Ornge Sikorsky Air ambulance accident Northern Ontario

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Cat Driver
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Cat Driver »


...and so why are the old helicopters operating where the biggest challenges are? Politics?
There was a time when Helijet operated S76's IFR on sked runs Vancouver to Victoria.

Have they quit doing that because the machines are to old?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by nothingbeatsflying »

There was a time when Helijet operated S76's IFR on sked runs Vancouver to Victoria.

Have they quit doing that because the machines are to old?
Not at all. Perfectly valid point. Just wondering why the ORNGE keeps all the Agusta 139's down south when the "biggest challenge" for the rotor pilots is in the northern part of the province. I'm not an expert by any means, just seems backwards doesn't it?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Double Wasp »

Cat Driver wrote: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?

Cat I respect who you are and what you have done but why do you treat people like they are idiots by asking rhetorical questions?

CFIT is a plague in aviation, has been for as long as it has been around.

How can additional emphasis on dangerous situations be a bad thing? Am I right to assume with all your experience you have done initial and recurrent training on CRM, aircraft icing etc.? This is no different. CFIT training and situational awareness training may be common sense type stuff but reiterating common sense themes is what we do to encourage safe behaviours and attitudes. In fact it is usually part of the CRM course.

It is not that people do not have the skills to avoid CFIT it is that they are not using them. How is TC mandating this additional training wrong?

How are the questions you are asking above making anything safer? It makes one question credibility, I expect better from a teacher and a mentor. After all gaining wisdom is about asking the right questions is it not?


Doc, agreed, only problem is if now you know every back of the clock flight is critical how will that change the "gotta get in" dynamic. I guess that is where professionalism comes in.

Cheers
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

I'm super-stunned by the spokesperson saying that's OK ... no big deal .... "We rarely fly IFR" in response to a question on why the IFR operating authority was voluntarily surrendered due to not being able to prove the crews met at least the bare minimums of training in the operation .... heaven forbid they should actually strive to do better than the absolute minimum ... especially with all the money that has been funnelled through ORNGE. We were told all along that .... "yup, the financial stuff is a little screwy, but operationally, the place is on a super-solid footing .... clean as a whistle, state of the art, an example to the world, the public can be assured there is no scent of rot in the operation outside of the Board Room."

So the people of the province have paid mega-millions for multiple IFR equipped multi-engine platforms and they are still flying the airframe like it's a Cessna 185 on it's way to a fish camp. Is that really the state of the art? Good freakin' God.

Next flabbergasting statement is that the managers want the line pilots to tell them if their training status is up to date and whether they are sufficiently trained to fly if dispatched.

They don't have a clue.

Maybe they should read the list of their responsibilities that are clearly laid out in every Company Operations Manual from coast to coast. After they finish that, they should have a quick skim of the outcome of the trials and legislation arising from the Westray Mine Disaster with loss of life in the workplace, and see how that directly affects the persons holding supervisory and managerial positions in any company, but particularly one with intrinsic dangers such as is the case with aviation.

Obviously, there are very deep, very basic AOC management problems at ORNGE which have been brought to light by this latest cost of human life. Those problems of leadership and inadequate operational oversight cannot help but trickle down into the many bases scattered across the province .... most likely bases with "localized procedures" that have just evolved in the operation and become the norm, with everyone thinking they are "just fine thank-you."

After reading the news release closely and determining what would prompt ORNGE to make such statements to the public, I was in conversation with some other aviation supervisory people at length about how would the ORNGE operations ever be brought up to speed, dragged into proper consistent IFR operations, crews trained in simulators in a well planned out training program which addresses the type of operational flying requirements encountered to a high standard on both initial and recurrent programs, cure the low level of morale in what must surely be a terrible workplace corporate culture at present following a fatality on the heels of the financial scandal and microscopic examination of the operation in the news media daily and a source of embarrassment on the floor of the legislature, ensure the hardware is in tip-top condition that can be counted on and is capable of IFR range and reserve if they are going airport to airport or heliport with certified approaches, put operational control procedures and written standards on how the job is to be done procedurally ..... more important ... and then have those standards strictly enforced by Check Pilots and Line Checks with remedial activity as required based upon observed performance, get the the administrative record keeping required under control so that the people responsible for knowing the status of their crews actually have a grip on what's happening now .... and then on a pro-active basis so that something as simple and basic as having compliant training records for staff is looked after, to foster a co-operative team effort between the medical and flight operational elements, .... and the list just goes on and on, and on ...... the more questions I ask, the more come to light.

