1. 1
How do Australian contractors determine
real-world preparedness of helicopter crews
for winch rescue operations?
Have responsible stakeholders missed an
opportunity to evaluate emerging
(yet partially anecdotal) factors that may
have contributed to a recent helicopter
winch rescue occurrence?
15-foot training winch:
50-100-foot operational winch:
100-foot + operational winch:
Author: Mick Macfarlane MEmergMgt CSU
Date: 29th
May 2015

2. 2
Author/Report Details:
Mick Macfarlane
Independent Publication, 29th
May 2015
ISBN: 978-0-646-93981-0
Email: mmac3546@bigpond.net.au

3. 3
Executive Summary
A report published by the Australian Transport Safety Bureau (ATSB) in April 2015, analyses
factors associated with a helicopter winching accident that occurred in Victoria on the 31st
August 2013. This accident occurred when a patient was being recovered to a helicopter
hovering above steep and heavily wooded terrain at a height of approximately 80 feet. The
patient, accompanied by a paramedic on the winch hook, slipped from a rescue strop and
fell to his death. The ATSB identifies three contributing factors.
1. The patient probably lost consciousness due to the compressive nature of the strop,
his weight and pre-existing medical conditions.
2. Use of the strop without the integral hypothermic strap was not suitable for the size
and condition of the patient.
3. Limited guidance was provided by the operator and Air Ambulance Victoria to crews
on selection of the most appropriate winch rescue equipment given operational and
medical considerations.
As limited guidance (point 3) may also indicate a deficiency with supportive training, this
independent report evaluated existing arrangements that determine persons suitable to
undertake rescue work as described in AO-2013-136 (ATSB, 2015), and searched for
deficiencies in such provisions.
Identification of a milestone reduction in winch rescue training preparedness for rear-cabin
crewmembers’ provided focus and, challenged the minimal training and assessment to
prepare persons for the dynamic environment associated with specific operational rescue
helicopter tasking.
Furthermore, existing decision-making research and national guidance on rescue is applied
to the helicopter rescue crew environment to support analysis of relevant aspects of AO-
2013-136 and, how similarities exist with another incident AO-2011-166 (see appendix F).
This report identifies that although in general helicopter crews are well prepared, a difficult
to quantify weak-link exists with regard to high winch preparedness for the type of tasks
described in both AO-2013-136 and AO-2011-166 (ATSB, 2013).

4. 4
Contents Page
Common acronyms
5
Introduction
6
Aim and objectives
7
Objective 1 analysis
8
Objective 2 analysis
9
Objective 3 analysis
15
Objective 4 analysis
23
Objective 5 analysis
26
Findings against objectives
29
Conclusion
35
Recommendations
36
References
39
Appendix A – Stretcher-carry process
43
Appendix B – Fitness tests
45
Appendix C – Fly-away requirement
48
Appendix D – Potential winch delays and fending off branches requirement
50
Appendix E – Winch control check
52
Appendix F – Analysis of AO-2011-166
54
Appendix G – ACM/ARC logbook examples
58

5. 5
Acronym Meaning
ACM Aircrewman
AGL Above Ground Level
AMSA Australian Maritime Safety Authority
ARC Ambulance Rescue Crewman
ATSB Australian Transport Safety Bureau
CAO Civil Aviation Order
CAR Civil Aviation Regulation
CASA Civil Aviation Safety Authority
CFA Country Fire Authority
CRM Crew Resource Management
ERGT ERGT Australia – Registered Training Organisation brand
HART High Angle Rescue Techniques
HEMS Helicopter Emergency Medical Service
HI Heave In
ICS Inter Communication System
IMC Instrument Meteorological Conditions
ISO International Standards Organisation
MHF Major Hazard Facility
RAAF Royal Australian Air Force
RAN Royal Australian Navy
RC Rescue Crewman (not ambulance service, has specialist rescue skills)
RPDM Recognised Prime Decision Making
SAR Search and Rescue
SCAT Special Casualty Access Team
SES State Emergency Service
USCG United States Coast Guard
VET Vocational Education Training

6. 6
Introduction
The intent of this analysis, like the purpose of ATSB investigations, is to identify and reduce
safety-related risk. The specific risk to be examined is the preparation of Aircrewmen (ACM)
and Ambulance Rescue Crewmen (ARC) for decision-making associated with operational
winch rescue tasks.
Whilst acknowledging investigation AO-2013-136 provides a detailed account of this
occurrence and evaluates procedures, processes and equipment relevant to the winch
rescue task, its specific analysis of crew capability appears to have omitted an emerging, yet
partially anecdotal, weakness in helicopter search and rescue (SAR) preparedness i.e.
appropriate, task focused (and realistic), winch rescue training and assessment of ACM and
ARC for high winch operations. However, to ensure perspective during reader analysis,
acknowledgement and reinforcement of the positive actions of the SAR crew of VH-VAS
(HEMS 5) is important. As indicated by AO-2013-136 data, the crew followed appropriate
procedure, utilised crew resource management (CRM) and operated within company and
regulatory directives. This is not disputed. Furthermore, the author acknowledges the
positive aspects of Australian Helicopters and Air Ambulance Victoria’s introduction of
greater rescue equipment guidance to HEMS crews and a seat-type harness for improved
safety.
My interest in this area stems from 15 years working in aviation rescue as an ACM and
Rescue Crewman (RC) on RAAF SAR and HEMS contracts in most states and territories, plus
United Nations work in East Timor. Additionally, time as an Australian Parra-Jumper where
helicopter winch rescue was common practice provided unique insight into demanding
rescue operations.
With a total of 37 years’ experience in emergency operations, consulting and facilitation,
ranging from navy clearance diving to professional firefighting, I have gained a broad
knowledge base and experience of real-world emergency operations that is consolidated
with a Master of Emergency Management degree and other formal qualifications.

7. 7
My current position of consultant and facilitator to the oil and gas sector based in Western
Australia requires me to train and assess command teams of Major Hazard Facilities (MHF)
both on and offshore. Focus of such training is preparedness and response, of which one
component within the broader scope is helicopter medevac and SAR arrangements.
Aim and Objectives
Aim:
To determine whether the preparedness of Australian helicopter SAR/HEMS crewmembers
is sufficient for operations and decision-making encountered in the dynamic environment of
winch rescue i.e. environments that exceed typical training height limitations.
Objectives:
1. To verify the existing process of gaining qualifications to be rostered on a SAR/HEMS
helicopter.
2. To determine whether flight-hours recorded in a logbook accurately portray ACM
and ARC winch rescue experience and capability.
3. To identify existing research and/or national guidance that support decision-making.
4. To identify whether any aspect of AO-2013-136 may indicate a weakness in ACM or
ARC preparedness for the task undertaken.
5. To determine whether realistic ‘other options’ were available to the rescue crews
detailed in AO-2013-136.

8. 8
Objective 1: To verify the existing process of gaining qualifications to be
rostered on a SAR/HEMS helicopter.
Winch authority
The Civil Aviation Safety Authority (CASA) through the Air Operator Certification process
(AOC) (CASA, 2003, 2008) provides directives and approvals for winch rescue. Therefore,
helicopter operators must demonstrate to CASA that they can undertake winch rescue in
accordance with relevant Civil Aviation Orders (CAO’s) (ComLaw1, 2015) and Civil Aviation
Regulations (CAR’s) (ComLaw2, 2015).
A key to determining this capability is CASA verification of appropriate fight operations and
engineering standards for the operating company, supported by other relevant
documentation including an operations manual (CASA, 1997). The operations manual must
provide sufficient guidance on how to undertake all aspects of winching (identified within
the operators AOC) including the scope of equipment to be used, initial training of new staff
and recurrent training for specific skills and procedures. However, despite meeting
minimum CASA competency requirements, the scope of initial and recurrent training
documented within an operations manual may vary between operating companies.
Variation is likely dependent upon factors associated with: a) commercial responsibility, b)
safety analysis, and c) operational and contractual requirements.
A member of flight training staff from within a company’s training and checking organisation
(CASA, 2012) typically assesses recurrent winch training during a line-check in accordance
with CAR 217 (CASA, 2014) and operations manual criteria. This verification process requires
a demonstration of typical activity the staff member being assessed may have to undertake
operationally. Additionally, staff will undertake further recurrent training as specified in the
operations manual and, as described in AO-2013-136 i.e.
“…The operations manual recommended that an ACM conduct a winch at least every
6 months to maintain winch proficiency…” (p. 5 – Air Crewman) and,
“…His most recent winch procedure was a 3-month winch currency check…” (p. 5 –
Ambulance Rescue Crewman)

9. 9
Although a minimum of 6-month and 3-month recurrent winch practice may appear low,
additional periodic criteria and operational shift process will increase the recurrent winch
experience. For example, it is highly likely that ACM and ARC will exceed minimum recurrent
periods due to other crewmember training obligations not aligning with their own.
Furthermore, staff will typically undertake multiple winches on a single recurrent-training
flight, thus increasing the winch training volume.
In addition to flying training, ACM and ARC are required to pass a compulsory CASA medical
and some operating companies will also mandate a periodic fitness test involving
cardiovascular, muscular strength and specific role fitness evaluation, such as swimming
ability for water rescue (see appendix B).
However, despite the process and intent of initial and recurrent training, plus line-checks, it
is the alignment of such activity to real-world operational conditions where the gap
between capability preparedness and not exceeding mandated safety confines might need
further scrutiny.
Objective 2: To determine whether flight-hours recorded in a logbook
accurately portray ACM and ARC winch rescue experience and capability.
Training for quick response operational tasking
For persons whose primary function is short notice response to emergency events there is
typically conflicting viewpoint on the level of preparedness required to be operationally
effective. Key factors in this argument are:
 Realistic capability i.e. what might I have to do and what do I need to do to prepare?
 Safety i.e. what level of preparation will achieve realistic preparedness, without
undue risk?
 Cost i.e. what is realistic expenditure for training (the commercial reality of
operational preparedness)?

