WPR13GA338

The premature hoisting operation and the inadvertent disengagement of the hoist hook on the rescuer’s harness in dark night conditions. Contributing to the accident was a lack of direct audio communication between the rescuer and the hoist operator.

The purpose of the flight was to rescue a stranded hiker from the side of the mountain in dark night conditions. Once on scene, the pilot, copilot, hoist operator, and two rescue crewmembers briefed that one of the rescue crewmembers would be lowered down to the hiker and that he would then help the hiker into the strop harness. The rescuer was to remain attached to the hoist hook that was attached to his sit harness via a carbineer throughout the rescue operation, which was planned to take about 30 seconds. The hoist hook had three attachment points: a main hook, a secondary hook, and a utility eye; it is likely that the rescuer's sit harness was attached to the main hook and that the strop harness was attached to the utility eye. The hoist operator reported that, after the rescuer was lowered down to the hiker, he observed the rescuer helping the hiker into the strop harness. The hoist operator then told the pilot that he would be cleared to move the helicopter to the left and aft to clear the rock face as soon as he "had the load." The hoist operator added that he saw the rescuer signal to begin the hoisting operation. The hiker reported that the rescuer put him into the harness while remaining attached to the hoist hook. He stated that the rescuer was moving purposefully and that his actions appeared very deliberate. The rescuer then told him to stand up, and he heard what he thought was the sound of a carabineer unclipping. It is likely that the rescuer's carabineer inadvertently became disengaged or partly disengaged from the hoist hook at this point. As the cable started moving upward, the hiker then noticed that the rescuer began rushing his actions, likely indicating that the hoist operation had begun before the rescuer was ready. As the hook was ascending, the rescuer grabbed both of the hiker's hands and placed them on the harness just below the hoist hook, which was at the hiker's eye level, and told to the hiker to hold on. During a rescue using a strop harness, the rescuer is supposed to leave the ground first. However, the hiker reported that his feet left the ground first while the rescuer remained on the ledge. The hiker then started to rotate and move away from the rock face. While moving away from the rock face, the hiker felt the rescuer grab him around his waist and then slide down his body until the rescuer fell, which resulted in his death. The hiker was hoisted into the helicopter and was uninjured. Examination of the harness and hoist hook revealed no damage that would have precluded normal operation. The hoist's main and secondary hooks did not have self-locking safety mechanisms; this design could allow a carabineer to travel upward against the hoist hook's nonlocking safety latch and inadvertently disengage the hook. Given the hiker's statement about hearing a carbineer unclipping and the rescuer's subsequent fall, it is likely that the hoist hook inadvertently disengaged from the rescuer's harness. The helicopter was not equipped to allow direct intercommunications between the hoist operator and the rescuer. Therefore, once the rescuer departed the helicopter, the only effective communication between the hoist operator and the rescuer was hand signals. Although the hoist operator was using night vision goggles during the flight, the dark night conditions likely limited his detail vision and made it difficult to see the rescuer's hand signals. The lack of direct audio communications between the hoist operator and the rescuer prevented the rescuer from being able to report a problem after the hoist operation began and might have contributed to the hoist activation occurring before the rescuer was ready.

