Helicopter - HEMS accident USA - Four killed - Contributing factor: Lack of oversight - Curt Lewis

Ineffective oversight, organizational woes cited in ORNGE air ambulance crash

Safety watchdog urges better Transport Canada oversight and improved training after probe of fatal chopper crash.

Using a model of a Sikorsky S-76A helicopter lead investigator Daryl Collins explains how the ORNGE air ambulance crashed.

OTTAWA-As the crew of Lifeflight 8 boarded their ORNGE air ambulance helicopter for a night flight to pick up a sick child, the trap had already been set.

Management turmoil within ORNGE meant the pilots lacked the required training and experience, that operating procedures were "inadequate" for their night flight and supervision was lax. Coupled with "ineffective" oversight by Transport Canada, the stage was set for the helicopter's devastating crash on May 31, 2013.

Accident investigators were able to quickly determine how the Sikorsky S-76A helicopter crashed mere seconds after take-off from Moosonee, Ont., killing Capt. Don Filliter, First Officer Jacques Dupuy and flight paramedics Dustin Dagenais and Chris Snowball.

Soon after departure, the helicopter began an inadvertent descent during a turn that went unnoticed until it was too late, according to a long-awaited report by the Transportation Safety Board of Canada released Wednesday.

Yet the reasons for the crash extended beyond the cockpit, investigators found.

"What went wrong that night went well beyond the actions of this crew," said Kathy Fox, chair of the safety board.

"They weren't operationally ready for the conditions they faced that night, that's true. But they never should have been put in that situation," she told a Toronto news conference. "The system let them down."