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Release Final Report of National Airborne Service Corps, Ministry of the Interior AS-365, NA-104 Major Transportation Occurrence Investigation

Publication Date 2019-10-31
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The Taiwan Transportation Safety Board (TTSB) releases final report on the investigation of a National Airborne Service Corps, Ministry of the Interior (NASC) AS-365N2 helicopter, registration numbered NA-104, the patient fell off the stretcher into the sea when performed hoisting rescue mission from Kaohsiung Outer Harbor.

On November 4, 2018, an AS-365N2 helicopter, took off from Kaohsiung International Airport at 1715 to carry out a sea emergency medical hoist up rescue mission, with 5 crewmembers on board. About 1726, while hoisting the patient, the patient fell off the stretcher into the sea from the air and a hoisting was carried out again, the patient was pronounced dead after returned to the Kaohsiung International Airport for medical treatment.

 According to the Transportation Occurrence Investigation Act of Republic of China (ROC) and the content of Annex 13 to the Convention on International Civil Aviation Organization, the National Transportation Safety Board (TTSB), an independent transportation occurrence investigation agency, was responsible for conducting the investigation. The investigation team also included members from NASC and Coast Guard Administration of Ocean Affairs Council. The Final Report was reviewed and approved by TTSB’s 4th Board Meeting on October 4, 2019.

Findings related to probable causes:

The patient greatly flailed his arms, and was unable to stop his actionduring hoisting through request. The patient started slid outward from the safety belt of the stretcher, then fell out from the tilted stretcher and dropped into the sea.


Full Final Report is in Chinese only and available for download at



Sherry Liu, Safety Investigator
Tel: 02-89127388-ext6286

Last updated 2019-11-19
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