I don't envy the people in the operational team who will be tasked with turning around this place. After going through a few days of the "Saviour Syndrome," and things not being cured overnight, the push-back from staff and overseers will be substantial. It took a long time for things to become this bad, and it will take a long time and a Herculean effort for it to be fixed.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by J31 »

Wow an large air ambulance reduced to DAY VFR??!! And their management does not think there is a problem??!! :shock:
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

They haven't been reduced to it ..... (according to the news release) .... that's how they do pretty much all the time as the normal way of doing business, and they seem to think that's just fine.

Maybe what they really need is a fleet of Beavers on wheels if that's the way they run the IFR rotary section..... far cheaper for ..-running operational costs.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Special K »

Management not understanding the operational side of its operation? That can't happen! That's what TC is fo.......
:shock:
....disregard.

K
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

Special K wrote:Management not understanding the operational side of its operation? That can't happen! That's what TC is fo.......
:shock:
....disregard.

K
Well, it would see that's what they did this time by having them ground themselves or be suspended over training standards ..... that's the usual least paperwork solution offered until the septic tank can be pumped out enough for the toilets to flush once again.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by ipilot54 »

http://www.thestar.com/news/canada/2013 ... cerns.html

Ornge helicopter crash prompts safety concerns
Fatal helicopter crash sparks concerns about Ornge's management of its chopper fleet.

A memorial for the victims of the Moosonee ORNGE helicopter crash was held at the Toronto Police College in Etobicoke on Tuesday.

On Runway 06 at Moosonee airport, the Sikorsky S-76A helicopter rocked uneasily on its landing gear, its four rotor blades beating the night air.

In the cockpit of the ORNGE air ambulance was Capt. Don Filliter. At 54, he was a respected veteran of Canada’s helicopter industry. Beside him was First Officer Jacques Dupuy. In the cabin behind them were flight paramedics Dustin Dagenais and Chris Snowball.

The chopper, call sign “Lifeflight 3,” had been dispatched on a midnight trip to Attawapiskat to pick up a patient.

But their flight barely lasted a minute, ending in a fiery crash in the forest, killing all four onboard.

The Star spoke at length with pilots with years of experience in air ambulance operations, including several who still work at ORNGE. They spoke on the condition of anonymity because of a concern about retribution.

Pilots and critics say the roots of the May 31 accident can be traced from that patch of burned and devastated forest in northern Ontario back to ORNGE headquarters in Mississauga and the management decisions that began under the controversial reign of Dr. Chris Mazza.

“I think ORNGE is praying that it’s a pilot error accident and then they will accept no blame for this,” one pilot told the Star.

“But the question is whether the pilots were put in a situation where an accident was inevitable.”

A Star investigation has found troubling issues arising from the accident that could impact the safety and service of ORNGE’s helicopter operations, including:
Whether ORNGE had the organizational “competence” to assume responsibility for the helicopter operations just over a year ago.
An exodus of senior, experienced pilots — more than one-quarter of the workforce — that has strained training and scheduling. In the last 18 months, more than 20 disgruntled rotor-wing pilots with thousands of hours in their logbooks have left, including three who handed in their resignations this week. The turnover could impair the busy flying schedule in the summer “trauma” season.

The training given to Filliter. Though an experienced pilot, he had returned to air ambulance flying only in March after several years away.
The pairing of Filliter and Dupuy. Veteran pilots tell the Star this “green-on-green” scenario — a pairing of pilots relatively new to their flying positions — is at the root of the accident. Such pairings are banned in commercial aviation because of the inherent risks. In this case, Filliter was returning after a hiatus and Dupuy had less than a year’s experience.
Questions about the management of ORNGE’s helicopter operations after the service suspended night flights to remote helipads and flights in bad weather in the wake of the crash. As well, sources say that helicopters are routinely out of service because of maintenance problems or lack of staffing.

