National Défense Defence nationale

ISSUE 1, 2018

CHECK SIX Cause Obscure FROM THE FLIGHT SURGEON Crash Scene Hazard Management

VIEWS ON FLIGHT SAFETY Commander of the Royal Canadian Air Force Cover – Investigating the wreckage of CF188738 that crashed while conducting an air show practice on 23 July 2010 at Lethbridge County Airport, Alberta. Photo: Cpl Raulley Parks Raulley Cpl Photo:

From the Flight Surgeon 12

Keep Scanning 26

Recognizing and Reacting... 27

Unintended Hood Ornament 29

Don't Forget to Look Up 30

Follow Through... 32

From the Flight Surgeon 12 TABLE OF CONTENTS Issue 1, 2018

Regular Columns Views on Flight Safety 4 The Editor’s Corner 5 Good Show 6 For Professionalism 9 From the Flight Surgeon 12 Check Six 17 On Track 22 Dossier 24 Lessons Learned 26 From the Investigator 33 Epilogue 34 The Back Page 39 Flight Safety Contact Information 40

Lessons Learned Keep Scanning 26 Recognizing and Reacting to Change 27 Unintended Hood Ornament 29 Don't Forget to Look Up 30 The Importance of Follow Through 32

DIRECTORATE OF THE CANADIAN ARMED Send submissions to: To contact DFS personnel on FLIGHT SAFETY FORCES FLIGHT SAFETY an URGENT flight safety issue, MAGAZINE National Defence Headquarters please call an investigator who is Director of Flight Safety Directorate of Flight Safety available 24 hours a day at Colonel John Alexander Flight Comment is produced up to four times Attn: Editor, Flight Comment (DFS 3-3) 1-888-927-6337 (WARN-DFS). a year by the Directorate of Flight Safety. 110 O’Connor Street Editor The contents do not necessarily reflect Ottawa, ON, Canada, K1A 0K2 Visit the DFS web page at Major Claire Maxwell official policy and, unless otherwise stated, www.rcaf-arc.forces.gc.ca/en/flight-safety. Imagery Technician should not be construed as regulations, Telephone: 613-971-7011 Corporal Daisy Robin orders or directives. Contributions, comments FAX: 613-971-7087 Flight Comment magazines and and criticism are welcome. Contributions Email: [email protected] flight safety posters are available Graphics and design become the property of Flight Comment and on the flightcomment.ca website. d2k Graphic Design & Web may be edited for content, length or format. This publication or its contents may not be reproduced without the editor’s approval. ISSN 0015‑3702 A‑JS‑000‑006/JP‑000 Views on Flight Safety

Photo: Cpl Lisa Fenton by LGen A.D. Meinzinger, Commander of the Royal Canadian Air Force

recently read an interesting article on to make something safer can lose their of command. This essential attribute of our the Royal Canadian Air Force (RCAF) relevance over time or come into conflict Flight Safety program helps to ensure a I Aerospace Warfare Centre’s online forum as technology and capability advances. robust safety culture and allows for self- that discussed the challenge of creating, It is possible therefore that the intended reporting and openness. As the Commander implementing and following policy. As many procedural safety net may then become a RCAF, I recognize the importance of a strong of the people in the subsequent discussion hazard. It is for this reason that the leadership Just Culture within our Flight Safety Program, stated, rigidly adhering to policy without of the RCAF relies heavily on its members to as it enables free and open reporting from all taking context into consideration can create identify procedural shortfalls for revision members of our team, military and civilian. friction and may lead to unwanted results. and refinement. Observations need to be RCAF leadership at all levels must continue to In the Flight operations domain that could communicated to unit leadership so that lead by example and openly promote the key result in a catastrophic accident. solutions can be adopted or, at the very least, principles of our Flight Safety Program. the related risks can be better understood It’s important to note that many of our and assumed by the appropriate level RCAF policies, especially flight and maintenance of command. procedures, were adopted to make our day to day practices safer. Checklists were created so The success of the Canadian Armed Forces that important steps would not be overlooked. Flight Safety Program, first and foremost, Tool control practices were implemented to relies on support from its leadership and avoid leaving items in critical aircraft spaces. the complete buy in from its membership. Air traffic control procedures were created to As Commander of the RCAF, I expect that prevent two aircraft from occupying the same RCAF personnel are following defined policies space at a given time. In short, following and procedures but I also trust that anyone can policies and procedures has greatly reduced come forward, without fear of retribution, to our human propensity to put ourselves in identify issues to their leadership. This is how danger and makes our Air Force operations we collectively strengthen our Air Force. much safer. Another critical aspect of our Flight Safety Sometimes, however, policies and procedures Program is the independence of our Flight fail to meet their purpose. They can become Safety specialists. It is essential that anyone cumbersome, dated and cause frustration. can engage members of our Flight Safety Procedures that were originally developed team without the need to consult the chain

4 Flight Comment — Issue 1, 2018 Editor’sThe Corner

n addition to our regular columns, addressed in the PPE article. After the call is This issue also includes an informative and relevant this issue of Flight Comment will focus received, a critical step in protecting ourselves account written by Col (Retd) Chris Shelley of I on ways that accident investigators can is anticipating, recognizing and properly an aircraft accident that occurred on the outskirts reduce risk and mitigate hazards at an aircraft reacting to the actual hazards that are present of Ottawa, Ontario, in 1956. There is a plaque accident site. Over the years, investigators at the crash scene. This aspect is discussed located behind the Bruyère Village senior’s from the Directorate of Flight Safety (DFS) more fully in this issue’s “Crash Scene Hazard residence on Hiawatha Park Road in Ottawa have learned many valuable lessons on how Management” article. that commemorates the lives lost in this best to respond to an accident. We have accident (see photo insert). Studies of these refined our information gathering process past accidents serve to remind us of the and conducted post-occurrence action reports challenges encountered in the flight safety to try and identify potential short falls in our investigation process, that we must be response. We have accident “Go Kits” that prepared to react to a tragedy and how contain equipment and clothing to address unanswered questions can linger on for a wide variety of conditions. However each decades after an accident. occurrence can be quite unique and it is not unusual for an accident scene to introduce As usual, you will find a very useful article something unexpected. Curve balls include written by the Instrument Check Pilot School rapidly changing weather, remote accident on Human Performance in Military Aviation sites, challenging terrain and visits from (HPMA) that highlights the various tools we curious wildlife. How does one prepare for have at our disposal to recognize and address these unknowns? human factor errors. Much like dressing up to protect ourselves Looking for flight safety posters? They are now from the cold, the best type of protection available on the flightcomment.ca website. is the adaptable, layered kind. Protecting Lastly, I would like to take this opportunity to ourselves can begin well ahead of time and is DND Baillie-David, Alexandra Photo: say a fond farewell to a stalwart member of accomplished by first aid training, having up our Flight Safety organisation. Sergeant Lucille to date vaccinations and being physically and (Lucy) Calderone has been a quiet voice of mentally fit. Having a seasonal “Go Kit” packed Our centre-fold poster portrays the Crash wisdom, counselling many of us through with appropriate clothing and following a Scene Hazard Matrix, a valuable tool used FSIMS woes and other flight safety matters detailed kit check list goes a long way to based on the Risk Management process that within DFS for 20 years! We are going to sorely speeding up the pack before departure process is modifiable to suit the needs of any safety miss her when she hangs up her uniform on and helps ensure important items are not organisation. The poster also includes images May 5th. She is leaving behind very huge boots left behind. Bringing and having access to of two levels of PPE available in both military to fill...although she may decide to keep her appropriate Personal Protective Equipment and commercial off-the-shelf products. This boots as hiking shoes for the many adventures (PPE) that is designed to protect investigators poster can be used as a visual tool to provide she is about to embark upon. Safe travels Lucy! from the anticipated hazards such as burnt guidance on the assessment of hazards, carbon fibres, sharp objects, and fuel and oil mitigation of risk and the type of protective Major Claire Maxwell contaminated surfaces is important and is equipment to be worn at a crash site.

Issue 1, 2018 — Flight Comment 5 Captain Daniel Schade

uring a night flight on 2 June 2017, Captain Daniel Schade, a Sea King helicopter co-pilot, was taking off from the deck D of HMCS ST JOHN’S to continue a high-value operation. Mid take-off, a rare failure of the tail probe system caused the tail probe to extend and become locked in the fantail of the flight deck. Capt Schade’s quick recognition of the problem and expert handling of the aircraft prevented a catastrophic accident at sea. The crew had just returned from a mission for a hot-refuel, with much real operational pressure to return on station as quickly as possible. Once ready for take-off, they conducted a Silent Launch Recovery (ZIPLIP), where the clearance for takeoff was given through the use of light signals rather than voice communications.

At the exact moment the helicopter began to lift, the tail probe Hawkins Chris WO Photo: system failed, causing the probe to extend down and engage in the fantail. The main landing gear raised approximately five feet the helicopter and the flight deck, which is particularly important off the deck while the tail probe remained locked in the rails. when sea state is high. Capt Schade’s immediate recognition on The critical condition developed rapidly, leaving minimal time for the initial collective pull coupled with his smooth handling of the others to react other than the pilot at the controls. Without verbal aircraft in a critical phase of flight averted the possibility of striking prompting from the LSO or a change in trafficator signals from the tail rotor blades on the quarter-deck or inducing a dynamic FLYCO and as the helicopter was reaching an estimated ten degrees rollover. Either scenario could have resulted in catastrophic damage nose up, Capt Schade expertly recognized there was an irregularity to the aircraft, serious injury to personnel, or loss of life. with the take-off and elected to promptly abort the take-off by safely lowering the helicopter back on the flight deck. From the As inputs to tail rotor pedals would have had no effect on heading, critically nose-high attitude and in night conditions, he skillfully set an over controlling situation of the pedals could have created a the helicopter back on the deck with the main probe in the trap. catastrophic and sudden failure of the tail probe. Capt Schade’s actions were exceptional for a first tour maritime Capt Schade displayed situational awareness, decisiveness, and aircraft helicopter co-pilot (MHCP) who had not attained deck landing handling skills far above what is expected of a MHCP; his actions would qualification. The common procedure for shipborne take-offs is to be considered exemplary for even the most experienced pilots. initiate a sharp, but controlled, collective pull once the aircraft is For his outstanding reactions in preventing a devastating outcome, light on oleos. This technique creates quick separation between Capt Schade is highly deserving of this Good Show award.

