News conference for the release of Aviation Investigation Report A13H0001 (Moosonee): Opening remarks
Chair, Transportation Safety Board of Canada
Investigator-in-Charge, Transportation Safety Board of Canada
Toronto, Ontario, 15 June 2016
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On May 31, 2013, shortly after midnight, a Sikorsky S-76 air ambulance helicopter operated by Ornge Rotor-Wing crashed just after taking off from Moosonee Airport in Northern Ontario, killing all four on board: the captain, first officer and two paramedics.
Every accident is the result of many factors, and this one was no exception.
The Cockpit Voice Recorder quickly told us what happened. But the big question was why? How could an experienced, professional flight crew operating an airworthy helicopter crash so soon after take-off?
Today we're going to answer that question. You're going to hear about two pilots who were not adequately prepared to fly in the conditions they encountered that night. You'll hear about an operator, Ornge Rotor-Wing—or Ornge RW—that was operating with insufficient and inexperienced personnel in key positions, which allowed unsafe conditions to develop and persist. And then we're going to tell you about a regulator, Transport Canada, that knew this, but whose collaborative approach to surveillance activities was ineffective at bringing a willing, but struggling, operator into compliance.
This accident went well beyond the actions of this flight crew. That's why today we are making 14 recommendations to address safety deficiencies we have identified in Canada's aviation system—recommendations aimed at improving the equipment onboard aircraft; at changing the rules by which pilots operate, and how and when they are qualified to fly; and finally, at how Transport Canada oversees the entire system.
But first, I'll turn things over to the investigator-in-charge, Mr. Daryl Collins. He'll walk you through the events of that evening, explaining exactly how and why things unfolded the way they did. Daryl?
Thank you, Kathy.
Shortly before 7:00 pm on the evening of May 30, 2013, Ornge RW received a request for an emergency medevac flight for a patient in Attawapiskat, Ontario; however, poor weather delayed the flight for several hours. At 11 minutes after midnight, the helicopter took off from Runway 06 at Moosonee. The flight was to be conducted under night visual flight rules, or VFR—meaning that the pilots would have to maintain “visual reference to the surface” at all times.
As the helicopter climbed through 300 feet into the 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. As he completed the post-takeoff check, the captain identified the excessive bank angle and the first officer indicated that he would correct it. Seconds later, the captain recognized that the aircraft was descending and called for the first officer to initiate a climb. However, this occurred too late and at an altitude from which it was impossible to recover before the helicopter struck the ground. A total of 23 seconds had elapsed from the start of the turn until impact.
Night VFR operations present unique challenges compared to daytime VFR. It is critical that pilots who conduct night VFR flights, particularly in sparsely settled areas, possess strong night- and instrument-flying skills. As the crew turned toward Attawapiskat that night, they were turning into an area of total darkness, devoid of any ambient or cultural lighting—no town, no moon, no stars. With no way to maintain visual reference to the surface, they would have had to transition to flying by instruments. Although both pilots were qualified according to the regulations, they lacked the necessary night- and instrument-flying proficiency to safely conduct this flight.
The causes of this accident, though, extended far beyond the cockpit. To start, the company did not ensure that the crew was operationally ready for that flight. In particular, the pilots had not received sufficient and adequate training. Nor did the company's standard operating procedures address the hazards specific to night operations. Compounding this was the issue of insufficient and inexperienced personnel in key positions, which led to some company policies being bypassed and, ultimately, a sub-optimal crew pairing that night.
Looking beyond the operator, the investigation discovered a regulator that knew Ornge RW was struggling to comply with regulations and company requirements. However, the training and guidance provided to Transport Canada inspectors led to inconsistent and ineffective surveillance. In particular, despite clear indications that Ornge RW lacked the necessary resources and experience to address issues that had been identified months before the accident, TC's approach to dealing with a willing operator allowed non-conformances and unsafe practices to persist.
I'll now turn things back to Kathy Fox, who will tell you more about the recommendations we are issuing today. Kathy?
Thank you, Daryl.
I want to emphasize again: this accident goes beyond the actions of a single flight crew. In taking over its aviation operations, Ornge RW was undertaking a significant and challenging transition. Its willingness to operate safely and within regulatory requirements exceeded its capacity to do so. Which led us to ask: When Transport Canada has significant concerns about an operator, as was the case with Ornge RW, when and how should the regulator intervene? When is enough, enough?
Our first 3 recommendations address this.
One: The TSB is calling on Transport Canada to require all commercial air operators to implement a formal safety management system.
Two: TC should conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.
And three: Transport Canada needs to adapt its surveillance policies, procedures and inspector training to ensure that its oversight activities, including enforcement, are commensurate … not just with an operator's willingness to identify and fix problems, but with its capability to effectively do so.
Next we looked at what other defences exist in the aviation system to reduce the risk of such accidents.
Flying at night is much more challenging than flying during the day, and flying by instruments is harder still. It's also a perishable skill. Yet, under today's regulations, some pilots are still considered current even though they haven't conducted any instrument flying for up to 12 months. Moreover, while pilots flying “VFR” at night must maintain visual reference to the surface at all times, the regulations don't clearly define this. For the fourth and fifth recommendations, we are calling on Transport Canada to amend these regulations to ensure that visual references are clearly defined for night operations, and that pilots maintain instrument proficiency.
In this accident, the captain had passed his proficiency check two months prior. However, the evaluator had expressed concerns about the captain's limited instrument experience and ability to operate in a multi-crew environment, and recommended he first gain experience in a first-officer capacity. But the standards for the proficiency check didn't differentiate between captain and first-officer skills, and this captain was employed as a pilot-in-command without additional training or supervision. That needs to change. Our sixth recommendation is for Transport Canada to revise the pilot proficiency check standards to clearly distinguish between and assess the competencies of captains versus first officers, considering their increased responsibilities.
Our seventh recommendation deals with something known as TAWS, or Terrain Awareness and Warning Systems. As its name suggests, it provides pilots on many commercially operated aeroplanes—and some private ones—with a warning if they come too close to the ground. Helicopters, however, don't have to have TAWS, which is why we're recommending it, so that their passengers and crews are afforded an equivalent level of safety, especially in darkness or in poor weather.
Finally, recommendations 8 through 14 are aimed at improving another technology—in this case, to the onboard emergency locator transmitter (or ELT). To improve search-and-rescue capabilities in the event of future accidents, we're recommending that Transport Canada work with international bodies that oversee ELT construction standards to improve their survivability in a crash, and to make sure ELT transmissions are able to be detected by the international search-and-rescue satellite system.
This has been a complex and lengthy investigation. We looked at many aspects of the aviation system before focusing in on the key safety issues revealed by this accident. It's not often that we make so many recommendations at the conclusion of an investigation, but in this case, it's a sign that what went wrong that night went far beyond the actions of this crew. They weren't operationally ready for the conditions they faced that night—that's true. But they never should have been put in that situation. The system in which they were operating let them down that night.
Although Ornge RW and Transport Canada have taken significant steps since the accident, we feel much more must be done. If implemented, the 14 recommendations we make today will have a profound impact on Canadian aviation, making flights safer for passengers, for crews, for those who fly at night, and for those who fly by instruments. 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.