CANADIAN FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FINAL REPORT

FILE NUMBER: 1010-CT114065 (DFS 2-2) DATE OF REPORT: 16 February 2010

AIRCRAFT TYPE: CT114 - Tutor DATE/TIME: 18:35Z (12:35 CDT) 9 October 2008 LOCATION: N50 20.973 / W105 35.284 Approximately 2.5 km northwest of CFB Moose Jaw, SK CATEGORY: "A" Category Accident

This report was produced under authority of the Minister of National Defence pursuant to section 4.2 of the Aeronautics Act, and in accordance with the A-GA-135-001/AA- 001, Flight Safety for the Canadian Forces.

With the exception of Part 1, the contents of this report shall only be used for the purpose of accident prevention. This report was released to the public under the authority of the Director of Flight Safety, National Defence Headquarters, pursuant to powers delegated to him by the Minister of National Defence as the Airworthiness Investigative Authority for the Canadian Forces.

SYNOPSIS

The accident aircraft, Tutor CT114065, crewed by a pilot in the right seat and a military photographer in the left seat, was part of an approved four-plane formation (“Snowbird Blues”) tasked with taking pictures of Moose Jaw, SK based aircraft for publicity purposes. The accident aircraft was being used in a photo-chase role. Following a fly-past at Assiniboia and some photographic work south of the Moose Jaw airfield, the formation returned to Moose Jaw to take pictures of the formation against a background of the headquarters building and the control tower. Following the first photo pass, the photo chase aircraft struck the ground, fatally injuring the two occupants and destroying the aircraft.

The investigation determined that the pilot lost situational awareness while fixating on the main formation and attempting to stay in his assigned quadrant. Contributing to the accident was an underestimation by all involved of the inherent risk and training requirements to safely complete such a mission.

i TABLE OF CONTENTS

1 FACTUAL INFORMATION...... 1 1.1 History of the Flight ...... 1 1.2 Injuries to Personnel...... 3 1.3 Damage to Aircraft ...... 3 1.4 Collateral Damage...... 3 1.5 Personnel Information ...... 3 1.6 Aircraft Information...... 5 1.7 Meteorological Information ...... 6 1.8 Aids to Navigation...... 7 1.9 Communications ...... 7 1.10 Aerodrome Information ...... 7 1.11 Flight Recorders...... 7 1.12 Wreckage and Impact Information...... 8 1.13 Medical ...... 10 1.14 Fire, Explosive Devices, and Munitions ...... 10 1.15 Survival Aspects ...... 12 1.16 Test and Research Activities ...... 13 1.17 Organizational and Management Information ...... 14 1.18 Additional Information ...... 16 1.19 Useful or Effective Investigation Techniques...... 19 2 ANALYSIS ...... 20 2.1 General...... 20 2.2 Personnel Selection ...... 20 2.3 Risk Evaluation/Mitigation...... 21 2.4 Formation Briefing ...... 23 2.5 Traffic Pattern Restrictions ...... 23 2.6 Photo-Chase Pilot’s Actions ...... 24 2.7 Lack of Warning Calls...... 26 3 CONCLUSIONS...... 28 3.1 Findings: ...... 28 3.2 Cause Factors: ...... 30 4 PREVENTIVE MEASURES ...... 31 4.1 Preventive Measures Taken ...... 31 4.2 Preventive Measures Recommended...... 31 4.3 Other Safety Measures Recommended...... 31 4.4 DFS Comments...... 31 Annex A Photographs ...... A-1 Annex B Harvard II Flight Recorder Data...... B-1 Annex C Formation Flight Track on ATC Radar...... C-1 Annex D 1 Canadian Air Division Order 2-002 - Dissimilar Formation ...... D-1 Annex E Abbreviations Used in this Report...... E-1

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1 FACTUAL INFORMATION

1.1 History of the Flight

1.1.1 The planned mission was a four-plane dissimilar formation flight for the purpose of photographing all three Moose Jaw aircraft types in formation. The formation, call sign “Snowbird Blues”, was led by a Snowbird Tutor with Number 2 being a CT156 Harvard II on the right side and Number 3 being a CT155 Hawk on the left side. The accident aircraft was Snowbird Blue 4, which was the photo-chase aircraft. The crew of Snowbird Blue 4 consisted of a pilot in the right seat and an imagery technician in the left seat. The planned mission consisted of one flypast at the town of Assiniboia; two flypasts at a grain elevator approximately 11 km east of the town of Assiniboia and then six passes over and around the 15 Wing Moose Jaw airfield. The first three passes were uneventful and the accident occurred just following the first pass of the six planned over 15 Wing (Annex A Photo 1).

1.1.2 On the morning of the planned flight, the Wing Commander received a personal briefing from the formation Lead on the planned mission, after which he authorized and signed the Flight Authorization Form (CF773). The mission was then briefed by the formation Lead, with all aircrew present, with the exception of the imagery technician, who was being fitted with Aviation Life Support Equipment (ALSE) at the time of the briefing. Also present at the briefing was a Harvard II instructor who was the alternate photo-chase pilot (to be employed if the Snowbird Blue 4 aircraft became unserviceable on start-up). Prior to the main mission briefing, the formation lead briefed the pilot of Snowbird Blue 4 and the back-up photo-chase pilot on the photo-pass requirements and talked in detail about each planned pass. The photo-chase pilots were briefed to remain above and right of the formation at all times. The planned series of passes was predicated on the airfield being “sanitized” for their use, i.e., no other traffic in the pattern. Snowbird Blue 4 was briefed to use the Snowbird smoke feature of the aircraft to highlight the visibility of his aircraft to other traffic in the area. All participants described Lead’s formation briefing as being professional, well executed and thorough.

1.1.3 Following the briefing, the Snowbird Blue 2 aircraft captain spoke with Air Traffic Control (ATC) personnel by telephone and was advised that runway 29L would remain active and the formation would be restricted from operating south of the inner runway (29R) (See Section 1.10). This information was relayed to the Snowbird Blue 4 pilot by phone, however, Snowbird Blue Lead was not informed of this change. 2 Canadian Forces Flight Training School (2 CFFTS) operations agreed to limit the flights during this period to dual only (no solo students). If the formation needed to transit across both the inner and the outer runway the controllers advised they could clear both patterns of traffic with approximately one-minute notice.

1.1.4 The flight conducted an uneventful stream takeoff at 18:01Z (12:01 local time) and turned towards the south prior to joining up and transiting towards the first flypast location at the town of Assiniboia. Sometime during the aerial work around Assiniboia Snowbird Blue 4 made a radio transmission that indicated that the imagery technician

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was actively air sick. After completion of the first three briefed passes, which included several air-to-air photographs by Snowbird Blue 4, the formation proceeded towards 15 Wing to carry out the remaining passes. At approximately 18:30Z, when the formation was approximately 11 nautical miles (nm) southeast of the airfield, Snowbird Blue Lead was informed by the tower controller that the “inner” pattern (Runway 29R) was clear but that the “outer” pattern (Runway 29L) was still active. Lead acknowledged this and advised the tower that the formation would remain north of the centreline of the inner (northern-most) runway. Shortly after this exchange with Air Traffic Control (ATC) Snowbird Blue Lead directed Snowbird Blue 4 to operate within a quadrant defined by Lead’s line abreast or 3 o’clock position and not left of Lead’s 6 o’clock position. This was transmitted on a discreet pre-briefed inter-plane VHF radio frequency. This direction was given to ensure that Snowbird Blue 4 would not conflict with the traffic on runway 29L during the first photo pass.

1.1.5 Approximately 10 miles southeast of the airfield the formation was level at 3,400 feet (ft) above mean sea level (MSL) and flying at 220 knots indicated airspeed (KIAS). Crossing five miles from the airfield the formation began a gradual descent to 2,200 ft MSL (approximately 300 feet above ground level AGL) and maintained 220 KIAS. Two and one-half miles northeast of the airfield, the formation began a left turn using 10 to15 degrees of bank, crossing over the married quarters and heading towards a point just north of the O.B. Philip building. As they approached this building, Snowbird Blue Lead transmitted over the discreet frequency that he was reversing the turn and gently rolled his aircraft into a 30°angle of bank to the right, remaining at about 300 ft AGL and 220 KIAS. Prior to crossing in front of the building, Snowbird Blue 4 manoeuvred his aircraft to a position several hundred feet higher than the formation and moved forward to a position slightly aft of the Snowbird Blue Lead’s wing line (line abreast). The imagery technician took a photograph from Blue 4 as the main formation passed the O.B. Philip building and then the control tower (Annex A Photo 2). The formation lead did not visually check the position of the photo chase aircraft prior to reversing right and his expectation was that the photo chase aircraft would stay high and right throughout this portion of the flight. As the formation continued its right-hand turn towards the northwest, Snowbird Blue 4 was observed to turn with the formation and descend. The turn and descent continued until he was observed to be at the formation’s 3 to 4 o’ clock position and below the plane of the formation at a lateral distance estimated to be 200 to 300 ft. Within the main formation, some pilots noted and remarked on the accident aircraft’s low altitude, but no radio transmission was made. Similarly, Air Traffic Control personnel watching the formation remarked to their co-workers on the low altitude of Snowbird Blue 4, but no radio transmissions were made. As the main formation turned through a heading of 300° magnetic, Snowbird Blue 4 impacted the ground in a slightly nose low, right wing down attitude. No radio calls were made from Snowbird Blue 4, no ejection was attempted and both occupants were fatally injured.

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1.2 Injuries to Personnel

Injuries Crew Passengers Others Total Fatal 2 0 0 2 Serious 0 0 0 0 Minor 0 0 0 0 Total 2 0 0 2 Table 1: Injuries to Personnel

1.3 Damage to Aircraft

The aircraft was destroyed as a result of the ground impact, subsequent explosion and post-crash fire.

1.4 Collateral Damage

The aircraft crashed on a privately owned grain field (stubble) 2.5 km northwest of the airfield. The crash site had burn areas and some fuel and oil contamination to the soil. 15 Wing undertook the environmental assessment and final debris collection. The Flight Safety investigation team is not aware of any pending claim against the Crown.

