National Défense Defence nationale

ISSUE 2, 2012

IN THIS ISSUE:

From the Flight Surgeon 9 The Common Cold Dossier 16 Mountainous Terrain Clearance Profiles Lessons Learned 26 Do You “Think” or Do You “Know” ? Views on Flight Safety By Chief Warrant Officer Jacques Boucher, Directorate of Flight Safety

“Invest” in Flight Safety

t one time or another, you have likely There are several factors constantly at work all applicable paperwork prior to releasing the been briefed on the significance of that challenge our Flight Safety record: personnel aircraft for service, ensuring that close-out A investing prior to retirement. However, inexperience, new fleets in service and high checks are completed at the end of inspections, have you given any thought to “investing” operational tempos are only a few of the ensuring that tool control is adhered to, and in a new generation of air force personnel, examples. For most members of the Royal last but not least, ensuring that junior technicians prior to retirement? Whether intentional or Canadian Air Force, these factors are largely understand the importance of properly not, hopefully this is occurring! out of our control. One key factor within your completing their work and how it fits within control, and one that could help reverse the the big picture of flight safety. As experience For those who have participated in this year’s rising trend of the “personnel” cause factor, levels remain low, the need for effective annual Flight Safety briefing, you are likely is ensuring effective supervision. I am not supervision is not only applicable in the aware that with respect to ground occurrences, referring to micro-management here but maintenance arena, but critical throughout the “personnel” cause factor is the only one more about the basics of good supervision. the air force. that has consistently increased since 2005. As related to the maintenance world: being Although part of this trend might be explained there for critical juncture points during Before you leave the Canadian Forces, how through better reporting, which is a good maintenance tasks, ensuring that the tasks were much of your valuable experience are you thing, this does not account for many of the carried out as per the approved maintenance willing to “invest” in your subordinates, incidents occurring. manual, ensuring that subordinates complete today?

2 Flight Comment — Issue 2, 2012

Photo: Cpl Igor Loutsiouk Table of Contents Issue 2, 2012

Regular Columns Views on Flight Safety 2 Good Show 4 For Professionalism 5 18 The Editor’s Corner 8 From the Flight Surgeon – The Common Cold 9 Diminishing Skills? Maintenance in Focus – Maintenance Documentation 11 Check Six – If you want to live, have Something In Reserve 14 From the Investigator 35 Epilogue 37 The Back Page – 2012 RCAF Flight Safety Conference 40 26 Dossiers Mountainous Terrain Clearance Profiles 16 Diminishing Skills? 18 Wildlife Strikes – Part 1 22 Do You“Think” Lessons Learned Do You “Think” or Do You “Know”? 26 or Do You“Know”? Near Miss 27 No Problemo 28 32 Supply and Demand – of Attention! 29 Share the Power 30 The Wrong Mix 32 Snowmobile vs Twin Otter 34 27

DIRECTORATE OF THE CANADIAN FORCES Send submissions to: Subscription orders should be directed To contact DFS personnel FLIGHT SAFETY FLIGHT SAFETY MAGAZINE Editor, Flight Comment to: Publishing and Depository Services, on an URGENT flight safety issue, Directorate of Flight Safety PWGSC CGP/EGC, Ottawa, ON K1A 0S5 please call an investigator who Director of Flight Safety Flight Comment is produced three times Telephone: 1-800-635-7943 is available 24 hours a day at Colonel Yvan Choinière a year by the Directorate of Flight Safety. NDHQ/Chief of the Air Staff MGen George R. Pearkes Building Email: [email protected] 1-888-927-6337 (WARN-DFS). Editor The contents do not necessarily reflect official policy and, unless otherwise 101 Colonel By Drive Annual subscription rates: for Canada, The DFS web page at Captain John Dixon stated, should not be construed as Ottawa, Ontario Canada $19.95, single issue, $7.95; for other www.airforce.forces.gc.ca/dfs Graphics and design regulations, orders or directives. K1A 0K2 countries, $19.95 US, single issue, offers other points of contact d2k Marketing Contributions, comments and criticism Telephone: 613-992‑0198 $7.95 US. Prices do not include GST. in the DFS organization or Communications are welcome. Contributions become the FAX: 613-992‑5187 Payment should be made to write to [email protected]. property of Flight Comment and may be Email: [email protected] Receiver General for Canada. Imagery Technician ISSN 0015‑3702 edited for content, length or format. This publication or its contents A‑JS‑000‑006/JP‑000 Corporal Alex Paquin may not be reproduced without the editor’s approval. Corporal Dean Smith

n 21 February 2011, Corporal Smith, a Flight Engineer under training at 440 Transport Squadron Yellowknife was deployed O on exercise Northern Bison in Churchill Manitoba. He was part of a CC138 ski-equipped Twin Otter crew which had been tasked to support and resupply members of the 38 Canadian Brigade Group who would be travelling by snowmobile over frozen tundra and ice.

440 (T) Squadron utilizes an Engines Running Operation (ERO) to maximise utilization of the aircraft and minimise turn-around time. This ensures that an aircraft does not become disabled in remote areas, while guaranteeing that safety is not jeopardized. On one such ERO resupply, Corporal Smith was directed to organise and supervise the next offloading from the Twin Otter to the inbound snowmobiles. Corporal Smith was situated outside and to the rear of the engines running aircraft while awaiting their arrival when he observed the first snowmobile approaching his position. It quickly became evident that the snowmobile was not stopping at the rear of the aircraft as directed, but intended to continue towards the spinning propeller.

Corporal Smith took immediate action by physically grabbing the shoulder of the driver to prevent further movement towards the front of the aircraft. The snowmobile came to a stop approximately six feet Corporal Smith currently serves with 440 Transport from the running propeller. Squadron, Yellowknife.

Corporal Smith’s quick recognition of a dangerous situation and immediate actions most likely prevented a serious injury or possibly even loss of life. His exemplary actions serve as an inspiration to his peers and supervisors alike, and make him very deserving of this Good Show Award.

4 Flight Comment — Issue 2, 2012 Professionalism For For commendable performance in flight safety

Private Matthew Ligon Pte Ligon was a new apprentice aviation technician recently arrived from Borden. His n 18 November 2010, a work crew was experience level at recognizing and repairing tasked with conducting the replacement aircraft faults was very limited, yet he had O of the Air Cycle Machine in the tail the aptitude to identify an anomaly and the compartment of Dash 8 aircraft CT142803. confidence to bring this to his supervisor for During the close out and inspection phase, what he thought to be an issue of importance. Private Matthew Ligon noticed what appeared to be damage to one of the flight control Inspection of the flight control cable was cables in an adjacent area of the compartment. not a part of the task at hand, and Pte Ligon He brought this to the attention of his supervisor, is commended for his exceptional diligence who confirmed that there was significant in looking beyond the immediate work area. damage to the cable requiring immediate Through his acute attention to detail and replacement. personal drive, he was able to eliminate the possibility of an airborne failure of the elevator It was eventually determined that the damage flight control system, and thus, avoid a occurred during a previous maintenance activity significant and hazardous flight control that occurred approximately one year earlier. malfunction. He is most deserving of this Private Ligon serves with 402 Squadron, A flight safety incident report was initiated For Professionalism award. Winnipeg. and all squadron aircraft were inspected.

Corporal James Meikle Cpl Meikle assisted flight safety personnel by researching technical orders and doing visual hile performing a visual inspection inspections of hydraulic line checks on other of the utility hydraulic system as part aircraft. It was subsequently determined that W of a Supplementary Inspection on a the line chaffing was caused by bends in the CH124 Sea King helicopter, then Private Meikle, hydraulic lines that compromised the allowable from 423 (MH) Squadron, discovered a serious clearance criteria, and that this was an isolated chaffing condition that posed a significant flight incident. safety risk. Cpl Meikle’s action averted the possible Cpl Meikle went above and beyond the failure of multiple CH124 utility systems such required scope of inspection by removing a as blade fold, hoist, landing gear, main probe flight control access cover to gain better access and sonar. His initiative to go above and to hydraulic system lines for inspection. While beyond the inspection requirement and his Corporal Meikle currently serves with in this area he discovered that a rotor brake exceptional professional attitude averted 423 Maritime Helicopter Squadron, hydraulic supply line and a hoist hydraulic a potentially serious accident and is highly 12 Wing Shearwater. line had come into direct contact with a cyclic deserving of a For Professionalism flight pitch control rod. He immediately informed safety award. a Level “A” technician who confirmed the existing unsafe condition and they contacted the flight safety section.

Issue 2, 2012 — Flight Comment 5 Professionalism For For commendable performance in flight safety

Corporal Jonathan McArthur In trying to locate the u/s pylon, Cpl McArthur discovered that the pylon had been installed n Friday 08 April 2011, Cpl McArthur, on aircraft 188928 and was scheduled to fly. an aircraft structures (ACS) technician He also found that the pylon had been worked O at 410 Tactical Fighter (Operational on by unqualified and unauthorized personnel Training) Squadron was requested to inspect and had undergone an unauthorized repair. a wing pylon at 1 Air Maintenance Squadron Recognizing the seriousness of the situation, (AMS) armament shop. He discovered that he immediately identified the airworthiness the pylon had misaligned drill holes on the concerns, flight implications and notified bracket mounts for the encoder/decoder. 410 Squadron Flight Safety personnel. The aircraft was subsequently removed from He recommended that the pylon be returned the flying program and placed in quarantine. situation, having the conviction to act and to 1 AMS for repair or have a Defect Report then following it through to a safe conclusion and Engineering Disposition (DRED) produced Cpl McArthur’s diligence and professional are all traits worthy of praise. Cpl McArthur’s to repair it in the unit ACS shop. As a courtesy, actions prevented a non-airworthy aircraft actions epitomize what Flight Safety is all Cpl McArthur called the ACS technician at the from going airborne. It is very likely that the about and he is truly deserving of this For 1 AMS shop to inform them of the misaligned ad hoc repair would have resulted in a serious Professionalism award. holes to raise awareness of the mistake made. Flight Safety occurrence on a future flight. His willingness to step in and act on this Corporal McArthur serves with 410 Tactical The following Monday, Cpl McArthur potentially dangerous situation demonstrated Fighter (Operational Training) Squadron, accompanied the 1 AMS ACS technician to superlative integrity. Recognizing an unsafe 4 Wing Cold Lake, Alberta. view the misaligned holes of the pylon.

HMCS Vancouver the crew with an ideal approach for landing. The ship’s company was closed up and the n 30 September, 2011, HMCS Vancouver Captain gave permission to land. The helicopter and its embarked Sea King helicopter immediately landed safely on deck and O were patrolling the Mediterranean conducted an emergency shutdown without Sea off the coast of Libya as part of Op Unified further incident. Protector/Mobile. This emergency required the aircraft to land Approximately 45 minutes into a routine as soon as possible, and the speed, precision patrol flight and 25 miles from HMCS Vancouver, and enthusiasm of the entire ship’s crew enabled the ship’s Sea King experienced an intermediate them to accomplish this quickly and safely. gearbox emergency. The ship’s company immediately came to Emergency Flying Stations, The actions and performance of the Captain changed course and increased speed in order and Crew of HMCS Vancouver is a testament HMCS Vancouver is based in Esquimalt, to minimize the time for aircraft recovery. to their professionalism, teamwork and British Columbia. dedication. The efficiency of their reaction At precisely the right moment, HMCS Vancouver mitigated and minimized any further flight simultaneously slowed and executed a turn to compromise. They are most deserving of this match the aircraft’s flight course, providing For Professionalism flight safety award.