ORNGE president and chief executive officer Dr. Andrew McCallum says the two pilots involved in the accident were “highly qualified and experienced” and had received the required training.

And McCallum told the Star that he believes operating the fleet of helicopters in-house “is the most appropriate way for us to deliver the service.

“I believe that the people here are equipped and able to properly supervise and maintain an aviation service,” McCallum said.

----------------------

The troubled saga at ORNGE has cost taxpayers money. But in the wake of the Sikorsky crash, some question whether that turmoil has now cost lives. They point to the decision by ORNGE to take over the operation of its helicopter fleet, despite repeated warnings that the agency lacked the “competence” to handle the complex demands of such a move.

It was under Mazza’s tenure as chief executive officer that ORNGE decided to cut short its contract with Canadian Helicopters Ltd., which through a series of competitive bids, had operated Ontario’s rotor-wing air ambulances since 1977 without a fatal accident.

Instead, ORNGE said it would handle the operation and maintenance of its helicopter fleet and the training of its pilots starting April 1, 2012. The fatal crash came just over a year later. Today, there is growing anger among ORNGE employees who saw this as a preventable accident set in motion by the turmoil of recent years.

“ORNGE was never set up with the original mandate of operating an aircraft. We are paying for it now. They should never have been involved in aviation,” said one insider.

“You can back this up since the day they took it over and see how everything is connected to that crash.”

There were warnings voiced at Queen’s Park that ORNGE lacked the expertise to manage a fleet of sophisticated helicopters.

It’s a very, very complex operation. Putting it simply, there’s no learner’s permit for this. It’s very, very difficult to do. We’re very good at it,” Rob Blakely, a vice-president with Canadian Helicopters, told the public accounts committee probing the ORNGE controversy last year.

It was no idle boast. Canadian Helicopters had been recognized by Sikorsky for its safety record flying the S-76.

Jacob Blum, who served in several senior roles at ORNGE until his resignation in 2008, said he voiced doubts about the decision to bring the helicopter operations in-house but says he was ignored.

“What ended up happening was a desire to become an aviation company — what I cheekily call, ‘boys with toys.’ ” Blum, a former ORNGE vice-president, told a Queen’s Park committee probing the agency last year.

“ORNGE did not have the core competencies to become an aviation company. That was better left to the third-party aviators who do this for a living day in and day out,” Blum said.

Tom Rothfels, ORNGE’s former chief operating officer, told the committee that operating complex, twin-engine choppers “is not something that you do lightly.”

“It concerned me greatly that ORNGE was about to undertake this in a very short period of time,” he said.

------------------------------------

Preparing for takeoff that night, ahead lay the runway at the Moosonee airport. Beyond that, blackness. And unlike nights in southern Ontario, where urban life illuminates the night, this was an all-encompassing, inky darkness.

It was the kind of darkness that has a name — the “black hole” effect where the lack of visual references creates risks for pilots.

The condition is a bigger concern on landings, when such darkness makes depth perception difficult. But it can also play havoc on takeoff when pilots must cope not only with the lack of visual references but also the sensory illusions caused by the acceleration of the aircraft as it takes to the air.

It could be so disorienting that Canadian Helicopters gave its air ambulance crews repeated practice in “black hole” arrivals and departures to drive home the risks and the skills needed to safely in such conditions.

“Unlike southern Ontario, once you leave that runway there are no lights for 80 miles,” one pilot told the Star.

On the runway, the Sikorsky’s twin engines spooled up and the chopper took to the air.

“You want keep . . . straight and level until you’ve got a good rate of climb and at least 500 feet above ground in night-time before you do any turning,” one pilot told the Star.

The helicopter climbed initially and then turned north. But in the turn, it began to descend, crashing into the trees that border the airport.

