CF188789 Hornet - Epilogue - Flight Safety Investigation Report

Report / November 18, 2010 / Project number: CF188789-A category

Location: Near Cold Lake, Alberta
Date: 2010-11-18
Status: Investigation Complete

FSIR - download PDF version, 385 kb

Epilogue

The accident aircraft was a single seat CF188 flying as the second aircraft in a two-aircraft formation on a Night Vision Goggles (NVG) training mission.  The prevailing night time weather was instrument meteorological conditions.  During a radar trail instrument approach on NVG to runway 13L at 4 Wing, Cold Lake, AB, the formation lead called for the landing gear to be selected down.  After selection of the landing gear, the accident pilot was almost immediately disoriented by the sudden rush of falling snow that was illuminated by the landing light, which also reflected enough light through the Head-Up Display to washout the instrument references being used to control the aircraft.  The pilot, perceiving that the aircraft had entered a steep descent, made an aft stick input that then pulled the aircraft into a nose-high attitude.  Consequently, unable to confirm his attitude and believing that the aircraft was rapidly approaching the ground in a dive, the pilot ejected.  The ejection was successful and the parachute landing uneventful.  The aircraft crashed in a nose-down, near wings level attitude and was destroyed.  The uninjured pilot was located two hours later by the crew of the local Search and Rescue helicopter and transported to 4 Wing.

The pilot experienced severe spatial disorientation that ultimately led to his ejection.  The investigation revealed a number of factors that contributed to this accident.  Routine deviations to orders, application of approved airworthiness processes, NVG training and currency requirements and pilot experience were all areas of significant interest.

In response to this accident, the Royal Canadian Air Force temporarily suspended CF188 NVG-aided takeoff and landing operations until more stringent NVG operation guidelines were put in place.  Additional preventative recommendations were made, including a doctrinal review of CF188 NVG operations and a comprehensive NVG-aided takeoff and landing test and evaluation plan.


CANADIAN FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FILE NUMBER: 1010-CF188789-2 (DFS 2-3)

FSOMS NUMBER: 114753

DATE OF REPORT: 6 December 2013

AIRCRAFT TYPE: CF188789

DATE/TIME: 0632Z 18 (2332 MST 17) November 2010

LOCATION: N 54 29.0 / W 110 24.9 (7.5 NM NW of 4 Wing, Cold Lake, AB)

CATEGORY: "A" Category Accident

This report was produced under authority of the Minister of National Defence (MND) pursuant to section 4.2 of the Aeronautics Act, and in accordance with A-GA-135-001/AA-001, Flight Safety for the Canadian Forces.

With the exception of Part 1, the contents of this report shall only be used for the purpose of accident prevention.  This report was released to the public under the authority of the Director of Flight Safety, National Defence Headquarters, pursuant to powers delegated to him by the Minister of National Defence as the Airworthiness Investigative Authority for the Canadian Forces.

SYNOPSIS

The accident aircraft was a single seat CF188 flying as the second aircraft in a two-aircraft formation on a Night Vision Goggles (NVG) training mission.  The prevailing night time weather was instrument meteorological conditions.  During a radar trail instrument approach on NVG to runway 13L at 4 Wing, Cold Lake, AB, the formation lead called for the landing gear to be selected down.  After selection of the landing gear, the accident pilot was almost immediately disoriented by the sudden rush of falling snow that was illuminated by the landing light, which also reflected enough light through the Head-Up Display to washout the instrument references being used to control the aircraft.  The pilot, perceiving that the aircraft had entered a steep descent, made an aft stick input that then pulled the aircraft into a nose-high attitude.  Consequently, unable to confirm his attitude and believing that the aircraft was rapidly approaching the ground in a dive, the pilot ejected.  The ejection was successful and the parachute landing uneventful.  The aircraft crashed in a nose-down, near wings level attitude and was destroyed.  The uninjured pilot was located two hours later by the crew of the local Search and Rescue helicopter and transported to 4 Wing.

The pilot experienced severe spatial disorientation that ultimately led to his ejection.  The investigation revealed a number of factors that contributed to this accident.  Routine deviations to orders, application of approved airworthiness processes, NVG training and currency requirements and pilot experience were all areas of significant interest.

In response to this accident, the Royal Canadian Air Force temporarily suspended CF188 NVG-aided takeoff and landing operations until more stringent NVG operation guidelines were put in place.  Additional preventative recommendations were made, including a doctrinal review of CF188 NVG operations and a comprehensive NVG-aided takeoff and landing test and evaluation plan.

TABLE OF CONTENTS

1  FACTUAL INFORMATION

2  ANALYSIS

3  CONCLUSIONS

4  PREVENTIVE MEASURES

Annex A: Figures

Annex B:  References

Annex C:  Abbreviations

Annex D:  ALSE Observations


Top of page

1 FACTUAL INFORMATION

1.1 History of the Flight

1.1.1 The accident pilot reported for duty at 1300 hours (hrs) local on 17 November 2010.  He felt fit, well rested and prepared for his duty day.  He was scheduled for an NVG qualification (NVQ) flight, NVQ2, later that night.  Given that the pilot had not flown with the AN/AVS-9 NVG since 7 April 2010, 224 days previously, the mission was arranged to be a low task formation mission comprised of four scripted air-to-air interception exercises.  At 1500 hrs the formation lead and the accident pilot conducted a coordination briefing with the designated opposition force formation lead.  Lead next briefed the accident pilot on the details of the NVQ2 sortie in accordance with (IAW) the 409 Tactical Fighter Squadron (TFS) Mission Briefing Guide.  Lead asked the accident pilot about his NVG experience and briefed other details such as the weather, flight routing, communications instructions and the use of NVG.  The four air-to-air intercept scenarios were also briefed in detail.  Unusual attitude procedures and goggle failure procedures were then briefly discussed as well as the decision to arrive and depart through instrument meteorological conditions (IMC) using NVG.  The use of the landing light during the arrival was not discussed nor was it itemized in the briefing documents, although it was lead’s personal technique to avoid use of the landing light at night with NVG.  The planned engine start time was 2130 hrs.  During the remainder of the day prior to the flight, the accident pilot consumed his supper meal and worked continuously as a scheduler to support the 16 launches planned for that day and on other future missions.

1.1.2 Both formation aircraft were de-iced prior to the start and taxi, which were on schedule.  During taxi, the accident pilot reduced his cockpit lighting as his eyes adjusted to the darkness.  His Head-Up Display (HUD) light was selected to NIGHT and put on a low setting.  In addition to his HUD, he selected the Electronic Attitude Display Indicator (EADI) in his left Multi-purpose Display Indicator (MDI) as per direction in the CF18 How to Fly Manual, Chapter 2, Paragraph 12.  Prior to takeoff, lead requested that the runway lights be turned off and he lowered his NVG for an aided takeoff [1].  The accident pilot noted the runway lights were off; however, he was satisfied with the ambient lighting levels and proceeded with his takeoff unaided and with the aircraft landing light off.  During his cockpit scan in the climb, the pilot selected his landing light switch to the ON position (the normal position), which arms the landing light to come on automatically when the landing gear lowers.  The takeoff and climb out to the tactical flying area were uneventful.  The formation climbed through nearly 30,000 feet of clouds prior to beginning the tactical portion of the flight, which was then flown in visual meteorological conditions (VMC) on top of the clouds.  The pilot lowered his NVG at the top of the climb prior to beginning the tactical portion of the flight, which proceeded as briefed.

1.1.3 On completion of the tactical portion of the flight, lead contacted the terminal controller to arrange for a Precision Approach Radar (PAR) approach to runway 13L with the accident pilot in radar trail.  The accident pilot prepared for the arrival by setting his navigation aids for the Localizer Back Course Approach as a backup.  He left his situational awareness (SA) page in the left MDI although it was previously his practice to select a repeat of the HUD on his left MDI during the recovery [2].  Since graduation from 410 Tactical Fighter Operational Training Squadron (TFOTS) he no longer maintained this practice, nor was it required by the orders.  The formation began their descent and entered clouds at approximately 30,000 ft.  Both pilots were aided and intended to penetrate the cloud and land using the NVG.  The accident pilot was established in the radar trail position 1.5 to 2 nautical miles (nm) behind lead throughout the descent and PAR approach.

1.1.4 Lead was established on the final approach course at approximately 3,100 feet MSL (1,300 ft AGL) and 6.8 nm back from the runway.  Lead was just breaking out of the bottom of the overcast layer and encountered snow when he called for the formation to lower its landing gear.  The accident pilot was at this time approximately 8.1 nm back from the runway and levelling at 3,000 feet MSL.  About 10 seconds after lead’s call for the landing gear, a loud tone was heard over the radio by air traffic control (ATC) and aircraft in the vicinity.  The tone lasted for 23 seconds and then abruptly ceased.  Lead continued down the glide path with his aircraft landing light off, received his landing clearance, requested the runway lights be turned off, and conducted an aided landing to the unlit runway.  During the final approach, both ATC and lead lost communications with the accident pilot and attempted to communicate with him several times.  Lead recommended that ATC provide the accident pilot his landing clearance on the guard/emergency frequency 243.0 megahertz (MHz) in case he had suffered a communication failure.  ATC turned the runway lighting to setting two and provided the accident pilot his landing clearance on the guard frequency but did not get a reply.  Lead landed, taxied in and shut down.  The tower controller then recognized that the sound heard on the radio frequency was actually a bailout tone and directed the ground controller to activate the aircraft crash alarm.

1.1.5 The accident pilot was using his NVG and following lead on the PAR approach.  He was monitoring his altitude, airspeed and position behind lead when lead called over the radio for the formation to lower its landing gear.  The pilot checked his indicated airspeed (230 knots) and selected both the landing gear down and full flap.  Upon selection of the landing gear he noticed the light in his gear handle reflecting in the canopy as he looked through his HUD.  Suddenly, he became disoriented by the rush of snow flakes passing by the aircraft, which he likened to the reflection of snowflakes in vehicle lights during a violent snow storm at night.  Simultaneously, he felt a powerful sensation that the aircraft was in a steep descent.  Unsure of what had caused him to lose his HUD display and thinking that he was in a dive, the pilot made an aft stick input and pulled the aircraft into a nose up attitude.  This intensified the diving sensation and he became concerned that ground impact was imminent.  Because he was unable to confirm his attitude by using either outside references or his HUD, the pilot decided to eject.

1.1.6 A second formation of CF188 aircraft was following lead and the accident pilot on approach to runway 13L.  During the approach, the second formation lead spotted a fireball on the ground on the final approach course about 7.5 nm from the airport and reported the position to ATC.  This formation was then cleared to land on runway 13R and landed, taxied in and shut down.

