On Runway 06 at Moosonee airport, the Sikorsky S-76A helicopter rocked uneasily on its landing gear, its four rotor blades beating the night air.
In the cockpit of the ORNGE air ambulance was Capt. Don Filliter. At 54, he was a respected veteran of Canada’s helicopter industry. Beside him was First Officer Jacques Dupuy. In the cabin behind them were flight paramedics Dustin Dagenais and Chris Snowball.
The chopper, call sign “Lifeflight 3,” had been dispatched on a midnight trip to Attawapiskat to pick up a patient.
The Star spoke at length with pilots with years of experience in air ambulance operations, including several who still work at ORNGE. They spoke on the condition of anonymity because of a concern about retribution.
Pilots and critics say the roots of the May 31 accident can be traced from that patch of burned and devastated forest in northern Ontario back to ORNGE headquarters in Mississauga and the management decisions that began under the controversial reign of Dr. Chris Mazza.
“I think ORNGE is praying that it’s a pilot error accident and then they will accept no blame for this,” one pilot told the Star.
“But the question is whether the pilots were put in a situation where an accident was inevitable.”
A Star investigation has found troubling issues arising from the accident that could impact the safety and service of ORNGE’s helicopter operations, including:
Whether ORNGE had the organizational “competence” to assume responsibility for the helicopter operations just over a year ago.
An exodus of senior, experienced pilots — more than one-quarter of the workforce — that has strained training and scheduling. In the last 18 months, more than 20 disgruntled rotor-wing pilots with thousands of hours in their logbooks have left, including three who handed in their resignations this week. The turnover could impair the busy flying schedule in the summer “trauma” season.
The training given to Filliter. Though an experienced pilot, he had returned to air ambulance flying only in March after several years away.
The pairing of Filliter and Dupuy. Veteran pilots tell the Star this “green-on-green” scenario — a pairing of pilots relatively new to their flying positions — is at the root of the accident. Such pairings are banned in commercial aviation because of the inherent risks. In this case, Filliter was returning after a hiatus and Dupuy had less than a year’s experience.
Questions about the management of ORNGE’s helicopter operations after the service suspended night flights to remote helipads and flights in bad weather in the wake of the crash. As well, sources say that helicopters are routinely out of service because of maintenance problems or lack of staffing.
ORNGE president and chief executive officer Dr. Andrew McCallum says the two pilots involved in the accident were “highly qualified and experienced” and had received the required training.
And McCallum told the Star that he believes operating the fleet of helicopters in-house “is the most appropriate way for us to deliver the service.
“I believe that the people here are equipped and able to properly supervise and maintain an aviation service,” McCallum said.
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The troubled saga at ORNGE has cost taxpayers money. But in the wake of the Sikorsky crash, some question whether that turmoil has now cost lives. They point to the decision by ORNGE to take over the operation of its helicopter fleet, despite repeated warnings that the agency lacked the “competence” to handle the complex demands of such a move.
It was under Mazza’s tenure as chief executive officer that ORNGE decided to cut short its contract with Canadian Helicopters Ltd., which through a series of competitive bids, had operated Ontario’s rotor-wing air ambulances since 1977 without a fatal accident.
Instead, ORNGE said it would handle the operation and maintenance of its helicopter fleet and the training of its pilots starting April 1, 2012. The fatal crash came just over a year later. Today, there is growing anger among ORNGE employees who saw this as a preventable accident set in motion by the turmoil of recent years.
“ORNGE was never set up with the original mandate of operating an aircraft. We are paying for it now. They should never have been involved in aviation,” said one insider.
“You can back this up since the day they took it over and see how everything is connected to that crash.”
There were warnings voiced at Queen’s Park that ORNGE lacked the expertise to manage a fleet of sophisticated helicopters.
“It’s a very, very complex operation. Putting it simply, there’s no learner’s permit for this. It’s very, very difficult to do. We’re very good at it,” Rob Blakely, a vice-president with Canadian Helicopters, told the public accounts committee probing the ORNGE controversy last year.
It was no idle boast. Canadian Helicopters had been recognized by Sikorsky for its safety record flying the S-76.
Jacob Blum, who served in several senior roles at ORNGE until his resignation in 2008, said he voiced doubts about the decision to bring the helicopter operations in-house but says he was ignored.
“What ended up happening was a desire to become an aviation company — what I cheekily call, ‘boys with toys.’ ” Blum, a former ORNGE vice-president, told a Queen’s Park committee probing the agency last year.
“ORNGE did not have the core competencies to become an aviation company. That was better left to the third-party aviators who do this for a living day in and day out,” Blum said.