After listening to the cockpit voice recorder, investigators from the Transportation Safety Board of Canada said it didn’t appear that a mechanical problem was the cause.

While all potential causes officially remain on the table, that announcement has put the focus on the actions of the two pilots at the controls — and decisions by ORNGE management.

Though spread around the globe, Canadian helicopter pilots are a close-knit community. As word circulated that Filliter had been killed in a crash, the first reaction was disbelief. Then were there questions. That’s because all those who flew with Filliter say he was a consummate pro.

“He was a safe, competent pilot. Absolutely no one better,” said one pilot.

In the words of another, he had “good hands and feet,” perhaps the ultimate compliment to pay a helicopter pilot

Filliter flew helicopters for the Ministry of Natural Resources and flew part-time on the air ambulance fleet. Yet he had been away from the air ambulance business for several years before joining ORNGE in March as a contract pilot.

It’s the policy of some aviation companies that a captain who had been away for an extended time would have been paired with a training captain for a month or longer to ensure they are up to speed and proficient to act as a pilot-in-command.

Now some question whether Filliter had been pressed back into operations without proper training and supervision because of the staff turnover at ORNGE.

“I just can’t get my head wrapped around how this happened,” said one veteran pilot, who once flew with Filliter.

“It’s got to be something to do with the training not being done well and Don being left without the tools required to do this job,” the pilot told the Star.

“We’re getting away from those days when we call it pilot error. We’re calling it system failures and I think this is an example of system failure, that inexperienced people have been put in charge of a complex, expensive and potentially risky business.”

Canadian Helicopters had managers in charge of individual air bases across the province. Such a manager would never have paired Filliter and Dupuy together for a challenging night flight, one source said. But when ORNGE took over, they got rid of the base managers and moved to centralized scheduling run from its Mississauga headquarters.

“Yes, they both had lots of experience flying but not in this type of environment,” the source said.

----------------

As a former flight surgeon, chief coroner of Ontario and a pilot and aircraft owner himself, McCallum well knows the desire for answers after tragic deaths.

His first counsel is patience, to avoid quick judgments.

“Everybody has a thought about what happened and why it happened and conclusions have been drawn but the fact is we don’t know,” he told the Star during an interview at ORNGE’s Mississauga headquarters.

He says that Filliter had gone through all “recurrent training and checks” after joining ORNGE. Dupuy joined last August and McCallum says he was experienced as well with thousands of hours in his logbook.

“So neither of these guys were anything but highly qualified and experienced,” McCallum said, dismissing speculation of a green-on-green scenario.

“I think describing these two individuals as green would be unfair to them entirely,” he said.

He concedes that the takeover of helicopter operations from Canadian Helicopters has been challenging.

“Certainly there have been pilots who have left. We have also recruited more pilots than have left,” McCallum said.

“I think it would only be fair to say that the transition from CHL to us wasn’t entirely happy from the perspective of a number of veteran pilots,” he said.

Despite the turnover, McCallum said he’s satisfied that the new hires are “appropriately qualified. We bring them and train them properly.”

He said he expects the safety board to look at Filliter’s training, the pairing of Filliter and Dupuy, the turnover in the pilot ranks and determine whether any of it was a factor in the accident.

“It’s frustrating because it takes a long time and people want answers. My folks desperately want to know,” he said.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

There can be no question that CHL did an excellent job during the years they ran EMS ops in Ontario, it is a very sad realization that the disaster that is Ornge has needlessly claimed 4 lives. "Boys with toys" indeed.

When is enough, enough? Time to hit the reset button on this whole show imho.

Where is TC in all this...? Oh right... Never mind.

stl
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

Well, it appears that after an inspection of the training records of ORNGE pilots, TC grounded all the IFR pilots due to lack of training or lack of records of the training, and as a result of that finding accepted ORNGE's voluntarily surrender of the IFR portion of their AOC rather than suspending the total operation (leaving the province with zero lift capability) until their IFR staff had met at least the minimum required by law.

So what else should they have done beyond the legal remedies available to them?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

Day late, and a dollar short, as usual.