HISTORY OF FLIGHT On July 22, 2013, about 2220 Pacific daylight time (PDT), a rescue officer was fatally injured during a rescue hoist operation from a Bell HH-1H helicopter, N233JP, near Mount Charleston, Nevada. Las Vegas Metropolitan Police Department (LVMPD) was operating the helicopter as a public-use aircraft flight. The flight crew consisted of two commercial pilots and three crewmen: a crew chief/hoist operator; and two rescue officers. The helicopter sustained no damage. The local flight departed North Las Vegas, Nevada, about 2150. Night visual meteorological conditions prevailed, and no flight plan had been filed. According to the operator, the mission was to rescue a stranded hiker from the side of a mountain. During the hoist back to the helicopter, the rescue officer fell and was fatally injured. The civilian hiker was recovered to the helicopter via the hoist without injury. The hiker reported that while hiking in the area of Mount Charleston, he became trapped on a rock outcropping. He contacted the 911 operator using his cell phone, and was told that LVMPD would send help and to remain where he was. The hiker reported that once the rescue helicopter arrived, he watched as the rescuer was lowered. After the rescuer landed on the outcropping, the hiker was directed to remain in a crouched position as the rescuer put him into the harness. The hiker stated that the rescuer was moving very purposefully and his actions appeared very deliberate. He noted that the rescuer remained attached to the hoist hook while the hiker was put into the harness. The rescuer then told him to stand up. As the hiker stood up, he heard what he thought was the sound of a carabineer unclipping. The hiker stated that he was looking up at the helicopter, and the cable started to move. He never saw the rescuer make any indications to the helicopter that they were ready to be hoisted, but he did not know what those hand signals would have been. As the hoist cable was coming up, the movements of the rescuer changed cadence. The rescuer appeared to be rushing his actions. The hiker stated that as the rescue hook was at about his eye level, the rescuer grabbed both of his hands and placed them onto the harness below the hook. With a determined look on his face, the rescuer indicated everything was going to be okay, and directed him to hold on tight. The hiker stated that as his feet left the ground, he started to rotate and move away from the rock face. The rescuer was still on the ledge behind him as he was lifted off the ground. As they moved away from the rock face, he felt the rescuer grab him around the waist. The hiker felt the rescuer sliding down his body until the rescuer fell away. The lift continued, and the hiker was hoisted into the helicopter. Subsequently they landed, and he was taken off the helicopter. PERSONNEL INFORMATION PILOT The 45-year-old pilot held a commercial pilot certificate with ratings for airplane single-engine land, rotorcraft, and instrument airplane and rotorcraft. The pilot held a certified flight instructor (CFI) certificate with ratings for helicopter. The pilot held a second-class medical certificate issued on July 31, 2012. It had no limitations or waivers. The pilot had a total flight time of 2,754 hours, with 100 hours in the last 90 days, and 35 in the last 30 days. He had 90 hours in the accident helicopter make and model. He completed a biennial flight review on January 10, 2012. The pilot reported that he had 145 hours of rescue flight time, which included training time. He had completed 38 rescues in his 2 years as a rescue pilot for LVMPD. The pilot was interviewed following the accident and related that he was assigned as the pilot-in-command of Rescue Air-6. He was dispatched with a co-pilot and three rescue crew members to the area of Mount Charleston to rescue a hiker who was trapped on a ledge. The pilot, co-pilot, left-side rescue crew member, and the hoist operator were all utilizing Night Vision Goggles (NVG) during the rescue operation. Once on scene, the crews briefed that they would lower the rescuer down to the hiker, and use the strop harness to recover the hiker. The rescuer briefed that he would remain attached to the hoist during the operation. After the rescuer had been lowered to the hiker, and before being hoisted up, the hoist operator advised the pilot that as soon as they had the load he would be cleared to move to the left away from the mountain face. Shortly after the rescuer signaled to begin the hoist, as the helicopter was moving to the left, the hoist operator stated on the intercom that the rescuer had fallen. The pilot related that the hoist operation continued as the hiker was recovered into the helicopter. After a few minutes of trying to locate the fallen rescuer, the pilot landed the helicopter at the staging area, which had been set up for the rescue, and off loaded the hiker. The pilot and crew made one more attempt to locate the rescuer before another flight crew arrived and took over the search and ultimately the recovery operation. CREW CHIEF/HOIST OPERATOR-(HOIST) The crew chief/hoist operator's assignment was to operate the hoist from the right side of the helicopter and to assist the pilot in maintaining proper clearance from the mountainside. The hoist operator related that once they arrived on scene, an assessment was done after they saw where the hiker was located. The rescuer suggested that they use the strop harness, and the rescuer stated he would remain attached to the hoist hook during the rescue, which was estimated to take about 30 seconds. After configuring the rescuer with the strop harness, which was attached to the hoist hook, the rescuer was lowered down to the hiker. The hoist operator could not directly see what the rescuer did as his back was to the hoist operator, but the rescuer's movements were consistent with the rescuer putting the strop harness onto the hiker. The hoist operator was verbalizing to the flight crew what he was observing using the helicopter intercom. During this time, the hoist operator informed the pilot that as soon as the pilot "had the load," he was cleared to move left and aft to clear the rock face. The hoist operator stated he saw the rescuer signal to begin the hoisting operation. The hoist operator watched the hiker, who was facing the helicopter, and the rescuer, who had his back to the helicopter. The hiker was observed holding onto the strop harness and looking up at the helicopter. The rescuer was relaxed and looking up at the hoist operator, just like a typical rescue. As the hiker and the rescuer lifted off, they started to rotate, which is normal as the hook can free spin. The hoist operator saw the rescuer was positioned a little bit higher on the hook and was above and behind the hiker's left shoulder. As they came off the ground, the hoist operator cleared the helicopter away from the mountainside. The hiker was closest to the mountainside, and the rescuer was closest to the drop off. As he was operating the hoist, the hoist operator felt the weight on the cable change, and he watched as the rescuer fell. SEARCH AND RESCUE OFFICER-(SAR Officer) The SAR officer's assignment was as the left side crew member. As such, he helped with whatever was needed inside the helicopter and monitored clearance on the left side of the helicopter. The SAR officer related that most hoist rescue operations would be accomplished using a standard body harness, which is a pre-sewn harness with quick-attach buckles. Generally the rescuer would be lowered to the victim, detach from the hoist hook, and signal for the hook to be recovered. The helicopter would then move away to allow the rescuer to communicate and harness the victim. The rescuer, when ready, would signal to the crew, and the helicopter would return and lower the hook to the rescuer. The rescuer would