1.1.7 Once under a stable parachute, the accident pilot made a brief but unsuccessful attempt to completely remove his mask.  He then abandoned that effort and deployed his seat pack with his right hand.  Realizing he would be landing in a wooded area, he crossed his arms and braced for impact.  His parachute became hung-up in the trees and allowed for a cushioned landing.  The pilot released himself from his harness, realized he was uninjured and began to follow his survival training procedures, including the activation of his personal locator beacon (PLB).  Approximately two hours later he heard the 4 Wing-based 417 Combat Support Squadron (Sqn) Search and Rescue (SAR) helicopter and fired flares to attract its crew’s attention.  After the helicopter landed in a clear area close by, the accident pilot walked to it and was met by two SAR technicians.  The helicopter then transported the pilot back to 4 Wing where he was taken to the Cold Lake Hospital by ambulance for a medical examination.

1.2 Injuries to Personnel

There were no injuries.

1.3 Damage to Aircraft

1.3.1 The aircraft struck the ground at an estimated 55º nose low, near wings level attitude and at a speed of approximately 190 knots.  The aircraft was completely destroyed as a result of the ground impact and post-crash fire (Annex A, Figure 3).  The aft fuselage, including the engines, was heavily damaged and came to rest upright on top of the forward fuselage.

1.4 Collateral Damage

1.4.1 The aircraft crashed into a leased field on Crown land, 7.5 nm north-west of the airfield.  The crash site was on the north-eastern edge of a small frozen slough north of Maloney Lake (Annex A, Figures 1 and 2).  4 Wing undertook an environmental assessment and contacted Environment Canada concerning site remediation.  The Directorate of Flight Safety is not aware of any claim against the Crown.

1.5 Personnel Information

 

 

Accident Pilot

Formation Lead

Flying Currencies

Valid

Valid

NVG Qualification

No

Yes - NVGIP

Medical Category

Valid

Valid

Ejection Seat Training

Valid

Valid

HAI

Valid

Valid

NVG Hours

3.8

73.1

Total flying time (hrs)

472.9

3534.2

Flying hrs on type

138.1

1447.6

Flying hrs last 90 days

37.4

42.3

Flying hrs last 30 days

15.9

14.5

Flying hrs last 48 hrs

1.3

3

Time on duty last 48 hrs

22

20

Duty hours day of Accident

10.5

10.5

Table 1:  Personnel Information

1.5.1 Accident Pilot

1.5.1.1 The accident pilot was on his first tour in the Canadian Forces (CF).  He completed his Fighter Pilot Course (FPC) at 410 TFOTS on the CF188 aircraft in June 2010 and was assigned to 409 TFS as a line pilot in July 2010.  As part of his additional duties, he also functioned as a unit scheduler.  At the time of the accident, he had not fully completed his Combat Readiness Upgrade Training.  He had acquired a total of 22.9 hrs night, of which 16.5 hrs were flown on the CF188.  Prior to the accident flight he had 2.9 hrs of NVG time that he had acquired over four different CF188 sorties.  Furthermore, it had been 224 days since he last used NVG.  At the time of accident he had 3.8 hrs total NVG time; this included 0.9 hrs on the accident mission.  This flight was the first time that he had flown IMC on NVG.  Although he had flown IMC and had seen the effect of the landing light in IMC, this was the first time that he experienced the effects of the landing light in IMC with precipitation, either aided or unaided.  Since he did not possess an NVG qualification, he was not required to maintain NVG currency.

1.5.2 Lead Pilot

1.5.2.1 The formation lead was a multi-tour CF188 pilot with 1447.6 hrs on the CF188.  He was a qualified Tactical Pilot Leadership Level 4, (Section Lead) and NVG Instructor Pilot (NVGIP) with a total of 73.1 NVG hrs.

1.6 Aircraft Information

1.6.1 CF188789 was a single seat CF188 fighter aircraft.  The aircraft was fully serviceable at the time of launch from 4 Wing Cold Lake and had accumulated a total of 5,123.8 airframe hours.  The aircraft maintenance records were checked with no anomalies noted.

1.6.2 The aircraft was equipped with a Navy Aircrew Common Ejection Seat (NACES) SJU−17B ejection seat.  This ejection seat incorporates fully automatic electronic sequencing and is cartridge-operated and rocket-assisted.  The ejection sequence is initiated by pulling a seat firing handle situated on the front of the seat bucket between the occupant’s thighs.  After ejection, drogue deployment, man/seat separation and parachute deployment are automatically controlled by an onboard multimode electronic sequencer.

1.6.3 Cockpit Avionics Controls and Displays

1.6.3.1 The cockpit avionics controls and displays consist of HUD, left and right MDIs, a horizontal situation display (HSD), an up-front control (UFC) panel, hands-on throttle and stick (HOTAS) switches and standby instruments.

1.6.3.2 The HUD is the primary flight instrument in the aircraft, providing flight, navigational and weapon delivery information and projects collimated (focused at infinity) symbology into the aircrew’s forward field of view.  The HUD total field-of-view is 20 degrees and its optical center is four degrees below the aircraft waterline.  The binocular instantaneous field-of-view is approximately 16 degrees depending upon the viewing position.  The HUD symbology is night vision imaging system (NVIS) compatible green.  During NVG operations, the pilot looks through the NVG to see the HUD symbology.

1.6.3.3 The HUD brightness is controlled by a three position toggle switch (DAY, AUTO and NIGHT) on the UFC panel and a brightness control knob (Annex A, Figure 6).  Placing the switch to DAY provides maximum symbology brightness in conjunction with the HUD symbology brightness control.  Placing the switch to AUTO provides automatic control of the contrast by the automatic brightness control.  With the switch set to NIGHT, reduced symbology brightness is provided in conjunction with the HUD symbology brightness control.

1.6.3.4 The right and left MDIs are physically and functionally interchangeable with the ability to display desired information on either indicator.  Integral to each MDI are 20 pushbuttons distributed around the outside of the unit that are used by the pilot to select the desired information to be displayed.  Integral to each MDI is a toggle that adjusts display brightness and contrast.  The MDIs can display the SA and EADI pages and project information on the HUD in addition to a number of other tactical and support displays.  They are NVIS-compatible.

1.6.3.5 The HSD may display various formats of information; however, it normally is used to display the horizontal situation indicator (HSI) or the situational awareness (SA) display and a digital moving map.  It is NVIS-compatible.

1.6.3.6 The standby instruments consist of an attitude reference indicator, airspeed indicator, altimeter and a vertical speed indicator located in a cluster on the lower right instrument console.  A standby magnetic compass is located on the lower right hand side of the windscreen.

1.6.4 Exterior Lighting System

1.6.4.1 The NVIS-compatible exterior lighting consists of position lights, formation lights, anti-collision strobe lights, an in-flight refuelling light and covert lights [3].

1.6.4.2 A 450 watt (24,000-27,000 candelas) white landing/taxi light (Annex A, Figures 4 and 5) is installed on the nose landing gear strut and rotates up and down during landing gear retraction and extension.  The light faces forward and is used for landing and taxi operations at night.  The landing/taxi light is not NVIS-compatible.  The landing/taxi light switch is located on the left vertical console (Annex A, Figure 6) forward of the throttle quadrant.  Its ON/OFF switch controls the light regardless of the gear handle selection but the light will only come on when the gear is down or in transit.

1.6.5 Interior Lighting System

1.6.5.1 Most of the internal cockpit lighting in the CF188 was modified to make it NVIS-compatible.  This was accomplished using integrally illuminated faceplates, open ring bezels, NVIS-compliant flood light bulbs and annunciator cap filters.

1.6.5.2 Internal lighting of the standby instruments was disabled during the NVIS modification.  The standby instruments are now illuminated by two floodlights mounted in the upper left and right corners of the standby instrument group area.  The brightness of theses lights is controlled by the pilot using the INST PNL knob.

1.6.5.3 The AOA indexer, APU control panel, lock shoot strobe, white light selection on the utility light, radar altimeter decision height warning light, emergency flood lights and landing gear handle light were not modified and are not NVIS-compatible.

1.6.6 NVG

1.6.6.1 The accident pilot was wearing the AN/AVS-9 NVG.  The NVG consist of two image intensifier tubes on a lightweight binocular mount.  The image intensifier tubes produce a monochromatic green image of the outside world.  Unlike Forward Looking Infrared, NVG utilize reflected energy in the visible and near IR spectrum to produce a visible image.  Under adequate conditions of illumination, NVG can enhance situational awareness, collision avoidance (terrain and aircraft), navigation and target identification.

1.7 Meteorological Information

1.7.1 The local weather at the aerodrome at the time of the accident was characterized by overcast skies, light easterly winds, five statute miles visibility in snow, with locally reduced visibility in heavier snow showers.  Pilot reports indicated the cloud bases were around 1,000 ft above ground with solid cloud up to 30,000 ft MSL.

1.7.2 There was no turbulence or bird activity reported to affect the formation’s activities; however, testimony indicates that three aircraft formations (including the accident aircraft) all flew through areas of heavy snow showers during their approach that evening.

1.7.3 The following TAF and METAR were used at the pre-flight crew briefing:

METAR CYOD 171900Z 10009KT 6SM -SHSN OVC025 M11/M15 A3044 

TAF CYOD 1718/1818 09010KT 6SM -SHSN OVC020 TEMPO 1718/1724 P6SM NSW OVC025 FM180300 09012G22KT P6SM -SN BKN030 TEMPO 1803/1818 2SM -SN OVC015

1.7.4 The following TAF and METARs were in effect or issued near the time of the accident:

METAR CYOD 180600Z 12009KT 10SM -SN OVC020 M13/M15 A3029 RMK SC8 SLP305 56013 SKYXX

METAR CYOD 18640Z 09013KT 5SM -SN OVC022 M13/M16 A30.27 RMK SC10 SLP299 SKYXX

METAR CYOD 180700Z CCA 11011KT 1 1/2SM -SN VVC010 M13/M16 A3027 RMK SN8 SLP299 56013 SKYXX

TAF CYOD 180530Z 1806/1906 11012KT 6SM -SN OVC015 TEMPO 1806/1818 P6SM -SN OVC030 FM181800 07010KT P6SM -SHSN OVC025 TEMPO 1818/1906 OVC020 BECMG 1900/1902 VRB03KT RMK NXT FCST BY 181200Z

1.7.5 The night illumination data expected above clouds is identified in Table 2.

 

 

Time
UTC

 

Moon
Azimuth

Moon
Elevation

 

Illumination
mlx

 

Irradiation
uw/m2

0600

200.50

49.40 86.33

36.29

0629 210.77 47.64 83.37

35.05

0700 

220.34 45.25 79.19

33.29

Table 2:  Night Illumination Data

1.8 Aids to Navigation

1.8.1 The formation lead was on a Precision Approach Radar (PAR) approach using the Localizer Back Course (LOC(BC))/TACAN 13L (DND) approach to runway 13L as a backup.  The accident pilot flew in the radar trail position, defined as 1.5 to 2 nm following lead on the PAR approach.  The PAR, TACAN and Localizer were serviceable.