But hey, I'm sure the SMS program is up to snuff.

The name of the game is accident prevention, not accident reaction. We need to do better as an industry, full-stop.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by DonutHole »

A properly set up SMS would have caught the lack of training and records and should have generated a finding. That is the point of SMS, to catch these errors before they happen. I'm no huge fan of the downloading of TCs responsibility to the operator, but really an effective SMS would have caught this error, so I have to disagree with STLs (probably tongue in cheek) comment that they probably had a good SMS because clearly, they didn't.

The problem with SMS isn't SMS itself, it is TCs belief that SMS absolves them of oversight... to the contrary I believe that it simply re-arranges where their oversight takes place, it doesn't replace it.

If anything, to me this incident proves that not only is SMS needed, but it needs to be audited AND enforced by the government agency ramming this stuff down our throat.

Maybe part of the problem is perception of the goals and intent of SMS. I believe that it is intended to be a proactive system not a reactionary system. You can tell by the model, officers, auditing their respective managment areas within the system, generating findings and implementing solutions. The findings are the most important part and should come before an incident not after an incident... the findings are supposed to be proactive in eliminating the need to be reactive. That is why there is guaranteed anonymity when it comes to sms reports, however I personally don't feel as if it is needed because really, the findings are supposed to help prevent incidents, any employer should be happy to recognise the efforts of their employees to help better the company... Unfortunately I feel that the antiquated (room for debate on this one) idea that findings are bad is completely undermining the positive impact this program could have if implemented properly.

Sorry for the rant.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

Not to derail this thread into yet another SMS debacle, but this is the essence of the entire issue:
DonutHole wrote:TCs belief that SMS absolves them of oversight... to the contrary I believe that it simply re-arranges where their oversight takes place, it doesn't replace it.
The problem is, TC no longer practices real oversight, and therefore SMS remains a red herring as there is nobody holding operators accountable. It all looks good on paper, but in practise there are some abhorrent operations out there with perfectly acceptable SMS programs in place. I have no idea about the SMS culture at Ornge, but being quite familiar with many such programs with other operations or their customers, it's apparent we are no closer to operating "safely" now than we were five years ago. In some respects we may be a good bit further away from that goal.

Regardless, whether it be TC oversight, SMS, or a combination of the two, something should have caught the apparent operational issues there before people had to die.

stl
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by MUSKEG »

We were catching those kind of errors long before SMS came along. They are called training records and the CP knowing the qualifications of his crew. Lets call it what it is.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by armchair »

It was under Mazza’s tenure as chief executive officer that ORNGE decided to cut short its contract with Canadian Helicopters Ltd., which through a series of competitive bids, had operated Ontario’s rotor-wing air ambulances since 1977 without a fatal accident.

...

It’s a very, very complex operation. Putting it simply, there’s no learner’s permit for this. It’s very, very difficult to do. We’re very good at it,” Rob Blakely, a vice-president with Canadian Helicopters, told the public accounts committee probing the ORNGE controversy last year.

...

It was no idle boast. Canadian Helicopters had been recognized by Sikorsky for its safety record flying the S76.

...

“ORNGE did not have the core competencies to become an aviation company. That was better left to the third-party aviators who do this for a living day in and day out,” Blum said.

...

It was the kind of darkness that has a name — the “black hole” effect where the lack of visual references creates risks for pilots.

The condition is a bigger concern on landings, when such darkness makes depth perception difficult. But it can also play havoc on takeoff when pilots must cope not only with the lack of visual references but also the sensory illusions caused by the acceleration of the aircraft as it takes to the air.

It could be so disorienting that Canadian Helicopters gave its air ambulance crews repeated practice in “black hole” arrivals and departures to drive home the risks and the skills needed to safely in such conditions.

....

