31 months and a week since that day, It my sincerely heartfelt hope that the spouses and children of those that passed are starting have a sense of normalcy in their lives.
now getting back on track after reading those who are very familiar with the s76a and its systems.
I believe along with the aforementioned training an accident factor that may go unnoticed between the bean counting purchase of new tech and the user end on a dark night, It is the ad-hoc way the integration of new technology into existing platforms.
Most of us that have several thousand hours have seen this happen. As an example> the first bunch of ifr gps installed in panels were often in ad-hoc locations ,likely replacing an old adf or dme that probably was u/s for months.The gps /loc switches in less than ideal locations.
My point is the ergonomics of panel upgrade integration should be a important consideration of all concerned with safety, with eye on the future prevention of tragedy such has those aforementioned. caveat(I have never personally flown a 76a but have ridden in them and the ole man was a darn good wrench on them back in his day)
Ornge Sikorsky Air ambulance accident Northern Ontario
Moderators: sky's the limit, sepia, Sulako, lilfssister, North Shore
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Of course it is,
I just can't read this anymore,
The ultimate point here is, that the profesionals on the front line have all of the answers. Ergonomics, equipment requirements etc. OF COURSE, I as the PIC want my wass capable GPS slavable to the 4-axis autopilot, and, even the RMI course selection slaved to the #1nav, and I (I) want that switch placed into the panel right beside the RMI indicator (on the left side of the RMI) where the #1 selector accociated with that particular instrument IS.
This is my office, and I want that selector placed "where it should be", with a little green light, I want a little green light there too, to indicate the proper selection, in the proper location.
Wouldn't that be nice.
I'm the guy that spends 5hr a day behind this panel yet I had no say in how it was layed out. What I had to do, was learn, I had to learn how the panel was actually layed out, as stupid as it was.
It's my job to police it, control it, and make sure that everything is set-up as it should be, for what it is that I'm doing.
Sometimes, shi[ goes sidways, so far so, that I have to just turn everything OFF,
Wings level, max pwr, Gear-up..flaps-up....checklist....To-Go...
"ma main gauche"
As being, the most reliable peice of equipment in the aircraft.
In my opinion, if the pilot can't reduce the BS down to "ma main gauche", then he has no bussiness being there in the first place.
You don't have to agree with me, that's just my opinion.
...
I just can't read this anymore,
The ultimate point here is, that the profesionals on the front line have all of the answers. Ergonomics, equipment requirements etc. OF COURSE, I as the PIC want my wass capable GPS slavable to the 4-axis autopilot, and, even the RMI course selection slaved to the #1nav, and I (I) want that switch placed into the panel right beside the RMI indicator (on the left side of the RMI) where the #1 selector accociated with that particular instrument IS.
This is my office, and I want that selector placed "where it should be", with a little green light, I want a little green light there too, to indicate the proper selection, in the proper location.
Wouldn't that be nice.
I'm the guy that spends 5hr a day behind this panel yet I had no say in how it was layed out. What I had to do, was learn, I had to learn how the panel was actually layed out, as stupid as it was.
It's my job to police it, control it, and make sure that everything is set-up as it should be, for what it is that I'm doing.
Sometimes, shi[ goes sidways, so far so, that I have to just turn everything OFF,
Wings level, max pwr, Gear-up..flaps-up....checklist....To-Go...
"ma main gauche"
As being, the most reliable peice of equipment in the aircraft.
In my opinion, if the pilot can't reduce the BS down to "ma main gauche", then he has no bussiness being there in the first place.
You don't have to agree with me, that's just my opinion.
...
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Well I was wrong, April 2016 has come and gone, this topic had slipped to page 2, and still no Final Report or press conference. As we near the 3rd anniversary of this tragedy, lets all not forget the lessons we already know from our endless speculations, and be hopeful the TSB will provide some valuable conclusions in order to keep the air ambulance folks safely operating.armchair wrote:... Assuming the draft report has been in the hands of interested parties for a while and comments received and addressed, I expect the TSB to announce a press conference soon, no later than April 2016, where Dame Kathy Fox will sit at the head table with Daryl on the left and Mark Clitsome on the right and explain how...
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nothingbeatsflying
- Rank 1
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- Joined: Tue Jun 04, 2013 10:00 pm
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
I agree armchair. If you watch the YouTube videos of TC sitting in front of the Ontario government, one quickly realizes that TC must have been in full panic mode post accident.
