Ornge Helicopter Crashes - Northern Ontario

[Kip Powick]

Military rescue crews were attempting to reach an ORNGE helicopter that crashed shortly after takeoff from Moosonee at midnight, the provincial air ambulance service said.

“The helicopter has been spotted by search and rescue and they are making efforts to reach the aircraft,” ORNGE said in a statement Friday morning

.

Two pilots and two paramedics were on board, but no passengers, ORNGE said. The Sikorsky S76 helicopter was flying from its base in Moosonee to Attawapiskat.

Contact was lost shortly after takeoff, ORNGE said.

Search and rescue aircraft had been dispatched from the Joint Rescue Coordination Centre at CFB Trenton. The Transportation Safety Board of Canada has also been notified.

[blues deville]

Apparently the news is not good.

Sad day.

[boestar]

4 confirmed dead

[J.O.]

Very sad.

[Moon The Loon]

I offer all family, friends and colleagues my deepest condolences. A very sad day.

[Guest]

'793', as I always knew them. Great bunch of folks up in YMO. Spent many hours with them transferring from their rig to ours- sometimes routine, sometimes not. They graciously opened their lounge and ready room to us when we had extended waits, and they always had interesting stories to share. They are a tight group and I'm sure this has shaken them.

While I don't recognize any of the names released, and it's been several years since I last flew up 'the coast', I can tell you that it hits pretty close to home.

Condolences to the Ornge group.

'Access 4'

[Boney]

_{Oh my! Very sad.}

_RIP

[Mitch Cronin]

Sincere condolences to any and all who have lost someone dear to them.

“Don't be dismayed at good-byes. A farewell is necessary before you can meet again. And meeting again, after moments or lifetimes, is certain for those who are friends.”
― Richard Bach

[Airband]

.

“I think ORNGE is praying that it’s a pilot error accident and then they will accept no blame for this,” one pilot told the Star.
“But the question is whether the pilots were put in a situation where an accident was inevitable.”

Ornge helicopter crash prompts safety concerns

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[J.O.]

That's a well written article.

[Don Hudson]

J.O. - agree. The Toronto Star has led aviation reporting in Canada, (along with Larry Pynn of the Vancouver Sun). Like Andy Paztor of the WST, the Toronto Star has been worth reading on aviation reporting.

Regarding the organizational issues raised in the article, these things are familiar to anyone who knows aviation well, and can be read about in any one of Tony Kern's excellent books.

I'd have to review the Commission's Report but I wonder if these same threads / trends may have been discussed in Moshansky's work on the Air Ontario accident including the notion of regulatory oversight, especially during periods of organizational change? (Moshansky Commission of Inquiry Into the Air Ontario Crash at Dryden, Ontario - 1992). I'm not yet suggesting that there are commonalities because I haven't examined the two closely enough. However, it strikes me as at least worth considering. We have an extremely safe aviation system in Canada but the price of such levels of safety is, as we all know in this business, eternal vigilance and a tough willingness to ask the difficult questions, especially during such painful times as the occurence of an accident so that we can learn, maintain and even improve flight safety.

[Bryon Mask]

I am somewhat aprehensive to reply to this thread but here goes: I have over 2000 hours of helicopter time the majority of which is on the Twin Huey and the Sea King. I have done many night troop lifts, medevacs , and search and rescue missions. Let me say that flying VFR with an overcast ceiling with rain falling at night is not VFR despite what the rules may be. It is a difficult manoeuvre to transition from the hover to straight and level flight. You have to trust your instruments! The transition in fixed wing is much easier. The helicopter is much more difficult due mainly to the aerodynamics of the helicopter. From the picture I saw at the crash site it is apparent that the aircraft impacted the ground straight in ala CFIT. It does not appear to be a wreckage pattern that involved a mechanical failure such as a tail rotor or transmission failure.

One of the biggest problems from transitioning to straight and level flight with the heicopter is" the leans" Been there done that. Not saying that this is the cause of the crash but it it is a possibility.

