Fatal ORNGE crash: ‘The system let them down’

Safety board chair says crew wasn’t prepared for night flight, “but they never should have been put in that situation”

OTTAWA— As the crew of Lifeflight 8 boarded their ORNGE air ambulance helicopter for a night flight to pick up a sick child, the trap had already been set. Management turmoil within ORNGE meant the pilots lacked the required training and experience, that operating procedures were “inadequate” for their night flight and supervision was lax. Coupled with “ineffective” oversight by Transport Canada, the stage was set for the helicopter’s devastating crash on May 31, 2013.

Accident investigators were able to quickly determine how the Sikorsky S-76A helicopter crashed mere seconds after takeoff from Moosonee, Ont., killing Capt. Don Filliter, First Officer Jacques Dupuy and flight paramedics Dustin Dagenais and Chris Snowball.

Soon after departure, the helicopter began an inadvertent descent during a turn that went unnoticed until it was too late, according to a long-awaited report by the Transportation Safety Board of Canada made public Wednesday.

Yet the reasons for the crash extended beyond the cockpit, investigators found.

“What went wrong that night went well beyond the actions of this crew,” said Kathy Fox, chair of the safety board.

“They weren’t operationally ready for the conditions they faced that night, that’s true. But they never should have been put in that situation,” she told a Toronto news conference. “The system let them down.”

The safety board’s extensive report lays bare problems that existed at ORNGE at the time. It had just taken over management of its helicopter fleet from a private operator and was struggling with the complexities of the task.

Key positions, such as managers of flight safety and flight training and standards, were vacant and the agency had eliminated pilot managers at individual bases.

The workload proved too much for the remaining staff to handle, resulting in poor oversight of the helicopter operations, the safety board concluded.

It meant that ORNGE’s training, procedures, supervision and staffing in supervisory roles failed to ensure the crew was ready to safely conduct a flight in “difficult” conditions.

Indeed, safety board officials drove home the challenges of flying at night, especially in sparsely populated areas such as Moosonee, where the lack of ground lighting can create a disorienting darkness.

As the helicopter turned on course, “the crew would face total darkness, devoid of any ambient or cultural light. No town, no moon, no stars,” lead investigator Daryl Collins said.

Yet, the board found that both pilots had “minimal” proficiency flying at night and by reference to instruments alone, the kind of demanding flying that was required on this flight. Dupuy’s most recent night flight had been 85 days earlier.

“As a result, the crew were not operationally ready to safely conduct a night (visual) departure that brought the flight into an area of total darkness,” the report says.

Safety board officials also raised questions about Transport Canada’s oversight, saying that inspectors lacked the training and guidance, meaning their surveillance of ORNGE was “inconsistent and ineffective.”

The report details how inspectors who uncovered serious problems within ORNGE just months before the crash sparked discussions within the department whether they should shut down the agency’s helicopter operations. But Transport Canada instead opted for a collaborative approach that ultimately allowed ORNGE’s unsafe practices to continue.

Fox suggested Wednesday that such an approach is not always appropriate. What’s needed is a regulator that knows when “enough is enough and is prepared to take strong and immediate action,” she said.

The report confirms many of the concerns expressed by provincial politicians, ORNGE insiders and former pilots that were highlighted by the Toronto Star in the wake of the accident.

The safety board report made 14 recommendations around the equipment carried on board aircraft, the rules that govern how pilots operate and their qualifications to fly and Transport Canada’s oversight of aviation in the country.

If accepted, Fox said they would have a “profound” impact on the safety of aviation in Canada.

None of the recommendations is aimed at ORNGE. That’s because the agency had already taken steps to improve operations and address the problems that led up to the accident, Fox said. Dr. Andrew McCallum, ORNGE’s president and chief executive officer, told the Star Wednesday that his agency is a changed organization from the one that existed at the time of the crash.

“Aviation is a challenging enterprise and so we just have to continue to evolve and continue to look for ways to make things absolutely as safe as they can be,” McCallum said.

He noted that the older S-76 helicopters have been retired from the fleet.