Ornge Sikorsky Air ambulance accident Northern Ontario

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nothingbeatsflying
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by nothingbeatsflying »

Would does everyone think of the following:

CARS 602.114 and 602.115 states that "No person shall operate an aircraft in VFR flight within (un)controlled airspace unless (a) the aircraft is operated with visual reference to the surface;"

The flight that was to occur from Moosonee to Attawapiskat happened on an overcast night. Would it even be possible to maintain visual reference to surface? If not, would the pilots be required to file IFR?
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2R
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by 2R »

There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know.

Donald Rumsfeld



Me,i know nothing,meh.

I do hope they put a little bit more effort into this investigation,than they did with some of the previous sad and rather pathetic attempts at previous sideshows.
It is not really a safety investigation if all they do is look for ways to blame the pilots.
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petpad
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by petpad »

2R wrote:Me,i know nothing,meh.

I do hope they put a little bit more effort into this investigation,than they did with some of the previous sad and rather pathetic attempts at previous sideshows.
It is not really a safety investigation if all they do is look for ways to blame the pilots.
TSB investigators are not politicians and they are not out to blame pilots... Heck, many of them are pilots. I read a lot of reports, and from my perspective, they do an amazing job.
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Canoehead
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Canoehead »

Regarding the question of importance, the helicopter crew is critical care. With the exception of the YMO-Moose Factory shuttles, they don't typically dispatch the helicopter to do a trip if it can be done by fixed wing. It's an expensive machine to operate and they don't want a critical care crew tied up doing BLS transfers.

They almost certainly had a good reason for going flying that night.
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jjb
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by jjb »

Sidebar wrote:
Cat Driver wrote:If several people saw the helicopter on fire in flight and watched it crash straight ahead into the trees ...
The accident happened shortly after midnight and the Herc dropped in SAR techs at 0620.

If someone saw the helo airborne and burning, why was the search not initiated immediately with local resources? Who are these people who saw an inflight fire? Has this been reported in the media?

I think this is just a rumour.
Facts:

Nobody saw the aircraft burning in midair. When the aircraft was considered "overdue", Ornge staff climbed on top of the roof of the weather station next to the Ornge hangar and could see a small fire and smoke in the treeline.

It was at this time we were called in to conduct a prelim search. Trenton was called at the same time however knowing they would not be there for some time we were summoned as well. It wasn't so much as a search, but a more or less just to get a "pinpoint" of the crash. By the time we were fueled and launched, the fire was out, and we actually ended up not finding the crash site, as we had no moonlight or supplementary light. We searched for approximately 90 mins before giving up and landing, at which time Wabusk staff and FD volunteers were on the ground with ATV's ready to go in. However with no pinpoint, it was relatively pointless. From there we simply waited for daylight, and Trenton.

I am a Flight Paramedic on Ornge's fixed wing carrier (Wabusk) for Moosonee and James Bay. This was our darkest day, to go find our colleagues and come up empty.

jjb
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jjb
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by jjb »

Doc wrote:
Canoehead wrote:Regarding the question of importance, the helicopter crew is critical care. With the exception of the YMO-Moose Factory shuttles, they don't typically dispatch the helicopter to do a trip if it can be done by fixed wing. It's an expensive machine to operate and they don't want a critical care crew tied up doing BLS transfers.

They almost certainly had a good reason for going flying that night.
If there was. Somebody should know what it was. More likely, there was no fixed wing available?
Canoehead: Incorrect. The YMO rotor is NEVER critical care, sometimes advanced care, however usually primary care.

