Inquest into the death of Michael WILSON

Contributing factors

• Deviation from standard winching operating procedures
• Inadequate rescue plan with undefined belay anchor system
• Lack of ground-based backup resources despite SCAT protocol recommendations
• Poor inter-agency coordination between RCC, NSW Police and NSW Ambulance
• Communication failures between helicopter crew and paramedic on ground
• Deteriorating light conditions approaching darkness
• Helicopter positioned at excessive fleet angle exceeding operational limits (15 degree limit)
• Inexperienced crew member recently qualified on AW139 aircraft
• Absence of operational permission for hi-line procedure variant
• Lack of effective command and control at incident coordination level
• Failure to activate adequate ground-based SAR assets
• Use of unapproved roping techniques with rescue hook
• Inadequate briefing on critical operational details including anchor type, belay system, and weight transfer procedures

Coroner's recommendations

1. AMSA and NSW Police to develop a paper on early transfer of coordination of Land SAR operations from AMSA to NSW Police for presentation to National Search and Rescue Council
2. AMSA and NSW Police to review joint arrangements for prompt exchange of search and rescue incident data
3. Review the status of emergency services helicopter winching operations to clarify whether such operations constitute 'rescue' within the State Emergency and Rescue Management Act 1989 (NSW)
4. Complete review of Memorandum of Understanding between NSW Police Commissioner and NSW Ambulance Commissioner signed 21 October 2013, including inter-agency communications regarding mission tasking and conduct
5. Complete rollout of NSW Ambulance Aeromedical Integrated Risk Management Framework
6. Complete helicopter winch simulator including mission simulation as soon as practicable
7. Complete Enhanced Helicopter Paramedic Helmet System project and trial
8. Review position of SOT/SCAT Activation Officer including: incorporation into Aeromedical Operations Control Centre; training in SCAT land-based operations and helicopter paramedic operational roles; provision of protocols and training for helicopter beacon response and rescue operations planning and conduct
9. Complete revision of SCAT paramedic training materials
10. Schedule regular, ongoing SCAT paramedic training
11. Provide training to all NSW Ambulance paramedics, medical crew, aircrew and pilots on changes to NSW Ambulance Control and Command procedures relevant to aeromedical helicopter operations
12. Reinstate combined situational and scenario-based training for SCAT and Air Crew on annual basis as originally envisaged
13. CHC to review Hi Line Procedure in Operations Manual and develop comprehensive standard operating procedure governing use of Hi Line Procedure in overland winching operations
14. CHC to review current rescue helicopter crew training schedules including reintroduction of annual integrated scenario-based crew training
15. CHC to review cabin staff training documentation to ensure accuracy with current Operations Manual and Flight Staff Instructions
16. CHC to review company policy on video footage from winching cameras to ensure footage is captured and used in ongoing rescue training