National Défense Defence nationale ISSUE 2, 2018 CHECK SIX Risk and Leadership MAINTENANCE IN FOCUS Location, Location, Location ON TRACK Spot Heights and Max Elevation Figures Cover – Aircraft Technicians from 436 Transport Squadron out of 8 Wing Trenton, Ontario, look on a CC-130J Hercules aircraft taxiing to take off for a medical supply delivery scenario during RIMPAC 16 at Joint Base Pearl Harbor-Hickam, Hawaii on July 13, 2016. Fangs Out! 25 Photo: MCpl Mathieu Gaudreault, Canadian Forces Combat Camera Combat Forces Canadian Gaudreault, Mathieu MCpl Photo: Against the Grain 26 The Voice of Reason 27 Fatigue 28 Rung Out to Air 29 Epilogue 32 Fangs Out! 25 TABLE OF CONTENTS Issue 2, 2018 Regular Columns Views on Flight Safety 4 The Editor’s Corner 5 Good Show 6 For Professionalism 8 Maintenance in Focus 15 Check Six 17 On Track 22 Dossier 24 Lessons Learned 25 From the Investigator 31 Epilogue 32 The Back Page – Directorate of Flight Safety (Ottawa) & 1 Canadian Air Division Flight Safety (Winnipeg) Organizational Chart 34 Lessons Learned Fangs Out! – Lessons Learned From My First Accident 25 Against the Grain 26 The Voice of Reason 27 Fatigue 28 Rung Out to Air 29 DIRECTORATE OF THE CANADIAN ARMED Send submissions to: To contact DFS personnel on FLIGHT SAFETY FORCES FLIGHT SAFETY an URGENT flight safety issue, MAGAZINE National Defence Headquarters please call an investigator who is Director of Flight Safety Directorate of Flight Safety available 24 hours a day at Colonel John Alexander Flight Comment is produced up to four times Attn: Editor, Flight Comment (DFS 3-3) 1-888-927-6337 (WARN-DFS). a year by the Directorate of Flight Safety. 110 O’Connor Street Editor The contents do not necessarily reflect Ottawa, ON, Canada, K1A 0K2 Visit the DFS web page at Major Claire Maxwell official policy and, unless otherwise stated, www.rcaf-arc.forces.gc.ca/en/flight-safety. Imagery Technician should not be construed as regulations, Telephone: 613-971-7011 Corporal Bev Dunbar orders or directives. Contributions, comments FAX: 613-971-7087 Flight Comment magazines and and criticism are welcome. Contributions Email: [email protected] flight safety posters are available Graphics and design become the property of Flight Comment and on the flightcomment.ca website. d2k Graphic Design & Web may be edited for content, length or format. This publication or its contents may not be reproduced without the editor’s approval. ISSN 0015-3702 A-JS-000-006/JP-000 Views on Flight Safety Managing Airworthiness Risk in Support of Royal Canadian Air Force Operations Photo: Cpl Jax Kennedy by Bhupendra Patel, Team Leader for the DTAES Risk Management Center of Excellence, DGAEPM irworthiness is, in general terms, the Officer (SAMEO) was concerned and immediately By managing the risk, it was possible to assign measure of an aircraft’s safety and fitness brought the issue to the attention of the WSM a 30-day compliance time, which minimized A for flight. To be airworthy, an aircraft Senior Design Engineer (SDE). It was at this impact on operations. Upon successful must remain in conformance to its design point that the ARM process was initiated. completion of this SI, the fleet was returned requirements. Any deviation from these design to an Acceptable Level of Safety (ALOS). requirements could result in an airworthiness The SDE formed a Risk Management Team risk that requires timely action to be taken. (RMT), by reaching out to Engineering Officers Even with the fleet returning to ALOS on SI Royal Canadian Air Force (RCAF) and Assistant and LCMMs from the WSM cell, to Subject completion, there was more work to be done Deputy Minister (Material) (ADM(Mat)) staff play Matter Experts (SMEs) from the Directorate of and a need to transition the ARA to a Record of a critical role in managing this risk and are Technical Airworthiness and Engineering Airworthiness Risk Management (RARM). The routinely challenged to make decisions directed Support (DTAES), and specialists from Lockheed- RARM was now focused on determining the root at maintaining the continued airworthiness of Martin, the Original Equipment Manufacturer cause of the issue and the actions necessary to Canadian military aircraft. (OEM), and together they performed an prevent this risk from reoccurring. In this case, Airworthiness Impact Assessment (AWIA). the investigation determined that the original In-service issues that could result in an delivery configuration of the aircraft was not airworthiness risk can be detected at all levels of The team quickly determined that the improper in accordance with the design specification, aircraft operations and support, from flight crew rigging could result in an un-commanded causing the OEM to launch a formal quality and maintainers in operational units, to Aircraft in-flight inflation and release of the life raft, assurance investigation into their Engineering Officers (AEOs) and Life Cycle Materiel which could then become entangled in the manufacturing procedures. Managers (LCMMs) within Weapon System empennage, and