Aviation Investigation A13H0001

Collision with terrain

The occurrence

Shortly before 7:00 pm on the evening of May 30, 2013, Ornge Rotor-Wing (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 departed from Runway 06 at Moosonee, with 2 pilots and 2 paramedics on board. The flight was to be conducted under night visual flight rules (VFR), meaning that the pilots would have to maintain “visual reference to the surface” of the ground or water at all times.

As the helicopter climbed through 300 feet above ground 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, just prior to impact, 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 the impact. The helicopter struck the ground approximately one mile from the runway. The aircraft was destroyed by impact forces and the ensuing post-crash fire. There were no survivors.

Read the complete Executive summary

Map of the area

Investigator-in-Charge

Photo of Daryl Collins

Daryl Collins joined the TSB in 2009 after a 20 year career with the Canadian Armed Forces, having flown as a search and rescue helicopter pilot on the CH146 Griffon, the CH113 Labrador, and the CH149 Cormorant helicopter. In his last position with the Canadian Forces, Mr. Collins was the Commanding Officer of 103 Search and Rescue Squadron based out of Gander, Newfoundland and Labrador.

During his time with the Canadian Forces, Mr. Collins was responsible for the development and implementation of Canadian Forces-wide human performance training for all aircrew, maintenance, and air traffic control personnel and was heavily involved in flight safety. In addition, he obtained a Masters of Aeronautical Science with a dual specialization in Human Factors and System Safety.

Since joining the TSB, Mr. Collins has been actively involved in numerous accident investigations.

Mr. Collins holds an Airline Transport Licence – Helicopter with over 3200 hours of flying experience.

Photos

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TSB investigation process

There are 3 phases to a TSB investigation
  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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.

Report

Executive summary
Final report
2016-06-15

Aviation Investigation Report A13H0001
Controlled flight into terrain
7506406 Canada Inc.
Sikorsky S-76A (helicopter) C-GIMY
Moosonee, Ontario
31 May 2013

Safety communications

Recommendations
2016-06-15

TSB Recommendation A16-01: The Board recommends that the Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406 MHz ELT in accordance with International Civil Aviation Organization Standards.

2016-06-15

TSB Recommendation A16-02: The Board recommends that the International Civil Aviation Organization establish rigorous emergency locator transmitter (ELT) system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-03: The Board recommends that the Radio Technical Commission for Aeronautics establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-04: The Board recommends that the European Organisation for Civil Aviation Equipment establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-05: The Board recommends that the Department of Transport establish rigorous emergency locator transmitter (ELT) system crash survivability requirements that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-06: The Board recommends that Cospas-Sarsat amend the 406-megahertz emergency locator transmitter first-burst delay specifications to the lowest possible timeframe to increase the likelihood that a distress signal will be transmitted and received by search-and-rescue agencies following an occurrence.

2016-06-15

TSB Recommendation A16-07: The Board recommends that the Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe.

2016-06-15

TSB Recommendation A16-08: The Board recommends that the Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night visual flight rules flight.

2016-06-15

TSB Recommendation A16-09: The Board recommends that the Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument-rated pilots, who may operate in conditions requiring instrument proficiency.

2016-06-15

TSB Recommendation A16-10: The Board recommends that the Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.

2016-06-15

TSB Recommendation A16-11: The Board recommends that the Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command.

2016-06-15

TSB Recommendation A16-12: The Board recommends that the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.

2016-06-15

TSB Recommendation A16-13: The Board recommends that the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.

2016-06-15

TSB Recommendation A16-14: The Board recommends that the Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.

All aviation recommendations

Media materials

News releases
2016-06-15

Organizational, regulatory, and oversight deficiencies led to fatal May 2013 Ornge helicopter crash in Moosonee, Ontario
Read the news release

Backgrounders
Speeches
2016-06-15

News conference for the release of Aviation Investigation Report A13H0001 (Moosonee)
Opening remarks

Kathy Fox, TSB Chair
Daryl Collins, TSB Investigator-in-Charge
Read the opening remarks

Media advisories
2016-06-10

TSB will hold a news conference to release its investigation report into the May 2013 Ornge helicopter accident in Moosonee, Ontario
Read the media advisory

2013-06-01

TSB to hold news briefing regarding the ORNGE helicopter accident
Read the media advisory

Deployment notice
2013-05-31

Transportation Safety Board of Canada deploys a team of investigators to an air accident in Moosonee, Ontario
Read the deployment notice