10. 10
Milestone to winch rescue operational preparedness reduction
Prior to a winch rescue training accident in 1995 involving a Royal Australian Navy (RAN)
helicopter crew where a sailor fell to his death during a high winch (CASA, 1998 and ABC
1999) height limitations were typically influenced by the motivation of crews and the terrain
in their geographic surrounds. Although records of this event are limited, it is widely
acknowledged that a dynamic-rollout (un-commanded disconnect) from the winch-hook
occurred resulting in the sailor falling to rocks from just below the aircraft following a
routine winch-control-check (see appendix E).
Following investigation of this event, two significant changes occurred:
1. A new design of winch hook was introduced to prevent future dynamic-rollouts (see
appendix E).
2. Severe ‘live’ winch training height limitations were applied to both military and civil
operations.
Those height limitations: 15-feet over land and 50-feet over water are still common today,
but their enforcement predominantly lies with helicopter operators through operations
manual instructions. However, as such directives are significantly influenced by CASA
winching criteria described in CAO 29.11 (ComLaw, 2015) and general health and safety risk
management practice, it is unlikely responsible stakeholders would see the need for change.
Although this may be seen as a positive situation i.e. risk reduction achieved through
application of best-practice methods; conversely, it may produce just perceived risk
reduction in some areas? For example, if direct feedback from operational ACM and ARC
were to be obtained through robust application of the risk management principle of
‘monitor and review’ (ISO, 2009) data may reveal experience degradation that responsible
stakeholders are yet to identify?
Effect on winch rescue training:
Initially, many in Australian helicopter SAR saw the implementation of winch height
restrictions as a long overdue safety control. On the other hand, it is widely acknowledged
that many ACM and ARC challenged the 15-foot overland height restriction almost
immediately. A prominent concern at the time was lack of live practice winching to areas

11. 11
within the geographic boundaries of crew responsibility. Such areas included steep terrain
and any location requiring winching through ‘holes’ in tree canopies. Specific concern
centred on lack of preparedness for the complexities of such operations from heights that
were typically well in excess of 15-feet.
Complexities include, but are not limited to:
 Hazards associated with branch movement in rotor wash
 Reduced or loss of visibility of the ARC and casualty
 The need to stop winching to reposition the aircraft mid-winch
 Rotor wash causing branches to break
 Greater difficulty fitting rescue equipment
 Inappropriate stretcher tag-line angles
 Increased chance of wire swing and spin
 Heightened danger should intercom failure occur
 Poor or lost communication with ground parties
 ARC having to fend off branches
 Risk of casualties slipping from single strops during extended winches etc.
Although dedicated SAR/HEMS pilots were sympathetic to such concerns, the 15-foot rule,
for the vast majority of training, remained unchanged. An example where increased live
training height was permitted up to 50-feet over land is identified in another accident report
(ATSB, 2013). However, operations manual directives permitting increased height are likely
worded to discourage SAR/HEMS crews from undertaking such activity i.e. ATSB (2013)
states:
“…A comparison of the training benefit was to be made with the potential risk to the
involved personnel…” (p. 32)
Furthermore, and despite formal reporting to mandate higher recurrent winch training, a
typical counter to an ACM’s concern from company management at the time went along the
lines of this:

12. 12
“…That’s why we employ experienced blokes like you…” (Author experience)
Additionally, less sympathetic pilots would adopt the approach of, “hovering is just
hovering”. This regular rebuttal accurately reflects (to an extent) the consistent process
pilots use to maintain ‘hover-reference’ whilst winching is in progress i.e. regardless of
height above ground, a pilot will typically choose a hover height as close as practicable to
trees so that a branch (or other fixed object) can be used to judge movement. And, this
reference point will be the same whether the tree canopy is 10-feet or 210-feet above
ground level (AGL). Nonetheless, such a statement demonstrates potential ignorance of the
complexities (risks) that are very real for ACM and ARC?
During this period, the Managing Director of a prominent helicopter company possibly
demonstrated significant lack of winch rescue knowledge during enterprise bargain
negotiations. Although circumstantial, the quote below has been included to indicate the
potential level of misunderstanding at the time, and how this may have influenced training?
Moving his thumb back and forth as though it were on the control wheel of a winch
pendant, the MD stated:
“…Hey, why should I pay you more when all you do is winch in and winch out…”
(Direct correspondence ACM ‘B’, early 2000’s)
Situation today
Due to height restriction directives, it is unlikely that many ACM and ARC who have
undertaken initial winch rescue training post height restriction have gained the same
training experience as their predecessors. Furthermore, previous fitness tests (see appendix
B) involving running, swimming and upper-body gym work have been reduced to levels
where persons unlikely to be deemed suitable previously, are now permitted to undertake
ARC/RC work. The consequence of inappropriate physical fitness becomes abundantly clear
when correlated with typical operations manual ARC/RC role descriptors, plus the potential
for acute-task-stress when working alone (ground or water) in adverse conditions.

13. 13
Although a typical line-check will contain the real-world aspects associated with a
SAR/HEMS task such as: flight planning, navigating to an incident location, task assessment
and equipment selection during orbit, the actual ‘live’ winch practice will remain unrealistic
with the exception of bringing persons into the aircraft cabin. The unrealistic nature of the
task is the fact that the winch is routinely undertaken at a location where safe landing can
be achieved in the event of aircraft emergency i.e. large, flat, open area as described in
section 5 of CAO 29.11 (ComLaw1, 2015) and, within the 15-foot height restriction imposed
by the operating company.
Notwithstanding the above, high winch or ‘advanced training’ (ComLaw1, 2015) may occur
with ballasted weight (no person) on the winch hook, but from a height and position that
will permit the aircraft to ‘fly-away’ (see appendix C) with one engine inoperative. Although
this process exposes the ACM to aspects of a high winch i.e. there is extended hover time,
increased potential for wire swing, reduced winch-picture (visibility reduction due height)
etc., it does not replicate the challenges of winching through a tree canopy to steep terrain.
The result of this situation is the possibility that the first winch through a tree canopy to
steep terrain that an ACM undertakes will likely be during an operational task, from a height
well above 15-feet, with an ARC whose physical fitness may be questionable.
Flight-hour relevance to determining ACM and ARC winch experience?
In aviation a key determinant to flight experience for pilots, ACM and ARC is the flight hours
recorded in an individual’s logbook. To gauge more specific skill-sets hours are categorised
into day and night operations. For pilots, there are additional categories and endorsements
that support experience evaluation. For example, instrument flying. This skill is broadened
into ‘actual’ flight in instrument meteorological conditions (IMC) and ‘simulated’ IMC.
Additionally, because robust ability to fly in IMC is required, a formal ‘instrument-rating’ is
mandatory and pilot experience can be further assessed against the number of ‘instrument-
rating-renewals’ that have been completed.
Typically, to operate on a helicopter SAR/HEMS contract an ACM will require a minimum of
500 hours recorded in their logbook. However, on a similar contract the hours required are

14. 14
far less for an ARC and equate to those achieved through initial training i.e. 15-25 hours. The
significantly lower number is because the ARC is selected primarily for advanced
paramedical skills and not ability to undertake a lead role in the rear cabin of an aircraft. For
persons not familiar with ACM responsibility, the following narrative on crew
communication provided by a veteran SAR/HEMS pilot and ACM grants insight into the
complexity of winch operations, i.e.
“…When engaged in winching operations an aircrewman must provide verbal
information to the pilot so that the aircraft can be directed over the rescue point. The
pilot, who can’t see the rescue point below the aircraft, must follow the aircrewman’s
directions precisely if rescue and safety is to be achieved. Complicating this interaction
is anxiety produced when winching close to a moving vessel with multiple hazards.
During such a task expert crew coordination is essential, especially if weather and sea
conditions are poor…” (Personal correspondence pilot ‘A’ and ACM ‘C’, 28th
April
2012).
Relevant CASA documentation describing the need for effective communication (CASA,
2006) provides a more sterile description:
“…With an approved inter-communication system which will permit continuous
communication between the pilot(s) and aircrewman/winch operator…” (p. 5).
Therefore, if risk managers acknowledge the challenges of simply communicating effectively
whilst exposed to the dynamic hazards of winch rescue over hostile terrain, it would be
prudent to have robust understanding of the consequences of poor-communication in such
environments. Subsequently, correlation of such data with the hazards and risks of live
winch operation from height, in environments equivalent to that described in AO-2013-136,
may well produce valuable information demonstrating the experience required for safe
operations. If such data were then compared to typical recurrent training activity, analysis
may produce more accurate indication of the genuine experience and physical fitness
required to undertake ACM and ARC operational roles safely?

15. 15
Although the above raises some important questions, the only readily available gauge
contractors of SAR/HEMS operators have to determine ACM/ARC winch rescue experience
remains total flight hours. Consequently, were a minimum 500 hours obtained solely
responding to motor vehicle accidents (no winching), or was there a degree of operational
winch rescue included? Moreover, if ACM/ARC have only obtained recurrent winch rescue
experience during their 500 hours, there still remains (at best) ambiguity over the decision-
making ability this level of experience has produced to cope with high winch operations, to
steep terrain, through tree canopies (see appendix G for logbook examples).
Objective 3: To identify existing research and or guidance that support
decision-making.
Enhanced winch rescue experience through simulation
The concept of flight simulation to enhance airline piloting skill and crew management is not
new. Like airlines, the helicopter industry acknowledges the benefit of flight simulation as
demonstrated by the widely accepted practice of sending oil and gas contracted pilots and
military crews for recurrent simulator training. Through simulation pilots can be safely
exposed to both the slow, emerging incident situation and the critical emergency event,
each requiring disciplined action in accordance with flight manual and company directives to
prevent escalation. Such exposure and routine practice produces enhanced situational
awareness and skills that greatly support safety when pilots’ return to the real-world
cockpit.
For specific contracts, the need to maintain such skills and experience is deemed essential
despite the associated training burden and cost to an operating company. Whether the
same emphasis should be applied to ACM training where critical decisions may affect crew,
patient and aircraft safety was not clearly definable in available literature with the exception
of some military aircrews (Cobham, 2011). Nonetheless, as Cobham (2011) confirms,
simulation is available to complement ACM training. However, although the fidelity of such
systems is far from the standard demanded by regulatory bodies for pilots, the lesser quality

16. 16
of these relatively simple simulators does provide opportunity for ACM to gain greater
experience in a safe environment.
Additionally, live rescue winch trainers (AMST, 2015 and ATSB, 2013 p. 49) can be utilised
where ACM/ARC skills require a high degree of confidence and experience to combat the
stress associated with inexperience where demanding operations are likely.
Relevant decision-making research - RPDM
Recognition Primed Decision Making (Klein, 1998) or Naturalistic Decision Making (Klein and
Zsambok, 1997) describes cognitive processes by which individuals typically make decisions
under pressure. Through analysis of fire fighters, ICU staff, military personnel and other such
professions, this research identified a common theme; familiarity with a given situation
allowed individuals to recognise ‘patterns’ from situational ‘cues’ that enable selection of an
appropriate ‘mental model’ that supports rapid and appropriate decision-making.
Therefore, if we apply the basic principle of RPDM to the role of an ACM or ARC and look
holistically at generic criteria supporting their decision making ability, four yardsticks
become apparent: 1) Initial and recurrent training, 2) operational experience, 3)
understanding of and compliance with company directives, and 4) use of available visual and
audible cues.
Logic would suggest that reduction of any of these criteria reduces RPDM capability and
therefore, the effectiveness of a particular SAR/HEMS crewmember when critical decisions
need to be made. Notwithstanding this point, individuals will always have disparate real-
world experience that may challenge decision-making, yet SAR/HEMS crews routinely
manage this by reinforcement of procedures and proactive CRM. However, should a
reduction in training for critical rescue activity be allowed to exist, a weak, yet controllable,
RPDM criteria is likely to emerge. Therefore, reinforcement of minimum training needs to
support acceptable crewmember RPDM, in order to bolster CRM during periods of acute
task pressure, becomes a likely counter to poor decision-making in such situations as
suggested in figures 1 and 2 below.

