Canadian Safety Reporter - sample

5 Canadian HR Reporter, a Thomson Reuters business 2018 News | March 2018 | CSR Ornge cleared of charges after fatal helicopter crash Air ambulance service provider should have looked into night-vision technology for new helicopters, but crash involved older one equipped with searchlight BY JEFFREY R. SMITH AN ONTARIO air ambulance company has had all charges against it dismissed in the wake of a fatal helicopter night-time crash and a controversy over night-vision goggles for its pi- lots. Moosonee, Ont., has been the home of helicopter emer- gency medical services for the surrounding region since at least the 1980s. Most of the fly- ing involved short flights be- tween the base and a hospital in Moose Factory, which was on a nearby island. New hires were often placed there because of its simplicity, though some experi- enced pilots also worked there and there were challenges with night flying because there were no light sources on the ground to provide reference for pilots. As a result, night flying was gener- ally done completely by instru- ments, which required different rules than visual flying in day- light hours. It was a long-standing prac- tice at the Moosonee base that night flights were declared to be under visual flying rules but actually were operated under instrument flying rules. This was to circumvent the require- ments that instrument-only flights were supposed to have an alternate airport available and a weather report from the destination airport — neither of which were possible in remote locations such as Moosonee. In addition, the existing helicopters in Moosonee — Sikorsky S76 A airframes — had searchlights that could be used to reference the ground. Transport Canada tacitly approved this practice. In 1999, Canadian Helicop- ters Limited (CHL) took over the service in Moosonee, adding it to other operations it ran else- where in Ontario. CHL handled all aspects of the operation, in- cluding medical and the flying services. Eventually, Ornge — a non-profit company contract- ed by the Ontario Ministry of Health to provide air ambulance service — started providing the medical services and contracted the flying duties to CHL, who owned the helicopter fleet. Ornge soon decided to take charge of the flying part of the Moosonee operation as well and ordered 12 new helicopters with the intention of gradually phasing out the older aging fleet. In 2011, the contract between Ornge and CHL wasn't renewed and Ornge recruited several key employees from CHL who had been working at the Moosonee base. After a period of transition, Ornge took complete control of the helicopter emergency medi- cal services based in Moosonee in March 2012. All pilots and helicopters with both CHL and Ornge were certified and capa- ble of instrument-only flight. Base manager job eliminated, new technology declined When Ornge took over, it elimi- nated the position of base man- ager — who drew up the sched- ule for two-week shifts and the captain-first officer pairings for each shift — and the position's responsibilities were managed from a central office in Toronto. In the summer of 2011, the safety manager at the Moosonee base suggested to Ornge that a program for using night-vision goggles be established to as- sist with night flying, along with a short-term acquisition of enhanced searchlights until the goggles were in place for all the helicopters. Ornge looked into it, but the new helicopters that were being manufactured weren't configured for the night- vision goggles and it would be too expensive to retrofit them. It also didn't see the need to retrofit its existing fleet of older Sikorsky S76 helicopters, as they would soon be replaced and were equipped with searchlights already that helped with flying in dark conditions. In addition, about 80 per cent of the flying out of Moosonee was done in the daytime. In March 2013, the assistant chief pilot for Ornge test flew one of the new helicopters in dark conditions. He noted that it was challenging and wrote to Transport Canada that night-vi- sion goggles were the answer to easier flying in dark conditions. CHL had been operating un- der the Quebec region of Trans- port Canada and Ornge was under the regulatory supervi- sion of the Ontario regions, so it had to make some changes at the Moosonee base. As a result, there was some difficulty fill- ing certain positions and those who were hired — including the employees who had come over from CHL — were overworked and stressed. Due to limited re- sources, Ornge couldn't assign a new helicopter to Moosonee, so the base remained equipped with older Sikorsky helicopters. On May 31, 2013, an Ornge pilot was flying a Sikorsky air ambulance at night by his in- struments. Shortly after take-off from Moosonee base, the heli- copter crashed after a steep turn that caused it to descend quickly, killing four people on board — pilots Don Filliter and Jacques Dupuy along with two paramed- ics, Dustin Dagenais and Chris Snowball. Examination of the cockpit voice recording revealed that there was no mechanical failure or weather issues, and the pilots likely could have avoided the crash had the ground been visible so they could have seen how steep their descent was. Ornge was charged with three violations of the Canada Labour Code: • Failing to ensure employee safety by not providing pilots with a means to maintain visual reference while operating at night through available technology such as night-vision goggles • Failing to ensure employee safety by providing night- vision goggles that resulted in the deaths of employees • Failing to ensure the health and safety of employees through adequate supervision for daily flight activities at the Moosonee base by eliminating the base manager position. The court found that while CHL staffed the Moosonee base with a base manager, both that model and the model used by Ornge (managing from a central office) were used in the helicop- ter emergency medical services industry. While there was no base manager at the time of the fatal crash, there were "a number of senior experienced pilots and employees whose positions and presence in my view collectively Impossible > pg. 8 Credit: Shutterstock/Toronto-Images.Com

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