1.5 Personnel Information

Photo-Chase Pilot Imagery Technician (Right Seat) (Left Seat) Current Yes Tutor ejection seat training valid 07 Oct 08 (valid for 30 days) Valid Medical Category Yes Had approved AMT waiver Medical screening 02 Oct 08 Total flying time (hrs) 6,202.8 N/A Flying hours on type 1,514.7 N/A Flying hours last 30 days 28.5 N/A Flying hours last 90 days 48.5 N/A Duty hours last 24 hours 8.0 N/A Duty hours on day of 4.0 N/A Occurrence

Table 2: Personnel Information

1.5.1 Photo-Chase Pilot

1.5.1.1 The photo chase pilot commenced flying training in the Canadian Forces in 1984 and initially flew CH135 Twin Huey helicopters in the Tactical Aviation role. He

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was then posted to 2 CFFTS as a Qualified Flying Instructor (QFI) on the Tutor, where he attained an A1 instructor rating. 1 This was followed by an exchange tour in the United Kingdom where he was assigned to the Central Flying School (CFS) as an instructor pilot on the Tucano training aircraft (similar to the CT156 Harvard II). He then released from the military and was hired by British Aerospace and employed as an instructor pilot with the Royal Saudi Air Force for nine years. The photo-chase pilot rejoined the Canadian Forces in 2004 and was assigned to 2 CFFTS as a QFI on the Harvard II aircraft, where he again attained an A1 instructor category and was eventually employed as a Standards Pilot. Following a successful Snowbird tryout in March/April 2008, he was selected to join 431 (AD) Squadron for the coming 2009 show season as Snowbird 3 (the inner left pilot). At the time of the accident the photo-chase pilot was a qualified CT114 pilot with a valid Annual Proficiency Check and a valid Unrestricted Instrument Rating.

1.5.1.2 The photo-chase pilot enjoyed a very good reputation among the pilots at 15 Wing as an extremely capable pilot and instructor. He was known for his high degree of professionalism and his calm demeanor. He was also known to speak up if he had any concerns regarding a particular course of action, planned or otherwise. His formation flying during the CT114 Tutor conversion course in preparation for the Snowbirds tryout was described by one Snowbird Standards pilot as the best he had personally witnessed to date. Following his successful selection in April 2008 he returned to 2 CFFTS to continue instructing on the Harvard II until he formally joined 431 (AD) Squadron in August 2008. Beginning in August, the photo-chase pilot had been doing medium altitude Snowbird training flights or “work-ups” with the Squadron Standards pilots and the new incoming Lead. These training flights included manoeuvres as part of a multi-aircraft formation and rejoins to the formation. The work was done with a “hard deck” (i.e., briefed altitude below which the aircraft cannot descend) of 1,500 ft above ground level. Hard deck awareness was a constant briefing and debriefing item. His Snowbird training records indicated he had experienced some difficulty with energy management during turning rejoins and in some situations the accident pilot had attempted to stay on the inside of the turn instead of flowing to the outside of the turn to manage energy. It was reported by the standards officer that the accident pilot had overcome this issue prior to the accident flight and it was no longer a concern. The rejoin training also included some instruction and practice in the use of the vertical plane for energy management. The accident pilot had not received any training regarding how to fly as a photographic platform pilot and had not yet received the 431 (AD) Squadron Low Level Awareness Training (see Section 1.18).

1.5.1.3 There was nothing remarkable in the 72-hour history of the photo-chase pilot. On the day of the accident the photo-chase pilot was described as being in a positive mood and excited about participating in the planned mission.

1 The “A1” Qualified Flying Instructor Category is the highest possible category awarded and, in addition to other mandatory requirements, it denotes the instructor has demonstrated superior flying proficiency and instructional ability. Typically, the A1 Category is not commonly held and only a few instructors, at most, would hold the qualification at a given time.

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1.5.2 Imagery Technician

1.5.2.1 The imagery technician was a 30-year veteran of the Canadian Forces. He had flown in various Moose Jaw based aircraft on an infrequent basis. His ejection seat training was current and he was flying with an authorized Aeromedical Training waiver. There was no evidence that the imagery technician had received any training on how to safely carry and stow cameras while aboard ejection seat aircraft. With the exception of that provided at the Aerospace Engineering and Test Establishment (AETE) no such formal training syllabus exists in the CF.

1.5.3 Other Formation members

1.5.3.1 All other formation members were current and qualified. All the pilots were very experienced formation pilots and came from various supervisory and/or standards positions within 2 CFFTS. All the designated aircraft captains were qualified four-plane formation leads. The formation Lead was also a very experienced pilot, with previous tours as a maritime patrol aircraft pilot, an instructor at 2 CFFTS and as a Snowbird Show Team pilot. Both the CT156 Harvard II and the CT155 Hawk had the front seat pilot as the flying pilot at the controls.

1.6 Aircraft Information

1.6.1 The CT114 Tutor is a low-wing monoplane designed as a two-seat, side-by- side jet trainer aircraft. A single General Electric J85-CAN-40 axial flow turbo jet engine is installed in the centre fuselage, providing a take-off thrust of 2,700 lbs. Originally designed as a student pilot trainer, the CT114 Tutors are primarily used by 431(AD) Squadron and have been modified to allow them to be used as a single-pilot airshow aircraft. These modifications include the re-location of some vital controls so they can be reached from either seat. Also, the Snowbird aircraft have a smoke generation system installed to enhance the visibility and aesthetics of the air display. The CT114 Tutor aircraft is not fitted with a radio altimeter or any type of ground proximity warning system.

1.6.2 Tutor aircraft are fitted with dual ejection seats. These seats employ a ballistically operated lap belt and an automatic parachute opening system. The MK10B Automatic Parachute Opening Device is armed, and parachute deployment subsequently initiated, when tension is applied to the arming cable, which normally occurs during seat/man separation of the ejection sequence.

1.6.3 Tutor CT114065 was reactivated to flying status in Snowbird configuration in April 2008 (see Table 3). The reactivation process included a Periodic Inspection Level 4, which is the most extensive inspection in the Tutor maintenance inspection package. As part of the reactivation several components are replaced, such as flight control bellcrank lever bearings, flight control rod ends and hydraulic actuators. Test flights and maintenance documents indicated that the aircraft was airworthy and maintenance had been carried out in accordance with prescribed technical orders.

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1.6.4 Aircraft Maintenance Records

The aircraft maintenance records were checked with no anomalies noted. Inspection times are annotated in Table 3 (below).

Maintenance Action Completed At: Snowbird Conversion and Completed: 7 Apr 08 (11378.4 hrs) Periodic No. 4 431 (AD) Sqn Acceptance Completed: 29 Apr 08 Check Post Painting Flight Control Completed Serviceable: 16 Sep 08 (11387.2 hrs) Partial Card Test Flt Engine Change at SPAR Completed: 11392.9 hrs Trenton Post Engine Change and Completed Serviceable: 2 Oct 08 (11392.9 hrs) Smoke Tank Installation Test Flight Engine (S/N 8093)Hours at TSO: 733.5 hrs TSN: 8517.3 hrs TSI: 8.9hrs Time Of Accident Airframe Hours at Time Of 11401.8 hrs Accident Time Flown Since Periodic 23.4 hrs Last Aircraft Weighing 29 Mar 08 Last Weight & Balance 6 Oct 08 (Smoke Tank Installation) Amendment Symmetry & Alignment C/O 29 Mar 08 (New Aft Section Installed) Table 3: Aircraft Hours and Inspections

1.7 Meteorological Information

1.7.1 The local weather at the time of the accident was characterized by scattered clouds, good visibility and moderate to strong gusty north-westerly winds. The specific weather reported at the airfield at the time of the accident was winds from 320 degrees True at 21 knots, gusting to 28 knots, a few clouds at 3,500 ft above ground, scattered clouds at 25,000 feet, temperature 8 degrees Celsius, dew point minus 2 degrees Celsius, and an altimeter setting 30.02 inches of Mercury. The forecast called for a continuance of these same conditions.

1.7.2 Turbulence was reported to be light to moderate with no adverse effect on formation station keeping. Bird activity around the airfield was described as light to moderate local birds with heavy migratory bird activity in the area. Bird activity did not affect the formation’s activities.

1.7.3 The sun’s azimuth at the time of the accident, relative to the impact point, was 176 degrees True, with an elevation of 33 degrees above the horizon. This placed the sun at the accident aircraft’s approximate 7 o’clock to 8’oclock position relative to its

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heading at impact. As such, it would not have hindered the accident pilot’s view of the formation or of the ground.

1.8 Aids to Navigation

Not applicable.

1.9 Communications

1.9.1 The CT114 aircraft is equipped with a UHF radio and a VHF radio. The accident aircraft, along with the rest of the formation, was monitoring local ATC agencies throughout the flight using preset standard UHF frequencies. Lead was doing the actual communication with the inner tower air traffic controller on behalf of the entire formation. The formation was using the VHF radio for intra-formation communication.

1.10 Aerodrome Information

1.10.1 15 Wing Moose Jaw is a training base for NATO Flying Training in Canada and home base for the Snowbirds. There are two principal runways, which are parallel and oriented generally east-west (107/287 degrees magnetic). Runway 29R/11L (the “inner”) is used for departures and arrivals and as the primary runway for the CT155 Hawk aircraft. The “outer” or southern-most runway, 29L/11R is the primary runway for the CT156 Harvard II aircraft during visual meteorological conditions (VMC). A third runway, 21/03 (3,400x100 feet asphalt) is used primarily as a taxiway or for emergency situations. At the time of the accident, the inner runway traffic was restricted for the exclusive use of the Snowbird Blues formation. Normal operations were being conducted on the outer runway (29L), with several Harvard II aircraft in the pattern/circuit at the time of the occurrence.