The conspiracy side of my mind thinks that TC and Ornge must be somehow fighting the report to the bitter end because they know a large lawsuit is going to be following shortly after the findings are released.
I'm sure TSB must be under a lot of pressure to remove certain information from the report (even though they are supposed to be separate).
Sad state of affairs at TC to be sure.
The conspiracy side of my mind thinks that TC and Ornge must be somehow fighting the report to the bitter end because they know a large lawsuit is going to be following shortly after the findings are released.
I'm sure TSB must be under a lot of pressure to remove certain information from the report (even though they are supposed to be separate).
Sad state of affairs at TC to be sure.
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nothingbeatsflying
- Rank 1
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- Joined: Tue Jun 04, 2013 10:00 pm
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Media advisory 2016
TSB will hold a news conference to release its investigation report into the May 2013 Ornge helicopter accident in Moosonee, Ontario
Gatineau, Quebec, 10 June 2016 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 15 June 2016 to make public its report (A13H0001) about the investigation into the Ornge Rotor-Wing helicopter that crashed on 31 May 2013, in Moosonee, Ontario.
When: 15 June 2016 - 11:00 am Eastern Daylight Time
Who: Kathy Fox, TSB Chair - Daryl Collins, Investigator-in-charge - Yanick Sarazin, Manager, Standards and Quality Assurance, Air Investigations Branch
Where: Simcoe/Dufferin Room - Sheraton Centre Toronto Hotel - 123 Queen Street West - Toronto, Ontario
This event is for media only. Media representatives will need to show their outlet identification.
The news conference will be webcast live from Toronto. You can view the webcast at http://webcast.fmav.ca/tsbjune2016/
TSB will hold a news conference to release its investigation report into the May 2013 Ornge helicopter accident in Moosonee, Ontario
Gatineau, Quebec, 10 June 2016 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 15 June 2016 to make public its report (A13H0001) about the investigation into the Ornge Rotor-Wing helicopter that crashed on 31 May 2013, in Moosonee, Ontario.
When: 15 June 2016 - 11:00 am Eastern Daylight Time
Who: Kathy Fox, TSB Chair - Daryl Collins, Investigator-in-charge - Yanick Sarazin, Manager, Standards and Quality Assurance, Air Investigations Branch
Where: Simcoe/Dufferin Room - Sheraton Centre Toronto Hotel - 123 Queen Street West - Toronto, Ontario
This event is for media only. Media representatives will need to show their outlet identification.
The news conference will be webcast live from Toronto. You can view the webcast at http://webcast.fmav.ca/tsbjune2016/
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
News release
Organizational, regulatory and oversight deficiencies led to fatal May 2013 Ornge helicopter crash in Moosonee, Ontario
Toronto, Ontario, 15 June 2016 – In its investigation report (A13H0001) released today, the Transportation Safety Board of Canada (TSB) found that several organizational, regulatory and oversight deficiencies led to the fatal May 2013 crash of a Sikorsky S-76A helicopter in Moosonee, Ontario. As such, the Board is making 14 recommendations in 3 key areas.
On 31 May 2013, at 0011 Eastern Daylight Time, a Sikorsky S-76A helicopter operated by 7506406 Canada Inc. (Ornge Rotor-Wing (RW)) departed from the Moosonee Airport destined for Attawapiskat, Ontario. 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. 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. A total of 23 seconds had elapsed from the start of the turn until impact, approximately one nautical mile from the airport. The aircraft was destroyed by impact forces and the ensuing post-crash fire. All four on board—the captain, first officer and two paramedics—were killed.
“This accident goes beyond the actions of a single flight crew. Ornge RW did not have sufficient, experienced resources in place to effectively manage safety,” said Kathy Fox, TSB Chair. ”Further, Transport Canada (TC) 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 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.
As a result of risks to the aviation system found during this investigation, the Board is issuing 14 recommendations to address deficiencies in the following areas:
* Regulatory oversight
* Flight rules and pilot readiness
* Aircraft equipment
More details about the Board's recommendations can be found in the backgrounder.
“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,” added Chair Fox. “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.”
Organizational, regulatory and oversight deficiencies led to fatal May 2013 Ornge helicopter crash in Moosonee, Ontario
Toronto, Ontario, 15 June 2016 – In its investigation report (A13H0001) released today, the Transportation Safety Board of Canada (TSB) found that several organizational, regulatory and oversight deficiencies led to the fatal May 2013 crash of a Sikorsky S-76A helicopter in Moosonee, Ontario. As such, the Board is making 14 recommendations in 3 key areas.
