Ornge Sikorsky Air ambulance accident Northern Ontario

[sky's the limit]

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.

As it sits now, that pretty much sums it up for me too Doc.

[armchair]

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

No question they did. In fact, the entire EMS industry in Canada has done much better than the US, which had a horrible string of EMS accidents followed by NTSB hearings and all. My point is that I dont think this was as much an organizational failure as people seem to think it was, nor a TC lack of oversight at ORNGE. I recall crew pairing issues in other TSB reports too but these two guys were experienced professional pilots and they were as good a pair as they come. If anything at all, it should remind us of the true power of the black hole effect and illusion(s).

[single_swine_herder]

Experienced, yes, lots of it .... nice people? Judging by the excellent posts from their friends, .... without question.

But perhaps we need to open our thoughts to the possibility the crew was not current on the perishable commodity of instrument scanning, especially if the company culture is "We rarely fly IFR," according to the company spokesperson.

Somewhere right this moment, a crew is rotating into instrument conditions which will require their instrument scan to be in high gear the moment they raise the nosewheel and the runway lights disappear from forward view..... and they will fly away wings (or rotor disk) level to safe altitude..... regardless of Black Hole or other conditions where the transition to instrument flying is instantaneous.

I can recall feeling how rusty on the steam-powered gauges I was after being away for 2 weeks of vacation and the first minute of so of "time on the clocks" while still established in the climb on a night departure into snow and low cloud was pretty uncomfortable, .... complete with vertigo, and I was flying IFR very regularly up until the break.

[armchair]

...n the perishable commodity of instrument scanning...

...I can recall feeling how rusty on the steam-powered gauges I was after being away for 2 weeks of vacation and the first minute of so of "time on the clocks" while still established in the climb on a night departure into snow and low cloud was pretty uncomfortable, .... complete with vertigo, and I was flying IFR very regularly up until the break.

I'm totally with you, and this is where I now think, as you, and although unfortunately, that our mitigation must be towards this perishable commodity. I experienced the same thing on a couple of occasions I can vividly remember...

[ipilot54]

Somewhere right this moment, a crew is rotating into instrument conditions which will require their instrument scan to be in high gear the moment they raise the nosewheel and the runway lights disappear from forward view..... and they will fly away wings (or rotor disk) level to safe altitude..... regardless of Black Hole or other conditions where the transition to instrument flying is instantaneous.

Amen. And it takes discipline on the part of the crew as well as the company to foster that attitude. "We rarely fly IFR" attitude is probably the exact cause unfortunately.

[Doc]

Getting down to basics here, it does NOT take a high degree of skill to rotate, maintain a positive rate of climb to a safe (500 feet?) altitude, immediately after takeoff. What it does take is the attention to detail to make it happen. I say again. Nothing else matters until you get that first 500 feet of air between your ass and the ground. Brief it and do it. Every time. That's it. That's all. Lock on that VSI/Altimeter and brief the PNF to do the same. It's dark outside, you are IFR....are there any questions?

[midwingcrisis]

ORNGE chopper lacked safety system

THE CANADIAN PRESS




An air ambulance helicopter that crashed in northern Ontario killing four lacked a key piece of safety gear that may have provided an urgent warning to the pilots to “pull up” as they descended into a forest.

Several of the aging Sikorsky helicopters in ORNGE’s fleet had upgraded electronics, including a ground proximity warning system, but not the one that was based in Moosonee.

That left the crew of the Sikorsky S-76 without a potentially life-saving back-up as they departed on a midnight flight to Attawapiskat from their Moosonee base on May 31.

Their flight lasted barely a minute, crashing into the forest near the airport, killing the two pilots and two paramedics onboard.

Ground proximity warning systems have a visual display that maps high ground around an aircraft to assist with situational awareness.

And the system will also sound urgent aural alarms, such as “terrain, terrain, pull up,” when there is danger of hitting the ground.

Such a warning may have made all the difference to the crew of the Sikorsky chopper that crashed, one veteran pilot told the Star.

“I firmly believe it would have helped in that situation. ... The system would tell you you are in the wrong place,” he said.

