Ornge faces 17 labour code Charges

[ipilot54]

http://www.cbc.ca/news/canada/toronto/o ... -1.2659882

Charges relate to May 2013 crash that killed 4 Ornge helicopter crew members

Ornge, Ontario's air ambulance service, has been charged with 17 offences under the Canadian Labour Code, CBC News learned Friday.

Ornge didn't protect health, safety of pilots: federal investigators
4 Ornge helicopter crash victims ID'd as from Ontario, Quebec
LISTEN | Investigators hand down 7 directions to Ornge

The charges were officially laid on Thursday by the Federal Ministry of Labour.

All 17 charges relate to an incident that occurred on May 31, 2013, when four Ornge employees — two pilots and two paramedics — were killed after the Sikorsky S-76A helicopter they were travelling in crashed one kilometre from an airport in Moosonee, Ont., after taking off in the early morning hours.

The crew was on the way to pick up a patient on the Attawapiskat First Nation reserve in northern Ontario, and was flying in darkness at the time of the crash.

A court document obtained by CBC News reveals that many of the charges relate directly to sections of the Canada Labour Code that govern green pilots operating aircraft together.

The document alleges that Ornge permitted the pilots to fly the S-76A helicopter "without adequate training in the
hi-moosonee-crash-tsb-852

The Sikorsky S-76A helicopter crashed just one kilometre after taking off from a base in Moosonee, Ont., on May 31, 2013. (Transportation Safety Board of Canada)
​operation of that specific aircraft," failed to provide the pilots with "a means to enable them to maintain visual reference while operating at night," and that Donald Mark Filliter, the crew's captain, had "insufficient experience in night operations."

Filliter's pilot proficiency check in the helicopter was incomplete at the time of the crash, according to the charges laid out in the document, and in allowing Filliter and his first officer, Jacques Dupuy, to fly together, Ornge violated its own "green-on-green" pilot policy.

The embattled air ambulance service has also been charged with failure to ensure employee safety resulting in the death of the two pilots and failure to ensure that supervisors and managers had knowledge of the Canada Labour Code.

In October of last year, it was revealed that officials at the company were warned by a safety officer at the base in Moosonee that the combination of inexperienced pilots and nighttime operations would likely result in a fatal accident.
Company statement

"Ornge confirms it has received a summons with respect to charges laid in connection with the accident under the Canada Labour Code’s occupational health and safety provisions," reads a statement provided by the company to CBC News.

"Ornge is currently reviewing this documentation, and we cannot comment further as this matter is before the courts."

In November, investigators from Transport Canada handed down seven directions to Ornge following its investigation into the Moosonee crash.

The company was ordered to comply with the directions by May 31, 2014.

Ontario Liberal Leader Kathleen Wynne released an email statement on the charges Friday afternoon.

"We take these proceedings very seriously, as I’m sure Ornge’s leadership will. Since the incident, Ornge has been co-operating fully with all authorities, including the federal government, by responding to all directions, and it will continue to do so," Wynne said.

News of the charges comes amid an ongoing Ontario Provincial Police criminal investigation into the alleged mishandling of government funds by the company's top officials.

On mobile? Click here to read Ornge's full statement to CBC News

[timel]

I had met the copilot a few times, great guy it is such a sad event. Lost a very good friend who got stuck at night with a chooper and got CFIT too. Night and IFR with helicopters is scary. It is very different from airplanes.

[single_swine_herder]

Not so different at all timel.

One of the things which absolutely shocked me was finding out that with the IFR certified and equipped multi-million dollar helicopters, they had only flown about 5 IFR flights in half a year.

How anyone could possibly convince themselves that the operation is IFR capable when they have spent such little time flying IFR fleet wide is a joke.

They are still flying the same way as the mail pilots of the 1930's stooging along at low altitude following a road in crummy vis, and thinking that is the state of the art in rotary wing operations. By the way, "experienced" does not equate to being proficient and current on instrument flying. A person loses currency and proficiency very quickly .... but the label and perception of being "experienced" has no time limit.

The vast majority of Ornge flights are patient transfers from one facility to another. The popular notion is that ORNGE flights are almost all landing on the 401 as some poor devil is cut out of a car wreck by The Jaws Of Life but that just isn't supported by the numbers.