6 Flight Comment — Issue 1, 2018 Corporal Devin Berube Photo: AB Callum Rutherford Callum AB Photo:

n 4 May 2017, aircraft CF188746 was going through its the pilot wrote a note to the technicians indicating that the aircraft start sequence to return to 4 Wing Cold Lake from Inuvik had a left wing tank unlock advisory. While walking toward the left O and two ground crew members were involved in the wing tip to check the cause of the advisory, Cpl Berube noticed that start-up. The first member’s role was to oversee the start while the other member was walking towards the left wing external fuel remaining in full view of the pilot and Cpl Berube’s role involved tank and was within the nine foot danger area of the left engine arming the weapons and checking for leaks and hydraulic levels. intake. Cpl Berube grabbed the other member and pulled him out of danger. Had Cpl Berube not reacted quickly, the other member Cpl Berube had just armed the weapons on the right side of the may have been sucked into the left engine. aircraft when he noticed that the hydraulics were low. He relayed the low hydraulic signal to the other technician, who in turn Cpl Berube's quick thinking and decisive action potentially prevented signaled to the pilot. While waiting for the hydraulic unit to arrive, the loss of life. He is highly deserving of this Good Show award.

Issue 1, 2018 — Flight Comment 7 Corporal Zachary McNaughton Photo: DND

pl Zachary McNaughton, an Aviation Technician, was Cpl McNaughton quickly assessed that the bus was not slowing deployed to the west coast with 427 Special Operation down and immediately ran in front of the bus, frantically waving C Aviation Squadron. On the night of the 2nd of November 2015, his arms to signal the bus driver to stop. When the bus finally Cpl McNaughton was tasked to support a dual point Hot Closed stopped, the vehicle’s front tires were millimetres away from the Circuit Refueling (HCCR) operation. During night HCCR, for both pressurized fuel hose and a few meters from the helicopter rotor operational reasons and to prevent blinding aircrew who are using arc. If a collision had occurred between the bus and the rotating Night Vision Goggles, all lights are extinguished or limited to red. The main rotor blade, compounded by a potential break and leak in weather conditions that evening were light rain and low visibility. the pressurized fuel hose, the impact and damage would have been devastating. The day prior to the mission, the dual point HCCR site was repositioned to an unused parking lot that was adjacent to the pick-up zone. Cpl McNaughton’s exceptional situational awareness and quick For reasons unknown, the decision to use the parking lot was never response unquestionably prevented the loss of numerous lives and communicated to the bus drivers who, throughout the operation, preserved Royal Canadian Air Force assets. He is truly deserving of had been using the parking lot as a turnaround point when this Good Show award. dropping off troops at the pick-up zone. While two running helicopters were conducting HCCR operations, a transport bus entered the HCCR site at a high rate of speed, oblivious to the ongoing refuelling activity. Seeing this incursion,

8 Flight Comment — Issue 1, 2018 Professionalism r ForFo Fo r commendable For commendable performance performance in flight in flight safety safety

Master Corporal Steve Atchison Photo: OS Paul Green Paul OS Photo:

n 30 March 2017, MCpl Atchison, retroactively attributed as the likely cause immediate revision of the applicable publications. an Aviation Systems Technician of two previous CC130J oil flooding flight MCpl Atchison then helped LM write a Technical O at 8 Air Maintenance Squadron safety occurrences. MCpl Atchison’s discovery Awareness Bulletin to prevent future engine oil Trenton, discovered a CC130J fleet-wide issue of this incorrect sequence in the Job Guide was flooding occurrences. while conducting Auxiliary Power Unit/ confirmed by on-site Lockheed Martin (LM) MCpl Atchison’s superior attention to detail Engine Emergency Shutoff Valves and Fire engineers and a High Priority alert was sent to detected a latent condition that had gone Extinguishing Systems checks after an avionics LM headquarters to amend the Job Guide. undetected by 8 AMS and 436 Squadron modification. MCpl Atchison discovered that MCpl Atchison then conducted extensive personnel, as well as by LM engineers, and pulling an engine’s “Fire Handle Fuel” Electronic research into other CC130J publications and directly resulted in the issuance of high priority Circuit Breakers (ECBs), as per the Job Guide discovered two additional Job Guides that amendments to several technical orders. sequence, would override the Engine Oil contained the same erroneous sequence. MCpl Atchison’s diligence, professionalism and Sump Shutoff Valve to an open position and He promptly brought this new discovery to the tenacity is highly commendable and well inadvertently cause the engine compressor to Lead LM Field Service Rep, and the additional deserving of this For Professionalism award. be flooded with oil. Indeed, this condition was info was forwarded to LM headquarters for

Issue 1, 2018 — Flight Comment 9 Professionalism r ForFo Fo r Focommendabler commendable performance performance in flight in flight safety safety

Master Corporal Sean Côté and Corporal Stefan Van Chesteing Photo: DND

n 2 June 2017, MCpl Côté and While tracing the engine cable path further prevent the pilot from reducing engine Cpl Van Chesteing were tasked to back on the propeller reset caution cable slide speed and potentially forcing an inflight O rectify a reoccurring Propeller Reset assembly they discovered that a jam nut was engine shut down. By persevering in their Caution Light fault on CC138 Twin Otter aircraft missing at the aft end of the distance rod on efforts to identify and rectify the fault, 803. Upon illumination of the caution light, the the right hand power cable. The missing jam MCpl Côté and Cpl Van Chesteing went well normal course of action is to adjust or replace nut allowed the cable slide to move and beyond normal procedures and demonstrated the micro switch that triggers the light. In the periodically bind in its mount causing a caution a level of expertise and competency well above two weeks prior to their tasking, three faults light to illuminate intermittently. Thus the expectations. Their superior professional had been signed off as serviceable by adjusting normal action of adjusting or replacing the attitude may well have prevented a significant the micro switch twice and once by finding ‘no micro switch was inappropriate for the root hazard to flight safety and so they are most fault’ in the system. After ground runs were cause of the problem caused by the missing deserving of this For Professionalism award. carried out and the system was again deemed jam nut. serviceable in accordance with technical references, MCpl Côté and Cpl Van Chesteing Had the missing jam nut continued to have became unsatisfied and continued to gone unnoticed, the power lever cable could troubleshoot the issue. have bound sufficiently on the mount to

10 Flight Comment — Issue 1, 2018 Corporal Francis Séguin Photo: DND

n 24 July 2017, upon returning from inspections on other aircraft in the hangar to operate with improperly rigged cables, a long range trainer, Flight Engineer and determined that the sound was absent chafing could have occurred potentially O Cpl Séguin was conducting a post flight on the other airframes. resulting in the cables severing in flight and inspection on the control column and flight leading to catastrophic results. controls of the CC138 Twin Otter when he The issue was brought to the attention of heard a very faint binding sound when the squadron maintenance section who Cpl Séguin consistently displays remarkable operating the ailerons at full aft elevator inspected the cables under the control column attention to detail and professionalism while deflection. The noise was barely audible and revealed that the aileron cables had been carrying out his duties as a 440 Squadron and co-workers did not see this as an issue; incorrectly installed around the pulleys. flight engineer and this case is no exception. nevertheless Cpl Séguin was convinced Furthermore, it was discovered that in certain Cpl Séguin’s tenacity in conducting a thorough something was not right. To confirm his control configurations the rigging error was investigation resulted in the identification and suspicions, Cpl Séguin conducted similar causing one cable to rub on the nose wheel rectification of a potentially critical hazard. steering column. If the aircraft had continued Cpl Séguin is truly deserving of this Good Show.

Issue 1, 2018 — Flight Comment 11 Crash Scene Hazard Management: An Updated Approach

by Major Tyler Brooks, Diploma in Aviation Medicine, Medical Investigator; Major Claire Maxwell, Editor of Flight Comment magazine / Formerly – Rotary-wing Investigator and Personal Protective Equipment (PPE) Coordinator; Master Warrant Officer Gary Lacoursière, Technical Investigator.

FS has developed an updated approach to crash scene hazard D management and welcomes the opportunity to collaborate with other organizations to share best practices and lessons learned. On 21 January 2016, an updated approach to crash scene hazard management was presented to representatives of the major air investigator communities in Canada: the Canadian Society of Air Safety Investigators (CSASI), Transport Canada (TC), the Transportation Safety Board (TSB), and DFS. The updated approach is rooted in the risk management process recommended by the International Civil Aviation Organization (ICAO) and is Photo: DND designed as a comprehensive yet straight-for- ward evidence-based approach to managing crash scene hazards. infectious diseases such as Human Anecdotally, there was concern at DFS (the Immunodeficiency Virus (HIV), Hepatitis B, and independent investigator of CAF aircraft Background Hepatitis C. To emphasize the perceived risk, accidents), that some CAF flight safety the annual “Personal Protection” training for personnel were emerging from training From the early 2000’s, crash scene hazard aviation accident investigators was specifically with the impression that infectious diseases management in Canada focused largely on called “Blood Borne Pathogen (BBP) training.” were the primary hazards at a crash scene. biohazard protection. This was the logical Over time, DFS attempted to supplement consequence of changes in the late 1990’s to Unfortunately, the emphasis on biohazard BBP training with instruction on other hazards workplace health and safety guidelines aimed protection sometimes overshadowed other – such as chemical, explosive and radiological at protecting the worker from exposure to potential hazards at aviation crash scenes.

12 Flight Comment — Issue 1, 2018 hazards – but this led to ever-growing “shopping lists” of specific hazards, which were difficult to remember and not context- ualized in terms of the actual risks they posed. In 2015, DFS began a review of its crash scene hazard training package, ultimately leading to this updated approach that is believed to benefit not only Canadian air investigators but also international air investigators. Method DFS reviewed the ICAO guidance provided in Circular 315 “Hazards at Aircraft Accident Sites,” which discusses specific crash scene hazards and groups them into categories. DFS adopted this consolidated hazard categorical approach, but made slight modifications to the individual ICAO categories after broad consultation with DFS accident investigators, and CAF aviation medicine and occupational medicine experts. Thus, the previous

“shopping lists” of hazards were reorganized into Photo: DND five easy-to-remember categories: 1) Physical, 2) Chemical, 3) Environmental, 4) Psychological, and 5) Biological. and medical literature, hazardous material Disease Control, the Public Health Agency safety data, and expert consensus to assess of Canada, and a thorough literature search DFS then conducted a risk analysis of the five the overall risk of each hazard category. for documented cases of disease transmission hazard categories using a Risk Management The pre-assessment was intended to give from aircraft accident sites. Moreover, (RM) process. ICAO Circular 315 recommends investigators a “head-start” when confronting consideration was given to advances in medical applying a RM process to crash scene hazards a crash scene, allowing faster and more accurate science since the creation of health and safety involving the cycle of: 1) identifying hazards, risk assessment, safer scene hand-over, and guidelines in the 1990’s. For instance, Hep B 2) identifying exposure routes, 3) assessing improved safety measures. transmission can be prevented with vaccination, risk, 4) introducing controls, and 5) reviewing HIV transmission can be prevented with and revising the risk assessment. Rather Applying this RM process, DFS ultimately post-exposure prophylactic treatment, and than applying RM at the time of a crash, DFS assessed that there was a low risk associated Hepatitis C can now be medically cured. Thus, decided to take the ICAO recommendations with biohazards (i.e. Human Immunodeficiency the relatively low risk of biohazards can be put one step further and pre-assess the likely Virus (HIV), Hepatitis B, and Hepatitis C) at in proper context for accident investigators. hazards. With primary focus on CAF aircraft a crash site. This assessment was based on fleets, DFS gathered evidence from scientific reassuring information from the US Centers for Continued on next page