6 Flight Comment — Issue 2, 2012 Corporal Tanya Logan was discovered that the drawings were deficient and many of the drain holes were n September 2011, Cpl Logan, an aircraft not indicated in the reference documents. structures (ACS) technician at 436 (T) I Squadron noticed a discrepancy in the At her insistence, the FSR submitted a formal number of exposed drain holes found under request for corrected drawings in order to the fuselage of CC130 Hercules aircraft 130603. prevent future errors. Upon receipt of the new She reasoned that some drain holes had been drawings, she again noted that there were covered when protective tape was applied still several deficiencies and again brought to the fuselage. this to their attention. When the third iteration of drawings arrived with errors, Cpl Logan and weight and balance issues affecting the A covered drain had been discovered on another assisted the (LM) engineers in producing longevity of the CC130J fleet. If left unidentified, aircraft earlier and approximately a gallon of proper drawings of the CC130J drain-hole the likelihood that other aircraft would have trapped water was released when it was opened. locations. Equipped with accurate information, been incorrectly modified was very high. Concerned that a reoccurring condition might crews were able to identify and rectify Her decisive actions are commendable and exist, she examined an un-modified aircraft covered drain holes on several other modified a testament to her professionalism. She is and conducted a detailed visual comparison. aircraft in the fleet. definitely deserving of this For Professionalism This exam confirmed her suspicion that several award. drain holes had indeed been covered. She Through Cpl Logan’s persistence and attention engaged the Lockheed Martin (LM) Field to detail, she was able to identify a serious Corporal Logan currently serves Service Representative (FSR) in order to compare and insidious hazard in the modification with 436 Transport Squadron, the drawings used in the taping process to process which would have unquestionably 8 Wing Trenton, Ontario. that of the true location of the drain holes. It caused structural damage by internal corrosion

Corporal Greg Myers Although the propeller was not covered by the deviation, Cpl Myers took the initiative to pl Myers, an Avionics Technician (AVS) verify that the contractor hardware was installed at 440 (T) Squadron in Yellowknife NT, properly. Upon examination, he discovered C is employed in the AMCRO (aircraft that the safety threads were not visible. He maintenance control and repair office) section immediately informed his supervisors who and due to the small squadron maintenance confirmed the error, prompting a thorough organization, he is often called upon to do inspection. During this inspection of the work as a snags technician. propeller it was determined that the bolts did not meet safety specifications and required In Sept 2011, while working on a CC138 Twin replacement Otter, Cpl Myers queried a propeller replacement team about a previously authorized maintenance Cpl Myers’ actions prevented a potential Cpl Myers’ diligence, professionalism and deviation issued by the Twin Otter Aircraft aircraft accident or incident. His actions also concern for airworthiness, outside his area Engineering Office. The maintenance deviation prompted follow-up action by the engineering of expertise, make him a deserving recipient of addressed the need to ensure that the authority with regard to the 3rd line contractor this For Professionalism flight safety award. hardware securing the propeller zero thrust propeller overhaul process, thus preventing assembly had a visible safety thread and was subsequent improperly assembled propellers Corporal Meyers currently serves with torqued properly. He was advised that this was from entering the CC138 supply system. 440 Transport Squadron, Yellowknife. not required, because the installed propeller’s serial number was not listed on the deviation. Issue 2, 2012 — Flight Comment 7 The To the Editor Editor’s Corner Letter from Major Don Carver 14 Wing Air Traffic Control Officer, 14 Wing Greenwood Concern I read the article (RT Communications Discipline, Flight In my relatively short time (approaching two years) in the position of Editor Comment Issue 1, 2012) and like the way you used the climb of Flight Comment magazine, I have received, heard and seen some things of incident at the end to highlight the point. In keeping with concern. No, I am not referring to the occasional vilification of yours truly along the intent of FS to educate we used it to highlight to several new controllers/trainees the difference between rookie and with questions relating to my parentage, but more to the culture within our advanced control technique. More experienced controllers Flight Safety system. would not only not use the “to” but would also anticipate a possible “bust” of the restriction, assess if it would be Ouch critical with respect to conflicting aircraft and either advise On an anonymous aviation forum, I recently saw Flight Comment described as the aircraft climbing of the conflicting traffic (for critical situations) or prepare to level the aircraft if they pass being a mediocre publication (ouch!). Believe me when I say that I have heard through the altitude. Anticipation and projection of conflicts worse. While I am not here to prove or disprove the above, I will absolutely agree is a critical controller aptitude and the lack of it is a primary that our beloved magazine can always be improved and we must continually cause of our 50% failure rate. strive to do so. One point, in 25 years of controlling I’ve never used sarcastic How Many? responses to correct a pilot’s RT and the most I’ve said on air Some of you might wonder where the articles within these “hallowed” pages to address issues is “Call me when you get on the ground”. come from. A few are re-prints from other magazines, and some are from However; as a former instructor your point ref non-standard previous issues of Flight Comment, but most are from you, members of the CF. RT and controllers working in their second language is spot Since I have been in this position, we have published around 75 articles: some good on. Trainees working in their second language do not have and some probably not as good according to some, but all intended to contribute time to translate standard RT never mind try and figure out to the Flight Safety Program. From that 75, how many unsolicited article expressions like “spot on”. submissions from the CF do you think I have been inundated with? 100? 200? Anonymity Almost all of the articles printed in the Lessons Learned section are from attendees of the Flight Safety Course. Writing an article is a course requirement, and all of these articles eventually get sent to my inbox. Then they are read and authors of the ones deemed publishable are contacted for permission to print. At this point, two things are surprising to me: • the number of authors who request anonymity • the number of authors who do not allow their articles to be published at all Because sharing flight safety experiences is so important to our “blameless” flight safety culture, the second bullet in the above should be a concern to everyone. Why would someone not want to share his/her experience that others could learn from? I’ll leave that for you to answer. As to wanting to remain anonymous, I am not sure that this is a concern – or is it? I would be interested to hear what you think about these questions. Three The answer to the above question on the number of unsolicited articles received and published is a grand total of 3 articles in 20 months. I mention this in the hope that some might re-consider putting “pen to paper” and passing it along. What are we looking for? Anything related to Flight Safety that others might benefit from. In the final analysis, Flight Comment is your magazine and just one tool we use to promote aviation safety. To those who have contributed content in the past, we thank you; to those who have not, we look forward to your future consideration.

You can contact me directly at [email protected]. Fly safe. Captain John W. Dixon Editor, Flight Comment

8 Flight Comment — Issue 2, 2012 The Common Cold does flying on a commercial airline increase your risk?

By Major Helen Wright, Directorate of Flight Safety, Ottawa

neezing, sore throat, runny nose – If the anecdotal reports are true and there extreme altitude exposures such as mountain you know the signs of a cold. Although is a higher risk of colds after flying, air quality climbing or space fight have also been shown S the common cold is usually mild, with does not seem to be the problem: many to alter the immune system. symptoms lasting one to two weeks, it is a studies have shown that the filtered air in leading cause of doctor visits and missed days today’s aircraft is of very high quality. 99.9% Other notable physiologic stresses of flight are from school and work in North America. of bacteria and virus are filtered out and the dehydration due to low air humidity and Children have about two to six colds a year, air is completely exchanged at least 20 times fatigue associated with long days and disruption while adults average about one to three colds per hour. Studies of aircraft ventilation of circadian rhythm. Lack of sleep, circadian a year1. systems indicate the spread of pathogens changes and dehydration all appear to influence during flight occurs rarely4. Air recirculation the human immune system; however, it is Is Flying on a commercial airline itself is not a factor since passengers on not clear how the degree of the fatigue and a risk factor for the Cold? airplanes that did and did not recirculate air dehydration stresses experienced in flight had similar rates of post flight respiratory translate to susceptibility for illness. Many people complain of respiratory symptoms symptoms5. following air travel. Studies indicate that there may be a higher incidence of the common cold Prevention So if it is not the air quality or air recirculation, following commercial air flight. One study There are several ways you can keep yourself what else could be increasing the risk of a cold found 20% of passengers experienced cold-like from getting a cold or passing one on to others after flying? A recent study looked at altitude symptoms in the week following a flight whether you are flying or not: to see if physiologic stresses such as lowered which is a much higher rate than the 2.2 colds/yr barometric pressure and mild hypoxia can found in bus or train commuters2. Another • Touching environmental surfaces such as increase one’s chance of illness. They found study found high rates of colds in flight telephone, keyboard, stair railings or door that exposure to cabin altitudes of about 8000 ft attendants. On the other hand, there are handles that have cold viruses on them for 10 hrs causes temporary and very mild studies that indicate the incidence of the cold transfers the cold virus to your hand. The immune changes in the body that may does not increase with air travel, and one virus can survive up to 3 hours on objects. contribute to an increased susceptibility to looking at military aircrew found the rate of Cold viruses on your hands can enter your respiratory infections2. Interestingly, more colds is similar to the North American average3. body through your eyes and nose. Wash

Issue 2, 2012 — Flight Comment 9 your hands frequently and keep your hands Aircrew and others with jobs that may influence Endnotes away from your face. If soap and water are flight safety should use care selecting 1 http://www.niaid.nih.gov/topics/commoncold/ not available, alcohol-based disinfecting over-the-counter cold remedies at the Pages/default.aspx products can help. pharmacy. Some, such as decongestants and 2 Wilder-Smith A, et al (2012). Transient immune cough suppressants, may relieve symptoms impairment after a simulated long-haul flight. • Cover your nose or mouth so you sneeze or but they do not prevent or shorten the length Aviat Space Environ Med; 83:418-23. cough into your elbow rather than your hand. of the cold. Importantly, most of these medicines have some side effects, such as 3 Ungs TJ, Sangal SP. (1990). Flight crews with upper (Note that it has been consistently found that drowsiness, dizziness, and insomnia that are respiratory tract infections: epidemiology and risk of colds is reduced in those who engage in not safe for flying or other aviation-related failure to seek aeromedical attention. Aviat Space regular exercise while avoiding overtraining6). duties. See your flight surgeon for advice. Environ Med;61(10):938-41. 4 Leder K, Newman D (2005). Respiratory infections Treatment 7 Conclusion during air travel. Intern Med J. 2005;35(1):50-5. There is no cure for the common cold. It is possible that commercial airline flight 5 Zitter JN, Mazonson PD, Miller DP, Hulley SB, Symptoms present about two days after increases the chances of catching the common Balmes JR (2002). Aircraft cabin air recirculation infection. You may get some relief from your cold, but the evidence is not conclusive. The and symptoms of the common cold. cold symptoms by resting and taking plenty current science suggests that altitude, fatigue JAMA;288(4):483-6. of fluids. Over-the-counter medications such and crossing time zones, as well as exposure 6 Nieman DC(2000). Is infection risk linked to as a decongestant or saline nasal spray may to crowded facilities such as airports, and exercise workload? Med Sci Sports Exerc;32(7 help relieve nasal symptoms; aspirin or perhaps the very dry air in aircraft might Suppl):S406-11. TM acetaminophen (e.g., Tylenol ) will reduce contribute to risk of catching a cold following 7 Simasek M, Blandino DA (2007). Treatment of the headache or fever. Antibiotics are not used to a flight. The quality of cabin air is very good common cold. American Family Physician;:75(4). treat a cold, however, colds can occasionally in modern aircraft and many studies have lead to bacterial infections of the middle ear demonstrated that there is a low chance of or sinuses. If you suspect an ear or sinus catching an infectious illness during the flight. infection you should visit your clinic for assessment as these may improve with antibiotics. Photo: Cpl Pierre Cpl HabibPhoto:

10 Flight Comment — Issue 2, 2012 Maintenance INFOCUS

Maintenance Documentation By Major Barry Devereux, Directorate of Flight Safety, Ottawa

The Directorate of Flight Safety’s First and foremost, the vast majority of our So what can be done to improve our situation Debriefing Issue 1, January 2012, was technicians are genuinely dedicated to doing within our own scope of responsibility? T published to highlight records related a good job. So then why do we continue to Actually, quite a lot. There were many good occurrences as reported in Canadian Forces see so many FS reports and DTAES audit observations and suggestions put forward Flight Safety Occurrence Reporting System. observations on documentation? Maintaining (see inset), and a big thank you to those We reported that records-related occurrences an error free MRS seems to be a perennial who took the time to respond. In spite of account for roughly 10% of all FS reports, bug-bear of maintenance. At the beginning the various challenges across the fleets, the or roughly 300 reports every year. We also of my career, I was assigned to work in the common message that came through is that highlighted that the number and percentage AMCRO section for a few weeks as part of the fundamentals do not change. Keeping of FS incidents seemed to be fairly constant, my OJT. I distinctly recall the ongoing those fundamentals sound depends on the year after year. Put another way, we have frustrations of a certain Sgt i/c to get the front-line. The ultimate success of records been averaging nearly one FS occurrence paperwork correct and I was conscripted keeping depends on knowledge, supervision, per day due to “paperwork” errors for at into the effort to gain experience! When and vigilance. least the past few years. reading your feedback, I felt a certain sense of déjà vu. Knowledge is the entry key to documentation. The point of this Debriefing was to solicit But if knowledge is the key, then how do we your feedback for where you saw problems, It is true that we face many organizational gain the knowledge to become competent pitfalls and solutions. We also talked to your challenges in terms of training, experience, in all aspects of record keeping? In our friendly airworthiness auditors who “visit” manning levels, and ops tempo. We contend environment, much of our records-keeping you periodically to refresh your AMO with multiple Electronic Records Keeping knowledge is gained through experience certification and get cosy with your various Systems having varying capabilities and and learning from others. While formal training maintenance record sets (MRS). This edition user friendliness (or not). While these does occur to some extent, it is the units of Maintenance Corner is dedicated to what organizational factors are relevant, they are that must ensure the detailed knowledge is you have told us. also largely outside the control of front-line gained via OJT. Many of your responses maintenance.