[sstaurus]

They are still flying the same way as the mail pilots of the 1930's stooging along at low altitude following a road in crummy vis, and thinking that is the state of the art in rotary wing operations. By the way, "experienced" does not equate to being proficient and current on instrument flying. A person loses currency and proficiency very quickly .... but the label and perception of being "experienced" has no time limit.

Really? They tend to avoid IFR on purpose with the choppers?

[single_swine_herder]

When the IFR section of their AOC was temporarily suspended, the News Release downplayed the operational significance of the suspension because they rarely flew IFR anyway.

[tdawe]

"..And by failing to provide pilots with a means to enable them to maintain visual reference while operating at night..."

Is the Federal Ministry of Labour trying to force ORNGE (and therfore everyone else who operates and aircraft night VFR) to adopt Night Vision Goggles? Short of NVGs or installing lights over all of Canada how else is an operator supposed to ensure their pilots can maintain visual reference?

After Moose there isnt another lightbulb for 60-70ish NM till you get to Kash/Ft Albany, it can be sky clear with no moon = No horizon. Does this mean NVFR is restricted to only the more "Civilized" areas of Canada?

[timel]

Night vision googles on a dark night so : IFR in an commercial ops should be mandatory with choopers. Know some medevac guys just refusing to go at night with choopers, just too dangerous, dark spots.
Ideal CFiT. Actually dark night is IFR, except if you are fooling around big hubs, looks pretty much ifr all around.

[Heliian]

The accident aircraft was an old relic 76. Ornge is phasing them out for the more high tech 139 which is ifr certified and has a very modern avionics suite including EGPWS.

As a helicopter industry veteran, I take great offence to swine s comments. They are uninformed opinions and nowhere near factual. I would suggest furthering your research before posting more anti helicopter propaganda. 1930's mail planes? Really? Does the plane you fly still have wicker seats?

[Colonel Sanders]

1930's mail planes?

It might be chic to slam the guys that flew
the mail in the 1930's, but it was difficult
and extremely dangerous work, that none
of today's candy boys here could hack.

Charles Lindbergh - you may have heard
of him - flew the mail in the 1930's.

I am sure that all of the straight-and-level
autopilot heroes here fly much more difficult
and challenging flights than Lindbergh ever
did.

[Illya Kuryakin]

I don't know how much technology is required to understand the need for a positive rate of climb to a safe altitude before proceeding on course? Perhaps it's different in helicopters? I very much doubt it.
Illya

[Illya Kuryakin]

As a helicopter industry veteran, I take great offence to swine s comments. They are uninformed opinions and nowhere near factual. I would suggest furthering your research before posting more anti helicopter propaganda. 1930's mail planes? Really? Does the plane you fly still have wicker seats?

He stated that they were being "operated" the way they used to in the '30's.......no amount of high tech wizardry will get you over terrain that's higher than you are.
Illya

[single_swine_herder]

My statements are not "anti-helicopter," they are directed at the way that ORNGE elected to operate an IFR certified machine and the position that lack of operational control placed the crew in on a regular basis.

The S-76 is IFR certified .... in fact, when they were doing the cold weather testing of the '76, it was stored in our hangar for about a week, and I got to talk with the engineers (ring wearing types) that were gathering the data via telemetry.

[loopa]

What is scarier is how many aviation companies that can presently get charged with many of the above violations but will go unnoticed. This is just the tip of the iceberg.

[single_swine_herder]

Loopa .... I'd suggest that it isn't even the tip of the iceberg, but is actually only a bit of mist hovering over the iceberg which has yet to become visible.

The cynic in me says that regrettably, little to no change will come of it in other organizations.

Where change will and is slowly coming is through customers who demand more than the bare bones minimum for service and operational capability. Like 'em, or hate 'em ... places like "Contrails" who work on behalf of the customer who is paying the money are doing good for improving the industry. They have the right to demand more from an operator than they hold an AOC, and have a phone number in the book.

[Bede]

I'm not sure the Minister of Labour should be involved in this. It seems somewhat outside of their scope of expertise and is probably best left handled by TC.

[ipilot54]

Statement by Frank Klees on behalf of Tim Hudak and the Ontario PC Party
May 31, 2014

On the first anniversary of the tragic crash of an Ornge air ambulance helicopter, we have confirmation from the federal Ministry of Labour that Ornge air ambulance service has been charged with 17 offences under the Canadian Labour Code.

Four dedicated crew members lost their lives in that crash and we extend our condolences to the families of the Ornge Moosonee Crew 7793 members Captain Don Filliter, First Officer Jacques Dupuy, and Flight Paramedics Dustin Dagenais and Chris Snowball.

