Organizational, regulatory oversite led to ORNGE Moosonee crash: TSB
June 15, 2016 By Matt Nicholls
The Transportation Safety Board has released its report on the May 2013 crash of an ORNGE Sikorsky S-76-A helicopter, noting that a number of organizational, regulatory and oversite deficiencies led to the crash.
The accident occurred on the night of May 31, 2013, in Moosonee, Ont. At approximately, 12:11 AM EST, the Sikorsky S-76A departed from the Moosonee Airport destined for Attawapiskat, Ont. As the helicopter climbed through 300 feet into darkness, first officer Jacques Dupuy 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.
Both captain Don Filliter and Dupuy 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 – Filliter, Dupuy and paramedics Dustin Gagenais and Chris Snowball – were killed.
In its report on the crash, TSB investigators were stoic and direct in their assessment of the tragic accident, noting that the system – and organizational inadequacies – let the crew down. It also acknowledging neither Filliter nor Dupuy had the proper training to safely execute the flight that night, and the crew pairing underscored the flaws in place at ORNGE.
“This accident goes beyond the actions of a single flight crew,” said Kathy Fox, TBS chair. “ORNGE did not have sufficient, experienced resources in place to effectively manage safety. Further, Transport Canada (TC) inspections identified numerous concerns about the operator, but its oversight approach did not bring ORNGE 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 TSB 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, 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, 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 TSB is issuing 14 recommendations to address deficiencies in the following areas:
- Regulatory oversight
- Flight rules and pilot readiness
- Aircraft equipment
A detailed breakdown of the recommendations can be found here.
Fox noted that steps have been taken by both parties to ensure that enhanced safety measures have been put in place to help prevent future accidents. In an interview with the ORNGE corporate team earlier this year, Helicopters discussed the accident and some of the steps the organization has taken to improve operations. Some of those have included the introduction of NVGs for night flying operations, improved communication and safety commitments at various levels, enhanced pilot training, the reassessment of its helicopter fleet and deployment and more. More needs to be done and accountability is necessary, but steps are being taken. (For more, see “An ORNGE Revival“)
“Both ORNGE and TC have taken significant action since this accident, but there are still a number of gaps that need to be addressed,” added 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 president/CEO Andrew McCallum spoke with Helicopters shortly after the TSB press conference, noting that he has yet to fully analysis the details of the report and what further changes may be made. But he did note that safety enhancements are ongoing, including the addition of the AW139 at the Moosonee base, implementation of NVGs and more.
“Obviously this was a tragic event but we have not been complacent and we won’t be in the future,” McCallum said. “We have put a strong aviation team in place and will continue to make refinements and efforts to enhance our safety envelope. I think the fact TSB recognizes we have taken many steps to improve our operation since the accident is significant.”