1.9 Communications

1.9.1 The CF188 aircraft is equipped with two UHF/VHF radios.  The accident pilot monitored local ATC agencies throughout the flight using preset UHF frequencies while lead communicated with ATC.  The formation was using the other radio for intra-formation communication.  The accident pilot maintained communication with lead up to the time of ejection.

1.10 Aerodrome Information

1.10.1 The Cold Lake/Group Captain R.W. McNair aerodrome has two principal parallel runways, 13L/31R and 13R/31L, which are instrument flight rules (IFR) certified and oriented 308/128º magnetic (m).  The third runway, 04/22, is oriented 038/218º (m).  Both parallel runways were active near the time of the accident.  The accident pilot was expected to land on runway 13L, which was bare and dry.  All taxiway, runway and approach lights were serviceable.  The runway lights for runway 13L were on during the PAR approach.  These lights were turned off prior to lead’s landing at the pilot’s request.  ATC turned the runway lights back on to brightness setting two after lead’s landing and as they attempted to regain radio contact with the accident pilot.  The Cold Lake runways and taxiways are not fitted with NVG-compatible lights.

1.11 Flight Recorders

1.11.1 Advanced Memory Unit (AMU)

1.11.1.1 The CF188 is neither fitted with a Cockpit Voice Recorder (CVR) nor a Flight Data Recorder.  The CF188 does record certain aircraft parameters on a non-crashworthy Advanced Memory Unit (AMU), which is a programmable computer serving as a non-volatile solid state memory device.  The AMU has two computer memory card slots.  The PCMCIA maintenance card, which collects maintenance data, was found at the crash site undamaged and with recoverable information.  The data covered the entire flight up until the aircraft pitched up, approximately five seconds prior to the ejection, and did not indicate any anomalies in the aircraft’s systems or performance.  The data also indicated that the engines were operating normally and at relatively lower power immediately preceding the ejection.  The AMU data showed that the aircraft was heading 129º m on a stable approach at 228 knots indicated airspeed and 2,800 ft MSL when the pilot selected the landing gear and full flap.  As the flaps deployed, the aircraft’s pitch attitude began to decrease from about four degrees nose up to one degree nose up while the flight path of the aircraft remained constant.  About six seconds after gear selection, the aircraft nose pitched up abruptly with a slight roll to the right.  Approximately two seconds after the pitch up, the AMU data ended with the aircraft’s pitch attitude at 16 degrees nose up and six degrees right bank.

1.11.2 Non-Volatile Memory

1.11.2.1 The CF188 has non-crashworthy mission computers that contain non-volatile memory modules that can retain up to 45 seconds of flight information.  The mission computers were heavily damaged as a result of the ground impact and wreckage recovery process and, therefore, not recovered from the crash site.

1.11.3 Cockpit Video Recording (CVRS)/HUD

1.11.3.1 The CF188 has a Cockpit Video Recording System (CVRS) that records HUD audio and video information on a magnetic tape for viewing after flight.  Weapon video is provided by the stores management system while radar video is provided by the radar system.  The recording system was in operation at the time of accident.  Two of the three Hi-8mm magnetic tape cassettes were recovered from the crash site and sent to the National Research Centre Flight Recorder Playback Centre for analysis.  No data was recovered due to the damaged state of the tapes.

1.11.4 Air Combat Manoeuvring Instrumentation System (ACMI)

1.11.4.1 An Airborne Instrumentation Subsystem Pod (AIS Pod), the airborne terminal of the CF188 ACMI System, was installed on the aircraft’s right wingtip at the time of accident.  The pod autonomously and continuously determines its own time-space-position information (TSPI), including position, velocity, altitude and attitude, by means of Global Positioning Satellite (GPS) and inertial data.  Airspeed and angle of attack data is provided by a pitot-static system located on the front of the AIS pod.  All data is recorded to a data cartridge located in a slot in the aft end of the AIS pod.

1.11.4.2 The AIS data cartridge was recovered from the crash site.  The data was used to confirm the validity of the data recorded on the AMU card as well as to provide telemetry to ground impact.

1.11.5 Air Traffic Control Radar

1.11.5.1 Radar ground track, groundspeed and mode C (altitude reporting) data was available from the 4 Wing ATC Unit.  The radar tracked the accident aircraft’s PAR approach as a primary target since, as the wingman, the accident pilot’s transponder was in standby.  The radar system captured the accident aircraft’s emergency squawk, which was triggered automatically at the time of the ejection.

1.12 Wreckage and Impact Information

1.12.1 Based on the ACMI data and corroborated by the crash site evidence, the aircraft impacted the ground on a heading of 150º m with a 55º angle of incidence (nose down) at a speed of 190 knots.  The initial impact was on slightly sloping ground, 15 metres north of the edge a frozen slough.  Most of the wreckage was concentrated within a 10 meter radius around the impact point.  Parts from the cockpit and upper fuselage were projected from the aircraft upon break-up and were distributed throughout a fairly compact debris field on the shore and ice of the slough.  The remaining components, mostly cockpit displays, gauges and pieces of the dorsal area were dispersed over an area approximately 100 meters long and 180 meters wide.

1.12.2 The canopy and ejection seat were found along the final flight path, 778 metres and 588 metres respectively, before the impact point (Annex A, Figure 2).

1.13 Medical

1.13.1 The uninjured pilot was initially attended to by the two SAR technicians on board the SAR helicopter.  The helicopter could not proceed directly to the Cold Lake Hospital due to unsuitable weather and returned to 4 Wing where the accident pilot was then transferred by civilian ambulance to the Cold Lake Hospital.  He was initially seen by the civilian emergency room physician and then by the 4 Wing flight surgeon.  The pilot was subsequently given medical authorization to return to flying status.  The results of the toxicology samples drawn by 4 Wing clinic staff and analyzed by the Armed Forces Institute of Pathology in Bethesda, Maryland, were negative.

1.14 Fire, Explosive Devices, and Munitions

1.14.1 Fire

1.14.1.1 There was no evidence of a pre-impact fire.  On impact, the aircraft broke apart and the aft section burst into flames when approximately 6,000 lbs of JP8 fuel was expelled and exploded.  When first responders arrived on the site, the post-impact fire was primarily localized to the area underneath the aircraft wreckage.

1.14.2 Explosive Devices

1.14.2.1 The canopy was jettisoned and all pyrotechnics were expended during the ballistic removal of the canopy.  The internal canopy jettison handle was not found in the debris field and the condition of the cartridge could not be confirmed.

1.14.2.2 The NACES ejection seat was recovered and examined, indicating all pyrotechnics functioned normally and were expended as expected.  The center pull handle was up and all sears were extracted with the exception of the manual override handle, which would only have been deployed had the pilot tried to manually override the parachute deployment system.

1.14.3 Munitions

14.3.1                    There were two decoy dispensers installed on the aircraft, below and inboard of the left and right engine intakes.  The dispensers contained chaff and flares.  They were later recovered at the wreckage site during the salvage and clean-up process.

1.15 Survival Aspects

1.15.1 Ejection

1.15.1.1 At the time of ejection, the aircraft was in a wings level 30º nose up attitude at approximately 180 knots indicated airspeed, at 3,400 ft MSL (1,600 ft AGL).  Due to the accident pilot’s perceived time imperative to eject, he made no attempt to prepare for the ejection and, therefore, initiated it with his NVG in the down position.  The NVG came off during the ejection, causing minor damage to his oxygen mask mounting hardware; they were not recovered.

1.15.1.2 The field investigation and recorded data from the NACES ejection sequencer indicated that the pilot had a normal ejection.

1.15.1.3 The accident pilot saw the flash of the canopy rocket motors immediately after initiating the ejection.  Shortly thereafter he felt only a slight parachute opening shock.  While suspended in his parachute, he confirmed that he had a good parachute and then observed the aircraft impact the ground ahead of him.  The pilot was somewhat unsure of which post-ejection drill he was to complete as he had learned different drills on each of his previous training aircraft (CT156, CT155 and CF188 equipped with the SJU-9A seat).  He removed his mask from the right bayonet fitting but had difficulty with the left fitting.  Sensing his approach to the terrain below, he quickly gave up on the left fitting and started to locate and deploy his Seat Survival Kit (SSK).  The pilot had initial difficulty finding the deployment handle with his right hand, but he was eventually able to successfully release the SSK contents prior to landing.  He landed in a wooded area 1,500 metres northwest of the crash site.  The parachute became hung up in a tree, such that he was slightly suspended off the ground when he came to rest.

1.15.1.4 The pilot stated that during his conversion training from the CF188 SJU-9A seat to the NACES seat system only one in four pilots actually received the parachute suspension training.  He personally completed this training and believed it contributed to his successful ejection and release of the SSK.

1.15.1.5 The Aerospace Engineering Test Establishment (AETE) Crew Systems specialists classified the ejection as successful, meaning that the pilot was able to return to flying duties within 24 hours.

1.15.2 Post-Parachute Landing

1.15.2.1 The pilot released his parachute via the Koch fittings without difficulty and then removed his SLB 1000 (emergency locator beacon) and signalling devices from his survival vest.  Next, he commenced activities to prepare himself and the site IAW taught survival principles.  His initial attempt to notify ground vehicles with his Day/Night flair was unsuccessful.  The pilot fired three flares to alert the approaching SAR helicopter of his location.  Confident that the SAR helicopter had located him, he proceeded through the bush to the clearing where the helicopter had landed

1.15.3 Aircrew Life Support Equipment

1.15.3.1 The GQ5000 Aeroconical Parachute functioned as designed.  The riser covers were noted still in place covering the left and right steering toggle making them difficult to access.

1.15.3.2 The SSK and its contents were undamaged during the ejection sequence and landing.  The one man life raft deployed and inflated when the pilot pulled the SSK deployment handle.  The SSK contents bag hung up in a tree well above his reach.  He climbed up the tree until he could reach the drop line attachment and cut the bag free with his Tac Op knife.