Doc: Fixed wing was (see previous post, we got called to go perimeter search) is usually available 24/7 in YMO however as an SA carrier (not on-site) we have a one hour spin-up time. If they wanted the patient to Moose Factory hospital as soon as possible, the chopper would actually be quicker.
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pelmet
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by pelmet »

nothingbeatsflying wrote:Would does everyone think of the following:

CARS 602.114 and 602.115 states that "No person shall operate an aircraft in VFR flight within (un)controlled airspace unless (a) the aircraft is operated with visual reference to the surface;"

The flight that was to occur from Moosonee to Attawapiskat happened on an overcast night. Would it even be possible to maintain visual reference to surface? If not, would the pilots be required to file IFR?
Good catch. We used to operate into ice strips at night which was pitch black and of course no IFR approach. I remember mentioning this little tidbit which didn't get much of a response. It seems to be one of those rules where it gets overlooked, sometimes intentionally.
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J31
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by J31 »

pelmet wrote:
nothingbeatsflying wrote:Would does everyone think of the following:

CARS 602.114 and 602.115 states that "No person shall operate an aircraft in VFR flight within (un)controlled airspace unless (a) the aircraft is operated with visual reference to the surface;"

The flight that was to occur from Moosonee to Attawapiskat happened on an overcast night. Would it even be possible to maintain visual reference to surface? If not, would the pilots be required to file IFR?
Good catch. We used to operate into ice strips at night which was pitch black and of course no IFR approach. I remember mentioning this little tidbit which didn't get much of a response. It seems to be one of those rules where it gets overlooked, sometimes intentionally.
The flight was in uncontrolled airspace so no IFR flight plan is required. If the crew are appropriately qualified and the aircraft equipped they simply operate in accordance with IFR procedures at night. Lastly a visual departure or arrival can be part of an IFR flight, in fact there is always a visual segment.
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Canoehead
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Canoehead »

JJB
I didn't realize they weren't critical care there. However I still stand by the statement of cost- cheaper to do it fixed wing and if they weren't willing to wait for the 1hr callout then there was likely a good reason for them to go.



J31
Unless the airspace has changed since my days up there, it is controlled out to about 25 miles from YMO. If it's IFR you need a clearance to fly in/out of there.
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All Sides
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by All Sides »

2R wrote:Please feel free to use the free search function in the top corner .
You might want to check how some of the crash investigations have been conducted before you start picking a fight.
Thanks, but doesn't change those facts.

Not picking a fight, if it was me in that S76 I would hope that I was given a little more consideration.
I am assuming most of the pilots on here would feel the same way?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by AuxBatOn »

Doc wrote:Talking medevacs. Simply because of the stress levels, and the "hurry up offence" mentality that goes along with them. If you've done them, you know of which I speak.
Sitting alert a couple of times a month with a requirement to be airborne within a couple of minutes, I know that feeling of doing things fast (so to speak). I always tell younger guys that "slower is faster". If you try to do everything faster, you'll end up messing up and wasting time. I will normally slow myself down and double check/triple check everything, especially if scrambled at night, from sleep. This way, nothing is missed. I have never not made the mandatory timings by going this way.

I hope the TSB does ends up publishing a good report and that the findings are relevant and lead to changes. It does take time to analyze every lead and contributing factors. I would rather see a comprehensive and complete report, than a hasty, scratching the surface type of report.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Sulako »

This thread has value, at least most of it does. It's started to drift, so I have removed a whole bunch of off-topic posts. When you post in this thread, try to keep in mind what the original topic was. And let's try to be respectful, both to the crew who lost their lives, and to our fellow posters.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by ipilot54 »

ORNGE suspends night flights at remote sites across Ontario
Two weeks after the fatal crash of an air ambulance helicopter, ORNGE has temporarily suspended night flights to almost 60 sites across Ontario.

OTTAWA—Two weeks after the fatal crash of an air ambulance helicopter crash in northern Ontario, ORNGE has temporarily suspended night-time chopper flights to 58 remote sites across the province.

While the cause of the May 31 midnight crash in Moosonee may not be known for many months yet, the air ambulance service says it is taking the actions for “maximum safety.”

“Rotor operations at night are certainly an area where you have to be very vigilant,” Dr. Andrew McCallum, president and chief executive officer of ORNGE, told the Star in an interview.

ORNGE has implemented several changes in the wake of the crash that killed four employees, including suspending night flights to 58 landing sites that involve so-called “black hole” approaches.

