Ornge Sikorsky Air ambulance accident Northern Ontario

[MUSKEG]

That is by far the most honest, non confrontational post I have ever seen on Avcanada. I think there will be few who are qualified for the job willing to stick their neck out that far. What a mess. He/She would need to start with some loud public firings.

[SeptRepair]

well said single_swine_herder

[Doc]

That old swine herder is a pretty articulate guy!

[Colonel Sanders]

I am suspicious - he's too smart to be a pilot

[Doc]

I am suspicious - he's too smart to be a pilot

That thought had crossed my mind as well.

Hey Swine Herder......say something really stupid for us!

[GyvAir]

I am suspicious - he's too smart to be a pilot

That thought had crossed my mind as well.Hey Swine Herder......say something really stupid for us!

I'm sure he's legit... he is also a farmer after all.

[single_swine_herder]

I am suspicious - he's too smart to be a pilot

That thought had crossed my mind as well.

Hey Swine Herder......say something really stupid for us!

Well Doc:

Saying something stupid is fairly easy ... but generally I'm quite guarded about putting things like that into writing, because once "out there," you have no idea where it will end up, or to what end the stupid saying will be used.

After some contemplation while working on the restoration of my mid-70's travel trailer restoration project, the stupid saying that kept coming to mind was ....

"You can always trust your boss to do your career planning for you."

[single_swine_herder]

I am suspicious - he's too smart to be a pilot

Wrong guess mon Colonel .... I actually did fly for a long time, and will again soon .... the last couple of years has seen me on a huge project which has taken every bit of my time and brain power, and I knew I didn't have enough time available to do active line flying justice. I would likely have flown as badly as most Base Commanders .... LOL

Early in my career that someone gave me the advice to not limit myself to just flying airplanes .... this is a very big business ... take it all in rather than just a small slice.

Another saying one of my cousins has which he claims was passed down from our grandfather .... "find something you like to do, and you'll never work a day in your life, nor will you ever be unemployed."

[EA757]

OTTAWA—Four months before a deadly helicopter crash, ORNGE was forced to suspend operations at several bases and pull pilots from flying duties after problems were found with the training and paperwork for every helicopter pilot on its roster, the Star has learned.

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

[grimey]

http://www.cbc.ca/news/canada/toronto/s ... eivew.html

Operational issues at Ontario's troubled air ambulance service contributed to the deaths of as many as eight patients transported by Ornge over a six-year period, the province's chief coroner said Monday.

They directly contributed to the deaths of two patients, probably had an effect on one case and possibly affected five others, according to a long-awaited report by a panel of experts.

It reviewed 40 cases, which were among several hundred from January 2006 to June 2012 that were screened, said Dr. Dan Cass, the province's interim chief coroner.

[2R]

Does anyone know if they checked the gyros of the remaining fleet ?

I have had a few gyro failures at night and it can be a few seconds before you can figure out what is really happening.
If you are lucky you might get a big gyro failure and a flag indicating an easy failure. If you are unlucky you might get a slow insidious failure that is not big enough to raise the gyro inop flag yet.
I have had comical gyro failures where the gyro spin around like a flight into the Bermuda triangle. Some gyro failure you can hear before they show themselves as the bearings can get NOISY and really LOUD indicating an imminent failure.
The worst gyro failures are the slow toppling type where the attitude indicators fails slowly and slowly topples leading the pilot into an unsafe attitude.
A turn on a toppling gyro is a challenge that would catch even a well rested current pilot.
The thing that tips or topples a wonky gyro can be as simple as the extra g loading on the gyro gimbles by entering a climb or a turn.

I do hope that the AME's look at the gyro's in the rest of the fleet as it may be the weak link that a smoking hole will not reveal. Even a hard taxi turn will give some indication as to the health of your gyros.

Part of the pre-flight instrument checks require the pilot of an aircraft to do some taxi turns to see how the gyros are behaving. If you do a hard turn sometimes a gyro that is not quite up to speed will indicate a change in attitude.
I have never seen a helicopter do hard taxi turns prior to flight to determine whether the flight will be done by control and performance reference to instrument flight or by primary and supporting instrument flight. Most helicopters taxi very gently while on the ground. Probably so they do not flip over. Hard braking can also give an indication of the health of the gyros.
And of course the rapid acceleration during the take off roll can induce a g loading on the gyros giving you a gyro failure on rotation. The few seconds it takes to realize what the real attitude is might be all the time you have. Most of the attitude indicator failures I have had usually give some abnormal taxing indication ,so you can be ready for a partial panel flight. Or gives maintenance a chance to change it out before it fails.

