AVIATION INVESTIGATION REPORT A13H0001 CONTROLLED FLIGHT INTO TERRAIN 7506406 CANADA INC. SIKORSKY S-76A (HELICOPTER), C-GIMY MOOSONEE, ONTARIO 31 MAY 2013 Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2016 Aviation Investigation Report A13H0001 Cat. No. TU3-5/13-0001-1E-PDF ISBN 978-0-660-06206-8 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report A13H0001 Controlled flight into terrain 7506406 Canada Inc. Sikorsky S-76A (helicopter), C-GIMY Moosonee, Ontario 31 May 2013 Summary On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2 pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter’s satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter. At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors. Le présent rapport est également disponible en français. Aviation Investigation Report A13H0001 | 1 Table of contents 1.0 Factual information ........................................................................... 6 1.1 History of the flight .................................................................................................................... 6 1.2 Injuries to persons ....................................................................................................................... 9 1.3 Damage to aircraft ....................................................................................................................... 9 1.4 Other damage .............................................................................................................................. 9 1.5 Personnel information .............................................................................................................. 10 1.5.1 General ........................................................................................................................................ 10 1.5.2 Captain ........................................................................................................................................ 10 1.5.2.1 General ........................................................................................................................ 10 1.5.2.2 Chief Pilot, Ontario Ministry of Natural Resources .............................................. 10 1.5.2.3 Captain’s previous emergency medical services experience ............................... 11 1.5.2.4 Hiring of the captain by Ornge Rotor-Wing .......................................................... 12 1.5.2.5 Captain’s recurrent S-76 course ............................................................................... 13 1.5.2.6 Company indoctrination training ............................................................................ 15 1.5.2.7 Line indoctrination and aerodrome and area of operation qualification training ...................................................................................................................................... 15 1.5.2.8 Captain’s shift rotation history with Ornge Rotor-Wing ..................................... 16 1.5.2.9 Captain’s night flight and instrument flight rules experience/recency ............. 17 1.5.3 First officer .................................................................................................................................. 17 1.5.3.1 General ........................................................................................................................ 17 1.5.3.2 Initial S-76 training .................................................................................................... 17 1.5.3.3 Company indoctrination training ............................................................................ 19 1.5.3.4 Line indoctrination and aerodrome and area of operation qualification training ...................................................................................................................................... 19 1.5.3.5 First officer progression ............................................................................................ 19 1.5.3.6 First officer’s night flight and instrument flight rules experience/recency ....... 19 1.6 Aircraft information .................................................................................................................. 22 1.6.1 General ........................................................................................................................................ 22 1.6.2 Description .................................................................................................................................. 22 1.6.3 S-76A flight controls .................................................................................................................. 23 1.6.4 S-76A fleet differences at Ornge Rotor-Wing ......................................................................... 23 1.6.4.1 Automatic flight control systems / autopilots ....................................................... 23 1.6.4.2 Global positioning system ........................................................................................ 23 1.6.4.3 Enhanced ground proximity warning system ....................................................... 23 1.6.4.4 Landing gear “up” warning horn ............................................................................ 24 1.7 Meteorological information ..................................................................................................... 24 1.8 Aids to navigation ..................................................................................................................... 24 1.9 Communications ....................................................................................................................... 24 1.10 Aerodrome information ........................................................................................................... 25 1.10.1 General ........................................................................................................................................ 25 1.10.2 Weather camera .......................................................................................................................... 25 1.11 Flight recorders ......................................................................................................................... 27 1.12 Wreckage and impact information ......................................................................................... 28 1.12.1 General ........................................................................................................................................ 28 1.13 Medical and pathological information ................................................................................... 31 1.14 Fire ............................................................................................................................................... 32 1.15 Survival aspects ......................................................................................................................... 32 1.15.1 Helmets ....................................................................................................................................... 32 1.15.2 Seat belts and crew harnesses................................................................................................... 33 1.15.3 Emergency locator transmitter ................................................................................................. 33 1.15.3.1 General ........................................................................................................................ 33 1.15.3.2 Hook-and-loop fasteners for emergency locator transmitter retention .............. 35 1.15.3.3 Emergency locator transmitter performance studies ............................................ 36 1.15.3.4 Emergency locator transmitter regulatory requirements ..................................... 37 1.15.3.5 Emergency locator transmitter design standards and specifications ................. 39 1.16 Tests and research