Issue 1, 2018 — Flight Comment 13 Crash Scene Hazard (CraSH) Matrix

Hazard Exposure Route Risk Control • Broken structures • Cuts High • Control access • Composite fibres (CF) • Punctures Likely Probability • Avoid/cordon • Explosives • Crush Critical Severity • Disarm • Radiological† • Inhalation/ingestion • Severe injury and/or • Decontaminate

Physical • Stored energy • Contact/proximity • Severely degraded mission • No eating on site capability • Wear PPE • Apply Fixant (CF) • Petroleum, Oil, Lubricants/ • Inhalation Medium • Control access fluids • Ingestion Likely Probability • Avoid/cordon • Metals/oxides • Contact Moderate Severity • Neutralize • Viton (rubber) • Minor injury and/or • Decontaminate Chemical • Degraded mission capability • No eating on site • Wear PPE • Cold/heat • Variable Medium • Control access • Fatigue Likely Probability • Implement site security • Insects/wildlife Moderate Severity • Apply work/rest cycles • Enemy/Security • Minor injury and/or • Feeding/hydration • Political Situation • Degraded mission capability • Insect repellent/tick removal • Wear sunscreen

Environmental • Wear clothing appropriate for the weather • Wear PPE Traumatic exposure†† • Direct exposure Medium • Control access • Indirect exposure (vicarious Likely Probability • Apply work/rest cycles trauma, narratives) Moderate Severity • Monitoring • Minor injury and/or • Limit exposure and control • Degraded mission capability information release Psychological • Wear PPE Blood Borne Pathogens • Cuts Low • Control access • HIV • Punctures Unlikely Probability • Decontaminate • Hepatitis B/C • Via mucous membranes Critical Severity • No eating on site • Severe injury • Wear PPE Biological • Vaccinate†††

† Although the injury sustained from Radiological hazards could be severe, the probability of exposure is considered improbable and therefore the risk is considered LOW. †† The potential for severe traumatic exposure may increase the assessed risk level to HIGH in certain circumstances. ††† Advance vaccination is encouraged and could be mandatory for all personnel who attend a crash scene.

14 Flight Comment — Issue 1, 2018 Crash Scene Hazard Matrix their manoeuverability and efficiency and In both cases, the CraSH Matrix allowed the easing the level of difficulty in conducting their accident investigation teams to pre-brief and (CraSH Matrix) on-scene investigation. As the investigation safely prepare their crews on the anticipated In the end, DFS produced the following matrix progressed, the level of risk had to be adjusted hazards and associated risks of the crash describing the minimum expected risk level of due to environmental hazards (e.g. changing scenes, then allowed for rapid yet comprehensive each of the five crash scene hazard categories. weather), physical hazards (e.g. unexploded re-assessments of the crash scenes upon their The CraSH Matrix is intended to serve as a ordnance), and psychological hazards arrival. The matrix proved to be an excellent quick-reference and simple starting point for (e.g. human remains). tool for briefing off-site supervisors on local crash scene hazard management. At the same conditions and increased the effectiveness of time, investigators remain free to modify the Overall, awareness of hazards, their associated the crash scene handover to new personnel risk levels when necessary based on specific risks and the application of control measures arriving on-site. crash site circumstances. DFS has rewritten the was simplified and enhanced by use of the chapter on Crash Scene Hazard Management CraSH Matrix. As a practical tool, the CraSH Projected Future Development (previously entitled “Blood Borne Pathogens”) Matrix allowed the team to keep up with in its Airworthiness Investigation Manual (the changes in risk levels, anticipate and modify DFS will continue to use the CraSH Matrix investigation standards manual for the CAF). plans, and successfully complete the on-scene when investigating accidents; however, its The new approach is being taught on the CAF investigation. In addition, the CraSH Matrix use has highlighted areas that need to be Flight Safety course for aircraft accident served as a vital tool when handing over strengthened and updated particularly in the investigators and the medical course for responsibility of the crash scene to the Aircraft application of controls measures. Recovery and Salvage Team. Crash Scene Hazard Aviation Medicine providers. The first area that underwent review was the Management for this case also included the rationalization of appropriate PPE. DFS’ current first-ever follow-up medical screening for all Practical Application process involves the provision of items to CAF 109 personnel who worked on the crash site, flight safety units located across Canada. The DFS has now moved beyond the conceptual a process that was well-received by personnel challenge is to align the standardized equipment stage of this initiative and has had opportunities and their supervisors. Screening took place with the actual requirements of the crash to practically apply the CraSH Matrix in for potential injuries from all five hazard scene and requires an understanding of the the field. categories in the CraSH Matrix, with particular environment in which the equipment is to be attention to potential psychological injuries. The first practical application of the CraSH used and knowledge of the capabilities and Matrix occurred in November 2016 as a result The second practical application of the CraSH limitations of the equipment. This matter is of a CF188 Hornet crash in an unpopulated Matrix occurred due to an engine failure of a discussed in greater detail in the PPE article area near Cold Lake, Alberta, where the pilot CT156 Harvard II trainer in January 2017, which found in the Dossier section of this magazine. sustained fatal injuries. Based on reported forced both occupants to carry out an ejection The provision of PPE does not mean that every conditions, the accident investigation team and caused the aircraft to crash in a farmer’s crash site will require the investigator to wear used the CraSH Matrix while enroute to the field. Again, the aircraft accident investigators all the items for proper protection. Rather the crash scene to pre-assess the hazards. The used the CraSH Matrix tool to pre-assess the crash scene investigators need to know and resulting assessment indicated a probable expected risks and, as a result of the analysis, understand the hazards to which they are high risk level due to the type and quantity of made the decision to wear minimal PPE. being exposed and then they need to be able physical hazards and required the investigators Deteriorating weather forced a re-assessment to pick the appropriate protective items from to adopt the wearing of full PPE. Upon arrival, of the hazards and associated risks, resulting in a menu of available resources. Understanding it was determined that conditions were not a change of control measures to enhance PPE, that flight safety investigators have limited as initially reported and the physical risk modify the recovery plan and ultimately time to deal with the intricacies of PPE at was downgraded to a medium level. This resulted in the move of the wreckage to an re-assessment resulted in the investigators indoor location. having to wear less PPE thereby increasing Continued on next page

Issue 1, 2018 — Flight Comment 15 the time of an accident, DFS personnel have investigative community. Coincidentally, CSASI, TC We would like to thank the following people refined the selection of available PPE to better and the TSB were considering a periodic review of for their contributions towards this endeavour: protect against known hazards and have their own crash scene hazard management and developed a PPE poster to compliment the BBP training packages and the meeting with • Barbara Dunn, CSASI CraSH Matrix tool. DFS in January 2016 identified that there was a • Nora Vallée, Occurrence Response Analyst, great deal of consensus on the suggested way Flight Operations, TC Another area for review is the need to forward. Each group subsequently agreed to • Leo Donati, Director Operational Services, TSB develop education and training products that collaborate with DFS to further develop the complement the updated approach to Crash CraSH Matrix and to determine how to best • Susan Greene, Manager Multi-Modal Scene Hazard Management. For instance, the incorporate it as the basis for crash scene Training and Standards, TSB effective use of a PPE pocket-card relies on hazard management within their respective • Beverley Harvey, Senior Investigator flight safety investigators understanding the organizations. This common approach was hazards that they might encounter at a crash International Operations and Major- expected to enhance interoperability and Investigations – Air, TSB scene and knowing the limitations and allow collaboration on future work, such as capabilities of their equipment. To promote the rationalization of PPE. • Dr. Joan Saary, Occupational Medicine this understanding and knowledge, DFS is in Specialist, Canadian Forces Environmental the process of developing short training videos After the DFS article on Crash Scene Hazard Medicine Establishment (CFEME) that can be accessed via the internet. The Management was published in the October- intent of these videos is to provide accurate, December 2016 International Society for Air • Maj (retired) Rachel Morrell, former standardized, current and accessible informa- Safety Investigators (ISASI) Forum magazine, Head of Military Medicine, CFEME tion to flight safety personnel so that they can conversation was generated with other air • LCol Nathan Nugent, former Head of the easily educate themselves at the time and accident investigation agencies, notably the School of Operational Medicine, CFEME place that is convenient to them. United States National Transportation Safety • Col Pierre Morissette, Royal Canadian Air Board and the United Kingdom Air Accidents Force Surgeon, CF H Svcs Gp HQ Finally, the Canadian Forces Health Services Group Investigation Branch. These conversations are (CF H Svcs Gp) has developed a cross-platform indicative of a growing trend towards supporting • Col Helen Wright, former 1 Canadian Air mobile application called the “Div Surg App” this updated approach and demonstrate the Division Surgeon, CAF that features resource material and online importance of collaborating with other • Maj (retired) Tarek Sardana, SO Aerospace tools to meet the needs of the aerospace organisations to promote a greater under- Medicine, CAF medicine and flight safety communities. The standing of crash scene hazard management. CraSH Matrix is available for download from • LCol Carmen Meakin, Clinical Leader for this app, both as a read-only “pocket-card” Mental Health, CAF quick-reference and as a modifiable Conclusion “worksheet” document which can be shared Hopefully our shared knowledge will give • LCol Martin Leblanc, Chief Investigator, DFS, CAF via email. DFS intends to continue to collaborate our accident investigators a better idea of • Maj Patricia Louttit, former Acting Wing with CF H Svcs Gp to extend the features the actual hazards and associated risks Surgeon CFB Cold Lake, CAF within this app to support Crash Scene that may be encountered at a crash scene. Hazard Management. This knowledge will result in the application • Capt Roger Dib, Director Aerospace of more effective control measures and will Equipment Program Management Collaboration ultimately increase the health protection of (Fighters and Trainers), CAF our personnel working at a crash site. • WO Wil Tyhaar, Director Aerospace A key factor attributing to the success of this Equipment Program Management updated approach has been the collaboration (Transport and Helicopters), CAF. between members of the Canadian air

16 Flight Comment — Issue 1, 2018 CAUSE OBSCURE! by Colonel (Retired) Chris Shelley, C.D.

Chris Shelley joined the Canadian Forces in 1973. After graduation from Royal Military College he trained as a pilot, flying some 3,800 hours with 424 Squadron and 408 Squadron on CH135 and CH146 aircraft. He flew on operational deployments in Central America (1990) and Bosnia (2001). He commanded 408 Squadron and 1 Wing before serving as Director of Flight Safety from 2006 to 2008. Retired since 2008, Chris retains a lively interest in aviation history and flight safety.

