National Défense Defence nationale ISSUE 3, 2015 DOSSIER Use It or Lose It CHECK SIX Canada’s Aviation Medicine Pioneers – Part 2 VIEWS ON FLIGHT SAFETY Commander of the Royal Canadian Air Force Cover – A Royal Canadian Air Force technician guides a CP-140 Aurora to its parking area during Operation IMPACT in Kuwait on February 5, 2015. Use It or Lose It 23 Photo: DND Photo: Expanding Flight Safety... 29 Sleeping At The Wheel 30 Crossing Over 31 Dude Where’s My Jet? 35 Short on Time 36 Use It or Lose It 23 TABLE OF CONTENTS Issue 3, 2015 Regular Columns Views on Flight Safety 4 The Editor’s Corner 5 For Professionalism 6 Maintenance in Focus 10 Check Six 12 On Track 18 From the Investigator 37 Epilogue 40 The Back Page – Directorate of Flight Safety (Ottawa) & 1 Canadian Air Division Flight Safety (Winnipeg) Organizational Chart 42 Dossiers Risk Understanding and Management in the Establishment of a New Capability 20 Use It or Lose It 23 Expanding Flight Safety South of the Equator 29 Lessons Learned Sleeping at the Wheel 30 Crossing Over 31 The Holes Align 33 Dude Where’s My Jet? 35 Short on Time 36 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 Steve Charpentier 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. 101 Colonel By Drive Editor The contents do not necessarily reflect Ottawa, ON, Canada, K1A 0K2 Visit the DFS web page at Major Peter Butzphal official policy and, unless otherwise stated, www.rcaf-arc.forces.gc.ca/en/flight-safety. Assistant Editor should not be construed as regulations, Telephone: 613-992-0198 Aviator Amélie Labrie orders or directives. Contributions, comments FAX: 613-992-5187 and criticism are welcome. Contributions Email: [email protected] Imagery Technician become the property of Flight Comment and Corporal Daisy Hiebert may be edited for content, length or format. This publication or its contents Graphics and design may not be reproduced without d2k Marketing Communications the editor’s approval. ISSN 0015-3702 A-JS-000-006/JP-000 Views on Flight Safety by LGen M.J. Hood, Commander of the Royal Canadian Air Force Photo: Cpl Heather Tiffney Heather Cpl Photo: ome safety thoughts from the Commander to execute our diverse air power functions risk management principles. This is where the of the Royal Canadian Air Force... (whatever your trade) within the rules and raison d’être of Flight Safety comes into play, regulations established through our rich whereby we employ effective risk management S You might not realize how long the history. To this end, while we recognize that strategies to accomplish the mission at the Canadian Armed Forces’ (CAF) Flight Safety humans can occasionally make mistakes, we lowest level of risk practicable. Safety risks program has been in existence. The foundations do not culturally accept purposeful violations must be assessed then articulated to the chain of the program were first introduced during the of our rules, regulations, and procedures. of command to ensure that latent or residual latter stage of the Second World War at a time This is the foundation of our effective ‘just risk is accepted at the appropriate level. when it was assessed that we were losing too culture’ system. many Royal Canadian Air Force (RCAF) assets Further, we should avoid allowing ourselves to (aircraft and people) in accidents that were The statistical database of our Flight Safety drift unwittingly into a higher risk regime. For preventable and not directly attributable to program demonstrates clearly that the highest any airpower operation risk awareness is key; enemy action. Of course it has evolved over the proportion of our safety incidents, we must always assess risks, mitigate them last 73 years,1 but the fact that the program is notwithstanding the advances in aviation as much as possible, refer higher risk up the chain still functioning well today is testament to its technology, are either attributable to human as necessary, to ensure we make risk-aware importance and success. error directly or as a consequence of a human decisions to execute action when the factors causal linkage. While humans in the mission demands. These risk concepts are Why is this relevant? We need to remember loop represent our greatest strength, as a relevant for all Canadian air power missions, that many of our contemporary Standing consequence of our susceptibility to errors, training or operational. Operating Procedures and training techniques slips and lapses, we also naturally draw have been borne out of costly lessons learned concomitant risk—a risk that is always Statistically, we have had the lowest number of through the safety incidents of our air power prevalent and should drive us to maintain catastrophic accidents for some time, and while forbears. This lengthy period of commitment an ever-vigilant approach to human factors we should be justifiably proud of our to the safety review, learn, and