Issue 2, 2012 — Flight Comment 11 highlighted training/knowledge as a if not thousands of maintenance actions as secondary to the hands-on maintenance significant challenge. How do we ensure daily across the CF. Even realizing that the or viewed as a burden, we will not truly a sufficient knowledge base, especially in FS system only highlights the errors that confront and then minimize documentation smaller or new squadrons? How do we avoid result in a FS incident (not all errors), our errors. Documentation is vital to the continued the “sink or swim” scenario? How do we track record in general still shows that we airworthiness of the aircraft and is every bit pass on the correct knowledge and not the seem to be getting it right most of the time. as important as the hands-on maintenance. mistakes? However, in the aviation environment, even We must be vigilant, pay attention to detail, small errors can be unforgiving. In our busy and strive to get it right every time. Supervision is paramount. In our environment, workplace with its inherent pressure to achieve there will always be a cross-section of the mission, the opportunity for error is What will YOU do today to improve your experience and knowledge levels. Supervision always present. If the paperwork is considered maintenance recording knowledge and skills? provides the necessary guidance and oversight to ensure the job gets done right. Supervision is just as essential for documentation as it is Debriefing Feedback for maintenance, perhaps more so. There Learn from the experience of others. (You won’t have time to make all the mistakes yourself). will always be the element of human error, as well as incomplete knowledge to contend • Use regular AMCRO/FS briefs to raise awareness of documentation issues. with. What mechanisms do you have in • Use errors as teaching points. How can your technicians learn from errors if they don’t place to prevent errors and are they effective? realize they made one? When errors are found, are they used as positive learning opportunities to prevent • Commonality and sharing of info across fleets/squadrons can be very beneficial. Common future occurrences? procedures and annual AMCRO conferences are excellent forums to share experiences, best practices and highlight areas for improvement. Of note, one of the most common Preventive • Use the Quality Management System to identify and fix the underlying problem and also Measures (PM) reported in the FS System is to follow-up to ensure the fix was effective. “Personnel Briefed on importance of following rule/order/procedure X”. While an excellent Priority on Paperwork immediate corrective measure to pass on knowledge, this PM often misses underlying • Always open the paperwork FIRST. This is a good habit, if only to remind us of the importance causes. Memories fade, personnel rotate and of documentation, especially in the hectic pace of the front-line. we may have to relearn the same old lessons with new people. If this is the only PM, take Off-Aircraft Maintenance the time to ask: did we dig deep enough or • Raise a CF349 to remove an item from the aircraft AND raise a CF543 for the off-aircraft work. did we miss an opportunity to address an Above all, make sure that the CF349 and CF543 are LINKED. Shops can often spot the bigger underlying factor? picture if they have the information. Finally, vigilance underpins it all. Vigilance Independent Checks is an attitude that we must continually cultivate both individually and as an • Does the support work entry also need an independent check? In ADAM, independent checks organization. It is our primary defence are flagged via WUC, which do not get recorded in the support work entry. Be vigilant when against complacency and ensures we strive making support work entries. for the best results. We complete hundreds,

12 Flight Comment — Issue 2, 2012 Time Expired Items • Inspection Intervals. Ensure to restart the clock at the correct time. Know if the clock starts at the time of the inspection OR when the aircraft returns to service. Calendar time or Airframe Hours or both? • For kits containing multiple time expired items (ex. ALSE, palletized kits), the kit expires when the FIRST item expires. Do you have a reliable means to track these items? Relying on the computer • The computer will do all the error checking and auto-generate the next inspection/removal date, right? Always double check…YOU are responsible to ensure correctness, not the computer. • The computer is not always right. It depends on YOU for the correct information.

P04 The “P04” is the RCAF airworthiness maintenance policy publication for the Aircraft Maintenance Record Set (MRS). A significant rewrite of the P04 has recently been published which provides clarification and improvements affecting all RCAF aircraft MRS. Some of the recent P04 changes include: • Re-emphasis of fundamental principles of maintenance recording. • More generic, making it applicable to all fleets/Electronic Record Keeping Systems (ERKS). • Improved readability incorporating not only the how, but also the what and why. • Clarifies SMM and SAMS accountability. • Improved tie-in to the existing AF9000/Quality Management System. • Requires a P04 supplement to link P04 policy with ERKS User Guide. • ERKS training (initial and on-going) will become a 2 Cdn Air Div responsibility. • Rework on numerous topics including: major discrepancies, support work, independent certification requirements, FOD certification, mixing of corrective/preventive and unrelated maintenance, mixing of signatures. For details on all specific measures introduced by the new “P04”, visit the A4 Maintenance/ Air Maintenance Standards website: http://winnipeg.mil.ca/cms/en/DComdSp/A4Maint/AMStandards/AMStds.aspx

YOUR ATTITUDE > FLIGHT SAFETY > YOUR LIFE

Issue 2, 2012 — Flight Comment 13 If you want to live, have Something In Reserve Flight Comment Edition 2 1976

By Major Don Janson

e was an old fighter pilot who settled in the neighbourhood, and he had made H the Ace category a couple of times over. The other kids and I would crowd around and we could hear his stories of wild combat over the skies of Europe; and I suppose it’s more than coincidence that several of us later joined his club and vaulted over the clouds in fighters of our own. And if his stories inspired our careers, they also formed a foundation for our survival. Consider, for example, the story he told about his first encounter.

“What I didn’t know about flying,” he began, “was an ocean of darkness on which my 230 flying hours bobbed like a cork. But I knew “I don’t know how many times we went round. “And then it came, sounding clear and joyous that I didn’t know much, and literally camped I do know that it became unbearably hot inside above the noises of glasses and laughter in a within hearing distance of the few old heads the greenhouse canopy, that I grew soaking London club. around. wet with fear and perspiration, and that my “I’d bet’im five pounds ‘e couldn’t get away “Anyway, four of us took off over the sands of right arm ached from pulling on the stick. from me,” said the red-faced Australian at the North Africa, and promptly ran into a couple table next to mine. “But once I fastened m’self on of new ME-109s. Totally obedient to instructions, WHAT WAS IT? ‘is tail, ‘e suddenly starts to turn in tighter. When I latched my P-38 to my leader’s wing and hung “And all the time, my mind was searching I try to follow ‘im, my bloomin’ Spitfire snaps. on grimly as a 109’s tracers reached out past back through classes I had attended; the Back on the turf I learn the devil ‘as cranked a me and set him ablaze. Then I broke away hard lectures I had heard on aerodynamics, lift and little flaps in when the speed’s got down a bit.” and, and found myself in a tight spiral, looking drag; and manuals I had read. I was searching “With my eyes glued across the circle, and still across a 300-yard void at a 109 trying to tighten for something extra – for additional scrap of holding all the turn that I could get, I reached in and close on me. We were near the deck in knowledge or experience which was the reason my left hand down beside the seat and set the no time; and with full power and all the back for hours of reading, for hundreds of flaps lever to the first notch. Nothing seemed stick the birds would take, the two of us still sometimes laughed at questions, and many to happen at first. But ever so slowly my props stood on wingtips on opposite sides of the evenings listening to stories and exploits that began to eat away my half of the circle. Then I circle, neither able to close, and each knowing were mostly just hot air. Out of that mass of could see the nose of the 109 pull in slightly, that to break the ring would bring quick death. words of ideas there had to be one speck of see the bird oscillate a little, then settle back information that could help me now. to the same arc.

14 Flight Comment — Issue 2, 2012 “It took at least three full turns to bring him was plenty of time. We had 30,000 feet to lose, It came from a conversation I had with a flight through the top of my windscreen, plus and I used it to calm the panic in the passenger, surgeon during a noon break at a pressurization another turn and a half to bring him down to and to plan the altitude at which we would chamber. “Under conditions of stress,” he had the sights reticle. And during that last little leave the bird. said, “a person who is not trained to handle a time, I couldn’t understand why he just held On a winter night like that, there was no desire bad situation can become so tense that his muscles that turn while I lined him up inch by inch. But to punch out high and dangle freezing for a almost freeze up, and he can’t perform simple he was still turning, with the top of the canopy long descent. The book said 1,500 feet would actions.” glinting and his face turned back towards me be about right. Then I remembered the Fighter In the dull beam from my flashlight the altimeter over his shoulder when the bullets exploded in ace, and seemed to hear his words: “You’ve always unwound dangerously, but I managed to speak a trail across him.” got to have something in reserve!” So I jacked up with calm forcefulness: “Listen carefully! Do exactly “Flying back, when my arm quit twitching and our exit altitude by another 2,000 feet. what I tell you. Put your head against the headrest. the blood quit throbbing on the side of my neck, The passenger was thoroughly rebriefed by Put your feet in position! Put your right hand around I understood what had happened to the other the time we approached the chosen altitude; the ejection trigger. This time, don’t squeeze! guy. He had exhausted all his knowledge. He our dark visors were down, and I had a flashlight Instead, jerk it toward you heavily. Now!” had never learned a law that became almost trained on the instruments. As I pulled the There came a sudden explosion, and then the sacred to me – that you’ve gotta have something jettison lever and felt the canopy go, I had high intercom was silent. My passenger was gone. in reserve!” hopes of a perfect ejection. Through the rush Five seconds later I squeezed the trigger on my of noise over the intercom I told the passenger ejection seat, and was blasted clear of the aircraft. MY TURN to place his head against the headrest, put his There was no time to read the altimeter just Many times in the ensuing years I had occasion to feet into position, and squeeze the ejection before I left the aircraft, and so I can’t calculate remember that advice. And many times it snatched trigger on the armrest. Then I waited till the the closeness of our escape. But I do know this: me away from tragedy. Take the night the blast. Five seconds passed, and he was still there! after the chute opened it was a very short turbine blew. “You have to do it. Squeeze it now!” I repeated. descent to the farmyard where I landed – much too short to have compensated for the delay in It was late, and very cold. I told the crew His very frightened voice caught me by our ejection had I not planned that extra reserve. chief to check the flight surgeon’s parachute, surprise. And I also know that the altitude would have and strap him into the back seat of the T-33 “I have! Nothing happened!” while I did a fast walk-around inspection. Then made little difference to the passenger had I I started to climb in, but thought better of it, “Squeeze it again!” not taken the extra time and double-checked and decided to personally check my passenger. Blast from the back seat. Then his voice rose his straps before starting the engine. With two That little bit of attention would make him feel towards panic. undone, he would have fallen to his death. easier during his first ride in a jet aircraft. And “I’ve tried and tried. It won’t work!” As it was, his parachute draped across a power oddly enough, I discovered that the leg straps line and gently stopped him just a foot above of his parachute harness had not been “You’re sure you are squeezing the ejection a concrete highway. He stepped to the surface, connected! trigger under the handle on the right arm rest?” caught a ride with an attractive co-ed, and had We took off and climbed through a jet black His answer was a high-pitched, “Yes!” the best steak of the house, free, at the restaurant night to 36,000 feet, and had just settled for where he waited after calling the base. a long night’s drive when an explosion shook SOMETHING MORE But I failed to tell him that he owed the ride, the bird, and the sky around us brightened. My mind had gone far beyond the conversation. and the steak, to an old fighter ace who taught Looking back, we could both see jets of fire I couldn’t punch out without him, and there me that the unexpected can pile upon the spraying into the windstream, and I knew that was no way he could survive an attempt to unexpected – and that when it does, you can the turbine wheel had thrown some buckets climb out over the side and parachute manually. die unless you have something in reserve.” out the side. Yet, to ride the bird to the ground in total darkness I cut the throttle and master fuel switch, and was a forbidding prospect. Then I searched for put the nose down sharply until the flame died something extra, and as we ate up the altitude out; then shallowed to a long, dark glide. There I had thrown in for reserve, I found it.

