CEN15FA210

The helicopter rescue specialist was not properly attached to the hoist system, which resulted in a fall during a night hoist operation.

A helicopter with a pilot, a hoist operator, and a helicopter rescue specialist (rescuer) on board was dispatched to transport an injured person out of an area of rough terrain. Based on the patient's location and the time of the call, a night hoist operation was planned. The helicopter arrived on scene, and the hoist operator lowered the rescuer and equipment from the helicopter. While the rescuer and ground personnel prepared the patient for transport, the pilot and hoist operator looked for a nearby landing zone. Upon hearing radio calls from the rescuer that the patient was ready, the helicopter returned to the patient's location, and the hoist operator lowered the hoist hook. The patient, who was in a Bauman bag, and the rescuer were then lifted from the ground by the hoist. The hoist operator continued to reel in the patient and the rescuer as the helicopter transitioned from a hover to forward flight. When the patient and rescuer were about 10 ft below the helicopter's skids, the rescuer fell about 100 ft to the ground. The ground personnel who helped the rescuer prepare the patient for transport did not report seeing anything unusual. They said that, during the initial part of the lift, the rescuer and patient went into some tree branches, the helicopter maneuvered away from the tree, and then the rescuer and patient were lifted up towards the helicopter. Examination of the rescuer's equipment did not reveal any failures or malfunctions that would explain the fall. Additionally, examination of the hoist hook and helicopter equipment did not reveal any abnormities. Also, review of video from a camera located on the hoist did not identify any failures in the equipment nor did it show how the rescuer was initially hooked into the hoist. In the absence of any equipment failure, it is likely that the rescuer was not properly fastened to the hoist.

