TSB Aviation Investigation Report A13H0001 Executive Summary Controlled flight into terrain 7506406 Canada Inc. Sikorsky S-76A (helicopter), C-GIMY Moosonee, Ontario 31 May 2013 History of the flight Shortly before 7:00 pm on the evening of May However, this occurred too late and at an 30,History 2013, Orngeof the Rotor flight-Wing (RW) received a altitude from which it was impossible to recover request for an emergency medevac flight for a before the helicopter struck the ground. A total patient in Attawapiskat, Ontario; however, poor of 23 seconds had elapsed from the start of the weather delayed the flight for several hours. At turn until the impact. The helicopter struck the 11 minutes after midnight, the helicopter ground approximately one mile from the departed from Runway 06 at Moosonee, with 2 runway. The aircraft was destroyed by impact pilots and 2 paramedics on board. The flight was forces and the ensuing post-crash fire. There to be conducted under night visual flight rules were no survivors. (VFR), meaning that the pilots would have to maintain “visual reference to the surface” of the Why did this accident happen? ground or water at all times. The causes of this accident went well beyond the As the helicopter climbed through 300 feet actions of this flight crew. As the crew turned above ground into the darkness, the first officer toward Attawapiskat that night, they were commenced a left-hand turn and the crew turning into an area of total darkness, devoid of began carrying out post-takeoff checks. During any ambient or cultural lighting—no town, no the turn, the aircraft’s angle of bank increased, moon, no stars. With no way to maintain visual and an inadvertent descent developed. As he reference to the surface, they would have had to completed the post-takeoff check, the captain transition to flying by instruments. Although identified the excessive bank angle and the first both pilots were qualified according to the officer indicated that he would correct it. regulations, they lacked the necessary night- and Seconds later, just prior to impact, the captain instrument-flying proficiency to safely complete recognized that the aircraft was descending and this flight. called for the first officer to initiate a climb. The TSB is an independent agency that makes transportation safer by investigating marine, pipeline, rail and air transportation accidents, and communicating the results to Canadians. For more information, visit www.tsb.gc.ca or contact us at 819-994-8053 or [email protected] It was the role of the operator, Ornge RW, to TC’s approach to dealing with a willing operator ensure that the crew was operationally ready for allowed non-conformances and unsafe practices that flight. However, the pilots had not received to persist. sufficient and adequate training to prepare them for the challenges they faced that night. Nor did Key issues in the investigation the company’s standard operating procedures Training at Ornge Rotor-Wing (SOPs) address the hazards specific to night operations. Compounding this was the issue of Training is critical to ensuring that pilots are insufficient resources, and inexperienced prepared for the normal and abnormal situations personnel in key positions, which led to some they may face. To be effective, training must company policies being bypassed and, meet the operational needs of the company, be ultimately, a sub-optimal crew pairing that night. delivered effectively, and be followed up Transport Canada (TC), meanwhile, was aware afterward with ongoing opportunities for skill retention and development. that Ornge RW was struggling to comply with regulations and company requirements. This investigation found weaknesses in the However, the training and guidance provided to design of the training conducted at Ornge RW, TC inspectors led to inconsistent and ineffective notably with respect to controlled flight into surveillance. In particular, despite clear terrain (CFIT)-avoidance, night visual flight rules indications that Ornge RW lacked the necessary (VFR), and crew resource management (CRM). resources and experience to address issues that These weaknesses were exacerbated by had been identified months before the accident, EXECUTIVE SUMMARY TSB AVIATION INVESTIGATION REPORT A13H0001 Page 2 ineffective or inconsistent delivery of the accurate, and that errors are detected and material. For example, some pilots, including the trapped. Ornge RW’s SOPs, however, contained occurrence captain, were given little time and/or very little direction to pilots with respect to material to prepare, the training was not always cross-checking procedures, nor much in the way conducted in accordance with company SOPs, of readback requirements. nor was it necessarily conducted under Many SOPs also embed practical strategies for conditions considered to be operationally realistic. Afterward, pilots received little in the crew resource management, including the clear way of follow-up supervision or training. The definition of roles, especially during critical crew involved in the occurrence flight, for phases of flight. The SOPs for Ornge RW’s example, received no additional flight training or S-76As contained very little of this. As a result, checking after completing their simulator the captain’s attention was focused on training. completing the post-takeoff checks and locating the switch for the landing light while the first As a result, the crew was not operationally ready officer turned left, and neither crew member to safely conduct a flight under the conditions detected the inadvertent descent in time to they encountered on the night of the recover. occurrence. Supervision at Ornge Rotor-Wing Standard operating procedures At the time of the accident, there were a number Effective SOPs are a framework for consistent of safety deficiencies related to company and safe operations. They establish expectations supervision of pilots at Ornge RW. and norms with respect to specific operations, In 2012, for example, Ornge RW eliminated the and set parameters that enable detection of pilot manager positions at each base in favour of deviations from standard flight profiles. a centralized scheduling system. Knowledge of At the time of the occurrence, Ornge RW’s SOPs local operating areas and crews thus was no did not contain a dedicated night-flying section. longer considered when scheduling crews. Since Although there was a specific procedure for there was no consideration—beyond very basic “black-hole” departures, it did not apply to “green-on-green” crew pairing restrictions— Moosonee. As a result, the crew elected to given to pilot experience and proficiency when follow the daytime procedure of turning out at pairing pilots, the company did not recognize 300 feet, as opposed to climbing up to at least the risks associated with pairing the occurrence 500 feet before turning, which was an informal pilots together on a mission that they were not practice that had been adopted by most of the operationally ready to conduct. company’s experienced pilots for all night Moreover, when faced with pilot shortages or takeoffs. staffing pressures, Ornge RW altered or did not In multi-crew operations, SOPs also assist in use defences that it had previously put in place. communication, coordination of flight crew These included the decision to employ the duties, and threat-and-error management. captain in a pilot-in-command capacity, despite Instrument settings are cross-checked, and the concerns noted with regard to his pilot readbacks of checklist items, instructions, and proficiency check (PPC); permitting a newly hired clearances help to ensure that information is first officer with very little night- and instrument- EXECUTIVE SUMMARY TSB AVIATION INVESTIGATION REPORT A13H0001 3 flying experience to trade night shifts for day rectification of training-related problems; shifts for an extended period, thereby reducing support for pilot trainees; tracking/verification of his opportunities to gain instrument flight rules training records, pilot qualifications, and pilot (IFR) and night flight experience; not ensuring currencies; updating and approving company that all pilots received operationally realistic SOPs and company publications; and hiring black-hole training, or taking action when the more staff. captain’s lack of black-hole training was As a result of these staffing challenges, unsafe identified; and not applying the company’s own direct-entry captain procedure to nine new hires, conditions persisted—with the ultimate result including the occurrence captain. that the company was not ensuring that its pilots were qualified and adequately prepared for Staffing at Ornge Rotor-Wing operational duty. Ornge RW’s department of Flight Operations Regulatory oversight was under-resourced. Not only were the Operations Manager (who was also interim Chief All transportation companies have a Pilot until just prior to the accident) and the responsibility to manage the safety risks within Chief Pilot (who had been acting as Assistant their operations. However, given that companies Chief Pilot until just prior to the accident) new to will inevitably have varying degrees of ability or the management of Emergency Medical Services commitment to doing so, the purpose of (EMS) operations, but neither had much support regulatory oversight is to encourage companies given that a number of key positions were to be proactive, while intervening when vacant at the time of the accident. These necessary to ensure,