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S76, vicinity Moosonee ON Canada, 2013

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Summary
On 31 May 2013 the crew of an S76A helicopter positioning for a HEMS detail took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The helicopter was destroyed and the four occupants killed. The Investigation found that the crew had little relevant experience and were not "operationally ready" to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.
Event Details
When May 2013
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Fire Smoke and Fumes, Human Factors, Loss of Control
Day/Night Night
Flight Conditions VMC
Flight Details
Aircraft SIKORSKY S-76
Operator Ornge Rotor Wing
Domicile Canada
Type of Flight Public Transport (Passenger)
Origin Moosonee Airport
Intended Destination Attawapiskat Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport vicinity Moosonee Airport
General
Tag(s) Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight,
Helicopter Involved,
Deficient Crew Knowledge-handling,
Copilot less than 500 hours on Type
CFIT
Tag(s) Into terrain,
No Visual Reference,
VFR flight plan
FIRE
Tag(s) Post Crash Fire
HF
Tag(s) Inappropriate crew response - skills deficiency,
Manual Handling,
Procedural non compliance,
Spatial Disorientation
LOC
Tag(s) Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Extreme Bank
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Fatalities Most or all occupants (4)
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness
Investigation Type
Type Independent


Description

On 31 May 2013, a Sikorsky S76A (C-GIMY) being operated by Ornge Rotor-Wing on a HEMS positioning flight from Moosonee to Attawapiskat as Lifeflight 8 crashed following a night VMC take-off after the crew lost control at low level. Recovery did not occur and the helicopter was destroyed by the impact and the effects of a post crash fire. Both pilots and the two paramedics on board were killed. The wreckage, which was near to the departure airport, was not located for over 5 hours after the ELT failed to function.

Investigation

An Investigation was carried out by the Canadian Transport Safety Board (TSB). The Multi Purpose Flight Recorder (MPFR) carried, which was configured primarily as a 2 hour CVR, was recovered and its data successfully downloaded. These data proved crucial to the Investigation.

Both pilots were found to be experienced single crew day VFR helicopter pilots. The Captain had accumulated a total of 11,500 total flying hours of which 10,800 were on helicopters and which included 10,430 in command. He was employed full time as Chief Pilot of the Ontario Ministry of Natural Resources Rotor-Wing division and had only recently begun part time work for Ornge Rotor-Wing as a means to gain more night and instrument flying than his full time job provided. Whilst he had previously been rated on the S76 and had 500 hours experience on the type, much of this was not recent and only 28 hours had been flown with Ornge. His first operational shift with Ornge had been just over a month before the accident. He was also a licensed engineer. The First Officer had 3,706 total flying hours, all on helicopters, which included 3,369 in command. He had recently joined Ornge where he had gained his S76 type rating, accumulating 158 hours experience on the S76 since qualifying.

It was established that after twice declining the flight because of unsuitable weather conditions, the weather improved and the crew proceeded to Moosonee airport to prepare for the VFR flight which was expected to take just under 2 hours. The First Officer, without any documentary evidence that he was one of the First Officers explicitly approved for this, had occupied the right hand seat and acted as PF. The subsequent take-off was made from runway 06 after a briefing which had included the intention to make a left turnout towards Attawapiskat but had not mentioned either a planned turnout altitude or planned actions in the event of an emergency during the take-off part of the flight, both of which were Operator Standard Operating Procedures (SOPs). Just before take-off the First Officer had indicated that the flight to Attawapiskat would be conducted at 1,000 feet.

During the transition to forward flight, the Captain called the increasing torque and immediately after calling 95% indicated that airspeed was increasing through 35 knots. The First Officer had then indicated that he was commencing the climb-out and as he continued the climb, the Captain confirmed a climb at approximately 400 feet per minute. Approximately 10 seconds later, the First Officer called for the After Takeoff Checks, the Captain advised that they were climbing through 300 feet agl and the First Officer responded that he was commencing the left turn. The Captain acknowledged this and began the Checklist, announcing that “the gear was in transit, the aircraft’s emergency flotation system was off and the compasses were slaved”. He also offered to turn off the landing light and repeated this a few seconds later after there was no response. Two seconds after this repeat of the offer, he called “30 degrees of bank which the First Officer acknowledged, indicating that it was too much and apologised. One second later, the landing-gear warning horn sounded and the Captain stated that they were descending adding “let’s climb”. The aircraft struck terrain less than one second after this on a north westerly heading. Twenty-three seconds had elapsed from the time the First Officer had stated that he was commencing the left turn.