result in complete loss of Management (WSM) offices. Their coordinated control of the aircraft. The hazard severity and While this example offers a snapshot of what approach in swiftly dealing with risks as they arise probability were assessed and, based on the goes on behind the scenes to develop, document allows the RCAF to retain primacy of operations RCAF ARM process guidelines, it was determined and resolve airworthiness risks, RCAF staff and continue flying at a level of safety which is that this issue posed a “MEDIUM” airworthiness deals with these issues on a regular basis. accepted by appropriate authorities. risk for the CC130J fleet. Their likelihood is accepted as inherent to our operations and mitigation measures are not The following illustrates how an apparently The CC130J SDE issued a Risk Alert Notification always economically practical. This is why minor malfunction, discovered during a routine (RAN) for the fleet within hours of the original managing airworthiness risk in military aviation technical check, had the potential for catastrophic assessment, informing the operational chain of requires a structured, systematic and compre- consequences, had it not been assessed and command, which allowed for a decision on hensive organization-wide approach. addressed according to the RCAF’s rigorous continued operations while the risk process Airworthiness Risk Management (ARM) process. continued. Less than 24 hours later, the SDE Every issue that might pose a risk brings followed up with an Airworthiness Risk Alert together Risk Management Teams specific to During an inspection of the life raft system release (ARA), which documented the issue in greater the hazard at hand to review its probability and cables on a CC130J aircraft, the 436 Squadron detail, including immediate mitigation activities. severity. RCAF technical and operational staff are maintenance staff noticed the cables hanging The ARA content was jointly approved by the mobilized, within hours, to make effective and lower than normal. This discovery triggered a SDE, on behalf of the Technical Airworthiness informed operational and technical safety more thorough inspection of the complete life Authority (TAA), and the Divisional Operational decisions, guided by a robust Airworthiness raft system where it was determined that both Airworthiness Manager (DOAM), on behalf of Risk Management process. sides of the rigging from the fuselage were out the Operational Airworthiness Authority (OAA) of specification and the life raft CO2 release and the risk was accepted by the Operational Regardless of the origin of the risk, the RCAF cable length was abnormal. Command Risk Acceptance Authority (OCRAA). Airworthiness Risk Management process is a critical component of the DND/CAF Airworthiness At that point, it was not obvious how As part of the ARA risk mitigation actions, Program, on which the RCAF relies to ensure that the improper rigging could affect the flight a Special Inspection (SI) was issued on all military fleets operate as safely as possible in safety of the CC130J; however, the squadron CC130J aircraft to determine how widely, if at all, fulfilling their assigned missions. Senior Aircraft Maintenance Engineering the issue was spread throughout the entire fleet. 4 Flight Comment — Issue 2, 2018 Editor’sThe Corner ow quick we are to judge. I include myself in that “we.” My editor’s H education has chiefly come from studying other flight safety related publications. Neat photos and interesting articles get filed away for later use... with the appropriate permissions of course. Several days ago a publication created by the Flight Safety Department of the Swiss Air Force, Flight Safety Bulletin 1-2018, came across my desk. I read it from both an aircraft accident investigator and an editor’s perspective; At first sight, stories of error seem so simple: What if the vehicle owner had driven assessing the content of the articles and also frantically to the hospital because a family the layout and visual appeal of the images. • Somebody did not pay enough attention; member was in medical distress and had There were several photos in the Cats and Dogs • If only somebody had recognized the parked in the nearest available space, next to section of this magazine that struck my funny significance of this indication, or of that piece other cars that were already parked there? bone chord and I went around the office of data, then nothing would have happened; What if this photo was taken much later in the showing them to my peers. • Somebody should have put in more effort; day when cars had departed the lot making it • Somebody thought that making a shortcut look like spaces were available? What if the Apparently I was not only reading the was no big deal. vehicle owner was from another culture and magazine from an editor and investigator’s And then he goes on to say: did not recognize the significance of a large H perspective but also as an ex-helicopter pilot’s in a circle? Where were the systems in place to viewpoint.