What happened
On September 16, 2013, a Bell 412EP helicopter, registered JA20NA, operated by the Nara Disaster Prevention Air Corps, conducted a rescue mission in Nishiyoshino Town, Nara Prefecture. The mission was initiated to evacuate individuals isolated by heavy rainfall from a recent typhoon.
Due to the lack of a suitable landing site, the crew utilized the aircraft's hoist to retrieve the rescuee. Two rescuers descended to the ground to assist. One rescuer attached the rescuee's evacuation harness to their own harness using carabiners. Because the ground was wet and the rescuee was an elderly person in a kneeling position, the rescuer opted to lift them from this posture.
As the hoist began to lift the rescuer and the rescuee simultaneously, the rescuee grabbed onto a carabiner to stabilize themselves against falling backward. This movement caused the rescuee's finger to become caught between the connecting carabiners, resulting in a serious injury to the left hand. The operation was immediately halted, and the individual was later transported to a hospital via ambulance.
The investigation
The JTSB investigation examined the rescue equipment, the flight history, and the established operational procedures of the Nara Disaster and Prevention Air Corps. Investigators reviewed statements from the pilots and rescuers, as well as the testimony of the rescuee. The investigation also assessed the environmental conditions, noting that while visibility was good and winds were calm, the high noise levels from the helicopter likely prevented the rescuee from clearly hearing safety instructions regarding the danger of holding the carabiner.
Findings
- The investigation determined that the rescue equipment, including the evacuation harness and carabiners, was functioning correctly with no mechanical abnormalities.
- The rescuee's posture—kneeling rather than sitting—likely caused them to instinctively grab the carabiner to prevent falling backward during the ascent.
- The rescuee held onto the carabiner, which led to their finger being pinched between the rescuer's carabiner and the rescuee's harness carabiner as the weight shifted during the lift.
- The loud engine noise made it difficult for the rescuee to understand the verbal warnings provided by the rescuers.
- Existing procedures did not explicitly require rescuers to verify the hand position of the rescuee or specifically monitor for grasping the hardware.
Safety action
Following the accident, the Nara Disaster Prevention Air Corps implemented several safety improvements:
- The carabiners on the evacuation harnesses were replaced with sling carabiner sets designed to prevent hands from reaching the connection points.
- Procedures were updated to ensure rescuees are placed in a sitting position or a stable three-point contact position before lifting.
- Operational protocols now mandate checking the hand positions of rescuees and closely observing them during the initial lift.
- The unit established a monthly "Safety Management Enhancement Day" to conduct equipment checks and specialized rescue training.