2010 Annual Report on Flight Safety

Report / July 12, 2011 / Project number: RCAF-DFS-2010-annual

This report provides a synopsis of the activities carried out in 2010 by the Airworthiness Investigative Authority (AIA) and the Directorate of Flight Safety (DFS) in relation to the Flight Safety (FS) Program of the Canadian Forces. 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.

Airworthiness Progam

Investigations. During the calendar year, the AIA initiated 12 investigations and closed 34. The investigations tasked by DFS were for 9 accidents (4 Cat 'A', 3 Cat 'B', and 2 Cat 'C'), 3 incidents (one Cat 'D' and 2 Cat 'E'). These figures include 3 Air Cadet (categorized non-CF) investigations and 1 investigation for a UAV accident.

Aeronautics Act Amendment. DFS/AIA re-assessed the requirement for an Aeronautics Act (AA) amendment and concluded that such an amendment remains the best vehicle for providing aviation safety investigators the appropriate powers necessary to conduct investigations concerning aviation safety, particularly when civilians are involved in the occurrences. Because the original proposed amendments were not re-introduced in the last sessions of Parliament (40th Parliament -1st, 2nd & 3rd sessions), DFS checked with Transport Canada (TC) and were informed that AA amendment was no longer high on the TC priority list. DFS inquired if TC would support an AA amendment effort lead by the DND/CF, dealing primarily with augmenting safety investigator powers and received TC support for this initiative. Appropriate documents were forwarded to the MND with this theme, which received CDS and DM support; however, MND approval was not forthcoming prior to the dissolution of the current session of Parliament. DFS/AIA plans on pursuing this initiative with the new MND post the May 2011 election (41st Parliament).

Airworthiness Investigation Manual. The A-GA-135-003/AG-00 Airworthiness Investigation Manual (AIM) was published in Feb 2010 with the procedures and processes outlined in the manual coming into effect 15 Apr 10. Over the past year, all DND/CF Flight Safety Officers and NCMs that were previously trained and qualified to conduct safety investigations in the Flight Safety Program have been AIA authorized and recorded as being so authorized. This was through an update process initiated and completed primarily through the Division Flight Safety Officer's span of control and secondarily through a documentation process conducted within DFS. All subsequent Airworthiness (Flight Safety) investigators trained through the Division Flight Safety training program have been appropriately AIA authorized through a delegation from the AIA to the Div Flt Safety Officer. As well, advanced investigator training and qualification documentation is in place and continues to be updated for all investigators within DFS. During the coming year the goal will be to amend Specialty Specification Codes and track these qualifications utilizing that tracking system and through individual UER updates. The AIM is available on-line via the DFS website.

Amendments to A-GA-135-001/AA-001. Amendment #3 of the A-GA-135-001/AA-001, Flight Safety for the Canadian Forces, was released on 01 Mar 2010. The amendment covers changes relevant to the introduction of the AIM, a description of the FS strategic business model, the CVR/FDR parameter requirements by families of aircraft, the conditions required to carry out airworthiness investigations, amendments to the investigation class table, and illustrates the newly revamped occurrence/hazard PM management process. Amendment #4 of the A-GA-135-001/lAA-OO1 was in draft form at the end of the year.

CVR/FDR Working Group. The CVR/FDR Working Group continued its activities during the reporting period but has progressed as far as it can without funding approval. Implementation policy will focus on achieving an average of one fleet per year for the next 10 years based on the agreed upon fleet prioritizations.


Promotion. DFS presented 41 annual briefings (33 English and 8 French) at 23 locations covering several Wings as well as the Canadian Contingent at Geilenkirchen, CDLS (London) and SHAPE HQ Belgium reaching approximately 7500 personnel. DFS met with over 75 Commanding officers and their Squadron warrant officers as well as visits to 8 Control Towers. DFS published 3 issues of Flight Comment magazine, 1 issue of On Target, which focussed on night operations, and 7 issues of the electronic FS newsletter Debriefing. There were no FS Flash messages released during 2010. A total of 33 FS award submissions for individuals or groups were considered resulting in the granting of 2 Good Show, 14 For Professionalism awards and 9 recommendations for Commanders Commendations.