Canadian Helicopters had managers in charge of individual air bases across the province. Such a manager would never have paired Filliter and Dupuy together for a challenging night flight, one source said. But when ORNGE took over, they got rid of the base managers and moved to centralized scheduling run from its Mississauga headquarters.
Not to take sides here but this Oh Canadian Helicopters praise fails to mention the 2008 black hole crash I mentioned earlier... It as a Canadian Helicopters S76 and it did crash at night during a black hole approach. http://www.bst-tsb.gc.ca/eng/rapports-r ... 8o0029.asp


The difference between that one in 2008 Nd this one in 2013 is that nobody died in the earlier one... That's it. So not necessarily defending ORNGE here, but lets keep in mind the facts that it is a very challenging environment, whether its Canadian, ORNGE or any other.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

Armchair,

It needs to be pointed out that during its time operating EMS in Ontario and Nova Scotia, CHL had by far the best safety record of any air medical outfit in North America - and they did it for a long time. CHL has many faults, but the way they ran EMS ops was very good.

stl
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Sidebar »

DonutHole wrote:A properly set up SMS would have caught the lack of training and records ...
I'm not convinced this is true. A properly set up SMS might have caught this, but I don't think you can say with certainty that it would have.

Problems with training and records are symptoms of deeper organizational issues.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by single_swine_herder »

Sidebar wrote:
DonutHole wrote:A properly set up SMS would have caught the lack of training and records ...
I'm not convinced this is true. A properly set up SMS might have caught this, but I don't think you can say with certainty that it would have.

Problems with training and records are symptoms of deeper organizational issues.
I would submit that the SMS would not have detected the underlying problem of record keeping and/or training program delivery. I put that position forward because SMS is there to rectify issues which have been found through an audit or direct experience process and reported to the SMS Committee for resolution. After being dealt with, the information is then logged and analyzed for trends.

The core issue here is lack of competence in aviation matters by those whose responsibility is quite simple overall .... to read the regulations, develop a training plan, and ensure it is delivered and documented as having been completed.

It fell to Transport to do what the company should have done from square one, but for whatever series of reasons, failed to do so.

As far as whether TC should have entered the company without cause and performed a snap inspection relating to compliance, if they had done that the regular posters here would have been howling for TC to back off, imaging the sound of hobnailed boots, secret police activities, and the equivalent to aviation death squads if they had suspended the AOC.

ORNGE should have had a certified simulator training program in place which exceeded the bare bones minimum standard by a wide margin. They had no shortage of funding, were not hampered by a profit motive to return a maximum return to shareholders, were backed by provincial and federal regulations out the ying-yang, but instead chose to cut corners at every possible intersection.

Something as common as a "Black Hole Effect" should not prove to be the great death-defying feat of the century it is made out to be in a multi-million dollar state of the art IFR helicopter with a trained crew and correct monitoring of flight standards by the leaders of the organization.

Moderator STL has warned that this thread should not be allowed to explore SMS because his personal experience with it appears to have been negative and have no redeeming value. So lets' keep it on track with respect to operational oversight, training quality, performance monitoring, and competence which is not just measured by the term "experienced pilot." Lots of us have experience, but perhaps not the highest level of training along the way in dealing with a threat filled environment, and recognizing that IFR skills are very perishable.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by DonutHole »

single_swine_herder wrote: I would submit that the SMS would not have detected the underlying problem of record keeping and/or training program delivery. I put that position forward because SMS is there to rectify issues which have been found through an audit process and reported to the SMS Committee for resolution.
Going to have to disagree. Part of SMS is internal audits. These audits are intended to find deficiencies in areas such as training/record keeping. That in fact, is the entire point of SMS. To catch yourself making mistakes before they turn into incidents. If the system is properly set up, these record keeping/training deficiencies would be GLARING errors impossible to miss.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

single_swine_herder wrote: Moderator STL has warned that this thread should not be allowed to explore SMS because his personal experience with it appears to have been negative and have no redeeming value. So lets' keep it on track with respect to operational oversight, training quality, performance monitoring, and competence which is not just measured by the term "experienced pilot." Lots of us have experience, but perhaps not the highest level of training along the way in dealing with a threat filled environment, and recognizing that IFR skills are very perishable.


By your own admission:
The core issue here is lack of competence in aviation matters by those whose responsibility is quite simple overall .... to read the regulations, develop a training plan, and ensure it is delivered and documented as having been completed.
Of that there can be little doubt.