Such conditions occur in remote areas where the lack of lighting, such as house and street lights, leave the pilot with few visual cues for their landing, raising the risk of an accident.

“We do know that probably black hole approaches are the biggest challenge for rotor (emergency medical service) pilots,” McCallum said.

Rather than conventional lighting, these 58 helipads are marked by reflective cones that mark the landing site when illuminated by the landing lights of an approaching helicopter.

In the coming weeks, ORNGE chopper pilots will get additional training on landing at reflective cone helipads. As each crew completes the training, they will be allowed to resume flights into these sites. The training is expected to take two weeks.

Of the 58 sites, the helipads at Grassy Narrows, White Dog, and Sioux Narrows — the three used most often by ORNGE — are getting new lighting systems altogether.

“I’ve just said to our staff that this has got to be fast-tracked,” McCallum said. “Once we have those in and train people we will be able to return it to service.”

In the interim, ORNGE will be relying on its fixed-wing fleet of aircraft to perform medical evacuations, along with land ambulances, spokesperson James MacDonald said.

“Every effort will be made to minimize delays,” he said Friday.

“ORNGE generally uses these helipads for modified scene calls, where the patient is already in the care of emergency medical personnel. At this time of year, there is an abundance of daylight hours, reducing the instance of night time flights,” MacDonald said.

Finally, ORNGE is reminding pilots on its procedures for night-time departures, which typically involves climbing to 150 metres above the ground to ensure terrain clearance before making any turn towards the destination.

ORNGE has sent a bulletin, “reminding pilots to exercise heightened awareness during operations, especially when operating at night in remote areas,” the agency said in an email to the Star.

“We’re doing a whole bunch of things out of an abundance of caution. We’re reminding people about night departure procedures and reinforcing how you do this. We’re not saying that’s what it was,” McCallum said.

The Sikorsky S-76 crashed after a midnight departure from Moosonee en route to Attawapiskat to pick up a patient. After a brief climb, the chopper descended into the forest next to the airport. It was airborne for less than a minute.

The four crew onboard were killed: Capt. Don Filliter, First Officer Jacques Dupuy, and flight paramedics Dustin Dagenais and Chris Snowball. A funeral service was held Friday for Dupuy, the last crew member to be laid to rest. A memorial service is planned Tuesday in Toronto.

ORNGE initially grounded its remaining S-76 helicopters but they resumed service after the Transportation Safety Board of Canada has said it found no early evidence that a mechanical problem had crash the crash.

There are questions whether the inky blackness of the northern Ontario airport and the possibility of pilot disorientation played a role in the chopper’s crash so soon after take-off.

“I think it’s really important that we not jump to conclusions here. I think there’s a lot of things still in play,” McCallum said.

“This is not technically a black hole situation that is associated with this accident. We don’t know if disorientation at night was a factor.”

In the lobby of ORNGE’s Mississauga headquarters this week a small memorial was on display to pay tribute to four killed in the crash. A table displayed photos of the men along with books for visitors and employees to write notes of condolence. Bouquets of flowers dotted the tables in the reception area.

“It’s been extraordinarily difficult for our people,” McCallum said.

“We’re working with them to try and make this post-event period as easy as can be. We’ve been very respectful of people who have had concerns going back to the job.”
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by armchair »

This temporary suspension will help but in time the risk levels will creep back in. Not sure if the February 2008 crash of a EMS helicopter during a black hole approach at the Temagami Snake Lake Helipad was mentioned, but here is the short version which describes black hole well at :
http://www.tc.gc.ca/eng/civilaviation/p ... m#illusion

In my experience the black hole takeoff is more dangerous, due to the strong acceleration resulting from pulling torque and takeoff power. it is very powerful at tricking the inner ear that you are nose up when in fact you are nose down. Same for a night overshoot or missed approach. The Terrace BC accident involving a Metro in 1989 or 1990 is a classic case of that.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Doc »

