2016 Annual Report - Airworthiness Investigative Authority and Flight Safety Program Activities

Report / August 16, 2017 / Project number: RCAF-DFS-2016-annual


This is the 12th annual report on Airworthiness and Flight Safety (FS) activities for the Department of National Defence/Canadian Armed Forces (DND/CAF) and the Air Cadets. The report provides a synopsis of the investigations and activities carried out by the Airworthiness Investigative Authority (AIA) and the activities overseen by the Director of Flight Safety (DFS) in relation to the FS Program for 2016 with a statistical comparison to the previous 10 years.

In addition to one major catastrophic accident and fatality on a CF-18 last Nov. in Cold Lake, AB, the CAF suffered five air accidents and two ground accidents. The Air Cadets had two air accidents, one very serious and one serious. The overall results indicate no significant increase and we are trending near the 10-year mean.

The number of reported occurrences has increased slightly (3233) compared 2015. Although Units and Wings have made some headway over the last two years in reducing the investigation backlog, there is continued pressure and we are showing signs of losing ground again. This is possibly indicative of a need to ensure FS staff aren’t burdened with secondary tasks or there may be a requirement to permanently increase human resources assigned to investigate occurrences and implement preventive measures.

The FS Information Management System (FSIMS) collaborative project with the Information Management Group was released in June 2016. This new software was well received by the community. Key developments included enhanced search and report features down to the unit level as well as the new Fatigue risk management system (FRMS) data capture.

The Director and CWO of Flight Safety visited all Wings and numerous civilian facilities this year. There were 75 annual briefings presented in both official languages reaching approximately 8100 personnel. The overall message discussed basic skills, human factors and the fact that there are few random events. Different people at different bases and organizations keep making the same errors. These are recurring issues that we can manage, when they are reported.

Overall our FS program continues to be very effective. If we compare to the 1980s, the annual statistics were far worse than what we have today. We were losing 5 to 10 aircraft per year and the human cost was event greater. Given our positive results, we need to ensure that we don’t accept our current statistics as being “the standard” and as a result reduce our focus and resources on Flight Safety. Goal Zero within a year is achievable and has been done on a few occasions during the last decade. If we have been able to achieve no fatalities or no major accidents within a year, we can surely do so for 2, 3 or more years without any impact in our ability to deliver mission effect.

In closing, I want to reaffirm that everyone has a Flight Safety role to play, but first and foremost Flight Safety is a leadership responsibility.

Feedback and comments on this annual report are solicited and would be greatly appreciated. They should be forwarded to DFS at dfs.dsv@forces.gc.ca.

Steve Charpentier
Director of Flight Safety and Airworthiness Investigation Authority


This report provides a synopsis of the activities carried out in 2016 by the Airworthiness Investigative Authority (AIA) and the Directorate of Flight Safety (DFS) in relation to the FS Program of the Canadian Armed Forces (CAF). It covers statistical data for the Air Cadets Glider Program (ACGP). It also gives statistical details on FS occurrence data collected during the year in comparison with the last ten years and highlights areas of concerns.

The introduction of the Flight Safety Information Management System (FSIMS) has required a validation of the database content as well as the report queries. Consequently, some of our tables and graphs have seen changes due to these processes.



Preliminary draft versions of the regulations required for the full implementation of the Aeronautics Act (AA) amendment were produced but they still have to be reviewed within the Department of Justice before they can proceed to the Treasury Board Secretariat (TBS). The regulation triage that is prepared for TBS to explain the regulation requirement is near completion which then leads to the Regulatory Impact Analysis Statement (RIAS) as the first steps towards gazetting the proposed regulations. This activity is underway but this it may take up to another year before the gazette process commences. It is hoped the required regulations will be in place by the end of 2018.


The FS surveys are an integral part of a continuous improvement effort and provide a platform from which the safety culture at each organization can be sampled regularly. The FS staff at the Division conducted seven assistance visits to units located in Gander, Goose Bay, Ottawa, Shearwater, Trenton, Winnipeg, Yellowknife, and Victoria.


During the calendar year, the AIA initiated 3233 investigations. Of these, DFS initiated three investigations: two Class 1 investigations for, a CF188 Hornet fatal accident, a SZ23 Schweizer landing short and one Class 2 for a CT156 Harvard II landing gear malfunction. DFS completed 12 investigations in 2016.


Although units and wings have made significant efforts towards reducing the number of overdue occurrence reports to 495 at its lowest point in 2016, the first two quarters of 2017 have demonstrated an increasing trend to 605 as of 30 May 2017 (Graph 4). This is possibly indicative of a need to ensure FS staff aren’t burdened with secondary tasks or there is a requirement to permanently increase human resources assigned to investigate and implement preventive measures.

A trend in the ALSE related occurrence rate and volume requires additional in-depth analysis. The number of overdue occurrence reports increasing trend requires renewed attention. Revision to the ACGP Regional Flight Safety Officer positions have created concerns as to the implementation of the CAF FS Program.