HISTORY OF FLIGHT On April 27, 2015, about 2150 central daylight time, a helicopter rescue specialist (rescuer) fell during an external hoist rescue operation. The rescuer received fatal injuries; the pilot, flight paramedic and patient were not injured. The Eurocopter MBB BK 117 helicopter, N392TC, was not damaged during the accident. The helicopter was registered to the Travis County Purchasing office and operated by STAR Flight, Austin, Texas, as a public aircraft operation. Night visual meteorological conditions prevailed during the local rescue flight. STAR Flight operations was contacted in response to an injured individual located on the greenbelt of Barton Creek. First responders, consisting of ground units assessed that based on the patient's condition and the difficulty in transporting the patient out difficult/steep terrain, that an air rescue was necessary. The pilot, hoist operator (paramedic), and helicopter rescue specialist, gathered the required equipment and before departure and en route, completed the normal equipment checks. Shortly after arriving at the patient's location, the rescuer and the medical equipment were hoisted to the ground. The helicopter's hoist operator later deployed a backboard for the patient. During the time the rescuer was on the ground and was preparing the patient for the hoist operation, the flight crew had chosen a running track, located near a school, for a landing zone. After the rescuer had secured the patient in the Bauman bag, she radioed the helicopter; the helicopter moved into position and extended the hook to her. After receiving "ready for extraction", the hoist operator initiated the lift to the helicopter. Once the rescuer and patient cleared the trees, the patient and rescuer, began a steady spin. To arrest the spin, the pilot started moving the helicopter forward. The spin slowed and had essentially stopped as they were hoisted upwards. As they neared the helicopter, the rescuer then fell away from the patient and hoist. With the patient slightly below the helicopter, the flight crew continued to the rendezvous location, where the patient would be transferred via ambulance to the hospital. Once the helicopter arrived at the landing zone, emergency personnel disconnected the patient from the hoist connection. The pilot then landed the helicopter, and the hoist operator retrieved the medical bag that was on the hoist. The pilot and hoist operator then departed to assist in looking for the rescuer. Shortly, afterwards the helicopter landed back at the landing zone. Witness interviews The pilot reported that they were dispatched to rescue an injured hiker in the green belt area. The wind was reported from 350 degrees at 5 knots, but noted that it could be a bit more turbulent in the rescue area; so they would approach the area from the north. They deployed the rescuer and a little later, a backboard, to the rescuer. They then looked for a 7 meter [landing zone/rendezvous] location, and then loitered in the green belt area, waiting for the rescuer's call for extraction. After receiving the radio call from the rescuer, they proceeded to the rescuer's area and conducted the hoist operation. Upon hearing "axis clear" from the hoist operator, he transitioned to forward flight; he added that they were approximately 100-120 feet AGL, with the rescuer and patient just below the skids when the hoist operator stated the rescuer was gone and had fallen from the hook. The hoist operator reported that they were dispatched for a wilderness rescue. He and the rescuer completed the safety checks of their equipment prior to launch. Once at the rescuer area, he reported they deployed the rescuer from an altitude of 100 feet AGL; during the delivery of rescuer, medical and Bauman bag some incidental contact with tree branches occurred. Once the rescuer was on the ground, she reported "hook clear", and he retracted the hoist. During the retraction, a small tree branch came back wedged on the hoist bumper. He removed the branch and discarded it over a vacant area and then inspected the hook and cable, to confirm no damage. They then lowered a backboard via rope to ground personnel who were with the rescuer. They then departed to look for a 7 meter location. When the rescuer said "ready for pickup", they elected to do the extraction 50 feet higher, to minimize the effect of rotor wash on the ground personnel. Upon hearing "ready for extraction" on the radio, he brought the hoist cable up. He added that during the lift, the rescuer and victim made light contract with tree branches. Once clear of the trees, the rescuer and victim started to spin; he asked the pilot for some forward airspeed, after announcing "axis clear", to stop the spin. He added that it appeared the rescuer's legs were parallel to the victim, and thought it was due to the spinning. The hoist operator stated that after the helicopter gained forward airspeed, the spin had slowed and almost stopped. He noticed that the rescuer was riding in a position lower than normal. At which time, she fell from the rigging leaving the patient and medical bag still attached to the hoist hook. Several fire department emergency personnel were with the patient, when the STAR Flight helicopter arrived on scene. Emergency personnel reported that the rescuer was inserted below their location and had to climb slightly uphill to the patient. One of the persons stated that there was plenty of lighting, but didn't recall if people were using headlamps. They had also retrieved the backboard for the rescuer. He added that then the rescuer said she was about to call the helicopter in, he asked what else do you need, and she responded to just get the catch hook. One of the other individuals got the hook and handed it to her. He added that he didn't see the hookup and she gave the 'thumbs up" and they took off into the air with no hesitation. The rescuer and patient looked "okay". They moved into a small tree and looked like the rescuer was protecting the patient. He added that they stopped, lowered and moved over, or moved over and lowered at the same time; that it looked controlled or surgical, and then they took off into the sky. Another one of the fire department personnel added, that he asked the rescuer if she needed one of them to safety her gear, and she responded that she was fine. He added that he didn't see the hookup or signal; the rescuer and victim departed quickly and everything looked like other calls by STAR Flight. He stated that the patient's left foot went into trees a little bit, and he thought, that might hurt. They repositioned to get out of the trees, and then disappeared above the tree line. He added the rescuer looked chest level with the patient; he had seen three of these (type rescues) and it didn't look abnormal. Another fire department personnel reported that he was holding the HRV for the rescuer. She then took it from him and it looked like she hooked up the Bauman bag and backpack. He didn't see her hookup, but he didn't notice everything that was going on. He saw the "thumbs up" and they took off. He added that when the rescuer and patient went into the tree, he thought he heard someone holler; he was the only one that heard it, but figured it was the patient because every time they moved the patient or something hit her ankle, she'd holler out. He added that he didn't hear it clear enough to know who or what was hollered. He added that during the lift off from the ground, the rescuer was hunched over the patient. When they got into the tree they stopped, he couldn't tell if they were lowered down, but they moved over and they were gone. Another emergency personnel added that the rescuer had the HRV in her possession. She called the helicopter in and the hook came, which had two spot lights and a big orange boom around it. One of the other individuals handed her t