On 31 May 2013, at 0011 Eastern Daylight Time, a Sikorsky S-76A helicopter operated by 7506406 Canada Inc. (Ornge Rotor-Wing (RW)) departed from the Moosonee Airport destined for Attawapiskat, Ontario. 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. 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. A total of 23 seconds had elapsed from the start of the turn until impact, approximately one nautical mile from the airport. The aircraft was destroyed by impact forces and the ensuing post-crash fire. All four on board—the captain, first officer and two paramedics—were killed.
“This accident goes beyond the actions of a single flight crew. Ornge RW did not have sufficient, experienced resources in place to effectively manage safety,” said Kathy Fox, TSB Chair. ”Further, Transport Canada (TC) 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 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.
As a result of risks to the aviation system found during this investigation, the Board is issuing 14 recommendations to address deficiencies in the following areas:
* Regulatory oversight
* Flight rules and pilot readiness
* Aircraft equipment
More details about the Board's recommendations can be found in the backgrounder.
“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,” added Chair Fox. “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.”
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whistlerboy02
- Rank 3
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario
That the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.
SMS does not work! SMS will not work going forward.
Does transport think that an employee, unprovoked, will fill out paperwork stating that they are not competent at their job, or that they need additional training or equipment to do the job they are currently hired to do?
Confidentially interview 100 pilots at 100 different companies and ask them if they were in the same situation as those two Orange pilots would they have submitted SMS paperwork in advance of that accident?
SMS does not work! SMS will not work going forward.
Does transport think that an employee, unprovoked, will fill out paperwork stating that they are not competent at their job, or that they need additional training or equipment to do the job they are currently hired to do?
Confidentially interview 100 pilots at 100 different companies and ask them if they were in the same situation as those two Orange pilots would they have submitted SMS paperwork in advance of that accident?
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RatherBeFlying
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- Joined: Sat Sep 17, 2005 9:27 am
- Location: Toronto
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Am I the only one who finds TSB somewhat prissy about maintaining the purity of VFR (there must always be visual reference) in night VFR?
On my night takeoffs I was on the AH and other instruments for the first few hundred feet until I had enough outside to get off the AH.
No SIDs or ATC in Moosonee to add to the workload.
Just keep level and maintain a climb.
Kennedy had the same problem at the end of his last flight.
Flying at night requires knowing when you need to be on instruments.
There's lots of illusions in the dark. Think of the AH as an illusion buster, or better yet, preventer.
[Edit] The required equipment for night VFR along with the requirement for instrument time to gain a night rating conveys a strong expectation that working instruments and competence in their use can be needed at night.
On my night takeoffs I was on the AH and other instruments for the first few hundred feet until I had enough outside to get off the AH.
No SIDs or ATC in Moosonee to add to the workload.
Just keep level and maintain a climb.
Kennedy had the same problem at the end of his last flight.
Flying at night requires knowing when you need to be on instruments.
There's lots of illusions in the dark. Think of the AH as an illusion buster, or better yet, preventer.
[Edit] The required equipment for night VFR along with the requirement for instrument time to gain a night rating conveys a strong expectation that working instruments and competence in their use can be needed at night.
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Night vfr is a mixture of "pure vfr" (full moon clear night) and almost Ifr (dark overcast night, no moon, no ground lights). In other words the challenges certainly vary.
That said, with the utmost of respect to the crew, a Pilatus was probably a better choice for getting that "particular mission" done than a helicopter, but that decision is not the crew's
In challenging night vfr conditions ,even in a helicopter, a "no turns below 500 feet" policy might be a good personal policy,and certainly if there are no lights on the ground.
That said, with the utmost of respect to the crew, a Pilatus was probably a better choice for getting that "particular mission" done than a helicopter, but that decision is not the crew's
In challenging night vfr conditions ,even in a helicopter, a "no turns below 500 feet" policy might be a good personal policy,and certainly if there are no lights on the ground.
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Frankly I don't see anything wrong with expecting a pilot who is operating under VFR to require VMC, and for these Conditions to include the ability to orientate your aircraft relative to and by remaining in sight of the ground. A more accurate line of thinking would be to question whether the general perception that "IMC means you are inside a cloud" is the only accurate definition of IMC. In this scenario, as in a white out or flat light scenario a pilot could have weather conditions that pass as VMC by definition but in reality are not.