I don't say this very often, but KUDOS to Ornge for taking this approach (pun intended) to remove from the playing field, a very dangerous situation. Having never flown a helicopter, I have no idea if it's more difficult to maintain a rate of climb on instruments than it is on a fixed wing aircraft, but I'm very happy to see them taking these steps in, as I see it, the right direction!
Very forward thinking!
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Doc »

armchair wrote:This temporary suspension will help but in time the risk levels will creep back in. Not sure if the February 2008 crash of a EMS helicopter during a black hole approach at the Temagami Snake Lake Helipad was mentioned, but here is the short version which describes black hole well at :
http://www.tc.gc.ca/eng/civilaviation/p ... m#illusion

In my experience the black hole takeoff is more dangerous, due to the strong acceleration resulting from pulling torque and takeoff power. it is very powerful at tricking the inner ear that you are nose up when in fact you are nose down. Same for a night overshoot or missed approach. The Terrace BC accident involving a Metro in 1989 or 1990 is a classic case of that.
You may not be aware of this, but there is never a TOTAL fix to ANYTHING. Ask Toyota! There are temporary fixes. Some much better than others. But, nothing's perfect. In life, or in aviation. Ornge has taken the "bull by the horns" on this one, and that's great. The YMO accident obviously was a major wake up call, and Ornge woke up! It's time for the rest of the industry to follow suit. Black hole training should be discussed at every level of our industry. Our biggest defence against it is awareness. When I think of the mindless hours of educational drivel every pilot snores through to fulfil TC's mandate......well, I start to snore. This subject COULD actually SAVE LIVES! Really! Yes, there will be future black hole accidents. But lets raise awareness, so they become REALLY rare. And, lets everybody remember to put our gear down......couldn't help that one.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by RatherBeFlying »

Finally, ORNGE is reminding pilots on its procedures for night-time departures, which typically involves climbing to 150 metres above the ground to ensure terrain clearance before making any turn towards the destination.
That's 500 feet -- not much margin for error in black hole conditions. That's what we use for turning crosswind in visual conditions.

Others have mentioned maintaining a proper climb gradient.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Cat Driver »

Does Ornge give special training to their crews to convert to feet so they can use the altimeter correctly?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by CpnCrunch »

Surely there are tools such as synthetic vision / enhanced vision that can help in situations like this if you're not too cheap to install them. What is the cost of installing these systems on the fleet versus replacing a heap of burning metal (not to mention the human costs)?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Doc »

CpnCrunch wrote:Surely there are tools such as synthetic vision / enhanced vision that can help in situations like this if you're not too cheap to install them. What is the cost of installing these systems on the fleet versus replacing a heap of burning metal (not to mention the human costs)?
Ah yes, synthetic vision. One of my favourite quotes of al time by a certain air charter company....."I've installed synthetic vision, now the wimps have no excused not to go......" There is a place for it.....but not in the hands of this Jack Ass.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by ipilot54 »

New safety training ordered for ORNGE helicopter pilots
ORNGE halts helicopter flights in bad weather until pilots get training to avoid inadvertently flying into the ground.

ORNGE helicopter pilots must take new special safety training just over two weeks after an ORNGE Sikorsky helicopter crashed during a night flight in Moosonee, Ont., killing the two pilots and two flight paramedics on board.

THE CANADIAN PRESS



OTTAWA—ORNGE is barring its air ambulance helicopter pilots from flying in bad weather or clouds until they can show they have special training to avoid inadvertently flying into the ground.

The move comes just over two weeks after an ORNGE Sikorsky helicopter crashed during a night flight in Moosonee, Ont., killing the two pilots and two flight paramedics on board.

Since that accident, ORNGE has moved to restrict operations by its fleet of helicopters, first by banning night-time flights to almost 60 remote Ontario sites.

Then late last week, ORNGE’s helicopters were barred from flying in bad weather after a “licensing” issue with Transport Canada.

Progressive Conservative MPP Frank Klees said the continued turmoil at ORNGE is putting the lives of patients at risk and now even its front line staff.

