The Black Hole at Moosonee Ontario
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Joined: Jun 2008
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From: Canada
The Black Hole at Moosonee Ontario
Here we go again, another face saving story to suit insurance claims and political correctness.
The Aviation world rarely ever wants to admit pilot error.
Moosonee is a place that really determines if
a pilot an fly on instruments and if they can avoid optical illusions.
Over 20 years ago, I had a co-pilot who could not fly on instruments, could not land in a cross wind
or snow storm and had difficulty doing an instrument approach. He was next to go captain
according to the seniority list.
I spent dozens of hours making him fly every leg, but could not "fix" his problems and had to go to the
chief pilot and give him the bad news.
It was like I was committing heresy. Suddenly I was the worst person on earth and no-one wanted to me.
That month I hit 150 hours and had to go on leave.
When I returned, some transport inspector had given him a captains PPC and he was flying as captain.
Within a week or so, he flew into the dark terrain near Moosonee and it was blamed
on "Black Hole effect".
There is a trend to save money by using simulators however in the "old days" me real practice was required,
no sane chief pilot would let a new pilot loose unless they their night flying skills checked.
While these two pilots were highly experienced it is obvious something was missing. Just how did
TWO pilots both fall for what is called "the black hole effect".
It needs some other name, that reflects reality.
"Failure to monitor instruments and a failure maintain terrain clearance"
Here is the Toronto Star Story
ORNGE helicopter crash: ?Black hole? effect could have brought down air ambulance | Toronto Star
ORNGE helicopter crash: “Black hole” effect could have brought down air ambulance
“Black hole” effect, mechanical failure and pilot error among possible causes as probe begins into crash of ORNGE air ambulance in northern Ontario.
By: Bruce Campion-Smith Parliament Hill, Published on Fri May 31 2013
OTTAWA—It’s been called the “black hole” effect, when sky and ground blur into one seamless, disorienting curtain of darkness.
That’s what the crew of the ORNGE chopper would have faced soon after their midnight take-off from Moosonee airport. And it may have been their downfall as the Sikorsky S-76 crashed into the ground just minutes later, killing all four onboard.
It’s a phenomenon that has claimed many pilots, most notably John F. Kennedy Jr., who crashed his light plane into the Atlantic Ocean during a night flight over water in 1999. U.S. investigators later said that Kennedy lost control flying in the dark haze because of “spatial disorientation.”
On Friday, contact was lost with the chopper soon after its departure. So far, there has been no indication that crew signalled they were having troubles. In a statement Friday, ORNGE said it had no indication about what caused the accident.
Investigators from the Transportation Safety Board of Canada were on their way to northern Ontario Friday to begin their on-scene assessment. They will be looking at all elements of the accident, such as human factors, pilot training and the mechanical fitness of the 33-year-old helicopter.
The captain, Don Filliter, had been flying choppers for 20 years; the first officer, Jacques Dupuy, since 1996. With such an experienced crew at the controls, one veteran pilot speculated to the Star that a catastrophic mechanical failure may have caused the wreckage. If so, the position of the bits of wreckage will provide vital clues to investigators about the accident sequence, he said.
ORNGE said Friday it had temporarily grounded its five remaining S-76 helicopters “out of an abundance of caution.”
But investigators will almost certainly be looking at whether this crash fits a pattern they’ve already flagged as a worrisome safety trend in Canada — controlled flight into terrain.
That’s when pilots inadvertently fly into the ground or water, usually at night or in bad weather or poor visibility.
“Such conditions reduce a pilot’s situational awareness of surroundings and make it difficult to tell whether the aircraft is too close to the ground,” according to the safety board, which counted 13 such accidents in 2010 and 14 in 2011.
Visual spatial disorientation was blamed as the cause of a previous air ambulance accident in 2008 when a Sikorsky S-76 crashed into a forest during its night-time approach to a helipad in Temagami. Three of the four crew on board were seriously injured.
Investigators noted the risks of flying over a “featureless landscape” with few lights on the ground, creating a “black hole” effect due to the lack of visual clues for pilots.
“The pilot flying was likely affected by visual spatial disorientation,” the report concluded.
That crash happened even though the aircraft was equipped with an enhanced ground proximity warning system to alert the crew to a possible collision with terrain. And the pilots had received special training in night operations to learn “black hole approach and departure techniques,” according to the report.
