More than two years after a close call for two pilots and two paramedics on-board a Helijet helicopter in Tofino, the Transportation Safety Board has issued its report into the incident.
On Nov. 15, 2015, a Helijet Sikorsky S76 helicopter left Vancouver on a night medical evacuation flight to the Tofino/Long Beach Airport.
The intended landing area was a temporarily lit helipad at the airport.
The TSB reports says while on final approach to the landing area, the flight crew lost control of the helicopter, which descended about 67 feet (20.4 metres) below the landing area along the nearby shoreline.
The crew managed to regain control of the helicopter three feet above ground over the beach, then flew back up to conduct a second approach, while still experiencing flight control difficulties.
The second time, the helicopter landed successfully, and there were no injuries.
The TSB determined that flying under night visual flight rules (VFR) without adequate visual reference to the ground, along with a lack of crew coordination and ineffective standard operating procedures (SOPs) led to the helicopter nearly colliding with terrain.
“This occurrence was the result of risks of night operations not being effectively mitigated by the crew and more broadly by the company,” the TSB reports reads.
The investigation found that the night VFR flight was conducted without sufficient ambient or cultural lighting (e.g. lights on buildings and roads) to maintain an adequate visual reference to the ground.
In addition, the flight crew did not conduct the required briefings. As a result, by the final approach, neither crew member had developed a correct or complete understanding of the characteristics and challenges of the landing site.
Further, the investigation found that company SOPs provided little guidance in a number of areas, which contributed to poor decision-making and coordination.
The TSB says that Helijet reviewed its SOPs and increased employee training, specifically on crew resource management, night VFR operations, the black-hole effect and unprepared landing sites.
The company also developed a risk management plan for night VFR operations.
It will also be providing night vision goggles to its flight crews.
The Tofino/Long Beach Airport installed the necessary infrastructure for night operations and was fully night-certified by Transport Canada in January 2017.