17. 17
Figure 1: RPDM with equal criteria.
Figure 2: RPDM where one or more criteria contain less weight.
Furthermore, if physical fitness were to be included as another RPDM influence, risk
managers may well consider the added challenge to decision-making should an ARC be out
of breath or physically exhausted at a critical decision point during an operational task?
Equally, the effect of acute stress (USAMRICD, 2013) and stress related fatigue (Safer
Healthcare, 2015) on an individual’s ability to make decisions is very relevant.
Relevant decision-making research – stress
Research into how stress affects airline flight crew and cabin staff performance (Maymand,
Shaksian & Hosseiny, 2012) determined that because of a clear relationship between stress
and negative performance, all crewmembers and cabin crew should be aware of stress
1 Quals
Currency
2 Operations
Experience
3 Company
Directives
4 Cues
RPDM with equal strenght critiera 1 Appropriate Qualifications
and Recurrent Training
2 Real-World Operations
Experience
3 Knoledge and Compliance
with Company Directives
4 Visual and Audiable Cues -
Situational Awarenss
5 Decision Error Potential
Consequence:
Descision error potential is acceptable
5
1 Quals
Currency
2 Operations
Experience
3 Company
Directives
4 Cues
RPDM with only minimal training and expereicne, but
strong relainace upon company directives and cues
1 Appropriate Qualifications
and Recurrent Training
2 Real-World Operations
Experience
3 Knoledge and Compliance
with Company Directives
4 Visual and Audiable Cues -
Situational Awarenss
5 Decision Error Potential
Consequence:
Descision error potential increases
5

18. 18
factors (in all conditions) so that effective evaluation can be undertaken. Equally, suggesting
that annual appraisal of stress effects in ‘various situations’ would support performance
management, highlights the need for management personnel to promote such activity.
Maymand et al., (2012) utilised a stress curve (Nixon, P, 1979) to support their findings. This
widely acknowledged tool is used to show how increasing stress levels affect performance
through demonstration of increased fatigue and ultimately ill health. To support oil and gas
management preparation, registered training organisation staff (ERGT, 2013) adapted the
Nixon curve to show how fatigue and ill health are detrimental to individual decision-making
for command team members (Figure 3).
Figure 3: ERGT Australia (2013) command team training decision-making presentation.
The comfort zone factor in figure 3, ERGT (2013) suggest, becomes variable when aligned to
individual experience and/or ability to manage stress during an escalating oil and gas
emergency. Consequently, a reduced comfort zone means the ‘distress’ level is reached
more rapidly, which results in widely acknowledged survival reactions of either fight, flight
or freeze. Furthermore, the United States Army (USAMRICD, 2013) identifies that ‘distress’
will also have negative effect on vision, hearing, fine-motor skills and judgement. The
solution for preventing paralysis during high stress situations suggests Fink (2002) is simply
to train people appropriately, or as ERGT (2013) promote, provide regular, challenging and
realistic practice in the types of situations individuals are likely to be exposed to. Moreover,
to prevent hidden weaknesses coming rushing to the forefront during an emergency,
Critical to Success – Stress Management
• Function of stress - Stress Response Curve
Poor Decision Making
Exhaustion
Stress Level
ComfortZone
PerformanceLevel
Fatigue
DistressGood Stress
Too little
stress
Poor Decision Making
Comfort
Zone
Distress

19. 19
Lagadec (1993) reinforces genuine understanding of specialist capability, and not simply
reliance upon documented procedures yet to be fully tested.
Therefore, increasing an individual’s comfort zone by exposure to all relevant environments
during training will likely have positive results when the same individual is exposed to the
real-world demands of operational tasks.
Corroborative advice from the Australian Maritime Safety Authority (AMSA)
As the authoritative national body for Search and Rescue in Australia (AMSA, 2014), AMSA
provides pertinent advice with regard to hazards and risks associated with helicopter rescue
i.e. AMSA (2014) states:
…The importance of thorough training for all personnel employed on SAR missions
cannot be over-emphasised. Failure of a single link… can compromise the success of
the operation, resulting in loss of lives of SAR personnel, lives of those that might
otherwise have been saved and/or loss of valuable resources… Since considerable
experience and judgment are needed to handle SAR situations, necessary skills
require significant time to master. Training can be expensive but contributes to
operational effectiveness. Quality of performance will match the quality of training…
(p. 222).
Additional supporting research, Blue-Mist
The expression Blue-Mist describes a cognitive falling associated with both SAR and
medevac operations (Laws, 2012). A similar expression ‘Red-Mist’ is widely accepted by
militaries, and described by British police (Police Specials, 2008) as the:
…Narrowing of attention through heightened psychological and physiological arousal
in the pursuit of a goal, during which officers may take undue risks’... (p. 1)
Blue-Mist, suggests Laws (2012) & Macfarlane (2013), is similar to Red-Mist, but there is a
slower process. Not dissimilar to a veteran police officer a seasoned member of a SAR crew
will have belief in their own ability, their job is rescue, they are not used to failure. Equally,

20. 20
an inexperienced SAR crewmember may want to be accepted by such an individual to prove
his or her own ability. When confronted with problems during a rescue task it is highly likely
that the former individual will seek solutions and the latter will agree to them. This in itself
is a normal function of SAR, what is abnormal though, is when a logical solution doesn’t
work and illogical solutions are suggested.
Where a SAR crew is acutely aware of CRM the consequence of illogical suggestions is
simply that they are countermanded. However, should CRM skills be poor, or an individual
be a dominant force within the crew, it is possible that an illogical solution may be accepted.
This first step into illogical action, based upon emotive belief that rescue is critical to success
and/or there is a strong desire to be accepted, is when an individual or entire crew begin to
be affected by Blue-Mist. Moreover, if the same crew persists with rescue founded by
illogical action, there is a possibility that Blue-Mist will increase and further illogical
decisions will be made. Inevitably, this is a course of action that will lead to an accident.
Additional supporting research, Diffusion of Responsibility
Psychological analysis of how individuals are less likely to take action in a group situation
(Darley & Latane, 1968; Cherry, 2011) uses the term ‘Diffusion of Responsibility’ to explain
this phenomenon. Cherry (2011) identifies that a sequence of important internal decisions
need to be made prior to an individual deciding to act. If these steps are applied to an ACM
or ARC wishing to countermand what they believe to be unsafe action, they must first:
A. Notice a problem
B. Decide if what they are witnessing is actually an unfolding emergency
C. Next (and critical) is deciding to take personal responsibility to act
D. Then, deciding on what should be done and/or said
E. And finally, actually taking action
Cherry (2011) also identifies two factors that increase the potential for Diffusion of
Responsibility that can be related directly to ACM/ARC roles during operational winching:
1. Anonymity i.e. they do not know the victim and are more likely to expect someone
else to step up. This example may apply to ground party personnel deferring to the

21. 21
knowledge of an ARC who is typically deemed more experienced (Ambulance, 2012),
despite their concerns.
2. Ambiguous situations i.e. if they are not really sure what is happening they are far
less likely to take action. This example may apply to any ACM/ARC or ground party
personnel with insufficient training or operational experience remaining quiet,
despite their concerns.
Factors that Cherry (2011) identified to decrease Diffusion of Responsibility include having
appropriate skills i.e. specific training will produce confidence to step-up and take action.
Consequently, should either pilot, ACM, ARC or ground party lack specific exposure to high
winch operations of this type, it is possible they may have continued with the task despite
individual concern?
Identification of unacceptable decision error potential during winch rescue
The above research when combined and applied to operational SAR/HEMS crews identifies
the potential for reduction in either individual or multiple crewmember decision-making
ability, as suggested in figure 4.1 and 4.2 below.
Figure 4.1: Decision error-potential mitigation with equal RPDM variables and ARC with appropriate fitness.
1 Crew RPDM
Variables Equal
Crew RPDM and stress-management with equal
variables, plus appropriate ARC fitness level.
1 SAR crew RPDM variables
2 Decision error potential
3 Blue Mist suseptibility
4 ARC fitness level
Consequence:
Descision error potential and suseptibility
to Blue Mist remains acceptable.
4 ARC Fitness
Appropriate
2 & 3

22. 22
Figure 4.2: Decision error-potential increases with unequal crew RPDM variables and inappropriate ARC fitness.
Additional supporting research – Avoiding Systematic Decision Errors
Avoiding decision errors, suggests Hardcastle (2008), requires professionals who truly
understand the complexities of issues at hand, either through experience or thorough
education and technical training. This type of exposure will support identification of,
suggests Hardcastle (2008):
“…More viable alternatives…” and professionals who “…will more accurately
estimate probabilities than professionals with less experience or education…” (p. 1)
Therefore, the collective research and guidance of this objective suggests a requirement for
not only assertive written directives, but also equally assertive training; because without
such balance it is unlikely rescue crews would be able to fulfil all contacted obligations
safely. For example, an operations manual directive identified by the ATSB (2013) states:
“…All members of the crew were expected to participate in the consideration of the
potential risks to a mission. The mission was only to proceed if all crew members
were satisfied that it was safe to do so…” (p. 31)
Subsequently, if crews have never been exposed, or have had disparate exposure to high
winch operations through trees to steep terrain, it is possible that the above directive would
require crews to abort such missions? So why do they proceed? Despite the potential stress
1 Crew RPDM
Variables Unequal
Crew RPDM and stress management with unequal variables,
plus ARC with unsuitable physical fitness.
1 SAR crew RPDM variables
2 Decision error potential
3 Blue Mist suseptibility
4 ARC fitness level
Consequence:
Descision error potential and suseptibility
to Blue Mist increases.
2
3
4

23. 23
of an unfamiliar environment, one answer might simply be that crews believe they have
been sufficiently prepared and are therefore obligated to step up? However, a more realistic
appraisal might be the inhibitive affect upon decision-making generated by a combination of
human-factors (Reason, 1990 and CASA, 2012)?
Consequently, research suggests that awareness of individual and crew capability, in excess
of recorded flight hours, might be an area for closer scrutiny if decision-making, and
therefore safety, is to be maximised during future high winch rescue operations?
Objective 4: To identify whether any aspect of AO-2013-136 may indicate a
weakness in ACM or ARC preparedness for the task undertaken.
Note: the author acknowledges and reinforces the decades of experience Australian
helicopter operators have undertaking successful winch rescue operations. Therefore, this
specific objective’s analysis is not intended to diminish the collective expertise and
dedication of personnel involved in SAR/HEMS work. As stated in the introduction of this
report, the intent is to provide focus on a potential weak-link associated with preparedness
of personnel for high winch operations and how this may affect decision-making ability.
Personnel information (p. 5)
This section provides typical (and essential) detail relating to crew experience and health i.e.
total flight time, qualifications, last flight and more specifically the last winch operation. Yet
despite figures verifying time on type, total flight hours etc., there is no verification of the
number of winches the ACM, ARC or pilot had undertaken from heights above 15-feet, to
steep terrain, or through tree canopies etc. The investigative relevance of this becomes
clear when comparison is made to piloting. If, for example, a pilot had only been trained to
land on a sealed runway yet crashed whilst landing on an unsealed landing strip, without
prior instruction, it is likely that this would be identified as a contributing factor during
investigation. However, AO-2013-136 does not explore crew winch experience any further,
apart from a summation of contractual winch rescue tasks undertaken by the operator and
Air Ambulance Victoria in general.