On Friday, the weather around Moosonee was “adequate” for flying according to ORNGE, although there were patches of rain and mist.
The Sikorsky pilots would have faced inky darkness soon after lift-off and been relying on their flight instruments for reference, one former air ambulance pilot told the Star.
“Up north, there (are) no visual references, so you’d be right on the instruments right away,” said the pilot.
“You would take off and continue as if you went into cloud right away,” he said. “You wouldn’t be operating visual at all.”
The U.S. National Transportation Safety Board has investigated fatal incidents involving the Sikorsky S-76s and at least twice recommended these helicopters be equipped with terrain awareness and warning system, which would give the crew ample warning that they are danger of crashing into water or land, especially important during visual flight.
An investigation into a 2004 crash in the Gulf of Mexico off Galveston, Texas, determined that had the helicopter been equipped with this warning device the accident may not have happened.
“The flight crew was not adequately monitoring the helicopter’s altitude and missed numerous cues to indicate that the helicopter was inadvertently descending toward the water,” the board’s report stated.
“If a terrain awareness and warning system had been installed aboard the accident helicopter . . . (it) should have provided the flight crew with ample time to recognize that the helicopter was descending toward the water, initiate the necessary corrective actions, and recover from the descent.”
It’s not known whether the aircraft involved in Friday’s crash was equipped with the terrain warning system. A spokesperson for ORNGE said it would be up to safety board investigators to determine the helicopter’s equipment.
With files from Richard J. Brennan and Jim Rankin
The Aviation world rarely ever wants to admit pilot error.
Moosonee is a place that really determines if
a pilot an fly on instruments and if they can avoid optical illusions.
Over 20 years ago, I had a co-pilot who could not fly on instruments, could not land in a cross wind
or snow storm and had difficulty doing an instrument approach. He was next to go captain
according to the seniority list.
I spent dozens of hours making him fly every leg, but could not "fix" his problems and had to go to the
chief pilot and give him the bad news.
It was like I was committing heresy. Suddenly I was the worst person on earth and no-one wanted to me.
That month I hit 150 hours and had to go on leave.
When I returned, some transport inspector had given him a captains PPC and he was flying as captain.
Within a week or so, he flew into the dark terrain near Moosonee and it was blamed
on "Black Hole effect".
There is a trend to save money by using simulators however in the "old days" me real practice was required,
no sane chief pilot would let a new pilot loose unless they their night flying skills checked.
While these two pilots were highly experienced it is obvious something was missing. Just how did
TWO pilots both fall for what is called "the black hole effect".
It needs some other name, that reflects reality.
"Failure to monitor instruments and a failure maintain terrain clearance"
Here is the Toronto Star Story
ORNGE helicopter crash: ?Black hole? effect could have brought down air ambulance | Toronto Star
ORNGE helicopter crash: “Black hole” effect could have brought down air ambulance
“Black hole” effect, mechanical failure and pilot error among possible causes as probe begins into crash of ORNGE air ambulance in northern Ontario.
By: Bruce Campion-Smith Parliament Hill, Published on Fri May 31 2013
OTTAWA—It’s been called the “black hole” effect, when sky and ground blur into one seamless, disorienting curtain of darkness.
That’s what the crew of the ORNGE chopper would have faced soon after their midnight take-off from Moosonee airport. And it may have been their downfall as the Sikorsky S-76 crashed into the ground just minutes later, killing all four onboard.
It’s a phenomenon that has claimed many pilots, most notably John F. Kennedy Jr., who crashed his light plane into the Atlantic Ocean during a night flight over water in 1999. U.S. investigators later said that Kennedy lost control flying in the dark haze because of “spatial disorientation.”
On Friday, contact was lost with the chopper soon after its departure. So far, there has been no indication that crew signalled they were having troubles. In a statement Friday, ORNGE said it had no indication about what caused the accident.
Investigators from the Transportation Safety Board of Canada were on their way to northern Ontario Friday to begin their on-scene assessment. They will be looking at all elements of the accident, such as human factors, pilot training and the mechanical fitness of the 33-year-old helicopter.
The captain, Don Filliter, had been flying choppers for 20 years; the first officer, Jacques Dupuy, since 1996. With such an experienced crew at the controls, one veteran pilot speculated to the Star that a catastrophic mechanical failure may have caused the wreckage. If so, the position of the bits of wreckage will provide vital clues to investigators about the accident sequence, he said.