Just my WAG,I got out of a Bell helicopter in the Brent field years ago and it went flying a few hours later and flew right into the black North Sea. I have always wondered what happened to one of the nicest helicopter pilots we knew and our medic went down. Flying off helipads/helidecks does not allow pilots to check the health of their gyros before flight by reference to those instruments.

[The Mole]

Does anyone know if they checked the gyros of the remaining fleet ?



Part of the pre-flight instrument checks require the pilot of an aircraft to do some taxi turns to see how the gyros are behaving. If you do a hard turn sometimes a gyro that is not quite up to speed will indicate a change in attitude.
I have never seen a helicopter do hard taxi turns prior to flight to determine whether the flight will be done by control and performance reference to instrument flight or by primary and supporting instrument flight. Most helicopters taxi very gently while on the ground. Probably so they do not flip over. Hard braking can also give an indication of the health of the gyros.
And of course the rapid acceleration during the take off roll can induce a g loading on the gyros giving you a gyro failure on rotation. The few seconds it takes to realize what the real attitude is might be all the time you have. Most of the attitude indicator failures I have had usually give some abnormal taxing indication ,so you can be ready for a partial panel flight. Or gives maintenance a chance to change it out before it fails.

J

There are procedure for checking Gyros in a hover. But not all situation would allow for it to be safely done.

[single_swine_herder]

OTTAWA—Four months before a deadly helicopter crash, ORNGE was forced to suspend operations at several bases and pull pilots from flying duties after problems were found with the training and paperwork for every helicopter pilot on its roster, the Star has learned.

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

If I had $55 for each time a person struggled to cover up a gross inadequacy in the operation by quickly downplaying a poor quality training program as being "just a record keeping problem," I could have retired earlier in my career of diagnosing and curing these type of aviation ailments.

"The problem" in this operation is actually very widespread in the industry. Even the wonderful folks at the renowned "Buffalo Airways" had this issue come forward in considerable detail in an episode of "Ice Pilots" by making the error of believing training is measured in flight hours rather than content of material to be covered.

The required items are clearly spelled out and described in the CAR and CASS 703, and anyone who can take 10 minutes to do the reading should have the light bulb go on in microseconds when the word "shall" comes into the picture. After all, the person who carried the responsibility for training a large staff on the operation of a fleet of multi-million dollar IFR helicopters should be capable of reading what the absolute minimum requirements are, and designing a program which exceeds those minimums.

Whaddya bet that the sim program they get is an "out of the box" type training package sold by one of the sim program sellers? If so .... wait for it .... it is highly unlikely the program contains the items required of a 703 IFR operation.

Place your bets, and watch this thread for more information to come forward.

There is simply absolutely no excuse which can make this situation acceptable in a non-profit motivated operation which cannot even come close to crossing the threshold of being regulatory compliant..... let alone setting a professional example of how it should be done which should be the case in the service of the people of Ontario.

[ipilot54]

ORNGE considers night-vision goggles for its aircraft
Two nighttime crashes prompt a second look at goggles that help pilots see their surroundings and avoid disorientation in deep darkness.

OTTAWA—Helicopter pilots flying to nighttime medical emergencies in Ontario may get some high-tech help to see through the inky darkness.

In the wake of two night crashes — including a fatal accident on May 31— ORNGE says it is now considering equipping its helicopters with night-vision goggles.

The sophisticated gear gives pilots a better view of their surroundings in darkness, to aid in takeoffs and landings and watch for hazards.

“It’s absolutely on the table,” said Dr. Andrew McCallum, president and CEO of ORNGE, the province’s medical transport service, which operates both fixed-wing aircraft and helicopters to move patients around Ontario.
Photos View gallery

Two nighttime crashes of ORNGE air ambulances are prompting consideration of equipping pilots and retrofitting aircraft to use night-vision goggles, which help pilots see their surroundings at night and avoid the disorientation that can occur in deep darkness. zoom

“I’m looking at it with a positive disposition ... I want to make certain we make a good choice,” he told the Star in an interview.

Questions about the safety of night operations—and the possible advantages of night-vision goggles — were raised by the midnight crash of an ORNGE helicopter in Moosonee on May 31 that killed two pilots and two paramedics.

Investigators have so far ruled out mechanical failure as a cause of the crash. One possibility is “controlled flight into terrain,” a situation in which pilots inadvertently fly into the ground, usually in conditions of poor visibility or darkness.

That was determined to be the cause of an earlier air ambulance accident in 2008, when a Sikorsky S-76A hit trees during a landing at a helipad in Temagami. Three of the four crew on board were seriously injured.