ate in the evening of 15 May 1956, the Dominion Observatory near Dow’s Lake in Ottawa, Ontario, noted a curious

L Photo: DND seismic event. Its instruments recorded an intense pulse, too short and shallow to be one of the small earthquakes so common to the Ottawa Valley, but clearly significant. Little Despite a detailed flight safety investigation, The flight in question had originated as an did the scientists realize that this recording the causes of this accident remain a mystery. operational mission to intercept an unknown would provide key information for a flight Flight safety officers, unlike novelists, are no radar track north of Montreal. Two CF-100s had safety investigation. fans of mystery, yet even today, almost sixty been scrambled from St Hubert by CRYSTAL years on, the RCAF could encounter similar control (Radar Station Lac St. Denis), but had What the seismographs had measured was the frustrations to those the investigators faced in washed out after losing a rocket pod. The impact of a fully-armed CF-100 Mark 4B 1956. occurrence CF-100 had been scrambled as part interceptor smashing into the ground at 700 of a replacement section from RCAF Station miles per hour, just north-west of the small The first RCAF officer to reach the crash scene Uplands at 2129 hours and had contacted village of Orleans, Ontario, killing the pilot and found the building on fire from end to end, CRYSTAL control, but the unknown track was navigator. Had this been the only consequence, with great crowds of civilians blocking all the resolved before they could carry out an the crash would be little remembered today. entrances and exits to the property. He intercept. CRYSTAL handled both aircraft in a Unfortunately, the jet had made a direct hit on enlisted the Ontario Provincial Police to clear series of practice intercepts on their way back the only significant structure for miles around, the grounds and prevent civilian entry to the to Uplands and then passed control to the Villa St. Louis Convent. The ensuing scene. As soon as emergency services had dealt Foymount Ground Controlled Intercept (GCI) explosion and fire destroyed the building, with the casualties and brought the fire under Radar (ESKIMO) at 2211 hours. One of the killing a Chaplain, 11 nuns, and a kitchen control, RCAF crash investigators began their worker. 25 others escaped with their lives. work. Continued on next page

Issue 1, 2017 — Flight Comment 17 CF-100s landed at Uplands, but the occurrence surfaces or structure prior to impact, and the Early assistance came from an unlikely source, pilot tarried, asking ESKIMO for a practice engines had been developing full power. Given the Seismological Division of the Dominion intercept on two other inbound CF-100 aircraft. that the pilot had reported no problems to the Observatory, Ottawa, whose instruments had ESKIMO denied the request and monitored as GCI controller, whatever had happened to put recorded the impact. Knowing the distance the tracks of the inbound section at 35,000 from the crash site to the Observatory and the feet crossed the track of the occurrence aircraft speed at which shock waves travel through the at 33,000 feet. ESKIMO noted nothing unusual. earth, the scientists were able to provide the The occurrence CF-100 reported “normal” to investigators a precise time of 2216 hours and ESKIMO at 2214, before disappearing suddenly 51 seconds for the impact. The recorded pulse from the radar screen at 2215. Its last known correlated to a 15-ton aircraft hitting the position was 10 nautical miles north-east of ground at 700 miles per hour. As the last Uplands at 33,000 feet. transmission from the pilot had taken place at 2214 hours and 45 seconds (“Normal”), the Roughly one minute later, the CF-100 struck investigators now knew that the aircraft had the convent with such force that its engines taken no more than two minutes and 6 slammed through two upper floors, eight seconds to descend from 33,000 feet above sea inches of concrete and 35 feet of solid clay level and travel 5 kilometres to hit the convent before coming to a stop. The aircraft’s fuel, in a near vertical attitude. rockets and ammunition exploded, causing Photo: DND fire, massive destruction and death. Clearly Examination of the aircraft wreckage provided something had gone horribly wrong with few clues. Despite being extremely broken up incredible swiftness. the fighter out of control had been sudden and by the impact with the building, there were no disastrous. Then, as now, there were no obvious signs of pre-impact problems or RCAF investigators began the grim job of crashworthy voice or data recorders on RCAF failures. Having absolutely no data from the sorting out the aircraft wreckage from the ruin fighters, so telling the story of this accident of the convent. It soon became apparent that would prove to be a tremendous, and the CF-100 had suffered no loss of flight control ultimately futile, challenge. Photo: DND

18 Flight Comment — Issue 1, 2018 aircraft that would illuminate the last two minutes of the flight, the investigators turned their attention toward other factors: the weather and the crew. Weather at the time of the occurrence was a solid ceiling of cloud at 8,000 feet extending upward to 20,000 feet with better than 15 nautical miles visibility. Normally, this would not have posed a problem for a CF-100 to penetrate safely but combined with other factors could prove significant. The Board of Inquiry (BOI) began to consider whether the crew had lost control of the aircraft. Looking at the available facts, they came up with three working theories: an upset Photo: DND from jet wash, oxygen starvation (anoxia), or loss of control due to Mach tuck. Upset and subsequent loss of control could This left loss of control due to Mach tuck. As investigators focused in on the pilot’s have occurred due to the jet wash turbulence "Mach tuck" is a characteristic of all subsonic history, they found something that made this of the section that had crossed over the wings and was a problem with the CF-100. As a theory more chillingly plausible. occurrence aircraft, 2,000 feet higher. subsonic aircraft approaches the speed of Although not impossible, the BOI considered sound, a shock wave develops and begins to At first glance the pilot’s history was the scenario unlikely, given that 2,000 feet was move aft on the wing, killing lift and causing unremarkable. By all accounts, the 25-year-old adequate vertical separation and that the the nose to drop. The CF-100 would tuck at just man had been very conscientious, keen and occurrence pilot had spoken with GCI after the over .92 Mach. This was not necessarily sober. Despite the presence of a six-week-old cross-over and issued no distress call. disastrous because the aircraft would slow infant as well as a one-year-old baby in the family home, the BOI determined that he pilot Second was the possibility of anoxia. had gotten adequate rest before the flight. The Incapacitation due to oxygen starvation at Flight Surgeon had been concerned when the altitude was a spectre that stalked the RCAF ‘‘The Board of Inquiry (BOI) pilot followed a diet consisting solely of fruit through the 1950s. No fewer than 20 fatalities came up with three working juices, but he had responded to counseling and were attributed to anoxia in that decade. Even theories: an upset from jet wash, was eating more conventional meals. Medical today, anoxia is a concern in such advanced oxygen starvation (anoxia), evidence showed that the pilot had eaten a aircraft as the F-35 and F-22 and worries about proper meal before the flight. Investigators or loss of control due to Mach tuck." the safety of oxygen systems in many other also learned that the issue of Mach tuck in the aircraft persist. In this case, however, the CF-100 was well-known to the pilot. It had investigators considered it unlikely the pilot been publicized in a recent Flight Safety “Near had succumbed to anoxia. He had communi- quickly if power was reduced, and the wings of Miss” circular and the occurrence pilot had cated normally with GCI just two minutes prior the Mark 4 could take the stress. However, if participated in a general discussion of the to the crash, showing no signs of impairment. unchecked, Mach tuck could lead to loss of subject in the squadron, showing excellent The investigators also considered that if the control. If the occurrence pilot had inadver- awareness of the problem and how to recover. pilot had lost consciousness, the navigator tently exceeded the limiting Mach during There was no reason why the pilot would not would have radioed this information to the GCI descent through the clouds, a sudden pull-out have been able to recover from Mach tuck had or would have tried to bail out at least. might have caused a black-out and loss of it occurred. Therefore, anoxia was thought to be unlikely. control upset. Continued on next page

Issue 1, 2018 — Flight Comment 19 Then, buried in the pilot’s personal file, came a superimposed convulsive episode.” Further, “it Now the scenario of Mach tuck seemed more disturbing find. In early 1953, the Institute of is strongly recommended that this Flight Cadet sinister. If the pilot had inadvertently allowed Aviation Medicine at RCAF Station Downsview be trained as a multi-engine aircraft pilot and the CF-100 to exceed limiting Mach and had sent a letter to the Commanding Officer of that he, under no circumstances, be permitted experienced a “tuck,” the possibility of black RCAF Station Gimli, warning him that the pilot, to fly fighter aircraft.” out during an ensuing high G pull-out attempt then undergoing training, had a very low G was very likely, given the pilot’s history. The tolerance. “He registered blackout at 4.5 G, and Incredibly, the letter had been placed on the aircraft would have continued then to tuck he is considered to have a very narrow range pilot’s file in Gimli and then forgotten. It had past the point of recovery, becoming an between blackout and consciousness with not been forwarded to Air Force Headquarters, unguided missile accelerating toward the and no action had been taken to stream the ground and the convent far below. pilot away from employment on fighters. On the contrary, he had been selected for CF-100 Despite the plausibility of the Mach tuck interceptors despite the aeromedical scenario, the BOI failed to arrive at a definitive ‘‘Although the pilot had assessment that he was dangerously cause for the accident, citing a lack of solid certainly been made aware of unsuitable. Although the pilot had certainly evidence. Instead, they opted for “Cause his low ‘G’ tolerance, he may not been made aware of his low ‘G’ tolerance, he Obscure,” a common result for BOIs during the have been aware of the restriction, may not have been aware of the restriction, or 1950s. The BOI did state that there was no or he may have considered his he may have considered his posting to fighters “evidence to indicate any carelessness, posting to fighters as proof that the as proof that the RCAF was ok with his negligence or disobedience of relevant orders physiological limitations. Either way, faulty or instructions on the part of the pilot or of the RCAF was ok with his physiological handling of the paperwork had allowed an limitations. Either way, faulty extremely dangerous situation to develop. handling of the paperwork had allowed an extremely dangerous situation to develop." Photo: DND

20 Flight Comment — Issue 1, 2018 navigator in relation to this flight which also hampered by the absence of any kind of changed in 60 years, as RCAF crash investiga- terminated in this accident.” Higher level crashworthy on-board recording devices, and tors may once again be faced with a smoking reviewers gave most credence to the scenario often had only extremely scanty evidence on hole in the ground and little choice but to of Mach tuck and ensuing black-out by the which to base conclusions. Today, most RCAF conclude, “Cause Obscure!” pilot, given his medical history. Overall, it was aircraft carry crashworthy CVR/FDR, with a a less than satisfactory conclusion for an notable exception being the CF-18 fighter/ investigation into such a disastrous and interceptors. In that respect, not much has notorious accident and provided little in the way of useful preventive measures. As a result, the RCAF essentially closed the book on this accident and moved on. If this seems harsh, remember that the RCAF experienced 56 fatal accidents that year, as well as hundreds more Category A non-fatal accidents. There was plenty of work to be done correcting known deficiencies and little time left to ponder which systemic failures might have led to this crash. Many years would pass before the RCAF modified flight safety investigation procedures to provide a more sophisticated approach to “cause factors.” In the 1950s, Boards of Inquiry had administrative as well as safety responsibilities, and were instructed to find “the cause” (i.e.: responsibility) for accidents. While their reports produced many valuable recommendations for improving safety, they tended to be quite narrow in scope and had difficulty in tackling systemic issues. Flight safety today has a vastly improved system for identifying and classifying hazards and cause factors, and a much better record of tracking their resolution. As we have seen from this occurrence, the investigators of the 1950s were Photo: DND Photo: DND