1.15.3.3 The accident pilot was wearing standard issue flying coveralls, winter flying jacket, long underwear, socks, a blue Air Force T-shirt, issue steel toed boots, flying gloves with liners, a Sting G-suit, Life Preserver Survival Vest (LPSV) MSV 980, a Gentex 190A helmet with NVG mounting brackets installed and visors removed, and an oxygen mask.

1.15.3.4 An examination of his ALSE revealed a large number of anomalies and deficiencies.  These are detailed in Annex D.

1.15.4 Emergency Transmitters

1.15.4.1 The CF188 is equipped with a “bail-out tone” device that automatically transmits an audible tone on 243.0 MHz if either ejection seat is activated.  The device functioned as designed and the tone was received by ATC and other military aircraft in the vicinity, although the pilots did not recognize that the tone indicated an ejection had occurred.

1.15.4.2 The survival vest contained a Survivor Locator Beacon (SLB)-1000, which is manually activated by the pilot.  It incorporates a 12 channel GPS receiver.  The GPS position is embedded in the transmitted 406 MHz distress message within five minutes of activation.  It also transmits on 121.5 MHz and 243 MHz to enable homing to the beacon.  The beacon’s 406 MHz signal with encoded information was received by the Canadian Mission Control Center at 0656Z who then alerted the Joint Rescue Coordination Centre (JRCC) in Trenton, ON.  The JRCC contacted 4 Wing ATC at 0707Z to relay all pertinent information and obtained confirmation of the bailout tone.

1.15.5 Local Emergency Response

1.15.5.1 The crash alarm was activated by the Duty Air Traffic Control Officer at approximately 2334 hrs.  The Wing Combat Operations Centre Officer immediately activated the 4 Wing Emergency Response Plan.  All Wing units responded accordingly and the Command Post was activated at 0020 hrs.

1.15.5.2 At 0017 hrs, a local resident placed a call to the 911 emergency operator to confirm the crash site position.  At approximately 0027 hrs, the Fire Chief located the crash site with the assistance of the 911 caller.  A fire truck was on scene at 0042 hrs and CF188789 was positively identified by 0048

1.15.5.3 The 417 Squadron call out was initiated at 0000 hrs.  The SAR CH146 helicopter, c/s JOKER 77, was airborne at 0126 hrs and commenced homing an ELT at 0145 hrs.  Alerted by flares, JOKER 77 located the accident pilot and conducted a landing in a nearby field.  At 0156 hrs JOKER 77 reported to ATC that the pilot was found and his status was “green.”  JOKER 77 returned to 4 Wing and landed at 0214 hrs when the pilot was transferred to an ambulance and transported to the Cold Lake hospital.

1.16 Test and Research Activities

1.16.1 Fuel samples were taken from the fuel tender that fuelled the aircraft.  No anomalies were found.

1.17 Organizational and Management Information

1.17.1 409 TFS Pilot Scheduling

1.17.1.1 The daily flying schedule is the result of numerous coordination meetings concerning the availability of aircraft, external assets, taskings and the long range training plan.  The goal is to generate suitably-qualified aircrew for taskings and contingency operations.  The burden of upgrading pilot qualifications at the unit level is significant and requires foresight and chain of command involvement.  A review of the 409 TFS daily flying schedule process indicates that the accident pilot was methodically scheduled and that the schedule was properly authorized IAW orders and local procedures.

1.17.2 Pilot Production Pressure

1.17.2.1 In the minutes from the April 2008 Air Force Development Committee meeting, the 1 Canadian Air Division (1 Cdn Air Div) Deputy Commander Force Generation (DComd FG) stated that, “I’m telling the Operational Training Units (OTUs) that production is coming, so the capacity needs to be there… it will be changed to accept the capacity, the next step is to go to the Sqns and say new pilots are coming in, change the way you do things.”  The DComd FG stated that a change in perspective was necessary from “we are producing the best pilots in the world… to we are producing the pilots we need.”

1.17.2.2 During the 1 Cdn Air Div Fighter Capability Advisory Group (FCAG) spring meeting, 22 May 2009, in response to the previous year’s DComd FG direction, the decision was made to accomplish the NVQ at 410 TFOTS where FPC 46 would be the first course to have the NVQ included in the FPC training plan.  However, due to 1 Cdn Air Div pressures to meet graduation date timelines and the limited hours of darkness at Cold Lake in the May/June time period, 410 TFOTS was forced to make several amendments to the FPC training plan, including the elimination of several night and most NVG missions.  As a result, 410 TFOTS could not complete the NVG material or issue the NVQ to FPC 46 pilots.  The NVQ reverted back to the operational units, in this case, 409 TFS.  Testimony indicated that newly arrived FPC graduates at 425 TFS restarted their NVQ from the beginning.  The 409 TFS deemed the accident pilot’s FPC NVQ training to be equivalent to completion of NVQ1.

1.17.2.3 The accident pilot’s FPC course report stated that NVG training was conducted in the Clearhood, Instrument Flying, and Air Weapons Intercept phases, however, it did not determine an equivalency to NVQ1.

1.18 Additional Information

1.18.1 Spatial Disorientation

1.18.1.1 Spatial disorientation refers to a situation in which a pilot fails to correctly sense the position, motion or attitude of the aircraft.  Vision and vestibular processes interact in human spatial orientation, which is generally classified as recognized, unrecognized, or incapacitating.

1.18.1.2. Spatial disorientation can occur at any time during flight.  Although NVG usually improve situational awareness and reduce the possibility of spatial disorientation, they can produce conditions that may cause momentary disorientation due to their limited field of view and low visual resolution.  Maintaining spatial orientation at night in flight requires complex conscious processing of data from various instruments, displays and references.  The task of maintaining spatial orientation under these flight conditions competes with other tasks such as navigation, terrain masking, threat avoidance etc.  Add to this the fact that susceptibility to fatigue increases at night and it is easy to understand why the incidence of spatial disorientation in the NVG environment also appears to increase as variables are added.  Constant vigilance and a good scan pattern, both inside and outside the aircraft, must be maintained to help prevent spatial disorientation.  Keeping the horizon or instruments that portray the horizon in the NVG scan can help avoid spatial disorientation.[4]

1.18.1.3 A somatogravic illusion is a type of spatial disorientation that results from either positive or negative linear acceleration.  A deceleration, such as caused by lowered landing gear and flaps, can cause a pilot to perceive that the aircraft nose is pitching forward.  Linear acceleration is detected by a vestibular organ called the otolith.  When decelerating in straight and level flight, the otolith registers a forward inertial force that combines with gravity to produce a resultant inertial vector rotated forward from the pilot; the pilot perceives this as a pitch forward.  A typical response to this illusion is to pull the aircraft nose up.  Normally this illusion of pitching forward is overridden by maintaining good flight references, such as those available with a visible horizon or instrument data on HUD or ADI, and may not be noticeable to the pilot.

1.18.1.4 There are many visual effects and illusions that can also influence spatial orientation.  One such effect is visual optic flow.  A flow of visual scenery or texture in the central and/or peripheral vision will give the pilot a strong impression of movement.  The direction of movement depends on the type of visual stimulus and the relative direction of the flow.  In circumstances such as an aircraft flying in snow or rain the perception of forward velocity can be very compelling.

1.18.2 Landing Gear Extension Illusion

1.18.2.1 Another CF188 pilot who was flying aided while following his formation lead on approach that night also had his landing light preselected to the ON position.  The pilot recalled that when the landing gear was coincidentally selected while the aircraft passed through an active snow shower, he felt a short but intense sense of tumbling and a sudden sense of strong optical flow.  The pilot overcame these sensations by turning the landing light off and concentrating on his HUD flight instruments.

1.18.3 Night Flying and NVG Orders and Regulations

1.18.3.1 National Defence Flying Orders, B-GA-100-001/AA-000, Flight Rules (2001-05-25 Change 8), state that, except in an emergency, fixed wing aircraft shall not takeoff or land at night at an unlighted aerodrome.  There are no directives in this publication regarding NVG training or operations.  This direction is repeated in 1 Cdn Air Div Orders (CADORD), Section 2-002, which states that airfields suitable for peacetime operations shall be lighted for night and/or IFR operations.  No exception is provided for NVG operations.  Both the flight lead and the accident pilot departed the aerodrome with the runway lights off.

1.18.3.2 With regard to NVG operations, CADORD Section 2-002 states that crew duty time is limited to 12 hours for NVG flying.  The accident pilot had been on duty for 10.5 hours at the time of accident.

1.18.3.3 CADORD Section 3-303, Night Vision Goggles Operations, Annex B (Fixed Wing NVG Ops, promulgated in September 2007), states that the weather limits for NVG operations shall be the same as the Visual Flight Rules (VFR) minima defined in National Defence Flying Orders.  The National Defence Flying Orders define VFR minima as a ceiling of 1,500 ft above ground and a flight visibility of three statute miles.  The aircraft is required to maintain a minimum of 500 ft vertically and one mile horizontally from cloud.  Lower weather limits for NVG operations may be authorized by 1 Cdn Air Div Headquarters for operational requirements.  No waivers or authorizations for a deviation from this Order were found during the investigation.  The majority of the CF188 aircrew interviewed by the investigation indicated that flying at night in IMC while using NVG is a normal and accepted practice and that they were unaware of the CADORD prohibiting NVG flight in IMC.

1.18.3.4 CADORD Section 3-303 also states that the aircraft commander or flight lead shall conduct a thorough pre-flight briefing to cover planned NVG flight profiles, sequences, procedures, NVG emergencies and inadvertent IMC flight.

1.18.4 Introduction of NVG Operations into the CF188 Fleet

1.18.4.1 Prior to the introduction of a night vision imaging system into the CF188 fleet, AETE was tasked by 1 Cdn Air Div and Air Force Test and Evaluation Coordination (AFTEC) in February 2005 to determine if the CF188 aircraft NVIS modifications complied with airworthiness requirements and to identify potential safety of flight concerns associated with the use of NVG in the CF188 operational roles[5].  AETE’s final Engineering Test and Evaluation (ET&E) report, issued in November 2005[6], noted many lighting and equipment deficiencies but it did not specifically test for the effect of the landing light illumination while using NVG.  At the time of testing, it was not envisioned that NVG would be used during the takeoff, approach or landing phases of flight when the landing light would typically be illuminated.  The report identified that there was insufficient irradiance of the HUD in NIGHT setting against a high illumination background and that it was desirable to increase the irradiance of the NIGHT mode of the HUD in order to rectify this deficiency.  No NVG flights were conducted in IMC.

