A Coroner’s Inquest into the 2017 deaths of four Hydro One workers, two of whom were from the Kingston area, ended Wednesday, Jun. 15, 2023, with the jury making 16 recommendations to Transport Canada and Hydro One.
Powerline technicians Kyle Shorrock of Inverary (age 27), Jeffrey Howes of Bath (26), and Darcy Jansen of Long Sault, Ontario (26), as well as pilot James Baragar of Orillia (39) all died on December 14, 2017, from injuries sustained when their helicopter crashed at a construction site in Tweed.
That day, according to a report by the Transportation Safety Board of Canada (TSB), a Hydro One Networks Inc. Airbus AS350 B2 helicopter equipped with an external platform was transporting three powerline technicians from a transmission tower to a staging area near Tweed.
It had become common practice for powerline technicians to attach tool bags and other small items to the external platform for flights to and from work sites. In line with this practice, the technicians attached a few items to the platform while boarding the helicopter and then took their seats in the aft cabin.
An empty canvas supply bag with an attached carabiner that was being carried on the platform had not been not adequately secured before the helicopter departed for the return flight to the staging area. That canvas bag separated from the platform and struck the helicopter’s tail rotor, causing significant damage, severe imbalance, and intense vibration.
Shortly after, while the pilot was attempting to land, the helicopter’s tail rotor, tail rotor gearbox, and vertical fin separated from the helicopter. The helicopter became uncontrollable and collided with the ground. The three power line technicians were unrestrained and fell from the helicopter, either slightly before or during the impact, and received fatal injuries from contact with the helicopter or the terrain. The pilot was fatally injured on impact. The helicopter was destroyed.
During its investigation, the TSB found that the practice of carrying external loads attached to the platform for flight to and from work sites was not a formalized procedure at the company; as a result, adequate controls were not in place to ensure objects were properly stored or secured.
The investigation also found that, prior to the incident, the shoulder harness portions of the backseat safety belts had been rolled up and taped with electrical tape, thereby preventing them from being used.
TSB found that there was a perception within Hydro One that use of the shoulder harness was optional as long as the lap strap was used. “The Canadian Aviation Regulations currently define a safety belt as ‘a personal restraint system consisting of either a lap strap or a lap strap combined with a shoulder harness,’” said Kathy Fox, Chair of the TSB. “Because of the word either, pilots and passengers may interpret the regulation to mean that use of the lap strap alone is sufficient. We want that uncertainty removed.”
After eight days of testimony in June 2023, the Coroner’s Inquest jury made the following recommendations to Transport Canada:
1. Amend the Canadian Aviation Regulations (CARs) to explicitly stipulate that an air operator must obtain Transport Canada approval before attaching equipment, bags, or other material to the outside of a helicopter. The amendment and any associated guidance documents should set out the approval criteria and the approval process.
2. Review the sections of the CARs that apply to the practice of a person performing work at or in the vicinity of transmission towers and wires from a helicopter while it is in flight (including in a hover position), and develop a clear position on:
- a) whether this practice meets the definition of a Class A external load or a Class D external load,
- b) what type of helicopter may be used for this practice, with particular reference to safety precautions in the event of an engine failure,
- c) whether this practice requires approval from Transport Canada,
- d) the approval criteria,
- e) the approval process.
3. Provide the position referred to in Recommendation #2 to all aircraft operators who have approval and authorization to carry out helicopter operations. If the position is revised in the future, provide any updates to that position to all aircraft operators who have approval and authorization to carry out helicopter operations.
4. Conduct a comprehensive review of sections 702 and 703 of the CARs to identify any provisions related to helicopter modifications and approvals that require clarification. The review should include consultation with relevant stakeholders, including air operators and Design Approval Representatives who have delegated authority to make approvals under these sections.
5. Develop internal guidance material and educational programs to inform Transport Canada safety inspectors, engineers, and managers about the types of equipment modifications and aviation activities that require Transport Canada approval.
6. Develop public guidance material to inform air operators and Design Approval Representatives about the types of equipment, equipment modifications, and aviation activities that require Transport Canada approval.
7. Amend the CARs to include a definition of the term “attachment device” in section 702.45.
8. Review the practice of allowing Design Approval Representatives to approve their own helicopter designs and modifications. The review should include considering enhanced audits and a mandatory oversight or peer review process for each design approval.
9. Formalize the process for providing advice to air operators and Design Approval Representatives about the interpretation of the CARs. In particular, all advice that Transport Canada safety inspectors, engineers, or managers provide to air operators and Design Approval Representatives about the interpretation of the CARs should be documented in writing and confirmed with the operator in writing, and Transport Canada should maintain records of this advice in accordance with Government of Canada record-keeping and retention requirements.
10. Introduce an enhanced safety inspection regime to increase Transport Canada’s awareness about the types of aviation activities that air operators are engaged in and to identify design modifications, operational activities, or operational risks that might require Transport Canada approval. The enhanced regime should assist Transport Canada in fulfilling its mandate to ensure the safety of all persons travelling in aircraft and should include:
- a) increased frequency of onsite inspections,
- b) routine proactive, unannounced safety inspections,
- c) audits and reviews of all standard operating procedures,
- d) attendance at aviation training sessions put on or provided by air operators,
- e) observation of air operator activities,
- f) inspection of equipment or operational activities not previously inspected or approved by Transport Canada.
11. To facilitate the new enhanced safety inspection regime, develop regulations, policies, or guidelines to require air operators to provide notice to Transport Canada when an air operator:
- a) has amended its standard operating procedures,
- b) has scheduled aviation training sessions,
- c) has scheduled new or novel aviation operational activities not previously inspected or approved by Transport Canada,
- d) has acquired equipment not previously inspected or approved by Transport Canada.
12. Amend the CARs to require Standard Operating Procedures for all flight operations where an approval has been issued to carry an external load pursuant to section 702.45.
13. Review all of Hydro One’s current helicopter operations and any new operations not previously undertaken, inspected, or approved, for which an approval is required pursuant to the CARs and is not in place, to determine if such operations might require Transport Canada approval.
The jury further recommended to Hydro One:
14. If Hydro One introduces the practice of aerial transfers or mid-span work using helicopters:
- a) continue the prohibition against attaching tools, materials, or equipment to the outside of helicopters,
- b) ensure a placard is displayed on the helicopter to confirm the prohibition referred to in (a),
- c) ensure that adequate safety precautions are in place in the event of an engine failure,
- d) consider consulting a third-party expert on human factors to provide additional support in updating work activities and policies to ensure the safety of all workers involved in and performing this type of work,
- e) consider including in the new work method, work instructions that address the transportation of powerline technicians to the base of a transmission tower while work platforms of any type are installed on a helicopter; in developing this procedure, consider whether the helicopter should be used to transport crew while a work platform of any type is installed,
- f) consider developing policies or updating any existing policies, including training, to ensure that any new or novel use of equipment, bags, or other material by power line technicians while being transported on or working from a helicopter is reviewed and approved by Helicopter Services before deployment.
15. Ensure that the 30-minute Helicopter Services Safety video is made mandatory for any employee flying on Hydro One helicopters, and that employees review the video yearly and/or after any extended period that an employee has not been in the helicopter: for example, three months.
16. Periodically reassess policy and procedures (Hydro One Document System HODS) with fresh eyes and/or third party, and not assume it is safe because it has been in use for a number of years.