We regret the pain that this latest development must represent to the families and colleagues and we share in those emotions. But I am also convinced that those brave first responders would want us now to look forward with determination to ensure that we take the constructive steps necessary to prevent any similar tragedies.

These charges confirm what many of us believed was the case. Namely, that the tragic crash of May 31st, 2013 could have been prevented if Ornge and the Ministry of Health had exercised their oversight responsibilities.

Our commitment to the families and to the front line staff at Ornge, is that every step will be taken to ensure that the failures on the part of the Minister of Health, Deb Matthews, the Ornge Board of Directors and its Management, that were responsible for this tragic loss of life will be exposed and that those responsible will be held accountable.

The excuses and deflections of responsibility by the Minister of Health, Deb Matthews will not be accepted. The offences cited in the 17 charges were committed under her watch and under the watch of senior executives and a board of directors she directly appointed.

This is not about Chris Mazza. It is about Deb Matthews who must accept responsibility for failing in her oversight responsibilities as Minister of Health.

In January 2012, Deb Matthews appointed Mr. Ron McKerlie as CEO of Ornge and appointed a new board at Ornge. In March 2012, she announced the implementation of a new Performance Agreement and in July 2012 a new Air Ambulance Program Oversight Branch was appointed.

That was followed by the appointment of a new Chief Operating Officer in December 2012 who had responsibility to oversee all Aviation Operations. His first responsibility was to ensure that all safety measures and pilot training procedures were in place. He failed to do so.

The charges filed in court list 17 contraventions of the Canada Labour Code Part II that took place on May 31, 2013 - six months after Mr. Giguere assumed his responsibilities as COO and 16 months after the new CEO and Board had been appointed by Deb Matthews. The charges include:

• "failing to train Donald Mark Filliter in accordance to COM 2.4 Direct Entry Captain, resulting in the death of Donald Mark Filliter and Jacques Dupuy"

• "failing to provide pilots with a means to enable them to maintain visual reference while operating at night under, resulting in the death of Donald Mark Filliter and Jacques Dupuy"

• "permitting Donald Mark Filliter and Jacques Dupuy to pilot an aircraft contrary to the company's "Green-on-Green" Policy, resulting in the death of Donald Mark Filliter and Jacques Dupuy"

• "permitting pilots to fly the S-76A helicopter without adequate training in the operation of that specific aircraft, resulting in the death of Donald Mark Filliter and Jacques Dupuy"

• "failed to provide adequate supervision for daily flight activities at Moosonee, in contravention of Section 125 of the Canada Labour Code Part II, resulting in the death of Donald Mark Filliter and Jacques Dupuy "

• "permitting an aircraft to be flown by a pilot with insufficient experience in night operations, resulting in the death of Donald Mark Filliter and Jacques Dupuy"

• "permitting an aircraft to be flown by a pilot whose Pilot Proficiency Check on the S-76 helicopter was incomplete, resulting in the death of Donald Mark Filliter and Jacques Dupuy"


These charges confirm not only the Transport Canada investigations, but the reports from front line pilots and paramedics who, at risk of repercussion, reported their concerns regarding these issues to me.

As the record will show, numerous attempts were made to warn the Minister of Health, Deb Matthews, Deputy Ministers and Assistant Deputy Ministers of the risks at Ornge. They were ignored. I was accused by the Minister of fear-mongering.

These charges speak for themselves. Our commitment to the Ornge front line staff is that we will stand with them and will not rest until their health and safety is ensured and they have the necessary resources to carry out their calling to deliver essential emergency responses in our province.
- 30 -

[rigpiggy]

I am pretty sure they're aoc has an accountable executive......why are they not charged. Maybe if a few were charged convicted they would take the job of safety first as more than a motto, on the way to the bank with a bonus

[single_swine_herder]

Yes, of course they have an AE .... every AOC holder does.

In this case, it is likely an Assistant Deputy Minister, or Deputy Minister in the Health Dept.

I think the Fed Dept of Labour is exactly the group to take a swing at bat. TC has been kicking the can down the road for quite some time with only small kicks done with ballet slippers.

The infractions listed would not have been investigated in isolation by Labour Dept personnel. External to them expertise would been consulted closely. This is not a trivial matter and they wouldn't go rushing in blindly. These guys carry just about the heaviest clout of any dept short of the Revenue Canada folks.

