Blog Post #1389 – Report Fingers Lack of Training, Oversight

Report from the OH&S Canada magazine (July 2016)

Report Written by Jeff Cottrill – Editor

A report from the Transportation Safety Board of Canada (TSB) attributes responsibility for a helicopter crash that killed four people aboard in Moosonee, Ontario three years ago to air-ambulance company Ornge Rotor-Wing and Transport Canada.

It its report published on June 15, 2016, the TSB concludes that the company failed to provide adequate training, equipment and resources to the flight crew onboard the Sikorsky S-76A chopper, which was heading to Attawapiskat, Ontario on May 31, 2013. Shortly after takeoff from the Moosonee Airport, the first officer attempted a left-hand turn at about 90m above the ground, but the helicopter angle of bank increased, sending the vehicle into sudden descent. The aircraft hit the ground 23 seconds later, killing the captain, the first officer and two paramedics.

The TSB subsequent investigation revealed that Ornge had not sufficiently trained the crew to fly a helicopter in the conditions present that night. The company did not have dedicated night-flight standard operating procedures necessary to deal with hazards of total darkness, and the crew was working under ineffective nighttime visual-flight rules regulations that did not clearly define how to maintain a visual reference to the ground.

“This accident goes beyond the actions of a single flight crew,” TSB chair Kathy Fox says in a statement. “Transport Canada (TC) inspections identified numerous concerns about the operator, but its oversight approach did not bring Ornge RW back into compliance in a timely manner.”

The TSB issued a total of 14 recommendations in the areas of regulatory oversight, aircraft equipment and flight rules and pilot readiness to address all of the aviation risks identified in this investigation.

“Both Ornge RW and TC have taken significant action since this accident, but there are still a number of gaps,” Fox notes. “Our recommendations will help ensure that the right equipment is on board, that pilots are suitably prepared and that operators will face… a firm hand from the regulator that knows exactly when enough is enough.”

In response to the TSB report, Ornge president and chief executive officer, Dr. Andrew McCallum, says in a statement that immediately following the incident, the company initiated a full review of its safety processes, procedures and technology and took steps to minimize risks. “We will continue to honour the memory of the Moosonee crew with an unwavering commitment to protecting the safety of our patients, paramedics and pilots,” Dr. McCallum says.

My opinion

It seems that the lack of training is a common answer to so many accidents. It does not seem to matter which workplace sector we write about; the answer is still “Lack of Training.”

It is sad that changes only happen after people die on the job. Being pro-active is the key. Due Diligence is the standard of the day.

HRS Group Inc. has a great team that can help you with all your health and safety needs including ‘Due Diligence’ and ‘Safe Operating Procedures’. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259.

We can also be reached at 

Ensure your workplace is a safe place.

Remember – In Ontario, “ALL Accidents are Preventable”

‘Work’ and ‘Play’ safe.

Daniel L. Beal

CHSEP – Advanced Level
VP & Senior Trainer
HRS Group Inc.





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