA. It behoves both the industry and the Authority to look at Night VFR, how it is implemented and how it can be done safely in different environments. I know that the HAA is examining NVFR and coming up with some proposals.

Compared to the US? Well, different methods of operating, different business models, different regulations and, to be fair, Oz's recent experiences have been a spate of problems primarily involving one State I think.

No doubting though that something needs to be done and being primarily community based, hopefully the individual operators can pull together for the good of the patients and the industry...we will see!
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Old 15th Mar 2005, 01:36
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It's sad to note that nearly 2 years after this unnecessary tragedy that single engine helicopters with marginal instrumentation, no SAS, are still flying over built up areas & over the sea without floats, without any changes to CASA requirements.
I'm sure CASA are rushing through the changes.

I should have said by night VFR.

Last edited by Nigel Osborn; 15th Mar 2005 at 03:38.
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Old 15th Mar 2005, 07:56
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G'day All,

Got any examples Nigel? It seems that the majority of the machines up in my part of the world are suitably equipped for the task at hand.

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Old 15th Mar 2005, 12:24
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Page 3, Figure 2, a map of the flight path says it all.

If you ever want to answer the question about how long it takes for a non-instrument rated and proficient pilot to become a statistic....just look at the map in Figure 2. Approximately three miles in this case.

Management oversight.....the mention in the report where it was said the operator had been given a quote for the installation of SAS and a two axis auto-pilot system while the aircraft was being outfitted with the EMS interior tells me the old helicopter operator "Do it on the cheap" attitude struck again. I wonder how much money they saved by leaving off the SAS and Autopilot?

The fact a Consultant advised them the aircraft was not properly equipped and/or was not the correct type of aircraft was also ignored. Why do they hire the consultants if they are going to ignore their inputs?

Who in their right mind....would consider putting a pilot into this position...no instrument rating ( a grand total of 12 hours instrument training over his career), a single engine, un-Sas'ed, non-autopiloted machine, to fly at night over the sea.

In my book, they were either very callous or very stupid.

Anyone in Oz care to refute what I am saying? Can anyone down there convince me that what this guy was up against was rightous and holy?

The bigger question....since this crew of three died....have CASA, the operators, and the customers all taken effective corrective action to ensure this set of circumstances will not happen again? Or did the death of these three people just become another statistic and wind up being a sacrifice to corporate/governmental incompetence?

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Old 15th Mar 2005, 21:56
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Surf Life Saving use a vfr AS350 without floats, without any form of SAS, marginal night vmc instruments which are not required to be to IFR standard and fly by day or night vfr over built up areas & over the sea, generally below 200 ft by day and all I hasten to add completely within CASA requirements.
It is these CASA requirements my complaint is against, not the companies that observe them.
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Old 15th Mar 2005, 22:04
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Just because it is legal does not in any way make it the right thing to do. That attitude is what gets people killed.

What kind of safety culture are those operators operating within that can justify that? Day, VFR, VMC....is one thing but night over open water is a completely different matter.

It is time for pilots to get their collective heads out of their butts and do like Ma Regan suggested...."Just say No!"
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Old 16th Mar 2005, 01:34
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Here we go again.

At the risk of inflaming my detractors, it must be stated that the operator of this B407 was CHC Australia. And my reason to state this is that if it can happen to them, with their extremely robust CAR 217 Training and Checking system and EMS/SAR Standards, then it can happen to anyone.

Since that fatality, the Mackay EMS Base and that other notorious base at Rockhampton have both adopted IFR Mediums too undertake the tasks.

Thank goodness for that change of thinking and standard.

Night VFR EMS kills people. When will we ever learn?
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Old 16th Mar 2005, 03:26
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High Nr

Are you that familiar with the Mackay operation to call it notorious "the Mackay EMS Base and that other notorious base at Rockhampton". If the link between the two was unintended then I suggest you watch your wording.

Naming only one of the organisations involved in that region suggests you have taken the opportunity to take a cheap shot at one of your "pet" companys. Your reason for the public naming is transparent and weak.
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Old 16th Mar 2005, 03:57
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Sorry Mate. There was no suggestion regarding Mackay Base in my mind.

I was going to correct the assumption made by yourself. If you had PM me instead of going public, I would have done so quietly, however I am now standing firm.

However both bases have killed collegues of mine, Paramedics and patients, and why?

VFR EMS Helicopters operating at night.

Bring on better standards, better funding and less accidents will result.
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Old 16th Mar 2005, 04:14
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For this particular operation, it was company policy to fill in a form for management about why particular tasks were not completed, eg due weather, maintenance etc.

Whether this is 'Implied' pressure on a crew to perform a task, i dont know.

If you read the area forecast for that night, the only way to go would be IFR.

How in the pitch black night, with no visible horizon, that CASA call this NVFR is incredible. Its IFR or its no go for me.
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Old 16th Mar 2005, 04:15
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High Nr

I agree with your sentiment in part.

I disagree that Mackay can be compared to Rocky.

Nigel is right on the money with regard to CASA the ball is in their court, they must take the initiative and if operators aren't going to do the sensible thing then they must regulate to make it happen ergo if a Government/Community want a certain level of service then they must pay. If that level of service is not affordable then a lesser level of service is what you get. By service I mean from Day VFR all they way thru to IFR. You get what you pay for and by regulating, if that is what is required, would, one hopes take out the grey areas which are left open to imaginative interpretation.

CASA's attempts to date have been more or less par for their course. Read into that what you will.
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Old 16th Mar 2005, 05:06
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Being a CASA Supporter.....

Ok, boys settle down.

You will note that I have been accussed of being a CASA stooge in the past...so be it.

CASA is full of good folk, but its a Government Department none the less.

History will show that I [and others] have placed submissions into CASA following the invite to comment on the new make up of CASR 133.
Following a great "New and High" standard formulated by CASA [following our input I dare say] regarding Night Operations, EMS / MPT / SAR, further comment was sort from the Industry.

And guess what??

The industry rejected the new proposals!!!....great stuff guys.

I can only hope you have all written in regarding the proposed new CASR's..???....you have havn't you???

Give CASA a break.....you get exactly what you [we] deserve.
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