“The financial waste . . . on the taxpayer is minor compared to the lives that are being put at risk every day,” Klees said.

The blanket suspension of flights over the weekend has since been lifted but individual pilots are facing their own restrictions against flying under Instrument Flight Rules (IFR), ORNGE said in a statement.

In consultation with Transport Canada, IFR rotor operations were temporarily suspended over the weekend during reconciliation of a licensing issue,” ORNGE spokeswoman Laurelle Knox said in an email.

“These operations have since been reinstated. However, a restriction still exists for a number of rotor pilots who require reconciliation of the licensing issue,” she said.

Until pilots get “documented” training on a safety worry known as controlled flight into terrain, they will not be allowed to operate IFR flights, typically in poor weather, ORNGE said.

As well, senior managers at ORNGE are now demanding that all pilots provide confirmation they meet currency requirements for night flying prior to any flights after dark.

The Transportation Safety Board of Canada has already flagged controlled flight into terrain as one of its top safety concerns. This is when pilots inadvertently fly into the ground or water, usually at night or in bad weather or poor visibility.

It has not been ruled out as a possible cause of the May 31 crash of an ORNGE Sikorsky S-76 helicopter. That flight departed Moosonee just after midnight and crashed less than a minute later into a forest. Investigators have said there’s no early indication that a mechanical failure caused the crash.

Transport Canada, which has done its own audit of ORNGE’s air operations, suggested that the air ambulance operator suspended flights on its own accord.

Transport Canada was informed by ORNGE that the company voluntarily suspended all Instrument Flights Rules operations,” the federal regulator said in a statement. It referred all questions to ORNGE.

ORNGE suggested that the suspension of IFR flights would have little impact on the operations.

“We rarely fly IFR,” Knox said.

Knox added that the helicopters fly primarily under “visual flight rules,” which means in good weather. She said ORNGE’s fleet of Sikorsky S-76 choppers didn’t make any IFR flights in the last quarter and “only rarely” for the newer AW139 choppers.

However, one experienced pilot told the Star that said IFR certification is vital so the service can do its job.

“It’s a tool pilots need and use if weather is encountered or you’re flying at night and get yourself into cloud,” said the pilot, who spoke on condition of anonymity.

Klees said the suspension of flights in bad weather and to remote helipads at night calls into question the very mission of ORNGE to provide emergency health care.

“We have an organization that as its mandate is to provide emergency evacuation services,” Klees said in an interview. “The very core mandate is being undermined and has been undermined for some time.”

Klees said the aviation operations of ORNGE should be handed over to an organization “that knows what they are doing.”
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ipilot54
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by ipilot54 »

Ornge has only had their AOC for a very short period of time, about 18 months. As a "new" operator, why was this allowed to happen? All IFR operators are required to conduct CFIT training. Ornge wasn't?

"senior managers at ORNGE are now demanding that all pilots provide confirmation they meet currency requirements for night flying prior to any flights after dark."

It looks like the new operation is not following the rules at all. Tracking night flights is THE operator's responsibility....

723.98 Training Program

(24) Controlled Flight into Terrain (CFIT) Avoidance Training

Air operators shall provide the following initial and biennial CFIT avoidance training to all flight crew members operating helicopters approved for flight under instrument meteorological conditions:
(amended 2000/06/01; no previous version)

(a) factors that may lead to CFIT accidents and incidents;

(b) CFIT prevention strategies; and

(c) methods of improving situational awareness.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Cat Driver »

An instrument rating does not give you the skills to prevent CFIT, you need further training?

Or is Ornge dispatching pilots into conditions that require an instrument rating and they do not have valid IFR ratings?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

Can anyone tell us whether ORNGE has a compliant aircraft training program for it's pilots, and whether it is sim based, or do they do aircraft based training?

edited for the sake of simplicity
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by nothingbeatsflying »

“We do know that probably black hole approaches are the biggest challenge for rotor (emergency medical service) pilots,” McCallum said.
...and so why are the old helicopters operating where the biggest challenges are? Politics?
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