A16-14 - Oversight of commercial aviation in Canada: Policies, procedures and training

Summary

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.

Transportation Safety Board of Canada Recommendation A16-14

“The Department of Transport enhance 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.”

Transport Canada Response to Recommendation A16-14

Transport Canada agrees that it must continually enhance its oversight policies, procedures and training. In fact, independent to this accident or this recommendation, TC committed in its National Oversight Plan for 2016/2017 to conduct an evaluation of its surveillance program.

Further to that commitment, in July 2016, TC launched a Civil Aviation Surveillance Program Evaluation and Update Project. The purpose of this project is to analyse opportunities for improvement identified via inspector feedback, analyse lessons- learned, and leverage business intelligence to update the surveillance program. The goal of the project is to ensure the surveillance program effectively verifies regulatory compliance at appropriate intervals and is effective in carrying out enforcement action, as required. While the project is scheduled to complete in December 2017, the department will not hesitate to implement enhancements sooner, if warranted.

The Board’s recommendation A16-14 will be used as an input to this evaluation work.