Backgrounder: A13H0001-20160615B

Investigation findings in the May 2013 helicopter accident in Moosonee, Ontario

The investigations conducted by the Transportation Safety Board of Canada (TSB) are complex, and it is never just one factor that causes an accident. The May 2013 helicopter accident in Moosonee, Ontario, was no exception. There were many factors that caused this accident, the details of which are contained in the 12 findings as to causes and contributing factors. Furthermore, there were 17 additional findings as to risk as well as 4 other findings.

Findings as to causes and contributing factors

  1. The crew conducted a flight under night visual flight rules regulations without sufficient ambient or cultural lighting needed to maintain visual reference to the surface.
  2. When the pilot flying encountered a lack of visual cues off the departure end of Runway 06, necessitating transition to flight by reference to instruments, an excessive bank angle and rate of descent developed, which were not recognized by the crew at an altitude that permitted recovery.
  3. The severity of the impact forces caused the deaths of the first officer and one of the flight paramedics, and likely rendered the captain and the other flight paramedic unconscious. The latter 2 individuals likely succumbed rapidly to their injuries before significant inhalation of fire combustion products.
  4. The crew were not operationally ready to safely conduct a night visual flight rules departure that brought the flight into an area of total darkness.
  5. Insufficient and inadequate training contributed to the difficulties that the crew encountered during the departure from Runway 06 at Moosonee Airport (CYMO).
  6. Ornge Rotor-Wing did not have dedicated night-flight standard operating procedures (SOPs) to address the hazards specific to night operations, except for designated black-hole locations, which did not apply to Moosonee. As a result, the inadequacy of the company's night-flight SOPs contributed to the accident.
  7. Ornge Rotor-Wing was not using the company's currency tracking program (i.e., AvAIO) as intended to ensure that pilots were qualified in accordance with both company and regulatory night-flight currency requirements. As a result, the central scheduling department did not identify that, according to inaccurate data in AvAIO, the first officer was not qualified for the flight.
  8. Although Ornge Rotor-Wing had established policies and procedures defining the operational readiness of its pilots, these were bypassed and eroded by the company, which resulted in the crew not being operationally prepared for the conditions encountered on the night of the occurrence.
  9. Ornge Rotor-Wing was operating with insufficient and inexperienced personnel in key positions, which allowed unsafe conditions to persist.
  10. Transport Canada's approach to surveillance activities did not lead to the timely rectification of non-conformances that were identified, allowing unsafe practices to continue.
  11. The selection of the corrective action plan process as the sole means of returning Ornge Rotor-Wing to a state of compliance resulted from the belief that other options were either unavailable or inappropriate for use with a willing operator. This belief contributed to non-conformances being allowed to persist.
  12. The training and guidance that was provided to Transport Canada inspectors resulted in uncertainty, which led to inconsistent and ineffective surveillance of Ornge Rotor-Wing.

Findings as to risk

  1. If pilots engage in other work-related activities before the commencement of scheduled flight duty time, there is a risk that regulatory flight duty time limitations will be exceeded, which may degrade performance due to fatigue.
  2. Under current regulations, there is no requirement for multi-crew Canadian Aviation Regulations Subpart 703 pilots to undergo any type of line indoctrination. As a result, there is a risk that pilots will not be fully prepared to safely conduct operations in their designated positions on all company routes.
  3. If companies do not take adequate steps to protect the integrity of mandatory exams administered to their pilots, there is a risk that the tests will not be effective in validating that pilots possess the prerequisite knowledge needed to safely carry out their duties as flight crew.
  4. There is currently no regulatory process for multi-crew Canadian Aviation Regulations Subpart 702, 703, and 704 operators to have company standard operating procedures reviewed by Transport Canada. As a result, there is a risk that non-optimal procedures will be adopted.
  5. Under current regulations, Canadian Aviation Regulations Subpart 702, 703, and 704 helicopter first officers and captains are held to the same pilot proficiency check standard. As a result, there is an increased risk that a pilot assigned to captain duties will lack the required proficiency and crew resource management skills to safely carry out those responsibilities.
  6. If the experience and proficiency of pilots are not factored into crew scheduling, there is a risk of sub-optimal crew pairings, resulting in a reduction of safety margins.
  7. If safety issues are not reported formally through a company's safety reporting system, there is a risk that hazards will not be managed effectively.
  8. If head protection is not worn by helicopter flight crew, they are at greater risk of injury and death due to head injuries following a crash.
  9. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk for injury or death following an accident because search-and-rescue assistance may be delayed.
  10. The current emergency locator transmitter (ELT) system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search-and-rescue services may be delayed if an ELT antenna is damaged during an occurrence.
  11. The current 406 MHz emergency locator transmitter (ELT) specifications call for a first-burst delay of 50 seconds or more from the time of activation. As a result, flight crew and passengers may be at increased risk of injury or death following an occurrence if an ELT is rendered inoperable during the first-burst delay period.
  12. Hook-and-loop fasteners for emergency locator transmitter (ELT) installations continue to be permitted in Canada, and a large number of them will remain in service for the foreseeable future. Despite a well-documented history of problems with hook-and-loop fasteners, Transport Canada has not yet adopted Technical Standard Order C126b. As a result, there is an ongoing risk that signals originating from ELTs secured by hook-and-loop fasteners will not be received due to the failure of these fasteners during an impact sequence.
  13. Canadian Aviation Regulation 602.115 does not define “visual reference to the surface”, which has been widely interpreted by the industry as meaning visual meteorological conditions. As a result, night flights may be conducted with inadequate visual references increasing the risk of controlled-flight-into-terrain and loss-of-control accidents.
  14. If, during night visual flight rules operations, pilots continue flight in conditions where no cultural or ambient lighting exists without an alternate means of maintaining visual reference to the surface, there is an increased risk of controlled-flight-into-terrain and loss-of-control accidents.
  15. The instrument currency requirements in the Canadian Aviation Regulations allow pilots who have not flown using instrument procedures for up to 12 months to be considered current. As a result, pilots can conduct flights in instrument flight rules (IFR) or dark night conditions with minimum IFR proficiency, increasing the risk of controlled-flight-into-terrain and loss-of-control accidents.
  16. If helicopters are not equipped with terrain awareness and warning systems, flight crews and passengers are at an increased risk for controlled flight into terrain, particularly during night flights or instrument flights.
  17. Transport Canada's approach to systems-level oversight is predicated on all operators, even those without an assessed safety management system, possessing the capability to address non-conformances. If operators do not have the capability to address non-conformances, this increases the risk that unsafe conditions will persist.

