In a report released Wednesday, the Transportation Safety Board of Canada found that several organizational, regulatory and oversight deficiencies led to the fatal May 2013 crash of a Sikorsky S-76A helicopter in Moosonee.
The board is making 14 recommendations in three areas to prevent further tragedies such as the crash that caused the death of four helicopter crew members along the James Bay Coast on May 31 three years ago.
The Ornge helicopter crashed shortly after midnight, killing Skead resident and pilot Capt. Don Filliter and Moose Factory resident and primary care flight paramedic Dustin Dagenais. Filliter was the husband of a Health Sciences North employee and father of three.
Dagenais was the nephew of a Registered Practical Nurse who works in one of HSN's nephrology satellite clinics. Also killed in the crash was first officer Jacques Dupuy, of Otterburn-Park, Que., and primary care flight paramedic Chris Snowball, of Burlington.
The board's report said the helicopter departed from the Moosonee Airport destined for Attawapiskat.
“As the helicopter climbed through 300 feet into darkness, the first officer commenced a left-hand turn and the crew began carrying out post-takeoff checks,” the report said. “During the turn, the aircraft's angle of bank increased, and an inadvertent descent developed.
The pilots recognized the excessive bank and that the aircraft was descending; however, this occurred too late, and at an altitude from which it was impossible to recover.
The crash took place 23 seconds from the start of the turn until impact, about one nautical mile from the airport. The aircraft was destroyed by impact forces and the ensuing post-crash fire.
“This accident goes beyond the actions of a single flight crew,” said safety board Kathy Fox in the report. “Ornge RW did not have sufficient, experienced resources in place to effectively manage safety.
“Further, Transport Canada inspections identified numerous concerns about the operator, but its oversight approach did not bring Ornge RW back into compliance in a timely manner. The tragic outcome was that an experienced flight crew was not operationally ready to face the challenging conditions on the night of the flight.”
The investigation uncovered several issues. The night visual flight rules regulations do not clearly define “visual reference to the surface,” while instrument flight currency requirements do not ensure that pilots can maintain their instrument flying proficiency.
“At Ornge RW, training, standard operating procedures, supervision and staffing in key safety/supervisory positions did not ensure that the crew was ready to conduct the challenging flight into an area of total darkness,” the report said.
“The training and guidance provided to TC inspectors led to inconsistent and ineffective surveillance of Ornge RW, as inspectors did not have the tools needed to bring a willing but struggling operator back into compliance in a timely manner, allowing unsafe practices to persist.”
The Board issued 14 recommendations to address deficiencies in the areas of regulatory oversight, flight rules and pilot readiness and aircraft equipment
“Both Ornge RW and TC have taken significant action since this accident, but there are still a number of gaps that need to be addressed,” Fox said in the report. “Our recommendations will help ensure that the right equipment is on board, that pilots are suitably prepared, and that operators who cannot effectively manage the safety of their operations will face not just a warning, but a firm hand from the regulator that knows exactly when enough is enough, and is prepared to take strong and immediate action.”
Canadore College in North Bay and Essential Helicopters now offer an award in Filliter's memory.
Following the crash in 2013, Filliter was remembered by his family, friends and colleagues at a funeral in downtown Sudbury. Sudbury.com was there and produced a video to remember the fallen pilot. You can watch it below.
