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'Systemic' Safety Issues Identified with Hospital Helipads

The NHS and aviation bodies have been told to take coordinated action to improve safety procedures following the death of a pensioner who was blown over by rotor downwash from a search and rescue helicopter as it landed in a hospital car park in Plymouth.

The fatal accident occurred on 4 March, 2022 as the Sikorsky S-92A approached Derriford Hospital with a hypothermic casualty rescued from a river valley near Tintagel in Cornwall.

Fatal Head Injury Sustained

During the landing, several members of the public were subjected to high levels of downwash, resulting in an 87-year-old woman sustaining fatal head injuries and another woman breaking her pelvis. 

A report by the Air Accidents Investigation Branch (AAIB) found that Derriford Hospital staff responsible for managing the landing site were insufficiently briefed about helicopter operations to mitigate risks around the site.

The AAIB's chief inspector of air accidents said the inquiry had identified "systemic safety issues" around hospital helicopter landing sites that should be addressed at a national level.

The analysis by the AAIB, which is responsible for investigating civil aircraft accidents across the UK, showed that although Derriford Hospital's landing site was in a secured area within the car park, most of the car park was affected by the downwash from the rotor blades, which the commander of the helicopter described as "massive".

The investigation found that the underlying cause of the incident was that uninvolved people had not been prevented from being in publicly accessible locations around the helipad, and were thus subject to — and blown over by — high levels of downwash from the helicopter as it landed. 

The helicopter's commander, who had more than 7000 hours' flying experience, had assumed hospital staff had secured the landing site and the surrounding area, the report said. However, the hazard of helicopter downwash in the car parks adjacent to the landing site was not identified by staff responsible, and the risk of possible injury to bystanders had not been properly assessed.

Contributory factors included:

  • Guidance available at the time the hospital was built did not adequately address the downwash issue
  • Despite actions being taken in response to previous downwash complaints, the need to manage the hazards in the adjacent car parks was not identified, and the injury risks not properly assessed
  • No one at the hospital was aware of Civil Aviation Authority (CAA) standards for helicopter landing areas at hospitals, which in any case were not retrospectively applicable to the existing landing site
  • The helicopter operator was not fully aware of the relevant hospital staff's roles, responsibilities, and standard operating procedures
  • The staff responsible had insufficient knowledge about helicopter operations to manage the downwash risk around the site safely
  • Communication between helicopter operators and the hospital was ineffective, with no convenient mechanism for information sharing

Hospital Trust Took Action to Improve Safety

In a statement, University Hospitals Plymouth NHS Trust apologised for what happened and expressed sympathy to the pensioner's family and everyone affected. As a result of what took place it had "made immediate changes to the operational running of the helipad", closed the landing site to aircraft over five tonnes, shut the adjacent car park to patients and visitors, and increased signage in the area.

The AAIB said that although operators of search and rescue, and helicopter emergency medical services, are regulated by the Civil Aviation Authority (CAA), 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," it said.

Crispin Orr, chief inspector of air accidents, said the investigation revealed "systemic safety issues around the design and operation of hospital helicopter landing sites", which needed to be "addressed at a national level". He said it was "essential that the risks associated with helicopter downwash are understood and well-managed". The investigation had thus raised awareness and been "a catalyst" for safety actions to mitigate the immediate risk. 

Nine Safety Recommendations Issued

The AAIB issued nine safety recommendations, including that NHS England Estates, in conjunction with the CAA and relevant NHS organisations, "develop and promulgate enhanced risk management guidance for hospital helicopter landing sites, and provide information on the range and use of potential mitigations for the protection of uninvolved persons from helicopter downwash". 

It should also develop competency requirements, and introduce training, for all hospital helicopter landing site managers, to include a basic introduction to helicopter operations and safety management practices. 

There should be a database of existing sites, which should be reviewed and appropriate actions instigated to minimise the risk of injury. NHS England Estates should seek participation from the healthcare organisations in Scotland, Wales, and Northern Ireland.

In response, NHS England Estates had instigated national data collection with all hospital chief executives in England to seek assurance on levels of compliance with CAA standards, and to identify any staff training requirements. It has instigated a training programme for landing site managers, and is working towards a common database for all operators.