An Ontario court judge issued a ruling last week in the case of a 2013 crash, finding that helicopter ambulance service Ornge was not negligent under the Canadian Labor Code for failing to equip a Sikorsky S-76A with night vision goggles (NVGs). The crashed on a night flight shortly after departing Moosonee, killing both pilots and the two paramedics aboard. The helicopter was destroyed.
In 2014, Canadian health and safety investigators charged Ornge with 17 violations of the Canadian Labor Code related to the accident. The helicopter went down shortly after takeoff en route to a patient pick-up. The charges include pairing two pilots who had inadequate currency, experience and training in the S-76, including one who had not passed all required proficiency checks and one with insufficient night experience; failure to provide the pilots with “a means to maintain visual reference” during night flights; and failure to adequately supervise the helicopter base.
Justice Bruce Duncan dismissed the charges against Ornge. In his opinion, Duncan noted that NVGs were not required equipment in 2013 for Canadian EMS helicopters and were not commonly in use in the industry then, the crew was instrument rated, and that the advanced age of the accident aircraft made fitting it with NVGs an imprudent use of public funds. He also wrote that Ornge's decision to eliminate its base manager at Moosonee did not materially affect safety, noting that the command pilot of the accident helicopter had been a former helicopter EMS base manager at Moosonee and that Ornge pilots had a good safety culture.
However, in a stinging critique of the pilots, Ornge, and its Transport Canada (TC)safety overseers, Canada's Transportation Safety Board (TSB), concluded in its report, “The causes of this accident went well beyond the actions of this flight crew. As the crew turned toward Attawapiskat that night, they were turning into an area of total darkness, devoid of any ambient or cultural lighting—no town, no moon, no stars. With no way to maintain visual reference to the surface, they would have had to transition to flying by instruments. Although both pilots were qualified according to the regulations, they lacked the necessary night- and instrument-flying proficiency to safely complete this flight.”
The TSB faulted Ornge management for failing “to ensure that the crew was operationally ready for that flight” and took the service to task for having standard operating procedures that failed to “address the hazards specific to night operations. Compounding this was the issue of insufficient resources, and inexperienced personnel in key positions, which led to some company policies being bypassed and, ultimately, a sub-optimal crew pairing that night.”
In particular, the TSB found Ornge's pilot training to be seriously defective. “This investigation found weaknesses in the design of the training conducted at Ornge RW (Rotor Wing), notably with respect to controlled flight into terrain (CFIT) avoidance, night visual flight rules (VFR), and crew resource management (CRM). These weaknesses were exacerbated by ineffective or inconsistent delivery of the material. For example, some pilots, including the occurrence captain, were given little time and/or material to prepare, the training was not always conducted in accordance with company SOPs, nor was it necessarily conducted under conditions considered to be operationally realistic.
"Afterward, pilots received little in the way of follow-up supervision or training. The crew involved in the occurrence flight, for example, received no additional flight training or checking after completing their simulator training.” The TSB also found that Ornge's night flight training was virtually non-existent. “At the time of the occurrence, Ornge RW's SOPs (standard operating procedures) did not contain a dedicated night-flying section. Although there was a specific procedure for “black-hole” departures, it did not apply to Moosonee. As a result, the crew elected to follow the daytime procedure of turning out at 300 feet, as opposed to climbing up to at least 500 feet before turning, which was an informal practice that had been adopted by most of the company's experienced pilots for all night takeoffs.”
The TSB also took Transport Canada to task. “Transport Canada (TC), meanwhile, was aware that Ornge RW was struggling to comply with regulations and company requirements. However, the training and guidance provided to TC inspectors led to inconsistent and ineffective surveillance. In particular, despite clear indications that Ornge RW lacked the necessary resources and experience to address issues that had been identified months before the accident, TC's approach to dealing with a willing operator allowed non-conformances and unsafe practices to persist.”
Following the accident, both TC and Ornge took corrective actions and Ornge equipped its fleet with NVGs. However, through this past summer, staffing continues to be an issue for the service. CTV News Toronto found that that between July 1 and September 30 this year staffing shortages of both pilots and paramedics forced Ornge bases to shut down 186 separate times.