OTTAWA—ORNGE failed to ensure the safety of its helicopter operations and endangered its pilots, federal investigators say in a damning indictment that orders immediate changes at the medical transport agency.

Acting on health and safety concerns, the investigators say management at ORNGE did not safeguard flights at night and those in northern regions — the very conditions in which a helicopter crashed in May near Moosonee, Ont., killing four employees.

The concerns are spelled out in so-called “direction to the employer” orders issued Nov. 14 under the Canada Labour Code that detail the concerns and demand that ORNGE take immediate steps to “correct the hazard.”

“The employer failed to protect the health and safety of employees, being helicopter pilots . . . when performing the work activity of flying the helicopter,” federal health and safety officer Janice Berling writes in one order.

“You are hereby directed . . . to take measures to correct the hazard or condition that constitutes the danger immediately,” she writes.

The orders come after a workplace probe that began May 31, the very day that an ORNGE helicopter crashed in northern Ontario. Two paramedics and two pilots were killed when their Sikorsky S-76A helicopter crashed shortly after a midnight takeoff from Moosonee airport to pick up a patient.

The orders, obtained by the Star, detail hazards at ORNGE in six areas, including:

Failing to “adequately educate the pilots on the health and safety hazards associated with northern operations.”

Not ensuring that supervisors and managers responsible for pilots are adequately trained under the Canada Labour Code and “aware of their health and safety responsibilities.”

Failing to ensure that pilots who operate by night visual rules in northern areas of operation are “provided with a means to ensure visual reference is maintained throughout the flight.”

Failing to create a hazard-prevention program for pilots.

It’s not clear whether ORNGE will face fines for the safety shortfalls. The investigation was done jointly by Transport Canada and Human Resources and Skills Development Canada.

In a statement Monday, ORNGE said the orders deal with the issues arising from the May 31 crash.

“We welcome the agencies’ comments and will follow up on each of the directions to ensure our compliance. Our goal is to work with the agencies, employees, unions and regulators to address health and safety concerns,” ORNGE said in its statement.

In the wake of the fatal accident, ORNGE says it has been working with several agencies, including Transport Canada “to identify and address any concerns in relation to aviation matters.

These measures include new training to avoid controlled flight into terrain, revised procedures for night operations, including into so-called black hole sites, where remote locations mean few ground lights to provide visual references for pilots, according to agency spokesperson James MacDonald.

As well, ORNGE has hired a flight operations quality assurance inspector and a manager of flight training and standards. It has also grounded Sikorsky S-76 helicopters that lacked advanced avionics equipment, MacDonald said.

“ORNGE is committed to taking all necessary steps to ensure the safety of our staff, both on the ground and in the air,” the agency said.

Still, the orders spell more bad news for ORNGE, which has been under fire for the missteps of its previous management and, since the May crash, the safety of its helicopter operations.

ORNGE suspended night flights to unlit helipads and also barred pilots from flying in bad weather, because of training and licensing issues.

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The Star has previously reported that there were concerns within ORNGE about its helicopter operations. Months before the crash, a safety officer at the Moosonee base warned about risks of “green” pilots and night flights.

The crash remains under investigation by the Transportation Safety Board of Canada. It could be another 12 to 18 months before the board completes its probe.