Issue 2, 2012 — Flight Comment 15 DOSSIER Mountainous Terrain Clearance Profiles The author left the airforce in the late 90’s after 20 years in Air Transport Group and has spent the period since flying for various airlines in Canada, Europe and Asia.

n the fall of 1990, I was the mission More recently, I have crossed some of the Avoidance of these areas could add hundreds commander on a Canadian Hercules tasked same ground flying between the cities of of extra miles to the route with the associated I to move the headquarters of the United Almaty Kazakhstan and New Delhi India as additional flight time and costs so the ability Nations mission to the Kashmir from Srinagar, the Captain of an Airbus A320. This time, to overfly the high ground is highly desirable. India, to Islamabad in Pakistan. The route instead of vehicles, office equipment and Therefore careful pre-flight planning is between the two locations overflies the Pir personal effects, the load is as many as 150 required to ensure that the flight will have an Panchal mountain range which rises to over passengers and crew and a limited amount acceptable outcome in the event of an engine 18,000’. Srinagar is situated in a valley and, at of freight. As this flight is often scheduled at failure or a depressurization event. For airline the time, had limited navigation and approach night and is flown under almost all weather operations on repetitive routes, it is normally aids. The minimum IFR altitudes over the conditions, the strategies for depressurization the company that will do the route planning mountain range taxed the capability of the and engine failure are, by necessity, somewhat and provide the escape routes and procedures loaded aircraft. more robust than they were during the to be utilized by their crews. For “one of” United Nations airlift 22 years prior. flights, non-scheduled operations or military To accomplish the assigned lift, we required flights, it may be left to the crew to determine VMC conditions under which we were able In many parts of the world, aircraft are the route of flight. In all cases, the critical to shuttle climb in the valley until we had routinely flown over terrain that has minimum factors and the planning process should be adequate terrain clearance and then cross obstacle clearance altitudes (MOCA) exceeding much the same. the mountains “VFR” at about 22,000’. Our 10,000’. However, in most areas, the relatively contingency plans for emergencies were short exposure time to the high terrain There are many potential failures that can relatively simple. The on-board oxygen diminishes the requirement for occur while an aircraft is in flight. For operations system was more than adequate to sustain predetermined escape routes and over high ground, the most critical failures us in the event of decompression during the the associated strategies to be used are those which would require the aircraft to relatively short time we were over the high and the profiles to be flown in the make an immediate descent. For route ground. Likewise, in the unlikely event of an event of an emergency necessitating planning purposes, the failures which engine fire or failure we planned to turn an immediate descent. Central towards the low ground, set maximum Asia is one of several exceptions continuous power on the remaining engines to this premise due to its very and descend at the minimum possible rate extensive areas of high terrain. while manoeuvring visually using the mountain passes to maintain terrain clearance until we were out of the mountains.

Photo: MCpl Colin Aitken

16 Flight Comment — Issue 2, 2012 must be considered are loss of pressurization depressurization but must occur within and adopting an obstacle clearance drift and the failure of an engine. In most cases, an 30 minutes of exhaustion of the oxygen down profile until clear of the high ground. engine failure will result in the aircraft being generators. The depressurization scenario is slightly more unable to maintain its planned cruising altitude. complex. The crew immediately dons oxygen Over high ground, a drift down strategy at the For my company, the ability to descend to masks, starts timing and carries out QRH aircraft’s best lift over drag speed utilizing 14,000’ within 55nm defines the limits of the immediate actions inclusive of initiating an maximum continuous thrust or power on the planned route of flight. The flight route will emergency descent and turning towards the remaining engine(s) will maximize the time normally need to be segmented to comply escape fix. The initial descent target altitude available to clear the high ground before terrain with this limitation with one “escape fix” is 22,000’ corrected as required for wind, clearance is compromised. In the event of a identified for each route segment. At any point pressure and temperature. Once established depressurization, a combination of supplemental in time, the escape fix might be ahead of, to in the descent, the aircraft is accelerated to oxygen availability and endurance plus the the left, right or behind the aircraft. Using the the maximum prudent airspeed, the remainder applicable regulating authority’s legislation criteria from the preceding paragraph, escape of the QRH/ECAM items are satisfied and the on its use will dictate the descent profile. It routings to meet the required descent profile initial descent altitude is refined based on will be the more limiting of the engine failure can be planned using obstacle data from charted values from the route charts. The or depressurization scenarios that ultimately en-route and topographical charts. The escape aircraft is levelled on reaching the target determines whether or not a route under routing starts at the predetermined escape altitude and maximum airspeed maintained. consideration can be flown safely. fix, which is ideally a ground based navigation After 9 minutes from depressurization (sooner aid, and terminates at a suitable diversion if charted terrain values allow), descent to In most modern turbojet equipped passenger airfield. The escape fix may or may not be 14,000’ is initiated. The escape route planner aircraft, the limiting factor is the availability part of the planned route of flight. has verified that (based on the 5nm/minute of passenger oxygen. Almost all of these The next step in the process is to determine average ground speed criteria) this can be aircraft utilize chemical oxygen generators done safely. If the actual ground speed is less which, once activated, will produce oxygen the highest obstacle clearance requirement for the entire route. For my company, this than the 5nm/minute average, the descent for specified period of time. Most regulatory point can be delayed up to 10.5 minutes authorities allow unrestricted operations to a figure is 22,000’ which is a standard worst case altitude that is valid for all of the which will still allow the aircraft to reach cabin altitude of 10,000’ and make provisions 14,000’ prior to exhaustion of the passenger for a cabin altitude of up to 14,000’ without mountain routes that we fly. In the event of a depressurization (or engine failure) this is oxygen generators. Descent from 14,000’ supplemental oxygen for a maximum of will be conducted based on charted values. 30 minutes. It is therefore necessary to plan the initial descent altitude target that will guarantee obstacle clearance. Once the escape However, the escape route planner has also escape routes on which the aircraft can safely verified that descent to 10,000’ can be safely descend to reach 14,000’ within the specified profile has been initiated, this target altitude can be refined based on en-route, terminal initiated at the 29 minute point on any of production period of the oxygen generator our routes. and further descend to be at or below 10,000’ and approach chart information. Note that as not more than 30 minutes later. in all obstacle clearance situations, the initial Some of the operators that routinely overfly descent altitude and all subsequent safety this region have equipped their aircraft with The passenger oxygen generators installed altitudes must be corrected for temperatures 20 minute passenger oxygen generators. This on the A320 that I am flying will supply oxygen below ISA, altimeter settings below 1013mb additional eight minutes of oxygen supply for a period of 12 minutes once activated. For and for winds of sufficient velocity to cause and the roughly 40nm additional range that planning purposes, the company has arbitrarily wave action over the mountains. it represents allows them added flexibility reduced this figure to 11 minutes to compensate in the selection of their routes. However, for any required initial turn towards the The final step in the process is to define the vertical profile to be followed in the event irrespective of the generation time, the escape point (which could be directly behind escape planning process is the same. the aircraft) and allows for an average descent of an engine failure or loss of pressurization. groundspeed of 5 nautical miles (nm) per As mentioned earlier, for the Airbus 320 series Protracted flights over high terrain present minute. This means that the aircraft must be on the routes that I currently fly, the loss of additional challenges and risks beyond those able to safely descend to 14,000’ within 55 miles pressurization situation is by far the most encountered during normal flight operations. from any point on the planned route. Further limiting. However, the engine failure scenario With careful planning, robust procedures and descent from 14,000’ to 10,000’ or below is still taken into consideration in the published strict compliance with the escape profiles, the should ideally occur within 30 minutes of the profiles which direct an immediate turn risks can be mitigated and efficient aircraft towards the escape fix, selecting maximum routing can be achieved. continuous thrust on the operating engine

Issue 2, 2012 — Flight Comment 17 DOSSIER Diminishing Skills? An examination of basic instrument flying by airline pilots reveals performance below ATP standards.

By Michael W. Gillen

This story is taken from an issue of Flight Safety Foundation’s journal, AeroSafety World. A free subscription to the digital version of that publication is available though the signup form on the Foundation’s Web site home page, www.flightsafety.org.

Michael W. Gillen is an A320 captain of their own instrument skill levels. Analysis manual flying tasks, the requirement to perform for a major U.S. airline and a former of the findings revealed that, although the manual flying exercises during simulator manager of human factors at that pilots believed that they retained a high sessions (including recurrent training and airline. He also is owner and president degree of skill, all of the flight maneuvers were license renewal) and the need to be able to of Colorado Aviation Consultants, which performed at levels below those required for manually fly the aircraft should the automated provides consulting, safety seminars U.S. airline transport pilot (ATP) certification. systems fail. and worldwide aircraft ferry and test services. Previous studies have found that opportunities Nevertheless, it appears that both the pilots for pilots to practice and maintain their skills who were tested and their airlines have failed decrease significantly over time, in part to maintain their perceived level of manual ith the advent of advanced, highly because of airline policies, advanced automation flight skills. In response, some airlines have automated cockpits in current and increased long haul flying. In addition, implemented supplementary simulator W transport category jet aircraft, pilots a 1998 report from the Australian Bureau of programs to bolster these skills.2 no longer fly solely by reference to raw data Air Safety Investigation (now the Australian from airplane instruments, and as a result, Transport Safety Bureau) found that 43 percent A 1996 report by the U.S. Federal Aviation their basic instrument flying skills may have of pilots surveyed said that their manual flying Administration (FAA) Human Factors Team – diminished. skills had declined after they started flying established after the April 26, 1994, crash of a advanced technology aircraft.1 China Airlines Airbus A300 in Nagoya, Japan, In a study designed to assess their instrument that killed 264 people and seriously injured flying skills, 30 airline pilots were asked to Most pilots hand fly their aircraft at some seven – found that pilots often misunderstood perform five basic instrument maneuvers stages of each flight. Anecdotal evidence the operation of automation equipment, as without using automation. In addition, the indicates that the main reasons for this are well as when it should be used.3 pilots were questioned about their perceptions the pilot’s personal satisfaction in performing Photo: Sgt Norm McLean

18 Flight Comment — Issue 2, 2012 For example, accident investigators found Other studies in the 1990s found that highly The study focused on two aspects of basic that the China Airlines first officer had been automated cockpits tend to change the ways instrument flying. First, a qualitative survey hand flying the A300, with the autothrottles pilots perform tasks and make decisions. was given to pilots to gauge their perception engaged, on an instrument landing system (ILS) The studies identified problems in the use of their own instrument skills. The second part approach when he inadvertently selected the of advanced automated systems, including of the study required the use of “first look” takeoff/go-around mode, causing an increase mode misunderstanding, failures to understand data – data derived from a pilot flying a in thrust. The crew disengaged the autothrottles automated system behavior, confusion or lack maneuver without a pre-briefing – from and manually reduced thrust but then engaged of awareness concerning what automated participating airlines. The first look data were the autopilot and failed to recognize that it systems are doing and why, and difficulty obtained from a maneuver set comprising a was trimming the horizontal stabilizer nose-up. tracing the functioning or reasoning process takeoff, an ILS approach, holding, a missed of automated agents.4,5 approach and an engine failure at V1.6 These The Human Factors Team said that its members maneuvers were flown without the use of were concerned that incidents and accidents Focus on Instrument Flight autothrottles, a flight director or a flight such as this one appeared to highlight The study that is the subject of this article management computer/map and solely by difficulties in flight crew interactions with gathered data from airline pilots employed reference to raw data obtained from the increasing flight deck automation. by U.S. carriers during a recurrent training heading, airspeed, attitude and vertical speed cycle. The average experience level of the instruments. The data subsequently were A follow-up report by the FAA Performance- 30 participating pilots was 7.1 years (in both de-identified. Based Operations Aviation Rulemaking aircraft and seat) with a range from two to Committee and the Commercial Aviation 16 years. Seventeen of the pilots were captains Safety Team (CAST) is expected to be released and 13 were first officers; 18 flew narrowbody later this year. airplanes, and 12 flew widebody airplanes.

