ATSB: Miscommunication resulted to paramedic’s death

atsbA report into the death of a paramedic in 2011 when he fell to the base of a cliff after trying to rescue an injured canyoner from a rock ledge revealed issues with several safety measures in the NSW Ambulance Service.

The report released by the Australian Transport Safety Bureau found that the paramedic and the injured man were accidentally pulled from the rock ledge as the helicopter was manoeuvred in preparation to lift them out using its winch.

The ATSB also identified safety issues related to training and the use of the helicopter’s lighting and radios. Several organisation issues that could adversely influence the way crews act in similar circumstance were also identified.

ATSB chief commissioner, Martin Dolan through an ABC report said the crew had assumed the paramedic had given a hand signal to show he was ready.

“On our analysis of the evidence that securing rope was not done, so there was clearly a miscommunication at that point,” said Mr Dolan.

“This is a tragic accident – and it is an accident – and we stress that the pulling off the ledge was an accidental consequence in a situation where there was low light conditions,” he said.

In response to the accident, the Ambulance Service of New South Wales as well as the helicopter operator took some safety actions on the operating scope applied to retrieval operations and procedures used by helicopters and emergency crews.

Paramedics have also been required to conduct annual night winching currency training. Safety actions were also taken in the areas of general crew training and operational risk assessment.

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