A Sad Reality
July 14, 2016 By Walter Heneghan
Dear Transport Canada and ORNGE: “You have been weighed. You have been measured. You have been found wanting.” On June 15, 2016, the Transportation Safety Board of Canada (TSB) finally released its report into the fatal helicopter accident May 31, 2013 involving a Sikorsky S-76A helicopter in Moosonee, Ont. The investigation took more than three years to complete and it paints a damning picture of dysfunction within the organizational structures of the new operator for the province of Ontario, ORNGE and within Transport Canada (TC).
The shocking result of the culmination of these dysfunctions was the death of four men who were just trying to do their jobs. I was involved with the previous operator who provided the service for the people of Ontario with distinction since the inception of the air ambulance program in 1977, flying more than 165,000 hours in a wide variety of operational conditions with only one major accident and no fatalities.
To many of us, the accident at ORNGE was inevitable. The exhaustive exposé reported in the Toronto Star by Kevin Donovan over the past three years laid bare to many of the fault lines implicated in the accident. The dysfunctions were widely known yet, as the report reveals, there was an inadequate response from the regulator. In my view, TC was feckless and bears significant culpability. This view is reflected in the TSB report.
One of the more offending aspects of the accident is that dozens of industry experts, insiders and onlookers alike, saw all the signs of dysfunction and disease. Many raised the flag. Some sacrificed careers and their paycheques to cry out. Yet the leadership within the newly formed, arms-length, not-for-profit-yet-ego-driven non-governmental agency stood behind these self-same egos and plowed ahead.
They blamed it on sour grapes. They blamed it on divided loyalties from the staff and managers they inherited. They blamed it on everyone but themselves. The operational structure, bequeathed to them by Canadian Helicopters and battle hardened more than three decades, was cast aside. Controls, mitigation strategies, policies, procedures and good, real, common sense safety strategies, forged through firsthand experience, were discarded. Four men died.
Worse yet, TC Civil Aviation, the agency charged with a fiduciary duty “for advancing the safety of all aspects of civil aviation . . .” through the development and use of “. . . oversight activities, [to] verify [compliance] with the regulatory framework through certifications, assessments, validations, inspections and enforcement. . .” was woefully asleep at the switch.
Repeated evaluations, conversations and consultations regarding how to manage or eliminate the risks that had germinated within the ORNGE operation went nowhere. It is clear that the failure of the operational management structure informs this accident.
TC was armed with a wealth of information about the spectacular management and operational shortcomings of the ORNGE rotary wing operation, and yet was trapped in a stupefying paralysis in the execution of their responsibilities. Four men died
The report goes into some detail about the operational conditions that fateful night in May. I know these conditions. For six years, I flew that very same helicopter more times than I care to remember along the western James Bay coast back and forth and back again to Attawapiskat. Yes, some nights it was dark – my AME used to say that it was “dark, like the inside of a cow . . .” And yet, I was never too concerned because I knew that I had the training and the experience and the safety mitigations (SOPs, crewing policies, etc.) that created sufficient barriers to the risk of flying in the black to protect me. I knew that there was increased risk at 12:30 a.m. on a moonless, overcast night. I knew it was adequately managed. Yet, ORNGE and its managers discarded many of these controls, the Ministry of Health with the Ontario Government and TC couldn’t be bothered to properly oversee the operation. The Captain himself had self-identifed to his managers that he didn’t think the crew pairing was right. He was the last line of defence. He had no support. All the controls had failed. Four men died.
Helicopters safety expert Walter Heneghan was employed by Canadian Helicopters Limited from 2001 until 2014 and worked in a number of positions including a line pilot based in Moosonee, Ont. safety manager for its EMS Division and as vice-president of safety for the company. The opinions expressed in this piece are his alone and are not representative of any company, former or current employer, or this publication.