The Yukon government has until October to initiate a full health and safety audit of all its departments.
The order resulted from a yearlong investigation by Yukon Workers’ Compensation Health and Safety Board into the death of Yukon Geological Survey employee Geoffrey Bradshaw.
A helicopter blade struck the geologist in the head, killing him instantly on July 22, 2006.
The Health and Safety Board blamed Bradshaw’s death partly on his own error, but also on the pilot’s unprofessional conduct, and “a breakdown in the employer’s safety program.”
“I’ve ordered the Yukon government to do a government-wide audit of safety management practices encompassing all departments,” said Health and Safety board director Kurt Dieckmann.
The Yukon government will have to hire an external agent, at its own expense, to perform the audit.
“It won’t be cheap,” he said.
By September 30, the government needs to define the scope of the audit and be ready to put the job out for bids.
If it fails to comply with the order, the Health and Safety board will fine the government $200,000 and then $17,500 each day thereafter.
A year ago, Bradshaw was out with exploration geologists in the Bonnet Plume area of the Wernecke Mountains.
Just after 1:30 p.m. on July 22, he radioed for a pickup on a sloping grassy area near the mountain ridge he had been traversing with his work partner.
The contract helicopter pilot had to perform what is called a “toe-in” manoeuvre in order to pick the two workers up.
In a “toe-in” manoeuvre, the pilot sets the front skids on a slope and maintains a low hover.
Bradshaw and his partner crouched down with their packs to indicate they were ready for a pickup. A strong gusty upslope wind blew on the helicopter as the pilot moved in.
The pilot set down. The geologists were on the ground under the rotor in the safe zone, as far as the pilot could tell.
“It was a guesstimate sort of thing,” he later told the health and safety board.
Bradshaw’s partner was uphill of the helicopter’s skids and off to the right. The pilot couldn’t see Bradshaw.
The coworker said that Bradshaw was further uphill, 1.5 to three metres away.
As the first coworker boarded, the pilot adjusted for the weight shift, or possibly the wind, he said afterwards.
The front of the rotor disk tilted down as he did so.
Bradshaw stood up in front of the helicopter. The pilot could now see him over the console.
Bradshaw began walking upright with his head bent forward.
The pilot, concentrating on the coworker who was boarding, looked back to catch just a glimpse of the blade striking Bradshaw.
The pilot’s view was immediately obscured by blood on the windshield.
“The pilot lost sight of the worker at one point and at that point should have aborted the manoeuvre,” said Dieckmann.
“But he didn’t.
“The worker should have approached the helicopter in a crouched position as he had been trained to do.
“He did not.”
The pilot was also blamed for failing to brief the two workers on the proper procedure for boarding during a toe-in, a requirement under federal aviation law.
The health and safety board has no jurisdiction over the pilot’s actions.
Transport Canada alone licences helicopter companies and their pilots to perform in-flight manoeuvres like a toe-in.
Yukon government staff had raised concerns in 2005 about “unprofessional and unsafe service from some helicopter pilots,” the board’s report stated.
Aware of those concerns, the government should have assessed the hazard and dealt with it, Dieckmann said.
Also, co-workers had previously seen Bradshaw walking upright when leaving or boarding helicopters. The government should have had an incident reporting system in place.
“We don’t want to focus entirely on this little piece right here and miss a big piece over there, and next year be in the same position investigating a fatality,” he said.
The Yukon government is the territory’s biggest employer.