That accident should have been the catalyst for the agency to introduce night vision equipment in its helicopter fleet, one former air ambulance pilot told the Star.

“I believe that if the pilots had been using (night vision goggles) that they would have been able to see that they were low on the approach path and been able to correct for it, preventing the accident,” the pilot said.

He worried that it was “only a matter of time” before ORNGE suffered an accident.

“It only makes sense that if pilots can see something they will not fly into it,” he said. “Now that (night vision goggles) are commonly available, there is no good reason for them to not be used by ORNGE.”

McCallum, who joined ORNGE in January, agrees that the 2008 crash should have prompted consideration of night-vision goggles.

“It’s not helpful to revisit the events of years back, but this is a consideration that is coming now — but it could have been considered five years ago,” he said.

McCallum says the service will be looking at the experience of other Canadian operators, such as STARS, an air ambulance agency serving Western Canada.

“We’ve got people in the industry who use them now in Canada ... we’re going to leverage those types of contacts and make the best decision we can,” he said.

If ORNGE decides to go with night-vision goggles, it won’t be a quick or easy transition. For starters, the pilots would have to be trained and get experience flying with them.

The task would also require a costly retrofit of its helicopters, since ORNGE did not require its newly purchased fleet of Agusta-Westland AW139 aircraft to be compatible with night-vision goggles.

But the experience of other air ambulance operators suggests the technology is worth considering.

“Night-vision goggles increase safety, and it does that by dramatically increasing the pilots’ ability see in the dark. It allows greater access to patients,” STARS spokesperson Cam Heke said.

He said all its pilots are trained and certified to use the goggles, and all its helicopters have been equipped with the technology since 2003.

“It’s part of how STARS operates,” he said.

The agency has bases in Alberta, Saskatchewan and Manitoba, but Heke said the technology has proved especially valuable on night flights from Calgary and Edmonton, responding to calls in the mountains.

“It’s very useful in difficult terrain in the mountain areas,” he said.

Night-vision goggles are a “huge safety multiplier,” said Ken Lawson-Williams, a Canadian who works as a flight nurse on fixed-wing aircraft and helicopters with a company that flies across the U.S. Southwest.

“It’s a cliché, but it’s literally a night and day difference ... It’s just amazing,” he told the Star in an interview.

He said the true value of the goggles is that they allow pilots to keep their “situational awareness” and avoid becoming disoriented, which can happen when visual clues disappear in the darkness.

The goggles have their shortcomings. They narrow a pilot’s field of vision. Rain on the windscreen can distort the view, and clouds remain impenetrable to view.

“So it’s not the perfect answer for everything. But it does make a huge difference on a clear, no-moon, dark-environment night,” said Lawson-Williams, who worked as a flight paramedic in the Canadian north and Alberta before moving to the United States.

[Doc]

OR.....Now this would really a novel idea......WAIT TILL DAYLIGHT.....for ALL but REAL emergencies! Gee, now there's a potentially life saving idea.

[Tuk U]

comments like "wait til daylight" are nonsense... it's the same logic as nobody moves nobody gets hurt, or after you're done taking a leak just leave it out cause you're likely gonna have to go later anyways

I get the whole urgency thing, but what are you now all medical experts?..if you're a pilot and you are trained and you have the wherewithal to evaluate the go no go decisions which has got you to the multi thousands of hours you've got, then either go and do the job or say NO. What some of you are suggesting is that, in all your wisdom you will assess the medical needs of the patient and if it meets your criteria then you'll arc off into the ink black night...Then you'll have decided that you can now find the nearest phone booth and change costumes and go off over whatever, wherever in any weather at any time of the day or night. Then it's okay??? I suggest that it is better we don't know the anything at all about the patient, we just do what we are trained to do and decide period...if that gets you fired...well you were probably looking for a job when you found that one.

I recall the days in the 70's and early 80's in Tuk when the pilots of yesterday to name a few... Dev Anderson, Sandy Donaldson, Maurice Foss, Dan Riopel, Jerry Cutler, Jim Neill, Keith Bennett, Greg Neilly, and so many more would fly round the clock in all weather year round, they would be laughing and having a great time flying crews to the rigs or hook up to a 100 foot line and take a set of tools in the middle of the night to a rig that was down, 212's, 61's 76's with not much more than a NDB, well we did have a VOR there for a while, many of you probably don't have first hand knowledge of Tuk in December at 15:00 -40 black as ink, but for years...many years they just kept doing what they knew... and no they didn't have NVG's but they were trained and they knew how much of a bite to take....they didn't say wait a minute did the drill foreman check the foofoo valve first on the the round and round thing by the kitchen?