Said another pilot: “If they had had it and they were trained properly, it would have absolutely saved their lives. Absolutely.

“There’s no doubt. That thing goes off like a crazy fire siren and you’re aware of it all of a sudden,” said the pilot, with years of experience in air ambulance flying.

While this aircraft lacked the warning system, ORNGE has put another of its S-76A helicopters up for sale, boasting about its “excellent” electronics, including a ground proximity warning system. It’s being sold for parts for $500,000 (U.S.).

That’s caused some ORNGE employees to question why the chopper in Moosonee wasn’t better equipped, noting it even lacked an autopilot.

The Transportation Safety Board of Canada has said there is no early indication of a mechanical problem that may have caused the crash.

Investigators have not ruled out the possibility this was a controlled-flight-into-terrain, when pilots lose track of their position — usually in conditions of low visibility or bad weather — and inadvertently fly into the ground.

The safety board has previously urged installation of ground proximity warning systems in fixed-wing aircraft to prevent just such accidents.

ORNGE spokesperson Laurelle Knox confirmed the helicopter that crashed was not equipped with such a warning system but said it was not required by Transport Canada.

And she said that Canadian Helicopters, which previously held the contract to operate the air ambulance choppers, flew the Sikorsky in the same configuration.

Transport Canada has since imposed new requirements for most commercial aircraft to install a newer, more sophisticated version known as the terrain awareness and warning systems.

These systems are designed to provide even greater warning to pilots of potential collision with terrain and give them time to take evasive action.

“These types of accidents often happen when pilots are unaware of the danger until it is too late,” Transport Canada said in a 2011 news release announcing the regulation.

The regulations apply to private turbine-powered and commercial airplanes with six or more passenger seats. A department spokesperson said Friday that the new rules don’t apply to helicopters.




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

[Doc]

The horse needs another kick. What was the condition of the patient? Why has this been so conveniently swept under the rug. Need to fly at night with a company that "doesn't normally fly IFR" IS a huge factor here. It's largely being ignored. Why?

[ReserveTank]

lacked a key piece of safety gear that may have provided an urgent warning to the pilots to “pull up” as they descended into a forest

You mean they had no altimeter?

[flyinthebug]

First the Toronto Star reports that Mayor Rob Ford was a crackhead and they had a video to prove it. Gawker (website) raised over 200K to pay the drug dealers for their video. The video suddenly disappears and Ford continues doing his job...now they report that a GPWS would have "absolutely" saved this flight?
If that isnt the biggest line of BS ive ever heard, I dont know what is!! The Toronto Star is Canada`s version of the National Enquirer. Crap reporting and crap stories made up from fairy tales.

Fly safe all.

[sstaurus]

In my (limited) experience GPWS systems are ignored anyway, because they often go off during normal approaches (usually at the worst time), conditioning you to ignore them as false warnings.

[Cat Driver]

I have already had my ass reamed for asking the simple question of why an IFR rating is not sufficient to safely depart on instruments after lift off.....

.....Doc just said exactly what I said only better.

Getting down to basics here, it does NOT take a high degree of skill to rotate, maintain a positive rate of climb to a safe (500 feet?) altitude, immediately after takeoff. What it does take is the attention to detail to make it happen. I say again. Nothing else matters until you get that first 500 feet of air between your ass and the ground. Brief it and do it. Every time. That's it. That's all. Lock on that VSI/Altimeter and brief the PNF to do the same. It's dark outside, you are IFR....are there any questions?

[Doc]

In my (limited) experience GPWS systems are ignored anyway, because they often go off during normal approaches (usually at the worst time), conditioning you to ignore them as false warnings.

If you ignore a "PULL UP" just after takeoff, your "limited experience" is not likely to become any less limited.

[single_swine_herder]

If I may respond Cat ..... because holding an instrument rating in and of itself doesn't assure knowlege, proficiency, and currency. It means nothing more than for a short period of time, an individual managed to present a snap-shot of sufficient capability to to pass a flight test. The hour before, the pilot may have been incompetent, and the hour later may be equally incompetent, but for the hour of that flight test, the pilot was observed to be sufficiently knowlegeable and proficient at aircraft handling to make his or her way over the various hurdles required for the rating to be issued by an Approved Check Pilot.

