The Transportation Safety Board has issued 14 recommendations following the release of its long awaited report on Wednesday about the investigation into an Ornge air ambulance crash that killed four people in northern Ontario. 

They address safety deficiencies in regulatory oversight, aircraft equipment, and flight rules and pilot readiness.

The Ornge Sikorsky S-76A helicopter went down shortly after taking off from the Moosonee airport on May 31, 2013 during a night flight to pick up a patient in Attawapiskat, Ont.

Pilots Capt. Don Filliter, First Officer Jacques Dupuy, and flight paramedics Dustin Dagenais and Chris Snowball died in the crash.

Transportation Safety Board

Investigators with the Transportation Safety Board laid 14 recommendations following the release of its highly anticipated report about the investigation into the 2013 Ornge helicopter crash, but none were specifically issued for the Ontario air ambulance service. (Mike Crawley/CBC)

Transportation Safety Board (TSB) investigators said what occurred that night went far beyond the crew's control. 

Their report found the crew was inadequately prepared for the flight. 

"This is really what we would call a sub-optimal pairing of two pilots who weren't ready," TSB chair Kathy Fox said.

Executive Summary - ORNGE report

(Transportation Safety Board of Canada)

Transport Canada needs to 'intervene sooner and more strongly'

Compounding the issue, the report goes on to point the finger at Transport Canada for being aware of Ornge's struggles to comply with regulations and company requirements. 

It states the training and guidance provided to Transport Canada inspectors led to "inconsistent and ineffective surveillance."

"When Transport Canada has clear indications that a company is not able to comply with regulations or comply with its own internal policies, they need to intervene sooner and more strongly," Fox said.

Transport Minister Marc Garneau expressed his condolences to the families and friends of the four people who died in the crash. He said he will look at the TSB's recommendations. 

"I'm still new in the ministry so I want to go over the facts and I want to see what the TSB has to say about it," Garneau said. "Security is a priority for us and we will act accordingly."

Garneau says Transport Canada has 90 days to act on the TSB's recommendations. 

This was one of the longest air investigations in the TSB's history. 

Some of the recommendations from the report include:

  • The Department of Transport require all commercial aviation operations in Canada to implement and conduct regular assessments of a formal safety management system.
  • 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.
  • The Department of Transport amend regulations to clearly define visual references, such as lighting considerations, required to reduce the risks associated with night visual flight rules flight.
  • 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.
  • The Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.

A full list of the recommendations can be found here

No specific recommendations made to Ornge 

Ornge has taken a number of safety actions following the crash, so the board did not feel the need to make particular recommendations to Ornge, according to Fox.

She said it is not TSB's job to assign blame.

"We deeply regret the loss of our dear colleagues who died in service to the Ontario public, and our thoughts remain with their family members," Ornge president and CEO Dr. Andrew McCallum said in a statement.

"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."

Ornge has introduced a proficiency flying program following the crash, requiring pilots to conduct certain exercises.

It has retired the Sikorsky S76A model helicopter and replaced it with the modern AW139 helicopter. 

It is also in the process of introducing night vision goggles in its helicopter fleet.

hi-moosonee-crash-tsb-852

The Sikorsky S-76A helicopter crashed just one kilometre after taking off from a base in Moosonee, Ont., on May 31, 2013. (Transportation Safety Board of Canada)

Ornge faces 17 charges in separate investigation

The Federal Ministry of Labour laid 17 charges against Ornge in a separate investigation into the incident on May 30, 2014, exactly one day before the one-year anniversary of the crash. 

A court document obtained by CBC News revealed that many of the charges related directly to sections of the Canada Labour Code that govern pilots with little experience operating aircraft together.

The document alleges that the Ontario air ambulance service permitted the pilots to fly an S-76A helicopter "without adequate training in the operation of that specific aircraft," failed to provide the pilots with "a means to enable them to maintain visual reference while operating at night," and that Capt. Filliter had "insufficient experience in night operations."

Ornge has retained counsel and intends to defend these charges. A representative for the company said it would be inappropriate to comment further.

In November 2013, investigators from Transport Canada also handed down seven directions to Ornge following its investigation into the crash.

Federal investigators said Ornge failed to adequately educate its pilots on the health and safety hazards associated with northern operations, among other problems.

With files from the CBC's Mike Crawley and Casey Stranges.