1.18.4.2 In April 2007, the Fighter Operational Test and Evaluation Flight (FOTEF) issued its final Initial Operational Test and Evaluation (IOT&E) report after evaluating the NVG-aided suitability[7].  Operational scope, as defined in the Concept of Operations, technical clearance restrictions and resource limitations prevented FOTEF from assessing NVG-aided takeoffs or landings, however airborne events similar to takeoff and landing procedures were conducted above the minimum safe altitude to test the effects of the non-modified landing gear lights and landing light.  The report did not identify any issues with the illumination of the landing gear light while wearing NVG.  The report stated that the non-assessed procedures and capabilities should undergo Follow-on Operational Test and Evaluation (FOT&E) at the earliest possible opportunity prior to issuing an Operational Airworthiness Clearance (OAC).  No NVG flights were conducted in IMC.

1.18.4.3 On 1 October 2007, Operational Airworthiness Authority (OAA), Commander 1 Cdn Air Div, provided a Provisional Operational Airworthiness Clearance (POAC) for NVIS-modified CF188s in the aided role[8].  The POAC specified that NVG flying would be conducted as detailed in the CADORDs and other reference documents and it also described the qualifications required to operate with NVG.  On 31 October 2008, the OAA granted an OAC for CF188 NVIS-modified aircraft in the unaided and aided NVG roles[9].  Based on Record of Airworthiness Risk Management (RARM) findings, the OAC included clearance for NVG-aided takeoffs and landings and flight without visors.

1.18.5 RARMS

1.18.5.1 There were two approved RARMs dealing with the use of NVG in the CF188.  The first, issued in June 2007, dealt with the potential hazards associated with flying without visors while using NVG[10].  It assessed, among other things, the possibility of being injured during the ejection while wearing NVG.  The maximum risk was assessed as A4 Medium, with the highest risk associated with high aircraft speeds at ejection.

1.18.5.2 The second RARM was initiated by the fall 2007 FCAG Chairman who directed that a risk assessment be conducted to assess the risk associated with the introduction of CF188 NVG-aided takeoffs, landings and Air-to-Air refuelling[11].  The RARM was completed by 1 Cdn Air Div A3 Fighter Systems and approved by the Divisional Operational Airworthiness Manager in June 2008.

1.18.5.3 The RARM specifically assessed the hazard effect of an unmodified landing light causing an adverse lighting condition for the pilot during takeoff, approach or landing.  The RARM noted that the landing light was pilot-selectable and assessed that the lights’ effectiveness would be greatly increased under NVG.  The RARM recognized that the landing light could cause a condition where the CF188 pilot could no longer clearly see his surroundings through the HUD, resulting in the loss of the aircraft through pilot mishandling, although its likelihood of occurrence was defined as extremely improbable, or less than 1 in 10-7.  In making this assessment, the RARM assumed that the pilot would not be blinded and considered that the pilot was free to look under his goggles to regain awareness of his surroundings by using either external visual references or standard IMC instrument scan procedures.  The combination of an extremely improbable event with a catastrophic outcome resulted in an overall risk assessment of A5, meaning it was an Acceptable Level of Risk, requiring no further mitigating action and allowing it be signed off by the Divisional Operational Airworthiness Manager.

1.18.5.4 This RARM also examined the hazards of non-NVG compatible airfield lighting preventing the pilot from clearly seeing his surroundings through NVG during the takeoff, approach or landing phases of flight.  The loss of an aircraft due to this effect was also assessed as extremely improbable.  The RARM recommended that the CF188 be allowed to conduct unrestricted NVG-aided takeoffs and landings for training and operations at airfields of any illumination type including zero artificial illumination (i.e. runway lights off).

1.18.5.5 The implementation plan in the RARM called for the acceptance of the identified risks, publication amendments to include NVG-aided takeoffs and landings and an amendment of the NVG training syllabus by Fighter Standards and Evaluation Team (FSET) to include NVG-aided takeoffs and landings.  At the time of the accident, no changes had been made to the NVG orders, which still required the runways to be lighted and the weather to be VMC.  The RARM does not address the use of NVG in IMC.

1.18.6 Night Flying and NVG Training

1.18.6.1 During basic and advanced pilot training, i.e. Phase IIA, IIB and Phase III at 2 CFFTS Moose Jaw, night flying training includes one flight in the simulator, two flights during phase IIA and one flight during phase III for a total course requirement of 4.3 night hrs.  The accident pilot received 6.4 night hrs during these phases, more than the requirement, as two of his instrument cross-country flights were conducted at night.  There is no NVG training requirement during either the basic or advanced pilot training phase.  There is also no night or NVG flying during the phase IV fighter lead-in training conducted on the CT155 Hawk at 419 Sqn at 4 Wing in Cold Lake.

1.18.6.2 The initial CF188 NVQ, NVGIP and NVG currency requirements are described in the FSET-managed B-GA-050-000/RQ-G01, Fighter Pilot Training Directive (FPTD), and the NVG syllabi for these qualifications are detailed in Chapter 12.

1.18.6.3 The NVQ and NVGIP programs consist of academic training, Advanced Distributed Combat Training Simulator (ADCTS) training and flying sorties.  A pilot must be NVG-qualified to be considered Combat Ready.  The objective of the NVQ syllabus is to produce a pilot with the knowledge and ability to mission plan, brief, execute, and debrief both Air-to-Air and Air-to-Ground night aided missions with appropriate NVG considerations.  The NVGIP program is intended to produce an instructor with the knowledge and ability to teach the NVQ ground school and both ADCTS and flying missions safely and effectively.

1.18.6.4 NVQ academics consist of nine lectures and practical sessions with the AN/AVS-9 NVG.

1.18.6.5 Following the academic lectures, NVQ candidates must receive practical training adjusting the AN/AVS-9 NVG and terrain board exposure.  The flying portion of the NVQ syllabus begins with a 1.0 hr simulator mission, ENVQ1.  Subsequently, four dedicated flights, NVQ1 to 4, are conducted, each of which is 1.4 hrs in duration.  These consist of Air-to-Air, Air-to-Ground and Air-to-Surface missions incorporating the use of NVG.  NVQ1 must be flown dual with an NVGIP in the back seat.  The remaining NVQ missions are flown solo with one NVGIP monitoring the student from another aircraft.

1.18.6.6 Since the inception of the NVG program at 4 Wing, the NVQ had been conducted at 409 TFS where pilots obtain their NVQ within the initial Combat Ready Upgrade process.  Publications in use by 409 TFS specifically dealing with NVG training include the FPTD, the 409 TFS NVG Standards, the 409 TFS mission briefing guide, B-GA-583-001/FT-001 (Tactical Manual Volume 1, Amendment 4) and the Fighter Force Training Rules; none of these publications allowed for NVG operations in IMC conditions.  NVQ2 weather mission requirements specified in the FPTD on page 12B-2 are VMC training rules for conducting high war missions, i.e. a clearly discernable horizon, minimum 10,000 feet clear air between layers, remain 2,000 feet vertically above cloud and 500 feet vertically below cloud, minimum five nm flight visibility and one nm horizontally from cloud.

1.18.6.7 Following direction to incorporate the NVQ into the FPC, 410 TFOTS developed a document called the CF-18 Hornet Fighter Pilot Course Training Plan (dated 30 September 2009).  This training plan described suitable environmental conditions as IFR weather conditions for the broad accomplishment of some NVG training events.  No definition of IFR weather limits for NVG operations from the CADORDS or the CF Flying Orders was provided.

1.18.6.8 The academics, one ADCTS and four flights of the NVQ syllabus were split up and incorporated into the FPC with three hours of academics, four ADCTS missions and nine flights.  Comparison of the modified course produced by 410 TFOTS with the previous 409 TFS course indicated that the academic portion of the two courses were identical.  However, the material from the NVQ syllabus initial ADCTS mission was parted out to two FPC flights and two ADCTS missions.  NVQ1 was parted out to two FPC flights.

1.18.6.9 The accident pilot arrived at 410 TFOTS with 6.4 night hours and no NVG experience.  His FPC NVG flying training spanned the period of 4 February 2010 to 7 April 2010.  All training was scheduled and accomplished in a dual aircraft or the ACDTS.  During this period, three of the seven training events scheduled resulted in no NVG training being accomplished due to system unserviceabilities and higher order training priorities.  The pilot’s last NVG sortie before the accident was rated overall as above average; NVG pre-flight and adjustment and NVG scan techniques were rated level 4.  NVG formation keeping and contract adherence were rated level 3.  After he graduated FPC 46 with a total of 2.9 NVG hours, the responsibility to complete his NVQ was transferred to 409 TFS.  Training personnel at 409 TFS interpreted his previous NVG training as equivalent to completion of NVQ1 in the FPTD syllabus.

1.18.7 Inlet Ice Caution

1.18.7.1 The accident aircraft experienced three inlet ice cautions in the days prior to the accident.  These cautions were due to ice forming on and around the inlet guide vanes of one or both engines, which could have shed and damaged the engines.  The investigation observed that the technical order, C-12-188-000/NE-000, did not have a standard procedure for documenting an inlet ice caution and its maintenance rectification.

1.18.7.2 Shortly after the accident, CF188 senior maintenance leadership met to consolidate a request to the CF188 Aircraft Engineering Officer (AEO) to amend the technical order.

1.18.8 Aircraft De-icing

1.18.8.1 Interviews with maintenance crews revealed that CF188789 was reportedly de-iced prior to the aircraft’s last flight; however, a review of the servicing set did not reveal an entry to this effect.  A lack of clear direction concerning CF188 de-icing activities and associated CF335 Daily Aircraft Maintenance Certificate signing authorities was observed.

1.19 Useful or Effective Investigation Techniques

1.19.1 Not Applicable.

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2 ANALYSIS

2.1 NVG-Aided Takeoffs and Landings

2.1.1 The aircraft was modified for NVG operations as part of the CF18 Hornet Modernization Project.  The modification included the installation of NVIS-compatible exterior navigation and interior lighting and the installation of the NVG storage container on the CF188 right hand console.  The modification did not include a NVIS-compatible landing light or gear handle light.  Landings and takeoffs were not within scope of the original CF-18 NVIS project as defined in the original Concept of Operations and as such were not included in the original Statement of Work.