Instrument capability comes from a proper super-solid foundation of training to begin with .... (not taught to the absolute minimum standard required to pass a ride,) proper Line Indoctrination training & ability/suitability assessment, followed by operational mentoring after the rating, PPC and final Line Check is issued through "an apprenticeship" as an FO paired with a Captain interested and capable of developing the talent, then proper supervisory oversight, followed by currency .... sometimes wrapped up erroneously in the oversimplified words "experienced pilot."

To come up with a silly example of the concept I want to get across, we could take a WW2 Spitfire pilot aged 90+ and toss him into an F-18 and watch the poor devil kill himself off the end of the runway. There would be people saying ..... "But, I just don't understand it .... Bloggins was an experienced fighter pilot."

Without currency and maintaining proficiency, just holding the Instrument Rating on one's licence is simply not enough to be flying in conditions which requires the quick transition to instruments low to the ground.

[Cat Driver]

O.K. , single_swine_herder, your comments are valid and believe it or not I do grasp the concept.

However, the holder of an instrument rating who is flying any commercial aircraft with a current rating and current under the company ops manual for crew training should be able to transit from a visual lift off to the use of the instruments to maintain a climb on runway heading to a safe altitude before turning.

If it is two crew that " should " make it even more safe.

[single_swine_herder]

Cat .....

Your emphasis on "should" is highly appropriate.

The reality behind the "should" is that far too many so-called training programs are there to only reach the bare-bones minimum required for a semi-coerced ACP to sign off a pilot.

Then zero supervision, line checking, advanced training, or mentoring is done until next year when the absolute minimum number of hours is provided to the line pilot for training .... discounting that the training program requirements are not at all based on hours, it's based on required items being covered. The commonly misunderstood "The Ops Manual says I've gotta give 'ya 3 hours," is faulty.

Pretty hard under most properly delivered training for those items which are listed as "must be covered" and corrected to standard in the absolute minimum number of hours indicated in a typical small operator's COM.

This is especially so if the "program" consists of no briefing or aim of what is to be covered, no plan for what will be done in the air beyond ... "what do you want to practice? .... Oh, I don't know ... what do you want to do?" and then next to zero debrief.

[Cat Driver]

You and I are saying the same thing in a different way.

Lack of competence and lack of mental preparation before " Every application of take off power " is a systemic problem in many companies.

Bottom line is only you can fix this problem......for your flights.....

When I was flying I never considered my passengers safety, I only considered mine.....in my way of thinking if I arrived at the destination safe the passengers would be there with me.

[single_swine_herder]

One of the Beavers I used to fly had a button pinned to the headliner that said something to the effect of ..... "If the pilot's ass gets there safe, yours will too. Please don't talk to the pilot, he's busy."

[EA757]

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

[CFR]

...

When I was flying I never considered my passengers safety, I only considered mine.....in my way of thinking if I arrived at the destination safe the passengers would be there with me.

I have often thought that if ever I was in the situation like the Air Transat pilot with the fuel leak, at the news conference where they said "... and he saved 183 lives!" I would interrupt and say "actually I only saved one life, the rest came along for the ride"

[Doc]

...

When I was flying I never considered my passengers safety, I only considered mine.....in my way of thinking if I arrived at the destination safe the passengers would be there with me.

I have often thought that if ever I was in the situation like the Air Transat pilot with the fuel leak, at the news conference where they said "... and he saved 183 lives!" I would interrupt and say "actually I only saved one life, the rest came along for the ride"

Well said. I'm only really interested in MY ass as well.......well maybe I'm interested in SOME other asses, but this IS an aviation forum...

[ipilot54]

Pilot resignations hit ORNGE air ambulances
Pilot resignations have left ORNGE scrambling to fill vacancies and keep air ambulance helicopters flying in busy summer season.