Other findings

  1. There was no indication that, subsequent to the January 2013 program validation inspection, regional Transport Canada personnel had been influenced by Ornge Rotor-Wing’s provincial emergency medical services role.
  2. There were no signs of pre-existing or impact-related damage to explain why the helmets were not found on the victims, and it was not possible to determine whether they had been properly secured before the occurrence.
  3. It was not possible to determine whether all of the occupants were wearing their seat belts and shoulder harnesses at the time of impact.
  4. The landing-gear warning horn sounded just prior to impact, and was most likely activated as a result of erroneous pitot-static readings caused by impact with the trees.

Investigation findings in the May 2013 helicopter accident in Moosonee, Ontario

The investigations conducted by the Transportation Safety Board of Canada (TSB) are complex, and it is never just one factor that causes an accident. The May 2013 helicopter accident in Moosonee, Ontario, was no exception. There were many factors that caused this accident, the details of which are contained in the 12 findings as to causes and contributing factors. Furthermore, there were 17 additional findings as to risk as well as 4 other findings.

Findings as to causes and contributing factors

  1. The crew conducted a flight under night visual flight rules regulations without sufficient ambient or cultural lighting needed to maintain visual reference to the surface.
  2. When the pilot flying encountered a lack of visual cues off the departure end of Runway 06, necessitating transition to flight by reference to instruments, an excessive bank angle and rate of descent developed, which were not recognized by the crew at an altitude that permitted recovery.
  3. The severity of the impact forces caused the deaths of the first officer and one of the flight paramedics, and likely rendered the captain and the other flight paramedic unconscious. The latter 2 individuals likely succumbed rapidly to their injuries before significant inhalation of fire combustion products.
  4. The crew were not operationally ready to safely conduct a night visual flight rules departure that brought the flight into an area of total darkness.
  5. Insufficient and inadequate training contributed to the difficulties that the crew encountered during the departure from Runway 06 at Moosonee Airport (CYMO).
  6. Ornge Rotor-Wing did not have dedicated night-flight standard operating procedures (SOPs) to address the hazards specific to night operations, except for designated black-hole locations, which did not apply to Moosonee. As a result, the inadequacy of the company's night-flight SOPs contributed to the accident.
  7. Ornge Rotor-Wing was not using the company's currency tracking program (i.e., AvAIO) as intended to ensure that pilots were qualified in accordance with both company and regulatory night-flight currency requirements. As a result, the central scheduling department did not identify that, according to inaccurate data in AvAIO, the first officer was not qualified for the flight.
  8. Although Ornge Rotor-Wing had established policies and procedures defining the operational readiness of its pilots, these were bypassed and eroded by the company, which resulted in the crew not being operationally prepared for the conditions encountered on the night of the occurrence.
  9. Ornge Rotor-Wing was operating with insufficient and inexperienced personnel in key positions, which allowed unsafe conditions to persist.
  10. Transport Canada's approach to surveillance activities did not lead to the timely rectification of non-conformances that were identified, allowing unsafe practices to continue.
  11. The selection of the corrective action plan process as the sole means of returning Ornge Rotor-Wing to a state of compliance resulted from the belief that other options were either unavailable or inappropriate for use with a willing operator. This belief contributed to non-conformances being allowed to persist.
  12. The training and guidance that was provided to Transport Canada inspectors resulted in uncertainty, which led to inconsistent and ineffective surveillance of Ornge Rotor-Wing.