Issue 2, 2012 — Flight Comment 19 Simulator Performance ‘Glass’ vs. Non-’Glass’ Although their responses indicate that the The pilots performed the five basic instrument The study compared self-reported experience pilots believed that they could fly these maneuvers in an FAA-certified Level D in “glass” airplanes – those with highly maneuvers, the “somewhat agree” responses simulator – the most advanced type of automated flight management systems and indicate that some believed that their simulator, with a 180-degree wrap-around electronic flight instrument systems – and performance might not be perfect. visual display and a daylight visual system. non-glass airplanes, along with the amount The maneuvers were rated by an FAA-certified of time that had passed since the pilot last Asked if they believed that their basic check pilot and were graded on a scale of flew a non-glass aircraft, a majority of which instrument skills had declined over time, 1 through 5, based on the standards of both are being retired. These results were further 26 percent of pilots strongly agreed, and a major airline and the FAA. analyzed to take into account specific survey 53 percent said that they “somewhat agree.” responses relating to pilot experience. Only one pilot strongly disagreed with the The rating scale was as follows: statement; however, 16 percent said they In answer to these questions, more than “somewhat disagreed.” • 5 – Well within airline standards. 56 percent of the pilots said that they had Performance was exemplary. either never flown a non-glass aircraft or More than three-quarters of pilots said that • 4 – Within airline standards. Pilot flew that the last flight had been more than they practice basic instrument skills often, to ATP standards. 10 years earlier. with 33 percent strongly agreeing and 46 percent somewhat in agreement with • 3 – Minor deviations from airline that statement. Twenty percent of the pilots standards that were promptly corrected. Forty-six percent said that they had spent somewhat disagreed with the statement. Pilot flew at the basic instrument level. two years or less flying non-glass aircraft, compared to 20 percent who had flown • 2 – Major deviations (e.g., full-scale non-glass aircraft for more than 10 years. Simulator Performance localizer/glideslope deflection) for more Analysis showed that the average grades than 10 seconds. In contrast, 73 percent said that they had given the pilots for their performance of the five maneuvers were significantly below • 1 – Major deviations from airline standards been flying glass aircraft for at least 10 years. the FAA’s standards for acceptable ATP that were not promptly corrected and/or None of the surveyed pilots indicated that he performance and closer to the basic were unsafe; or the pilot was unable to or she had two years or less in glass aircraft. instrument level (Table 1). perform the maneuver/task without assistance. Crash or loss of control. Self-Assessments In assessing their own basic instrument flying The lowest rating – less than 2.4 – was for Comparisons skills, 80 percent of the pilots said that they the holding maneuver, which rarely, if ever, is performed by reference to raw data The type of aircraft the pilots typically flew ”strongly agree” with the survey statement instrumentation. The highest – 3.2 – was was a factor in comparing both the survey “I usually hand fly the aircraft below 10,000 ft.” for takeoffs, which typically involve reference responses and the performance of maneuvers. A pilot retains maximum skill by routinely to such instrumentation. The pilots were divided into two categories hand flying below this altitude in the most determined by the aircraft that they were maneuverintensive phases of flight. The Further analysis of the data revealed no flying at the time: widebody (A340, Boeing positive responses, however, did not indicate significant differences between the pilots 747, 767) or narrowbody (A320, 737, 717). This if the pilots had been using all of the aircraft’s of widebody and narrowbody airplanes in distinction was required because these two advanced capabilities or flying by “raw data” their performance on the individual maneuvers pilot groups fly a similar number of hours per while hand flying. or on a composite measure. month but have vastly different numbers of Sixty percent of the pilots agreed with the takeoffs and landings. During a typical 20-hour Misplaced Confidence? assigned flight sequence, a narrowbody pilot statement that they feel comfortable flying Technical failures in advanced glass may conduct as many as 12 or 15 takeoffs and by reference to raw data only. aircraft can significantly degrade cockpit landings, whereas a widebody pilot typically instrumentation. Poor basic instrument flying would conduct two. Because of the higher In response to the statement “I could fly a skills make these failures more difficult to number of cycles, narrowbody pilots might be takeoff, V1 cut, ILS and a missed approach detect because crosschecking raw data from expected to perform better on the maneuvers using only raw data,” 53 percent of pilots strongly the basic instruments is the key factor in than widebody pilots. agreed and 47 percent somewhat agreed. No pilots disagreed with the statement. quickly identifying failures.

20 Flight Comment — Issue 2, 2012 Maneuver ratings Notes • Table 1 Number Mean1 1. Australian Bureau of Air Safety Investigation. of Pilots Note Advanced Aircraft Technology Safety Survey Report. June 1998. 1. The mean is the average of Takeoff maneuver 30 3.2000 maneuver ratings received by 2. Ibid. V1 cut maneuver 30 3.0333 all 30 participants. Each maneuver 3. Abbott, Kathy et al. The Interfaces Between was rated on a scale from 1 to 5. Holding maneuver 30 2.3667 Flightcrews and Modern Flight Deck Systems, A grade of 4 represented the FAA Human Factors Team Report. June 18, ILS maneuver 30 2.9667 standards established by the U.S. 1996. Federal Aviation Administration Missed approach 30 3.0667 for an airline transport pilot. 4. Billings, Charles E. Human-Centered ILS = instrument landing system Aviation Automation: Principles and Guidelines. U.S. National Aeronautics and Space Administration (NASA), Ames Research Center. 1996. Source: Michael W. Gillen 5. Sarter, Nadine R.; Woods, David D. Cognitive In addition, when these failures occur, pilots pilots, and there was no statistical difference Engineering in Aerospace Application: must use basic instrument skills to safely fly between maneuver grades for the two groups. Pilot Interaction with Cockpit Automation. the airplane. Pilots who are competent in This is most likely because, as mentioned NASA Ames Research Center. 1993. basic instrument flying enhance their overall earlier, although both groups of pilots fly a 6. U.S. Federal Aviation Regulations Part 1.2 flying skills; because they can devote less similar number of monthly hours, narrowbody defines 1V as “the maximum speed in the attention and cognitive function to physically pilots fly many more cycles than widebody takeoff at which the pilot must take the first flying the airplane, they can spend more time pilots and spend more time maneuvering the action (e.g., apply brakes, reduce thrust, managing their environment. aircraft; one result is improved flying skills. deploy speed brakes) to stop the airplane within the accelerate-stop distance. V1 also Although most pilots in the study agreed The results of the maneuvers performed as means the minimum speed in the takeoff, that their instrument skills have declined over part of this study show that airline pilots’ following a failure of the critical engine at time, their survey responses indicated that basic instrument skills may decline over time. VEF, at which the pilot can continue the they felt they could still fly basic instrument This is associated with the decreased use of takeoff and achieve the required height maneuvers. However, their survey responses these skills in routine line flying. In addition, above the takeoff surface within the takeoff do not correlate with their actual maneuver newer-generation aircraft generally do not distance.” (VEF is “the speed at which the grades, leading to the conclusion that the lend themselves to basic instrument flying, critical engine is assumed to fail during pilots had a false sense of confidence. and most companies do not train or promote takeoff.”) this type of flying. Although rare, some failures The maneuver grades generally conform to in advanced glass aircraft can degrade aircraft what the literature review revealed in related instrumentation to the extent that pilots must studies that found that skills, when not used, fly the aircraft using raw data. During the past decline over time. This was observed throughout 10 years, two such failures have occurred at an the study in the average maneuver grades. airline that participated in the study. In both cases, the flight crews landed the airplanes The suggestion in earlier studies was that if a safely. skill set was learned and practiced over a long period of time, it would be retained longer Airline safety can be improved by ensuring than if it was practiced over a shorter period that pilots are competent not only when all of time. This was not seen in the widebody- advanced instrumentation is functioning but narrowbody comparison. Although pilots of also when that instrumentation fails. Pilots widebody aircraft had more experience flying possessed these basic instrument skills at one older-generation aircraft, their maneuver time in their careers, and their skill levels can grades were similar to those of narrowbody be increased through training and practice.

Issue 2, 2012 — Flight Comment 21 DOSSIER Photo: Cpl Alexandre Paquin Alexandre Cpl Photo:

Wildlife Strikes By Major Jason Trudel, United States Air Force, Hurlburt Field, Florida Part 1

Major Trudel wrote this paper as part Environmental Aspect – there is increasing pressure for wildlife to of a masters thesis. He is a former Avian Habitat Pressures move to more suitable locations. Airfields exchange officer with the Directorate Many aspects of airports make them attractive offer a sanctuary, often untouched by of Flight Safety Ottawa, previously flew to wildlife. There is a very large amount of development due to safety precautions the KC-135 and currently instructs air open space, usually with lush vegetation. surrounding flight operations (Multi-Resolution refuelling planning at the Mobility Further, the safety and security aspects of the Land Characteristics Consortium, 2011). Operations School, Hurlburt Field, Florida. airfield limit animal traffic as well as human intrusion. This results in an environment where Airspace Conflicts wildlife is free from many natural predators. The greatest risk to aviation occurs when Introduction there are high concentrations of bird activity The events of 16 January 2009 on the Hudson Continued development in industry, housing in conjunction with high levels of air traffic. It River brought worldwide attention to a very and transportation, place growing pressures is possible to encounter birds during any phase real danger that faces the aviation community on the availability of wildlife habitat. According of a flight. The highest bird strike on record each day. Every year, bird strikes are estimated to the Multi-Resolution Land Characteristics occurred off the coast of Africa at an altitude to cause up to $1.2 billion in damage to Consortium (MRLC), forested lands in the of 37,000 feet (Vulture strike). Some migratory commercial aircraft worldwide. This can range United States have declined from 29.22% in birds have been documented as flying at from a minor dent, to catastrophic damage 1992 to 24.95% in 2006. At the same time, altitudes of 29,000 feet. While high altitude (NTSB, 2010)(Dolbeer, Wright, Weller & developed land has increased from 2.83% to bird migrations could pose a threat to aviation, Begier, 2009). 5.46%. With a reduction in available habitat, bird strikes are far more likely to occur at lower

22 Flight Comment — Issue 2, 2012 altitudes. According to the United States Figure 1. Yearly Strike Reports for Highest Strike Rate Airports Geological Survey (USGS), most small birds 500 favor migratory altitudes between 500 and Yearly Strike Totals by Airport 1,000 feet. Roosting or feeding birds descending 450 to ground level further increases congestion 400 in lower altitudes. 350 Collision Avoidance 300 2005 2006 Avoiding damage from wildlife strikes is vital 250 to aviation safety. Most aircraft operate well 2007 above 1,000 feet unless they are operating on Strikes Total 200 2008 a military training route. While bird strikes 150 2009 along military training routes are a significant 100 concern, they remain outside the airfield environment, and therefore, beyond the 50 control of the airport authority. 0 KATL KJFK KORD KDFW KDEN Since all aircraft must operate in the low altitude Airport Identi er structure for takeoff and landing, this is the area of primary concern. The FAA defines Although this chart shows a large number of strikes, it only shows part of the picture. the standard for departure procedures, and The number of strikes at an airfield also needs to be compared to total movements, requires a climb-out performance of 200 feet and the risk posed by those strikes. per nautical mile. Since most strikes occur below 1,000 feet, this limits the area of greatest Figure 2. US Canada Goose Population interest to 5.0 NM from the airfield, and ranges 4 from the surface to 1,000 feet. By default, this Resident Geese also encompasses the same area where other Migrant Geese wildlife would pose a threat to aviation (Dolbeer, 2006). 3 Wildlife Strike Trends Based on the current environment and 2 trend information, wildlife management and mitigation measures are going to be increasingly important to the aviation 1 community. In order to determine the hazard, of Geese (x million) No. a detailed evaluation of airport operating areas is essential. Bird strikes are reported by both aircrew and ground crew, and collectively 0 gathered into several databases for analysis. As an example, the following chart depicts 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 the 5 highest strike rate airports in the United While the population of the Canada Goose was growing rapidly from 1984 until 2000, States based on the FAA strike database national level mitigation practices have been reducing the growth rate of this species. (Federal Aviation Administration, 2010). In particular, hunting permits and programs issued by the US Fish and Wildlife Services, as well as habitat management have led to a stabilization of this problem population. Although somewhat stable, the migratory population is still close to four million, and a single bird is able to do massive damage to an aircraft. This bird continues to be top priority for local management across North American airfields. (Dolbeer & Begier, 2011).

Issue 2, 2012 — Flight Comment 23 Hazardous Species – Table 1. Top 10 Wildlife Species by Cost Assessing Risk Rank Common Name Count Cost The risk posed by bird strikes is based on two factors: how likely is a strike and how likely 1 American White Pelican 21 $257,650,916.00 is that strike to cause damage to an aircraft? 2 Canada Goose 139 $92,829,720.00 As an example, the risk of hitting a flock of Sparrows is not nearly the same as hitting 3 Black Vulture 458 $56,811,479.00 a flock of Canadian Geese. 4 Turkey Vulture 860 $53,539,935.00

Although a species may be repeatedly 5 Spot-billed Duck 15 $24,920,198.00 reported as being involved with aircraft 6 Red-tailed Hawk 866 $15,738,015.00 strikes, this may not necessarily indicate a significant risk. The US Air Force tracks the 7 Barn Swallow/Swallow 2175 $11,599,704.00 strikes reported, as well as the associated 8 Mallard 346 $10,582,110.00 damage resulting from each strike. The following tables depict the USAF reports since 9 Dark-eyed Junco 156 $10,251,842.00 1987, detailing the species that did the most 10 American Mourning Dove 2862 $9,970,304.00 damage as well as those most frequently struck (US Air Force Safety Center, 2011).

