This image from a report released by the Transportation Safety Board of Canada today shows a helicopter’s approximate flight path in red, with the helicopter travelling from the top right to the bottom left. The helicopter is believed to have been roughly three feet off the ground when pilots regained control. ( Transportation Safety Board of Canada)

Transportation Safety Board releases report on 2015 near-miss in Tofino

Poor lighting pointed to as key culprit.

Poor lighting was a key cause of a terrifying near-miss at the Long Beach Airport in 2015, according to a report released by the Transportation Safety Board of Canada on Wednesday.

A helicopter owned by Helijet International Inc. left Vancouver late at night on Nov. 15, 2015, and headed to Long Beach Airport in response to a medevac call in Tofino, according to the report, which states that two pilots and two paramedics were onboard.

The pilots disengaged the autopilot about 600 feet above sea level as they prepared to land, but lost control when the helicopter’s airspeed slowed, a high rate of descent developed and rotor speed began to decrease, according to the report.

The aircraft was a mere three-feet above the ground when the pilots regained control and brought the helicopter back up to 500 feet before preparing to land, which they were able to do, though additional control difficulties were encountered. No injuries were reported.

“They couldn’t have got any closer,” Transportation Safety Board of Canada investigator Chris Johnston told the Westerly News on Wednesday afternoon. “They were all very lucky…Had they been another 100-200 feet further in the approach, and they settled like they did, they would have been in the trees. They were very fortunate that when they did settle, or come out of the sky, that they were over the beach.”

The helicopter was damaged in the incident, which caused the medevac to be cancelled and the patient was transported by vehicle over Sutton Pass,

“On further inspection, it was determined that each of the main rotor spindles had come into contact with the elastomeric blade retention bearings on the main rotor hub and that a main rotor damper oil line had been broken,” the report states.

A medevac landing area had been set up at Long Beach Airport after Transport Canada determined the Tofino Hospital’s medevac pad was unsafe in December, 2011.

“Plans were made to temporarily relocate medevac operations to CYAZ [Long Beach Airport], which was not certified for night operations. Helijet, the British Columbia Ambulance Service, and the airport operator worked with TC to develop an interim solution,” the report states.

The report suggests Transportation Canada officials had met with Long Beach Airport personnel as well as Helijet and a local B.C. Ambulance Service paramedic and provided a list of eight actions that needed to be taken before night medevac operations could take place at the airport.

Those actions included enhanced lighting around the main terminal building, the Tofino Air hangar, and the Quonset hut, the illumination of a windsock to the south of the runway, consultations with NAV Canada for a 24/7 automated weather observation system and a risk assessment by the airport to ensure the facility could handle the additional level of service.

“Only one of these requirements, the illumination of the windsock, had been implemented before night flights into CYAZ began,” the report states. “Neither the airport operator nor Helijet informed TC that night medevac operations had begun.”

Johnston said that, had they been completed, the eight actions laid out by TC would have significantly decreased the possibility of Nov. 15’s incident.

“I don’t think that Transport Canada, or the operator, or the airport, followed through on those recommendations that Transport Canada had made and flights commenced and continued without that being checked,” he said.

The lighting the helicopter pilots had to work with consisted of twelve “temporary Turboflares set up on the compass rose and an illuminated windsock,” according to the report.

“They were shooting their approach to a ring of lights. But, unfortunately, a ring of lights, when you’re a distance away, appears like it’s one light and it doesn’t give you any sort of closure rate,” Johnston said. “The 12 twinkling lights there looked like one light so they thought they were really far away when, in fact, they were quite close and that’s when they pulled on the reins so to speak and slowed the helicopter right down and that’s when their brains kind of got mixed up on where they were going.”

TSB investigator Rob Chiatto told the Westerly News that any disciplinary action for continuing medevac operations before those eight actions were taken would be up to Transport Canada.”

“The Transportation Safety Board has no regulatory power,” he said. “We do not assign liability. All we do is try to show what happened in the accident to prevent accidents from happening in the future.”

A Transport Canada spokesperson told the Westerly News the TSB’s report is being reviewed.

“Transport Canada welcomes the Transportation Safety Board of Canada’s report into this accident,” the spokesperson said. “We are thoroughly reviewing the report and will not hesitate to take actions should issues affecting aviation safety be identified. Transport Canada will follow up on any findings of non-compliance with the Canadian Aviation Regulations.”

The Westerly reached out to Helijet International for comment, but did not hear back by the time of this publishing.

Johnston pointed out that both Helijet and Long Beach Airport have undertaken significant steps since the 2015 incident to avoid similar events in the future, including Helijet announcing it would install Night Vision Imaging Systems in its three ambulance helicopters this winter.

The TSB’s report states that Long Beach Airport has installed the necessary infrastructure for night operations, and was fully night-certified by Transport Canada on Jan. 9, 2017. The airport received $1.27 million from the provincial government’s Air Access Program to spend on lighting upgrades on Aug. 5, 2015.

The new runway lighting earned the airport a B.C. Aviation Council William Templeton Trophy this year.

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