Air transportation safety investigation A13H0001

This investigation was completed 15 June 2016.

Table of contents

Controlled flight into terrain

7506406 Canada Inc.
Sikorsky S-76A (helicopter) C-GIMY
Moosonee, Ontario

View final report

The occurrence

On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2 pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter’s satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter. At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors.


Safety communications

2016-06-15

TSB Recommendation A16-01: The Board recommends that the Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406 MHz ELT in accordance with International Civil Aviation Organization Standards.

2016-06-15

TSB Recommendation A16-02: The Board recommends that the International Civil Aviation Organization establish rigorous emergency locator transmitter (ELT) system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-03: The Board recommends that the Radio Technical Commission for Aeronautics establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-04: The Board recommends that the European Organisation for Civil Aviation Equipment establish rigorous emergency locator transmitter (ELT) system crash survivability specifications that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-05: The Board recommends that the Department of Transport establish rigorous emergency locator transmitter (ELT) system crash survivability requirements that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.

2016-06-15

TSB Recommendation A16-06: The Board recommends that Cospas-Sarsat amend the 406-megahertz emergency locator transmitter first-burst delay specifications to the lowest possible timeframe to increase the likelihood that a distress signal will be transmitted and received by search-and-rescue agencies following an occurrence.

2016-06-15

TSB Recommendation A16-07: The Board recommends that the Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe.

2016-06-15

TSB Recommendation A16-08: The Board recommends that the Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night visual flight rules flight.

2016-06-15

TSB Recommendation A16-09: The Board recommends that the Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument-rated pilots, who may operate in conditions requiring instrument proficiency.

2016-06-15

TSB Recommendation A16-10: The Board recommends that the Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.

2016-06-15

TSB Recommendation A16-11: The Board recommends that the Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command.

2016-06-15

TSB Recommendation A16-12: The Board recommends that the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.

2016-06-15

TSB Recommendation A16-13: The Board recommends that the Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.

2016-06-15

TSB Recommendation A16-14: The Board recommends that the Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.

All aviation recommendations


Media materials

News release

2016-06-15

Organizational, regulatory, and oversight deficiencies led to fatal May 2013 Ornge helicopter crash in Moosonee, Ontario
Read the news release

Backgrounders

Speeches

2016-06-15

News conference for the release of Aviation Investigation Report A13H0001 (Moosonee)
Opening remarks
Kathy Fox, TSB Chair
Daryl Collins, TSB Investigator-in-Charge

Deployment notice

2013-05-31

Transportation Safety Board of Canada deploys a team of investigators to an air accident in Moosonee, Ontario

Richmond Hill, Ontario, 31 May 2013 - The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the site of an air accident in Moosonee, Ontario. The TSB will gather information and assess the occurrence.


Investigation information

Map showing the location of the occurrence


Investigator-in-charge

Photo of Daryl Collins

Daryl Collins joined the TSB in 2009 after a 20 year career with the Canadian Armed Forces, having flown as a search and rescue helicopter pilot on the CH146 Griffon, the CH113 Labrador, and the CH149 Cormorant helicopter. In his last position with the Canadian Forces, Mr. Collins was the Commanding Officer of 103 Search and Rescue Squadron based out of Gander, Newfoundland and Labrador.

During his time with the Canadian Forces, Mr. Collins was responsible for the development and implementation of Canadian Forces-wide human performance training for all aircrew, maintenance, and air traffic control personnel and was heavily involved in flight safety. In addition, he obtained a Masters of Aeronautical Science with a dual specialization in Human Factors and System Safety.

Since joining the TSB, Mr. Collins has been actively involved in numerous accident investigations.

Mr. Collins holds an Airline Transport Licence – Helicopter with over 3200 hours of flying experience.


Photos

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Class of investigation

This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

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