Of the total 95,383 strikes reported, the Table 2. Top 10 Wildlife Species by Strikes Horned Lark accounted for 3.69% of all strikes. Those strikes only accounted for Rank Common Name Count Cost 0.82% of the total dollar value of damages. 1 Horned Lark 3523 $6,770,650.00 Conversely, the American White Pelican and Canada Goose accounted for a mere 0.17% 2 Perching Birds 3148 $3,848,047.00 of the reported strikes, but were responsible 3 American Mourning Dove 2862 $9,970,304.00 for over $350 Million in damage, or 42.7% of the total losses incurred by the US Air Force. 4 Barn Swallow/Swallow 2175 $11,599,704.00 Based on this data, it is much more likely for 5 Eastern Meadowlark 1379 $2,163,875.00 an aircraft to hit a small bird, but even rare collisions with large birds prove to be extremely 6 Killdeer 1292 $4,465,838.00 costly (US Air Force Safety Center). 7 No Feather Remains Found 1137 $3,064,373.00 Unsafe Acts – Loss of Aircraft 8 American Robin 1112 $2,154,448.00 from Wildlife Strike 9 Chimney Swift 1109 $899,951.00 In the worst case, bird strikes can lead to loss 10 of the aircraft and the death of all personnel American Kestrel 1081 $2,744,742.00 on board. On 22 September 1995, a Boeing E-3B AWACS aircraft ingested Canadian Geese into the #1 and #2 engines shortly after takeoff. This caused the failure of both engines on the left wing, and directly contributed to the crash of the aircraft and loss of all personnel. The accident report for this example found that

24 Flight Comment — Issue 2, 2012 the airfield did not have an effective wildlife The radar antenna has to be physically moved Hazard Species mitigation program in place for deterring to complete its scan. This, by default, involves In a study conducted by the US Department hazardous bird species (Laeton, 1996). moving parts requiring maintenance and of Agriculture (USDA), Barn Swallows accounted subject to possible failure. The BSTAR radar, for approximately 1,500 strikes, and Canada Bird Detection and Mitigation developed by SRC, uses multiple elements for Geese accounted for approximately 1,300 strikes. Strike reports and accident data are valuable an electronically steerable array. While this The Barn Swallows accounted for less than tools in assessing the hazard of wildlife strikes. system has no moving parts, it requires more 1% of adverse effects on aircraft, while the While useful in determining the magnitude of complex software to operate. All of these radar Canada Geese were listed as causal in 60% the risk to aviation, comprehensive wildlife systems provide energy returns from birds, or of adverse effect events on aircraft. The risk strike management programs require evaluation possibly wildlife, that can be analyzed. Radar posed by this species makes it much more of a of a multitude of additional factors. Most bird returns provide information on mass, position, concern, and a much higher priority for mitigation activity occurs without impacting aircraft. As and rate of movement. Depending on distance activities (Johnson & Clifton, 2011). this bird activity defines the underlying from the airfield, these systems may not be potential for a collision, it must be carefully able to readily differentiate between one large At Salt Lake City, Utah, there were 37 wildlife studied. To properly mitigate risk, the entire bird and several small birds. In most cases, it is strikes reported between 2006 and 2010 that airport ecosystem must be evaluated as well simply not possible to determine the species had adverse effect on aircraft. Of these, 16 were as its place in the local and regional ecology. of a bird from a radar return. For this reason, from ducks and geese, seven were hawks and Migratory species and their movements need additional evaluation tools remain a necessity owls, two were gulls, six were form other species, to be continually monitored on a seasonal (Beason, 2011). and 6 were unknown. The mitigation priority basis. Local nesting bird populations need to for this airfield placed the Canada Goose as be tracked and counted to determine their Environmental Aspects – number one. Mitigation of the hawk and owl activity levels and flight patterns. Food sources, Ongoing Assessment risk was secondary, with gulls third, and all nesting locations, and shelter areas that are Currently, the only way to accurately determine other species at priority level 4 (Dolbeer & attractive to birds need to be evaluated for the species of birds flying near an airfield is with Begier, 2011). possible modification or removal (MacKinnon, visual identification, either from a distance, or Snowden, Russel, Dudley, Davis, Kelly, Huzieer by evaluation of physical subjects. This includes As an ongoing problem species, the national & Richardson, 2010). evaluation of bird strike remains as well as population of the Canada Goose is depicted living bird populations in the airfield vicinity. in the chart below (NTSB, 2010). Technology – Radar as an Aid By determining the species of birds present at to Detection an airfield, as well as their numbers and activity (“Wildlife Strikes – Part 2” will be provided Recent developments in radar technology are pattern, the reasons for their presence can be in Flight Comment Issue 3, 2012). greatly improving the data collection process determined. This is also applicable for other for wildlife activity. In particular, avian radar species of wildlife that may be present on systems offer a persistent detection capability airport grounds. with 24 hour coverage. Radar coverage is limited by the line of sight that the radar beam can Due to the complex environmental aspects scan, as well as the scanning volume requiring involving species attraction to an airfield, coverage. A narrow beam radar offers greater professionally trained biologists are often best precision, but sacrifices scanning volume. suited to evaluating the airport ecology. This Conversely, a radar beam that can cover a will aid in accurate assessment of wildlife large area has greatly reduced resolution. attractants, as well as developing a plan to The main companies in the United States and mitigate risk. Canada offering avian radar systems are Accipiter and Merlin. Both of these companies use mechanically actuated scanning systems.

Issue 2, 2012 — Flight Comment 25 Photo: Cpl Mathieu St-Amour Mathieu Cpl Photo:

Lessons Learned Do You“Think” or Do You“Know”? By Sergeant Lisa Joyal, 435 Transport and Rescue Squadron, Winnipeg

t was a balmy -45 degrees in Cold Lake trigger which made the cylinder shoot out and I was on night shift. Night shifts are the back of the gun like a bullet. The projectile I the time when all the heavy or long drawn contacted the middle of his chest, lifting him out snags are carried out; this night was no off the ground and sending him back at least exception. 10 feet.

My MCpl and I were assigned to do a wingshoot My first thought was “oh my god, I’ve killed on the left wing, which is the process of him”. Off to the hospital we go since we were sealing the integral fuel tank. The wing is pretty sure that he had a couple of broken divided into 3 different levels with each level ribs because of the pain he was experiencing. having a channel that requires a specific fuel After seeing the doctor, it was confirmed that sealant that comes in tubes. The equipment there were no serious injuries except for a wicked required to complete the task is a pneumatic bruise the size of a watermelon on his chest. (60 psi) powered gun where the tubes fit into a threaded cylinder. The moral of the story is that “THINK” should never be part of our vocabulary when working At the beginning of shift, we gathered up with or around aircraft. If you think you did Photo: Cpl Pierre Cpl HabibPhoto: all the equipment and went to work. Several something, go back and recheck your work. hours later, the tube ran out of sealant so it The only word that should be acceptable needed to be replaced. I got a new tube, is “KNOW”. unthreaded the cylinder, changed the tube and thought I threaded the cylinder back into place – the key word in this statement was “thought.” At this point my MCpl pulled the

26 Flight Comment — Issue 2, 2012 Photo: Capt Jean-Guy Pitre

Lessons Learned Near Miss By Captain Bruce Aitken, 403 Helicopter Operational Training Squadron, Gagetown

t was a marginal VFR day and I was At this point I had been impressed with small clearing in the trees. We then landed scheduled for a TAC (tactical) formation the new FO and gave him a little slack when in another field and discussed what had I training mission with a First Officer (FO) he was initially a little tight on lead for trail just happened with lead and decided to who had recently completed the Griffon OTU. loose (form spacing of 5 to 10 rotors) cancel the remainder of the trip and return We decided to “practise parade form” following the transition from parade form. to base. (where the wingman maintains a fixed Unfortunately, at this point lead identified distance and bearing from the lead with a confined area and elected to do a hard I learned several things from this incident. 2 rotors spacing minimum) during the first 180 degree turn to the right to align the First, I determined that the FO’s strong leg of the flight, as it was not going to be formation for landing into wind. We were initial performance had impressed me into flown at tactical altitudes. Upon departure, on the right side of lead and tighter than becoming more relaxed than I normally we determined that the weather between the we should have been at this point. Both the would have been on formation spacing. base and the Tactical Low Flying Area (TLFA) FO and I were surprised by this sudden turn This is sometimes referred to as the “halo was not within limits and so decided to and instead of moving left to avoid lead by effect”. The second lesson was the importance return to base and conduct TAC form crossing behind his tail, the FO elected to of taking control early when you see manoeuvres on field, as it was designated try to turn inside of lead’s turn. This did not something going bad. Had I taken control a TLFA allowing us lower weather limits. work out well. I took control about half way or instructed the FO to move to the outside through the turn with almost zero airspeed, when we initially tried to turn inside lead, We were the number two aircraft and I had max allowable angle of bank and 30 feet this incident could have been avoided. The allowed the FO to fly in order to practise his above the ground. As our aircraft began to third lesson learned was that as formation newly learned “parade formation” skills. sink, we had our belly towards lead and we lead, if an aggressive manoeuvre is required, He was doing well and I was impressed by were no longer visual. I pulled max torque give the remainder of the formation a heads his smooth aircraft handling and station and initiated a right pedal turn away from up on the radio. I am also more diligent keeping. After some further practise over lead in an attempt to regain air speed. At about taking the time to brief new FOs and the base we landed and lead informed us this point the aircraft sunk into a clearing students on the importance of “taking the that we were going to switch to TAC form just in time for me to look through the tail” (a turn toward lead aircraft’s tail and practise some TAC confined areas within cockpit roof window and see the lead during formation manoeuvres in order to the confines of the base. I acknowledged aircraft’s cargo hook and skids go over us maintain correct spacing) during TAC and we departed again with the FO at much too close for comfort. After lead formation in order to avoid lead. the controls. passed, we recovered to a 2 foot hover in a

Issue 2, 2012 — Flight Comment 27 light Comment 28

Lessons Learned F allowed for visual approaches (#7). approaches visual for allowed runwaythe terrain wasthat high to other end the of approach instrument runway (#6). was no there reason The wateroverrun with at ends ofthe both your day!). or Also, underrun is there little runway contamination –enough to ruin answerThe and is,tailwinds possible with “what’s feet?” 7000 with problem the are and thinking, props rotors with folks long (#5) feet only 7000 (I know –you single runway (#4), and, runway the was was available (#3) to only one end ofthe approach non-precision that only an offset weinformation had area onthe and found (#2).this airport We looked upwhat truly had norever yours flown into Officers to leg Roatan,second First neitherofthe Talking the about other pilots the with and center onein the seats “agony” seat. occupyingfront the pilots; three two require days crew planned overbecause 14 (#1) hours manythere Imention co-pilots before. times and Ihad been and co-pilots the was good the as weather was uneventful leg first The (Honduras), andto thenback Toronto. I Ottawa Safety, Flight of Directorate Dixon, John Captain By Problemo No double stop to Veradero stop double (Cuba), Roatan 737-800, a we to fly were scheduled a n oneofmy flying jobs previous

— Issue 2,2012 only tailwind allowed for our aircraft type was type allowedtailwind aircraft our for maximum the As wasn’t forecast! in the cell moving area. the through Hey, that aweather rain with heavy He also reported favouring visual the endrunway. ofthe to 15and gusting wind the knots... Control (ATC) ceiling the at 1200 reported feet approach, the Air Traffic for outbound over we passed navigation the As aid (#8) world. ofthe could in this be part reporting ofhow inaccurate question the weather the What Ihadn’t considered thoroughly was no problemo! visual tothe other end the – circuit well over AGL 1000 the for feet required and intensity, direction we hadwith still aproblem became winds andthe if approach We instrument expected). the for were good is arrival way ofsayingno weather affecting (ceiling okay, and visibility is which aquick aside, alternate our wasCAVOK of Cancun an As fuel. way muchin the bring ofextra (AGL).at 700 feet onthis, we didn’t Based minimums approach with compared feet ceiling of1500 above level ground (AGL) minimums light callinga with winds for to well be above instrument was forecast wasthat news weather the good The

always keeping alternatives. of flight and highlightthe importance ofa alter quickly safety can the forecasts and misleading unfamiliarity aerodrome an incident even or an accident. Fatigue, to create what could easily have become and easily 10 aligned neatly holes rather Learned Lesson The to astop. weight aircraft (about landing max our feet)to bring 5000 howme muchrunway used wasactually level 3(moderate) wasenlightening it to and braking reverse full spoilers, utilizing landing a firm After limits. within just which was and afinal askcheck wind for minimums (really!), Iwasable to callvisual ceiling, at weExactly wereCancun. off to or winds eventin the for ofago-around and avisualthat for option waspassed the (#10).20 knots crew the briefed Iquickly were slightly abeam and to now gusting visual option)the circuit (#9) and winds the we were(there incloud solid still goes passing finalthroughfeet, On approach 1000 to other end. the circuit we increased, winds could visual dothe approach, andthe if instrument the from 15 welanding the were for ok still knots for me washow me quickly for

