Release of investigation report A21C0038 - Griffith Island

A21C0038 - Opening remarks

Kathy Fox, TSB Chair
Daryl Collins, Regional Senior Investigator – Air
Jean-Pierre Regnier, Senior Investigator – Air

Ottawa, Ontario
15 February 2024
Check against delivery.

Kathy Fox

Good morning and thank you for joining us.

We are here today to issue four recommendations to Transport Canada, following the 2021 fatal crash of an Airbus Helicopters AS 350 B2 helicopter, operated by Great Slave Helicopters 2018 Ltd., which occurred on Griffith Island, Nunavut.

First, I’d like to offer our continued condolences to the families of those whose lives were lost that day.

Every accident is the result of many factors, and they are often preventable. This one was no exception.

The safety deficiencies that we will highlight today are not new. Unfortunately, for more than 30 years, the TSB has been calling for the implementation of safety measures to mitigate the risks that persist in helicopter reduced visibility operations.

But first, I'll turn things over to the investigator-in-charge, Daryl Collins, who will walk you through the events of that day, explaining how and why things unfolded the way they did.

Daryl Collins

Thank you, Kathy.

Late afternoon on April 25th, 2021, the helicopter departed from a remote camp on Russell Island to Resolute Bay, Nunavut, due to an approaching weather system forecasting blizzard conditions for the next several days. Onboard was a pilot, an aircraft maintenance engineer, and a biologist, who were returning following a 12-day polar bear research trip.

The flight was being conducted under day visual flight rules (VFR), which means that the pilot was required to maintain visual reference to the ground and navigate the helicopter using external references.

As the helicopter approached the highest elevation on Griffith Island, the uniformly snow-covered terrain, combined with an overcast sky and snow squalls, likely created flat light and whiteout conditions, which resulted in an unexpected loss of visual references, also known as inadvertent instrument meteorological conditions (inadvertent IMC).

Then, while the pilot was likely attempting to visually manoeuvre the helicopter in response to the inadvertent IMC, an unintentional descent resulted in the helicopter colliding with terrain, killing all three on board.

Currently there is no regulatory requirement for commercial helicopter operators to ensure that pilots have the training and technology required to be able to recover from an inadvertent IMC. The investigation found that Great Slave Helicopters 2018 Ltd. adopted an approach consistent with the current regulations that relies solely on a pilot’s ability to avoid such conditions. This is also known as the “avoid-at-all-costs” approach.

When the pilot lost visual references, he lacked the skills necessary to recover solely by using the flight instruments. Additionally, the helicopter was not equipped with the technology capable of alerting him to the helicopter’s height above ground or rate of descent. Therefore, the pilot had no means of receiving advance warning of the impending collision with terrain.

No one plans to find themselves flying in inadvertent IMC. Its very name, inadvertent flight into IMC, means unplanned. You can’t expect an “avoid-at-all-cost” approach to be effective against something you never planned to happen, so there needs to be additional, potentially lifesaving, defences in place for pilots.

I’ll now turn things back to Kathy, who will tell you more about the recommendations we are issuing today.

Kathy Fox

Because of these issues that Daryl has just spoken about, our first two recommendations call on Transport Canada to require commercial helicopter operators to:

1. ensure pilots possess the skills necessary to recover from inadvertent IMC. [A24-01]; and
2. implement technology that will assist pilots with the avoidance of, and recovery from inadvertent IMC [A24-02]

Moving on to our next recommendation. In Canada, thousands of pilots and passengers travel on single-pilot aircraft every year. In many instances, those flights are conducted in remote areas, with minimal external support. In these environments, additional defences must be put in place.

Standard operating procedures (SOPs) are essential, as they provide pre-determined successful solutions for specific situations that may be encountered. This is particularly beneficial when a pilot lacks knowledge and/or experience in a situation, such as reduced visibility operations in areas prone to flat light and white out conditions.

Currently, SOPs are required for multi-crew flight operations. However, single-pilot operators are not required to provide their pilots with SOPs, which puts them and passengers who travel on those aircraft at increased risk.

Therefore, the Board’s third recommendation calls for Transport Canada torequire private and commercial operators conducting single-pilot operations to develop standard operating procedures based on corporate knowledge and industry best practices to support pilot decision-making. [A24-03]

Our last recommendation focuses on the need to enhance regulatory requirements specifically for helicopters conducting reduced-visibility operations in uncontrolled airspace.

In Canada, helicopter and airplane operators who meet certain requirements can be approved by Transport Canada to conduct visual flight rules (VFR) operations in uncontrolled airspace at visibilities below those normally prescribed for VFR operations.

Despite the fact that loss of visual reference accidents are more than twice as likely to involve helicopters than airplanes, the requirements for visibility limits, aircraft equipment, and pilot training are less stringent for helicopters than for airplanes. These differences mean that helicopters may operate at half the visibility applicable to airplanes but without the same level of defences as airplane operations.  

Therefore, the Board recommends that Transport Canada enhance the requirements for helicopter operators that conduct reduced-visibility operations in uncontrolled airspace to ensure that pilots have an acceptable level of protection against inadvertent IMC. [A24-04]

The risks associated with the loss of visual references due to flat light and/or whiteout conditions are not new. The TSB has identified loss of spatial awareness in 13 investigations involving commercial helicopter flights conducted between 2010 and 2018. Furthermore, the TSB has issued 10 recommendations to Transport Canada aimed at preventing inadvertent IMC accidents.

While some operators have voluntarily implemented safety initiatives that go beyond the regulatory requirements, the cost of proactively implementing additional training and technology in a highly competitive industry deters many companies from doing so.

Yet, our investigations have shown that the “avoid-at-all-costs” approach to inadvertent IMC is not a realistic strategy, and more needs to be done.

Enough lives have been lost. It's time for Transport Canada to take action.

Thank you.