2.1.2 AETE was tasked to determine if the CF188 aircraft NVIS modifications were compliant with airworthiness requirements and to identify potential safety of flight concerns associated with the use of NVG in CF188 operational roles.  Following technical clearance, FOTEF conducted IOT&E and developed a comprehensive final report, dated 25 April, 2007.  The report’s annexes were developed in close consultation with FSET and became essentially the foundation for the introduction of NVG training into the CF188 fleet.  However, FOTEF’s efforts only concentrated on the roles and manoeuvres defined in the Statement of Operating Intent (SOI) concept of operations.  Because NVG-aided takeoffs, landings and Air-to-Air refuelling were not identified in the SOI, they were not assessed as part of FOTEF’s IOT&E test plan.  The covering letter, executive summary and main body of the report repeatedly recommended that procedures or capabilities that were not assessed should undergo FOT&E at the earliest possible opportunity prior to the issue of the OAC for CF188 NVG operations.  This recommendation was stated to ensure that any additional procedures would be subjected to the same rigorous OT&E processes in order to avert costly errors that could jeopardize the functionality of equipment or the safety of personnel.

2.1.3 Shortly after release to service, there was a fighter community push to introduce NVG-aided takeoffs and landings as well as NVG-aided Air-to-Air refuelling.  The recommendation for FOT&E contained in FOTEF’s report, was not acted upon; rather, the FCAG Chair directed in fall 2007 that a RARM be conducted to assess the risk associated with NVG-aided takeoffs and landings.  The RARM determined that NVG-aided takeoffs, landings and Air-to-Air refuelling could be accomplished within an Acceptable Level of Risk.  No additional technical analysis was conducted to evaluate and validate these flight sequences using NVG.

2.1.4 The RARM identified a catastrophic hazard severity with the unmodified landing light, landing gear handle warning, and radar altimeter warning lights because they could adversely affect a pilot’s NVG vision and, consequently, his aircraft handling during NVG-aided takeoffs and landings.  The hazard probability, however, was identified as extremely remote because the RARM assumed that the pilot would, in the event of poor NVG vision, utilize the under-the-goggle crosscheck in and out of the cockpit since it was taught on the NVQ and was standard practice within the community.  Furthermore, the CF188 NVG was among the most modern available and not as susceptible to adverse lighting as previous models.  Lastly, failing all this, the RARM expected that the pilot would transition to the instrument procedures routinely employed for takeoffs, approaches and landings during IMC.  Pilot experience and pilots undergoing initial NVQ training were not addressed in the RARM.

2.1.5 The Technical Airworthiness Authority (TAA), the Director General Aerospace Engineering Program Management, issued a Technical Airworthiness Clearance (TAC), 27 October 2008, which explicitly stated that NVG-aided takeoffs and landings were not approved, yet the OAA’s OAC, issued 31 October 2008, included the clearance to conduct them based on the recent RARM.  This RARM was initiated and processed in accordance with the operational airworthiness directives of the day, specifically CADORD Vol 1, 1-623 Annex A.  The TAA’s involvement in assessing the RARM consisted of representation on the risk management team and providing a technical airworthiness acceptance signature by the Senior Design Engineer.  As determined from email discussion, the TAA RARM review identified concerns with the methodology used to derive the extremely remote probability of accident, however, the investigation found no evidence of a 1 Cdn Air Div response to address these concerns.  The investigation concluded that the expansion of capabilities beyond those of the technical airworthiness process derived from the less rigorous RARM process, which concluded with unresolved TAA concerns, was inconsistent with sound airworthiness principles.

2.2 NVG Training and Currency

2.2.1 The NVG Training Plan Evolution

2.2.1.1 The key to using any weapon system/sensor effectively is to understand its limitations and capabilities.  As with any sensor, NVG need to be incorporated into an effective scan and cross check.  Focusing attention solely on NVG can lead to the rapid loss of situational awareness and create extremely dangerous situations.  Aircrew should have a sound knowledge of how NVG operate and sufficient exposure to the different visual effects and illusions present in the aided environment.  The original NVG training plan was designed and implemented to build the minimum level of experience to allow CF188 aircrew to train and operate in the aided environment.

2.2.1.2 The NVQ training completion constraints and course pre-requisites incorporated into the original NVQ training plan were derived from OT&E processes.  The training plan identified that, once commenced, the flying training must be completed within a 30 day window to provide both training continuity and a variance of illumination with a full lunar cycle.  A Combat Ready qualification and 20 hours of CF188 night experience ensured that the pilot had acquired sufficient experience and confidence in the employment of the CF188 prior to introducing him to the benefits, limitations and complexities of employing NVG.  Within a year of the NVG release to service, organizational pressures to absorb, train, graduate and upgrade CF188 pilots combined with the fighter community’s desire to tactically employ NVG resulted in the systematic removal of these requirements from the original NVG training plan.  FSET’s recommended changes to the FPTD, 3 October 2008, were approved and resulted in the permanent removal of these requirements.

2.2.2 Pilot Training

2.2.2.1 Throughout the early 2000’s, an existing fighter pilot shortfall, coupled with a large number of fighter pilot releases from the CF, caused a critical fighter pilot manning gap as experience declined.  As a result, DComd FG direction was given to shorten the training cycle times at all phases of fighter pilot training.  The CF188 OTU was reduced to seven months with a heavy emphasis to meet training graduation dates.  Additionally, the operational squadrons were directed to produce combat-ready wingmen in six months and combat-ready four plane leads within two years, a reduction of three months and one year, respectively, so that pilots could be cycled back to the OTU to instruct.

2.2.2.2 In 2009, the pressures placed upon the operational squadrons to qualify their pilots to combat ready status in six months resulted in a push to move NVG training from the operational squadrons to the OTU.  The CO of 410 TFOTS assessed this could be done within the same course time limits and elected to add this training to the current CF188 OTU syllabus.  A number of missions were changed in order to incorporate all NVQ syllabus performance objectives into the FPC.  The dissection and distribution of the performance objectives across a greater number of sorties had the effect of deviating further from the original concept of NVG flying training continuity within 30 days.  FPC 46 was the first course scheduled to graduate NVQ pilots.  Resource limitations, limited hours of darkness and strict adherence to graduation dates prevented the OTU from being able to provide NVG qualified CF188 pilots by end of course.  The accident pilot graduated from the FPC with a basic exposure to NVG operations, which were itemized on his course report.  409 TFS assessed the sequences flown and annotated performance levels to be equivalent to the successful completion of NVQ1, the only prerequisite for NVQ2.  Of note, this resulted in the accident pilot’s NVG training being fragmented between 410 TFOTS and 409 TFS from 7 February 2010 to 17 November 2010, some 284 days.

2.2.3 NVG Currency

2.2.3.1 At the time of accident, NVG-qualified pilots who did not fly an NVG sortie within 60 days were required to complete the FSET NVG ground school refresher, under the instruction of a qualified NVGIP, and complete the NVQ1 solo, under the supervision of a qualified and current NVG flight lead, in order to regain NVG currency.  Exceeding a currency period degrades the NVG scan and increases pilot susceptibility to disorientation.  Because the original approved training plan directed NVQ flying missions to be completed within a 30 day period or the training would re-commence at NVQ1, no currency requirement existed for pilots undertaking initial CF188 NVG training.  Subsequent to the approval of this training plan, it became apparent that operational commitments and other extenuating circumstances rendered the 30 day completion requirement to be too restrictive.  In December 2007, direction from 1 Cdn Air Div relieved the 30 day restriction on a case by case basis and directed NVQ time extensions to be requested from FSET.  In October 2008, FSET presented a list of recommended changes to the FPTD in advance of the issuing of the NVG OAC.  All recommendations, one of which was for the permanent removal of the 30 day course completion restriction, were approved.  Consequently, the accident pilot, who was an NVQ trainee, was deemed to be current to proceed on his NVQ2 mission given that no currency regulation or course completion restriction applied to his situation.  224 days had lapsed since his last NVG mission.  The investigation concluded that there existed an inconsistent approach to NVG currency requirements in that NVG-qualified pilots needed a recheck after 60 days yet NVQ trainees could fly an NVG sortie beyond the 60 day recheck timeframe.

2.3 The Mission

2.3.1 The NVQ2 mission was planned, briefed and executed into known IMC; however, there were no waivers or exemptions to CADORDS or B-GA-100-001/AA-000.  These orders state that the lowest permissible weather for fixed wing NVG operations are VFR minima.  The mission brief detailed the weather requirements for the upper air exercises as well as the terminal forecast for Cold Lake.  At the time of briefing it was well understood that departure to and recovery from the training area required flight in extended IMC.  The FPTD lists specific weather requirements necessary for the conduct of each NVQ mission.  These weather requirements vary depending on individual sequences associated with each NVQ mission but in all cases exceed the minimums stated in B-GA-100-001/AA-000.  Over time, an interpretation and understanding developed within the CF188 community that the weather requirements stated in the FPTD applied only to the execution of a mission’s tactical elements and not its domestic ones, such as transiting to and from the training area.  The investigation concluded that the weather requirement wording contained in the primary NVG training documents created conditions favourable for the development of this behaviour.  Most CF188 pilots interviewed were unaware that the CADORD and B-GA-100-001/AA-000 restrictions were applicable to all NVG operations, including both the tactical and domestic portions of each mission.

2.3.2 The accident pilot was on his first tour and, with only 473 hours, had little flying experience.  He was not aware of the disorienting effect of illuminating a landing light in snow while using NVG.  In fact, throughout his training and limited operational flying he had never landed in snow at night.  With the landing light switch ON, approximately six seconds after gear selection, the landing light illuminated the clouds and snow in front of the aircraft.  Though not blinded per se, the pilot was completely surprised by the unfamiliar conditions confronting him.  The non-NVG-compatible landing light reflected back at him and caused the NVG to “gain down,” as designed to prevent NVG damage, and simultaneously overpowered the HUD symbology, thus rendering all HUD information invisible through the NVG.

2.3.3 A fellow FPC 46 course graduate, who had a previous flying tour, was flying aided as number two in a formation behind the accident pilot.  He encountered the same landing light issue and sensed a strong optical flow.  However, based on experience flying in snow gained on a previous tour, he overcame this disorienting sensation and regained HUD attitude information by simply turning the landing light off.

2.3.4 The accident pilot stated that he set his HUD to a mid-NIGHT setting as directed in the CF18 How to Fly Manual.  No additional guidance was briefed to or obtained by the accident pilot during his pre-flight review on how best to optimize the HUD and console lighting for NVG operations.  Questioning experienced NVG-qualified pilots revealed that they typically set the HUD to low-DAY setting to ensure sufficient irradiation of the HUD when looking through the NVG.  The selection of the mid-NIGHT setting by the accident pilot provided adequate HUD irradiance during the normal mission profile and return to base, but did not provide the required irradiance to be seen against the intense external illumination caused by the reflected landing light while flying in snow.