Issue 1, 2018 — Flight Comment 21 ON TRACK HPMA – Past, Present and Future

This article is the next instalment the RCAF in the early 2000s and is the of a continuous Flight Comment follow-on to the old Crew Resource contribution from the Royal Canadian Management (CRM) program. The aim Air Force (RCAF) Instrument Check Pilot of the program is “Increased operational (ICP) School. With each “On Track” effectiveness through individual and team article, an ICP School instructor will performance training.” We are the H in HPMA, reply to a question that the school and 70 – 80% of all aviation problems are due received from students or from other to the fact that we (humans) are involved in aviation professionals in the RCAF. the process. Until there is a time that If you would like your question humans are no longer involved, there will featured in a future “On Track” article, be problems that we cannot AVOID, and by which we make decisions, we should please contact the ICP School at: we understand that. We have therefore be able to affect the outcome in a +AF_Stds_APF@AFStds@Winnipeg. developed strategies and tools that will positive way. help to TRAP and MITIGATE the problems that will inevitably arise, and I will now The PACE model (Probe, Alert, Challenge, This edition of On Track will discuss share some of these with you. Emergency) is another tool we have at our HPMA related topics and was written by disposal. It is a process for initiating a Captain Braden Buczkowski, HPMA Flight The first example is the AIPA (Awareness, discussion and can best be described as a Commander and ICP School Instructor. Implications, Plan, Act) model. It is the gradual escalation of the communication most recognized symbol of the current process that helps to prevent conflict. When HPMA program and describes our decision faced with a non-critical situation, a probing es, HPMA... you did read that making process. question may be sufficient. An alerting statement would be the next step if the correctly. The following article is The three critical resources affecting any a departure from the norm in that, situation becomes more urgent, followed by Y decision are Knowledge (Background or a direct challenge and finally an emergency unlike most other On Track articles, this Situational), Attention (Are we lacking command. In some extreme cases, it may be one focuses on HPMA aspects and is not any?) and Time (How much is available?). just directed towards pilots... members of necessary to jump straight to the emergency These must be carefully managed in order command, however, ideally the escalation every trade within the RCAF should be for the decision to be made effectively. able to take something away from this. would be gradual and the situation could be In order to do that, the person(s) involved resolved early, without the need to progress For those of you who do not know much must maximize awareness, determine the to the next level. about Human Performance in Military implications, develop a plan and then act Aviation (HPMA), it was introduced to accordingly. If we understand the process

22 Flight Comment — Issue 1, 2018 It is worth noting at this point that Regulations Another trap that people fall into at times Over the next few months, we will be and Orders, along with robust Standard is referred to as “STRENGTH OF AN IDEA” hearing the acronyms FRMS (Fatigue Risk Operating Procedures, well written Standard which can often be compared to tunnel Management System) and MALA (Mission Manoeuvre Manuals and detailed checklists vision. Many times when a decision must Acceptance – Launch Authority). These go a long way towards preventing many be made, particularly within a short time tools are being introduced to the RCAF situations from even occurring, which is why period, the result can be seen as a straight with the intent of enhancing both the they must be updated on a regular basis in path forward with no chance of altering current HPMA program and the way we order to remain effective. course. The individual often affected by perform as a whole. It is obvious from the this would be the one who is making the FRMS acronym that the focus will be on When any program is replaced with a new final decision (Aircraft Commander, shift fatigue, its associated risks and how to and improved version, it is inevitable that supervisor, etc.) and once that individual manage them. As you will learn, FRMS has certain aspects will be overlooked, either is moving forward with their thinking, the potential to be a game changer to the intentionally or inadvertently. This holds it is difficult to steer them in a different day to day operations of the RCAF. Surely true to HPMA. The old CRM program direction if and when things start going we can all relate to operating in a fatigued included some great tools and techniques poorly. It is then imperative for the state at some point in our careers, perhaps which did not necessarily transfer over to remaining team members to be assertive in even on a regular basis. One goal of FRMS the new documents. Fortunately, there are their statements to ‘right the ship’ or ‘get is to educate individuals with respect to some long-in-the-tooth individuals still the train back on the rails.’ If anyone has the numerous physiological aspects of around who remember and are willing to ever experienced ‘GET-HOME-ITIS’ you fatigue so that we can all learn the proper share their knowledge with the newbies. know exactly what I am referring to. countermeasures and mitigation strategies Aircrew (specifically pilots) from communities when we are faced with it. Much like all Another approach for your HPMA toolbox is the other concepts discussed in this article, who fly in formation or close proximity to called the “MOST CONSERVATIVE RESPONSE.” other aircraft have a simple three word phrase these new tools are intended to increase Very simply, when faced with multiple both the effectiveness and safety of that is universally recognized as a command possible options, it is often preferred to to put an immediate halt to the current our operations. However, like all tools, choose the answer that will allow for the they must be used properly and in the activities... those words are “KNOCK IT OFF.” least amount of contention. This can Unsurprisingly, this phrase is not to be used recommended manner to work as they sometimes be described as the safest course were designed to do. lightly as it will lose its importance rather of action. However, if the safest solution is quickly. There is another, lesser known, three always chosen, it would be difficult to get There are many different HPMA strategies word phrase that should hold the same level the job done, due to the fact that there is and tools that help trap and mitigate of urgency and can be used by anyone (not always some degree of risk in military problems and new HPMA techniques are still just aircrew) with the sole intent of raising operations. Choosing the most conservative being introduced. It is up to each individual awareness of a potential problem. That phrase response is not always easy for the leader or to educate themselves on their options and is “THIS IS STUPID.” It may sound silly to some, their followers, since many times the to then pick and choose the method that however, if these three words are ever spoken, decision that needs to be made is difficult works best for them. By strengthening it should serve as an immediate attention and has the potential of frustrating or even the individual approach, and practicing grabber. It is also important to remember, that alienating certain team members. Indeed, these methods as a team, operational this phrase should not be used lightly and we must not forget that we are all part of a effectiveness can be greatly enhanced. should be reserved for occasions where the larger team and we may not always have all outcome has the potential of going sideways the information at hand. very quickly, lest we end up with a ‘boy who cried wolf’ situation.

Issue 1, 2018 — Flight Comment 23 Personal Protective Equipment for FLIGHT SAFETY INVESTIGATORS

by Captain Sylvie Couture, Directorate of Flight Safety 2-4-2, Ottawa

he CraSH Matrix, introduced in the PPE may also offer psychological protection categories that are intended to allow “From the Flight Surgeon” article on the by providing physical separation from the flexible choices to suit the conditions of a T management of crash scene hazards, crash scene and reducing exposure to crash scene. The categories are: Low Risk identifies various methods of controlling distressing stimuli, such as smells. However, and High Risk. hazards at an aircraft crash scene including PPE is not a suit of armor. It can be damaged elimination, engineering, administrative or fail and a decontamination process should Low Risk PPE is for relatively clean sites, such measures and the use of personal protective be available if this happens. as intact aircraft interiors and hangar spaces, equipment (PPE). For example, a variety of where there is little, if any, contamination chemical and biological hazards may be When the flight safety crash scene hazards and only nuisance dust. Recommended PPE eliminated by decontaminating the site with management approach was updated, the items include non-impermeable coveralls, water or a 10% bleach solution. Explosive Directorate of Flight Safety (DFS) identified N95 dust masks, nitrile gloves, hard hats hazards may be eliminated by the specialized the need to improve its PPE process and that and boots with boot covers. intervention of explosive ordnance disposal flight safety personnel needed better training in the use of their equipment. High Risk PPE is for contaminated sites, such teams. Burned carbon fibres may be stabilized as a crash involving a post-crash fire, injuries by applying a fixant or soil tackifier such as Although the review is ongoing, DFS has made or fatalities, and broken or fragmented water, ice, firefighting foam or a 10% acrylic some important advancements. The Suffield aircraft wreckage. Recommended PPE items floor wax solution. Additionally, exposure to Research Centre’s Chemical and Biological (CB) include impermeable coveralls, full face all categories of hazards may be reduced by Assessment and Protection Section has masks, hard hats, nitrile gloves with leather strictly limiting and controlling access to confirmed that the military issued gas mask outer gloves and steel toe rubber boots. the site. system (C4 gas mask and C7A canister filter) Permissible alternatives to the standard High While PPE is considered the last line of is a viable respiratory protection option for Risk PPE order of dress include military issued defence and the least effective method, it investigators at an aircraft crash scene rain jacket and pants (or equivalent civilian remains an essential tool for flight safety provided that the individual has been trained attire), gas mask system, helmet, nitrile personnel. When used properly, PPE protects in its use and properly fit tested to ensure gloves with leather outer gloves and steel individuals from all categories of crash scene they have the correct size. This section has toe work boots. hazards by preventing: also confirmed that the military issued rain jacket and pants (or equivalent civilian attire) The CB Assessment and Protection Section a. Direct skin contact; provides similar or better protection than confirms the DFS practice of taping closures tightly shut to increase the performance of b. Ingestion or inhalation; the DFS issued coveralls provided they are properly prepared as described later in this the closure and significantly reduce (and c. Absorption through mucous article. These confirmations have allowed possibly eliminate) the penetration of membranes; and, DFS to develop the flight safety PPE Orders particulates. Whether using the issued rain jacket and pants or equivalent civilian attire, d. Injury due to sharp, penetrating, or of Dress. The new Orders of Dress (poster the section recommends that the rain suit is crushing hazards. included in this issue) consists of two

24 Flight Comment — Issue 1, 2018 National Défense Defence nationale CraSH Matrix

E

Hard hat Hard hat Hard hat Military N95 dust Full face helmet Full face mask mask Civilian mask Goggles Impermeable Gas mask rain suit Non-impermeable coverall Military coverall rain suit

Nitrile Leather gloves Nitrile Nitrile outer Nitrile Leather Leather gloves gloves gloves outer gloves outer gloves gloves

Steel toe Steel toe Steel toe rubber boots Boot rubber boots Lorem ipsum covers work boots