Now comes the crust of the matter.

Is there a requirement to carry out a "routine " patient transfer at midnight especally given the weather?. Can it wait till the morning? Questions to be asked? Weather, duty day etc?

It is always unfortunate and sad when aircrew lose their lives. It is not something that they consciously set out to do especially if they are involved in saving other peoples lives. Unfortunately "stuff" happens.

[conehead]

"Now comes the crust of the matter.

Is there a requirement to carry out a "routine " patient transfer at midnight especally given the weather?. Can it wait till the morning? Questions to be asked? Weather, duty day etc? "

Excellent point. We need to ask these questions.

[st27]

Did Rob Giguere have this in mind when he signed up for the job??

http://www.thestar.com/news/canada/2013/06/22/ornge_should_get_out_of_aviation_operations_critics_say.html

[blues deville]

This was a tragedy no doubt but I don't see why someone else should be running ORNGE. These guys have been landing on highways and baseball diamonds forever and one unfortunate day means restructure?

[J.O.]

I was involved in air ambulance work in Ontario years ago and this is my perspective on the situation. CHC ran the rotary-wing operation for many years, did so very safely and with excellent dispatch reliability. But CHC was also firm in saying "no" when conditions were such that they felt the risk wasn't justified. As a private company, Ornge didn't like the publicity that came from complaints by people who couldn't accept it when an air ambulance was held back for safety reasons. I have no information to support this theory, but I suspect that was part of the reason they took over the flying themselves. When MOH ran the program back in the day, they accepted the operator's call on flying conditions (for the most part) and took the flak because they understood the big picture.

[Bryon Mask]

" These guys have been landing on highways and baseball diamonds forever and one unfortunate day means restructure? ".

Yes, they have but this was not a landing accident. J.O. makes some very valid points with regards to safety operating margins. Politicians have no business sticking their noses into something as complex as medevac operations.

[boestar]

I watched "Bandage One" several years ago transferring human organs at pearson. The helicopter pulled onto the ramp and shut down. One of the crew jumped out and stood on the ramp next to the chopper. Minutes later I could see a Learjet Taxiing in the distance. At the same time the Engines were started on the chopper. The Lear taxied in and the door was opened while still in motion. The "cooler" was passed to the Crewmember from the chopper who ran and boarded the chopper. The clearance given to the chopper was Climb to 4000' heading and speed your discreation. It was likley the most efficient coordination of resources I had seen. Not so sure it is the same today.

[deicer]

A good example of what happens with privatisation.

[W5]

ORNGE endangered helicopter pilots, federal probe says

http://www.thestar.com/news/queenspark/2013/11/18/ornge_endangered_helicopter_pilots_safety_board_says.html

By: Bruce Campion-Smith Ottawa Bureau, Published on Mon Nov 18 2013

OTTAWA—ORNGE failed to ensure the safety of its helicopter operations and endangered its pilots, federal investigators say in a damning indictment that orders immediate changes at the medical transport agency.

Acting on health and safety concerns, the investigators say management at ORNGE did not safeguard flights at night and those in northern regions — the very conditions in which a helicopter crashed in May near Moosonee, Ont., killing four employees.

The concerns are spelled out in so-called “direction to the employer” orders issued Nov. 14 under the Canada Labour Code that detail the concerns and demand that ORNGE take immediate steps to “correct the hazard.”

• over site of fatal train-bus crash

“The employer failed to protect the health and safety of employees, being helicopter pilots . . . when performing the work activity of flying the helicopter,” federal health and safety officer Janice Berling writes in one order.

“You are hereby directed . . . to take measures to correct the hazard or condition that constitutes the danger immediately,” she writes.

The orders come after a workplace probe that began May 31, the very day that an ORNGE helicopter crashed in northern Ontario. Two paramedics and two pilots were killed when their Sikorsky S-76A helicopter crashed shortly after a midnight takeoff from Moosonee airport to pick up a patient.