2.3.5 Looking through NVG uses low photopic or high mesopic (day/dusk) vision.  The illumination level of the NVG causes the iris to close slightly such that the pilot’s eyes have to adjust to the reduced light level when looking under the NVG to see standby instruments.  Cockpit lighting set to an unaided night level that is dependent on scotopic (night) vision will be too low to allow a pilot to quickly look under the NVG and read an instrument.  When operating under NVG, the cockpit lights need to be increased in intensity to allow this quick look ability.  The ability to transition quickly from aided to unaided vision is essential in order to maintain an effective under-the-goggle crosscheck.  The accident pilot stated that he completed several under-the-goggle cockpit scans that included altimeter setting changes and fuel status checks during the IMC recovery.  This suggests that cockpit lighting was adequately set to facilitate unaided vision.

2.3.6 The landing light reflecting off the falling snow had the immediate dual effect of washing out the HUD information as well as causing a strong optic flow illusion that created an intense forward motion sensation.  This visual illusion was compounded by the mild somatogravic illusion due to deceleration forces present when the landing gear and flaps were selected and took effect.  In the event of an NVG failure, pilots are taught to raise their head and look at the HUD information unaided.  It is not known whether or not the pilot lifted his head to look under the NVG to see the HUD information nor was it possible to ascertain whether or not it would have been visible if he had.  In the absence of HUD information, or if feeling disoriented, a pilot is trained to transition to the standby attitude indicator located by the right knee.  The accident pilot had no recollection of actively employing the under-the-goggles crosscheck to check the standby instruments as taught during NVQ training.  The absence of any attitude information, coupled with the intense accelerating pitch down sensation reported by the pilot, caused him to instinctively pull back on the stick.  During the pull up, a slight right roll was induced that caused him to believe that the aircraft was rolling over onto its back, even though it had only rolled about five degrees to the right.  Cognizant of his proximity to the ground and his spatially-disoriented state, the pilot ejected from the aircraft.

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3 CONCLUSIONS

3.1 Findings

3.1.1  The mission was properly authorized IAW orders and unit procedures. (1.17.1.1)

3.1.2  The accident pilot was current and qualified IAW existing orders to fly the NVQ2 mission. (1.5.1.1)

3.1.3  The aircraft was fully serviceable to conduct the planned mission. (1.6.1)

3.1.4  Largely due to 1 Cdn Air Div pressure to reduce OTU training time, the responsibility to conduct NVQ was passed to 409 TFS.  This fragmented the accident pilot’s NVG training, which spanned 284 days. (2.2.2.2)

3.1.5  There were no applicable NVG currency requirements for NVQ trainees whereas NVQ-qualified pilots required recurrence training after a 60 day lapse. (2.2.3.1)

3.1.6  224 days had elapsed since the accident pilot’s previous NVG flight. (1.5.1.1)

3.1.7  NVQ2 was the accident pilot’s first solo NVG mission. (1.18.6.9)

3.1.8  NVQ2 was the accident pilot’s first night mission, aided or unaided, during which he experienced the effects of the illuminated landing light while conducting an instrument approach in falling snow. (2.3.2)

3.1.9  Unusual attitude procedures and goggle failures were briefly reviewed as part of the mission brief.  The briefing focused mainly on the tactical portion of the mission and NVQ2 performance objectives. (1.1.1)

3.1.10  The HUD and internal and external light settings were not discussed in detail during mission brief but rather left to the pilot’s discretion. (2.3.4)

3.1.11  Experience-based deviations from stated cockpit and HUD lighting settings existed within the CF188 community. (2.3.4)

3.1.12  The ET&E and OT&E programs did not assess NVG for use in IMC. (1.18.4.1)

3.1.13  The ET&E and OT&E programs did not assess NVG-aided takeoffs or landings. (1.18.4.2)

3.1.14  An FCAG-directed RARM assessed that NVG-aided takeoffs and landings could be accomplished with an acceptable level of safety. (1.18.5.3)

3.1.15  Based only on RARM results and FSET recommendations, the OAC was granted to conduct NVG-aided takeoffs and landings notwithstanding that the TAC did not authorize aided flight below 1000’ AGL. (1.18.4.3, 2.1.5)

3.1.16  Minimum weather for fixed-wing aircraft in all phases of NVG operation is VFR as defined in B-GA-100-001/AA-000. (1.18.3.3)

3.1.17  Contrary to B-GA-100-001/AA-000 direction, the CF188 community routinely conducted NVG flight in IMC, particularly for domestic flight phases. (2.3.1)

3.1.18  The decision to arrive and depart through IMC using NVG was briefed by the NVGIP. (2.3.1)

3.1.19  The sudden landing light illumination of the falling snow caused the HUD to washout completely, rendering that information imperceptible to the accident pilot’s aided vision. (2.3.2)

3.1.20  The accident pilot experienced an intense optic flow illusion, due to the illumination of the snow, which made him perceive an increased forward velocity sensation. (2.3.2, 2.3.6)

3.1.21  The accident pilot’s nose-down pitching sensation was likely augmented by a mild somatogravic illusion when the landing gear and flaps were lowered. (1.18.1.3)

3.1.22  In response to the perceived nose-down attitude, the accident pilot was startled and instinctively pulled back on the control stick.  (1.1.5, 1.18.1.3, 2.3.6)

3.1.23  The abrupt control stick input then caused the accident pilot to experience severe spatial disorientation.  (1.11.1.1, 2.3.6)

3.1.24  The accident pilot had no recollection of employing the under-the-goggle scan to re-acquire attitude information. (2.3.6)

3.1.25  The ejection was successful and all ALSE functioned correctly.  (1.15.1.2, 1.15.1.5)

3.1.26  The accident pilot received NACES parachute suspension training, however, this training was not available to all CF188 pilots. (1.15.1.4)

3.1.27  Sound survival techniques were employed.  The pilot was well prepared to spend the night in a post-ejection survival situation. (1.15.2.1)

3.1.28  Numerous deficiencies or anomalies regarding the pilot’s ALSE were noted.  Improperly sized equipment, poor maintenance, overdue inspections and improper documentation were significant areas of concern. (1.15.3.4)

3.1.29  All emergency transmitters functioned normally.  The SAR response and 4 Wing Emergency Response Plan were very effective. (1.15.4, 1.15.5)

3.3.1.30  The pilots of military aircraft in the vicinity of the ejection did not recognize the bail out tone initially. (1.15.4.1)

3.2 Cause Factor

3.2.1 The accident pilot experienced severe spatial disorientation while flying a radar trail approach using NVG in IMC.  The non-NVG-compatible landing light reflected off the snow to generate a startling, intense optic flow illusion while also impairing the pilot’s ability to perceive HUD information; collectively this caused him to instinctively pull back on the control stick and induce a spatial disorientation.  In a disoriented state, unable to regain his situational awareness, and cognizant of his proximity to the ground, the pilot ejected.

3.3 Contributing Factors

3.3.1 Minor somatogravic effects likely contributed to the accident pilot’s overall disoriented state once he was no longer able to perceive the HUD attitude information.

3.3.2 The CF188 community routinely planned, briefed and executed NVG missions in known IMC contrary to the CADORDS and B-GA-100-001/AA-000.

3.3.3 The accident pilot was neither proficient nor sufficiently experienced to counter the unexpected demanding conditions associated with the NVG-aided approach in IMC.

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4 PREVENTIVE MEASURES

4.1 Preventive Measures Taken

4.1.1 1 Cdn Air Div released, COMD 120, RESTRICTION TO CF-18 NIGHT AIDED OPERATIONS, 182143Z Nov 10, prohibiting NVG-aided flying operations in the CF188 until a review of NVG tactics, training and procedures was completed and briefed to Comd 1 Cdn Air Div no later than 26 November 2010.

4.1.2 1 Cdn Air Div released DCOMD FG 019, RE-INSTATEMENT OF NIGHT AIDED CF-18 FLYING OPERATIONS, 061433Z Dec 10, after previously suspending CF188 aided operations.  This message authorized the resumption of CF188 aided flying under the following conditions:

a. Aircrew must have 25 hrs night flying and an unrestricted instrument ticket to commence NVQ;

b. NVG are to be donned or doffed when stabilised above 3,000 ft AGL and when stable with a minimum of 1,000 ft lateral separation from other aircraft;

c. Once NVG are donned, aircrew are authorized to descend to 1,000 ft AGL to conduct tactical flights;

d. NVG-aided takeoffs and landings are prohibited until further notice (UFN);

e. NVG currency of 60 days will remain in place UFN;

f. All aircrew are required to review the ground school and conduct a low task-load NVG mission profile (save for aided takeoffs and landings, which are prohibited) prior to normal NVG operations;

g. NVQ syllabus remains unchanged (save for aided takeoffs and landings, which are prohibited); and

h. All aircrew shall employ NVG IAW Fighter Force Training Rules; specifically, NVG may only be used during night VMC conditions.  NVG flight in IMC is prohibited.

4.1.3 The CF188 Weapon System Manager staffed AICP 2182/188/12/11 to add a new condition inspection to cover Inlet Ice Cautions.  The condition inspection mandated an intake crawl identical to the current A-Check after an Inlet Ice caution indication.

4.1.4 The CF188 Weapon System Manager issued Special Inspections C-22-442-000/NS 001 and C-22-144-000/NS 002 to inspect and confirm that the upper and lower NACES seat garters were the proper length and embodied serviceable hook and loop fasteners.

4.1.5 The CF188 AEO produced a draft fleet-wide directive detailing CF188 de-icing procedures.  The directive is currently under review and awaiting feedback from 1 Cdn Air Div and CF188 squadrons.

4.1.6 NACES harness suspension training was included for all CF188 pilots during initial or recurrent training.

4.1.7 DTAES conducted a technical audit of all CF188 squadrons that addressed, amongst other points, 409 TFS ALSE concerning the proper fitting of harnesses, record keeping and the serviceability of the contents of the LPSV and the SSK; and a process to ensure that CF335 entries are being made following de-icing and replenishment of aircraft fluids.  CF188 squadrons implemented Corrective Action Plans addressing the audit’s findings.

4.2 Preventive Measures Recommended

4.2.1 Comd 1 Cdn Air Div conduct a doctrinal review to validate the requirement for CF188 NVG-aided takeoffs and landings.

4.2.2 Comd 1 Cdn Air Div coordinate with DRDC, AETE and FOTEF to develop a comprehensive NVG-aided takeoff and landing test and evaluation plan prior to authorizing CF188 NVG-aided takeoffs and landings.

4.2.3 FSET review and validate NVG currency requirements for all CF188 NVQ trainees, NVQ-qualified pilots, and NVGIPs.  Consideration should be given to more stringent NVQ trainee currency requirements.

