ORNGE safety officer — months before May’s deadly Moosonee helicopter crash air ambulance — warned about combining night flights and inexperienced pilots.
OTTAWA—Months before May’s deadly crash of an ORNGE air ambulance helicopter in Moosonee, a safety officer at the northern Ontario base warned the combination of “green” pilots and night flights was putting safety at risk.
And he warned that the “holes in the Swiss cheese are beginning to line up,” a prophetic warning of the accident to come.
That memo is one of several obtained by the Star that flag concerns in the organization in the run-up to the May 31 accident that killed two pilots and two flight paramedics.
In one note to ORNGE, an inspector with Transport Canada raised questions about “black hole” operations — one scenario that may lie at the heart of the crash now being probed by the Transportation Safety Board of Canada.
In the weeks after the accident, veteran pilots at ORNGE as well as in the industry voiced concerns about “green-on-green” — the pairing of two pilots relatively inexperienced in their positions.
Now documents obtained by the Star under the province’s Freedom of Information Act reveal that some of those same concerns were being aired within the organization prior to the crash.
In his Sept. 11, 2012 note, Malcolm Macleod, the base safety officer in Moosonee, near James Bay, noted that two new hires at the base were scheduled to start immediately on night shifts.
Such flights are challenging in remote areas because the lack of lights on the ground can create a disorienting darkness.
Macleod pointed to a previous occasion when two pilots were brought in from Thunder Bay for flying assignments though neither had previously flown at Moosonee.
“This seems to me to be a real safety concern,” Macleod wrote to ORNGE’s safety manager and its director of flight operations.
“I feel that safety is being jeopardized in an effort to make sure the slots are filled,” he wrote. “What happened to the green-on-green policy, gentlemen the holes in the Swiss cheese are beginning to line up.”
In an interview with the Star, another experienced helicopter pilot explained the “Swiss cheese” analogy.
“When all the problems line up, the holes in the cheese line up,” said the pilot, who spoke on the condition of anonymity.
“There’s supposed to be training, standard operating procedures and management oversight and aircraft redundancies. All those things are supposed to block those holes in the cheese,” he said. “When they aren’t there, you go right through and end up at a crash site.”
In his reply to Macleod, Peter Cunnington, the director of flight operations and interim chief pilot (rotor wing), said the new pilots were cleared for operations.
“I can assure you that all of our new hires have met all of the requirements … to be qualified for the operation,” he wrote.
Dr. Andrew McCallum, president and CEO of ORNGE, told the Star Friday that concerns voiced by Macleod and others did prompt the agency to put in place formal procedures in the fall of 2012 to ensure that two “green” pilots weren’t paired together.
“The pilots were concerned and the company responded,” McCallum said.
In a December, 2012, exchange, Transport Canada inspector Ken Walsh asks about ORNGE’s policy for avoiding green-on-green pair-ups. And he also asks about so-called “black hole” procedures.
“Black hole” operations refers to flights in remote areas where the combination of night sky and lack of ground lights leaves pilots with few visual references.
“How does the company mitigate the risk of a captain (new to the area) being called to a Black Hole for the first time at night without having seen the site during the daylight,” Walsh writes in a Dec. 17, 2012 note to ORNGE.
ORNGE’s response to Walsh detailed the directive meant to prevent new first officers from flying with new captains. “ORNGE is committed to providing experienced crews on all flights,” the directive said.
It also said that pilots are given training at bases once initial training is completed.
The captain on the flight that crashed was Don Filliter, a veteran helicopter pilot who had flown air ambulance part-time but had been away for just over two years. He resumed flying part-time for ORNGE in March in addition to flying duties at the Ministry of Natural Resources. Jacques Dupuy, the first officer, joined ORNGE in August, 2012.
ORNGE has said both pilots were qualified though other pilots have questioned the decision to pair the two for a challenging night flight.
Yet McCallum said that both pilots had thousands of hours in their logbook and that Filliter, in particular, had six years experience operating from Moosonee during his earlier stint with ORNGE.
“He certainly would have known the environment and the terrain,” said McCallum, who joined ORNGE in January,
“All of our pilots are highly experienced so it’s really a matter of local familiarity, which I would say those gentlemen did have,” he said.
Another ORNGE pilot also used the Swiss cheese analogy as he warned managers about outdated equipment on the Sikorsky S-76A fleet. The email, obtained by the Star, was directed to ORNGE but also copied to pilots at northern Ontario bases.
In a June, 2012 email, he noted that the Sikorsky helicopter that would eventually crash lacked both a Garmin GPS system to aid in navigation and an autopilot to reduce pilot workload.
“Did the pilots ever get asked what would be the safest option? No, again we were not consulted,” the pilot wrote.
“Yet it is our asses that are tasked to fly off into the Black Abyss of NW Ont. to perform approaches to unlit cone sites. The most dangerous flight regime in all of (emergency medical services). And you wonder why we are frustrated and quitting,” he wrote.
McCallum said that ORNGE is looking at getting new equipment for northern Ontario bases now using the Sikorsky helicopters.
“Those are 30-year-old airplanes. They’re safe … but we want to use airplanes are closer to current,’ McCallum said.
“That is an issue for me. I want them to have appropriate equipment in the environment they are working in.”