The Director and the DFS Chief presented 75 annual briefings to different locations across Canada reaching more than 8100 personnel. The Directorate published three issues of Flight Comment magazine, three issues of the electronic FS newsletter Debriefing as well as three FS FLASH messages.


A total of 34 FS award were handed out consisting of 7 Good Show and 27 For Professionalism awards. Each Good Show recipient is also awarded an RCAF Commander’s commendation. A total of 38 FS coins were also handed out. The SICOFAA award was presented to the Quality Engineering Test Establishment (QETE) in recognition of many decades of stellar technical support to aircraft occurrence investigations.


1 Cdn Air Div FS staff conducted five FS courses (FSC) where 162 personnel were trained, including Air Cadets staff members, civilian contracted service providers, Army personnel, DND firefighters and four investigators from the Ukraine Armed Forces.


A draft revision of the A-GA-135-003/AG-001 Airworthiness Investigator Manual (AIM) was undertaken to reflect the changes to the AIA investigation processes, procedures and orders as a result of the 2015 AA amendments should be completed by May 2017. The AIM is produced as an electronic publication and is available on the Defence Wide Area Network website. Changes in the newly revised document include updating the investigator training and certification requirements, changes to the delegated authorities for investigators, publishing draft versions of the proposed Orders in Council (regulations) and including information regarding the amendments to the AA.


DFS provided Flight Safety training to the Ukraine Air Force (UAF) as part of the provision of military assistance to Ukraine under the auspices of Op UNIFIER/Line of Effort (LOE) 4. Two serials of the Ukraine Flight Safety Course (UFSC) were delivered in November 2016 and February 2017. The UFSC trained 65 Ukraine Air Force personnel in ICAO Safety Management System (SMS) principles and how the RCAF applies SMS principles within a military context.

DFS coordinated closely with ICAO HQ in Montreal for the delivery of the ICAO SMS portion of the course and the DFS-led team was augmented internationally by a representative from the Polish Air Force, Czech Air Force and a Ukrainian ICAO expert. In support of the capability development goals of Op UNIFIER, senior UAF FS officers attended the RCAF FS course in Winnipeg in Sept 2016 and were included as teaching staff on the UFSC and UFSC training materials were provided to the UAF FS leadership upon completion of the LOE4 training. A UAF Aviation Safety Roadmap was developed to provide a possible path for the UAF to achieve NATO aviation safety standards and as guidance for future bilateral or multilateral cooperation. Op UNIFIER LOE4 completed activities as of 31 March 2017.

DFS also delivered FS presentations in Bolivia as part of the SICOFAA FS meeting. DFS maintains close liaison with Air Forces Flight Safety Committee Europe (AFFSCE), NATO FS Working Group, International Society of Air Safety Investigators (ISASI) and the Canadian Aviation Safety Officer Partnership (CASOP).

DFS presented an updated approach to crash scene hazard management to representatives of major air investigator communities in Canada. Part of the presentation included a Crash Scene Hazard (CraSH) matrix organizational tool. The content and layout was reviewed by participant and a final version was developed with their participation. Each group subsequently agreed to collaborate with DFS to determine how to best incorporate this within their respective organisations. This ongoing approach is expected to enhance interoperability and allow collaboration on future work. The endorsed updated approach was published in the October-December 2016 International Society for Air Safety Investigators (ISASI) Forum magazine.



The overall flying hours indicate a slight decrease (.21%) from 146633 to 146322 compared to the previous year. This overall decrease consisted of a trade-off between fighters and gliders with minor variation in other fleets.

Personnel reported 3233 occurrences distributed almost equally between Air occurrences at 50.44% and the Ground occurrences at 49.56%. This represents a very slight increase in the number of reported occurrences when compared to the previous year (3180) and remains slightly above the 10-year mean value of 3077.


The CAF experienced six air accidents during 2016. The breakdown of air accidents was one Category ‘A’ (CF188 Hornet) and five Category ‘C’ (CT114 Tutor, CC138 Twin Otter, CT146 Outlaw, CT155 Hawk, and CT156 Harvard II). The overall CAF Air Accident rate decreased to 0.5 which is slightly lower than the 10-year mean of 0.6. The CAF had two ground accidents; one Category ‘C’ (CH142 Sea King) that suffered serious damage during shipboard operations, and one Category ‘C’ (CF188 Hornet) occurrence where one person suffered serious injury.

The Air Cadets had two air accidents, one Category ‘B’ accident (SZ23 Schweizer), and one Category ‘C’ (SZ23 Schweizer). The Air Cadets Air accident rate decreased to 1.3 from last year and remains within one standard deviation of the mean, hence not problematic. There were no Air Cadets ground accidents in 2016.


The FS Information Management System (FSIMS) collaborative project with the Information Management Group deployed the initial version of the application in Jun 2016. The FS Team adapted quickly to this new software. Development continued throughout the year as additional capabilities such as fatigue risk management as well as refinements to the Air weapons related occurrences were introduced. Additional capability development continues throughout 2017.

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