24. 24
Progress of the winch procedure (p. 18)
This section of the report makes statements that warrant cross-examination i.e.
“…Compounding the developing situation, the progress of the winch was delayed in
the initial stages due to the need to avoid trees during the ascent…” (para. 1)
And,
“…Although the crew would not have anticipated the initial delay in the winch due to
the tree canopy… “ This could have suggested “…discontinuing the winch and
exploring other options…alternately, had the trees not been an issue and the ARC
been able to focus on maintaining the position of the patients arms, the accident may
not have occurred…” (para. 3)
The above indicates a lack of understanding by either the crew or, perhaps the ATSB
investigator, of the complexities of winching from height through tree canopies i.e. persons
exposed to regular live winching through tree canopies have robust awareness of the
potential for the delay described and the need to fend off branches (see appendix D).
Combined crew experience and crew resource management (p. 5)
As previously stated, specific detail of the crew’s operational winch experience is not
provided in AO-2013-136. However, the ACM received his first winch qualification with the
Army in 2009 and joined the helicopter operator in October 2012, receiving his winch type
endorsement in the same month. From that time, a period of approximately 9-months
elapsed prior to the occurrence.
Despite the minimum recurrent training approved by CASA through the AOC process,
analysis of the type of winch training undertaken by the ACM during this period, and during
his time in the army, may well have provided a more realistic appraisal of role preparedness.
Equally, the same applies to the ARC and pilot. For example, due to radio problems the ATSB
identify that:

25. 25
“…The ARC and ACM decided that the ARC would use standard winching hand signals
to indicate whether a winch extraction would be required…” (p. 2, Arrival at the
scene)
This suggests that the final decision to winch was left with the ARC and was an escalation
away from primary process i.e. not using the radio for critical winch communications. If so,
evaluation of this crewmembers specific winch experience may have been beneficial to the
investigation, as reinforced by the ARC’s decision, due to the position of the patient on the
steep terrain, not to use the hypothermic strap i.e.
“…The ARC reported that this would have made it difficult to fit the hypothermic
strap…they also did not consider a hypothermic strap was necessary on this
occasion…” (p. 18, Rescue equipment selection)
An appropriate rebuttal to this statement, for the purpose of ARC preparedness analysis,
might have been to seek clarification on how many times the ARC had fitted a hypothermic
strap (on land) in other than an approved training location i.e. flat, clear area. Or more
precisely, had the ARC been given the opportunity to practice fitting straps and other role-
rescue-equipment in ground conditions likely to be encountered within his aircrafts
operational boundaries and, how often did the ACM and ARC practice winching without
radio communication?
Furthermore, the widely accepted intent of the hypothermic strap as a means to maintain
blood pressure post retrieval from water and therefore, prevent patient collapse and fall
were a single strop to be used is challenged with the ATSB statement below i.e.
“…Another of the operator’s ARC’s reported that they also would not have used the
hypothermic strap, as it would have made it more difficult for an ARC to keep the
patients arms down…” (p. 18, Rescue equipment selection)
The above contradicts widely accepted equipment selection practice i.e. where a patient is
cold, weak or injured and a stretcher lift is impracticable, a hypothermic strap is typically

26. 26
used to provide additional physical support and patient reassurance. This general advice is
supported by AMSA (2014) i.e.
“…Without jeopardising the ultimate safety of survivors, foremost consideration shall
be given to the potential impact on any medical condition of the survivors by the
method of recovery…” (p. 206).
Other ARC concern about instability (p. 18) due to the size of the patient compared to the
ARC and how this also influenced the decision not to use the hypothermic strap may have
benefited from greater analysis too. For example, comparison with the ARC’s concern
(Presumably a developing spin caused by rotor-wash on an unsymmetrical shape?) with that
obtained from a range of ACM may have identified differing assessments of such risk i.e.
accepting spin verses the risk of a large, injured man, who had been administered
Morphine, slipping from a single strop?
Equally beneficial would be determination of the pilot’s exposure to this type of task as the
pilot has ultimate responsibility under CAR 224 (CASA, 1998b) criteria for approving the
winch method identified by the ACM and ARC.
Although AO-2013-136 describes good CRM process between all crewmembers, which
extends to liaison with ground personnel, should one or more of these persons lack
sufficient experience applicable to the task, be influenced by acute stress or, be physically
exhausted, the decision-making process is likely to be flawed. The critical significance of this,
as possibly indicated by the ATSB (p. 18), is the crew’s final decision to winch in lieu of
exploring “…other options...”
Objective 5: To determine whether realistic ‘other options’ were available to
the rescue crews detailed in AO-2013-136.
Medical assessment and ground evacuation option
AO-2013-136 advises that ground party paramedics assessed the patient as being:
“…Alert and able to follow instructions…” (p. 6, Patient information)

27. 27
Additionally, Morphine had been administered intravenously to relive pain and an inflatable
splint had been applied to the patients left ankle. This suggests, although not detailed in AO-
2013-136, a closed fracture i.e. no bone protruding. Furthermore, medical records indicated
that the patient had a history of heart disease, although it is not specified whether this
information was available to ground party paramedics, or the ARC, at the time.
Notwithstanding the above, the patient was a large man (138kg) aged 65 and of medium
height, so it would be safe to assume experienced paramedics would have assessed this
person as a possible cardiac risk. Therefore, the paramedics determination of the actual risk
to the patient is important when evaluating the decision to winch i.e. did paramedics
determine the patient was time-critical and had to be winched for life saving purposes, or
was his condition less serious? This is not clearly identified, despite the “...Alert and able to
follow instructions…” statement, yet it is nonetheless a critical determinant to any winch
go/no-go decision where ambiguity exists, as reinforced by AMSA (2014) i.e.
“…Evacuations should therefore only be carried out…in the event of serious injury…or
where lack of other means of rescue might result in loss of life…” (p. 211)
Supporting this guidance is widely accepted operations manual directives that reinforce
winching as a last resort i.e. due to inherent dangers; the crew must look for alternative
methods before committing to a winch. Furthermore, as the side effects of intravenous
Morphine are readily available (WebMD, 2015) i.e. abnormally low blood pressure, dizzy,
drowsiness, feeling faint etc., and notwithstanding ATSB physician and pathologist advice
post occurrence (p. 17), winching a large, injured man, in a single strop, when Morphine has
been administered would likely have flagged additional risk to the existing danger for ACM
and ARC with suitable experience. Therefore, whether the patient was time-critical remains
an important element when evaluating the final decision to winch.
Available data to support a winch go/no-go decision
Data available to commence evaluation of the winch decision came early i.e. AO-2013-136
indicates pre-departure advice to the crew confirmed the steepness of the terrain and that:

28. 28
“…A winch extraction would likely be required…” (p. 1, Departure)
And prior to arrival,
“…Due to the steep terrain and injury sustained by the patient, it was decided that a
winch extraction was the best method for retrieving the patient…” (p. 18, Rescue
equipment selection)
Similar ATSB statements supporting the HEMS 5 crew’s assessment of the situation advise
evaluation of tree height, state of branches, steepness of the terrain and the hazards these
presented during winching. This indicates a systematic winch assessment by an experienced
crew. Conversely, a lack of discussion on stretcher-carry options, available daylight to
support such action, plus the criticality of the patient suggests that the crew’s recovery
assessment had focused on winching?
Ground party influence on the decision to winch
Early advice on the need to winch came from a ground party consisting of police, country
fire authority (CFA), ambulance and state emergency service (SES) personnel who had hiked
into the site. Although this hike took just thirty minutes (p. 1, Departure) and contained
acceptable numbers of human resources (see appendix A), it is highly likely that a stretcher-
carry of a patient weighing 138kg would take significantly longer and expose rescuers (and
patient) to additional hazards associated with slips, trips and falls. Additionally, a long
stretcher-carry may have been detrimental to the patient if his condition was declining,
although this is not clearly defined within AO-2013-136. However, as this combined advice
from the ground party no doubt influenced the HEMS 5 crew’s decision to winch, which
ultimately came down to the final recommendation of the ARC, it may have been prudent to
include evaluation of these personnel in the investigation to determine whether Diffusion of
Responsibility (Cherry, 2011) was a factor? For example:
 Had they ever been exposed to helicopter winch rescue before?
 What was their understanding of general helicopter winch rescue hazards and those
specific to this task?
 What was their experience in transporting patients in stretchers over steep and
uneven terrain?

29. 29
 What equipment did they take with them for this purpose?
 Was the level of fitness of the combined ground party suitable to undertake such a
task?
 What back up personnel were available and what was the time frame for their
support?
 Was the option to stay until additional help arrived evaluated?
The poignant aspect of this is a ground party ultimately extracted the patient/body in a time
(reported by the media) to be approximately an hour and a half.
Findings against stated objectives:
1. To verify the existing process of gaining qualifications to be rostered on a
SAR/HEMS helicopter.
a. Through the AOC process CASA verifies and approves operating company
suitability to undertake winch rescue operations, including how persons
undertaking winch rescue are to be trained and how specific skills are to be
maintained.
b. Helicopter operators produce an operations manual that provides (CASA
approved) winch rescue procedures inclusive of equipment and training for its
aircrew to follow.
c. Operations manual directives may differ between operating companies in terms
of minimum training requirements and specific equipment to be utilised to
achieve rescue.
d. With the exception of CASA medicals, physical fitness levels of ACM/ARC remain
variable between operators.

30. 30
2. To determine whether flight-hours recorded in a logbook accurately portray ACM
and ARC winch rescue experience and capability.
a. Flight hours recorded in ACM/ARC logbooks are typically divided into day and
night only; therefore accumulated logbook hours are unlikely to provide
quantitative data on winch experience.
b. AO-2013-136 does not provide definitive information on the specific winch
rescue experience of the ACM, ARC or pilot involved in this occurrence, yet
confirms they met the required regulatory requirements to undertake the
operation. However,
i. AO-2013-136 also identifies Air Ambulance Victoria statistics confirming 96
‘patient extractions’ in a period approximating 2 years and 10 months. This
figure is divided into 52 stretcher and 37 strop double-lifts and 7 single
strop-lifts.
ii. HEMS 5 crews conducted 15 of these extractions: 10 stretcher lifts, 3
strop-lifts utilising the hypothermic strap and 2 single strop-lifts.
iii. The proportion of the above experience pertaining to the HEMS 5
crewmembers operating VH-VAS on the day of the occurrence is not
detailed.
3. To identify existing research and or guidance that support decision-making.
a. Research (Klein, 1998) into Recognition Primed Decision Making (RPDM) and
(Zsambok and Klein, 1997) research into Naturalistic Decision Making examining
how effective decision-making is achieved whilst under pressure, identifies real-
world exposure to enhance decision-making ability.