I see that along with IFR skills being perishable, Trolling skills seems to fall into the same category...

Should you wish to talk about SMS to the tune of tens of thousands of words, please feel free to hit the "New Topic" button and start an appropriate thread. Until such time, lets keep this thread on track as per website guidelines and discuss the Ornge accident, shall we?
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Sidebar »

DonutHole wrote:If the system is properly set up, these record keeping/training deficiencies would be GLARING errors impossible to miss.
You seem quite certain about this. One could also expect that descent shortly after takeoff would also be impossible to miss, yet it happened to this helo crew.

I suggest that, unless training records are specifically targeted for an internal audit, AND the auditors have sufficient training and experience, the SMS is unlikely to detect this. If SMS does detect such an issue, it will likely have been present for some time before detection.
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sky's the limit
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by sky's the limit »

Donut,

You are operating under the assumption that the people running companies have A) The skills, experience, and desire to do so properly, and B) That a stand alone reporting system devoid of consequence - SHOULD it be circumvented - is enough to make absolute safety a reality... It just is not. SMS is not a magic bullet.

Unfortunately we all know the fallibility of the human beings associated with aviation in all sectors, particularly when money becomes an issue. There are a great many people in our industry in positions of power with little or no reason, much less the training and experience to be there. Regardless of the safety system in place, they will fail - sometimes deliberately.

As SSH states, the people at the top in this scenario are the most likely core issue given all we know about Ornge and its operation over the past years, and no system, Regulatory or SMS is going to prevent abuses and incompetence from making its presence felt.

Who's call was it to dispatch this "Medivac?" Who's call put this crew together? Who's call is it to mandate proper training? These seem to be a few of the questions that need to be answered.

stl
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by DonutHole »

Sidebar wrote:
DonutHole wrote:If the system is properly set up, these record keeping/training deficiencies would be GLARING errors impossible to miss.
You seem quite certain about this. One could also expect that descent shortly after takeoff would also be impossible to miss, yet it happened to this helo crew.

I suggest that, unless training records are specifically targeted for an internal audit, AND the auditors have sufficient training and experience, the SMS is unlikely to detect this. If SMS does detect such an issue, it will likely have been present for some time before detection.
A cyclic argument.

In the end it doesn't matter what the system is called if the oversight into training and record keeping is not being properly conformed to. Unless training records are specifically targeted for an audit of any type there is a possibility that the same issues could exist. The compartmentalization implemented with SMS is supposed to make this kind of information easier to obtain by creating raw data that can be easily audited. This to me shows that the system at Ornge was not properly set up, and if so, definitely not properly executed.

What you are saying is that the errors will not be identified becaue they haven't been identified. Using this argument we can effectively discredit any system, be it tc oversight or sms and I simply don't agree with your contention, and that is OKAY with me.

I believe this discussion is on topic as a. it was brought into the topic by the events and b. is the way we are supposed to be providing oversight to ensure these errors to not occur.

I agree with STL that there needs to be some 'designated provisions' (enforcement) via the regulator when audits find glaring deficiencies with the required local company oversight, when thigs go wrong there needs to be consequences. I believe stiffer penalties should be levied when audits create a situation which seems is perfectly aligned with the responsibilities of the operator when in fact, as in this case, the situation is clearly not satisfactory.

In the end, I believe this issue is the responsibility of the employer, however, and more importantly, the fact that nobody caught this error is indicative of the lack of responsibility TC is taking for its own actions, the action of inaction. The regulator needs to step up and put some meat on the bones here. If people cannot handle self managment then there needs to be somebody out there who is identifying these shortcomings and ensuring compliance otherwise we have what SMS has degnerated into, a circle jerk.
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Re: Ornge Sikorsky Air ambulance accident Northern Ontario

Post by Doc »

I see SMS as the biggest politically correct JOKE to come down the pipe in many years. Lets keep our dirty little secrets in house. They'll all just miraculously cure themselves if we fill out enough forms, and kill enough trees.
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