1.11 Flight Recorders

1.11.1 CT114 Tutor

1.11.1.1 The CT114 Tutor is not equipped with either a cockpit voice recorder (CVR) or a flight data recorder (FDR). It is equipped with a non-crashworthy Data Acquisition Unit (DAU) that records basic flight parameters such as airspeed, altitude, roll rate and vertical ‘g’. The DAU was found intact and sent to the National Research Council Flight Recorder Playback Laboratory for examination. The recording chip from the accident aircraft DAU was then placed in a serviceable “surrogate” DAU and the data downloaded by personnel at 431 (AD) Squadron, under the supervision of a Directorate of Flight Safety investigator. DAU data was also downloaded from the Snowbird Blues Lead aircraft. Both sets of DAU data contained corrupted data that precluded their potential use to accurately reconstruct the aircrafts’ performance or flight paths.

1.11.2 CT156 Harvard II

1.11.2.1 The Harvard II is equipped with a modern Flight Data Recorder. Data was downloaded from the Harvard II aircraft that was flying in the formation. This

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information provided an accurate flight profile (see Annex B) of the main formation from the perspective of the Harvard II’s position in echelon right at standard “School” separation (estimated at 40 to 50 ft lateral separation between Lead’s fuselage and the Harvard’s fuselage.) This would place the Lead aircraft lower than the Harvard II during left turns and higher during turns to the right. During the minute of flight time leading up to the time of the accident and using the Harvard II’s FDR data as a reference and using 1,890 ft as the ground level elevation, the formation began a descent from an altitude of approximately 500 ft above ground and entered a left turn with approximately 15 degrees of bank angle. The formation levelled at about 240 ft above ground level (AGL) and then reversed the turn, at a rate of 6 degrees per second, into an approximate 30 degree right bank turn. This bank angle was maintained and, about 5 seconds before the crash, the formation began a gentle climb and Lead was at approximately 270 feet above ground when the accident occurred. Indicated airspeed through these manoeuvres remained at approximately 215 knots.

1.11.3 CT155 Hawk

1.11.3.1 The CT155 Hawk aircraft is equipped with a Heads-up-Display (HUD) video recording system and, while a tape was inserted in the machine prior to the flight, the system was not activated during the flight. As a result, no HUD tape of the accident flight was available to the investigation.

1.11.4 Air Traffic Control Radar

1.11.4.1 Radar ground track, groundspeed and mode C (altitude reporting) data was available from the Moose Jaw ASR/SSR (ATC radar). The radar did not track the actual accident aircraft because its transponder was in the standby position (which is normal for a wingman in a formation), but it did track the lead aircraft of the accident formation in the period leading up to the accident (Annex C). The mode C information from the radar data indicated that Lead was maintaining approximately 2,200 ft above sea level (approximately 300 feet above ground) during the latter part of the photo run and up to the time of the accident.

1.12 Wreckage and Impact Information

1.12.1 The aircraft crashed into a flat stubble field, at an approximate altitude of 1,890 feet above sea level. Ground scars indicate the aircraft heading at impact was 297 degrees magnetic. The wreckage area/burn area was approximately 1,000 feet long and 280 feet wide. A set of low power electrical transmission lines traverses the mid point of the crash site in an east-west direction (Annex A Photo 3). The wires were singed by the fireball, but otherwise there was no apparent contact between the wires/poles and the aircraft wreckage. Ground scars indicate the aircraft contacted the ground in a slightly nose low, right wing down attitude. First contact with the ground was made by the right wing tip and outer portion of the right wing (Annex A Photo 4), followed almost immediately afterwards by the nose and forward fuselage, destroying the front lower portion of the aircraft, popping the Plexiglas out of the canopy and opening up the cockpit area. The aircraft tumbled and broke into three major sections

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with the main portions of the wreckage coming to a rest in close proximity to each other, with the fuselage/wings (Annex A Photo 5) stopping first, followed by the empennage and finally the forward nose area/instrument panel. Other larger pieces of debris included the tail pipe, the smoke tanks, the right flap, the right wing tip, a two-foot section of the right aileron, the batteries and the ejection seats. A detailed examination of the windscreen and canopy surfaces did not reveal any evidence of a bird strike.

1.12.2 The engine compressor exhibited minor first stage compressor blade rotational damage, indicative of a relatively low power setting at impact. There was no apparent damage to the last turbine stage. Foreign debris, consisting of a mixture of small fragments of aircraft structure and soil was found at the mouth of the compressor, in the combustor section and in the turbine section. The forward face of the mud had a brushed appearance with lines in the direction of compressor rotation indicating the compressor continued to turn after the mud had been ingested. This evidence suggests that the engine was rotating and began to spool down during the impact sequence. No impact marks were found on the main fuel control unit, the bleed valve system components or on the throttle quadrant. However, a definitive reading of engine oil pressure at the time of ground impact was obtained from impact marks on the oil pressure indicator which indicated the oil pressure was at 13 psi at the time of impact. Tests with a serviceable Tutor engine indicated that this equates to an approximate engine RPM of 60% (low power, near flight idle).

1.12.3 The left and right speed brake hydraulic actuators were in found in the fully extended position (within 1/8th of an inch) and in reasonably good condition. The flaps and landing gear were found in the retracted position. The elevator and aileron trim motors were found in relatively good condition. When tested, both trim motors were observed to operate through the full range of travel. Based on the position of the trim motors, as found, it is highly probable that the aircraft was trimmed slightly nose down and right wing down at the time of aircraft impact.

1.12.4 Distinct impact marks were found on the right hand Rate of Climb indicator, indicating a 1,200 fpm rate of descent at the time of aircraft impact. Both altimeters read approximately 1,900 feet and had 30.03 inches of mercury set as the altimeter setting. The technical examination of the annunciator lights was inconclusive.

1.12.5 The two ejection seats were found in separate locations in the debris field. Both seats incurred significant damage during the impact and break-up sequence. The left ejection seat (Annex A Photo 6) was found in the middle of the debris field. The right ejection handle was found broken away from the ejection seat and in the down position. The left seat left ejection handle remained on the ejection seat, however, it was extensively damaged and all linkages were broken during ground impact. The left seat pin was found placed in its expected position on the dash shroud. The left seat was set to the bottom of its crew adjustable vertical travel.

1.12.6 The right ejection seat (Annex A Photo 7) came to rest next to the cockpit instrument panel. The head rest / main beam structure was severed just above the backrest of the seat pan and only remained attached by the ballistic lines. The right

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seat inertia reel was found to be fully extended beyond its normal stops. The ejection seat handles were found in the up position. The three M27 charges were found with their sears intact. The ejection seat pin was found in its expected position on the dash. The right seat was set at the bottom of its crew adjustable vertical travel.

1.12.7 Both occupants’ Rigid Seat Survival Kit (RSSK) were found severely damaged with their contents disbursed throughout the debris field. The left seat parachute was severely compromised by the left pedal control rod from the right seat rudder assembly when it was forced into the parachute during the break up sequence. The right seat parachute was activated by the crash dynamics after the occupant was expelled from the seat.

1.12.8 The imagery technician’s camera was found intact and relatively undamaged in the debris field. The digital photographs taken during the flight were recovered from the internal memory card. A used air sickness bag was also recovered from the crash site.

1.13 Medical

1.13.1 Both the pilot and imagery technician immediately suffered fatal injuries during the aircraft impact sequence. These injuries were consistent with multi-axis loads from both rapid deceleration and impact. There was post-mortem exposure to heat and fire.

1.13.2 Blood and tissue samples were taken from the two fatalities and sent to the Armed Forces Institute of Pathology (AFIP) in Washington D.C. for analysis. In accordance with orders, active air traffic control personnel and ground crew who serviced the accident aircraft also submitted blood and urine samples at the 15 Wing medical clinic, which were then sent for processing at the local hospital. Toxicology testing did not detect any substances that would have negatively affected the crew’s performance.

1.13.3 The remains were identified by the local coroner and autopsies were performed on both fatalities at the Moose Jaw Union Hospital prior to releasing the remains to next of kin. No pre-existing medical issues were found during the autopsies.

1.14 Fire, Explosive Devices, and Munitions

1.14.1 Fire

1.14.1.1 There was no evidence of a pre-impact fire. Some witnesses had reported smoke coming from the aircraft but this was determined to be smoke from the Snowbird aircraft smoke system which was switched on to intentionally highlight the position of the chase aircraft. Upon impact, the aircraft’s approximately 1,200 lbs of JP8 fuel was expelled and exploded. This fireball set localized areas of the surrounding stubble field and some of the wreckage on fire.

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1.14.2 Explosive Devices

1.14.2.1 All explosive devices in the CT114 aircraft are associated with the ejection system and were accounted for in the wreckage or debris field.

1.14.2.2 The Canopy Jettison System

1.14.2.2.1 The canopy was on the aircraft at the time of impact and none of the pyrotechnics had been initiated for the ballistic removal of the canopy. No pre-impact anomalies were noted with the canopy or canopy locks.

1.14.2.3 The Ejection System

1.14.2.3.1 The CT114 has two Weber designed ejection seats, which are ejected via a Talley Industries 2400 Series Rocket Assisted Catapult (ROCAT). The ejection seats provide a means of emergency escape from the aircraft provided that the airspeed is between 60 and 350 KIAS and the aircraft altitude is 150 ft (wings level) or greater from the ground level. Each seat must be independently initiated by the occupant, i.e. no command ejection system is installed. Examination of the wreckage revealed that the internal/external canopy jettison cartridge sear2 was removed during the break-up of the airframe. Additionally, all three M1A1 cartridge extractor pins were activated thus allowing the M1A3 canopy remover to fire. All the pyrotechnic devices associated with the jettisoning of the canopy, including the M3A2 internal/external canopy jettison initiator, were found expended in the wreckage.

1.14.2.3.2 All the pyrotechnics from the left seat were recovered. With the exception of the inner tube of the ROCAT, all were found co-located with the seat. The left seat HBU-12B lap belt was found with the occupant. There was no evidence that an ejection had been attempted prior to ground impact. The destructive forces of the aircraft breakup activated the three M27 cartridge activated devices. In turn, the M27s supplied gas pressure to the canopy jettison system and the two M72 cartridge activated devices located on the ejection seat. The M72 provides gas pressure to the rocket motor, however, the rocket motor was compromised at the head rest, allowing the rocket motor to puncture through the head rest of the ejection seat. Additionally, the M32A1 trip rod was activated, causing the lap belt and rotary actuator to be fired, opening up the lap belt at the ballistic connection and allowing the occupant to separate from the seat.