31. 31
b. Research (Laws, 2012 & Macfarlane 2013) into a phenomenon called Blue-Mist
identifies the importance of robust training to support early identification and
mitigation of inappropriate decisions during SAR/medevac tasking.
c. The national SAR manual (AMSA, 2014) provides specific advice to support
rescue decision-making.
d. Research (Cherry, 2011) into Diffusion of Responsibility suggests inexperienced
individuals within a crowd may not take action when an emergency event is
unfolding.
e. Research (Maymand et al, 2012 and USAMRICD, 2013) identifies stress as a
factor in poor performance for operational personnel.
f. Simulation (Cobham, 2011) and live practice simulation (AMST, 2015 & ATSB
2013 p. 49) support ACM and ARC develop confidence and skills in lieu of actual
flight training.
g. Avoiding systematic decision errors (Hardcastle, 2008), suggests benefits of
knowledge and training to support accurate estimate of probabilities.
4. To identify whether any aspect of AO-2013-136 may indicate a weakness in ACM or
ARC preparedness for the task undertaken.
a. AO-2013-136 identifies that the HEMS 5 crew decided upon a double strop-lift in
lieu of a stretcher lift after assessing the scene, but whether the crew
determined a hypothermic strap was required at this point is not indicated.
b. AO-2013-136 identifies that the ARC experienced difficulty fitting the
hypothermic strap due to the steepness of the terrain.
c. AO-2013-136 identifies the final decision to winch was made using hand signals
between the ACM and ARC. And, the decision was to winch the patient via

32. 32
double strop-lift (with chest strap fitted) and no hypothermic strap due to
difficulty in its fitment. However,
i. AO-2013-136 does not indicate whether the ARC confirmed via hand
signals to the ACM that he would not be using the hypothermic strap or,
whether the ACM saw relevance of no hypothermic strap fitment after the
initial lift.
d. AO-2013-136 identifies that other operator ARC determined that a hypothermic
strap was not required, and that it is easier to keep patients arms down in a
single strop.
e. AO-2013-136 identifies (ATSB evaluation) that it is easier for patients to keep
their arms down when a hypothermic strap is used.
f. AO-2013-136 identifies operations manual directives specifying that the
hypothermic strap should be used “…as a matter of course when recovering
untrained people…” but adds that this is when a single strop-lift is undertaken.
Consequently,
i. The emphasis of a hypothermic strap for safety reason and subsequent
lessening of this imperative may have provided ambiguous instruction to
ACM and ARC, which contributed to the winch method selected on the
day.
g. AO-2013-136 identifies the HEMS 5 rescue crew experienced unexpected
difficulty during winch rescue in the form of winch delay and a need to fend off
branches.

33. 33
5. To determine whether realistic ‘other options’ were available to the rescue crews
detailed in AO-2013-136.
a. AO-2013-136 identifies the patient was aged 65, weighed 138kg, had sustained
an ankle injury requiring placement of an inflatable splint and had a pre-existing
heart condition. However,
i. With the exception of Morphine being administered intravenously to
relieve pain, there is no definitive advice as to whether the patient was
time-critical and therefore required immediate winch rescue for life saving
purposes.
ii. Additionally, there is no definitive advice as to whether the time taken to
stretcher-carry the patient would have been detrimental to his health.
b. AO-2013-136 identifies a ground party consisting of at least seven personnel
from Ambulance, Police, SES and CFA took approximately 30 minutes to hike
from the road to the patient’s location. However,
i. No details are provided of the equipment this party carried, or their
capability to stretcher-carry the patient to the nearest road, reported to be
1 to 1.5 kilometres from the incident site.
ii. Nevertheless, this ground party had the capacity to ‘fell’ several trees and
‘relocate’ the patient to a more suitable area for winching.
iii. From the time of the ground-party’s arrival at the incident site there was,
conservatively, 5 hours of daylight remaining.
iv. Although not identified in the AO-2013-136, media reports following this
incident advised that a ground-party carried the patient/body to the road
in approximately 1.5 hours.

34. 34
c. AO-2013-136 does not provide much detail as to why the ground-party
supporting HEMS 5 did not consider a stretcher-carry, other than to imply the
size of the patient and steep terrain was a factor. Therefore,
i. Without detail of equipment the ground-party carried that may have
supported a stretcher-carry option and, the experience this group had
transporting casualties across such terrain, analysis of this option would be
inconclusive.
ii. However, as the patient/body was ultimately stretcher-carried out,
comparison between the team that undertook this task to the team
supporting HEMS 5 may have been beneficial to holistic analysis of the
winch decision.

35. 35
Conclusion:
Although findings indicate areas where greater exposure to real-world winch rescue
environments during training may support decision-making, without specific detail of actual
crewmember and ground-party rescue experience this is likely to remain subjective analysis.
However, objectivity may be gained with re-analysis of another fatal winching accident
(ATSB, 2013) where an ARC was killed and a patient sustained further injury in similar
circumstances (see appendix F). Furthermore, formal evaluation by responsible stakeholders
as to how the mid-nineties training winch height restriction has affected, or is affecting,
SAR/HEMS crew decision-making ability may cast light upon preparedness reduction as a
contributing factor in both these tasks, that occurred within a two-year period?
Moreover, as “…experienced blokes…” are approaching retirement age, defining minimum
experience criteria for ACM and ARC to undertake operational winch rescue tasks from a
realistic height, followed by subsequent analysis of existing ACM/ARC experience against
such criteria, may support more accurate analysis of existing hazard and risk and therefore
the associated training needs. Consequently, and with regard to the ATSB definition of a
safety issue i.e.
‘…An event or condition that increases safety risk and (a) can reasonably be regarded as
having the potential to adversely affect the safety of future operations, and (b) is a
characteristic of an organisation or a system, rather than a characteristic of a specific
individual, or characteristic of an operating environment at a specific point in time…’ (ATSB,
2015)
This analysis has identified a safety risk: there is a potential that ACM and ARC receive
insufficient preparation for the complexities of high winch rescue operations, to steep
terrain, through tree canopies. Furthermore, without corrective action by responsible
stakeholders, it is believed that existing decision-making preparedness may adversely affect
future winch rescue operations of similar type.
Yours Sincerely
Mick Macfarlane MEmergMgt CSU

36. 36
Recommendations:
For maximum benefit the author recommends analysis of the following recommendations
by organisations in addition to aviation agencies. The purpose of this is to utilise fresh eyes
to gain differing perspective on long held practice, thus providing robust objectivity for any
corrective action requirements.
1. In accordance with ISO (2009) monitor and review guidance, undertake a formal
survey of all Australian SAR/HEMS crews (civil and military) to evaluate operational
perspective on mandatory increase of the 15-foot height restriction i.e. ACM, ARC,
RC and Line Pilots.
2. Evaluate the specific increase in risk that an ARC/RC is exposed to during the
additional time suspended on the winch wire from 50-feet AGL when compared to
15-feet AGL, and the practical benefits of accepting such risk to better prepare for
operational tasks.
3. Verify whether a 15-foot AGL restriction is comparative to global SAR operations,
and should greater training height be permitted verify how the associated risk is
managed.
4. Evaluate CASA and ATSB staff to determine whether they have appropriate
qualifications/experience to make robust judgement on the complexities of winch
rescue from the ACM/ARC/RC perspective.
5. Evaluate the risk associated with conducting live winch rescue training between
trees, from a height not exceeding 50-feet AGL, where a clear landing area (as per
CAO 29.11) on the non-winch side of the aircraft is within range should emergency
landing be required.

37. 37
6. Consider the benefit of mandating enhanced ‘ground training’ for ARC/RC that
exposes them to typical tasks utilising rescue equipment i.e. loading persons into
role rescue equipment on steep slopes and confined areas.
7. Confirm whether sufficient formal directives are available within operations manuals
to genuinely empower SAR/HEMS crews to (say no) to winching non-critical patients.
8. Ensure persons likely to be involved in ground-party operations fully appreciate the
hazards and risk associated with winch rescue. The intent being for ground parties to
have the same understanding as helicopter SAR/HEMS operations manual directives
i.e. due to inherent risk, winching is a last resort.
9. Determine what minimal stretcher-carry training is required for likely ground-party
personnel and formalise this into a ‘Helicopter SAR Support’ qualification. The aim
being for SAR/HEMS crews to quickly evaluate input from ground personnel when
future winch go/no-go decisions are presented.
10. Evaluate the benefit of mandatory winch rescue simulation training (computer
generated and live) as a means to enhance capability for ACM and ARC.
DECLARATION: ERGT Australia has previously proposed commercial ventures to
support live winch simulation to helicopter operators within Australia.
11. Consider mandating logged winch recurrence criteria for helicopter flight crews in
excess of day/night. For example, height criteria could be categorised as follows:
i. < 25-feet
ii. >25-feet to <100-feet
iii. >100-feet to <200-feet
iv. >300-feet
b. Additionally, operating areas may also be divided into relevant types:
i. Water or raft
ii. Vessel
iii. Clear terrain
iv. Wooded terrain

38. 38
c. A final criteria may specify role-equipment used i.e.
i. Single strop-lift (with or without hypothermic strap)
ii. Double strop-lift (with or without hypothermic strap)
iii. Stretcher lift (with or without attendant)
iv. Basket lift
v. H.I. Line.
12. Conduct a mapping-comparison of the CAR 217 process for determining check and
training competence, against Vocational Education Training (VET) training and
assessment to TAE4010 (Aust-Gov, 2014) to determine whether learning/assessing
inconsistencies exist.
13. Evaluate the supporting ATSB winch occurrence reports (post 2000) identified within
AO-2013-136 against the specific winch experience of ACM/ARC involved to
determine whether: reduced RPDM criteria, Blue Mist, Fitness, Diffusion of
Responsibility or Stress may have been contributing factors in these occurrences.
14. Evaluate fitness requirements to undertake both land and water winch rescue
tasking as an ARC/RC to determine whether existing company fitness requirements
are appropriate for persons to operate effectively i.e. still be able to make sound
decisions when under physical duress.

