Ornge didn't protect health, safety of pilots: federal investigators

Health Minister Deb Matthews insists Ontario's troubled air ambulance service is taking steps to fix safety problems following a deadly crash in the province's north.
The Transportation Safety Board released this picture of the Ornge helicopter crash site near Moosonee. (Transportation Safety Board of Canada)

Health Minister Deb Matthews insists Ontario's troubled air ambulance service is taking steps to fix safety problems following a deadly crash in the province's north.

Scandal-plagued Ornge suffered another blow after federal investigators said it failed to protect the health and safety of its helicopter pilots.

Two paramedics and two pilots died after their helicopter crashed May 31 in a remote area near Moosonee while on their way to pick up a patient in a First Nations community.

The northern Ontario crash involved Ornge's Sikorsky S-76A helicopter. Four people — two pilots and two paramedics — were killed. (Supplied)

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

They've directed Ornge — which is under a criminal probe — to correct all the problems by the end of May.

The organization says it will comply with those orders and take all necessary steps to ensure the safety of its staff.

Nickel Belt MPP France Gelinas raised the topic Tuesday at Queen's Park. Speaking during question period, she said the revelation is deeply distressing.

"Months before the crash, a safety officer in Moosonee warned about the risk of green pilots and night flights," she said. "But tragically, this whistle blower, like many like him before, seemed to have been ignored and, as a result, four people lost their lives."

Matthews said Ornge is taking steps to operate more safely.

"Some of the steps that have been taken, speaker, since May 31 [are] additional training for helicopter pilots, including controlled flight into terrain. They've revised their operating procedures for night operations."

The incident is still under investigation by the Transportation Safety Board.

Ornge has been under the microscope for nearly two years over financial irregularities.

The province's auditor general has questioned its business dealings and slammed the government for failing to oversee a publicly funded organization that received $730 million over five years and borrowed $300 million more.

Ornge statement regarding directions from Transport Canada/HRSDC

Ornge has received directions from Transport Canada/Human Resources and Skills Development Canada, relating to the Canada Labour Code’s occupational health and safety provisions.  Each direction deals with issues arising from the May 31, 2013 air ambulance helicopter accident in Moosonee.

 We welcome the agencies’ comments and will follow up on each of the directions to ensure our compliance. Our goal is to work with the agencies, management, unions and regulators to address health and safety concerns.

Since the tragic events of May 31, we have been working with a number of agencies examining Ornge’s operations. As the health and safety of Ornge’s crews and patients is our top priority, we welcome each agency’s review as an opportunity to enhance safety.  Specifically, we have been working closely with Transport Canada since the date of the accident to identify and address any concerns in relation to aviation matters.

The Transportation Safety Board investigation into the May 31 accident continues, and Ornge is cooperating fully. Ornge is committed to taking all necessary steps to ensure the safety of our staff, both on the ground and in the air.

Here are the seven directions from Transport Canada/HRSDC:

  • Ornge failed to protect the health and safety of helicopter pilots when flying the helicopter and when working together in the helicopter while it was in operation. Ornge is directed to take measures to correct the hazard or condition that constitutes the danger immediately.

The directions below require action by December 31, 2013:

  • Ornge failed to consult with the workplace health and safety committee in the development of health and safety policies that affect the health and safety of pilots.
  • Ornge failed to create a hazard prevention program in consultation with the Work Place Committee specific to Pilots, while the aircraft is not in operation.
  • Ornge failed to adequately educate the pilots on the health and safety hazards associated with northern operations.
  • Ornge failed to consult with the Workplace Health and Safety Committee on changes that could affect health and safety of the employees.
  • Ornge failed to ensure that all supervisory and managerial personnel responsible for pilots are adequately trained under the Canada Labour Code, Part II, and are aware of their health and safety responsibilities under this part.

The direction below requires action by May 31. 2014:

  • Failure to ensure the health and safety of pilots who operate by Night Visual Flight Rules are provided with a means to ensure visual reference is maintained throughout the flight.


The federal legislation allows for enforcement action for non-compliance, including the issuance of fines.  However, Ornge does not plan to be non-compliant on any point.  To that end, we have retained outside counsel to ensure we are in compliance.

Ornge Actions

The following is a list of a number of the measures we taken to enhance health and safety of our crews:

  • Controlled Flight into Terrain training for all rotor pilots
  • Revised Standard Operating Procedures for night operations, including operations into ‘black hole’ sites
  • IInstalling solar lighting at 91 helipads across Ontario
  • Study of additional technologies on helicopters to enhance night safety
  • Hiring of a Flight Operations Quality Assurance Inspector and a Manager of Flight Training and Standards
  • Emotional/psychological support for Moosonee staff following the crash
  • Audited all training records to identify and address any training deficiencies
  • Temporary suspension of S76 operations until Transportation Safety Board determined no mechanical deficiencies
  • Training package and examination for S76 model ‘differences’
  • Removed from service S76 aircraft that did not have advanced avionics

With files from CBC News Sudbury


To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.