I sure wouldn't want them on my trail.

[Bede]

I am pretty sure they're aoc has an accountable executive......why are they not charged. Maybe if a few were charged convicted they would take the job of safety first as more than a motto, on the way to the bank with a bonus

From https://www.tc.gc.ca/eng/civilaviation/ ... u-3459.htm

There is no personal liability associated with the position of an Accountable Executive as this individual represents the certificate holder. The certificate holder retains all liability for non-compliance with the regulations. This should not create an additional regulatory burden for operators, as the certificate holder has always been responsible for compliance. The Accountable Executive requirement is primarily a matter of identifying the senior individual who will discharge the certificate holder’s responsibilities, and particular, lead the necessary cultural change.

[dstechnical]

i was told a few years back by a chc engineer when ornge was first contemplating taking over the ops etc from canadian helicopters that they had no idea what they were doing. not only did pay a way too much for the helicopters and bases etc, my guy actually predicted what would happen. the govt shuld have let a company with 50 plus years in the industry keep running the ops side of ornge

[frozen solid]

I am pretty sure they're aoc has an accountable executive......why are they not charged. Maybe if a few were charged convicted they would take the job of safety first as more than a motto, on the way to the bank with a bonus

From https://www.tc.gc.ca/eng/civilaviation/ ... u-3459.htm

There is no personal liability associated with the position of an Accountable Executive as this individual represents the certificate holder. The certificate holder retains all liability for non-compliance with the regulations. This should not create an additional regulatory burden for operators, as the certificate holder has always been responsible for compliance. The Accountable Executive requirement is primarily a matter of identifying the senior individual who will discharge the certificate holder’s responsibilities, and particular, lead the necessary cultural change.

...But that's not what "Accountable" MEANS!!!!

[nothingbeatsflying]

After all I have read about this organization, I'd suggest that the only reason TC hasn't shut them down is due to the POSSIBLE liability of shutting down an entire province's air ambulance.

Read the Standing Committee Report. My jaw dropped on more than one occasion.

http://www.scribd.com/doc/227578242/Orn ... ary-Report

[halfmilevis]

Illya,

Perhaps you shouldn’t make comments on how easy things are about guys who aren’t here to defend themselves? What makes you think everything was so simple? We dont know why this happened yet.

The fact that Ornge doesn’t fly IFR often is simply because it doesn’t make sense. Majority of the flights are Interfacility, this is true, but the IF calls are primarily serviced by the fixed wing guys (outside of southern Ontario. That’s right! Ontario is larger than just Toronto, London and Ottawa!). Once the summer rolls around and "trauma season" is in full bloom, the scene call percentage dramatically increases.

Another factor regarding IFR in the southern Ontario region is because a lot of the calls are Interfaculty, you simply can’t file IFR from hospital to hospital, and therefore the advantage of using a helicopter is lost when you consider all of the other delays associated with moving patients from the airport to the facility. The simple fact remains, should you ever need one, they will be available to you... Hopefully you don’t!

(DISCLAIMER:: This post is not intended to start shit, just to maybe put some things in perspective!)
Cheers all!
HMV

[NotDirty!]

The fact that Ornge doesn’t fly IFR often is simply because it doesn’t make sense. Majority of the flights are Interfacility, this is true, but the IF calls are primarily serviced by the fixed wing guys (outside of southern Ontario. That’s right! Ontario is larger than just Toronto, London and Ottawa!). Once the summer rolls around and "trauma season" is in full bloom, the scene call percentage dramatically increases.

I thought they didn't fly IFR often because they don't have the range to do so, except in southern Ontario, where there are plenty of alternates. Would the AW139 be able to do YMO-YAT-YMO and hold a YTS or YYU alternate (departing with crew only, picking up a patient in YAT)?

[halfmilevis]

Very specific example, and you would have to speak with a pilot, but I suspect not.

If you block the chopper at 150Kias, YMO-YAT-YMO + YYU and 45min looks like 3hours 15mins. Im fairly certain they dont fuel past 3 hours endurance. That being said, I dont think the YMO chopper does that YAT route very often... Therefore I would say you are correct that they are not doing IFR in the north (YMO area) for that reason (No alternate). But due to the rarity of the flight, I dont think weather concerns are typically a problem... Most things out of YMO are headed down south, and therefore the fixed wing will most likely get the call.

Cheers,

HMV