System at fault for fatal air ambulance crash: TSB
This is a Postmedia Network file photo of the actual ORNGE Sikorsky S-76A air ambulance, registration C-GIMY, which crashed in Moosonee in May 31, 2013 and is the subject of the investigation by the Transportation Safety Board. The crash killed all four people aboard, the two pilots and the two medical personnel.
The formal investigation into the fatal crash of an air ambulance helicopter in Moosonee three years ago, which claimed the life of paramedic and Kapuskasing native, Dustin Dagenais and three other crew members, has concluded the pilots should have had more training for the nighttime and instrument flying conditions often required in Northern Ontario.
“The issue here is that both pilots were qualified for night flying and instrument flying, in accordance with Transport Canada regulations. However, night flying again, requires visual references to the surface, and instrument flying requires people to maintain proficiency,” said Kathy Fox, chairwoman of the Transportation Safety Board of Canada. “What we found is that this crew, although qualified according to Transport Canada regulations, were not proficient.”
Fox said the board isn’t blaming the pilots for the fatal crash — instead, she suggested it was the system that was at fault.
“It’s not often that we make so many recommendations at the conclusion of an investigation, but in this case it is a sign that what went wrong that night went far beyond the actions of this crew,” Fox told Postmedia Network. “They were not operationally ready for the conditions they faced that night, that’s true, but they never should have been put in that situation. The system in which they were operating let them down that night.”
The TSB released its final report Wednesday into the crash that killed two pilots and two flight paramedics on the night of May 31, 2013. The helicopter, a Sikorsky-S76A, was departing Moosonee to go to Attawapiskat.
At 12:11 a.m., the chopper lifted off from Runway-06 and rose into the darkness. Twenty-three seconds later, it had crashed into a densely wooded area north of the Moosonee airport and burst into flames.
The crash claimed the lives of Capt. Don Filliter of Sudbury, First Officer Jacques Dupuy of Otterburn Park, Que., Flight Paramedics Chris Snowball of Burlington, and Dagenais.
All were employed by Ornge, the company contracted to carry out air ambulance flights in Ontario. They were flying to Attawapiskat to pick up a pediatric patient.
The details of the crash and subsequent investigation were revealed Wednesday morning at a news conference held in Toronto.
At the same time, the TSB released its full 210-page report, listing 14 recommendations.
One of those recommendations spoke directly to the challenges of night flying operations, especially in Northern Ontario, faced by air ambulance pilots, whether they’re flying VFR (visual flight rules) or using instrument flying. It noted that flying over the vast dark regions of the North are distinctly different than flying at night over Southern Ontario where there are towns, highways and other landmarks that can be seen at night.
“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,” the board stated in their report.
“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.”
In a telephone interview with Postmedia Network on Wednesday, Fox, the TSB chairwoman, said Transport Canada rules are not specific enough for nighttime flying.
“There are really different ways to address this recommendation. The issue is that the visual references required for safe flight at night are not defined in the regulations. A lot of pilots have interpreted it that as long as the weather is OK, as long as the base of the cloud and the visibility is good enough to fly visually, then it is OK to fly at night,” she explained.
Fox said that leaves too much room for interpretation and the Transport Canada rules need to be clarified and more in-depth.
“The regulation simply says pilots must maintain a visual reference to the surface at night but it is not defined what that is,” she said.
Fox added that lighting was not an issue during the initial take off phase because the helicopter was departing from Runway-06 in Moosonee, which was lit.
“It was only after they passed the runway environment, and they were climbing out at about 300 feet in the darkness and commenced the turn toward Attawapiskat that they found themselves in this complete dark situation,” said Fox.
What happened next was described by Daryl Collins, the TSB investigator in charge of the Moosonee crash investigation.
“As the helicopter climbed through 300 feet into the darkness, the first officer commenced a left-hand turn and the crew began carrying out post take-off checks,” said Collins.
“During the turn, the aircraft’s angle of bank increased, and an inadvertent descent developed. As he completed the post take-off checks, the captain identified the excessive bank angle. The first officer indicated he would correct it. Seconds later the captain recognized the aircraft was descending and called for the first officer to initiate a climb. However, this occurred too late and at an altitude from which it was impossible to recover before the helicopter struck the ground.”
Speaking with Postmedia Network, Fox elaborated on the pilot’s qualifications versus proficiency that she mentioned during the news conference.
She said flight captain Filliter had recent night flying experience, but it had been done with night-vision goggles, which totally changes the perspective. The first officer Dupuy had limited night flying experience and minimal instrument experience.
In an interview with CityNews, Josée Cousineau, Dagenais’ widow, said she felt like Ornge and Transport Canada, had let her, the couple’s daughter Névia down.
“I was surprised by the report,” she commented. “I expected a lot of things that were in there, but at the same time I think it was worse. The details really were worse than I thought.
“I found it difficult because we trusted them,” she continued. “(Dustin said) he wasn’t nervous about flying during his job because the company was really diligent with the paramedics and he trusted they were doing the same on the aviation side and I did as well.”
Asked by CityNews if she felt the report and recommendations would lead to any changes, Cousineau remained somewhat skeptical.
“I feel like it’s so political that it’s just going to get swept under the rug,” she said. “Some people will follow up on some policies. I’m not sure how it’s going to improve. ”
Dustin’s father, Jacques said that the details of the report only further enraged, inflamed and confused the deceased paramedic’s family.
In a related matter, Ornge issued a public statement following the news conference to reveal that it is replacing the older Sikorksy S76 helicopters with the newer and more advanced AgustaWestland 139 helicopter. Ornge also said night-vision goggles (NVG) are being introduced to helicopter pilots following a successful trial of this equipment that was carried out in Northern Ontario.