ORNGE has been hit by a wave of resignations of senior pilots in the 18 months since it took over helicopter operations from Canadian Helicopters, with at least three announcing their departure last week alone.

ORNGE has been hit by a wave of resignations of senior pilots in the 18 months since it took over helicopter operations from Canadian Helicopters, with at least three announcing their departure last week alone.
By: Bruce Campion-Smith Parliament Hill, Published on Thu Jun 27 2013

OTTAWA—An exodus of helicopter pilots has left ORNGE scrambling to fill shifts, meaning air ambulance choppers could be unable to fly at times during the busy summer trauma season.

Dozens of flying slots are empty, forcing ORNGE’s central scheduling office to appeal for pilots to work overtime to fill shifts at bases in London, Toronto and Ottawa in the coming weeks.

According to one veteran pilot, the staffing shortfall is unprecedented and he predicted it will impact the agency’s ability to move patients.

“We will see a significant shortage of service in the coming months,” the pilot said.
Video


Related:

· ORNGE should get out of aviation operations, critics say

· ORNGE boss defends chopper safety

· ORNGE suspends night flights at remote sites across Ontario

ORNGE has been hit by a wave of resignations of senior pilots in the 18 months since it took over helicopter operations from Canadian Helicopters, with at least three announcing their departure last week alone.

A spokesperson for ORNGE said addressing pilot staffing has been an ongoing priority for the agency.

“These positions are highly specialized and recruitment can be time consuming when a pilot leaves the organization,” James MacDonald said in an email.

He said ORNGE makes “every effort” to fill shifts left vacant by sick leave or training.

The call for overtime work comes amid reports from frontline employees that bases across the province have been frequently out of service because of a shortage of pilots and medics, as well as maintenance needs.

London was out of service for an entire weekend earlier this month because there were no medics or pilots to staff the helicopter, insiders say.

Moosonee, home base to an ORNGE helicopter that crashed on May 31, killing two pilots and two medics, had been out of service for “long periods” on night shifts because of maintenance woes and staffing troubles, sources tell the Star.

The staffing shortages are driving home the emerging crisis at ORNGE as disgruntled pilots, unhappy about management and now openly airing safety concerns, are leaving for more lucrative flying jobs elsewhere.

“It is out of control and they can’t stop the exodus,” one pilot told the Star. “The entire operation is at risk.”

Veteran air ambulance pilots, including several working at ORNGE, spoke to the Star on the condition of anonymity for fear of reprisal.

Progressive Conservative MPP Frank Klees plans to put those concerns in the spotlight Thursday with a news conference to air the worries voiced by ORNGE employees.

“These are paramedics and pilots who tell me that they have serious concerns about accountability, about the safety issues, about training and very concerned about the exodus of their colleagues,” Klees told the Star.

“I believe the (health) minister must now step in and demand that an objective third party be brought in to assess the capacity of this organization to continue,” said Klees.

Klees says he is certain that any independent review will conclude that ORNGE’s aviation operations should be handed over to “an experienced company that understands the intricacies and technicalities.”

“This is no longer now a matter of efficiency . . . I’m much more concerned now about the safety of the patients and the frontline staff and the competence of that organization,” Klees said.

Health Minister Deb Matthews said Wednesday she awaits the outcome of the Transportation Safety Board’s probe of the May 31 crash. She pledged to take any recommendations “very seriously, as will ORNGE’s leadership.

“ORNGE continues to focus on enhancing the safety of their operations,” Matthews said in a statement to the Star. “It would be unfair to those affected by the tragedy to rush to premature conclusions on the outcome of that investigation.”

She said that “rigorous” audits of ORNGE by Transport Canada and the Ministry of Natural Resources have turned up “no major outstanding issues.”

In the meantime, she said that the agency is recruiting new employees.

“I know that ORNGE continually works to ensure that they have the staff they need, including helicopter pilots, to meet patient needs,” Matthews said.

MacDonald said the agency has been hiring to fill the pilot ranks.

“Despite a competitive international market for helicopter pilots, we have been successful in our recruitment efforts,” MacDonald said.