Dry Environment - tucked and taped Wet Environment - loose and layered clothing clothing

appropriately sized for the user. A tailored be taped at the neck line. It is important to While DFS will continue to supply standard fit avoids the bellowing effect that draws in ensure that the rain jacket is not designed PPE items as listed in the A-GA-135-001/ particulates. In a dry environment, the jacket in a way that leaves a gap that exposes the AA-001 Flight Safety for the Canadian Armed should be tucked into the pants and the “tuck skin at the neck, or that the hood cannot be Forces, units have more flexibility now that line” at the waist should be taped. In a wet tightened against the respirator. The rain suit the military issued rain suit (and civilian environment, the jacket should be left option should provide someone trained in equivalent) and gas mask system have been untucked in a loose and layered style to using PPE in a hazard zone, moderate to high added to the approved list of PPE options. allow the particulates to be directed down protection performance, depending on the and off. The ankle and wrist closures and the activity level. In addition to the enclosed articles and front zipper of the jacket should be taped, poster, DFS is producing a series of short including a small patch along the neck line Depending on the conditions of the crash videos to increase awareness of crash scene over the top of the zipper. Any passive scene, flight safety personnel will not hazards, introduce the new flight safety PPE venting under the armpits should be tightly necessarily be required to wear all PPE items Orders of Dress and improve training on zipped closed. Passive venting on the back specific to the Low and High Risk categories. the use of PPE. These videos will soon be (or elsewhere) should be taped to reduce The PPE Orders of Dress are intended to serve available on the DFS website. the air flow through the closures due to the as a framework that the investigator-in- bellowing effect. If the hood fits loosely to charge should use to determine the PPE the respirator, it should be taped, and if the required to be worn at the crash scene. hood is separate from the jacket, it should

Issue 1, 2018 — Flight Comment 25 LESSONS LEARNED

Keep Scanning by Corporal Mirjon Gjoza, 450 Squadron, Petawawa

t was Friday afternoon in mid-September. to position the aircraft for landing. On the happening again. This time the damage The sun was shining, and we were enjoying final few strokes of the approach we came to a was minor, with only some wet and damaged I unusual high temperatures for that time of hover approximately 60 feet above the ground. camping gear, but the potential for severe injury year. With the weekend up ahead and great My focus was to the aft of the aircraft where or worse was there, considering we had people weather it was the perfect time to go flying. rocks and trees were the biggest danger. so close to being blasted with our rotor As we came into a hover, I heard the other down wash. Our trip was a local area training flight in the crewmember from the ramp announce north Tactical Low Flying Area (TLFA). It included “Overshoot! Overshoot! Overshoot!” while The moral of this story is to always keep scanning a tactical navigation with multiple landings simultaneously I watched camping gear your areas of responsibility. Especially during in confined areas throughout the route. start to fly around. those last few feet of the approach where the The north TLFA is a vast, sparsely populated tendency is to focus on the immediate danger. area of natural beauty and abound with rivers, A tent, stove and cooler were thrown by the Had I been paying attention forward just as lakes, forests and dirt roads. The crew was immense rotor wash of the Chinook. In the much as aft we would have overshot the area standard for a CH147 Chinook consisting of overshoot, the condition was exacerbated as early, high enough above the landing site to not 2 pilots and 2 flight engineers with a mixture power was increased, and the gear flew into the affect the canoeists. In addition, knowing this of experienced and junior crewmembers. lake and farther around the rocks. During the site is a popular area for campers and picnic departure a canoe, with two men fishing out of goers, the crew could have briefed it Amongst the Landing Zones (LZ) was one that it, was spotted at the end of the lake. They were beforehand. The brief could have stated that is commonly known as the waterfall. A chute in still in the canoe, floating and uninjured, so we we would conduct a low recce (reconnaissance) the Colounge River with a small rocky outcrop proceeded with the rest of our training mission of the LZ prior to turning into a final approach to to one side, just big enough to set the two aft without further irritating them. land. Instead of creating two angry gentlemen, wheels of the helicopter. This place is very we would have possibly gotten a wave and the popular to conduct a pinnacle landing, it’s quite Back in Petawawa, after shutting down, I two canoeists would have had a good story to spectacular. Due to its beauty and access from reflected on the incident and tried to figure out tell rather than having all their gear soaked the road it’s also a popular destination for what went wrong and how to prevent it from and their fishing trip possibly ruined. outdoor enthusiasts. On short final, the area started to open up through the trees. I was positioned at the cabin door of the aircraft, voice marshalling the pilots, Photo: Sgt Marc-André Gaudreault Sgt Marc-André Photo:

26 Flight Comment — Issue 1, 2018 LECONSLESSONS APPRISES LEARNED Photo: Cpl Audrey Solomon Audrey Cpl Photo:

Recognizing and Reacting to Change

by Sergeant Andrew Latta, 431 Squadron, Moose Jaw

e’ve all heard that humans are realize that the temperature had dropped the outer wing of the first CC130 would have to “creatures of habit.” This is probably significantly and the wet looking flight line pass over a piece of equipment on the way out W why we find change difficult to was actually covered in a thick layer of ice. of the hangar. Since the wing of a Hercules handle but, unfortunately, change is inevitable. After a few steps my feet and my shoulders aircraft is quite high, I wasn’t worried. We Luckily, changes that happen gradually are were horizontally even and I quickly learned towed the aircraft out without issue, passing easier to mitigate and we can prepare for the the painful lesson of not recognizing and over the equipment with lots of space to spare. foreseeable outcomes. However it’s the little adapting to change. changes that happen quickly that we have a We connected the tow bar to the second difficult time recognizing and reacting to. CC130 and proceeded towards the hangar, to the spot we had just towed the first aircraft When organizing aircraft maintenance and “After a few steps my feet and my from. As the CC130 entered the hangar, servicing, the influencing factors of aircraft I noticed something significant. This Hercules shoulders were horizontally even schedules, personnel levels, available aircraft was fitted with air-to-air (AAR) qualifications and weather, all must be and I quickly learned the painful refueling pods while the first aircraft was not. considered. When these factors change lesson of not recognizing and The AAR pods hang down about four feet suddenly we need to recognise the changes adapting to change.” below the wing. I looked to my wing walker and react accordingly. who was happily walking with their thumb up in the air indicating everything was good. One morning, while walking out to an aircraft As the pod approached the piece of equipment to see how a B check was progressing, I noticed On another occasion, I was in charge of a in the hangar, I could see that it wasn’t going the flight line was wet due to the rain we had crew towing a CC130 out of the hangar to to have the needed clearance, so I yelled for experienced overnight. A few hours later, on a make space for another CC130 that required subsequent trip to the aircraft, I failed to maintenance. The hangar was congested so Continued on next page

Issue 1, 2018 — Flight Comment 27 LESSONS LEARNED

Recognizing and Reacting to Change ...Continued

the aircraft to be stopped. I walked over to the popular saying to what happens when we well trained which makes adapting easier, but wing walker and we looked at the pod versus “assume”, then we moved the equipment out we need to work on maintaining our situational equipment battle we had narrowly avoided. of the way and safely carried on with the tow awareness to help us recognize the changes. I asked the wing walker why they hadn’t of the second CC130. If we can do that, then maybe we can avoid warned me about the imminent collision. The the negative consequences that make changes wing walker replied that they weren’t really What these experiences have taught me is so difficult to bear. paying attention because they had assumed that situations and environments change, that if the first aircraft cleared the equipment whether by our hand or due to forces beyond on the way out than the second aircraft would our control. As technicians, we need to recognize clear it on the way in. I reminded them of the these changes and then adapt quickly. We are Photo: Cpl Ian Thompson Ian Cpl Photo:

28 Flight Comment — Issue 1, 2018 LECONSLESSONS APPRISES LEARNED Photo: MCpl Robert Bottrill

Unintended Hood Ornament by Master Bombardier Corey Bowe, W Battery, The Royal Regiment of Canadian Artillery School, Gagetown

rior to the use of the current RAVEN B We intended to land the Skylark nearby to ease Shortly afterwards, the Skylark dropped on the and the Maveric Unmanned Aerial the recovery process but, upon time to do so, an hood of the pickup truck and then bounced on P Systems (UAS), the Canadian Armed unexpected pickup truck rolled up. The driver, to the ground. Captain Pink jumped out of his Forces used the Skylark. Like many miniature an unqualified officer named Captain "Pink," vehicle and proceeded to go above and beyond UAS, the Skylark was designed to be hand stopped his truck, rolled down his window and to declare that we were in the wrong and launched and was recovered by inducing a asked how things were going. I told him that we should have "controlled the aircraft better." deep stall and using a highly visible, yellow were preparing to land the Skylark near the spot We made it abundantly clear that we were not where he was parked and suggested that he in the wrong and that he had neglected the airbag system which allowed it to land should move his vehicle back off the landing warning to move back from the landing site. gracefully on the ground. point. Captain Pink looked out the window People make the joke that "if a warning exists, The following event occurred in 2010, in a trying to spot the aircraft but did not seem to see it. He shrugged off my warning, stating it's usually because someone had ignored a large, open area of the CFB Gagetown training situation before and something, most likely area. A small detachment of three members, that he was going to be quick and would pass through and be on his way. From behind me, bad, had happened because of it." This rings including myself, Gunner (Gnr) "Red" and our I heard Gnr Red say “the aircraft is in Autoland”, true to this situation and is the reason why we detachment commander, were sent out on a meaning the aircraft had stalled and started its tell people to remain clear of landing sites so tasking to fly the Skylark over one of the many descent. We had less than a minute before the injury and/or damage can be avoided. Despite impact areas. Skylark reached the ground. this event being only a minor incident in the end, we were all lucky that no one was injured. The flight went as expected with Gnr Red as I tried to tell Captain Pink that he should wait It was, however, a valuable lesson of why we the pilot and I as the launcher. We had no to move but he disregarded my suggestion should all take heed to warnings, no matter complications during its flight until the landing. and started to turn the truck around. the rank or position of those who give them.