1.14.2.3.3 All the pyrotechnics from the right seat were recovered. There was no evidence that an ejection had been attempted prior to ground impact. Of the nine charges on the seat (with the exception of the four pencil cutters on the Aero Rigid Canopy Drogue) seven were found to be live and two were expended as a result of ground impact. The three M27 charges were found with their sears intact indicating that the ejection handles had not been pulled prior to seat break up, even though the ejection seat handles were found in the up position. The HBU-12B lap belt, found

2 A sear is part of the mechanism required to trigger the cartridge.

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attached to the ejection seat, was ballistically opened and the rotary actuator was expended, allowing the occupant to be separated from the right seat prior to its final resting position.

1.14.3 Munitions

1.14.3.1 No munitions were carried on this aircraft.

1.15 Survival Aspects

1.15.1 Crash Survivability

1.15.1.1 The impact forces and post impact explosion were such that the crash was not survivable.

1.15.2 Aviation Life Support Equipment (ALSE)

1.15.2.1 Pilot

1.15.2.2 The pilot, seated in the right seat, was wearing a CF-issue flying coverall, a Snowbird issued blue short sleeve T-shirt, blue long underwear, commercial blue socks, non CF-issue outer white leather flying gloves and CF-issue Terra flying boots. In addition to the clothing, he was also wearing a CF-issued Gentex 190A helmet equipped with one dark visor, a CF-issued MBU-12/P oxygen mask and a 28-ft flexback parachute. The ALSE worn by the occupant of the right seat was relatively intact but was contaminated and exhibited minor burn damage. The parachute was deployed and intact at the site, with little evident damage. No pre-existing anomalies were noted with the pilot’s ALSE.

1.15.2.3 Imagery Technician

1.15.2.4 The imagery technician, seated in the left seat, was wearing a CF-issue flying coverall, a CF-issue summer flight jacket, a CF-issue blue short sleeve T-shirt, CF-issue white long underwear, CF-issue grey wool socks, CF-issue outer flying gloves and CF- issue Greb combat boots, vice flying boots. He was also wearing a CF Universal Carrier/Life Preserver, a CF-issued Gentex 190A helmet equipped with two visors, CF- issued High Altitude/Low Profile oxygen mask and a 28-ft flexback parachute. The ALSE worn by the occupant of the left seat was severely compromised and largely destroyed during the aircraft impact and post impact fire.

1.15.3 Emergency Transmitters

1.15.3.1 The CT114 is equipped with a “bail-out tone” device that automatically transmits an audible tone on 243.0 MHz if either ejection seat is activated. No tone was heard or recorded on this frequency.

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1.15.4 Emergency Response

1.15.4.1 The off-base crash alarm was signalled almost immediately after the crash. The 15 Wing fire truck departed the firehouse within a few minutes and due to the rapid assembly of other 15 Wing first-response vehicles at the initial rendezvous point (near the base of the control tower) a convoy was formed, led by the firefighters. This convoy also included the On-Scene Command and Emergency Response (OSCER) vehicle, the 15 Wing ambulance, two Ground Search and Rescue (GSAR) vehicles and the Military Police. The local civilian Emergency Medical Services (EMS) ambulance joined the convoy en route to the crash site. These vehicles arrived at the crash site within 11 minutes of the one-bell crash alarm. The responding flight surgeon and accompanying medic arrived 28 minutes after crash alarm.

1.15.4.2 When the fire truck arrived at the crash scene there were two civilians present. One was holding down a parachute that had reportedly been dragging one of the aircraft occupants along the ground. The other civilian was located near a vehicle and not in close proximity to the aircraft debris.

1.15.4.3 The firefighters directed GSAR personnel to refrain from entering the crash site until the area was safe due to ongoing fires. Within five to ten minutes of arriving, all the fires were extinguished and OSCER cleared two of the GSAR personnel to check for survivors. An EMS technician determined that neither of the crew members exhibited any vital signs.

1.15.4.4 The emergency vehicles were repositioned after five to ten minutes in order to avoid the smoke and fumes. The majority of personnel on site were wearing appropriate personal protective equipment (masks and gloves) although there were reports of a couple of individuals not wearing any.

1.16 Test and Research Activities

1.16.1 Fuel Testing

1.16.1.1 There was no fuel available from the accident aircraft for testing. Fuel samples from the fuel tenders that refuelled aircraft CT114065 were sent to the Quality Engineering and Test Establishment for analysis. The fuel was determined to be of the correct type (NATO F-34) and free of contamination.

1.16.2 Oxygen Testing

1.16.2.1 There was no oxygen available for testing from the accident aircraft. However, the Lead aircraft and other Tutor aircraft were refilled from the same oxygen tender and no odours or ill effects were noted by any aircrew that used oxygen from that source.

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1.16.3 Photogrammetric Analysis

1.16.3.1 To aid in the investigation, the Technical Intelligence section of the Canadian Forces Joint Imagery Centre was asked to calculate the altitude, above ground level (AGL), of CT114065 based on two of the hand-held images taken from the aircraft cockpit during the last minute of the flight (the second of the two images can be viewed in Annex A Photo 2 – the first image is from a similar aspect but taken as the aircraft overflew the northwest portion of the Base). The altitude of the aircraft was calculated using two methods: a photogrammetric process using specialized software to determine camera parameters; and 3D modelling / "photomatching" to place the camera in 3D space. Of the two, the photogrammetric process was deemed to be more reliable. Using the photogrammetric process, the camera altitude in the first image of the sequence was found to be 700 ft AGL (+/- 35 ft) and the second image was 576 ft AGL (+/- 30 ft).

1.17 Organizational and Management Information

1.17.1 Mission Tasking and Authorization

1.17.1.1 A dissimilar formation mission request was initiated by 15 Wing in the spring of 2008 (Message WCOMD 16 231540Z APR 08) to update the library of CF aircraft photos for the purpose of public relations and possible use for OP CONNECTION. The intention was to obtain photographs of all three 15 Wing based aircraft in formation with typical prairie scenery and 15 Wing buildings, such as the O.B. Philip (Headquarters) building or the control tower, in the background. This message indicated that the formation Lead would be an experienced 431 (AD) Squadron standards pilot. As provided for in 1 Canadian Air Division Order 2-003, the dissimilar aircraft formation request was approved by 1 Canadian Air Division Headquarters in April 2008 (message DCOMD 034 252030Z APR 08). This message stated that formation “GULAPS”, (gear- up low approaches) were authorized. The planned mission was cancelled shortly afterwards due to the 18 April 08 on-base crash of CT155215 and the resultant flying restrictions imposed on the CT155 Hawk aircraft. The mission was revived on 1 October 2008, and a window of opportunity was identified for the period between 6 October 2008 and 15 October 2008. In the absence of the Wing Commander, who was away on temporary duty, the request for a mixed aircraft close formation flight was sent to 1 Canadian Air Division via email by the 15 Wing Headquarters Chief of Staff (COS) / Acting 15 Wing Commander on 2 October 2008. This email stated that “The pilot of the photo-chase aircraft is experienced performing this type of mission.” Although a specific pilot had not been nominated at that time, the COS indicated this statement in the email request was made on the assumption that the photo-chase pilot would be a 431 (AD) Squadron pilot, probably one of the Standards pilots, and would therefore be experienced in this type of tasking. The Air Division approved the request, via email on 8 October 2008. Friday, 10 October was chosen as the specific date for the photo mission.

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1.17.1.2 The town of Assiniboia was hosting the Fall Conference for the Saskatchewan Economic Development Association (SEDA) from 7 to 9 October 2008. On 3 October 2008, the town of Assiniboia submitted a request to 15 Wing for a two aircraft flypast at 12:15 on 9 October 2008, the last day of the SEDA. On 7 October 2008, 2 CFFTS operations requested that both the photo mission and the Assiniboia flypast be combined into a single mission. This request was agreed to on the morning of 8 October by the Acting Wing Commander, pending 1 Canadian Air Division approval for the Assiniboia flypast. 1 Canadian Air Division approval came before the end of the day on 8 October 2008 for “a mixed aircraft close formation for a one time only flight with Wing Commander supervision.”

1.17.1.3 The 1 Canadian Air Division coordination instructions authorized a flypast to take place no lower than 1,000 ft above obstacles but stipulated that the Wing Commander could authorize an altitude waiver to conduct the flypast at a lower altitude. As required by regulations, the Mayor of Assiniboia provided his approval for a flypast at 500 ft over the town. The Mayor’s approval was received at 15 Wing on 7 October 2008. The flypast altitude of 500 ft was in turn approved the next day by the Acting Wing Commander and a copy of the approval was forwarded to the 1 Canadian Air Division Special Events Coordinator, via email, from 431 (AD) Squadron.

1.17.1.4 In recognition of the stipulation regarding Wing Commander’s supervision, the Wing Commander, as per his direction, was provided with a briefing by the formation lead on the planned flight at approximately 09:30 local time the day of the mission, 9 October 2008. The briefing covered, in detail, the planned flight profile and who would be flying in the various aircraft. Photo chase aircraft low altitude manoeuvring considerations were not discussed. The Wing Commander was very comfortable with the plan and the personnel chosen to fly in the formation, including the pilot chosen to fly the photo-chase aircraft. Following the briefing, the Wing Commander personally signed the Flight Authorization Form (CF773). In doing so and in accordance with direction stated in B-GA-100-001/AA-000, (National Defence Flying Orders) Chapter 3, he was indicating that he was satisfied that the aircraft crew was qualified and competent to accomplish the assigned duty and that they were properly briefed and understood the assigned duty. The photo-chase pilot then initialled the CF773 to acknowledge, as the aircraft commander, that the assigned duties were fully understood and that the flight details and requirements specified in the flight authorization would not be deviated from.

