Recommendations arising from Investigation A13H0001 (Moosonee)
The Transportation Safety Board of Canada (TSB) is issuing 14 recommendations as a result of its investigation into the May 2013 fatal crash of an Ornge Sikorsky S-76A helicopter in Moosonee, Ontario.
The recommendations are being issued to address safety deficiencies in:
- Regulatory oversight
- Flight rules and pilot readiness
- Aircraft equipment
Regulatory oversight
Transport Canada (TC) began phasing in the requirements for safety management systems (SMS) in commercial aviation in 2005. To date, only the largest operators require SMS, while 90% of Canadian commercial air operators do not require SMS, though a number have been voluntarily implementing it in varying degrees. Even with SMS requirements, companies vary in their commitment and abilities to implement an SMS effectively.
The regulator must be able to vary the type, frequency and scope of oversight activities to ensure companies are willing and able to manage risk effectively, and take appropriate enforcement action when necessary. In this occurrence, the Board found a company that was willing to address safety issues in its operation, but did not have the capacity to effectively do so. TC's approach to returning the operator to compliance was not matched by the operator's capabilities.
The Board therefore is making three recommendations regarding commercial aviation oversight:
That the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.
Transportation Safety Recommendation A16-12
That the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.
Transportation Safety Recommendation A16-13
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.
Transportation Safety Recommendation A16-14
Flight rules and pilot readiness
Night visual flight rules (VFR) regulations
The visual references required for safe night VFR flight are ill-defined. Many pilots believe that it is acceptable to fly at night as long as the reported weather conditions are acceptable, regardless of lighting conditions.
Many night VFR flights safely take place over well-lit, populated areas. However, in remote areas, very little ambient or cultural lighting exists to help pilots maintain visual reference to the ground. Because the regulations don’t define ambient or cultural lighting requirements or an alternate means of meeting the night VFR requirements, it is very likely that accidents such as this one will continue to occur.
Therefore, 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.
Transportation Safety Recommendation A16-08
Instrument flight currency requirements
Instrument flying is a perishable skill requiring frequent practice to maintain proficiency. However, instrument-rated pilots can go 12 months after the instrument flight test before being required to do any instrument flying. After that, they must conduct 6 hours of instrument flying and 6 instrument approaches every 6 months.
These currency requirements are not sufficient to ensure that instrument-rated pilots are proficient enough to fly safely in challenging instrument flying conditions. The Board is thus recommending 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.
Transportation Safety Recommendation A16-09
Pilot proficiency check (PPC) standards
There is currently no requirement for captains to demonstrate a higher degree of proficiency commensurate with their increased responsibilities. In this occurrence, Ornge Rotor-Wing was aware that the captain had encountered problems during the PPC and it was recommended that he fly as first officer to gain experience in the air ambulance environment. However, the company chose to employ the captain as a pilot-in-command without any additional training or supervision.
As seen in this occurrence, there is a risk that pilots will continue to be assigned to captain duties without having first demonstrated a degree of proficiency, commensurate with the responsibilities of the captain of a multi-crew aircraft. Therefore, 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.
Transportation Safety Recommendation A16-11
Aircraft equipment
Terrain awareness and warning systems (TAWS)
The helicopter in this accident did not have TAWS. Without TAWS, aircraft are at significantly greater risk of controlled flight into terrain (CFIT) accidents, such as this one. The TSB has investigated numerous helicopter occurrences that took place at night or in instrument flying conditions where TAWS might have prevented an accident.
Most commercial and some privately-operated fixed-wing aircraft are required to have TAWS, but commercial helicopters are not. Consequently, the regulations do not provide an equivalent level of safety between fixed-wing and rotary-wing aircraft. Therefore, 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.
Transportation Safety Recommendation A16-10
Emergency locator transmitter (ELT) crashworthiness and performance
No signal was received from the occurrence helicopter’s ELT. As a result, the Search and Rescue (SAR) crew did not have a precise location of the crash site. While the ELT was not a factor in the accident outcome, the investigation highlighted several factors as to risk related to ELTs.
Canada has no requirement for aircraft to have an ELT capable of transmitting a distress signal at 406 MHz, the frequency monitored by search-and-rescue satellites, as required by International Civil Aviation Organization (ICAO) standards. If regulations are not amended, it is highly likely that non-406 MHz ELTs will continue to be used on Canadian-registered aircraft, thus exposing people to life-threatening delays in SAR services. Therefore, the Board is recommending 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.
Transportation Safety Recommendation A16-01
The ELT aboard the occurrence helicopter activated as a result of the crash; however, no signal was received due to a broken antenna. The current design standards are robust for the ELT unit, but significantly less so for the entire ELT system, including such components such as external wiring and the antenna. The TSB has investigated 20 other occurrences where ELTs have been rendered inoperable due to damage sustained during the crash sequence.
Therefore, the Board recommends to ICAO, the Radio Technical Commission for Aeronautics, the European Organization for Civil Aviation Equipment and TC that they
… 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.
Transportation Safety Recommendation A16-02, A16-03, A16-04, and A16-05
The 406 MHz ELTs are required to have a minimum delay of 50 seconds from the time of activation to the first transmission of a distress signal. As such, people may be at increased risk of injury or death following an occurrence in case an ELT is rendered inoperable during the first transmission delay period.
Therefore, 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.
Transportation Safety Recommendation A16-06
There is a documented history of the ELT type used in the occurrence helicopter coming free from the hook-and-loop fastener intended to secure it. While hook-and-loop fasteners are no longer acceptable in new installations, this requirement is not applicable to previously installed ELTs. Therefore, 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.
