AAIB Report - Derriford

​The UK Air Accident Investigation Branch this morning issued the much-anticipated report into the tragic accident which took place at Derriford Hospital on the 4th of March 2022. 
 
I think first and foremost, I have to extend my sincere condolences to the family of Jean who unfortunately passed away as a result of this accident. 
 
And to the crew of Rescue 163 of whom some I know personally; my thoughts are with you at this time. Our emergency services go to work to save lives that’s it, they are all heroes as far as I am concerned.
 
The full report can be downloaded here: 
 
https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-2-slash-2023-sikorsky-s-92a-g-mcgy#download-report
 
Below a quick down and dirty breakdown of the report.  I will break it down further, but I felt it appropriate to get the basics out to you as soon as practical.
 
Don’t forget NHS England are hosting a webinar on the 9th of November and will be presented by Michael Bellas, National Estates Policy Lead and John Stephens, Director of Estates and Facilities, UH Plymouth.  The link to register is below:
 
https://www.events.england.nhs.uk/events/national-webinar-hospital-helipads
 
If anyone wants to chat through the report with me, please give me a shout, more than happy to have teams chat (with coffee!).

Introduction
The Air Accidents Investigation Branch (AAIB) were notified of this accident on 4 March 2022, the day that it occurred.  The sole objective of the investigation of an accident or serious incident under these regulations is the prevention of accidents and serious incidents. It shall not be the purpose of such an investigation to apportion blame or liability.
In accordance with established international arrangements, the National Transportation Safety Board (NTSB) in the USA, representing the State of Design and Manufacture of the helicopter, appointed an Accredited Representative to the investigation. The helicopter operator, the hospital Helicopter Landing Site (HLS) Site Keeper, and the UK Civil Aviation Authority (CAA) also assisted with the investigation.
Summary
The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. 
During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured.
The investigation identified the following causal factors:

1. The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS.

 

1. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash.

 
The investigation identified the following contributory factors:

1. The HLS at DH was designed and built to comply with the guidance available at that time, but that guidance did not adequately address the issue of helicopter downwash.

 

1. The hazard of helicopter downwash in the car parks adjacent to the HLS was not identified, and the risk of possible injury to uninvolved persons was not properly assessed.

 

1. A number of helicopter downwash complaints and incidents at DH were recorded and investigated. Action was taken in each case to address the causes identified, but the investigations did not identify the need to manage the downwash hazard in Car Park B, so the actions taken were not effective in preventing future occurrences.

 

1. Prior to this accident, nobody at DH that the AAIB spoke to was aware of the existence of Civil Aviation Publication (CAP) 1264, which includes additional guidance on downwash and was published after the HLS at DH was constructed. The document was not retrospectively applicable to existing HLS.

 

1. The operator of G-MCGY was not fully aware of the DH HLS Response Team staff’s roles, responsibilities, and standard operating procedures.

 

1. The commander of G-MCGY believed that the car park surrounding the DH HLS would be secured by the hospital’s HLS Response Team staff, but the co‑pilot believed these staff were only responsible for securing the HLS.

 

1. The DH staff responsible for the management of the HLS only considered the risk of downwash causing harm to members of the public within the boundary of the HLS and all the mitigations focused on limiting access to this space.

 

1. The DH staff responsible for the management of the HLS had insufficient knowledge about helicopter operations to safely manage the downwash risk around the site.

 

1. The HLS safety management processes at DH did not result in effective interventions to address the downwash hazard to people immediately outside the HLS.

 

1. HLS safety management processes at DH did not identify that the mitigations for the downwash hazard were not working well enough to provide adequate control of the risk from downwash.

 

1. Communication between helicopter operators and DH was ineffective in ensuring that all the risks at the DH HLS were identified and appropriately managed.

 

1. Safety at hospital HLS throughout the UK requires effective information sharing and collaboration between HLS Site Keepers and helicopter operators but, at the time of the accident, there was no convenient mechanism for information sharing between them.

 
 
Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. 
It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. 

 
HLS site findings 
1.     The DH HLS had been operating for seven years and records indicated there had been over 2,500 landings, of which around 140 were SAR type helicopters. 
 
2.     The DH HLS was built in accordance with the guidance material available at the time. 
 
3.     The advice provided in the guidance at the time was inconsistent between the different types of HLS and could lead to an interpretation that downwash was not a factor for an HLS on a mound, such as the DH HLS. 
 
4.     The DH HLS is intentionally situated close to the ED so that casualties can be transferred quickly. This is a busy area for pedestrian and vehicular movements. 
 
