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.”
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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