39. 39
References
ABC. (1999). 7:30 Report – Transcript 21/6/1999 – Call for external investigations
into Defense Forces accidents. Retrieved from
http://www.abc.net.au/7.30/stories/s30536.htm 5th
May 2015.
Ambulance Victoria. (2012). Types of Paramedics. Retrieved from
http://www.ambulance.vic.gov.au/Paramedics/Types-of-Paramedics/Air-
Ambulance-Paramedics.html 8th April 2012
AMST. (2015). Indoor Helicopter Rescue Hoist Trainer - Worldwide Unique
Simulation Centre for the Mountain and Air Rescue Teams. Retrieved from
http://www.amst.co.at/en/training-simulation-products/helicopter-rescue-
hoist-trainer/ 3rd
May 2015.
Aust-Gov. (2014). TAE40110. Certificate 1V in Training and Assessment. Retrieved
from https://training.gov.au/Training/Details/TAE40110 22 April 2015.
Australian Business Lawyers and Associates. (2011). The new work health and safety
laws – who has duty of care? Retrieved from
http://www.australianbusiness.com.au/lawyers/expertise/ohs/the-new-
work-health-and-safety-laws---who-has-a-du May 14th
2015.
ATSB. (2013). Helicopter winching accident involving Agusta Westland AW139, VH-
SYZ, 16k WSW of Wollongong Airport, NSW 24th
December 2011. Retrieved
from https://www.atsb.gov.au/media/4123815/ao-2011-166_final.pdf May
2015.
ATSB. (2015). Helicopter winching accident involving Bell Helicopter Co. 412EP, VH-
VAS, 19 km south-south-east of Mansfield, Victoria on 31 August 2013.
Retrieved from
https://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-
2013-136.aspx April 2015.
AMSA. (2014). National Search and Rescue Manual (Rev. 11). Retrieved from
http://natsar.amsa.gov.au/Manuals/Search_and_Rescue_Manual/documents
/NATSARMAN2014.pdf 15th
April 2015.
CASA. (1997). CAAP 215-1 (0) Guide to the preparation of operations manuals.
Retrieved from http://www.casa.gov.au/download/caaps/ops/215_1.pdf
18th April 2012.
CASA. (1998). Airworthiness Articles. AAC 1-103 Helicopter Personnel Winching 9/98.
Retrieved from
http://www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD:1001:pc=PC_90746
5th
May 2015.

40. 40
CASA. (1998b). REG 224 Pilot in Command. Retrieved from
http://www5.austlii.edu.au/au/legis/cth/consol_reg/car1988263/s224.html
18th
May 2015.
CASA. (2008). Air Operator Certification Manual. Retrieved from
http://www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_91271 18th
April 2012.
CASA. (2006). CAO Part 29, Section 29.11 (Rev 4). Helicopter Winching and
Rappelling Operations. Retrieved from
http://www.casa.gov.au/download/orders/cao29/2911.pdf 18th April 2012.
CASA. (2003). Air Operator Certification Manual, Air Operator Certification – General
(Example One). Retrieved from
http://www.casa.gov.au/wcmswr/_assets/main/manuals/regulate/aocm/011
r0203.pdf 18th April 2012.
CASA. (2012). SMS for aviation a practical guide – Human Factors. Retrieved from
http://casa.gov.au/wcmswr/_assets/main/sms/download/2012-sms-book6-
human-factors.pdf May 2015.
CASA. (2012). The AOC Handbook – Volume 2 – Flying Operations, 5.0 Training and
Checking Organisation. Retrieved from
http://www.casa.gov.au/wcmswr/_assets/main/manuals/regulate/aocm/220
r005_Vol2.pdf April 20 2015.
CASA. (2014). CAR 217 Flight Crew- Training and checking organisations. Retrieved
from
http://www.casa.gov.au/wcmswr/_assets/main/newrules/ops/download/dra
ft-caap217-1.pdf 20th
April 2015.
Cherry, K. A. (2011). What is diffusion of responsibility? Retrieved from
http://psychology.about.com/od/dindex/f/diffusion-of-responsibility.htm
Cobham. (2011). UK MOD Defense Helicopter Flying School. Retrieved from
https://www.youtube.com/watch?v=VfGhsf70oFA 12 April 2015.
ComLaw1. (2015). CAO 29.11 – Air service operations – Helicopter winching and
rappelling operations. Retrieved from
http://www.comlaw.gov.au/Details/F2006C00168 15 April 2015.
ComLaw2. (2015). CAR 1988. Retrieved from
http://www.comlaw.gov.au/Details/F2015C00266 April 2015.
Darley, J. M; Latane, B. (1968). Journal of Personality and Social Psychology 1968,
Vol. 8, No. 4, 377-383.

41. 41
ERGT. (2013). PMAOMIR418 Coordinate Incident Response and PMAOHS511A
Manage Emergency Incidents – PowerPoint presentations. Available through
ERGT Australia http://www.ergt.com.au/
Hardcastle. (2008). Avoiding Systematic Decision Errors. Turnaround Management
Association, Nov 19, 2008. Retrieved from,
https://www.turnaround.org/Publications/Articles.aspx?objectID=10070
19th
May 2015.
ISO. (2009). ISO 31000:2009 Risk Management Principles and Guidelines. Retrieved
from https://www.iso.org/obp/ui/#iso:std:iso:31000:ed-1:v1:en April 2015.
Fink, S. (2002) Planning for the inevitable. iUniverse, Inc. Lincoln, NE.
Klein, G. (1998). Sources of Power: “How People Make Decisions", MIT Press,
Cambridge, Mass.
Zsambok, E; Klein, G. (1997). Naturalistic Decision Making, Lawrence Erlbaum
Associates, Mahwah, New Jersey.
Lagadec, P. (1993) Preventing chaos in a crisis, strategies for prevention, control and
damage limitation, 54-56 (J. M. Phelps, Trans.). Retrieved from
http://www.patricklagadec.net/fr/pdf/Preventing_Chaos.pdf 20th
May 2015.
Laws, T. (2012). Global CRM Manual (internal company document). Bristow
Helicopters (Australia). Perth, WA.
Macfarlane, M. (2013). Do oil and gas risk owners understand real-world helicopter
winch rescue hazards? (Unpublished Masters project). Charles Sturt
University, Bathurst, NSW)
Maymand, M; Shakhisan, F & Hosseiny F. (2012). The effects of stress on flight
performance. World Applied Sciences Journal 19 (10): 1381-1387. Retrieved
from,
Journalhttp://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.389.5094
&rep=rep1&type=pdf April 2015.
NSW Ambulance. (2015). Aeromedical paramedic fitness testing. Retrieved from
http://www.ambulance.nsw.gov.au/Media/docs/Aeromedicalupdate-
8e666be7-6fb0-4804-a069-a4bf1b91cf94-0.pdf May 2015.
NSW Ambulance 2. (2015). Emergency Operations - Ambulance officer criteria.
Retrieved from http://www.ambulance.nsw.gov.au/about-us/Emergency-
Operations.html May 2015.
Police Specials. (2008). Police Specials, Forum – Red Mist. Retrieved from
http://www.policespecials.com/forum/index.php?/topic/64142-red-mist/
2nd
April 2013.

42. 42
USCG. (2014). AST Candidate Screening Test. United States Coast Guard. Retrieved
from http://www.uscg.mil/epm/docs/AST_%20CandidateScreen_Test.pdf
23rd
April 2015.
Reason, J. (1990). Human Error. Cambridge: University Press, Cambridge.
Safer Healthcare. (2015). Safer healthcare Newsletter – Stress and Fatigue
management. Retrieved from http://www.saferhealthcare.com/high-
reliability-topics/stress-and-fatigue/ 20th
May 2015.
USAMRICD. (2013). Graduate Education and Simulation Training for CBRNE Disasters
Using a Multimodal Approach to learning. Part 1: Education and Training
from a Human Performance Perspective, 6-7. Retrieved from
http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&
ved=0CB0QFjAA&url=http%3A%2F%2Fwww.dtic.mil%2Fcgi-
bin%2FGetTRDoc%3FAD%3DADA590741&ei=2FtlVZrXH8rY8gXFyICgAg&usg=
AFQjCNEwq4t2LMX3LGsQiyNu1nHDXu14Qw&sig2=VvLkVUdo6a7pCFqDWe1
uQA&bvm=bv.93990622,d.dGc 25th
May 2015
Westpac. (2015). Aircrewman Qualifications. Retrieved from
http://www.rescuehelicopter.com.au/resources/Aircrewman%20Employmen
t%20Criteria.pdf May 13th
2015.
W. Arthur, W. Bennett, P. L. Stanush and T. L. McNelly. (1998) Factors That Influence
Skill Decay and Retention: A Quantative Review and Analysis. Human
Performance, 11(1), 57-101 Lawrence Erlbaurn Associates. Retrieved from
http://www.owlnet.rice.edu/~ajv2/courses/12a_psyc630001/Arthur,%20Ben
nett,%20Stanush,%20&%20McNelly%20(1998)%20HP.pdf May 26 15.

43. 43
Appendix A – Stretcher-carry process:
Carrying a patient in a stretcher is a ubiquitous process that has been undertaken for
centuries to move injured persons to advanced medical care. There are numerous types of
stretchers and stretchers designed for specific purposes, but key factors to support effective
stretcher-carry remain unchanged, for example:
 The stretcher is of appropriate size and strength to support the weight of the
person being carried.
 The stretcher has sufficient points for stretcher-attendants to lift from.
 Dependent upon a patient’s condition, the stretcher permits safe loading and
security i.e. there is no exacerbation of trauma/illness and the patient will not fall
during carry.
 There are sufficient stretcher-attendants to carry the patient and manoeuvre them
past obstacles encountered on route to advanced medical care.
 The stretcher-party plan the carry-route to ensure obstacles are avoided and all
hazards are known.
 All stretcher-party personnel are aware of hazards associated with stretcher-carry
such as: dropping the patient due to fatigue or, slipping on unstable ground.
 Where more technical rescue is required, the stretcher is the specified type and the
stretcher-party is trained in the technical aspects required for safe transport.
Stretcher-carry over steep and uneven terrain as described in AO-2013-136:
The weight of the patient would typically require a minimum of 6 stretcher-attendants (23kg
each + share weight of stretcher), but an ideal number would be 8 stretcher attendants
(17.25kg each + share weight of stretcher) plus another 8 persons for periodic rest periods.
Because of the steep terrain it is likely that many areas along the route taken to the road
would not support a normal ‘walk’ and therefore, would require multiple ‘lifts’ and ‘lowers’
for personnel to reposition themselves.
Additionally, due to the risk of losing control of the stretcher on steeper terrain a simple
rope belay would likely be incorporated i.e. secured to the head-end of the stretcher, a rope
is taken uphill and ‘turned’ around a tree. Slack line is taken in with stretcher travel

44. 44
therefore preventing slippage should those carrying it lose control of the stretcher. The
same process is reversed when going downhill.
Had there been significantly steeper areas, that could not be avoided, a more technical ‘Z-
Pulley-System’ might have been employed for raising uphill. In this situation stretcher-
attendants would be used to guide the stretcher past obstacles such as rocks and tree roots
i.e. no heavy lifting as this is undertaken by the pulley system.
Author stretcher-carry experience:
Royal Navy: transporting exercise casualties through passageways and between decks.
Melbourne Port Emergency: multiple training exercises and live evacuations of
crewmembers from ships in Melbourne docks utilizing fit for purpose stretchers.
National Safety Council: full day stretcher-carry of a ballasted stretcher (100kg) through the
Snowy Mountains as part of training, plus introduction to technical rescue. Additionally,
regular stretcher-carry/technical rescue as part of ongoing training and operational tasking.
Melbourne Fire Brigade: initial training including use of ladders as improvised stretchers,
plus operational tasking. Additionally, technical rescue training as a High Angle Rescue
Techniques (HART) instructor.
Lloyd/CHC Helicopters: technical rescue associated with helicopter activity, including
manoeuvring of patients between decks during offshore rescue where time-management
was critical to support return-to-base fuel limitations. Plus, multiple RAAF SAR-ex’s where
transport of pilot ejectee’s to suitable landing sites or, locations where winching could take
place was required.
ERGT Australia: training of onshore/offshore emergency response personnel in stretcher-
carry methods up and down ladders, plus development of staff rescue plans incorporating
use of stretchers for high risk training activities.