5.     An independent helicopter adviser was used during the feasibility stage of the helipad design. 
 
6.     The feasibility report recommendations were consistent with HBN 15-03, ICAO Annex 14 version 3 and ICAO heliports manual version 3. 
 
7.     The feasibility report considered the effects of downwash but downplayed the potential effects and concluded that most of the downwash would be confined to the DH HLS surface. 
 
8.     Involvement of the helicopter adviser by the designers was informal. 
 
9.     The hospital Trust believed the downwash hazard was adequately controlled by the design of the DH HLS. 
 
10.  The feasibility report made recommendations about managing the DH HLS site and downwash hazard that were over and above the available guidance at the time. 
 
11.  The hospital Trust did not implement the recommendation in the feasibility report to manage the public areas outside the DH HLS.
 
12.  The hospital Trust’s Standard Operating Procedures and onsite Operational Procedures and Response to an Emergency Incident for the HLS did not include any operational procedures for managing the areas outside the HLS boundary. 
 
State-level safety leadership for hospital HLS
At an individual hospital HLS, the aircraft operator is responsible for the safe flight of the helicopter and the HLS Site Keeper (often the hospital Trust) is responsible for providing a safe landing site. The safety of people in the vicinity of a hospital HLS is an area of joint responsibility because in a hospital environment, neither party can ensure safety without the cooperation of the other. 
 
Because this responsibility is joint, safety relies on effective sharing of information between the HLS Site Keeper and each operator so that the characteristics of the HLS, the procedures, and the roles of each party at each site are understood. 
 
This is currently a laborious process that requires each individual operator and HLS Site Keeper pair to collaborate. Operators use multiple hospital HLS, and each site can have multiple operators.
 
Evidence also suggests that the problem is not confined to this particular hospital, Trust, or helicopter operator. 
 
As well as there being no convenient mechanism to support communication, there is limited aviation competence, resource, and centralised support for the task of managing an HLS within the NHS. 
 
Therefore, these HLS Site Keepers have a responsibility for which they do not have the capability to properly fulfil.
 
 
NHS England Estates
 
In late 2019, before this accident, a working group on HLS was established. Although there wasparticipation by the DfT, CAA, MCA, helicopter operators and other stakeholders, it noted that no oneprincipal stakeholder was taking the lead in addressing the issues they were discussing. However, in commonwith the OnSLG, they were also proposing a national HLS database.
 
Since this accident, several workstreams have been initiated, that appear to be addressing some of the issuesraised during this investigation. However, the results of some of these were not known at the time this report was published.

 
SUMMARY OF SAFETY RECOMMENDATIONS
 
Safety Recommendation 2023-028
 
It would be of benefit to hospital Trusts, or any other organisation that manages an HLS, to be able to find all the applicable downwash guidance in one document without the need to cross refer.

Safety Recommendation 2023-029
 
For the HLS Site Keepers, performing adequate risk assessments is a task requiring specialist knowledge that is not readily available within the health service. 
 
Hospital HLS managers would benefit from enhanced guidance on how to risk assess their sites and the range of potential mitigations that might be used to reduce the risk of uninvolved persons being exposed to the hazards associated with HLS.
 
Safety Recommendation 2023-030
 
There are currently no minimum competency requirements for those personnel who are responsible for managing hospital HLS. To manage the risks effectively, these personnel need to have the knowledge to understand the risks and to also have effective systems in place for the communication and management of safety risks that may be highlighted by other organisations. 

Safety Recommendation 2023-031

If downwash zones were implemented to the guidance in CAP 1264 and ICAO documents at all hospital HLSin the UK, the risk of injuries to uninvolved.
persons would be reduced.
 
Safety Recommendation 2023-032

Safety Recommendation 2023-034 / 035

An HLS database could, provided that everyone is able to openly share information, lead to bettercooperation and communication between the HLS.
Site Keepers and the helicopter operators using them.
 
Safety Recommendation 2023-036
 
There are a diverse range of stakeholders involved in the decisions around hospital HLS; business needs,local planning, design, risk assessment and ongoing risk management responsibilities are distributed over anumber of government departments and current improvement efforts appear to be somewhat fragmented.
 
Healthcare, emergency services and transport are all State functions in the UK, so it would be appropriate for astate organisation with the necessary expertise and channels of communication between other governmentdepartments to provide the necessary leadership. The DfT has
such expertise and remit for aviation safety policy.
 
Si @ Green Deck Operations www.greendeckops.com