Findings as to risk

  1. If pilots engage in other work-related activities before the commencement of scheduled flight duty time, there is a risk that regulatory flight duty time limitations will be exceeded, which may degrade performance due to fatigue.
  2. Under current regulations, there is no requirement for multi-crew Canadian Aviation Regulations Subpart 703 pilots to undergo any type of line indoctrination. As a result, there is a risk that pilots will not be fully prepared to safely conduct operations in their designated positions on all company routes.
  3. If companies do not take adequate steps to protect the integrity of mandatory exams administered to their pilots, there is a risk that the tests will not be effective in validating that pilots possess the prerequisite knowledge needed to safely carry out their duties as flight crew.
  4. There is currently no regulatory process for multi-crew Canadian Aviation Regulations Subpart 702, 703, and 704 operators to have company standard operating procedures reviewed by Transport Canada. As a result, there is a risk that non-optimal procedures will be adopted.
  5. Under current regulations, Canadian Aviation Regulations Subpart 702, 703, and 704 helicopter first officers and captains are held to the same pilot proficiency check standard. As a result, there is an increased risk that a pilot assigned to captain duties will lack the required proficiency and crew resource management skills to safely carry out those responsibilities.
  6. If the experience and proficiency of pilots are not factored into crew scheduling, there is a risk of sub-optimal crew pairings, resulting in a reduction of safety margins.
  7. If safety issues are not reported formally through a company's safety reporting system, there is a risk that hazards will not be managed effectively.
  8. If head protection is not worn by helicopter flight crew, they are at greater risk of injury and death due to head injuries following a crash.
  9. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk for injury or death following an accident because search-and-rescue assistance may be delayed.
  10. The current emergency locator transmitter (ELT) system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search-and-rescue services may be delayed if an ELT antenna is damaged during an occurrence.
  11. The current 406 MHz emergency locator transmitter (ELT) specifications call for a first-burst delay of 50 seconds or more from the time of activation. As a result, flight crew and passengers may be at increased risk of injury or death following an occurrence if an ELT is rendered inoperable during the first-burst delay period.
  12. Hook-and-loop fasteners for emergency locator transmitter (ELT) installations continue to be permitted in Canada, and a large number of them will remain in service for the foreseeable future. Despite a well-documented history of problems with hook-and-loop fasteners, Transport Canada has not yet adopted Technical Standard Order C126b. As a result, there is an ongoing risk that signals originating from ELTs secured by hook-and-loop fasteners will not be received due to the failure of these fasteners during an impact sequence.
  13. Canadian Aviation Regulation 602.115 does not define “visual reference to the surface”, which has been widely interpreted by the industry as meaning visual meteorological conditions. As a result, night flights may be conducted with inadequate visual references increasing the risk of controlled-flight-into-terrain and loss-of-control accidents.
  14. If, during night visual flight rules operations, pilots continue flight in conditions where no cultural or ambient lighting exists without an alternate means of maintaining visual reference to the surface, there is an increased risk of controlled-flight-into-terrain and loss-of-control accidents.
  15. The instrument currency requirements in the Canadian Aviation Regulations allow pilots who have not flown using instrument procedures for up to 12 months to be considered current. As a result, pilots can conduct flights in instrument flight rules (IFR) or dark night conditions with minimum IFR proficiency, increasing the risk of controlled-flight-into-terrain and loss-of-control accidents.
  16. If helicopters are not equipped with terrain awareness and warning systems, flight crews and passengers are at an increased risk for controlled flight into terrain, particularly during night flights or instrument flights.
  17. Transport Canada's approach to systems-level oversight is predicated on all operators, even those without an assessed safety management system, possessing the capability to address non-conformances. If operators do not have the capability to address non-conformances, this increases the risk that unsafe conditions will persist.

Other findings

  1. There was no indication that, subsequent to the January 2013 program validation inspection, regional Transport Canada personnel had been influenced by Ornge Rotor-Wing’s provincial emergency medical services role.
  2. There were no signs of pre-existing or impact-related damage to explain why the helmets were not found on the victims, and it was not possible to determine whether they had been properly secured before the occurrence.
  3. It was not possible to determine whether all of the occupants were wearing their seat belts and shoulder harnesses at the time of impact.
  4. The landing-gear warning horn sounded just prior to impact, and was most likely activated as a result of erroneous pitot-static readings caused by impact with the trees.