Issue 1, 2018 — Flight Comment 29 LESSONS LEARNED

DON’T FORGET TO LOOK UP by Master Corporal Chris Sheehan, 429 Transport Squadron, Trenton

en years ago our “periodic inspections” my walk around the aircraft and talked to all I immediately turned the system off and went of the CC177 Globemaster were being technicians to ensure that no one had an issue to see what was going on. Outside the aircraft T carried out in the United States due to a with hydraulic power being applied. Everyone I saw my teammate and partner in crime lack of internal infrastructure. Our maintenance was fine with the intended application but by coming down from a suspended maintenance section consisted of myself and one other platform at the tail. He had finished his tasked person. This meant that we had to prepare and job and thought he would give us a hand by build the pack for the trip and also manage the affecting a quick repair up between the upper team pairings and assignments when the main ‘‘There was no injury or damage and lower CC177 rudders. In his haste to assist, body for the inspection was pulled from the and a decade later we are still he neglected to safety the surface he was working servicing section. This was a never ending cycle friends but this occurrence abruptly on and he did not inform anyone of his intentions. of two weeks deployed and then two weeks of taught us to be mindful of all of our Luckily, he had just pulled his arm out of the unpack, followed by pack and prepare for the next surroundings, to pay close attention danger area between the rudders seconds before inspection. It was a busy job for the two of us. to details and to follow I applied power. I had almost crushed his arm. During one trip to the States, when we were recommended practices.’’ There was no injury or damage and a decade in the repair and operational checks phase of later we are still friends but this occurrence the inspection, I required hydraulic power to abruptly taught us to be mindful of all of our check an item that I had repaired. I did my then I had made my second mistake. I had surroundings, to pay close attention to details normal look around the cockpit for tags, forgotten to look up during my walk around. and to follow recommended practices. breakers or locks and everything looked good. Satisfied with my checks, I proceeded back to Had I looked up during my walk around, But, by failing to take the time to review all the the cockpit and pressed the hydraulic systems paperwork of the morning’s events, I had just power button. Within seconds I heard yelling made my first mistake. I then proceeded to do and could see people scrambling to get to me.

30 Flight Comment — Issue 1, 2018 I would have seen my friend or at the very least seen the suspended maintenance platform and had I checked the paperwork of the morning’s events, I would have seen my friend’s entry into the work log. Having an awareness of at least one of these things would have alerted me to not turn on the hydraulic system. In regards to my friend, had he safetied the hydraulic breakers in the cockpit, he would have prevented the hydraulic system from being turned on. And, had my friend informed others of his intention to conduct the work on the area between the rudders, I would have been informed about the potential conflict when I conducted my walk around. Four safety holes lined up that morning, but we were lucky. Here’s your chance to read my story and learn how you too can fill in some of your own safety holes! Photo: Cpl Kenneth Galbraith Photo: MCpl France Morin

Issue 1, 2018 — Flight Comment 31 LESSONS LEARNED Photo: MCpl Pierre MCpl ThériaultPhoto: The Importance of Follow Through

by Captain Joel Wilson, 2 Canadian Forces Flight Training School, Moose Jaw

s a flying instructor, follow through desired height above the ground. Rather than to be airworthy following the incident; is the act of observation physically, rectifying the situation by overshooting nevertheless, many lessons were brought A visually, and mentally as the student is from the unsafe flight condition, the student forward from the ensuing flight safety investiga- flying the aircraft. Following a student through made the opposite control inputs resulting in tion. The intensity of the situation reinforced the on the controls allows for easy identification a stall and hard landing. In recent history, a importance of active follow through during of errors and, most importantly, helps ensure hard landing from a similar situation on the student handling especially during critical phases the maneuver being flown is done so safely. same aircraft type lead to catastrophic damage of flight such as landing. Regardless of airborne As a junior flight instructor, the importance of to the aircraft and an ejection as the crew was or ground operations, familiarity with a student follow through was reinforced abruptly when unable to achieve a suitable landing configura- should never be an excuse for weak follow I found myself where no instructor ever should tion. With this in mind, I immediately took through or supervision during a task; no one is ever be: out of control of the situation. control of the aircraft to abort the subsequent immune to mistakes especially in the training takeoff roll and taxied the aircraft back to the environment. Finally, with respect to this specific I was flying a basic aircraft handling mission ramp without further incident. scenario, anticipating student errors and being on the CT-156 Harvard II with a student I had prepared for intervention before they occur become quite familiar with having flown the Due to familiarity with the student, my follow is the best way to maintain control over the majority of the course with them. Landing through as an instructor was weak at best. situation and to ensure safety in the aircraft the aircraft, up to this point in the course, Therefore the time required to rectify the is never jeopardized. had been well performed and safety of flight situation, caused by the student’s incorrect was never an issue in previous missions. control inputs, far exceeded the time available In this particular instance, the student pilot to recover. I had lost control of the situation. commenced a landing transition above the The aircraft involved was inspected and found

32 Flight Comment — Issue 1, 2018 TYPE: SAR Griffon CH146432 LOCATION: Opa Locka, Florida DATE: 28 February 2018

he six person crew was operating the Approaching the Opa-Locka airport control zone The incident was reported to local police who 424 Squadron CH146432 Griffon after the mission, the crew had commenced assisted the crew in recovering the life raft T helicopter (search and rescue configuration) the pre-landing checks when the life raft from the house. There were minor injuries out of Opa-Locka airport, near Miami, Florida, inadvertently departed the aircraft. The raft sustained by an occupant of the house, and as part of Ex Southern Breeze. During the was visually tracked by the instructor flight the house sustained damage to the roof and a winter months, search and rescue crews travel engineer as it fell from approximately 500 feet bedroom. There were no injuries to the crew to Florida to conduct overwater training that above ground level and was seen to impact the or damage to the aircraft. cannot be accomplished at the home unit. roof of a house. The crew circled the helicopter The mission was a training flight for an back overhead the house to mark its location, The investigation is focusing on how equip- under-training flight engineer consisting then continued to the airport for landing. ment is secured in the aircraft during flight. of mostly overwater hoisting work. Photos: Maj Andy Haddow Andy Maj Photos:

Issue 1, 2018 — Flight Comment 33 Epilogue light Comment 34 Epilogue D Victoria International Airport. International Victoria to the water from returned and off lifted then water. helicopter maritime The flight instructor touching down onthe helicopter unexpectedly descent. the This in resulted the arrest fully wasnot able but to down attitude a nose descent by power applying and adopting the to pilot stop and student attempted the from control took helicopter flight instructor and down. maritime The rearward drifting helicopter the several feet, hundred began over the water from hoverclimb vertically to helicopter the where manoeuvre initially must training plan.co-pilot afreestream During accordance helicopter maritime the with in manoeuvres tactical various out carried operator, systems electronic and an airborne pilot, officer, anstudent air combat systems helicopterof amaritime flight instructor, a

F Vancouver Island, crew, the consisting ofpilot south conversion flight anuring over water CH124 King Sea —Issue 1,2018

and did not completely carry out a vortex ring ring avortex out and did not completely carry state ring ofvortex not recognize onset the investigationThe did concluded that crew the manoeuvres. freestream conducting for state, and procedures power, with ring settling vortex for required conditions the investigationThe explored and human factors. onaircrew actions focused investigation The revealed faults. no technical monitoring system panel video instrument Post-occurrence maintenance and inspections LOCATION:

DATE: TYPE:

A 102, 2 December2014 CH12424 SeaKing South CY Squadron student pilot flight currency policy. pilot flightcurrency Squadron student (Maritime) Training 406 the Operational conversionmaritime and course, areview of (Maritime)406 Training Operational Squadron and ground simulatorstate training to the ring adding vortex procedures, recovery state ring Helicopterevaluating vortex Maritime preventativeRecommended measures include training. state to lack ring the helicopter ofmaritime vortex procedure. This waslikely recovery state due f itra BC Victoria, of

Photo: Maj Devereux

Photo: Cpl Blaine Sewell Epilogue Epilogue T almost lost consciousness. Mig-6 experienced experienced Mig-6 consciousness. lost almost into overhead the break and at 6.8g, Mig 6 undone. Two zippers comfort with g-suit seconds maneuver, fitting a loose with and wasflying straining anti-g the perform not did Mig-6 finalgear with turning down and for locked. in preparation to in6.8g order slow aircraft the bank angle to 81 and pulled upto degrees, to idle, initially throttles the the set set Mig-6 overhead the later During break by Mig-6. followed seconds handin aright three turn 470 Mig-1 knots, entered overhead the break at 1,500 above level ground of and aspeed ft ColdOverhead Lake runway aerodrome 13R to airport. the higher airspeed Mig-1to base maintained a and Mig-6 returning the other aircraft with deconflict wingman. wasthe In to order and Mig-6 Mig-1 formation. asatwo-ship together led Air Weapons to base Range and returned missions uneventfully in the Cold in the missions Lake uneventfully completed individualMig-6) Maple Flag wo CF188 (call pilots signs Mig-1 and

pulled 7.0g and avoided by ground the 270 ft. Mig-6 improved cognitive and motor functions, Terrain Warning System, Alert and with the heard audible the warning from Mig-6 descending towards began ground. the aircraft and theof cognitive and motor functions, (approximately term short seconds) 5 impairment LOCATION:

DATE: TYPE: Photo: DND Issue 1, 2018—

Lake, AB Lake, 20 June2017 CF188796 Hornet Cold lasting education/awarenesslasting CF188 for pilots. an appropriate to aircrew publication provide into fitting g-suit regarding responsibilities and pilot requirements inspection g-suit the recommendation is to incorporate safety The six months. to completed every be check fit Technical onbody ag-suit requiring Orders adherence to an ALSE –Canadian Forces due to pilot weight loss, and lack offitting was g-suit loose The g-suit. fitting aloose with pilot The wasknowingly flying human factors. due to incident The occurred malfunction. equipment(ALSE)aviation support life or no aircraft evidenceThe demonstrated evaluation. for hospital 4Wingthe base taken and responders to by wasmet first Mig-6 landing. to asafe Mig-6 and calmly assisted to land airgivepriority to control traffic them assistance and to desire the land. Mig-1 notified recovered, Mig-1fully advised for need ofthe away and ground climbed the now from Mig-6 Flight Comment

3

5 Photo: Cpl Pierre Habib EpilogueEpilogue TYPE: Jet Ranger C-FTHA LOCATION: Portage la Prairie, MB

DATE: 6 May 2015 Photo: DND Photo: Photo: DND

he accident aircraft, a Bell 206B Jet selected landing area – a field of low-cut hay what energy remained in the rotor to settle Ranger III helicopter, was on mission which included several water-filled depressions. the helicopter onto the ground. The helicopter NAV 1 of the Phase III pilot training landed firmly with considerable forward speed T With no intention of continuing the autorotation course out of 3 Canadian Forces Flight Training and came to a stop approximately 200 feet School in Portage la Prairie, Manitoba. to a landing, the qualified flying instructor took past the initial touch down point, after which The helicopter was crewed by a qualified control of the helicopter at approximately 120 feet the helicopter was shut down. flying instructor and a student pilot. above ground level and initiated a power recovery, but the engine did not respond as expected. The helicopter sustained serious damage to During the return to base following completion the tail boom and numerous components of the navigation portion of the mission, the This resulted in the rotor revolutions per minute surrounding the main rotor transmission. qualified flying instructor gave the student pilot decaying as the helicopter continued in a There were no injuries. a simulated engine failure emergency at slight descent over the field. While overflying approximately 500 feet above ground level. approximately 1,200 feet of distance over the The investigation focused on the apparent slow The qualified flying instructor reduced the open field, the qualified flying instructor response from the engine and on human and throttle to idle to simulate the unexpected continued to gradually increase collective to organizational factors. With no deficiencies engine flameout while advising the student prevent the helicopter from settling into a found related to the engine power response, pilot of the simulated emergency. The student couple of shallow, water-filled depressions. the preventive measures are aimed at human pilot responded by reducing the collective to factors related to maintaining rotor speed Running out of energy in the rotor, it became during autorotations. enter autorotation. The student pilot completed apparent that an overshoot was not possible. the required radio call while establishing the The qualified flying instructor flared and used aircraft into wind on final approach to the

