Inquest into the death of Michael Wilson
Anders Mykkeltvedt, CSO Senior Solicitor, Inquiries
On 16 September 2014, Deputy State Coroner Forbes delivered findings in relation to the inquest into the death of Michael Wilson.
Mr Wilson was an ambulance paramedic with some 20 years' experience. At the time of his death, he was a well-regarded member of the NSW Ambulance Specialty Access Casualty Team ("SCAT"), an elite paramedic unit with expertise in difficult medical retrieval operations. Mr Wilson died while attempting an extremely challenging rescue at Budderoo National Park on Christmas Eve, 2011.
Earlier that day, a canyoner had fallen while abseiling down a 70-80 metre sheer cliff face at the Bridal Veil Waterfalls within the National Park. The canyoner fell a distance of approximately 10 metres before coming to rest on a ledge close to the bottom of the cliff. He suffered injuries to his back and leg in the course of that fall and was unable to climb to the bottom of the cliff.
A friend of the canyoner activated a personal locator beacon, which was subsequently detected by the Australian Maritime Safety Authority ("AMSA"). AMSA, in turn, dispatched Rescue 24, a helicopter operated by the Canadian Helicopter Company ("CHC"), to respond to the incident. Rescue 24 was crewed by a CHC Pilot, a CHC Aircrewman/hoist operator, a doctor, Mr Wilson, and Mr Tom Thistleton, another SCAT paramedic.
On attending the scene of the accident, it became apparent that it would not be possible to winch directly down to the injured canyoner. Accordingly, Rescue 24 landed in a paddock a short distance west of the falls and the crew developed a plan as to how best to rescue the canyoner. Ultimately, it was decided that the two paramedics would be winched down to the top of the falls. Mr Wilson would then abseil down to the canyoner while Mr Thistleton remained at the top. When Mr Wilson was ready, the rescue hook was to be winched down to Mr Thistleton, after which the helicopter would descend into the canyon. Because the helicopter was not likely to be able to be positioned directly above Mr Wilson, he planned to use a 'belay' or stabilising rope to 'plumb' himself and the canyoner out from the ledge and directly under the helicopter. The belay line was to be connected to the winch hook and used by Mr Wilson to control any horizontal swing that developed as he and the canyoner moved away from the ledge.
The contemplated plan was not one that appeared in any of the relevant policies or procedures, nor was it one for which Rescue 24's crew had specifically trained.
Unfortunately, the operation did not go according to plan. Mr Wilson and Mr Thistelton were placed at the top of the falls at approximately 6.45pm and Mr Wilson had abseiled down into the gorge by about 7.30pm. By the time, however, that Mr Wilson was ready to be winched, darkness had begun to envelop the gorge.
At about 8.20pm, Rescue 24 moved into position at the head of the falls and the rescue hook was lowered by the Aircrewman to Mr Thistleton on the top of the falls. Rescue 24 then began its descent into the gorge. A series of problems with the crew's communication equipment meant that neither Mr Thistleton, nor Rescue 24 were able to establish radio or telephone contact with Mr Wilson at this time.
Because of the rapidly encroaching dark, Rescue 24 had difficulty establishing a good hover position. They ultimately established a hover position in the gorge at a position about 22 metres above the ledge and about 25 to 30 metres out from the cliff face – an angle of about 45 degrees from Mr Wilson on the ledge. This position was beyond the permissible operating angle of the winch.
Nevertheless, Mr Wilson connected the winch hook to himself and the canyoner. Very shortly thereafter, Mr Wilson and the canyoner came off the ledge somehow and fell or swung down into the gorge below, striking some large rocks as they went. Mr Wilson suffered catastrophic blunt force injuries and, despite the best efforts of Mr Thistleton and a subsequent rescue crew, died at the site. The canyoner was not seriously injured in the fall.
Findings and recommendations
The bottom of the falls was, at the time of the accident, a dark, wet, and fairly hostile environment. There was no clear and cogent evidence as to what exactly led Mr Wilson and the canyoner to come off the ledge and fall to the rocks below. Deputy State Coroner Forbes considered a number of different theories, including the possibility that Mr Wilson was pulled off the ledge after the helicopter winch was engaged prematurely.
Ultimately, Deputy State Coroner Forbes recorded Mr Wilson "died as a consequence of extensive blunt trauma injuries he sustained during the course of rescuing an injured canyoner." Her Honour was not, however, able to determine precisely how Mr Wilson and the canyoner came off the ledge. In addition to making a number of recommendations arising from the incident, her Honour commended the efforts of NSW Ambulance, NSW Police Force, AMSA and CHC Helicopters in relation to the implementation of measures since the incident to improve rescue training, planning, communications and co-ordination.