Changes coming to aviation regulations after fatal Ornge crash in Moosonee

In its investigation report (A13H0001) released today, the Transportation Safety Board of Canada (TSB) found that several organizational, regulatory and oversight deficiencies led to the fatal May 2013 crash of a Sikorsky S-76A helicopter in Moosonee, Ontario.

As such, the Board is making 14 recommendations in 3 key areas.

On 31 May 2013, at 0011 Eastern Daylight Time, a Sikorsky S-76A helicopter operated by 7506406 Canada Inc. (Ornge Rotor-Wing (RW)) departed from the Moosonee Airport destined for Attawapiskat, Ontario. As the helicopter climbed through 300 feet into darkness, the first officer commenced a left-hand turn and the crew began carrying out post-takeoff checks. During the turn, the aircraft’s angle of bank increased, and an inadvertent descent developed. The pilots recognized the excessive bank and that the aircraft was descending; however, this occurred too late, and at an altitude from which it was impossible to recover. A total of 23 seconds had elapsed from the start of the turn until impact, approximately one nautical mile from the airport. The aircraft was destroyed by impact forces and the ensuing post-crash fire. All four on board—the captain, first officer and two paramedics—were killed.

“This accident goes beyond the actions of a single flight crew. Ornge RW did not have sufficient, experienced resources in place to effectively manage safety,” said Kathy Fox, TSB Chair. “Further, Transport Canada (TC) inspections identified numerous concerns about the operator, but its oversight approach did not bring Ornge RW back into compliance in a timely manner. The tragic outcome was that an experienced flight crew was not operationally ready to face the challenging conditions on the night of the flight.”

The investigation uncovered several issues. The night visual flight rules regulations do not clearly define “visual reference to the surface”, while instrument flight currency requirements do not ensure that pilots can maintain their instrument flying proficiency. At Ornge RW, training, standard operating procedures, supervision and staffing in key safety/supervisory positions did not ensure that the crew was ready to conduct the challenging flight into an area of total darkness. The training and guidance provided to TC inspectors led to inconsistent and ineffective surveillance of Ornge RW, as inspectors did not have the tools needed to bring a willing but struggling operator back into compliance in a timely manner, allowing unsafe practices to persist.

As a result of risks to the aviation system found during this investigation, the Board is issuing 14 recommendations to address deficiencies in the following areas:

• Regulatory oversight
• Flight rules and pilot readiness
• Aircraft equipment

To view more details about the changes to aviation standards, CLICK HERE.

“Both Ornge RW and TC have taken significant action since this accident, but there are still a number of gaps that need to be addressed,” added Chair Fox. “Our recommendations will help ensure that the right equipment is on board, that pilots are suitably prepared, and that operators who cannot effectively manage the safety of their operations will face not just a warning, but a firm hand from the regulator that knows exactly when enough is enough, and is prepared to take strong and immediate action.”

ORNGE RESPONDS

Ornge, Ontario’s provider of air ambulance and related services, reaffirms its commitment to crew and patient safety following the release of the Transportation Safety Board of Canada investigation report into the 2013 Moosonee helicopter accident.

“We deeply regret the loss of our dear colleagues who died in service to the Ontario public, and our thoughts remain with their family members,” said Dr. Andrew McCallum, President and CEO of Ornge.  “We will continue to honour the memory of the Moosonee crew with an unwavering commitment to protecting the safety of our patients, paramedics and pilots.”

On May 31, 2013, an air ambulance helicopter crashed shortly after it departed the Ornge Moosonee base en route to perform a patient transport.  Captain Don Filliter, First Officer Jacques Dupuy, Flight Paramedics Chris Snowball and Dustin Dagenais died in the accident.  Over the past three years, Ornge has cooperated fully with the TSB throughout the investigative process.

“Immediately following the accident, we initiated a full review of our safety processes, procedures and technology and took steps to minimize risk,” said Dr. McCallum.

On pages 163-166 of its report, the TSB outlines many of the safety actions taken by Ornge.  Among the enhancements put into place:

• The legacy Sikorsky S76A model helicopter has been retired from the provincial air ambulance fleet and replaced with the modern AW139 helicopter.  Ornge’s Kenora and Thunder Bay bases transitioned to the new aircraft in 2014 and the Moosonee base transition is currently underway.  The AW139 helicopter has advanced avionics, safety equipment and meets the highest certification standards.
• Ornge is in the process of introducing Night Vision Goggles (NVG) in its helicopter fleet. In 2015, a trial of this technology was conducted in northern Ontario, and feedback from frontline staff was overwhelmingly positive. Additional northern-based aircraft will be outfitted with NVGs this summer and fall, with completion across the fleet by the end of 2017.
• A Proficiency Flying Program was introduced, requiring pilots to conduct certain specific exercises and minimum flight time within a 90 day period. These exercises are above and beyond what is required by regulation.
• Key personnel with extensive rotor wing experience have joined the aviation management team, including a new Director of Aviation Safety, Director of Maintenance and Manager of Flight Training and Standards.

“With the investigation now complete, we will review and study the recommendations and findings outlined in the report carefully as we strive to be industry leaders in safety,” said Dr. McCallum.