Surveys. DFS conducted 4 FS surveys with contracted organizations: Cascade Aerospace Ltd in Abbotsford, AVEOS Fleet Performance in Montreal, IMP Aerospace Ltd in Halifax, and Standard Aero Ltd in Winnipeg. The flight safety staff at the division level (1 and 2 Cdn Air Div) conducted surveys of deployed Task Force air assets in Kandahar and Camp Mirage, 7 Air Wings, and the 3 CH149 Cormorant Sqns. A FS staff assistance visit (SAV) to CFB Edmonton and Camp Wainwright during air exercises was completed. With over 50 visits to Squadrons, Supporting Units, and Contracted service providers, the FS staff was able to provide the CoC with effective feedback on the stressors affecting each Squadron/Unit, along with specific recommendations for improving FS prevention programs with the aim of reducing risk and FS accidents or incidents.

Training. A total of 4 Basic Flight Safety Courses were conducted by 1 Cdn Air Div FS staff. They qualified 111 personnel, including 6 Air Cadet staff members, 9 civilian contracted service providers, 1 person from Nav Canada, 1 Army member and 4 firefighters. They also conducted 1 Advanced Flight Safety Course which qualified 19 personnel, including 1 Nav Canada member and 3 civilian contracted service providers.


Standard Deviation in Trend Analysis. The goal of this trending methodology is to highlight areas of concern based on expectations. When comparing 2010 with the previous 10 years, results are calculated as the difference of 2010 data from the 10-year mean expressed in standard deviation units (Deviation coefficient).

Randomness Algorithm. The randomness algorithm assesses the level of randomness in the frequency of occurrences. It is specifically applied for HFACS Cause Factors and System Descriptors. A low level of randomness suggests a possible pattern/problem and will require further analysis to detect the cause of the pattern / problem. Used in conjunction with the Deviation coefficient value described above, it provides a better indication of how significant and reliable the data value is.

Flying Hours and Reporting. The overall number of hours flown in the CF, for the Air Cadet Glider Program (ACGP), and Unmanned Aerial Vehicles (UAV) has increased by 9% compared to 2009. Personnel reported 3,138 occurrences, of which 57% were classified as Air occurrences. This represents a reduction in the rate of reporting per 10,000 hrs (210.69 compared to 239.10 in 2009) and could indicate a deteriorating reporting culture.

Occurrences Breakdown. The CF had a less than favourable FS record. Although major and minor injuries decreased, (3 serious, 38 minor), a total of 3 aircraft were lost (2 CF188 Hornet and a CH147 Chinook). The Air accident rate for the CF was 0.88. This was attributable to 3 category 'A' accidents (2 CF188 Hornets, 1 CH147 Chinook) and 8 category 'C' accidents (1 CT145 King Air, 3 CT114 Tutors, 2 involved in the same accident, 1 CC130 Hercules, 1 CC130J Hercules, 1 CF188 Hornet, 1 CH146 Griffon, and 1 CH147 Chinook). This is greater than the 10-year average rate of 0.54, and marks the third consecutive year above the mean. The statistics for the Air Cadet program continue to show a significant increase compared to 2008 (3.42 vs. 1.94) and the previous 5-year mean (1.68). On a positive note, the UAV accident rate was 0.0.

System Descriptors. This report compares the numbers of aircraft system descriptor occurrences in order to determine the top three systems on each aircraft type that could be of concern. The rates were analysed to determine the relative validity of the information. For fleets representing concern areas, data was compared with information presented by the AIA at the Airworthiness Review Board. The following are of note:

  • CC130. The CC130 Hercules is an aging fleet with 15 Open/Active RARMs. Propeller Low Oil Light indications will continue to be a concern with the legacy CC130 fleet. There are no other specific safety concerns at this time.
  • CT114. There was a small increase in the flight instruments descriptor from the previous year. Although minimal, it did highlight an area of concern. The 2009 occurrence 139410 concerning a failure of the pitot static anti-icing system listed the following PM "Recommend normal fault monitoring for trend development". There were two similar occurrences in 2010 (143094 and 143095). The PM for these occurrences state that "The trend during the summer airshow season is to not completely verify this system is operating given its minimal use during airshow performances". This would be indicativeof human factors rather than equipment failure.

Personnel Cause Factor - Human Factors Analysis and Classification System (HFACS). Following a review of HFACS routine/exceptional deviation entries conducted by DFS in conjunction with 1 Cdn Air Div FS staff, recommendations were made to better train our investigators. Additional syndicate work was done under the guidance of the DFS FIt Surgeon to identify ways to ensure quality control. The findings will be published when the work is completed.

Preventive Measures. Efforts made in the last few years to track PM have led to improvements in the staffing process in terms of time to implement and record management of measures taken or decisions made. The number of outstanding recommended PM was reduced to 31 for the 2001-2007 period which is a significant reduction from the previous report (43 for the 2000-2006 period in the 2009 annual report). The PM tracking process is helping the CoC deal with the proposed measures and hopefully prevent recurrence.

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