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Fatal crash of the RACQ CQ Rescue helicopter near Cape Hillsborough on the…
Fatal crash of the RACQ CQ Rescue helicopter near Cape Hillsborough on the 17th of October 2003.
Pilot
Competency
• Inexperienced with regards to long distance over water night operations
• Did not hold an instrument rating
• Limited flying experience
• New to the organisation
• Previously worked as a marine pilot transfer operator
HEALTH
• The pilots last medical examination was completed on the 6th of December 2002
• No abnormalities were indicated
• The pilot reported to have slept and ate normally
• No indication he was affected by fatigue
• Non smoker
AGE
31
MANAGEMENT
Organisational / System Factors
Resourcing
• 3 fulltime pilots are available at the Mackay Service
• The pilots are provided with sleeping and eating facilities
Organisation of Work
• Actual or perceived pressures may have existed to not reject missions due to weather or other reasons
• An apparent lack of awareness of helicopter EMS (Emergency Medical Services) safety issues and helicopter night VFR (Visual Flight Rules) limitations
• Divided and diminished oversight for ensuring safety
Policies
• The risk management policy was called a Quality Risk Assessment
• The Quality Risk Assessment did not assess day to day operational risks or potential hazardous issues relating to flight regimes
Procedures
• Flight was conducted under the night visual flight rules
• Pilots are required to obtain a meteorological forecast for the flight, specifically as the flight was over water
• Weather briefing information was obtained nearly 4 hours prior to the flight by the pilot
• No formal operational risk management program in place, nor was there a requirement to do so
Management
• RACQ CQ Rescue was formed in 1994
• Commenced flight operations in 1996
Job Design
Rosters
• The pilot’s duty cycle is to ensure fatigue is not a factor
• 9-day rotating shift cycle of 6 days on and 3 days off
Job Requirements
• Required to fly over water at night
Information Transfer
Communication
• Hamilton Island medical clinic contacted Mackay Base Hospital to report they had a patient who required transfer to the mainland for medical attention
• The patient had suffered a fractured leg and possible neck injuries
• The clinic coordinator requested the use of the helicopter through the Queensland Department of Emergency Services Queensland Ambulance Service Communications Centre (ACC)
• ACC contacted the standby duty pilot and asked about the feasibility of the flight to Hamilton Island
• The pilot advised the flight was possible
• The ACC contacted the standby duty in-flight paramedic
• At 2132 the helicopter departed for Hamilton Island
• At 2137, the pilot contacted the ACC and informed them that they were “On Case”
• Shortly after the pilot contacted the ACC to advise they had left the Mackay Airport with 3 personnel on board
• Approximately 2217, Hamilton Island contacted ACC to ask when the helicopter would arrive
• The ACC made several attempts to contact the helicopter to no avail
• At 2239, the ACC contacted the Australian Search and Rescue (AusSAR) and notified the helicopter was overdue
WORKPLACES
Equipment Design
Displays
• Fitted with an attitude indicator, directional gyro, turn and balance indicator along with other flight instruments
• Not fitted with an autopilot or stability augmentation system
Controls
• The pilot is located in the front right seat
• The helicopter crewman is located in the left rear seat
• The paramedic in the right rear seat
• Dual controls were not installed on this helicopter
Warning Systems
• Helicopter was fitted with a transponder
• The helicopter was fitted with a digital electronic engine monitoring unit
• The helicopter was not fitted with a flight data or cockpit recorder
Helicopter
• Bell Helicopter Textron
• Model 407
• Registration – VH-HTD
• Built in 1997
• Certificate of Airworthiness – issued 14th September 2000
• Certificate of registration – Issued 3rd August 2000
• Manufactured in Canada
• Has a Rolls-Royce Allison 250-C47B engine
Workplace Factors
Training
• The training pilot did not note any concerns with the pilots’ skills
• This included, area familiarisations, winch training, nite sun training (High powered candle searchlight), night VFR, and type endorsements of the Bell 407 and 206L helicopters
• The pilot conducted flight training at Mackay and was conducted by the operators check and training pilot
Work Environment
Noise
• Standard operational noise from the helicopter
• Crewman wear hearing protection on board
Temperature
• 22.6 degrees at 2130 at the Mackay airport
Visibility
• Forecast weather in the flight path included possibility of cloud
• Dark night with no surface/ground based lighting
• 2000m in thunderstorms / rain, 4000m in showers / rain otherwise 7km in smoke reducing to 2000m in thick smoke
Flight Path
• Over water at night-time with no fixed surface lit areas
Weather
• Isolated thunderstorms and scattered showers with isolated smoke below 7000ft
• Wind at 2000 ft was 15 kts from the east-south-east and at 5000 ft was 15 kts from the south-east
• Cloud was isolated
PEOPLE
PARAMEDIC
Expectations
• His role was to stabilise and attend to the patient
Age
31
Crewman
Expectations
• Assist with loading and unloading of the patient
Age
31