He said ORNGE has hired six new pilots who are now in training and should be ready by early July.

“ORNGE’s practice is to hire fully qualified pilots and then to provide several weeks of training before they begin to fly missions,” he said.

[ipilot54]

For Immediate Release
June 27, 2013

ONGOING LIBERAL COVER-UP AT ORNGE EXPOSED

QUEEN'S PARK - Newmarket-Aurora PC MPP Frank Klees will ask Information and Privacy Commissioner Ann Cavoukian to investigate the actions of the Minister of Health on suspicion that the destruction of emails practised in the Premier's office also occurred in the Ministry of Health.

"We are witnessing a cover-up of unprecedented proportions," said Klees. "The Liberals continue to hide documents that will shed light on the truth behind the scandal at Ornge, provide answers to taxpayers and help us ensure the provincial air ambulance system is fit for purpose."

MPP Klees was reacting to the findings of a Freedom of Information Request filed with the Minister of Health's office, for all correspondence related to Ornge at the height of the scandal. His request returned a mere 16 email messages.

"As the Liberals were engulfed in scandal and taxpayers learned the true cost of mismanagement and shell games at Ornge, I find it unbelievable that no more than 16 emails were exchanged on this topic," Klees continued. "So, I am left to conclude that the Liberals continue to hide records that reveal the true depth of this scandal."

At a Queen's Park press conference today, Klees also questioned why a Coroner's Report into patient deaths involving ORNGE patient transport that was originally promised to be made public by the end of 2012 has still not been made public.

"Given the recent tragic crash of an Ornge helicopter and the loss of four lives, I am calling on the Coroner to release that report immediately. There may have been valuable lessons to be learned from that report and yet, for some unknown reason it was withheld" said Klees.

Klees also criticized Health Minister Deb Matthews for saying she would do nothing until the Transportation Safety Board completes its investigation. "That could be months from now" said Klees."There are numerous safety concerns that have been brought to the attention of Ornge management that are being ignored, and once again the Minister is content to do nothing. That is unconscionable"

"Since the tragic crash in which two pilots and two flight paramedics lost their lives, three more helicopter pilots have left Ornge" Klees told the Queen's Park press conference. "One of those pilots was a training captain. When will the Minister and the management at Ornge recognize that immediate steps must be taken to protect the integrity of this essential service?"

The solution according to Klees is that Canadian Helicopters Limited, the company that provided aviation services without incident for 30 years in Ontario before the service was brought in-house by Chris Mazza, should immediately be brought in to shore up the aviation operations of Ornge. "Rather than protect the jobs of inexperienced people, the Minister should be protecting the lives of our front line pilots, paramedics and patients" said Klees.

-30-

For further information, contact:
Alan Sakach, (647) 522-0263
alan.sakach@ontariopc.net

MPP Frank Klees Speaking Notes 062713



LEGISLATIVE ASSEMBLY

FRANK KLEES, M.P.P.
Newmarket-Aurora Queen's Park Office:
Room 447 Ontario Legislature
Queen's Park
Toronto, ON M7A 1A8
Tel: 416-325-7316
E-mail: fklees@frank-klees.on.ca
Mailing Address
14845 Yonge St
Suite 201
Aurora, ON L4G 6H8
Tel: 905-750-0019
E-mail: fklees@frank-klees.on.ca

[Doc]

Health Minister Deb Matthews said Wednesday she awaits the outcome of the Transportation Safety Board’s probe of the May 31 crash. She pledged to take any recommendations “very seriously, as will ORNGE’s leadership.

.

One of my favourite lines in the Canadian aviation industry. Lets stick our heads up our asses for 18 to 36 months, waiting for the "official" word from these guys.

Lets get ORNGE out of the medevac business, and let the private sector do it properly. Perhaps it's time for the political hand wringing to cease, and the padlocks to go on the doors?

[single_swine_herder]

The removal of the profit motive from daily operations in this emergency medicine service of the healthcare program is important. Therefore, I'm not fully convinced that going to a private carrier would immediately cure all ills.