It was noted that the aircraft was equipped with a satellite tracking system which reported take-offs, landings and position updates every two minutes. In the absence of an ELT signal, the first suspicion of a problem was triggered by the absence of these signals and after all methods of establishing contact had failed, a search was commenced. The wreckage was located from the air 5½ hours after the helicopter had taken off approximately 1 nm northeast of Moosonee runway 06.

Investigators determined that ground impact into a densely wooded environment had occurred at “steady, shallow descent angle (approximately 9 degrees)” and with approximately 20 degrees of left bank. Although the exact speed of the helicopter at impact could not be determined, site evidence “indicated a high-energy state” consistent with being at or near cruise speed and recorded data from the MPFR showed that after take-off, the main rotor rpm had reached and stabilised at the 104% used for normal operations at the Operator. The evidence indicated that the post crash fire had been intense and had probably involved an explosion.

The approximate flight path of the helicopter (reproduced from the Official Report)

An examination of the recovered 406MHz ELT, which was configured to transmit on transmit on 121.5 MHz and 243 MHz with a 406 MHz data burst approximately every 50 seconds, showed that it had been released from its normally secured position due to failure of its ‘hook-and-loop’ retaining strap during the impact sequence. It was found ‘armed’ but the battery was depleted. Since it functioned normally when power was applied and the ‘g’ force activation threshold would have been exceeded in the impact sequence, and since the tailboom-sited external antenna had been severed, the absence of a received signal was attributed to the damaged antenna.

It was found that the helicopter “had no known deficiencies before the occurrence flight and was being operated within its load and centre-of-gravity limits” and “nothing was found to indicate that the aircraft encountered any type of system malfunction during the flight”.

The weather conditions reported by the Moosonee AWOS at the time of the accident included lowest cloud at 4,600 feet and an overcast ceiling at 9,000 feet with a light north easterly breeze and visibility exceeding 9 statute miles. The area to which the helicopter flew towards after take-off lacked “cultural lighting” and so, with very few visual cues available and the prevailing overcast, it was concluded that the take-off had been into what could be characterised as ‘black hole’ conditions in which some instrument flying competence would be a prerequisite for safe flight. However, neither pilot had much instrument flying experience and the evidence gathered suggested that neither had been able to demonstrate more than marginal performance in this respect during their S76 training and re-qualification/qualification processes.

It was found that there was no commonly used standard procedure for ‘black hole’ approaches and departures at Ornge but rather a range of informal approaches which varied amongst both individual pilots and between different bases. Many of these differences were found to be related to the past experience of pilots, some of whom had acquired practices at previous EMS employers and it was clear that “experienced Captains at Ornge Rotor Wing recognised the inherent risks of night flying and some had implemented their own procedures to ensure safety margins were maintained during night flights”. In the absence of any recommended or maximum bank limit for night operations in SOPs, many pilots were found to have “adopted the widely accepted practice of restricting all turns at night to a maximum of rate 1”. Another widely accepted practice among experienced pilots was “to closely monitor the PF during night takeoffs and night landings” and “many pilots indicated that they would not conduct any in-flight checks during the departure phase” and would instead “closely monitor the flight instruments in case the PF experienced difficulties” leaving non-essential post take-off checks until no longer in a critical phase of flight at low altitude. The subject of night vision goggles (NVG), which were not used by the accident aircraft crew or colleagues at Ornge, was examined and it was noted that it has been reported that more than 90% of civilian HEMS operators in the USA now use NVGs routinely.

It was considered after a detailed analysis of on and off duty time prior to the accident flight and “a rigorous analysis of crew communications” during the flight, that “there was no indication that fatigue played a role” in the accident in the case of either pilot.

It was found that Ornge Rotor-Wing had a “diverse fleet” of S-76A helicopters, that differed considerably, which “created challenges” for their pilots. Some “were uncomfortable switching, on short notice, to an unfamiliar S-76A in the fleet” and it was found that “in some cases, pilots refused to fly at night in unfamiliar S-76As because they deemed it to be unsafe”. Other pilots were reported to be unhappy at the lack of modern GPS and Autopilots in some S76As since this led to increased pilot workload. EGPWS was not a regulatory requirement and it was found that at the time of the accident, only 5 of the S76As were so equipped and the accident helicopter was not one of them.