1.17.2 Crew Composition and Assignment

1.17.2.1 The 15 Wing request for the flypast specified that all pilots involved would be qualified and current on type, that the 2 CFFTS pilots would be QFIs and that, due to the possible requirement to cycle aircraft through different formation positions, all aircraft captains would be four-plane formation lead qualified.

1.17.2.2 In the original message reply to 15 Wing in April 2008, the Air Division stipulated that the formation would be led by 431 (AD) Squadron. The source for the photo-chase pilot was not stipulated. When the tasking was resurrected the Wing

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assumed that 431 (AD) would lead the formation and that a 431 (AD) Squadron standards pilot would fly the photo chase aircraft. This was the initial plan but the chosen date of 9 October meant that the accident pilot was the only 431 (AD) Squadron pilot (other than the formation lead) available to fly on the day of the planned mission. One of the 431 (AD) Squadron Standards was on leave and the other was away on temporary duty. Since the 431 (AD) Squadron Commanding Officer was in San Francisco with the show team the formation lead sent him an email to outline the mission plan, identified himself as the formation lead and the accident pilot as the photo chase pilot. No concerns were raised among any of the personnel involved in the planning of the mission when it became apparent who the pilot would be for the photo- chase aircraft. In fact, the pilot had the full and unwavering confidence of everyone involved. The formation lead expressed to the CO of 431 (AD) Squadron that he was totally comfortable with the accident pilot manoeuvring around the three-ship formation in a non-aerobatic photo chase role. The 431 (AD) Squadron Commanding Officer approved the plan and advised the formation lead to go ahead with the mission.

1.18 Additional Information

1.18.1 Harvard II Manual of Flying Training

1.18.1.1 General

1.18.1.2 The photo chase pilot was an experienced Harvard II flying instructor and previous Harvard II Standards Pilot. As such, he would have been very familiar with the Harvard II Manual of Flying Training (MFT), which contains information pertaining to formation flying and, in the context of low-level visual navigation, operating in the low- level environment. These are the procedures and techniques taught to Harvard II pilots under training. As such, procedures would be well practiced and ingrained in the flying instructors, and ex-instructors, such as the occurrence pilot.

1.18.1.3 Formation Flying Procedures

1.18.1.3.1 With respect to formation procedures, the MFT describes a “break-out” as an intentional and rapid manoeuvre away from the last known position of either the lead or another aircraft in the formation. During this manoeuvre several things must be considered, including other aircraft in the formation and ground proximity. A breakout is required when any of the following occurs: (1) loss of visual contact; (2) hazardous situation develops; (3) directed to do so by the lead; or (4) if ahead of or under the lead. As soon as possible after commencing a break-out, the wingman must advise the lead and continue with the break-out manoeuvre until adequate separation is assured or until direction is received from lead.

1.18.1.3.2 With respect to rejoins, the MFT states that for turning rejoins the pilot should manoeuvre the aircraft to ensure sufficient clearance to be able to pass safely behind and below the lead aircraft in the event of an overshoot. It goes on to state that if reducing power and extending the speed brake will not prevent an overshoot, safe separation is maintained by passing behind and below the lead. Increasing bank in an

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attempt to salvage a rejoin is not recommended as it may cause the wingman to lose sight of the lead at a critical phase of flight. Once the decision to overshoot has been made, the collision course must be broken by rolling the wings level and reducing power. The rejoining pilot is to ensure that the aircraft does not climb as it crosses below and behind the lead aircraft. At no time must the pilot allow the aircraft to climb to or above lead’s altitude. By ensuring vertical separation at all times, the possibility of collision is greatly reduced. These procedures are based on the premise that the manoeuvring will occur well above ground level, typically thousands of feet above the ground.

1.18.1.3.3 As a wingman, the pilot is expected to maintain a constant awareness of the collision potential associated with formation flying and to keep the lead in sight at all times. If sight of lead is lost, the wingman is to follow the briefed break-out procedures.

1.18.1.3.4 The MFT discusses low-level safety considerations only with respect to low-level (500 ft AGL) visual navigation. The MFT emphasizes that the first and most important item in the low-level crosscheck is terrain clearance. The MFT also contains a list of Low-Level Training Rules which were developed to ensure that all pertinent flight safety and other related issues are reviewed immediately prior to conducting training missions in the low-level environment. It covers items to be briefed such as weather, contingencies and terrain considerations.

1.18.2 Canadian Forces Formation Regulations

1.18.2.1 The National Defence Flying Orders (B-GA-100-001/AA-000) state that prior to commencing the assigned flight, the aircraft commander and/or formation leader shall ensure that all members of the aircraft crew and/or formation are adequately briefed on all factors that may affect safety or completion of the assigned duty.

1.18.3 Dissimilar Formation Requirements

1.18.3.1 Orders pertaining to the conduct of close formations comprising different types of aircraft, otherwise known as dissimilar formation, are contained in 1 Canadian Air Div Order Vol 2, 2-003 Section 3 Paragraphs 22 (f) and 23 (see Annex D). All units shall apply to 1 Canadian Air Division Deputy Commander Force Generation for approval to conduct mixed aircraft formation flying. The Order states that approving officers shall ensure that the mixed formation requirement is of sufficient importance to the Department of National Defence (DND) to warrant exceptional approval and that adequate training and safety constraints are applied.

1.18.4 Photo-Chase Procedures

1.18.4.1 With the exception of specific 431 (AD) Squadron flights and AETE test flights, photo-chase missions are not common in CF flying and individual pilots would have limited or very limited opportunity to participate in this type of mission over the course of their operational flying. There is no published guidance with respect to photo chase procedures in National Defence Flying Orders or 1 Canadian Air Division Orders.

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The established procedures in effect at AETE detail considerations to ensure the correct information is captured on camera but do not detail specific safety considerations of manoeuvring as a photo-chase aircraft around a formation. The AETE document also outlines the qualifications of the Photo Technician and provides guidance on the security of photography equipment in the cockpit.

1.18.4.2 Snowbird pilots routinely fly with photographers during the show season while conducting media flights. However, these are not typically flown specifically as photo- chase missions. 431 (AD) Squadron does require a specific Squadron qualification be held to be able to fly as photo-chase around the 9-plane formation in an aerobatic role. This involves intense training and a check ride and is regarded as a demanding role, requiring a strong formation and aerobatic background. This qualification would normally be held by one of the Squadron standards pilots who had previous experience as a Show Team pilot. The accident pilot had just begun training to be a display pilot and had received no photo-chase training.

1.18.4.3 Interviews with numerous pilots indicated there was no standard methodology regarding how a camera should be stored in the cockpit when not in use or whether a strap should be attached to the camera. No formal training is provided to imagery technicians during their training regarding the safety considerations of carrying a camera in an ejection seat equipped aircraft.

1.18.5 Low Level Awareness Training (LLAT)

1.18.5.1 There is no formal LLAT program in the 2 CFFTS Harvard II flying syllabus although safety and terrain avoidance considerations are covered with respect to manoeuvring on a low level visual navigation mission. A Low Level Training Rules briefing is included in the Harvard II MFT and is required to be briefed prior to flying a low level navigation mission. 431 (AD) Squadron has a LLAT program which includes a mandatory slide package and briefing on the hazards of low level flying. The briefing is adapted from and closely follows the CF188 Hornet LLAT briefing and is primarily targeted at the single pilot/aircraft scenario. It does not generally deal with low-level formation or photo-chase considerations but does include briefing items on low-level rejoin hard-deck awareness and potential restrictions with respect to out-of-plane manoeuvring at low altitude. This briefing is given during the Fall/Winter work-up training period prior to the practice of show routines at low altitude. During work-ups, the Squadron follows a progressive step-down approach, beginning approximately 2,000 ft above ground and, as proficiency in the various manoeuvres improves, working down to as low as 300 ft above ground. The occurrence pilot had joined the team in August and had not yet received the 431 (AD) Squadron LLAT training and all his formation manoeuvring/training had been conducted at medium altitudes using hard decks to simulate the restrictions inherent in manoeuvring in the low level environment.

1.18.5.2 The CF188 LLAT briefing states that large portions of flying accidents happen in Visual Flight Rules low altitude flying and that most of these happen during turning and vertical manoeuvres. Both the 431 (AD) Squadron and CF188 LLAT briefs clearly state that the first priority is to miss the ground, and only if that can be safely

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accomplished, do the mission. The 431 (AD) Squadron LLAT briefing warns to be careful of angular issues and “hard deck” situational awareness during rejoins and that going low (out-of-plane manoeuvring) during the later portion of a rejoin may not be an option.

1.18.5.3 Fighter Force (CF188) training rules state that for flights below the “transition altitude” (generally meaning flights in the low-level environment), briefing items must include that the flight path and terrain clearance are primary tasks and that wingmen fly above Lead except, where terrain or comfort level dictates otherwise. This is regularly briefed and re-enforced during routine training missions.

1.19 Useful or Effective Investigation Techniques

Not applicable.

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2 ANALYSIS

2.1 General

2.1.1 The imagery technician was not trained aircrew. Although he had specific airborne duties and thus was a crew member (vice passenger), the responsibility for maintaining a safe flight path rested with the pilot of the accident aircraft.

2.1.2 The investigation found no evidence of a mechanical malfunction or a control restriction which could have either distracted the pilot or impeded his control of the aircraft. Witness testimony was consistent in describing the flight path as a smooth steady turning descent, with no abrupt movements. Presumably a pilot who could no longer control his aircraft and who was aware of the impending ground impact would attempt an ejection. Additionally, had the imagery technician been aware of the impending ground contact it is reasonable to assume that this danger would have been quickly communicated to the pilot in some manner or he may have even unilaterally decided to attempt an ejection. The physical evidence clearly indicated that no ejection was attempted by either occupant.

2.1.3 The maintenance of position in general relation to the main formation and the extension of the speed brakes indicate the pilot was conscious and actively attempting to achieve a desired flight profile. The investigation did not find any evidence to suggest that the pilot was medically, psychologically, physically or physiologically incapacitated prior to impact with the ground. There was no evidence that would indicate a state of physiologically generated spatial disorientation.