improve cycle is consideration across all our air power operations. commitment to safety, we must guard against fundamentally important as it provides the safe complacency. Our Flight Safety program is operational platform from which we execute Another important flight safety principle second to none, but the positive statistics and training and operational missions today. is force preservation. Some might suggest that data are irrelevant if we do not maintain an force preservation and mission execution ongoing commitment to accident prevention. Out of great respect for the airmen and represent almost naturally opposing functions, Do not believe in our Flight Safety program airwomen that went before us, and as a but I do not support this view. Force preservation as a consequence of positive statistics; the well-established Air Force, we always need and mission execution are linked by effective integrity of the program is only as good as 4 Flight Comment — Issue 3, 2015 the commitment of all members of the team Remember that Flight Safety is everyone’s to the Flight Safety culture. The RCAF responsibility but, first and foremost, it is a airworthiness and safety philosophy demands leadership responsibility. that all understand their role to be vigilant, speak up loudly and confidently, stand by the rules and Reference regulations, and work to effectively manage risks. 1. The first known formal recognition of the need for a dedicated Flight Safety Organization I am fully committed to a healthy and robust occurred in mid-1942 when the RCAF Aircraft Flight Safety program for the CAF, and I expect Accident Investigation Board (AIB) was formed Commanders at all levels to assume a forceful under a Chief Inspector of Aircraft Accidents. cultural role in our program. It is essential that our aircrew, our maintainers, as well as our support trades, actively participate in the program so that we are able to deliver Canadian air power safely and effectively. Editor’sThe Corner elcome back! I hope you had a fun the ever-increasing use of systems guidance fighters/ trainers, fixed-wing, rotary wing and and enjoyable summer. within the training syllabus and the difficulty maintenance sections. Readers can check out W for most students to appropriately navigate the “Back Page” to see just who they are. It is that time once again whereby we when said guidance (read: GPS) did not function welcome to the position a new Commander of correctly. Please have a read. I would enjoy Finally, as a reminder to those who could find the Royal Canadian Air Force and invite him to hearing any of your comments or anecdotes on themselves dealing with a Flight Safety share his thoughts on and vision for the Canadian the matter. In addition, Part 2 of “Canada’s occurrence investigation, if you need guidance Armed Forces’ (CAF) Flight Safety (FS) program. Aviation Medicine Pioneers” continues in this and/ or you want to get a second opinion on your As the General mentions in “Views on Flight issue with the development of pressure suits, initial investigation plan, you ALWAYS have Safety”, we within the CAF find ourselves helmets and oxygen masks. 24/7 access to the duty DFS investigator at [fortunately] in a lull regarding catastrophic 1-888-WARN-DFS (927-6337) for advice. That’s accidents but nevertheless must be on top of our On another note, it is also that time of year when part of the duty DFS investigator’s role. game in the fight against complacency that can the Director of Flight Safety soon begins his tour easily set in. Of greater note is his remark that FS is of military units and civilian contractors across the Volare tute everybody’s responsibility however; the onus is on country. In October, the Director will start off this Major Peter Butzphal the leadership to forcefully instill the culture season’s journey in Halifax/ Shearwater. Check throughout all levels of command. with your FS representative for the tentative dates at your unit. In this issue, we borrow an interesting article from a study recently completed in the United States With the passing of another posting season on the loss of proficiency in pilot cognitive skills comes the arrival of new members to the due to the extensive use of automation in flying. Directorate of Flight Safety (DFS). I would like to I found this article quite relevant, case in point take the opportunity to welcome those who just having witnessed as a Qualified Flight Instructor, checked-in on the investigative side within the Issue 3, 2015 — FlightFlight CommentComment 5 Professionalism For For commendable performance in flight safety Major Anthony Ambrosini n 20 November 2013, Maj Anthony Ambrosini, analysis discovered that the breather valve Maj Ambrosini is commended for his astute a CH146 Griffon First Officer with within the oil cap had deteriorated over time and observation and highly professional conduct.