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ORNGE memo flagged key safety issues

October 7, 2013  By The Hamilton Spectator

Oct. 7, 2013, Mississauga, Ont. - Months before May's deadly crash of an ORNGE air ambulance helicopter in Moosonee, a safety officer at the northern Ontario base warned the combination of "green" pilots and night flights was putting safety at risk.

And he warned that the "holes in the Swiss
cheese are beginning to line up," a prophetic warning of the accident to

That memo is one of several obtained by the
Star that flag concerns in the organization in the run-up to the May 31
accident that killed two pilots and two flight paramedics.

In one note to ORNGE, an inspector with
Transport Canada raised questions about "black hole" operations — one
scenario that may lie at the heart of the crash now being probed by the
Transportation Safety Board of Canada.


In the weeks after the accident, veteran
pilots at ORNGE as well as in the industry voiced concerns about
"green-on-green" — the pairing of two pilots relatively inexperienced in
their positions.

Now documents obtained by the Star under the
province's Freedom of Information Act reveal that some of those same
concerns were being aired within the organization prior to the crash.

In his Sept. 11, 2012 note, Malcolm Macleod,
the base safety officer in Moosonee, near James Bay, noted that two new
hires at the base were scheduled to start immediately on night shifts.

Such flights are challenging in remote areas
because the lack of lights on the ground can create a disorienting

Macleod cited a previous occasion when two
pilots were brought in from Thunder Bay for flying assignments though
neither had previously flown at Moosonee.

"This seems to me to be a real safety
concern," he wrote to ORNGE's safety manager and flight operations

"I feel that safety is being jeopardized in
an effort to make sure the slots are filled," he wrote. "What happened
to the green-on-green policy, gentlemen the holes in the Swiss cheese
are beginning to line up."

In an interview with the Star, another
experienced helicopter pilot explained the "Swiss cheese" analogy. "When
all the problems line up, the holes in the cheese line up," said the
pilot, who spoke on the condition of anonymity.

"There's supposed to be training, standard
operating procedures and management oversight and aircraft redundancies.
All those things are supposed to block those holes in the cheese," he
said. "When they aren't there, you go right through and end up at a
crash site."

In his reply to Macleod, Peter Cunnington,
the director of flight operations and interim chief pilot (rotor wing),
said the new pilots were cleared for operations.

"I can assure you that all of our new hires
have met all of the requirements … to be qualified for the operation,"
he wrote.

Dr. Andrew McCallum, president and CEO of
ORNGE, told the Star Friday that concerns voiced by Macleod and others
did prompt the agency to put in place formal procedures in the fall of
2012 to ensure that two "green" pilots weren't paired together.

"The pilots were concerned and the company responded," McCallum said.

In a December, 2012, exchange, Transport
Canada inspector Ken Walsh asks about ORNGE's policy for avoiding
green-on-green pair-ups. And he also asks about so-called "black hole"

"Black hole" operations refers to flights in
remote areas where the combination of night sky and lack of ground
lights leaves pilots with few visual references.

"How does the company mitigate the risk of a
captain (new to the area) being called to a Black Hole for the first
time at night without having seen the site during the daylight," Walsh
writes in a Dec. 17, 2012 note to ORNGE.

ORNGE's response to Walsh detailed the
directive meant to prevent new first officers from flying with new
captains. "ORNGE is committed to providing experienced crews on all
flights," the directive said.

It also said pilots are given training at bases once initial training is completed.

The captain on the flight that crashed was
Don Filliter, a veteran helicopter pilot who had flown air ambulance
part-time but had been away for just over two years. He resumed flying
part-time for ORNGE in March in addition to flying duties at the
Ministry of Natural Resources. Jacques Dupuy, the first officer, joined
ORNGE in August, 2012.

ORNGE has said both pilots were qualified
though other pilots have questioned the decision to pair up the two for a
challenging night flight.

Yet McCallum said that both pilots had
thousands of hours in their logbook and that Filliter, in particular,
had six years experience operating from Moosonee during his earlier
stint with ORNGE.

"He certainly would have known the
environment and the terrain," said McCallum. "All of our pilots are
highly experienced so it's really a matter of local familiarity, which I
would say those gentlemen did have."

Another ORNGE pilot also used the Swiss
cheese analogy as he warned managers about outdated equipment on the
Sikorsky S-76A fleet. The email, obtained by the Star, was directed to
ORNGE but also copied to pilots at northern Ontario bases.

In a June, 2012 email, he noted that the
Sikorsky helicopter that would eventually crash lacked both a Garmin GPS
system to aid in navigation and an autopilot to reduce pilot workload.

"Did the pilots ever get asked what would be
the safest option? No, again we were not consulted," the pilot wrote.

"Yet it is our asses that are tasked to fly
off into the Black Abyss of NW Ont. to perform approaches to unlit cone
sites. The most dangerous flight regime in all of (emergency services).
And you wonder why we are frustrated and quitting."

McCallum said ORNGE is looking at new
equipment for northern Ontario bases. He said the 30-year-old Sikorsky
helicopters are "safe … but we want to use airplanes are closer to
current. That is an issue for me. I want them to have appropriate
equipment in the environment they are working in."


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