2.1.4 Therefore, it is concluded that the accident crew were not incapacitated in any way but also that they did not recognize the danger of their spatial situation. They were obviously unaware of their close proximity to the ground and that continuance of their flight path would result in a controlled flight into terrain (CFIT) accident. This loss of situational awareness, in which the pilot is unaware of the problem and thus fails to recognize and correct the flight path is called Type 1 (unrecognized) Spatial Disorientation (SD) and is considered the most dangerous type of disorientation.

2.2 Personnel Selection

2.2.1 The selection of pilots and aircraft for the mission was heavily influenced by resource constraints. The Tutor aircraft was chosen for the primary photo-chase aircraft to minimize impact on flying training in Moose Jaw. Consequently, the photo-chase pilot would be supplied by 431 (AD) Squadron since they are the only unit at 15 Wing operating that type of aircraft. The photo-chase mission was originally planned to occur on the Friday but it was moved ahead to Thursday due to the request for a fly-past at the civic event in Assiniboia. This decision to combine the two missions and fly on the Thursday meant that the only 431 (AD) Squadron pilot available to fly photo-chase was the accident pilot, as all other potential Snowbird pilots were either away on other missions or on leave.

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2.2.2 During the early planning stages and the solicitation of higher headquarters’ permission it was envisioned that the photo-chase pilot would be one of the more experienced 431 (AD) Squadron Standards pilots and someone who had flown in a photo-chase role before. Given his relatively recent arrival on the Squadron, it is possible that the accident pilot would not have been the first choice to fly this profile if other, more experienced Snowbird pilots had been available. However, because of the relatively late decision to move up the date of the exercise, none of the Snowbird Standard’s pilots were available. That said, no one involved in the planning or the conduct of the mission, from the Wing Commander down to any of the other formation members, had the slightest reservation about the accident pilot flying in this role. This is understandable, considering that all were very familiar with the accident pilot’s extensive instructional background, his demonstrated skill level and professionalism and the fact that he was now a member of 431 (AD) Squadron. Further, the accident pilot himself was directly involved in the mission planning and was highly motivated to fly the mission.

2.3 Risk Evaluation/Mitigation

2.3.1 While everyone was completely comfortable with the choice of pilot for the photo-chase role, part of that comfort level was based on the perceived risk inherent in the mission profile. The main risks perceived were the hazards of flying in a dissimilar aircraft formation. It was the dissimilar aircraft formation aspect that required the permission of higher headquarters, not the photo-chase element. The decision to man the formation with very senior and experienced pilots was an attempt to mitigate some of the perceived hazards of flying in a dissimilar aircraft formation. The mission profile itself was repeatedly described as “benign” by all involved, meaning that it was viewed as a straightforward, non-complex task and well within the capabilities of all involved. The formation would not be doing anything but gentle or medium banked turns and the photo-chase pilot simply had to capture photographs of the formation at the appropriate times and avoid hitting the formation. Nevertheless, when examined more closely, this photo mission profile required the pilot to do something he had not done before, something he was not specifically trained to do, and to do it in the low-level environment. Fluid manoeuvring around a formation at low altitude is potentially a high risk activity and typically involves specialized training, including LLAT. The photo-chase pilot’s low level flying experience was limited to visual navigation exercises that did not involve manoeuvring around a formation. With the exception of take-offs and recoveries, all his formation training and instructional experience had been flown thousands of feet above the ground. He had not received LLAT training and, unlike experienced Snowbird pilots or fighter pilots, he had not been specifically trained in ground avoidance techniques for low altitude fluid formation manoeuvring and these techniques were not ingrained in his habit patterns. These gaps in his experience were not fully considered by those planning and briefing the mission and were overshadowed by his overall high experience level and reputation as a very capable pilot. Consequently, the inherent risk in this aspect of the mission was underestimated.

2.3.2 Risk mitigation in the context of Air Force operations can be viewed as occurring via three principle methodologies. The first is regulatory in nature and is

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executed via the implementation of policy and formalized training and qualifications. Typically these aim to mitigate the risks associated with certain situations that have been encountered in the past, and which have either resulted in an accident or have been recognized as being inherently risky. The intent of such guidance is to provide aircrew with the collective experience of years of previous air operations. The second method is through formalized risk assessment processes, such as the generation of a Record of Airworthiness Risk Management. This process may be used where there is a recognized risk but no formal Air Force doctrine to provide a mitigation strategy. Commanders and supervisors (depending on the assessed risk level) are given the authority to make a decision concerning the acceptability of the risk through a formal assessment process based on advice from the operational and technical airworthiness authorities. The third methodology of risk assessment and mitigation occurs at the tactical level and is done, or should be done, by the Flight Authorization Officer in authorizing the flight, and also by the aircrew who are about to conduct the mission during the mission planning or mission brief itself. Their previous training and experience can be used to match individual skill sets against the perceived mission requirements to recognize the inherently risky portions of that mission. Mitigation takes the form of modifying the plan until the level of risk is assessed as “acceptable”. This determination of an acceptable level relies upon collective pilot experience and is subjective. If the pilots who are conducting the brief have never encountered a situation before, and there is no policy to provide guidance, they may lack the ability to adequately assess that risk.

2.3.3 In this situation there was no operational policy or direction concerning the conduct of low-level photo chase duties or the qualifications required to perform this duty. None of the pilots in the formation had experience in conducting low-level photo- chase missions. The combination of a lack of guidance and a lack of experience created a situation in which all the aircrew and flying supervisors involved in the mission underestimated the inherent risks to a safe completion of the mission. There was a further reduction in the assessed level of risk because of the notable flying experience possessed by the accident pilot (“halo” effect). Consequently, all personnel interviewed stated that this mission was “benign” and all were surprised that it resulted in a fatal accident.

2.3.4 The Wing Commander endeavoured to provide the appropriate level of oversight to ensure that the mission could be conducted in a safe and effective manner. This is demonstrated by his personal approval of the selection of the formation members, the direction to the Lead to brief him on the planned mission prior to the formation brief, and his personal written authorization of the flight. One of the stated requirements of a Flight Authorizing Officer is to ensure the aircraft crew is qualified and competent to accomplish the assigned duty. He was evidently satisfied with the planned activity and the skill level of the personnel but had the same biases and weaknesses as everyone else involved – he had not flown such a profile himself, it was viewed as a simple mission, it was being flown by very experienced aircrew and was being led by the Snowbird Lead designate.

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2.4 Formation Briefing

2.4.1 All the formation members described the formation briefing as being well presented, thorough and conducted in a professional manner. All of the participants indicated they were very clear on what the plan was and how it would be executed. There was, however, no discussion about what would happen when the formation manoeuvred towards the photo-chase aircraft and no concerns were raised by any of the attendees. The Lead did succinctly brief the photo-chase pilot to remain at or above Lead at all times and it was assumed by Lead that the photo-chase pilot would take any required action to avoid ground collision. The main points discussed were for the photo- chase pilot to get the pictures and avoid colliding with the main formation.

2.4.2 In hindsight, given the photo-chase pilot’s lack of experience in photo-chase, and particularly, low-level photo chase “fluid” manoeuvring, more time could have been spent reinforcing this risk area of the planned mission. A statement to the pilot of the photo-chase aircraft that he was to remain above Lead at all times did not successfully compensate for a lack of ingrained training or experience in this area. This area was not dealt with in more detail because of the experience and perceived capabilities of the photo-chase pilot and the perceived simplicity of the planned mission. As well, there was no formal organizational level direction/guidance related to photo-chase briefing considerations that would trigger the Lead to consider the additional risks and mitigating actions with the photo-chase pilot.

2.5 Traffic Pattern Restrictions

2.5.1 The change in the anticipated runway closures forced an airborne change to the original plan that had been briefed on the ground. Based on his telephone conversation with the Tower, the photo-chase pilot was aware that only the inner pattern would be available prior to take-off. However, this information was not passed to Lead prior to take-off. Lead only became aware that the outer runway was still active when he checked in on the tower frequency. While he would have preferred the entire airfield to be restricted for their use only, he was not unduly surprised at this turn of events. His solution to de-conflict with the outer traffic and continue with the mission was to advise tower that the formation would stay north of the inner runway at all times. His other consideration, to avoid any conflict with outer runway traffic, was to restrict the photo- chase pilot from manoeuvring through his 6 o’clock position. The photo-chase pilot would have been monitoring the ATC frequency so he would be aware of the reasons for Lead’s imposition of the manoeuvring restriction.

2.5.2 The photo-chase pilot did not voice any concerns with this restriction over the radio. Given that the photo-chase pilot was known to be a safety conscious pilot who would speak up if he had concerns with a situation, it seems the ramifications of this restriction on his freedom to manoeuvre when the formation manoeuvred towards him were probably not fully appreciated at the time (see Section 2.6, below, for a discussion of the manoeuvre limitations). Lead also did not consider that this would create an undo problem for the photo-chase aircraft and his expectation was that the photo-chase aircraft would do whatever was required to miss the formation and miss the ground.

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2.6 Photo-Chase Pilot’s Actions

2.6.1 Psychological studies have shown that when performing in high states of arousal, people tend to exhibit the “overlearned, overtrained, dominant response”. While sometimes useful, this overlearning and overtraining is gained at the expense of a flexible response. Skills learned to the point of sufficiency may be potentially the most dangerous since the trainees, trainers and supervisors alike will assume that the skill is available. In reality, that skill will be the first to disappear under pressure. It will be replaced by a much more primitive action that has been practiced for a much longer time3. The “Einstellung” effect is a psychological term used to describe this type of response.

2.6.2 “Einstellung” is a psychological term relating to one of the brain's ways of finding an appropriate solution/behaviour as efficiently as possible. It refers to a person's predisposition to solve a given problem in a specific manner even though there may be more appropriate methods of solving the problem. This reaction is observed when a person is presented with a problem or situation that is similar to problems they have worked through in the past. If the solution to the problem/situation has been the same in each past experience, the person will likely respond in the same manner, without giving the problem too much thought, even though a more appropriate response might be available. Essentially, the Einstellung effect is the negative effect of previous experience when faced with and attempting to solve new problems. It has been experimentally shown that being in a stressed state can increase the prevalence of this response.