Lessons Learned

By Steve Captain Jurkowski, Unit Officer, Flight Safety Gimli Gliding Centre Supply T all the personnel within it. within all personnel the and radiusgliders ofthe operating the that abubble is surrounds responsible for launching and recovering LCO The gliders. Control OfficerLaunch (LCO) is engaged in launchThe up, point is set the and soon anoperation efficient going.get gliding is at and maximum motivation is high to Attention and refreshed. fed well-rested, day, ofthe At start the is crew the of gliding operations. conduct in the situations experienced oftypical a single event, an but abstract a regular basis. This is not an analysis of gliding onthe field on occurring tendency concurrently.happening notice I this onmanyattention tasks/situations to maintain your increasingly difficult

and focus to drift. It becomes to drift. and focus one’s for activity, repetitive attention here is atendency, in any given of n! n T A t

and to eat Air have andCrewpositions drink. and sit down to havebreaks something positions, allowingto take personnel and signsrotatethe duty oftiredness How to combat complacency? Recognize in themover time. left and ‘work’ less have who personnel less from more and demand more factors These decreases. remaining and fuel increases, traffic weatherturbulence increases, changes, as in difficulty conditions increase Typically,toll personnel. onthe flying down, chill the or wind, ofthe take their conditions, issun it the beating whether Environmental stations. to their duty in getting are not asenergetic crews Ground next. the situationthe is similar oneflight to from as diminishes. Pilotcurtailed are briefings oftime, to naturally detail period attention some for task same the performing After e

Demand t io Issue 2, 2012— attention to support it! to support attention available the demands past supplyof consequences ofpushing operational than potential the drastic is muchbetter and levels tasks ofactivity various through spent time to rotate personnel extra A little about it. to dosomething ofpeople group tired sharp.staff Do not wait until you have a in keeping your schedule.pro-active the Be into changes asupervisor, buildAs duty of pace, abreak. for your or need Communicate achange your for desire and way. should viewedsame the be time; cancockpit other workstations continuous for maximums established

– Flight Comment

2 9

Photo: Cpl Gayle Wilson light Comment 30

Lessons Learned F Share

caps, etc. fuel radios, stiff details ofintermittent were dependenteach upon other to share towere homebase, occasionally we ferried until aircraft the logging faults from superiors over again. we were by As discouraged our rotation the deploymentthe and started to morning, we back rode sleep. next Early commute homeinashort oneairplane for we would to outstation, the had returned end long ofour days, all when aircraft the Atpilot, routes. onvarious fanning out the number flyers. ofintrepid flewWe single among rotating an equal aircraft transport maintenance base. were There several light the toassigned remote an operation from in thatmyoccasion Ifailed habit. Iwas Here is what onenotable onthe happened flight. next Ithought might bear onthe any factors airplane in the and quirks mechanical of going.” into list a would I launch directly “Hi, with me how’s greet would it often My colleaguesoperational circumstances. and onanymachine Iwasexiting relevant aviators condition flying on the ofthe career, my ahabit to has fellow it been brief I forflying jets a major airline. currently He is abroad. and Canada across aviation, civil levels of at all types, 35 many aircraft in years for over flown Fraser has Mr applies to aviation. my Throughout one. an angle Let’sthat from examineit is power.nformation We all know that the

— Issue 2,2012 POWER

good. I carefully felt the opening action. opening the action. felt Icarefully good. and latch. door the It allto inspect looked oversquirmed load again the and dangled I strip. landing onascorching desert I cancelled IFR and spiralled down to a ahead. just airport wasasuitable There there’s a problem. listening good adarn to. boss the Now that require That Igiveout. would certainly load might ofthe fall hatchthe pops, part However, OK. airplane be will probably if Atflight? unpressurized, the knots, 200 So, in opens what door happens the if otherwise. though, states that warningbuzzer, correctly.The door myself, no autopilot. Iam sure that Iclosed mind that noise. Think this through. I’m by do Do wasnoThere cancel button. warningwent door top cabin off. the speed, and reaching altitude levelling at cruise after off, glad the of air climbed. Just cooling asI miserable. the upengines and Ifired took on my face. dripping To Iwas least, say the suit. flying was slidingMy headset around and Ihad soaked my inside aircraft, the degrees forty It was into flight the deck. and dropped door. forward Ithencrawled clamshell anddown to latch close aft the ceiling.cabin reach It wasan awkward on top against cargo, the ofthe squeezed bulked to Iwaslying out point where the to hub. the returning Ihad before stop last Ifinished loading at my afternoon, One something, it insisted. Alright, it something, never something, something, the wreck.” down this morning. He’s missing from “Joe’sand looks. disapproving plane went were by met sombre greetings cheerful into My back work. I breezed Refreshed, it. needed Tomorrow wasaday me.for off really I until we had landed exited. and others the my aholebulkhead in jaw the and stared Iclamped my furious. limit, I wasinstantly beat you just or up.” Completely beyond to givewhether you silent the treatment, (let’s callhim Joe) “We said don’t know then, fellowexperience. Just the me beside them, too. my to Iopened relate mouth my mates that theyhad along hard day behind ofmy by Icouldfaces the see frustrated. and Iwashot, tired deck. plywood on the Really annoyed now, cross-legged Isettled ofprop-wash. ablast me onside the engine and gave started Captain aboard, to take night. the ushomefor The other pilots the waiting, with aircraft my gear. to tarmac the the Iranacross load intothe awaiting van, and collected warning. Finally at destination, Iheaved nuisance half hour late. wasno There further melted now,Doubly off again, Irushed a time!whole the fine and hatch. locked the reclosed It had been positively I bent. andgrimy possibly looked sensing door micro-switch The By Mr Collin Fraser Collin Mr By What bizarre story was this? The airplane, Whatever happened next led to the pilot necessary advantage. It might seem foolish the one I had been in two days prior, had being outside of his airplane. It is one of and weak to just give away your resources. cratered from a steep descent. There was the genuine regrets of my life that I believe I urge you to reconsider that viewpoint. no evidence of an occupant. Despite a I missed a chance to break the chain of month of searching, Joe was never found. events that led to a tragic accident. I wish Whatever our present flying assignment, My speculation was that, outbound to the that, in spite of all the negative factors be it fighter, transport, surveillance or last stop in the morning, the remaining weighing on me, I had kept to my discipline rescue, we all have one thing in common; load would have been very small. As the and told Joe of my incident with that we are professional aviators. As such, aircraft reached cruising speed, the airflow airplane door and warning horn. we are obliged to share our hard-won started pulling on the door, and that knowledge, no matter how we feel at the maladjusted micro-switch had triggered a The point of my tale is that, in our business time. It’s not about individual gain. relentless warning. Perhaps Joe felt goaded of aviation, information often has power Habitually and generously passing along into action. Alone, and with no autopilot, over life and death. It can mean survival to what we know that might be of use to he might have dialed in a measure of you or someone else. We pilots are, among someone else advances the profession as nose-down trim. Maybe he unbuckled, and other prominent characteristics, a competitive a whole, and can save lives. took three quick steps back to the door, bunch. Also, some organizations cultivate intending to give the handle a good push dynamic sparring within their own ranks. If you share the power of information, toward locked. Maybe you think that what you know, and in the long run, you won’t regret it. the other guy doesn’t, can give you a

Issue 2, 2012 — Flight Comment 31 light Comment 32

Lessons Learned F Mix Wrong T T runway and taxiways. near its activities summer construction wasalso army undergoing base some the accommodate six C-17s. Unfortunately, had a“small” ramp that could easily which nearby runway ofthe armyuse base C-17s.40 optionswasto ofour make One to recovertorequired close and turn and materiel support the to disperse quickly that summer. Consequently, had wing the going had to doneit to be happen quickly was waslow it if so ongoing conflicts, operational tempo, driven by two the high ofextremely to dothis aperiod during Desire Iwasstationed. where wing airlift 10,000the runway foot at strategic the to repaveHere isstory. the It wasdecided ofgravel.piles ofhaving C-17s risks the over taxi large C-17 USAF the with asamaintenance officer on 12 Shearwater Wing Officer, Safety Flight Wing F. John Major By Peetsma, Globemasters see that. HereIwas,see onexchange well. You would would anybody think he C-17 engine and gravel don’t mix he

— Issue 2,2012 , finding myself debating debating finding , myself

posed a hazard to any C-17. ahazard taxiing posed piled to runway the close that and taxiways material construction wasmore there In fact I notedthat nothingairfield, relocated. was daysA few later, again army visitingthe admirable. less something condition passing over could it also create anyengine with reasonable power setting/ that awell placed pile ofgravel an with power over ground. Iimagined saturated applied aircraft the when created vortices admire impressive the ground-to-engine my during tour to ample opportunity Toaircraft. this me wasobvious asIhad away the lanes transit for from farther materials (i.e. gravel) should relocated be I made mention that construction the recce the of army airfield, first the During I have? I this,go. it Ilet agreement with so Should in seemed ofgravel. piles the Everybody to reducenear poweradvised taxiing when and FOD hazard onthe would briefed be NOTAM would and issued all be C-17 aircrew and maintenancethatme assured a staff concerned. Heand other senioroperational and riskcould managed be and hewasn’t and opinion, in hisbut experience this hazard potentialWFSO the hazard, acknowledged Officer. Wing the Flight The with Safety it and finally and Idocumented discussed at Wingmentioned the Operation’s meetings, I meeting, at it myI mentioned unit safety Idid. –so ensure that would it addressed be could who toto thisthose raise hazard Well, and to act wasmy it responsibility

A few weeks later I had my answer as I was Now, several years later as I assume the effective operations. Equally, the system now responsible for an engine change and 12 Wing WFSO duties, I reflect back on that relies on those in a position to do something getting that critical aircraft back in the accident and ask myself: What could I have to actually do something about concerns operational loop. The engine change was done differently? What should the WFSO brought forward. When neither side steps no big deal as the more than capable USAF have done differently? What would have up, accidents happen, so my advice to you technicians would have that sorted out in been the outcome if I had been more (and to me, I guess, as a new WFSO) is to quick time. Though it was regrettable that forceful in my concerns? Had I dismissed not only step up and be heard, but equally a multi-million dollar engine was probably others who had brought concerns to me? as important, to listen. written off, what bothered me the most Will I dismiss others as a new WFSO? was the suggestion by some senior staff at the wing that I wasn’t forceful enough in The Flight Safety Program relies heavily making my concerns known, and that I on people coming forward, voicing their didn’t take the required action to address concerns and identifying hazards in the the hazard and prevent the occurrence. interest of the program and safe and Photo: Sgt Matthew McGregor

Issue 2, 2012 — Flight Comment 33 Snowmobile vs

Lessons Learned Twin Otter Photo: Capt Cheryl Major Capt Photo: By Captain Mat Giroux, 440 Transport Squadron, Yellowknife

s a first tour pilot, my experience With the drag complete and the ice deemed Were they completely in the wrong? Not is limited when it comes to working suitable, we commenced our final approach. necessarily. The soldiers were on exercise A with other elements of the CF. I am When on final for our full flap ski landing, and their task was to deny access to the lake. a recently upgraded CC138 Twin Otter we noticed a snowmobile with two soldiers Their actions were in accordance with the ski-equipped Aircraft Commander, and the driving along the edge of the lake. As long exercise plan and they did not receive mission in question was a reconnaissance as they stayed away from our landing zone information that our Twin Otter was not flight. there wouldn’t be a conflict. It wasn’t until part of their plan. Also, the soldiers had short final that the snowmobile drove into planned to place obstructions on the lake, We were tasked to recce a lake to determine the middle of the lake – right into our landing but couldn’t due to a risk of cold casualties it’s suitability as a landing zone for a path. With a sufficient landing distance amongst the workers. Had these obstacles potential VIP flight later in the exercise. beyond the snowmobile, we elected to adjust been installed as planned, and not detected Normally, our main concerns are the our aim point versus completing a go-around. by the aircrew, this incident may have landing conditions, weather and the odd As we were passing over the soldiers we ended up being an accident. curious animal that decides to join us. This noticed that one of them was shooting at time, we had a couple of hundred army the aircraft (fortunately with blanks!). This incident stresses the fact that what soldiers spread out in the general area as may seem like common sense to aircrew, part of the exercise. As the aircraft came to a stop, the soldiers may not be so for those who are not used drove up to the left wing tip and started to working around aircraft. Pre-Op planning Before landing on the lake, we conducted walking in front of the running aircraft. has to ensure the message is passed all the a ski drag. The drag is a procedure where after The flying pilot signalled them to stop and way down to the lowest levels regarding initial touchdown, we maintain around the Flight Engineer disembarked to talk to safety around aircraft versus exercise 50 knots with the main skis on the ice and the soldiers. They were informed about our gamesmanship. the nose ski airborne. We then complete a safety concerns with respect to their actions takeoff and assess the snow conditions around the aircraft and were instructed before committing to a full stop landing. to move back and not to interfere with our departure.