4.2.4 FSET add a summary of this accident to the Fighter Force NVQ ground training lectures.

4.2.5 FSET update and re-emphasize the CF188 bail-out tone recognition presentation to all CF188 aircrew.

4.2.6 CFSSAT add a summary of this accident to the NVG illusion training package.

4.2.7 CFSSAT enhance initial spatial disorientation training through the incorporation of a virtual terrain board into the AMT training syllabus.

4.3 Other Safety Recommendations

4.3.1 Nil.

4.4 DFS Comments

4.4.1 Our inability to reliably predict those factors that conspire to cause an accident demands that we strictly adhere to established processes and practices - in doing so, we maximize our ability to prepare for their eventuality.  In this particular accident, factors such as CF188 NVIS modification deficiencies, reduced NVQ training pre-requisites, fragmented NVQ training syllabi and inconsistent currency requirements accumulated over a protracted period of time and insidiously eroded the safety margins needed to facilitate an inexperienced, partially-trained pilot to execute the mission successfully.

4.4.2 Operational pressures, fiscal constraints and force generation limitations will continue to challenge the safety of our operations, as will spatial disorientation which has been present in RCAF operations since 1923.  There will be situations where compromise, involving abbreviated processes and procedures, will be necessary in order to get the job done; however, in the face of unanswered questions or unresolved concerns, we must remain responsive to engaging the more rigorous airworthiness processes that involve comprehensive testing to clearly understand the consequences and mitigate the risks.  In this way, we protect our personnel from undue hazards by capturing and converting experienced-based techniques into formalized practices and procedures.

4.4.3 Our rules, regulations, and directives are the products of many years of lessons learned that have been captured by talented RCAF personnel.  When acknowledging periods of low experience, they become an even more important beacon to guide our personnel through the challenges and demands of the unrelenting pace of RCAF operations.


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Annex A:  Figures

Figure 1: An overview of the accident location and the flight path of the aircraft on approach to runway 13L at Cold Lake airport.

Figure 2: Close up of the ejection point and the aircraft impact point.

Figure 3: Photograph of the aircraft at the impact point.

Figure 4: Side view of the CF188 indicating the landing/taxi light location.

Figure 5: Front view of the CF188 indicating landing/taxi light location.

Figure 6: CF188 instrument panel.  The right console is located immediately adjacent to the bottom right corner of the instrument panel.

Figure 7: CF188 right console.

Figure 8: Representative HUD image.

Figure 9: NVG image looking into an incompatible light source.


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Annex B:  References

1. 1 Cdn Air Div message: COMD 120, RESTRICTION TO CF-18 NIGHT AIDED OPERATIONS, 182143Z Nov10

2. 1 Cdn Air Div message: DCOMD FG 019, RE-INSTATEMENT OF NIGHT AIDED CF-18 FLYING OPERATIONS, 061433Z Dec 10

3. B-GA-100-001/AA-000, NATIONAL DEFENCE FLYING ORDERS, BOOK 1 OF 2, FLIGHT RULES 2001 05 25 (Change 8)

4. 4 Wing Aircrew Information File, 3179-1 (RAPTOR), 13 Oct 09, 4 WING AIF 35-09 NVIS AERODROME SOPs

5. ATC Manual of Operation, para 370 Airport Lighting, pg ATC 3-67

6. 409 TFS NVG STANDARDS, 18 Aug 10

7. RECORD OF AIRWORTHINESS RISK MANAGEMENT (RARM), CF188 NVG AIDED TAKEOFFS AND LANDING AND NVG AIDED AIR-TO-AIR REFUELING, CF188-2008-007, 03 June 2008

8. CC177 SMM, NVG Operational Weather Limits

9. B-GA-050-000/RQ-G01, Chapter 12, NVG Syllabi

10.  C-12-188-NFM/MB-003, Section 24 – Image Intensifier Set, Night Vision F4949 Type AN/AVS-9G-VG

11. 1 Cdn Air Div Orders:

a. Vol 2, 2-002, Fighter Force

b. Vol 3, 3-303, Night Vision Goggle Operations

c. Vol 5, 5-502, Fighter Force Aircrew Standards

d. Vol 5, 5-005, Annex A, AF IT&E roles, Responsibilities & Qualification Requirements


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Annex C: Abbreviations

1 Cdn Air Div: 1 Canadian Air Division

2CFFTS: 2 Canadian Forces Flying Training School

AETE: Aerospace and Engineering Test Establishment

AF: Air Frame

AFIP: Armed Forces Institute of Pathology

AFTEC: Air Force Test and Evaluation Coordination

AGL: Above Ground Level

AICP: Aircraft Inspection Change Proposal

AID: Automatic Inflation Devise

AIS: Airborne Instrumentation Sub-system

ALSE: Aviation Life Support Equipment

AMU: Advanced Memory Unit

ASR/SSR: Airport Surveillance Radar/Secondary Surveillance Radar

ATC: Air Traffic Control

CADOR: 1 Canadian Air Division Order

CF: Canadian Forces

CVRS: Cockpit Video Recording System

DAU: Data Acquisition Unit

EADI: Electronic Attitude Direction Indicator

ET&E: Engineering Test and Evaluation

FCAG: Fighter Capability Advisory Group

FOT&E: Follow-on Operational Test and Evaluation

FOTEF: Fighter Operational Test and Evaluation Flight

FPC: Fighter Pilot Course

FSET: Fighter Standards and Evaluation Team

HOTAS: Hands on Throttle and Stick

HSD: Horizontal Situation Display

HUD: Head Up Display

IMC: Instrument Meteorological Conditions

IOT&E: Initial Operational Test and Evaluation

MDI: Multipurpose Display Indicator

MHz: Megahertz

MSL: Above Sea Level

NACES: Navy Aircrew Common Ejection Seat

nm: Nautical Miles

NVG: Night Vision Goggles

NVGIP: Night Vision Goggle Instructor Pilot

NVIS: Night Vision Imaging System

NVQ: Night Vision Qualification

OAA: Operational Airworthiness Authority

OAC: Operational Airworthiness Clearance

OSCER: On Scene Command and Emergency Response

PAR:  Precision Approach Radar

PLB: Personal Locator Beacon

POAC: Provisional Operational Airworthiness Clearance

RARM: Record of Airworthiness Risk Management

SAR: Search and Rescue

SOI: Statement of Operating Intent

Sqn: Squadron

SSK: Seat Survival Kit

TAA: Technical Airworthiness Authority

TAC: Technical Airworthiness Clearance

TSI: Time Since Inspection

TSN: Time Since New

TSO: Time Since Overhaul

UFC: Up-Front Control

UHF: Ultra High Frequency

VMC: Visual Meteorological Conditions

Z: Zulu (Greenwich Mean Time or Universal Coordinated Time)


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Annex D:  ALSE Observations

1. The LPSV MSV 980 was a size Double Extra Large and improperly sized to the accident pilot, as the remainder of his upper torso ALSE was all sized as Medium.  The Tac Op knife located in the LPSV MSV 980 was not properly attached to the beaded handle and during removal via the beaded handle the knife remained in the pocket.  The finger light stored in the LPSV MSV 980 was unserviceable due to dead batteries.  The Recta DP 6G compass had a large air bubble in the liquid reducing its serviceability and effectiveness.  The Day/Night Flare and the Jet Flares had no recorded expiry date in the CF 363 Log Record.  The water IV bag did not have the grommet installed that would allow it to be suspended for use as designed.  The Log Record Set for the LPSV MSV 980 consisted of three different record books, each with discrepancies described as follows:

a. There was an open entry from 29 June 2010 stating the Automatic Inflation Device (AID) and knife were removed from the LPSV MSV 980, but this was not the case;

b. The Record Set listed 410 TFOTS as the owner, verses 409 TFS;

c. The wrong serial number for the SLB 9000 was entered and it was entered as a time-expired device; and

d. The wrong oxygen regulator was listed and the oxygen regulator’s 90 day inspection was overdue.

2. Other anomalies noted as well.  The AID Record Set listed the AID as installed in an MSV 975 vice the MSV 980.  The upper leg garters installed on the NACES seat were worn beyond usefulness as the Velcro was no longer functional and many places no longer attached to the garters.  Additionally, they were the incorrect length (24”) verses the required 28” that were necessary to accommodate winter weight flight gear.

3. The pilot was wearing a Medium PCU 56 harness, which was doffed after landing in the bush.  It was found in good condition.  The PCU 56 was not properly fitted to the pilot in that the chest strap was not correctly routed through the lift harness, one strap was through the upper slot and one was through the lower slot.

4. The pilot was wearing a personally-procured knee board and attached to it was a service-issued white light flashlight.  These were lost during the ejection and not recovered.

5. The 190A helmet worn by the pilot had the NVG mounting brackets installed.  The plastic adjustment buckles for securing the bayonet fittings to the mask exoskeleton showed evidence of impact as the buckle on the right side was cracked.  The location of the crack aligns with the eyepiece position of the NVG.


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Notes 

[1] The term “aided” refers to the use of NVG during flight manoeuvres.  The term “unaided” refers to conducting manoeuvres without the use of NVG.

[2] The SA format gives the operator information about air to air and surface tracks, tactical information, and geographic information about the area around his own ship in a god’s eye view.

[3] NVIS-compatible lighting can be seen by the naked eye, but has limited adverse effect on NVG.

[4] AFMAN11-217V3, 23 February 2009.

[5] Project Tasking – 10081-1 (A3 Ops) Project Tasking Letter, 4 February 2005.

[6] AETE 2004-008 (D/OIC FTr Eval) Final Report CF188 NVIS Modifications ET&E, 25 November 2005.

[7] 10081-2005-004 (OC FOTEF) Final Report – Project F-2005-004 CF-188 Night Vision Goggle IOT&E Phase 2, 25 April 2007.

[8] 10081-1 (A3 Ftr Sys) Provisional Operational Airworthiness Clearance – Night Vision Imaging System Modified CF188 Hornet Aircraft in the Aided Role, 1 October 2007.

[9] 10081-1 (A3 Ftr Coord) Operational Airworthiness Clearance – Night Vision Imaging System Modified CF188 Hornet Aircraft in the Aided Role, 31 October 2008.

[10] RARM-CF188-2007-007 Rev 0 Wearing NVGs Without Visors, 22 June 2007.

[11] RARM CF188-2008-007 Rev 0 CF188 NVG AIDED (sic) TAKEOFFS AND LANDINGS AND NVG AIDED (sic) AIR-TO-AIR REFUELLING, 3 June 2008.

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