45. 45
Appendix B – Fitness tests:
The following provides examples of fitness variations to allow independent analysis of how
degraded, or perhaps inappropriate, fitness standards may affect personnel undertaking
helicopter rescue roles. Comparison is made to Australian operations from the 1980’s,
international operations, and reductions that have occurred from the mid-nineties.
Note: the author was not able to obtain sampling from all operators and therefore
recommends the following data be cross-referenced by responsible stakeholders with all
Australian suppliers of SAR/HEMS personnel.
NSCA 1980’s:
Persons winched from NSCA helicopters were also trained Para-Jumpers i.e. capable of
parachuting into remote rescue sites and/or being winched by helicopter (author
experience):
Minimum fitness test requirement, initial selection and 2-month recurrent evaluation, no
rest period between activities. Note: participants were expected to exceed these figures
during initial and recurrent assessment. The lesser figure was to support operators coming
back from injury or ill health:
 50 x Push-Ups in 2min
 60 x Sit-Ups in 2min
 10 x Pull-Ups in 1min
 3.2k Run in 14min
 2000 yard Swim in 40min
US Coast Guard
Rescue Swimmers are personnel deployed from helicopters for primary water tasking, but
they are tasked as required following disaster or lesser emergency situations.
The following are bare minimum for selection to the program. If upper-body exercises are
not completed strictly i.e. no swinging legs, a fail will likely be recorded (USCG, 2014), no
rest period between activities:
 40 Push-Ups in 2min
 50 Sit-Ups in 2min
 3 Pull-Ups (no time specified)
 3 Chin-Ups (no time specified)
 1.5mile Run in 12min

46. 46
 450yd Swim in 12min
 Underwater 25m Laps x 4 (90sec rest between laps)
Royal Australian Air Force (RAAF) civilian contracted helicopter SAR 1990’s:
Civilian personnel trained as ACM/RC required to be winched by helicopters.
Minimum fitness test requirement, initial selection and 6 month recurrent evaluation, no
rest period between activities:
 40 x Push-Ups in 2min
 50 x Sit-Ups in 2min
 8 x Chin-Ups in 2min
 3k Run in 15min
 1k swim in 20min
HEMS ARC 1990’s
Ambulance service personnel selected and rostered on HEMS aircraft to undertake winching
as per contract requirements (secondary role to casualty care for non-winch tasking)
Insufficient data to verify, however it is widely acknowledge the fitness requirement varied
dependent upon ambulance service and helicopter operator contractual arrangements. An
example provided (Direct correspondence ACM ‘C’, April 2015) suggests similar disciplines
to RAAF ACM/RC but with fewer repetitions, was utilised as an entry test and then repeated
every 2-years.
RAAF contractors 2000’s and onwards
Minimum fitness test requirement amended to an alternate 4-month recurrent period of
land and water evaluation.
Water:
 700m swim in less than 20min
 Tread water post swim 10min
 Fin 300m in less than 10min
 Water rescue 25m
 Total test time must be less than 1-hour
Land:
 This has not changed, although anecdotal advice suggests many line personnel from
one major operator do not complete it, and have not for some time, due to ongoing
internal issues over health and safety.

47. 47
HEMS ARC 2000’s and onwards
Ambulance service personnel selected and rostered on HEMS aircraft to undertake winching
as per contract requirements (secondary role to casualty care for non-winch tasking): as
previously stated, but some operators no longer have a requirement for recurrent fitness
assessment (Direct correspondence ACM ‘C’, April 2014).
NSW Helicopter Paramedics
Intensive care paramedics typically cross-trained as Special Casualty Access Team (SCAT)
officers, these persons undergo specific fitness testing for their role, but limited advice on
recurrent training was available through literature search (NSW Ambulance, 2015 and 2015
2).
Westpac Rescue Helicopter (Westpac, 2015)
 600 metre freestyle swim non-stop in 14mins. (age scale applies)
 1km walk with a 15kg back pack up and down a steep incline.
 20 sit-ups in 45 secs
 20 push-ups in 45 secs.
On selection a surf awareness swim will be conducted for successful candidates, which
will consist of:
 A surf swim out past the break, around a buoy
 A duck dive
 Mask and snorkel clearing
 Fin removal and replacement
 Swim back to shore through the surf
 The above will be conducted with full kit ie wetsuit, harness, mask, snorkel.
Summary:
Although there are ARC/RC operating on helicopter SAR/HEMS contracts with very high
levels of physical fitness, it is widely acknowledged that this is as a result of self-discipline
and not company or industry directive. Notwithstanding this point, some operators do
require minimum fitness levels, but such data and recurrent training specifications were not
readily available through literature search.
Consequently, there remains a degree of ambiguity associated with the physical ability of a
person being lowered form a helicopter to undertake rescue duty, or whether authorities
believe minimal fitness criteria necessary (notwithstanding medical certification). However,
duty of care legislation (Australian Business Lawyers and Advisors, 2011) may challenge
inappropriate fitness levels were it determined as a contributing factor in a workplace
accident.
Additionally, and from a very practical standpoint, it is safe to assume that the public would
expect helicopter rescue persons coming to their aid to be of above average physical ability.

48. 48
Appendix C – Aircraft fly-away requirement
A critical component of any helicopter flight is performance planning. Examples of criteria
utilised to support such performance evaluation include: wind, fuel, density-altitude and
operational aircraft weight. Aircraft weight is a key factor and divided in three areas:
 Maximum all up weight
 Empty weight
 Operational weight and available payload
Therefore, when preparing for an operational task a pilot’s calculation of aircraft weight
forms a critical component of performance planning. The figure above indicates factors
determining whether an aircraft can safely take-off i.e. not exceed the ‘maximum all up
weight’ specified by the manufacture.
However, this figure primarily provides guidance towards safe ‘forward’ flight at sea-level,
or ‘hover’ flight close to the ground.
Therefore, should a flight be planned into mountainous terrain where winch rescue is
required other criteria become critical to performance planning. For example, the reduced
air density at altitude or, in hot weather, means rotor blades and engines have to work
harder. Additionally, although strong wind may support hover performance, conversely a
gusting wind may significantly hinder performance due to the need for frequent and rapid
power adjustments. Furthermore, fuel required to complete a task, plus the minimum
reserves, must be carried and the greater fuel load will further reduce performance.
A pilot will evaluate such criteria prior to lift-off and undertake on scene evaluations to re-
verify how site conditions may affect performance prior to committing to a winch rescue.
Such evaluation will likely confirm that single engine hover is not achievable in the aircraft
type utilised in AO-2013-136 i.e. if one engine becomes inoperative the remaining engine
will not produce enough power to maintain ‘hover’ flight. In such a situation SAR/HEMS
crews will brief a ‘fly-away’ option. In simple terms this means the pilot executing an
immediate and assertive dive to assist transition from ‘hover’ to ‘forward’ flight, where the
power of the remaining engine is sufficient to sustain flight and climb away from danger.

49. 49
In this situation an ACM will either winch in full speed to recover the ARC, or winch out full
speed to get the ARC as close to the ground a possible before cutting the winch wire.
Without such action the ARC and/or wire may become fouled, therefore impeding the fly-
away. This procedure is widely accepted as a standard component of helicopter winch
rescue briefing and is typically included as a supplementary on-scene brief prior to winch
rescue commencement.
As the safety of an ARC and patient cannot be guaranteed during a fly-away the associated
hazards and risks are well documented within operations manuals i.e. winch as a last resort.
Notwithstanding this fact, CASA approve operational winch rescue where one engine hover
performance cannot be achieved as part of its winching directives (CASA, 2006).
B) The pilot dives the aircraft,
increasing speed for either transition
to forward flight, or preparation for
emergency landing.
A) One engine fails leaving insufficient
power to remain in hover.
‘Advanced’ winch training from height is typically undertaken without ground hazards.
Example of a ‘fly away’ profile: The height lost during transition to forward flight is dependent upon
the weight of the aircraft, air density and wind speed. Pilots will accelerate to a pre-determined air
speed to enable climb with a single engine.
However, where a helicopters operational weight is light and performance is assisted by strong wind,
there may, in fact, be minimal loss of height during recovery to forward flight. Conversely, should the
aircraft be operating close to maximum performance and there is insufficient height for a fly-away,
the pilot will have no option but to land in the immediate vicinity. In such a situation should steep
terrain or trees be below (and in front) of the aircraft, a safe landing is unlikely.

50. 50
Appendix D – Potential winch delays and fending off branches requirement
Wire swing:
Prior to lifting an ARC and patient off the ground when undertaking winch rescue, an ACM
will direct the pilot to position the aircraft directly overhead i.e. so that the winch wire is
plumb above. If this is not achieved, once the ARC and patient are lifted from the ground a
swing will be induced of speed and arc commensurate to the angle away from vertical.
To control the swing an ACM can winch out immediately to place the ARC and patient back
on the ground, then reposition the aircraft and winch again or, push and pull on the winch
wire against the direction of swing. Although the push/pull method is standard practice, the
greater the weight and arc of the swing the harder it is to control.
Why swings occur:
Although the obvious cause is the wire not being perpendicular, swings do still occur. There
are two main reasons for this;
1. The pilot is not providing a precise hover and the aircraft moves as either the ACM
winches in or, the pilot ‘lifts’ the aircraft to pull the ARC and patient off the ground.
2. The ACM has not positioned the aircraft directly overhead due to: possible depth-
perception issues, urgency to complete the task or, perhaps just finger trouble i.e.
the ACM winches in by mistake.
Controls:
During any winch recurrent training activity both pilot and ACM practice the process of
winching from directly above. To support this disciplined practice, prior to lifting the ARC
and patient from the ground a typical process requires the ACM to ask, “Clear to winch?”
This request is a final confirmation from the ACM to the pilot that the ARC and patient are
secure and ready, slack wire has been winched in and that the aircraft is directly overhead*.
Upon receipt of the winch clearance request, the pilot will make a final power assessment
check before acknowledging with the executive command of, “Clear” or “Continue”. This
process, or variants of it, when undertaken from the safe training height of 15-feet is
typically considered routine. However, when the height is increased and complicated with
real-world operational pressures, swings can and do occur. The severity of the swing is
typically dependent upon the circumstances of the task and, the experience of the crew.
Winching through trees from height:
Where winching is taking place through a ‘hole’ in a tree canopy any swing is likely to
require the ARC to fend off minor branches. Furthermore, where the swing is of sufficient

51. 51
arc that contact with larger branches has occurred, to ensure the safety of the ARC and
patient the ACM will automatically stop (‘delay’) the winch to either control the swing or
reposition the aircraft.
Although the process of swing prevention and control is obvious for ACM who are exposed
to this environment regularly, the simplicity of risk exacerbation with increased height is
often not fully appreciated by persons without similar ACM experience. This exacerbation is
demonstrated with the diagram below.
15-foot training winch:
No trees or slope – swing
unlikely, risk minimal.
50-100-foot operational winch:
Potential depth perception issues,
degrading aircraft performance
factors, swing potential and risk
increases.
100-foot + operational winch:
Winch complexity multiplies.
*May not always apply. For example, when undertaking winch rescue to a vessel with hazards that may
foul the winch wire, an offset winch position is used incorporating a Heave-In (HI) line.