36 Flight Comment — Issue 1, 2018 Epilogue Epilogue T Swift 32 32,Swift Swift and lasing for who target the 31 Swift trail 2 of miles in with about flying lead, 32 tactical Swift assumed then process. in the ofaltitude losing over ft impact, 200 toof apilot visually attempting spot his weapon in amanner that wassuggestivehis aircraft Following his 32 83 Mark drop, Swift manoeuvred ofheading change. degrees 90 through turn “breakaway comprising asteep manoeuver” each their pilotdropping bombs would a fly To avoid simulated after fragmentation bomb above level. ground feet 600 weapons from plan andThe drop wasto target the ingress bombs, Cold in the Lake Air Weapons Range. simulating rounds, guided training laser guided followed laser bombs by two 83Mark inert level deliveries wasto oftwo practice objective an air-to-ground training mission. mission The two-ship formation led by “Swift 31” by led “Swift formation two-ship for 32”, signcall “Swift ofa waspart CF188747,he pilot ofaircraft using the

struck the ground in a descending left turn. in adescending ground left the struck and aircraft injured the when wasfatally no radio calls did not turn, the eject during 32 Swift made occurred. impact ground when to approximatelyincreased minus 10 degrees and pitch the angle approximately left 30 degrees rollingbegan bank The angle right. had to reduced aircraft the 1.5About impact before seconds generating alargeconcurrently descent rate. pitch angle ofminus 17nose-down and degrees belowthen horizon, the eventually reaching a to began pitch towards nose and aircraft The 118 while pulling degrees approximately 5g. bank angle of reachingturn, left amaximum 32training Swift left round initiated asteep his dropping laser guided Immediately after aboveapproximately level. ground feet 500 at wasflown to target the ingress The his training laser round. guided dropped then LOCATION:

DATE: TYPE:

Issue 1, 2018— vember 2016

28 No CF188747 Hornet W Cold LakeAir Awareness Warning System reactions. Terrain on and improved training principles low of enforcement level training awareness recommendations include re- the Safety to his spot weapon impact. attempting clearance ofterrain task while critical the that from pilot the may have distracted been evidence suggests circumstantial certainty, monitoring is anypath not knowable with this While lack for reason offlight the aircraft. availableenough altitude recover to safely the wasnot there but second at last the attempted maybelow horizon. the Arecovery have been an overbank situation to well and drop nose the environment, to enter and allowed aircraft the low in the whilepath manoeuvring level flight did not adequately monitor aircraft’s the but ofcontrollingpilot wascapable aircraft the scenario.tation that the appears it Therefore, failure,mechanical pilot or incapaci strike bird availableThe a evidence did not support eapons Range Flight Comment

- 3 Photo: Cpl Bryan Carter 7 EpilogueEpilogue TYPE: CC130338 SAR Technician LOCATION: Yorkton, Saskatchewan DATE: 8 March 2017

he accident occurred during a The Team Member was observed to attempt to must be taken quickly to resolve the problem 435 (Transport and Rescue) Squadron untwist the lines, and at one point performed or cut-away the main parachute and deploy T CC130H Hercules Search and Rescue the non-standard action of releasing his Search the reserve. training mission. The aircraft departed and Rescue – Personnel Equipment Lowering Winnipeg with a crew of nine and proceeded System bag, presumably to aid in the required Preventive measures are focussed on enhanced to the Pelly / Kamsak area of Saskatchewan to kicking motion with his legs. His efforts were training processes and the implementation complete basic Search and Rescue sequences unsuccessful and while attempting to clear the of an automatic altitude awareness aural and then transited to the Yorkton airport with twists he likely lost situational awareness of warning device. the intent of doing live static line parachute his altitude and descent rate. As a result, he jumps followed by supply drops. did not take action to cut-away and deploy his reserve parachute before reaching the ground. Once in the Yorkton area the aircraft was The Team Member was fatally injured when he established at 2,000 feet above ground in level struck the ground. flight at 124 knots indicated airspeed in a flap 50 percent configuration and flown into wind The investigation did not find any evidence over the desired target. The sky was clear, it of an improper pack or a materiel failure of was -16o Celsius and the surface wind was out of the Team Member’s equipment. Malfunctions the northwest at 19 knots gusting to 24 knots. during parachute jumps from the lower After completing their briefings and safety altitudes (for example 1,500 to 2,000 ft above checks, the Search and Rescue Technician Team ground) leave little room for error and action Leader exited the aircraft via the open rear ramp at the pre-determined point. The Team Leader Photo: Cpl Ian Thompson exited using the “ball” style technique. The Search and Rescue Technician Team Member followed a few seconds after the Team Leader using the “reverse arch” (semi-sitting) exit technique. Immediately after leaving the aircraft the Team Member appeared to interact with the aircraft’s slipstream, causing his left leg to move upwards and his body to roll slightly to the right. As this was happening, the static parachute line system began to deploy his main parachute. The parachute did not deploy normally and the evidence strongly suggests that the main canopy suspension lines became severely twisted. This resulted in an uncontrollable parachute that entered a rapidly descending clockwise spiral. Maheu Johanie MCpl Photo:

Note: These are stock images and not from the actual occurrence.

38 Flight Comment — Issue 1, 2018 THE BACK PAGE

United Kingdom Flight Safety Symposium Photo: PO Valler DAIB

n December 2017, DFS was invited to participate in a United Kingdom Flight Safety Left to right: I (FS) Symposium and to make a presentation Colonel John Alexander, Director of Flight Safety, RCAF; on RCAF Wing FSO duties. While there, the Canadian FS team visited the Defence Accident Group Captain Andrew Bastable, Head of the DAIB, Royal Air Force (RAF); Investigation Branch (DAIB) at Farnborough Colonel (Retd) Steve Charpentier, DFS 3 – Promotion and Safety, RCAF; House, in Hampshire, England, to learn more Major Alasdair Clarke, 4 Wing Flight Safety Officer, RCAF; about the United Kingdom Ministry of Defence flight safety and investigation organisations. Wing Commander Stuart Oliver, SO1 Air, DAIB, RAF.

Issue 1, 2018 — Flight Comment 39 Flight Safety Contact Information To report an Aircraft Accident or a Safety Concern which requires IMMEDIATE attention, call 1-888-WARN-DFS (927-6337).

Directorate of Flight Safety 5 Wing Goose Bay 17 Wing Winnipeg • Col John Alexander/613-971-7014 • Capt Dan Gillis/ 709-896-6900#7253/ • Capt Dan Rossi/204-833-2500#5483 [email protected] BB 709-897-7422/ [email protected] [email protected] • LCol Martin Leblanc/613-971-7836 • Sgt Kiel Lalone/ 709-896-6900#6610/ • WO Fabian Marshall/204-833-2500#5983 [email protected] BB 709-899-6648/ [email protected] [email protected] • CWO Ward Golden/613-971-7007 [email protected] 8 Wing Trenton 19 Wing Comox • Maj Chris Hepburn/613-392-2811#7620 • Maj Marty Combe/250-339-8211#8227 • MWO Fred Boutin/613-971-7826 [email protected] [email protected] [email protected] • Capt David Hicks/613-392-2811#7622 • MWO Colin Brydon/250-339-8211#6903 1st and 2nd Canadian [email protected] [email protected] Air Division – Flight Safety • Rob Clarke/613-392-2811#7156 22 Wing North Bay • LCol Ken Bridges/204-833-2500#6520 [email protected] [email protected] • WO Marc Sicard/613-392-2811#3737 • Capt Neeraj Pandey/705-494-2011#6562 [email protected] • CWO Doug Harry/204-833-2500#6973 [email protected] [email protected] • Sgt Danette Weyh/705-494-2011#6470 9 Wing Gander [email protected] • Maj Tim Woodward/204-833-2500#5268 [email protected] • Capt Claude Rivard/709-256-1703#1116 [email protected] ATF-I Op Impact JOA/WFSO/1-613-996-7811; 1 Wing Kingston ask for 86-353-2032 12 Wing Shearwater • Capt Jason Kornder/613-541-5010#8215 CANSOFCOM/Michael Sampson/613-998-4330 [email protected] • Maj Carl Rioux/902-720-1295 [email protected] [email protected] • WO Ron McMullen/ 613-541-5010#8258 CFB Edmonton/Capt Laszlo Beothy-Zsigmond/ [email protected] • Capt Marlon Mongeon/902-720-1087 780-973-4011#8174 [email protected] [email protected] 2 Wing Bagotville • MWO Gary Pitman/902-720-1058 CFB Gagetown/Capt Greg Juurlink/506-292-7693 [email protected] • Maj Lacharité/418-677-4000#3044 [email protected] [email protected] • WO Al Green/902-720-2526 CFB Valcartier/Maj Jean-Eudes [email protected] Ainsley/418-561-6876 3 Wing Bagotville [email protected] • Maj Patrick Dumont/418-677-4000#7500 14 Wing Greenwood CFB Shilo/Capt Dwayne Guymer/ [email protected] • Maj Len Kosciukiewicz/902-765-1494#3679 204-765-3000#3232 [email protected]; and • Adj Michel Larose/418-677-4000#4178 [email protected] [email protected] • WO Stacy Wood/ 902-765-1494#3749 CFB Shilo/Sgt Bobby Billard/204-720-5812 [email protected] • Cplc Eric Martin/418-677-4000#4179 [email protected] [email protected] • WO Pierre Rodrigue/ 902-765-1494#3732 CFB Suffield/Capt Mathew Mackenzie/ [email protected] 403-544-4313 4 Wing Cold Lake [email protected] • Maj Alasdair Clarke/780-840-8000#8005 15 Wing Moose Jaw CFB Suffield/MWO John Furber/403-544-4155 [email protected] • Capt Corey Csada/306-694-2222#5372 [email protected] • WO Yves Daigle/780-840-8000#7408 [email protected] CFB Suffield/Sgt Jeremy Firmin/403-544-4316 [email protected] • MWO Mark Fenton/306-694-2222#5371 [email protected] [email protected] CFB Wainwright/Maj Jayson Gordy/ 780-843-1363#5306 16 Wing Borden [email protected] • Sgt Carl Coney/705-270-3427 [email protected]