2.6.3 Based on witness testimony and the recovered photographs, it is clear that as the formation approached the airfield from the northeast in level flight at low altitude, the accident aircraft was manoeuvred to a position above and to the right (north) of the main formation so the imagery technician could photograph the main formation against the desired background objects. As the photo-chase pilot was seated on the right side, with his seat adjusted to the bottom limit, he would have to bank the aircraft to the left to keep the formation in sight. Top side (right) rudder may also have been used to attempt to maintain a straighter flight path and enhance the imagery technician’s ability to take an unobstructed photograph of the main formation. At about this time, as was pre- briefed and announced over the internal formation radio frequency, the formation reversed the turn and began a 30-degree banked turn to the right (towards the northwest).

2.6.4 The formation’s turn to the northwest combined with his higher altitude generated a heading closing-angle and overtake (excess energy) problem that the photo-chase pilot was required to solve to honour his miss contract with the formation and not overtake the lead position of the formation. He was now several hundred feet above the formation and on the inside of the formation’s turn radius. He was also

3 Weick, K.E, A Stress Analysis of Future Battlefields in J.G. Hunt and J.D. Blair, eds, Leadership on the Future Battlefield, Washington, Pergamon Brassey’s 1985. Quoted in Snook, S.A., Friendly Fire, (Princeton, Princeton University Press, 2000)

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looking cross-cockpit, which would hamper his ability to maintain visual contact with the formation anytime he was above and on the right side of the formation. The photo- chase pilot was further constrained in his ability to manoeuvre and deal with the excess energy by Lead’s ad hoc imposition of the restriction not to manoeuvre left of the 6 o’clock line and potentially conflict with traffic in the outer runway pattern.

2.6.5 There were a number of potential solutions to the overtake problem but not all of them were available to this particular pilot. The pilot could simply break out by manoeuvring up and away from the formation (which would involve a temporary loss of visual contact with the formation), advising Lead he was “out” followed by a rejoin or a move back into position when safely able. Another possible solution would be to ignore Lead’s direction and transit through the 6’oclock position of the formation to the outside of the turn and then move back to the assigned quadrant. A solution available to those with more experience in advanced manoeuvre training (which the accident pilot lacked) would be to manoeuvre in the vertical plane (a “high yo-yo” manoeuvre) to bleed off the excess energy.

2.6.6 Based on the available evidence, however, it is apparent that the photo-chase pilot felt he could manage the situation and still honour his assigned 3 o’clock to 6 o’clock restriction. The photo-chase pilot remained on the inside of the right-hand turn of the formation and, presumably to keep the formation in sight, began a descent. To control the resulting closure with the formation and not overtake Lead, he would also have to turn with the formation and slow down. This is consistent with the witness testimony and physical evidence, in that he was observed to turn and descend and the power was at or near flight idle with the speed brakes extended at impact. Although the photo-chase pilot would not be attempting to actually rejoin the main formation, the circumstances were such that it resembled a formation rejoin scenario, with the formation in a right turn and the photo-chase aircraft on the inside of the turn and closing. However, the aircraft likely had too much energy to stay on the inside of the turn and ended up with an excessive closure rate on the formation. The usual, or flying training school, solution to this problem is to deal with the excessive overtake by descending below and/or behind the formation, crossing to the outside of the turn if required, and then stabilizing in position before crossing back to the right side. This recommended technique or procedure is based on being at higher altitudes and that is where it is practiced - typically several thousand feet above the ground, where the potential for ground collision is negligible and the main concern is avoiding a collision with the formation. The photo-chase pilot would have been well practiced at this manoeuvre, having flown and taught this manoeuvre numerous times during the course of his instructional duties.

2.6.7 The observed flight path strongly suggests that this is what the photo-chase pilot was attempting to do. While we will never know for sure, this choice of action, while not appropriate to the situation, was likely a manifestation of the Einstellung effect. He probably did not recognize initially that his closure rate would lead to a possible overshoot of the formation. He had been practicing numerous rejoins of various types during his initial Snowbird training. Snowbird rejoins are typically more aggressive (faster or “hot”) than a typical flying school rejoin and, although he initially had

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experienced some trouble perfecting the technique, he had resolved these problems prior to the accident and was probably feeling more confident in his newly acquired ability to handle a “hot” rejoin. Either the pilot felt he had sufficient room under the formation to conduct the manoeuvre or, while focused on the task of remaining in his assigned quadrant, reverted out of habit to his well practiced previous rejoin experience and lost sight of the fact that he was now manoeuvring very close to the ground.

2.6.8 Based on the pilot’s known character and past performance, it is deemed very unlikely that the pilot would have deliberately chosen to fly under a formation that he knew was flying only a few hundred feet above the ground. He had no reason to believe they would have climbed significantly in the last 30 seconds or so since the last photograph was taken. Far more likely is that the photo-chase pilot’s attention became fully focused on the formation to monitor and ensure positive separation between it and his aircraft. He had to keep the formation in sight at all times to ensure that he would not collide with them. As he approached from the right-rear quarter, he would have to descend to keep the formation visual from the right seat and his attention would increasingly be focused above and to the left of the aircraft. His difficulty in keeping the formation in sight would have been exacerbated by his cross-cockpit view from the right seat and the fact that his seat was positioned at the lower limit of its travel. At some point, since he would be focused on Lead, he should have realized that he was lower than Lead with reference to the horizon, which, to pilots more experienced in low-level fluid formation manoeuvring, or perhaps less task saturated, would have served as a strong cue to immediately climb up and away from the formation and the ground. However, the approaching terrain that would be visible out the front windscreen would not be in his field of view unless he deliberately turned his attention away from the formation, which was now only several hundred feet away, and closing. The photo- chase pilot was likely becoming task saturated and fixated on the main formation, above and to the left of him. Becoming task saturated and fixated in this way resulted in the loss of situational awareness (Type 1 spatial disorientation) and missing or being unable to process the available cues which would indicate his dangerously low altitude and impending ground impact. The imagery technician would not have been taking pictures at this point because they were in the process of repositioning for the next photo run. However, it is natural that his attention would also be drawn up and to the left to the nearby and closing main formation and therefore he most probably was also unaware of the close proximity to the ground. It is also possible that he was air sick at the time and not monitoring the flight path for that reason. Although he was not an experienced flyer, it is still anticipated that had he noticed the very low altitude, he would have become alarmed at the closeness of the ground and verbally warned the pilot, who would have attempted a last second flight path vector change. However, as no change in attitude was observed by witnesses during the last few seconds of the flight it is concluded that no such warning was issued.

2.7 Lack of Warning Calls

2.7.1 Although the accident aircraft’s approach to the ground was witnessed by the non-flying pilots in the other formation aircraft and by personnel in the control tower, no warnings or “pull-up” calls were transmitted over the radio. The reason given by the

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other pilots in the formation was that, although they considered it unusual that the aircraft was flying that close to the ground, the common assumption was that the photo- chase pilot must be aware of his proximity to the ground and knew what he was doing. The photo-chase pilot was well known to the other members of the formation and based on their knowledge of his extensive experience as a military flying instructor, his A1 instructor category and his overall reputation as a professional pilot with excellent handling skills, they were not unduly alarmed by what they saw and therefore did not see any reason to issue a warning over the radio, until it was too late.

2.7.2 The experienced on-duty control tower personnel also observed the situation developing and remarked to each other that they were uncomfortable with the low altitude of the photo chase aircraft. However, they were reluctant to transmit to an aircraft flying as part of a formation, particularly a Snowbird aircraft, and assumed that the pilot was intentionally flying at such a low altitude.

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3 CONCLUSIONS

3.1 Findings:

3.1.1 The photo-chase pilot was current and qualified in accordance with existing Orders. [1.5.1.1]

3.1.2 The photo-chase pilot had been a very experienced, A1 Qualified Flying Instructor prior to joining 431 (AD) Squadron in August 2009. [1.5.1.1]

3.1.3 The imagery technician was qualified for the planned mission. [1.5.2]

3.1.4 Toxicology testing did not detect any substances that would have negatively affected the crew’s performance. [1.13.2]

3.1.5 The mission was properly authorized in accordance with the Orders. [1.1.2, 1.17.1.1, 1.17.1.4]

3.1.6 The pre-flight formation briefing included a statement from Lead to the photo- chase pilot to remain above Lead at all times. [1.1.3]

3.1.7 The planned and ground briefed pattern of photo passes had to be modified airborne when Lead was informed by ATC that the outer runway was still active. [1.1.4, 2.5.1]

3.1.8 The photo-chase pilot was aware prior to commencement of the flight that the outer runway would remain active. [1.1.3, 2.5.1]

3.1.9 The aircraft was airworthy and serviceable at the time of the accident. [1.6.3, 2.1.2]

3.1.10 The CT114 Tutor aircraft is not fitted with a radio altimeter or any form of ground proximity warning system. [1.6.1]

3.1.11 Weather and sun angle were not a factor in the accident. [1.7]

3.1.12 The accident aircraft transitioned from above and right of the formation to below and right of the formation as the formation completed a 30-degree right bank turn. [1.1.5]

3.1.13 No low altitude warnings were transmitted by other aircraft or ATC. [1.15, 2.7]

3.1.14 The accident aircraft struck the ground in a slightly right wing low, slightly nose low attitude with a descent rate of 1200 feet per minute. [1.1.5, 1.12.1, 1.12.4]

3.1.15 At impact, the engine was at or near flight idle, the speed brakes were deployed and the landing gear and flaps were retracted. [1.12.2, 1.12.3].