Transportation Safety Recommendation A16-07
Recommendations arising from Investigation A13H0001 (Moosonee)
The Transportation Safety Board of Canada (TSB) is issuing 14 recommendations as a result of its investigation into the May 2013 fatal crash of an Ornge Sikorsky S-76A helicopter in Moosonee, Ontario.
The recommendations are being issued to address safety deficiencies in:
- Regulatory oversight
- Flight rules and pilot readiness
- Aircraft equipment
Regulatory oversight
Transport Canada (TC) began phasing in the requirements for safety management systems (SMS) in commercial aviation in 2005. To date, only the largest operators require SMS, while 90% of Canadian commercial air operators do not require SMS, though a number have been voluntarily implementing it in varying degrees. Even with SMS requirements, companies vary in their commitment and abilities to implement an SMS effectively.
The regulator must be able to vary the type, frequency and scope of oversight activities to ensure companies are willing and able to manage risk effectively, and take appropriate enforcement action when necessary. In this occurrence, the Board found a company that was willing to address safety issues in its operation, but did not have the capacity to effectively do so. TC's approach to returning the operator to compliance was not matched by the operator's capabilities.
The Board therefore is making three recommendations regarding commercial aviation oversight:
That the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.
Transportation Safety Recommendation A16-12
That the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.
Transportation Safety Recommendation A16-13
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.
Transportation Safety Recommendation A16-14
Flight rules and pilot readiness
Night visual flight rules (VFR) regulations
The visual references required for safe night VFR flight are ill-defined. Many pilots believe that it is acceptable to fly at night as long as the reported weather conditions are acceptable, regardless of lighting conditions.
Many night VFR flights safely take place over well-lit, populated areas. However, in remote areas, very little ambient or cultural lighting exists to help pilots maintain visual reference to the ground. Because the regulations don’t define ambient or cultural lighting requirements or an alternate means of meeting the night VFR requirements, it is very likely that accidents such as this one will continue to occur.
Therefore, 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.
Transportation Safety Recommendation A16-08
Instrument flight currency requirements
Instrument flying is a perishable skill requiring frequent practice to maintain proficiency. However, instrument-rated pilots can go 12 months after the instrument flight test before being required to do any instrument flying. After that, they must conduct 6 hours of instrument flying and 6 instrument approaches every 6 months.
These currency requirements are not sufficient to ensure that instrument-rated pilots are proficient enough to fly safely in challenging instrument flying conditions. The Board is thus recommending 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.
Transportation Safety Recommendation A16-09
Pilot proficiency check (PPC) standards
There is currently no requirement for captains to demonstrate a higher degree of proficiency commensurate with their increased responsibilities. In this occurrence, Ornge Rotor-Wing was aware that the captain had encountered problems during the PPC and it was recommended that he fly as first officer to gain experience in the air ambulance environment. However, the company chose to employ the captain as a pilot-in-command without any additional training or supervision.
As seen in this occurrence, there is a risk that pilots will continue to be assigned to captain duties without having first demonstrated a degree of proficiency, commensurate with the responsibilities of the captain of a multi-crew aircraft. Therefore, 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.
Transportation Safety Recommendation A16-11
Aircraft equipment
Terrain awareness and warning systems (TAWS)
The helicopter in this accident did not have TAWS. Without TAWS, aircraft are at significantly greater risk of controlled flight into terrain (CFIT) accidents, such as this one. The TSB has investigated numerous helicopter occurrences that took place at night or in instrument flying conditions where TAWS might have prevented an accident.
Most commercial and some privately-operated fixed-wing aircraft are required to have TAWS, but commercial helicopters are not. Consequently, the regulations do not provide an equivalent level of safety between fixed-wing and rotary-wing aircraft. Therefore, 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.
Transportation Safety Recommendation A16-10
Emergency locator transmitter (ELT) crashworthiness and performance
No signal was received from the occurrence helicopter’s ELT. As a result, the Search and Rescue (SAR) crew did not have a precise location of the crash site. While the ELT was not a factor in the accident outcome, the investigation highlighted several factors as to risk related to ELTs.
Canada has no requirement for aircraft to have an ELT capable of transmitting a distress signal at 406 MHz, the frequency monitored by search-and-rescue satellites, as required by International Civil Aviation Organization (ICAO) standards. If regulations are not amended, it is highly likely that non-406 MHz ELTs will continue to be used on Canadian-registered aircraft, thus exposing people to life-threatening delays in SAR services. Therefore, the Board is recommending 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.
Transportation Safety Recommendation A16-01
The ELT aboard the occurrence helicopter activated as a result of the crash; however, no signal was received due to a broken antenna. The current design standards are robust for the ELT unit, but significantly less so for the entire ELT system, including such components such as external wiring and the antenna. The TSB has investigated 20 other occurrences where ELTs have been rendered inoperable due to damage sustained during the crash sequence.
Therefore, the Board recommends to ICAO, the Radio Technical Commission for Aeronautics, the European Organization for Civil Aviation Equipment and TC that they
… 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.
Transportation Safety Recommendation A16-02, A16-03, A16-04, and A16-05
The 406 MHz ELTs are required to have a minimum delay of 50 seconds from the time of activation to the first transmission of a distress signal. As such, people may be at increased risk of injury or death following an occurrence in case an ELT is rendered inoperable during the first transmission delay period.
Therefore, 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.
Transportation Safety Recommendation A16-06
There is a documented history of the ELT type used in the occurrence helicopter coming free from the hook-and-loop fastener intended to secure it. While hook-and-loop fasteners are no longer acceptable in new installations, this requirement is not applicable to previously installed ELTs. Therefore, 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.
Transportation Safety Recommendation A16-07