Tom Rothfels, ORNGE’s former chief operating officer, told the committee that operating complex, twin-engine choppers “is not something that you do lightly.”
“It concerned me greatly that ORNGE was about to undertake this in a very short period of time,” he said.
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Preparing for takeoff that night, ahead lay the runway at the Moosonee airport. Beyond that, blackness. And unlike nights in southern Ontario, where urban life illuminates the night, this was an all-encompassing, inky darkness.
It was the kind of darkness that has a name — the “
black hole” effect where the lack of visual references creates risks for pilots.
The condition is a bigger concern on landings, when such darkness makes depth perception difficult. But it can also play havoc on takeoff when pilots must cope not only with the lack of visual references but also the sensory illusions caused by the acceleration of the aircraft as it takes to the air.
It could be so disorienting that Canadian Helicopters gave its air ambulance crews repeated practice in “black hole” arrivals and departures to drive home the risks and the skills needed to safely in such conditions.
“Unlike southern Ontario, once you leave that runway there are no lights for 80 miles,” one pilot told the Star.
On the runway, the Sikorsky’s twin engines spooled up and the chopper took to the air.
“You want keep . . . straight and level until you’ve got a good rate of climb and at least 500 feet above ground in night-time before you do any turning,” one pilot told the Star.
The helicopter climbed initially and then turned north. But in the turn, it began to descend, crashing into the trees that border the airport.
While all potential causes officially remain on the table, that announcement has put the focus on the actions of the two pilots at the controls — and decisions by ORNGE management.
Though spread around the globe, Canadian helicopter pilots are a close-knit community. As word circulated that Filliter had been killed in a crash, the first reaction was disbelief. Then were there questions. That’s because all those who flew with Filliter say he was a consummate pro.
“He was a safe, competent pilot. Absolutely no one better,” said one pilot.
In the words of another, he had “good hands and feet,” perhaps the ultimate compliment to pay a helicopter pilot
Filliter flew helicopters for the Ministry of Natural Resources and flew part-time on the air ambulance fleet. Yet he had been away from the air ambulance business for several years before joining ORNGE in March as a contract pilot.
It’s the policy of some aviation companies that a captain who had been away for an extended time would have been paired with a training captain for a month or longer to ensure they are up to speed and proficient to act as a pilot-in-command.
Now some question whether Filliter had been pressed back into operations without proper training and supervision because of the staff turnover at ORNGE.
“I just can’t get my head wrapped around how this happened,” said one veteran pilot, who once flew with Filliter.
“It’s got to be something to do with the training not being done well and Don being left without the tools required to do this job,” the pilot told the Star.
“We’re getting away from those days when we call it pilot error. We’re calling it system failures and I think this is an example of system failure, that inexperienced people have been put in charge of a complex, expensive and potentially risky business.”
Canadian Helicopters had managers in charge of individual air bases across the province. Such a manager would never have paired Filliter and Dupuy together for a challenging night flight, one source said. But when ORNGE took over, they got rid of the base managers and moved to centralized scheduling run from its Mississauga headquarters.
“Yes, they both had lots of experience flying but not in this type of environment,” the source said.
As a former flight surgeon, chief coroner of Ontario and a pilot and aircraft owner himself, McCallum well knows the desire for answers after tragic deaths.
His first counsel is patience, to avoid quick judgments.
“Everybody has a thought about what happened and why it happened and conclusions have been drawn but the fact is we don’t know,” he told the Star during an interview at ORNGE’s Mississauga headquarters.
He says that Filliter had gone through all “recurrent training and checks” after joining ORNGE. Dupuy joined last August and McCallum says he was experienced as well with thousands of hours in his logbook.
“So neither of these guys were anything but highly qualified and experienced,” McCallum said, dismissing speculation of a green-on-green scenario.
“I think describing these two individuals as green would be unfair to them entirely,” he said.
He concedes that the takeover of helicopter operations from Canadian Helicopters has been challenging.
“Certainly there have been pilots who have left. We have also recruited more pilots than have left,” McCallum said.
“I think it would only be fair to say that the transition from CHL to us wasn’t entirely happy from the perspective of a number of veteran pilots,” he said.
Despite the turnover, McCallum said he’s satisfied that the new hires are “appropriately qualified. We bring them and train them properly.”
He said he expects the safety board to look at Filliter’s training, the pairing of Filliter and Dupuy, the turnover in the pilot ranks and determine whether any of it was a factor in the accident.
“It’s frustrating because it takes a long time and people want answers. My folks desperately want to know,” he said.