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3.1.16 No ejections were attempted. [1.14.2.2.2, 1.14.2.2.3]

3.1.17 The accident was not survivable and both crew members were killed instantly on impact. [1.13.1, 1.15.1]

3.1.18 The 15 Wing crash response was rapid and appropriate. [1.15.4]

3.1.19 There was no evidence of crew incapacitation or pre-existing medical issues that could have contributed to the accident. [1.13.3, 2.1.3]

3.1.20 The photo-chase pilot had no experience flying photo-chase missions, had no experience in low level manoeuvring around a formation, and had not received any formal Low Level Awareness Training. [1.5.1.2, 1.18.5.1]

3.1.21 There was a widely held belief that the photo-chase pilot, based on his extensive experience and demonstrated instructional abilities, was more than capable of safely and effectively completing the assigned mission. [2.2.2, 2.3.3]

3.1.22 The inherent risks of manoeuvring around a formation at low altitude were underestimated by all involved in the planning and supervision of the mission. [2.3.1, 2.3.3]

3.1.23 No formal organizational level direction is available to guide the briefing and conduct of generic or low-level photo-chase missions. [1.18.4.1, 2.3.3]

3.1.24 The combination of the normal 3 o’clock and ad hoc 6 o’clock restriction limited the manoeuvring options available to the photo-chase pilot. [2.6.4]

3.1.25 The photo-chase pilot allowed his aircraft to descend below Lead while manoeuvring in the low-level environment. [1.1.5, 2.6.8]

3.1.26 The photo-chase pilot likely became fixated on the formation while attempting to stay in his assigned quadrant, resulting in Type 1 Spatial Disorientation and a loss of situational awareness with respect to ground proximity. [2.6.8]

3.1.27 The photo technician did not receive any training on how to safely carry and stow cameras while aboard ejection seat aircraft. With the exception of AETE, no such training syllabus exists in the CF. [1.18.4.3]

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3.2 Cause Factors:

3.2.1 The inherent risks of manoeuvring around a formation at low altitude were underestimated by all involved in the planning and supervision of the mission. [3.1.22]

3.2.2 No formal direction is available to guide the briefing and conduct of generic or low-level photo-chase missions. [3.1.23]

3.2.3 The photo-chase pilot had no experience flying photo-chase missions, had no experience in low level fluid manoeuvring around a formation, and had not received any formal Low Level Awareness Training. [3.1.20]

3.2.4 The imposition of the 6 o’clock restriction limited the manoeuvring options available to the photo-chase pilot. [3.1.24]

3.2.5 The photo-chase pilot descended below Lead while manoeuvring in the low- level environment. [3.1.25]

3.2.6 The photo-chase pilot likely became fixated on the formation while attempting to stay in his assigned quadrant, resulting in a loss of situational awareness with respect to the proximity of the ground. [3.1.26]

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4 PREVENTIVE MEASURES

4.1 Preventive Measures Taken

Nil

4.2 Preventive Measures Recommended

4.2.1 In a manner similar to the order currently in existence for dissimilar formation, 1 Canadian Air Division develop and promulgate a Division Flying Order that will provide personnel tasked with planning and flying photo-chase missions with the appropriate guidance to consider and minimize the inherent risks. [3.1.23, 3.2.2].

4.2.2 1 and 2 Air Division develop an Operational Risk Management tool for use by Flight Authorization Officers to aid them in the identification and mitigation of mission specific risks. It is envisioned that this tool would be most useful for non-routine missions and/or those for which normal training would have not fully prepared the crews. [3.2.1]

4.2.3 1 and 2 Canadian Air Division develop and promulgate a Division Flying Order to direct that pilots selected to fly photo-chase missions requiring fluid manoeuvring below 2,000 ft AGL be provided with suitable LLAT prior to the execution of the mission. [3.2.1]

4.3 Other Safety Measures Recommended

4.3.1 2 Canadian Air Division / Air Force Technical Training develop and incorporate into imagery technician training, guidance on recommended procedures and safe practices for imagery technicians tasked with photo-chase missions. [3.1.27]

4.4 DFS Comments

4.4.1 What is striking in this accident is that, other than having dissimilar aircraft types in the formation, no one saw any unusual risk in the planning and execution of the mission. No one recognized the inherent risk involved in flying photo-chase, particularly in the low-level environment. Throughout the entire planning process, all levels were very comfortable with the planned mission and the choice of the photo-chase pilot. It was viewed as a straight forward formation mission being flown by very experienced pilots with an ex-A1 instructor/ now Snowbird pilot, flying photo-chase. The word “benign” was used commonly by different individuals to describe the planned mission. Clearly, with the benefit of hindsight, this mission was anything but benign. In fact, on the very first turn towards the photo-chase side of the formation, the pilot found himself “jammed”, and while attempting to turn and stay with the formation, descended until impact with the ground.

4.4.2 When examined more closely, it is clear that this mission profile required the pilot to do something he had not done before, something he was not specifically trained to do, and to do it in the low-level environment. The ability to recognize and implement

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the non-break-out solutions required experience in low-level fluid manoeuvring around a formation, or advanced manoeuvres, experience which the accident pilot did not possess. Using the available evidence, we can speculate what caused the pilot to choose the course of action that he did; however, a definitive understanding of his thought processes was forever lost with the pilot.

4.4.3 With the changes in demographics and experience levels in the Air Force, the recommended preventive measures will address specific considerations for photo- chase missions. Considering the development of an Operational Risk Management program (process) for use at the tactical level may aid aircrew and flying supervisors in identifying hazards and risks more readily. While the Air Force can quite rightly pride themselves on the expertise of their personnel and their ability to get the job done, it is important they remain particularly diligent when presented with situations which depart from the normal range of operations. Each level of organization must take the time to examine the risks closely and ensure that these risks are mitigated to the best degree possible and that the personnel selected to complete the tasks have the training and experience to carry out the task safely and effectively.

// original signed by //

G.R. Doiron Colonel Director Flight Safety

32/32 Annex A 1010-CT114065 (DFS 2-2) 16 February 2010 ANNEX A: PHOTOGRAPHS

Photograph 1: Depiction of planned passes (1 to 6) from the formation briefing board.

North O.B Philip Building Control Tower

Runways

Photograph 2: Picture taken from the photo-chase aircraft approximately 25 seconds prior to the crash. The formation is highlighted by the yellow circle, with the control tower in the background.

Impact point Engine/fuselage

Threshold area of Runway 11R

A-1 Annex A 1010-CT114065 (DFS 2-2) 16 February 2010

Photograph 3: Aerial view of crash site, looking west. Large arrow indicates direction of flight.

Power line poles

Direction of Initial impact point Flight

Photograph 4: Initial Impact point looking back towards the Moose Jaw control tower.

Control Tower Initial impact by right wingtip

A-2 Annex A 1010-CT114065 (DFS 2-2) 16 February 2010

Photograph 5: Main debris field, looking southeast towards impact point.

Photographs 6,7: Left and right (respectively) ejection seats, as found.

A-3 Annex B 1010-CT114065 (DFS 2-2) 16 February 2010 Annex B Harvard Flight Data Recorder Information

B-1 Annex C 1010-CT114065 (DFS 2-2) 16 February 2010

ANNEX C

Ground Track of Snowbird Blues formation based on Moose Jaw radar data

Snowbird Blue Lead’s transponder identification is SB15.

The information displayed below the SB15 tag is the aircraft’s altitude above sea level to the nearest 100 ft. The number to the right is the distance from the YMJ VORTAC.

Snowbird Blue Lead

C-1 Annex D 1010-CT114065 (DFS 2-2) 16 February 2010

Annex D

Extracts from the Dissimilar Formation section of 1 Canadian Air Division Order 2-003

“27 f. Mixed Aircraft Close Formations. To minimize this activity, all Units shall apply to 1 Cdn Air Div DComd FG for approval to conduct mixed aircraft formation flying. The exception to this requirement is Fighter Force operations where approval authority has been delegated to WComds who may further delegate this authority as required. Approving officers shall ensure that the mixed formation requirement is of sufficient importance to the Department of National Defence (DND) to warrant exceptional approval and that adequate training and safety constraints are applied. Authorized in- flight refuelling, essential SAR escort, or emergency in-flight recovery operations are not affected by this Order.

Aircrew Briefing

28. … the following shall be briefed as a minimum:

a. the method of join-up;

b. the position of all aircraft in the formation;

c. the methods and signals to be used in changing position;

d. the methods of breaking off;

e. emergency procedures including inadvertent IMC procedure;

f. communications failure procedures; and

g. recovery procedures.

Request Procedures

30. Wing requests for formation flying requiring the approval of the Commander 1 Cdn Air Div or DComd FG will include the following information:

a. date of flight;

b. purpose and substantiation for the flight;

c. foreign countries involved (if applicable);

d. aircraft types and numbers involved;

e. details regarding pilot training/currency/qualification;”

Additional non-pertinent information from Order not shown

D-1 Annex E 1010-CT114065 (DFS 2-2) 16 February 2010

ANNEX E

Abbreviations used in this Report

1 Cdn Air Div 1 Canadian Air Division 2CFFTS 2 Canadian Forces Flying Training School AD Air Display AETE Aerospace and Engineering Test Establishment AFIP Armed Forces Institute of Pathology AGL Above Ground Level ALSE Aviation Life Support Equipment ASR/SSR Airport Surveillance Radar/Secondary Surveillance Radar ATC Air Traffic Control CFI Chief Flying Instructor CFS Central Flying School CVR Cockpit Voice Recorder DAU Data Acquisition Unit EMS Emergency Medical Services FDR Flight Data Recorder GSAR Ground Search and Rescue KIAS Knots Indicated Airspeed MSL Above Sea Level NM Nautical Miles OAA Operational Airworthiness Authority OSCER On Scene Command and Emergency Response QFI Qualified Flying Instructor ROCAT Rocket Assisted Catapult RSSK Rigid Seat Survival Pack SEDA Saskatchewan Economic Development Association TAA Technical Airworthiness Authority TSI Time Since Inspection TSN Time Since New TSO Time Since Overhaul UHF Ultra High Frequency VHF Very High Frequency VMC Visual Meteorological Conditions Z Zulu (Greenwich Mean Time or Universal Coordinated Time)

E-1