So shut the hell up about with your nonsense about the poor guys didn't have this or that or is the guy actually sick, man up and own the facts, the ultimate decision always lies with the guy at the wheel. They are dead because they either screwed up or unless the machine just blew up right after take off then they had no chance... but unless that happened they had every chance to have a successful flight, so you bleeding sensitive hearts who read this and are offended...go be a walmart greeter, doc is the foreman and the bonus if you get to work with him is he'll tell how great and smart he is and how he did everything first...his opening line is There I was at 10,000 feet in a flat spin, nothing on the clocks but the makers name.... ENJOY

[Sidebar]

What some of you are suggesting is that, in all your wisdom you will assess the medical needs of the patient and if it meets your criteria then you'll arc off into the ink black night...

I am not in this camp. What I suggest is that the medical people make the first decision based on medical factors. Is it necessary for the patient to be transported immediately, or can the move be deferred for a few hours? As many posts here have stated, not all patients are in need of immediate transport.

Once the decision to transport has been made, then the PIC gets to make the go/no-go decision based on aviation factors.

[midwingcrisis]

I remember my 1st Tuk U sweatshirt...bought it in '78. I also remember the fresh daisys flown in everyday for the potato salad at Canmar. No whimpy crybabies were babysat as far as I can recall.

[Cat Driver]

Several times I have asked this question.

What happened to the patient that was so critical they had to evacuate him/her at midnight.

We know the air ambulance crew of four died on that flight.

What happened to the dying patient when the helicopter never showed up?

[Tuk U]

Several times I have asked this question.

What happened to the patient that was so critical they had to evacuate him/her at midnight.

We know the air ambulance crew of four died on that flight.

What happened to the dying patient when the helicopter never showed up?

It's really a moot point, and no ones business what happened to the patient... you've got a dispatch... medivac, as a pilot, ours is not to reason why, just deal with it, am I going? do I feel good about this? am I capable? you know all that stuff you get TRAINED for as you climb the ladder and get to be a captain of such a ship...

[Cat Driver]

It's really a moot point, and no ones business what happened to the patient... you've got a dispatch... medivac, as a pilot, ours is not to reason why, just deal with it, am I going? do I feel good about this? am I capable? you know all that stuff you get TRAINED for as you climb the ladder and get to be a captain of such a ship...

Really? Pilots should not be concerned with missuse of the medivac system because they are highly trained and know when to fly and when not to.

Bullshit.

Missuse of the system was common when I flew medivacs forty five or more years ago and it seems not much has changed.

[Tuk U]

/quote]

Really? Pilots should not be concerned with missuse of the medivac system because they are highly trained and know when to fly and when not to.

Bullshit.

Missuse of the system was common when I flew medivacs forty five or more years ago and it seems not much has changed.[/quote]

Ya really...makes no difference what the purpose of the flight is, the aircraft is capable, the crew should be as well, if it's flying a light bulb or a medivac makes no difference...your JOB is to FLY the effing thing not micro manage the rest of the people in the chain...

Think about it!! come on man... The only issue I need to concern myself with as a PIC is my flight that's what I'm trained to do, yes I better know when to fly and when not to fly... period.

Oh and by the way a lot has changed in 45 years... I know this for a fact because I've witnessed it... I understand that you want to "defend" this tragic accident...good on you... it is a very noble thing for a guy to do, but we mustn't forget that many youngsters are reading this and what they need to know is that the buck stops with them and the options available to them are but one...stay alive, keep it simple don't confuse your responsibilities with things you've got not business needing to worry about... like Hmmm I think the health people are misusing me tonight on purpose so I'm not going or some such bullcrap... just assess your ability to do the flight safely and if it doesn't feel good don't go... no one will fault you for that, and at least you'll be alive to do it when the conditions are within your abilities.

[Doc]

Tuk U, I've done the "odd" medevac in my day. I'd be willing to wager, as many as you. All hours. All weather. I absolutely KNOW flying in the middle of the night is inherently more hazardous than daylight flight. I guess our dicks become shorter as we age, but I don't see the point of the added risk (and if you think there is NO added risk, you left your common sense in TUK) of unnessecary midnight flights. I'm curious, as is CAT, what happened to the dying patient when the helicopter failed to arrive? I can pretty much GUARANTEE the four that died on board would still be with us if they'd departed at dawn's early light. Four dead vs., a nice safe flight. I pretty much rest my case.

[Tuk U]

please.... Doc keep your personal SHORTCOMINGS out of this

[Sidebar]

I absolutely KNOW flying in the middle of the night is inherently more hazardous than daylight flight.

Agreed.