I flew for the previous operator out of this base and left when it transitioned to ORNGE controlled operation. Having flown this exact leg more times than I care to look up in my log book I can assure anyone who has never had the pleasure that after you leave YMO if the winter road is not open you do not see another light for some 60 odd NM till you get halfway to the Northern Ontario paradise that is Attawapiskat. Not. A. Single. One. So on an overcast night with no moonlight to say you can fly visually is to admit that you don't understand or appreciate what constitutes visual reference. On a clear night with a moon reflecting off every cursed swamp en route its an entirely different story, but this is not the hand they were dealt.
Like many people I was initially surprised and almost angry to see this report take 3 years. After reading it however, I am quite happy with the result. This accident could have easily been brushed off as "CFIT - PF flew it into the ground" or "Fatigue - PNF was too tired to monitor the PF" - especially with duty time limits being the popular topic right now. Instead this report went deep to look past that and look at the failings of ORNGE and TC. I think we can all agree that no one has much time for SMS, especially how Transport has rolled it out, but this report gives me hope for how a System approach to aviation safety should be run, holding all levels accountable.
Wait, let me change that last sentence, this report identified the failings of the organizational levels, whether or not anyone at these levels is ever held accountable will be an entirely different subject, but sadly one that is out of Mr. Collins' or the TSB's scope.
I flew for the previous operator out of this base and left when it transitioned to ORNGE controlled operation. Having flown this exact leg more times than I care to look up in my log book I can assure anyone who has never had the pleasure that after you leave YMO if the winter road is not open you do not see another light for some 60 odd NM till you get halfway to the Northern Ontario paradise that is Attawapiskat. Not. A. Single. One. So on an overcast night with no moonlight to say you can fly visually is to admit that you don't understand or appreciate what constitutes visual reference. On a clear night with a moon reflecting off every cursed swamp en route its an entirely different story, but this is not the hand they were dealt.
Like many people I was initially surprised and almost angry to see this report take 3 years. After reading it however, I am quite happy with the result. This accident could have easily been brushed off as "CFIT - PF flew it into the ground" or "Fatigue - PNF was too tired to monitor the PF" - especially with duty time limits being the popular topic right now. Instead this report went deep to look past that and look at the failings of ORNGE and TC. I think we can all agree that no one has much time for SMS, especially how Transport has rolled it out, but this report gives me hope for how a System approach to aviation safety should be run, holding all levels accountable.
Wait, let me change that last sentence, this report identified the failings of the organizational levels, whether or not anyone at these levels is ever held accountable will be an entirely different subject, but sadly one that is out of Mr. Collins' or the TSB's scope.
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RatherBeFlying
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- Location: Toronto
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Except for 1300 in the NDB A circling approach, all the missed approaches at Moosonee specify a climb to 1500 on approach track before turning back to fix.
A bit of overbank in the turn at 1500 is a whole bunch easier to catch before hitting the ground than at 300.
Even 500' in a black hole departure doesn't leave much margin when turning.
What's it going to cost you on a black hole departure to follow the missed approach procedure - a couple more minutes?
Or maybe the rest of your life if you take a shortcut?
A bit of overbank in the turn at 1500 is a whole bunch easier to catch before hitting the ground than at 300.
Even 500' in a black hole departure doesn't leave much margin when turning.
What's it going to cost you on a black hole departure to follow the missed approach procedure - a couple more minutes?
Or maybe the rest of your life if you take a shortcut?
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
Why aren't they flying with goggles?
They aren't that expensive when you consider the cost of a wrecked S76 and 4 lives.
Even with a dim night, flying aided brings VMC to a whole new light. They eliminate "black holes."
They aren't that expensive when you consider the cost of a wrecked S76 and 4 lives.
Even with a dim night, flying aided brings VMC to a whole new light. They eliminate "black holes."
Qui desiderat pacem, praeparet bellum
Semper Fidelis
“De inimico non loquaris male, sed cogites"-
Do not wish death for your enemy, plan it.
Semper Fidelis
“De inimico non loquaris male, sed cogites"-
Do not wish death for your enemy, plan it.
Re: Ornge Sikorsky Air ambulance accident Northern Ontario
I agree, however it seems that Ornge and TC could not even manage training and oversight on a VFR/IFR operation.Nark wrote:Why aren't they flying with goggles?
They aren't that expensive when you consider the cost of a wrecked S76 and 4 lives.
Even with a dim night, flying aided brings VMC to a whole new light. They eliminate "black holes."
To add night vision googles there needs to be a higher standard of training and discipline.
