Inquest Into The Death Of David Wood

Contributing factors

• inadequate reconnaissance and risk assessment of fuel cache site with known crevassing
• failure to formally debrief pilots after observing crevassing on 28 December 2015
• insufficient training of pilots in crevasse identification and dynamic terrain assessment
• inability to deploy Field Training Officers during sling-load operations due to CASA regulatory interpretation
• inadequate cold-weather protective clothing worn due to helicopter constraints
• prolonged exposure time (4 hours 39 minutes) before extraction and medical care
• limited medical equipment and expertise available at remote extraction site
• miscommunication between AAD staff and pilots regarding fuel cache site suitability
• lack of formal post-flight debriefing procedures
• reliance on pilot expertise to assess landing sites without input from glaciologists or FTOs

Coroner's recommendations

1. Establish Field Location Assessment Group (FLAG) to undertake environmental and hazard assessment of identified locations with glaciologist engagement
2. Formalize post-aviation operations debriefs and field landing site assessments as mandatory documented procedures
3. Implement field landing site and fuel cache database accessible to all aviation contractors
4. Establish presumption that all Antarctic ice sheet is dynamic terrain until proven otherwise, with mandatory site assessment process
5. Provide mandatory training for helicopter pilots including Dynamic Terrain Awareness, Aircraft Crevasse Probing, and Station Operating Area Aerial Reconnaissance training
6. Require specific protective clothing for pilots including AAD-approved flight suits and down/insulated jackets when operating in crevassed areas
7. Implement prohibition on solo helicopter flights to unmanned locations
8. Require minimum group size of three people for deep field operations including helicopter pilots
9. Review and revise interpretation of Civil Aviation Order 29.6 to enable Field Training Officers to accompany sling-load operations
10. Establish formal mechanisms for inter-jurisdictional cooperation with other Antarctic nations for emergency response
11. Reform coronial arrangements in Antarctica to avoid Station Leader serving as Deputy Coroner due to inherent conflicts of interest
12. Ensure PMU has access to next-of-kin details for all deployed personnel in Antarctic Program
13. Enhance availability of advanced medical equipment in rescue operations, including oxygen, reliable heat sources, and defibrillators
14. Consider deployment of resident doctor with the rescue team to provide advanced medical care at the scene
15. Provide broader search and rescue training to base medical officers and senior pilots
16. Continue regular review and refinement of risk mitigation practices for Antarctic operations