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FACTUAL INFORMATION

EXECUTIVE SUMMARY

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.

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