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“Black hole effect” could have brought down Ornge S-76

June 3, 2013  By The Toronto Star

June 3, 2013, Ottawa - It’s been called the “black hole” effect, when sky and ground blur into one seamless, disorienting curtain of darkness.


That’s what the crew
of the ORNGE chopper would have faced soon after their midnight take-off
from Moosonee airport. And it may have been their downfall as the
Sikorsky S-76 crashed into the ground just minutes later, killing all
four onboard.

It’s a phenomenon that
has claimed many pilots, most notably John F. Kennedy Jr., who crashed
his light plane into the Atlantic Ocean during a night flight over water
in 1999. U.S. investigators later said that Kennedy lost control flying in the dark haze because of “spatial disorientation.”

On Friday, contact was
lost with the chopper soon after its departure. So far, there has been
no indication that crew signalled they were having troubles. In a
statement Friday, ORNGE said it had no indication about what caused the


Investigators from the
Transportation Safety Board of Canada were on their way to northern
Ontario Friday to begin their on-scene assessment. They will be looking
at all elements of the accident, such as human factors, pilot training
and the mechanical fitness of the 33-year-old helicopter.

The captain, Don
Filliter, had been flying choppers for 20 years; the first officer,
Jacques Dupuy, since 1996. With such an experienced crew at the
controls, one veteran pilot speculated to the Star that a catastrophic
mechanical failure may have caused the wreckage. If so, the position of
the bits of wreckage will provide vital clues to investigators about the
accident sequence, he said.

ORNGE said Friday it had temporarily grounded its five remaining S-76 helicopters “out of an abundance of caution.”

But investigators will almost certainly be looking at whether this crash fits a pattern they’ve already flagged as a worrisome safety trend in Canada — controlled flight into terrain.

That’s when pilots inadvertently fly into the ground or water, usually at night or in bad weather or poor visibility.

“Such conditions
reduce a pilot’s situational awareness of surroundings and make it
difficult to tell whether the aircraft is too close to the ground,”
according to the safety board, which counted 13 such accidents in 2010
and 14 in 2011.

Visual spatial
disorientation was blamed as the cause of a previous air ambulance
accident in 2008 when a Sikorsky S-76 crashed into a forest during its
night-time approach to a helipad in Temagami. Three of the four crew on
board were seriously injured.

noted the risks of flying over a “featureless landscape” with few
lights on the ground, creating a “black hole” effect due to the lack of
visual clues for pilots.

“The pilot flying was likely affected by visual spatial disorientation,” the report concluded.

That crash happened
even though the aircraft was equipped with an enhanced ground proximity
warning system to alert the crew to a possible collision with terrain.
And the pilots had received special training in night operations to
learn “black hole approach and departure techniques,” according to the

On Friday, the weather
around Moosonee was “adequate” for flying according to ORNGE, although
there were patches of rain and mist.

The Sikorsky pilots
would have faced inky darkness soon after lift-off and been relying on
their flight instruments for reference, one former air ambulance pilot
told the Star.

“Up north, there (are) no visual references, so you’d be right on the instruments right away,” said the pilot.

“You would take off and continue as if you went into cloud right away,” he said. “You wouldn’t be operating visual at all.”

U.S. National Transportation Safety Board has investigated fatal
incidents involving the Sikorsky S-76s and at least twice recommended
these helicopters be equipped with terrain awareness and warning system,
which would give the crew ample warning that they are danger of
crashing into water or land, especially important during visual flight.

An investigation into a
2004 crash in the Gulf of Mexico off Galveston, Texas, determined that
had the helicopter been equipped with this warning device the accident
may not have happened.

“The flight crew was
not adequately monitoring the helicopter’s altitude and missed numerous
cues to indicate that the helicopter was inadvertently descending toward
the water,” the board’s report stated.

“If a terrain
awareness and warning system had been installed aboard the accident
helicopter . . . (it) should have provided the flight crew with ample
time to recognize that the helicopter was descending toward the water,
initiate the necessary corrective actions, and recover from the

It’s not known whether
the aircraft involved in Friday’s crash was equipped with the terrain
warning system. A spokesperson for ORNGE said it would be up to safety
board investigators to determine the helicopter’s equipment.


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