Two cases were blamed on inadequate staffing of paramedics qualified for the mission. The interiors of the AW139 helicopters, making it difficult to perform CPR, were flagged as a serious problem. The panel made 25 recommendations for improvements. 2013 Ornge air ambulance Moosonee crash On May 31, 2013, a Sikorsky S-76A helicopter crashed resulting in the deaths of two Ornge pilots, Capt. Don Filliter and first officer Jacques Dupuy, and two Ornge paramedics, Dustin Dagenais and Chris Snowball. The crash occurred one kilometre from the Moosonee Airport, shortly after a night-time take-off. TSB report The Transportation Safety Board of Canada investigated the accident. The report noted: "The causes of this accident went well beyond the actions of this flight crew." The pilots had not received sufficient training. The company lacked standard operating procedures to deal with night operations. The company lacked resources and key personnel were inexperienced. Crew pairing was deemed "sub-optimal" for that flight. Some pilots were given inadequate time to prepare for training; the training did not meet company SOPs and was not operationally realistic. It was noted that in 2012, Ornge eliminated the pilot manager positions at each base, switching to a centralized scheduling system. Knowledge of local conditions and familiarity with crews was therefore lost. Ornge was understaffed at the time of the accident. The Operations Manager and the Chief Pilot were new to the management of Emergency Medical Services operations. Key positions, such as Manager of Rotor Wing Flight Safety, Manager of Rotor Wing Flight Training and Standards, his assistant, and an aviation clerk (who was to track records) were vacant. Transport Canada was aware that Ornge was struggling to meet regulations and company requirements. There were clear indications of Ornge's problems months before the accident. TSB chair Kathy Fox said "[Ornge's] willingness to operate safely and within regulatory requirements exceeded its capacity to do so." Canadian Labour Code charges On 29 May 2014 Ornge was charged with 17 offences under the Canadian Labour Code. Court documents disclosed that the charges included permitting pilots to fly the S-76A helicopter "without adequate training in the operation of that specific aircraft," failure to provide the pilots with "a means to enable them to maintain visual reference while operating at night", that the aircraft captain, Donald Mark Filliter had "insufficient experience in night operations", that his pilot proficiency check in the helicopter was incomplete, plus the two pilots