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Views on Flight Safety Check Six Dossier National Défense Defence nationale ISSUE 2, 2019 CHECK SIX “A lonely impulse of delight...” DOSSIER Waking up with a Fresh Perspective VIEWS ON FLIGHT SAFETY MGen Pelletier, Comd 1 Cdn Air Div Cover – A CF-188 Hornet aircraft at Mihail Kogalniceanu Air Base in Romania during Operation REASSURANCE, September 1, 2018. Ejection Systems... 22 Photo: Cpl Dominic Duchesne-Beaulieu Dominic Cpl Photo: Fresh Perspective... 33 Sharing the Passion... 38 Flying Bricks 39 Oh no! We’re Going Over! 40 Epilogue 47 TABLE OF CONTENTS Issue 2, 2019 Regular Columns Views on Flight Safety 4 The Editor’s Corner 5 Good Show 6 For Professionalism 9 DFS Commendation 21 Maintenance in Focus 22 Check Six 23 On Track 30 Dossiers 33 Lessons Learned 39 From the Investigator 42 Epilogue 47 The Back Page – Directorate of Flight Safety (Ottawa) 1 and 2 Canadian Air Division (Winnipeg) 50 Lessons Learned Flying Bricks 39 Oh no! We’re Going Over! 40 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. 25 Nicholas 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: 613-971-6345 Corporal Bev Dunbar orders or directives. Contributions, comments Email: [email protected] Flight Comment magazines and and criticism are welcome. Contributions flight safety posters are available Graphics and design become the property of Flight Comment and This publication or its contents on the flightcomment.ca website. d2k Graphic Design & Web may be edited for content, length or format. may not be reproduced without the editor’s approval. ISSN 0015-3702 A-JS-000-006/JP-000 Views on Flight Safety by MGen J.P.A Pelletier, Commander of 1 Canadian Air Division Photo: DND hroughout the first three months of my involved in RCAF operations; everybody and supervisors, along with their integrated Command, CWO Parent and I have had should feel encouraged to report and share team of flight safety experts need to keep in T the chance to visit some of our Wings and lessons learned to help all of us understand the their daily cross-check. witness Air Power execution through NORAD, deeper cause(s) of an error and enable ways to domestic and international Operations. prevent reoccurrence. The Wing and Unit Flight Safety Officers and All along, we have been impressed by the their team of dedicated professionals use keen dedication and exemplary execution Now the difficult question: What comes first? their privileged positions to influence positive demonstrated by RCAF personnel across our Flight safety or mission accomplishment? changes from the floor up as well as to provide squadrons, units and Task Forces to ensure Well, I believe both are integral in the trusted advice to the leadership. Their constant we can optimize the Air Power delivery at an planning of every mission we are tasked for. involvement and initiatives contribute directly acceptable level of risk. At the center of today’s An important element to be considered is to the good health and promotion of the FS RCAF mission success is our historically low the level of acceptable risk for each mission, Program and relies heavily on leadership accident rate which, without a doubt, relies on a variable that is well captured in our Mission commitment and engagement to flight safety our collective commitment to the flight safety Acceptance and Launch Authority (MALA) tool principles and practices. which involves a detailed leadership assess- program; a program that continues to be a So what remains to be done? We need to reference for our allied Air Forces. ment along with authorities linked to specific mission. But the MALA neither covers every mentor our people to better understand the Our safety culture relies on our duty to report, contingency, nor every phase of maintenance higher intent and to be confident in their our ability to learn from previous mistakes and actions leading up to an asset being available ability to operate safely. Air mindedness needs our collective ownership of RCAF maintenance for the mission; hence, proper management to constantly be associated with a culture of activities and operations. Our safety (ourselves, our and control of operating procedures as well professionalism and collaboration at all levels. team partners, and our assets) must rely on as operational pressures remains necessary. Moreover every leader, from 1 Canadian Air more than just willingness in order to avoid Division HQ to the tactical unit, needs to the potential loss of life, limb or resources; Today’s flying environment is becoming ensure clear communication of the acceptable hence the duty to report. more complex. The danger of mid-air collision risk, while ensuring that all associated risks are is accentuated by an increasingly busy airspace understood and accepted at the right level. In the conduct of RCAF operations I expect compounded by the proliferation of drones Loss of life and limb in peace time along with that when someone sees something wrong, in urban area. Aircraft systems are also mission failure should never be an option! they will not be afraid to take either immedi- more complex leading to increased system ate action when required or to speak out management and a tendency for less eyes It has been said that: A great safety culture while seeking solutions. Bottom line is that out of the cockpit. In addition, the experience is defined by always doing the right thing safety is not a supervisor’s business but level within flying units has decreased over when no one is watching. This can only everyone's business. My own experience in the last few years resulting in the right level of happen when people feel safety is important; the Fighter Force has been one whereby no supervisors and experience mentors not being feel that they have an important role to play matter the rank of any members in the always available. The Ops tempo has remained in it; and, feel that their safety attitude is formation, every member was allowed to high both at home and abroad while today's well appreciated. question a tactical action that may have family environment may require greater had an impact on safety or mission success. involvement of the RCAF member on the home The same approach is expected of members front; these are all elements that unit leaders 4 Flight Comment — Issue 2, 2019 Editor’sThe Corner ow does one start an investigation? for many families whose loved one had been In memoriam, Photo: Kate Armour It often begins with a phone call. In our involved in an accident, Jim was often the Jim (James) Robert Armour H job as accident investigators with the connection between a family and the Royal 28 May 1953 – 28 April 2019 Directorate of Flight Safety (DFS) you’d think Canadian Air Force flight safety process. Comfort we’d be used to receiving calls involving bad was often provided because families knew that Jim Armour joined the Canadian Armed Forces news. The reality is that these calls are always Jim was tenaciously in pursuit of determining in 1977 as a pilot and completed flying tours received unexpectedly. Armed with our safety the cause of the accident so that effective on the Sea King, Tutor, Silver Star and Aurora statistics and our risk analysis we sometimes preventive measures could be implemented. aircraft. His first direct role with Flight Safety anticipate a call will come in from a certain The loss of their loved one would not be in vain... was as a backup Unit Flight Safety Officer in community but normally we are broadsided with Jim would not let it be so. Moose Jaw, Saskatchewan. He subsequently the news. Spring loaded to respond, the call is completed five tours with DFS as an accident always followed by a period of intense activity as Jim’s sudden unexpected departure has left investigator, which included responsibilities a team is sent out to investigate the cause of the us a bit unbalanced. For several days after the in nearly every aircraft cell in the directorate. accident. That activity marks the beginning of news we would walk by his cubicle and see his He became the first Senior Investigator with a process where we have an active role in stained coffee mug, his kicked off shoes and DFS in 1999 and was involved in more than answering questions. In short, we can help. the myriad of projects he had piled on his 50 field investigations. These investigations desk. Jim’s empty chair reminded us that his notably included Labrador 305 (FSIMS 79005), On 29 April 2019, a call came in to DFS that mentorship had come to an end, the flight Griffon 420 (FSIMS 109081), numerous was different. We received the awful news safety torch had been passed and we needed CF188 Hornet crashes in the 1990s and that Jim Armour, one of our colleagues, had to take on his teachings and projects and multiple Snowbird mid-air collisions passed away the previous day as a result of advance them along.
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