34 Flight Comment — Issue 2, 2012 TYPE: CC130 Hercules (130342) LOCATION: Key West, Florida DATE: 21 February 2012

he accident occurred during a touch The flight data and Cockpit Voice Recorders and go at Naval Air Station Key West. were recovered along with many parts related T During the takeoff just prior to the to the auxiliary hydraulic system, located in aircraft becoming airborne, the Loadmaster, the aircraft’s rear. The investigation team who was seated in the rear of the cargo identified that a stainless steel braided flexible compartment, heard an electrical buzzing hydraulic line associated with the auxiliary sound and observed an orange jet-like flame hydraulic system pump was breached where shoot across the cargo ramp from left to right it routed next to an electrical power cable. at floor level. He then unbuckled his harness The ongoing investigation is focussed on the and was reaching for the fire extinguisher maintenance history of the auxiliary hydraulic when an expansive orange fireball erupted, system. causing him to protect his head with his jacket. Once the fireball receded, he proceeded forward and alerted the crew to the fire while calling for the takeoff to be aborted.

Concurrently, the aircraft had just become airborne and reached 10 feet above the runway. With sufficient runway remaining, the flying pilot landed straight ahead and aggressively stopped the aircraft while the non-flying pilot notified ATC. Once the engines were shut down, all nine crewmembers quickly egressed and moved upwind of the aircraft. Crash, fire, and rescue services responded and expeditiously extinguished the fire. The aircraft was extensively damaged and one crewmember received a minor injury during egress.

Issue 2, 2012 — Flight Comment 35 TYPE: CH146 Griffon (146453) LOCATION: Approximately 6.5 NM northwest of Yellowknife airport (YZF) DATE: 13 February 2012

hile supporting Ex ARCTIC RAM, Griffon CH146453 was conducting a W night area of operations familiarization in the approved Temporary Tactical Low Flying Area. All three aircrew were qualified, current and authorized for the mission. They were all wearing night vision goggles.

The crew departed YZF, proceeded into the approved exercise area and conducted their planned landings and take offs at two Forward Operating Bases. On the return to YZF, while conducting low level flying training, the aircraft contacted three high power transmission lines approximately 6.5 NM north west of YZF. The three wires were guided through the wire strike protection system and were severed, which removed electrical power to the city of Yellowknife.

Post-impact, windshield plexiglas and other The aircraft sustained “B” category damage. The investigation is focussing on aircrew debris entered the cockpit and entangled the Severe damage was found to the left pilot supervision, pre-flight preparations and Aircraft Captain’s helmet. Shortly thereafter, windshield, top window and adjacent fuselage briefings, aircrew human factors, in-flight the First Officer initiated a 180-degree turn structure. Electrical burn marks were found decision making, low level flying in the wires to return to YZF and then overflew the same on the left tail pylon and the left and right environment and the wire strike protection high-tension power line. The aircraft then fuselage, which indicate electrical discharge system. approached YZF from the north, overflew exit points. The aircraft was returned to several taxiways, ramps, and the main runway third line contractor for further damage before turning onto the Golf taxiway and assessment. hover-taxing to the ramp for landing and shut down.

36 Flight Comment — Issue 2, 2012 TYPE: CF188 Hornet (188925) LOCATION: Salina, Kansas, USA DATE: 17 November 2009

he incident occurred at night on the Smoky Hill Air National Guard Range T (SHANGR), near Salina Kansas. Canadian military personnel conducting a Forward Air Controller (FAC) course were using a Intended Target Ground Laser Target Designator (GLTD) to LGTR Impact Location guide a laser guided training round (LGTR) from aircraft CF188925 to a range target located approximately 790 metres (m) to GLTD their south.

Using standard procedures and following pilot/FAC mutual confirmation of the correct target using infra-red markers, the pilot was cleared for his attack run; however, instead of guiding on the intended target, the LGTR impacted approximately 50 feet southwest of the ground personnel and the laser designator. There were no injuries and further training using the GLTD was terminated.

The investigation determined that the Contributing to the occurrence was insufficient Observation Post (OP) was established within guidance and information available to allow the LGTR seeker Field of View (FOV) when the FAC team to ensure they were positioned lasing was commenced and the FAC team had outside of the LGTR’s FOV. positioned the GLTD so that the laser beam Recommended preventive measures include passed through tall grass immediately in front developing a tool that will aid the FAC to of the GLTD. This created a second laser spot determine the appropriate location for the that was disregarded by the LGTR seeker while OP and updating the relevant user publications the target area laser spot was still visible. At to include the lessons learned from this some point during the LGTR fly-out, the seeker investigation. lost sight of the target area laser spot and switched to the laser spot in the grass and guided to that location.

Issue 2, 2012 — Flight Comment 37 TYPE: CH146 Griffon (146476) LOCATION: Yuma Marine Corps Air Station, Arizona DATE: 22 February 2011

H146476 was scheduled as part of a night two-ship Close Combat Attack training C mission that included the insertion / extraction of a Joint Tactical Air Controller. The aircraft was serviceable and the crew was

the extraction, while the crew attempted its second approach using night vision goggles (NVG) to a spot 100 feet south of an observation post and fence, a dustball formed at 30 to 40 feet above ground level (AGL). By 20 feet the

then lost his forward visual references and instead made use of lateral ground references but did not take control. After entering the dustball the FE and AC made several “drifting right” calls, though no consideration to transfer aircraft control was made, no statement of lost references was given, and no decision

helicopter yawed and drifted approximately 120 feet before it came to rest within 20 feet overshoots due to DVE, the crew still elected verbal crew calls when losing references. of the fence. Damage to the left skid and to conduct an approach into the same area. Other recommendations included domestic fuselage, lower Wire Strike Protection System implementation of a Mission Authorization and landing light was observed. and closure rates. Post occurrence, unexploded The investigation focused on supervision, ordinance (UXO) was found in the vicinity of GPS and radar altimeter information, the decision making, dust landings and operations the selected landing site. pursuit of technical solutions to reduce the in the Degraded Visual Environment (DVE). risk of CF helicopters operating in DVE, and Under external pressure and time constraints, Safety recommendations included amendments a review of investigator training to include to CH146 NVG operations to unprepared consideration of UXO when managing an which included dust landings, in low illumination surfaces in low illumination and in DVE. accident site. conditions. The AC, under similar external Amendments were also recommended to pressures, elected to accept the mission. Once day/night currency requirements for brownout airborne and after having conducted multiple challenging approaches that resulted in parameters for dust landing procedures, and

38 Flight Comment — Issue 2, 2012 TYPE: Bellanca 8GCBC Scout (C-GSSD) LOCATION: Gimli, Manitoba DATE: 25 July 2011

he tow pilot was flying the Bellanca Scout supporting the Air Cadet Gliding T Program (ACGP). After landing from a glider tow the pilot realized that he was quickly approaching his pre-selected stopping point abeam the glider launch point. He applied the brakes abruptly and aggressively which slowed the aircraft and forced the tail to rise. He then released the brakes and ensured that the control stick was in the full aft position. Moments later he felt a bump, possibly from uneven terrain, and re-applied the brakes, bringing the aircraft to a stop; however, the tail resumed its upward movement and the aircraft slowly nosed over and came to rest in an inverted position. The pilot egressed the aircraft with minor injuries and was taken to the local medical facility.

In the absence of any technical malfunction with the Scout, the investigation focussed on ground handling, pilot technique, self-induced constraints, and staff arrival procedures and The investigation concluded that in order to Preventative measures taken consisted a review of the training documents. The stop the aircraft prior to a pre-selected and of additional ground school training and investigation found that over time, the pilot self-imposed point and to avoid a perceived confirmation flights for the tow pilot prior developed a tendency to relax back pressure potential traffic conflict, the pilot applied the to returning to flying duties. A National Pilot on the control stick and apply the brakes in brakes abruptly and aggressively while not Information File was published requiring a more aggressive manner than what was maintaining full back pressure on the control all tow pilots of the ACGP to review the required for the Scout. These inappropriate stick, causing the tail of the aircraft to rise and Flight Safety Investigation Report for the techniques were possibly developed during initiating the accident sequence. Prior to the L-19 Nose Over in Comox on 19 June 2010 as the pilot’s flying experience on the heavier tail wheel settling back on the ground, the well as the Enhanced Supplementary Report Pawnee tail dragger aircraft. Despite a Currency pilot inappropriately re-applied the brakes for this accident. Recommended preventive and Annual Proficiency Check flight and an abruptly and aggressively, causing the aircraft measures included amendments to the local Area Check flight, the pilot’s inappropriate to nose over. flying orders concerning airfield layout techniques were not identified and, therefore, and a review of decision-making training were not corrected. provided to Air Cadet pilots.

39 Flight Comment — Issue 2, 2012 Issue 2, 2012 — Flight Comment 39 The Back Page 2012 RCAF Flight Safety Conference

The Directorate of Flight Safety hosted the RCAF Flight Safety Conference 21 – 24 February 2012 at the Lord Elgin Hotel in Ottawa. This conference represents the one opportunity each year for Wing and Unit flight safety officers and NCMs to meet with their counterparts from 1 Cdn Air Div and DFS to discuss all facets of flight safety. The conference was opened by the Chief of the Air Force, Lieutenant-General André Deschamps. He described the current FS Program as an excellent one, respected world-wide, with the resultant pay-off of low accident rates. The demographics are changing in the air force and soon 45% of our people will have nine years of service or less. LGen Deschamps suggested that WFSOs/UFSOs are advisors to senior management and emphasized their importance as an early warning and are critical for assessing risk. He then cautioned everyone that as operational tempo drops, accident rates during routine missions can climb and that everyone must remain vigilant.

LCol Paul Dittmann, DFS 2, briefs on the Some of the highlights of the conference included: outstanding items from the previous seminar. Major Helen Wright, DFS’s Flight Surgeon, spoke on the difficulties of defining “pilot error”. In trying to find a definition, a “Systems Approach” or combination of conditions that are not of themselves unusual or abnormal, is examined. This approach professes that human error/deviation is not random but is systematically linked to task, tools, operational environment and context. Also, it suggests that there are many error types and that failures are an outcome of normal behaviour. Major Wright then briefly discussed CF-HFACS and said that the current fundamental structure will not change, however, there could be minor alterations to some definitions in order to improve clarity and minimize overlap. Col Yvan Choinière, DFS, Mr Daryl Collins, a Senior Investigator with the Transportation Safety Board, provided a candid review answers a question from of the Cougar Sikorsky S-92 accident 12 March 2009 along with valuable lessons learned relating a participant. to the investigation process and some of the difficulties incurred. Mr David Hurst from the Directorate of Technical Airworthiness and Engineering Support, spoke on the airworthiness risk management (ARM) process and colour coded Airworthiness/Survivability Risk Index. Lots of questions and a good discussion followed. From Public Affairs, Major Lynne Chaloux provided some very informative points to assist in situations where the civilian press is involved. Major John Meurling, from the Directorate of Air Programs, spoke on the status of Aviation Life Support Equipment (ALSE) within the RCAF. A very lively discussion followed. Dr Bob Cheung, from Defence Research and Development Canada (DRDC), spoke on a number of topics related to FS and research and development. One included the impact and consequences of degraded Photos: Cpl Alexandre Paquin Alexandre Cpl Photos: visual environment (DVE), such as experienced with rotary wing brownout. Several technologies are being LGen André Deschamps, Chief of the Royal Canadian developed and DRDC is tasked with providing a recommended solution. Air Force, closes the proceedings of the seminar by fielding numerous questions from the 50+ FSOs There were many other very interesting, productive and lessons learned presentations throughout the in attendance. week. It was mentioned that almost one third of FS staffs are new to the discipline and therefore the sharing of FS information at all levels proved most invaluable.

40 Flight Comment — Issue 2, 2012