The management at the Operator, which was a part of “Ornge Global Air Inc.”, was examined. It was found that at the time of the accident, “the majority of the senior management team of Ornge Fixed Wing and Ornge Rotor Wing came from a predominately fixed-wing background” with the only members of the Ornge Rotor Wing management team with rotor-wing experience being Operations Manager (OM) and Chief Pilot (CP). The Investigation found that “there was a widespread perception among employees that the senior management did not have a full appreciation of the challenges associated with running a HEMS operation, due to their lack of rotor-wing experience”. It was concluded that “in the months leading up to the accident, the OM had reached task saturation” due to the extreme workload associated with combining his OM and “Interim CP” positions. A new ‘full time’ Chief Pilot had been appointed just over a month before the accident. It was noted that the position of Manager of Rotor Wing Flight Training and Standards was vacant at the time of the accident.

Considerable time was taken during the Investigation to examine all aspects of the operational context for the accident at the Operator. It was concluded that the two accident pilots “were not operationally prepared for the conditions they encountered on departure from Moosonee” and that although Ornge “had established a series of policies and procedures defining the operational readiness of its pilots that exceeded minimum regulatory requirements, these were bypassed and eroded as challenges arose”.

The effectiveness of the regulatory oversight performed by Transport Canada (TC) was also subjected to scrutiny. It was found that there had been “problems with respect to the timely rectification of regulatory non-conformances at Ornge RW, as well as with the manner in which those non-conformances were addressed by TC and by Ornge RW itself”. It was noted that this situation occurred in a period when TC “was transitioning to a more systems-level approach to surveillance, with one result being that the training and guidance provided to inspectors resulted in uncertainty and in surveillance that was either inconsistent, ineffective, or both”.

The formal statement of Causes and Contributory Factors was as follows:

  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 recognised 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.
  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 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 the currency tracking program, 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 were also identified as follows:

  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 pilots operating in accordance with Subpart 703 of the Canadian Aviation Regulations 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 Operators of multi-crew aircraft in accordance with Subpart 702, 703, and 704 of the Canadian Aviation Regulations 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 the current Subparts 702, 703 and 704 of the Canadian Aviation Regulations, 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 (of) 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 (as a means to secure) 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 (the applicable) TSO 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 (of) 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.

Four ‘Other Findings’ were also made:

  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.

Safety Action taken by the Operator as a result of the event was noted to have included the following:

  • the immediate suspension of ‘black hole’ operations until an acceptable risk mitigation plan could be put in place.
  • a major revision of SOPs relevant to the accident.
  • introduction of restrictions for all night take off and departure procedures - calls for the after take-off checklist only after passing 500 feet agl and no turns below 1000 feet unless in accordance with an ATS request or a published procedure.
  • no checklist usage during turns unless operationally necessary.
  • no turns at greater than rate 1 during operations at night or under IFR.
  • enhanced recurrent on-aircraft pilot training on CFIT avoidance, black hole flying and night VFR operations.

Fourteen Safety Recommendations were made as a result of the Investigation as follows:

  • that the Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406 MHz ELT in accordance with International Civil Aviation Organization standards. [A16-01]
  • that the International Civil Aviation Organisation (ICAO) establish rigorous emergency locator transmitter (ELT) system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence. [A16-02]
  • that the Radio Technical Commission for Aeronautics (RTCA) establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence. [A16-03]
  • that the European Organisation for Civil Aviation Equipment (EUROCAE) establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence. [A16-04]
  • that the Department of Transport establish rigorous emergency locator transmitter (ELT) system crash survivability requirements that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence. [A16-05]
  • that Cospas-Sarsat amend the 406-megahertz emergency locator transmitter first-burst delay specifications to the lowest possible timeframe to increase the likelihood that a distress signal will be transmitted and received by search-and-rescue agencies following an occurrence. [A16-06]
  • that the Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe. [A16-07]
  • that the Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night visual flight rules flight. [A16-08]
  • that the Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument-rated pilots, who may operate in conditions requiring instrument proficiency. [A16-09]
  • that the Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions. [A16-10]
  • that the Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command. [A16-11]
  • that the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system. [A16-12]
  • that the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety. [A16-13]
  • that the Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk. [A16-14]

The Final Report of the Investigation was authorised for release on 20 April 2016 and officially released on 15 June 2016.

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