There is zero doubt a major influx of operational knowledge, attitude, leadership, and especially a totally revamped training and monitoring program is desperately needed, and finding the right team to bring those badly needed qualities into the public sector will be difficult. This is an aviation operation that needs to be dragged kicking and screaming, crying and begging into the 21st century state of the art.

What should come from this debacle is the commitment to grossly exceed the bare minimums of training and flight operations.

However, the old bugaboo of Ontario being more than broke comes into play here. Running an exemplary operation which meets public expectation in the wake of scandal after scandal requires lots of money, lots more money than has been spent on the daily operations to date because those monetary resources were squandered on frivolous and inappropriate things ... money Ontario doesn't have, and if spent would attract a huge amount of attention.

Doubtless, the operational staff at ORNGE are demoralized .... how could they not be? Being a conscientious person there must be pretty tough to maintain confidence in the system. The only gratification must come from playing a role in the actual saving of a person's life. Being a small gear in the clockwork of the healthcare system can be a highly gratifying part to play in society.

Giving them some hope that things are about to improve, and then see sufficient positive change so that deeds not words form their opinions is required. It took a long time for things to deteriorate to this horrendous level of competence, and it will take even longer to fix.

There really is absolutely no acceptable reason that ORNGE should be dysfunctional ... they have good facilities (at least the ones I've seen in S Ont,) have decent basic equipment to work with as a starting point compared to the equipment of private industry, are not pressured to make money and squeeze every possible dime out of operating a machine and managing personnel, have a good level of income plus benefits package and the "protection" of a large public sector union, shouldn't be expected to break the law in their daily operations, .... and the list of positives goes on.

HOWEVER ...... they appear to be bereft of leadership, modern IFR flight standards, and operational control. That is where the fix is needed.

So let's imagine ourselves in the unenviable position of taking on that initially thankless, complex job which is a political minefield where every step, statement, candid conversation with the wrong person, email and memo written could cost you your job because you offended somebody and gored their favourite ox.

Further, the media are all over this .... the first time you used the phone for a personal call, took the corporate car home, smoked a little crack with a Somalian dealer, or who knows what they could conjure up based upon people who hate you for their own potential gain .... you'd be on the front page..... and it would be personal...... highly personal.

Assuming you & I were perfectly qualified professionally to gain the confidence of the operational flight crews .... (and that would have to be one hell of a good resume) .... at first, many of the staff would welcome you under "The Saviour Syndrome." That's where they expect that you'll lead them to The Promised Land as if you were Dr. Martin Luther King following his famous "I Have A Dream" speech. They also have little to no understanding how long it will take to show marked improvement and their support will be fickle. http://youtu.be/V57lotnKGF8

There will be a small segment of the staff that will absolutely never ... ever .... never ... be satisfied with the outcome of any form of change and will be too trapped by various circumstances to leave ... they will be the dog in the manger types who will be poisonous in the workplace, fight any change to SOPs, training syllabus because it's too much work, fill the workplace with negative baseless gossip, and they should be fired ..... but nobody has the balls to dedicate the hundreds of hours it takes to encourage them to move along to "other opportunities" in life. This is especially true when getting the place to fly safely is the highest priority and dealing with the "Typhoid Marys" who wouldn't be happy regardless simply has to slip to a lower priority while they are trying to stab you in the guts for the entertainment of watching your intestines fall to the floor.

The third group will be the largest ....they fall into the "lets wait and see, but in the meantime, let's keep our mouths shut and heads down" group. Unfortunately they are too afraid, or disinterested, or beaten up to be of real help in the transformation and contains lots of "that's not my job" personality types.

So it's going to be one hell of a tough nut to crack, in an operation geographically spread over a large area where keeping everyone "in the loop" will be a huge part of the job in changing the culture and proficiency. Whomever takes over is well worth probably a 300 K per year salary because he or she will be burning up a lot of their future lifespan in this job .... it could well be a guaranteed MI job ... and it's one that needs a great deal of support from the Accountable Executive.

And ..... I don't envy the poor buggers that come into try and fix this place. I don't think immediately privatizing the service is the answer just yet.