ORNGE said Friday it had temporarily grounded its five remaining S-76 helicopters “out of an abundance of caution.”
But investigators will almost certainly be looking at whether this crash fits a pattern they’ve already flagged as a worrisome safety trend in Canada — controlled flight into terrain.
That’s when pilots inadvertently fly into the ground or water, usually at night or in bad weather or poor visibility.
“Such conditions reduce a pilot’s situational awareness of surroundings and make it difficult to tell whether the aircraft is too close to the ground,” according to the safety board, which counted 13 such accidents in 2010 and 14 in 2011.
Visual spatial disorientation was blamed as the cause of a previous air ambulance accident in 2008 when a Sikorsky S-76 crashed into a forest during its night-time approach to a helipad in Temagami. Three of the four crew on board were seriously injured.
Investigators noted the risks of flying over a “featureless landscape” with few lights on the ground, creating a “black hole” effect due to the lack of visual clues for pilots.
“The pilot flying was likely affected by visual spatial disorientation,” the report concluded.
That crash happened even though the aircraft was equipped with an enhanced ground proximity warning system to alert the crew to a possible collision with terrain. And the pilots had received special training in night operations to learn “black hole approach and departure techniques,” according to the report.
On Friday, the weather around Moosonee was “adequate” for flying according to ORNGE, although there were patches of rain and mist.
The Sikorsky pilots would have faced inky darkness soon after lift-off and been relying on their flight instruments for reference, one former air ambulance pilot told the Star.
“Up north, there (are) no visual references, so you’d be right on the instruments right away,” said the pilot.
“You would take off and continue as if you went into cloud right away,” he said. “You wouldn’t be operating visual at all.”
The U.S. National Transportation Safety Board has investigated fatal incidents involving the Sikorsky S-76s and at least twice recommended these helicopters be equipped with terrain awareness and warning system, which would give the crew ample warning that they are danger of crashing into water or land, especially important during visual flight.
An investigation into a 2004 crash in the Gulf of Mexico off Galveston, Texas, determined that had the helicopter been equipped with this warning device the accident may not have happened.
“The flight crew was not adequately monitoring the helicopter’s altitude and missed numerous cues to indicate that the helicopter was inadvertently descending toward the water,” the board’s report stated.
“If a terrain awareness and warning system had been installed aboard the accident helicopter . . . (it) should have provided the flight crew with ample time to recognize that the helicopter was descending toward the water, initiate the necessary corrective actions, and recover from the descent.”
It’s not known whether the aircraft involved in Friday’s crash was equipped with the terrain warning system. A spokesperson for ORNGE said it would be up to safety board investigators to determine the helicopter’s equipment.
With files from Richard J. Brennan and Jim Rankin
Joined: Sep 2004
Aviation Qualifications: ATPL(H)
Posts: 2,372
Likes: 877
From: Canada
I think the article is badly written, speculative, sensationalistic and certainly not based on facts now in evidence.
Why can't journalists not wait for a the TSB report.
There are certainly a lot of airports in Canada that have "black holes" at the end of the runway but is that the cause of this accident?
Our thoughts and prayers for the families, friends and co-workers of the crew.
A well done to the CAF Search and Rescue crews and especially to the SARTECHs who parachuted to the site. Thank you!
Why can't journalists not wait for a the TSB report.
There are certainly a lot of airports in Canada that have "black holes" at the end of the runway but is that the cause of this accident?
Our thoughts and prayers for the families, friends and co-workers of the crew.
A well done to the CAF Search and Rescue crews and especially to the SARTECHs who parachuted to the site. Thank you!
Last edited by albatross; 2nd June 2013 at 05:03.
Joined: Oct 2001
Posts: 2,517
Likes: 0
From: Vancouver Island
Why can't journalists not wait for a the TSB report.
If they wait two years for a TSB report the general public will not consider it newsworthy.
Joined: Oct 1999
Aviation Qualifications: ATCO
Posts: 1,245
Likes: 141
From: the dark side
Alouette Get to Cochrane and take the train. When the lights go out up north its properly dark too.
Station Locations - Ontario Northland
Station Locations - Ontario Northland
Joined: Oct 2007
Aviation Qualifications: ATPL
Posts: 1,027
Likes: 120
From: Wherever I go, there I am
Chuck,
Not trying to be a dink, but 33T in Taloyoak (CYYH) is a great example during the winter when the moon is below the horizon. I've got video from this runway that I took for a group of Air Cadets. Not that you see anything once the aircraft rotates, but I think that's the point.