The orders, obtained by the Star, detail hazards at ORNGE in six areas, including:

• Failing to “adequately educate the pilots on the health and safety hazards associated with northern operations.”

• Not ensuring that supervisors and managers responsible for pilots are adequately trained under the Canada Labour Code and “aware of their health and safety responsibilities.”

• Failing to ensure that pilots who operate by night visual rules in northern areas of operation are “provided with a means to ensure visual reference is maintained throughout the flight.”

• Failing to create a hazard-prevention program for pilots.

It’s not clear whether ORNGE will face fines for the safety shortfalls. The investigation was done jointly by Transport Canada and Human Resources and Skills Development Canada.

In a statement Monday, ORNGE said the orders deal with the issues arising from the May 31 crash.

“We welcome the agencies’ comments and will follow up on each of the directions to ensure our compliance. Our goal is to work with the agencies, employees, unions and regulators to address health and safety concerns,” ORNGE said in its statement.

In the wake of the fatal accident, ORNGE says it has been working with several agencies, including Transport Canada “to identify and address any concerns in relation to aviation matters.

These measures include new training to avoid controlled flight into terrain, revised procedures for night operations, including into so-called black hole sites, where remote locations mean few ground lights to provide visual references for pilots, according to agency spokesperson James MacDonald.

As well, ORNGE has hired a flight operations quality assurance inspector and a manager of flight training and standards. It has also grounded Sikorsky S-76 helicopters that lacked advanced avionics equipment, MacDonald said.

“ORNGE is committed to taking all necessary steps to ensure the safety of our staff, both on the ground and in the air,” the agency said.

Still, the orders spell more bad news for ORNGE, which has been under fire for the missteps of its previous management and, since the May crash, the safety of its helicopter operations.

ORNGE suspended night flights to unlit helipads and also barred pilots from flying in bad weather, because of training and licensing issues.

The Star has previously reported that there were concerns within ORNGE about its helicopter operations. Months before the crash, a safety officer at the Moosonee basewarned about risks of “green” pilots and night flights.

The crash remains under investigation by the Transportation Safety Board of Canada. It could be another 12 to 18 months before the board completes its probe.

With files from Kevin Donovan

[DEFCON]

It sounds like they're still operating back in the seventies employing the 'mail must go through (regardless)' style of management.

[CD]

Media advisory 2016

TSB will hold a news conference to release its investigation report into the May 2013 Ornge helicopter accident in Moosonee, Ontario

Gatineau, Quebec, 10 June 2016 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 15 June 2016 to make public its report (A13H0001) about the investigation into the Ornge Rotor-Wing helicopter that crashed on 31 May 2013, in Moosonee, Ontario.

When: 15 June 2016 - 11:00 am Eastern Daylight Time
Who: Kathy Fox, TSB Chair - Daryl Collins, Investigator-in-charge - Yanick Sarazin, Manager, Standards and Quality Assurance, Air Investigations Branch
Where: Simcoe/Dufferin Room - Sheraton Centre Toronto Hotel - 123 Queen Street West - Toronto, Ontario

This event is for media only. Media representatives will need to show their outlet identification.

The news conference will be webcast live from Toronto. You can view the webcast at http://webcast.fmav.ca/tsbjune2016/

[Critter]

Is it just me, or does 3 years from accident to report seem a little lengthy?

[st27]

Its Ornge and its the Ontario gov't..the last thing they want is bad publicity/lack of oversight etc. Yes, this is federal but nothing the liberals would do would surprise me [sadly]. Still waiting for the results for the investigation of the file deletion/gas plants or the investigation of the Douglas Creek embarassment.

[CD]

News Release

Organizational, regulatory and oversight deficiencies led to fatal May 2013 Ornge helicopter crash in Moosonee, Ontario

Toronto, Ontario, 15 June 2016 – 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

More details about the Board's recommendations can be found in the backgrounder.

“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.”