52. 52
Appendix E – Winch control check
Rescue winch:
A common winch utilised on rescue helicopters will have between 250-300 feet of winch
wire and operate at variable speeds of up to 250 feet per minute. It is a precise piece of
equipment far in excess of typical winches used on vehicles or industrial lifting equipment.
Image source: Goodrich website
To ensure safety, micro-switches included as part of the control mechanism will
automatically slow the winch-in speed from maximum at a pre-determined distance below
the helicopter, usually about 15 feet. The reason for this is to prevent the hook (and
potentially ARC and patient) contacting with the underside of the aircraft and/or winch head
at full speed should an un-commanded ‘runaway-in’ occur. This is where the mechanism
continues to winch-in despite the ACM moving the control wheel to the stop position. If not
controlled very quickly such un-commanded movement may cause injury to ARC and patient
or, worst case, cause the winch wire to break.
Winch-control-check:
To add another layer of safety to the micro-switch speed reduction and ACM will, as part of
standard procedure, stop the winch manually at approximately 5-10 feet below the
automatic speed reduction point. By doing so, if the wire continues un-commanded the
ACM has time to execute emergency procedures.

53. 53
Immage sources: author
Left: The yellow lock-mechanism is duplicated on both sides; both locks must be pushed inwards to unlock the
spring-gate of the hook. Older style hooks had either a pin inserted through the spring-gate to prevent un-
commanded opening or, relied upon the ARC to keep ‘D’ rings and carabineers clear of the spring-gate.
Right: The central lever (or wheel) is rolled forward or back to either winch-out or winch-in, when released it
returns to a neutral ‘stop’ position. The amount of wheel movement will determine the speed variation.
Dynamic roll out:
The action of the winch-control-check may cause a jolt through the wire if the hook comes
to an abrupt stop. If this occurs when using an older style hook that does not have a locked-
spring-gate, the ‘D’ ring of a patients strop or the carabineer from an ARC harness may
inadvertently roll against the hook spring-gate causing it to open, thus allowing body weight
to pull it clear i.e. roll out.

54. 54
Appendix F – Analysis of AO-2011-166
This analysis is just a snap shot of AO-2011-166 (ATSB, 2013). Therefore, readers are
encouraged to review this appendix only after reading AO-2011-166 and the contents of this
report in full. Appendix ‘F’ focuses on areas where Blue Mist, Stress, Diffusion of
Responsibility or reduced RPDM may have been contributing factors.
Acknowledgment: the author acknowledges the ‘safety action’ undertaken by operator and
Ambulance NSW since this event i.e. expanded CRM, scenario based training, construction
of a winch simulator at Bankstown, increased recurrent training and crew familiarisation of
potential difficult rescue sites etc. However, the author also notes no mandatory increase in
live recurrent training height.
Overview
A NSW air ambulance helicopter VH-SYZ (Rescue 24) was tasked to recover an injured
person from a rock ledge near the bottom of a waterfall. This crew had a second ARC. Due
to overhanging rocks Rescue 24’s crew determined a standard winch would not be possible
and briefed a process to conduct an offset winch using role equipment as an ad-hoc belay
line. The task was undertaken at last light and ended in darkness.
Step 1
This required the ARC’s being winched to the top of the waterfall where one would abseil to
the casualty and the other would then attach the winch hook to a rope prior to the aircraft
moving clear (away from the waterfall) to allow the ARC with the casualty to pull the rope
and hook in, under the overhang, as the ACM winched out.
Step 2
The ARC with the casualty would rig an anchor-system to belay (control lateral movement)
himself and the casualty as the ACM winched them both off the ledge and clear of the
overhang. Once plumb under the winch, the ARC would discard the rope and the ACM
would winch the ARC and casualty to the helicopter in normal double lift fashion – during
this component light was so low the ACM had difficulty seeing the ARC.
Outcome
The ARC and casualty fell (or were pulled) from the rock ledge, and then struck a lower
ledge before swinging underneath the helicopter and striking a rock at the base of the
waterfall. The ARC received fatal injuries and the casualty was recovered the next day
having suffered a fractured vertebrae – the ATSB advise the casualty was sufficiently alert to
take note of the rescue process and post accident events.
Crew experience
Pilot
 Air Transport Pilots Licence, Command Instrument Rating.
 4269 hours.

55. 55
 2 years and 3 months on HEMS contracts. No other advice about flying experience
involving winching.
Author observation:
1. Although total hours, licence and rating equates to an experienced pilot, the
documented experience on a winch rescue contracted aircraft suggest limited
exposure to high winches.
ACM
 827 hours.
 4 years on a RAAF SAR contract: 1 year as a Rescue Crewman (RC) and 3 years as an
ACM.
 Less than 1 month as a HEMS ACM.
Author observations:
1. RAAF SAR aircraft are crewed with 2 x pilots compared to the single pilot of a HEMS
machine, this means that the ACM responsibility is greater on HEMS contracts as
non-flying co-pilot duties are performed in addition to winching and supporting the
ARC(s) with medical care.
2. When winching is being planned and/or underway on HEMS aircraft, the pilot relies
heavily upon input from the ACM as there is no other pilot to offer support.
3. RAAF SAR winch training rarely exceeds 15 feet in height over land (author
experience with all RAAF SAR contracts).
ARC 1
 No total hours advised.
 Special Casualty Access Team (SCAT) (NSW Ambulance, 2015) trained in 2006.
 Initial ARC training November 2008 (indicating 3 years helicopter experience).
 In addition to standard recurrent training:
o 14 recorded live winch operations
o 2 of these at night
o 2 of these at last light
Author observations:
1. SCAT paramedics are typically very fit individuals when compared to their Victorian
ARC counterparts. They are trained in unique skills to gain access to casualties where
normal paramedics would be unable – they have a very high esprit-de-corps.
2. Although HEMS crews typically fly more than their RAAF SAR counterparts, in 3 years
it is unlikely that the ARC exceeded 900 hours.
3. Although no specific detail of the winch tasks is supplied, typically NSW HEMS winch
operations are high, and undertaken in wooded terrain if overland.

56. 56
4. The listed winch operations and likely flight hours suggest the paramedic was
reasonably experienced and would be confident with helicopter winch rescue
process.
ARC 2
 No total hours advised
 SCAT trained in 1994
 Initial ARC training completed in 2008 (indicating 3 years helicopter experience)
 In addition to standard recurrent training:
o 18 recorded live winch operations
o 2 of these at night
o Possibly 1 at last light
Author observations:
1. As per ARC 1
Summary
From the outset of this task the crew were behind the time-clock leading to last light, “…the
helicopter was operated on the ground for 13 minutes in order to reduce fuel…” They landed
nearby, shut down the aircraft and discussed options for rescue. The crew had been advised
the casualty had, “serious injuries”, but no other detail is mentioned in the report other than
a post incident evaluation i.e. fractured vertebrae. During shut down the ad-hoc belay plan
was suggested by the most experienced of the rear crew in winch rescue: the ARC’s. This
was the first significant step into Blue-Mist, perhaps supported by unequal RPDM and
Diffusion of Responsibility.
Time pressure continued to build as the aircraft had to depart the area in order to hot-
refuel. As the task continued, communication issues, uncertainty with the process briefed by
the ARC, fading light and the need to reposition for better hover reference, very likely
increased stress levels (as indicated by use of ICS instead of radio) by both the ACM and
pilot. Consequently, the possibility of wanting to push on to beat the fading light (Blue-
Mist), lack of high winch training in realistic environments, significant stress and Diffusion of
Responsibility from both pilot and ACM led to a situation where:
 The ACM was likely undertaking his first live night winch from much greater height
than routine training.
 The ACM was likely operating in an environment he had never been exposed to
before.
 The ACM could not easily see the winch wire, or the ARC and casualty to whom his
winch hook was attached.
 The pilot had less than ideal reference and was undertaking a winch in an area he
later described as “...unacceptably hazardous…” (p. 12)

57. 57
The important question from this event is what was the root-cause of the decision-making
that led to the accident? Because after all, the crew all met CASA qualification
requirements, all had undertaken required recurrent training – yet they attempted a winch
method not documented in the operator’s procedures, for a casualty with (apparently) non-
life-threatening injuries, in poor light?
The image below is an (estimation only) of the situation based upon ATSB images and
relevant data.
AO-2013-166 Page 37 & 15
 Estimated 150-feet of winch cable
deployed when ACM and casualty
fell from the ledge.
 Winch wire at approximately 30 to
45 degrees.
 Winch manufacture maximum
angle limits for the wire is 30
degrees.
AO-2013-166 Page 39
 The lighting fitted to the winch
illuminated the ground below the
aircraft only.
 The ACM’s handheld light was of
limited use as the ACM had to keep
his hands on the wire and winch
control pendant.
 The pilot’s searchlight was required
for hover reference and therefore
did not aid ACM visibility.
AO-2013-166 Page 21
 Bureau of meteorology advised
weather in the area was light winds,
no precipitation and significant low
cloud
 The ACM’s reported localised low
cloud early, but that it cleared up
later
 Last light was 2040, but ATSB advise
low cloud and high terrain would
end daylight earlier.

58. 58
Appendix G – ACM/ARC logbook examples
Example 1: RAN ‘Aircrew Other Than Pilot’ used by some ACM on civilian SAR contracts
‘D’ = Total hours day.
‘N’ = Total hours night.
‘’D’ and ‘N’ = Total hours
per flight recorded on
each row. One page
equals one month.
Although winching can
be documented in the
‘remarks’ section, there
is no direct evidence to
detail number of
winches, their height or
terrain type.
Consequently, how
many winches were
undertaken ‘125 west
Bunbury’, or was there
indeed any winching?
Additionally, ‘SAR-EX
Kalbarri’ indicates a
rescue exercise, but did
the crew land to recover
casualties or did they
winch?