A new report from the Transportation Safety Board of Canada (TSB) has pointed the finger of responsibility at air-ambulance company Ornge Rotor-Wing, as well as Transport Canada, for a helicopter crash that killed all four people aboard in Moosonee, Ont. three years ago. The Board stated in the report, published on June 15, that the company had failed to provide adequate training, equipment and resources to the flight crew.
The accident occurred on May 31, 2013, when the Sikorsky S-76A chopper was taking off from the Moosonee Airport, heading to Attawapiskat, Ont. Shortly after the 12:11 a.m. departure, the first officer attempted a left-hand turn at about 90 metres above the ground, but the helicopter’s angle of bank increased, sending the vehicle into sudden descent. The aircraft hit the ground 23 seconds later, about one nautical mile from the airport, killing the captain, the first officer and two paramedics.
The TSB’s subsequent investigation revealed that Ornge had not sufficiently trained the crew to fly a helicopter in the conditions present that night, according to the report. The company did not have the dedicated night-flight standard operating procedures necessary to deal with the hazards of total darkness, and the crew was working under ineffective nighttime visual-flight-rules regulations that did not clearly define how to maintain a visual reference to the ground.
“This accident goes beyond the actions of a single flight crew,” TSB chair Kathy Fox said in a press statement. “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.”
The TSB issued 14 recommendations in the areas of regulatory oversight, aircraft equipment and flight rules and pilot readiness, to deal with aviation risks perceived from this investigation.
“Both Ornge RW and TC have taken significant action since this accident, but there are still a number of gaps,” said 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… a firm hand from the regulator that knows exactly when enough is enough.”
In response to the TSB report, Ornge president and CEO Dr. Andrew McCallum said in a media statement that the company would review and study the Board’s recommendations.
“Immediately following the accident, we initiated a full review of our safety processes, procedures and technology and took steps to minimize risk,” said Dr. McCallum.
“We will continue to honour the memory of the Moosonee crew with an unwavering commitment to protecting the safety of our patients, paramedics and pilots.”