Backgrounder: A13H0001-20160615A

Recommendations arising from Investigation A13H0001 (Moosonee)

The Transportation Safety Board of Canada (TSB) is issuing 14 recommendations as a result of its investigation into the May 2013 fatal crash of an Ornge Sikorsky S-76A helicopter in Moosonee, Ontario.

The recommendations are being issued to address safety deficiencies in:

• Regulatory oversight
• Flight rules and pilot readiness
• Aircraft equipment

Regulatory oversight

Transport Canada (TC) began phasing in the requirements for safety management systems (SMS) in commercial aviation in 2005. To date, only the largest operators require SMS, while 90% of Canadian commercial air operators do not require SMS, though a number have been voluntarily implementing it in varying degrees. Even with SMS requirements, companies vary in their commitment and abilities to implement an SMS effectively.

The regulator must be able to vary the type, frequency and scope of oversight activities to ensure companies are willing and able to manage risk effectively, and take appropriate enforcement action when necessary. In this occurrence, the Board found a company that was willing to address safety issues in its operation, but did not have the capacity to effectively do so. TC's approach to returning the operator to compliance was not matched by the operator's capabilities.

The Board therefore is making three recommendations regarding commercial aviation oversight:

Flight rules and pilot readiness

Night visual flight rules (VFR) regulations

The visual references required for safe night VFR flight are ill-defined. Many pilots believe that it is acceptable to fly at night as long as the reported weather conditions are acceptable, regardless of lighting conditions.

Many night VFR flights safely take place over well-lit, populated areas. However, in remote areas, very little ambient or cultural lighting exists to help pilots maintain visual reference to the ground. Because the regulations don’t define ambient or cultural lighting requirements or an alternate means of meeting the night VFR requirements, it is very likely that accidents such as this one will continue to occur.

Therefore, the Board recommends that

Instrument flight currency requirements

Instrument flying is a perishable skill requiring frequent practice to maintain proficiency. However, instrument-rated pilots can go 12 months after the instrument flight test before being required to do any instrument flying. After that, they must conduct 6 hours of instrument flying and 6 instrument approaches every 6 months.

These currency requirements are not sufficient to ensure that instrument-rated pilots are proficient enough to fly safely in challenging instrument flying conditions. The Board is thus recommending that

Pilot proficiency check (PPC) standards

There is currently no requirement for captains to demonstrate a higher degree of proficiency commensurate with their increased responsibilities. In this occurrence, Ornge Rotor-Wing was aware that the captain had encountered problems during the PPC and it was recommended that he fly as first officer to gain experience in the air ambulance environment. However, the company chose to employ the captain as a pilot-in-command without any additional training or supervision.

As seen in this occurrence, there is a risk that pilots will continue to be assigned to captain duties without having first demonstrated a degree of proficiency, commensurate with the responsibilities of the captain of a multi-crew aircraft. Therefore, the Board recommends that:

Aircraft equipment

Terrain awareness and warning systems (TAWS)

The helicopter in this accident did not have TAWS. Without TAWS, aircraft are at significantly greater risk of controlled flight into terrain (CFIT) accidents, such as this one. The TSB has investigated numerous helicopter occurrences that took place at night or in instrument flying conditions where TAWS might have prevented an accident.

Most commercial and some privately-operated fixed-wing aircraft are required to have TAWS, but commercial helicopters are not. Consequently, the regulations do not provide an equivalent level of safety between fixed-wing and rotary-wing aircraft. Therefore, the Board recommends that

Emergency locator transmitter (ELT) crashworthiness and performance

No signal was received from the occurrence helicopter’s ELT. As a result, the Search and Rescue (SAR) crew did not have a precise location of the crash site. While the ELT was not a factor in the accident outcome, the investigation highlighted several factors as to risk related to ELTs.

Canada has no requirement for aircraft to have an ELT capable of transmitting a distress signal at 406 MHz, the frequency monitored by search-and-rescue satellites, as required by International Civil Aviation Organization (ICAO) standards. If regulations are not amended, it is highly likely that non-406 MHz ELTs will continue to be used on Canadian-registered aircraft, thus exposing people to life-threatening delays in SAR services. Therefore, the Board is recommending that

The ELT aboard the occurrence helicopter activated as a result of the crash; however, no signal was received due to a broken antenna. The current design standards are robust for the ELT unit, but significantly less so for the entire ELT system, including such components such as external wiring and the antenna. The TSB has investigated 20 other occurrences where ELTs have been rendered inoperable due to damage sustained during the crash sequence.

Therefore, the Board recommends to ICAO, the Radio Technical Commission for Aeronautics, the European Organization for Civil Aviation Equipment and TC that they

The 406 MHz ELTs are required to have a minimum delay of 50 seconds from the time of activation to the first transmission of a distress signal. As such, people may be at increased risk of injury or death following an occurrence in case an ELT is rendered inoperable during the first transmission delay period.

Therefore, the Board recommends that

There is a documented history of the ELT type used in the occurrence helicopter coming free from the hook-and-loop fastener intended to secure it. While hook-and-loop fasteners are no longer acceptable in new installations, this requirement is not applicable to previously installed ELTs. Therefore, the Board recommends that