In saying that, I agree. Unless you operate into and out of an airport on a regular basis, it would be hard to predict whether you would encounter a black hole or not.
Not trying to be a dink, but 33T in Taloyoak (CYYH) is a great example during the winter when the moon is below the horizon. I've got video from this runway that I took for a group of Air Cadets. Not that you see anything once the aircraft rotates, but I think that's the point.
In saying that, I agree. Unless you operate into and out of an airport on a regular basis, it would be hard to predict whether you would encounter a black hole or not.
Joined: Sep 2004
Aviation Qualifications: ATPL(H)
Posts: 2,372
Likes: 877
From: Canada
Fund Raising for the families.
Joined: Jan 2003
Posts: 365
Likes: 15
From: CYPG
Have done Human Factors in Aviation training and instruction and I can honestly say that I linked "Black Hole" to approaching an airport, such as in the Moosonee Beech King Air accident, and not departing....
Tragic and difficult to understand regardless, and for us that DO fly in the deep black of the north, it hits home.
I have departed from helipads in the arctic in the dark with the only lights behind us, and it is VITAL to stay on the gauges...
Cheers
H.
Tragic and difficult to understand regardless, and for us that DO fly in the deep black of the north, it hits home.
I have departed from helipads in the arctic in the dark with the only lights behind us, and it is VITAL to stay on the gauges...
Cheers
H.
Joined: Nov 2011
Posts: 630
Likes: 0
From: Canada
I flew with these guys on a daily basis.
I'm not saying that they are not prone to making mistakes.... just like any other human on this earth. But they were a very very professional crew and I find it hard to swallow that both of them would let something like that happen.
Wait and see I guess.
I'm not saying that they are not prone to making mistakes.... just like any other human on this earth. But they were a very very professional crew and I find it hard to swallow that both of them would let something like that happen.
Wait and see I guess.
Joined: Feb 2006
Posts: 980
Likes: 11
From: On the dark side of the moon
Was the S76 equipped with a EGPWS system? What about a radio altimeter? Just curious if there was anything on board that could have helped to alert the crew - if they were getting close to the ground.
Joined: Apr 2008
Aviation Qualifications: ATPL
Posts: 1,118
Likes: 182
From: cowtown
Some unsuccessful helicopter companies follow a pattern,their first accident they blame the pilots.In this case two very well respected,competant current IFR rated pilots in an aircraft that was operated safely for over a decade with a different company.
Now some mystery black hole is supposed to have caught two experienced pilots.
I cannot believe that based on the information released so far.
The second accident starts the thought process that maybe the first accident was not properly investigated .
The third accident usually closes the doors on any new helicopter company.
ORNGE is effectively a new operator Quango formed by corrupt and criminal process.Formed by crooked corrupt provincial contractors to OHIP to funnel money away from health care into the pockets of the corrupt crooks who stole money directly from the government health care funds with giving any value to the patients and at the expense of patient quality of care.Stealing commisions on aircraft purchases was just one of the criminal acts of corruption as yet unpunished.The Toronto Star ran an expose on the crimes of those at ORNGE.
Even British Airways Helicopters got out of the helicopter business after the Vertol Chinook crashes in the North Sea.
It took a proper investigation with people with Phd's in engineering to get to the truth of those crashes.
The Toronto Star and the TSB lack the resources to get to the truth of a crash in the James Bay , never mind come to any truthful conclusion as to the cause or causes of this crash in a week.
Maybe the AAIB could lend some of its expertise of helicopter crashes from the North Sea to the TSB to get to the truth and prevent a second mysterious crash.The AAIB can be trusted to get to the truth and help prevent future disasters.
Experience has taught me when the first accident with a helicopter company is not investigated throughly and by qualified competant investigators, a second crash will happen and then everyone will cry WHY.
Now some mystery black hole is supposed to have caught two experienced pilots.
I cannot believe that based on the information released so far.
The second accident starts the thought process that maybe the first accident was not properly investigated .
The third accident usually closes the doors on any new helicopter company.
ORNGE is effectively a new operator Quango formed by corrupt and criminal process.Formed by crooked corrupt provincial contractors to OHIP to funnel money away from health care into the pockets of the corrupt crooks who stole money directly from the government health care funds with giving any value to the patients and at the expense of patient quality of care.Stealing commisions on aircraft purchases was just one of the criminal acts of corruption as yet unpunished.The Toronto Star ran an expose on the crimes of those at ORNGE.
