What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
On July 11, 2016 at approximately 1900 hours while conducting "hoist" training with Delaware state police and lewes fire department (Delaware air rescue team (dart), a fireman, in the position of systems operator (so) fell to his death as he departed the helicopter for hoist operation training. During this training the helicopter was operating in public aircraft operations (pao) status. The height of the helicopter was approximately 60-70 feet. There were 4 crew members on board the aircraft which was not damaged during this incident. Each person had a specific job function during the training/actual mission. The following positions were identified during the training:
1. The system operator (so) (fireman/deceased) operates the winch devise and eventually directs the aircraft to the site, once pilot loses visual contact.
2. Rescue specialist (rs) Delaware state police: is the paramedic that is hoisted down to site.
3. Pilot (Delaware state police): PIC of aircraft and operates the helicopter.
4. Safety officer (fireman): although not required during an actual emergency flight, the Delaware state police does require the safety officer during all training missions. Acts as a "third set of eyes" for all safety issues.
Each crew member performing the duties listed above are secured to the aircraft by restraints fitted to attaching points installed on the aircraft. Each person was to switch positions during the training mission. There are approximately 3-4 hoisting evolutions completed for each of the crew members.
During the final training phase, but the first evolution as the so. The accident occurred. The so requested permission to exit aircraft and "step on the skid"( this is standard procedure), PIC gave the permission. As the so stepped out onto the skid he fell to the ground. It appears that this system operator (so) was not tethered to the aircraft, although the rescue specialist (rs) and safety officer verified that they observed the system operator (so) secured to the restraint system., as required in check list. Inspection of the restraint system, tether straps, and hooks showed no damage or failure of any kind.
Check lists were used during actual and training missions. These check lists include checking the restrain systems and tethering of each crew member two times before the actual hoisting takes place. Although there is documented training for hoist training which is an external load operation, this public aircraft operation (pao) does not have a rotorcraft load combination flight manual (rlcfm) which would incorporate a multitude of policies, procedures and weight and balance information, to name a few. This rlcfm is approved by the FAA. Counseling can be accomplished to discuss the proper development of a rlcfm and authorization of a external load operating certificate.
As the FAA filed it
ON JULY 11, 2016 AT APPROXIMATELY 1900 HOURS WHILE CONDUCTING "HOIST" TRAINING WITH DELAWARE STATE POLICE AND LEWES FIRE DEPARTMENT (DELAWARE AIR RESCUE TEAM (DART), A FIREMAN, IN THE POSITION OF SYSTEMS OPERATOR (SO) FELL TO HIS DEATH AS HE DEPARTED THE HELICOPTER FOR HOIST OPERATION TRAINING. DURING THIS TRAINING THE HELICOPTER WAS OPERATING IN PUBLIC AIRCRAFT OPERATIONS (PAO) STATUS. THE HEIGHT OF THE HELICOPTER WAS APPROXIMATELY 60-70 FEET. THERE WERE 4 CREW MEMBERS ON BOARD THE AIRCRAFT WHICH WAS NOT DAMAGED DURING THIS INCIDENT. EACH PERSON HAD A SPECIFIC JOB FUNCTION DURING THE TRAINING/ACTUAL MISSION. THE FOLLOWING POSITIONS WERE IDENTIFIED DURING THE TRAINING:
1. THE SYSTEM OPERATOR (SO) (FIREMAN/DECEASED) OPERATES THE WINCH DEVISE AND EVENTUALLY DIRECTS THE AIRCRAFT TO THE SITE, ONCE PILOT LOSES VISUAL CONTACT.
2. RESCUE SPECIALIST (RS) DELAWARE STATE POLICE: IS THE PARAMEDIC THAT IS HOISTED DOWN TO SITE.
3. PILOT (DELAWARE STATE POLICE): PIC OF AIRCRAFT AND OPERATES THE HELICOPTER.
4. SAFETY OFFICER (FIREMAN): ALTHOUGH NOT REQUIRED DURING AN ACTUAL EMERGENCY FLIGHT, THE DELAWARE STATE POLICE DOES REQUIRE THE SAFETY OFFICER DURING ALL TRAINING MISSIONS. ACTS AS A "THIRD SET OF EYES" FOR ALL SAFETY ISSUES.
EACH CREW MEMBER PERFORMING THE DUTIES LISTED ABOVE ARE SECURED TO THE AIRCRAFT BY RESTRAINTS FITTED TO ATTACHING POINTS INSTALLED ON THE AIRCRAFT. EACH PERSON WAS TO SWITCH POSITIONS DURING THE TRAINING MISSION. THERE ARE APPROXIMATELY 3-4 HOISTING EVOLUTIONS COMPLETED FOR EACH OF THE CREW MEMBERS.
DURING THE FINAL TRAINING PHASE, BUT THE FIRST EVOLUTION AS THE SO. THE ACCIDENT OCCURRED. THE SO REQUESTED PERMISSION TO EXIT AIRCRAFT AND "STEP ON THE SKID"( THIS IS STANDARD PROCEDURE), PIC GAVE THE PERMISSION. AS THE SO STEPPED OUT ONTO THE SKID HE FELL TO THE GROUND. IT APPEARS THAT THIS SYSTEM OPERATOR (SO) WAS NOT TETHERED TO THE AIRCRAFT, ALTHOUGH THE RESCUE SPECIALIST (RS) AND SAFETY OFFICER VERIFIED THAT THEY OBSERVED THE SYSTEM OPERATOR (SO) SECURED TO THE RESTRAINT SYSTEM., AS REQUIRED IN CHECK LIST. INSPECTION OF THE RESTRAINT SYSTEM, TETHER STRAPS, AND HOOKS SHOWED NO DAMAGE OR FAILURE OF ANY KIND.
CHECK LISTS WERE USED DURING ACTUAL AND TRAINING MISSIONS. THESE CHECK LISTS INCLUDE CHECKING THE RESTRAIN SYSTEMS AND TETHERING OF EACH CREW MEMBER TWO TIMES BEFORE THE ACTUAL HOISTING TAKES PLACE. ALTHOUGH THERE IS DOCUMENTED TRAINING FOR HOIST TRAINING WHICH IS AN EXTERNAL LOAD OPERATION, THIS PUBLIC AIRCRAFT OPERATION (PAO) DOES NOT HAVE A ROTORCRAFT LOAD COMBINATION FLIGHT MANUAL (RLCFM) WHICH WOULD INCORPORATE A MULTITUDE OF POLICIES, PROCEDURES AND WEIGHT AND BALANCE INFORMATION, TO NAME A FEW. THIS RLCFM IS APPROVED BY THE FAA. COUNSELING CAN BE ACCOMPLISHED TO DISCUSS THE PROPER DEVELOPMENT OF A RLCFM AND AUTHORIZATION OF A EXTERNAL LOAD OPERATING CERTIFICATE.
NTSB investigation
The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.