Even British Airways Helicopters got out of the helicopter business after the Vertol Chinook crashes in the North Sea.
It took a proper investigation with people with Phd's in engineering to get to the truth of those crashes.
The Toronto Star and the TSB lack the resources to get to the truth of a crash in the James Bay , never mind come to any truthful conclusion as to the cause or causes of this crash in a week.
Maybe the AAIB could lend some of its expertise of helicopter crashes from the North Sea to the TSB to get to the truth and prevent a second mysterious crash.The AAIB can be trusted to get to the truth and help prevent future disasters.
Experience has taught me when the first accident with a helicopter company is not investigated throughly and by qualified competant investigators, a second crash will happen and then everyone will cry WHY.
Last edited by fitliker; 8th June 2013 at 18:57.
Joined: Sep 2007
Posts: 336
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From: USA
I don't mean to second guess the TSB.I am sure they will eventually get to the bottom of this tragedy.
Also,I certainly don't want to call into question the experience and the skill of the two pilots.By all accounts,those skills were unimpeachable.I extend my deepest sympathies to those left behind.
However,I would just like to add that, if indeed it was a case of CFIT (just speculating at this point with very sketchy information ,so please,bear with me) then, we have to remember, that spatial disorientation is impartial and the great leveller.It can strike the very experienced and the inexperienced equally and unexpectedly.Secondly,if the pilot flying is disoriented, the pilot not flying may not realize what is happening quickly enough to take over and rectify the situation.SD rarely hits the pilot not flying.If they were accelerating and still a bit low, it all could have happened in a few seconds before the PNF could intervene.
Again, not disparaging the dead or making judgements.Just offering a point of view.
Alt3.
Also,I certainly don't want to call into question the experience and the skill of the two pilots.By all accounts,those skills were unimpeachable.I extend my deepest sympathies to those left behind.
However,I would just like to add that, if indeed it was a case of CFIT (just speculating at this point with very sketchy information ,so please,bear with me) then, we have to remember, that spatial disorientation is impartial and the great leveller.It can strike the very experienced and the inexperienced equally and unexpectedly.Secondly,if the pilot flying is disoriented, the pilot not flying may not realize what is happening quickly enough to take over and rectify the situation.SD rarely hits the pilot not flying.If they were accelerating and still a bit low, it all could have happened in a few seconds before the PNF could intervene.
Again, not disparaging the dead or making judgements.Just offering a point of view.
Alt3.
Joined: Apr 2008
Aviation Qualifications: ATPL
Posts: 1,118
Likes: 182
From: cowtown
AVCANADA ? View topic - Transport Canada Makes Out-of-Court Deal in Pilot's Death
You might want to talk to Kirsten Stephens in Campbel River B.C. aka "Widow" on Avcanada if you want to know what an underfunded understaffed safety board means to the travelling public and working pilots.
Their basic philosophy is simple.It must be pilot error as if the pilot had not made an error there would not have been a crash.
I did not intend to suggest that the TSB could not do a proper investigation.Just that the AAIB has proven experience in getting to the truth in Helicopter accidents.Often more complex than simple pilot error accidents.
The AAIB might be able to help prevent this new taxpayer funded private company from joining the ranks of previous failed new helicopter companies.
You might want to talk to Kirsten Stephens in Campbel River B.C. aka "Widow" on Avcanada if you want to know what an underfunded understaffed safety board means to the travelling public and working pilots.
Their basic philosophy is simple.It must be pilot error as if the pilot had not made an error there would not have been a crash.
I did not intend to suggest that the TSB could not do a proper investigation.Just that the AAIB has proven experience in getting to the truth in Helicopter accidents.Often more complex than simple pilot error accidents.
The AAIB might be able to help prevent this new taxpayer funded private company from joining the ranks of previous failed new helicopter companies.
Last edited by fitliker; 9th June 2013 at 00:51.
Joined: Feb 2006
Posts: 980
Likes: 11
From: On the dark side of the moon
I am very familiar with the case. But unlike the accident which killed her husband, the Ornge S76 was equipped with a flight data recorder. Additionally, the TSB is very experienced in investigating helicopter accidents, seeing as Canada has a very large helicopter industry and several crashes happen annually.
Last edited by J.O.; 9th June 2013 at 11:38.