2013 Annual Report - Airworthiness Investigative Authority and Flight Safety Program's Activities

Report / August 18, 2014 / Project number: RCAF-DFS-2013-annual


This is the 9th annual report on Airworthiness and Flight Safety (FS) activities for Department of National Defence/Canadian Armed Forces (DND/CAF) and the Air Cadets. The report was formerly published as the ‘Flight Safety Annual Report’. The report provides a synopsis of the investigations and activities carried out by theAirworthiness Investigation Authority (AIA) and the activities overseen by the Director of Flight Safety (DFS) in relation to the FS Program for 2013 with a statistical comparisonto the previous 10 years.

At first, I would like to highlight the professionalism and dedication demonstrated by all FS personnel across the country. The Wing and Unit Flight Safety Officers and their team of dedicated professionals used their privileged positions to influence positive changes from the floor and up as well as to provide counsel to the leadership. Their constant involvement and initiatives contributed directly to the good health and promotion of the FS Program.

The year 2013 was a very good one for the CAF and the Air Cadets. The number of hours flown by the CAF has increased by 2.9% to 137,799 hours. The CAF suffered five air accidents, none being a category ‘A’; the air accident rate thus decreased to 0.4, which is well below the 10-year mean of 0.6. The CAF had four ground accidents; this number represents a 62% reduction from the previous year and is in line with the 10-year mean value. The number of major injuries totaled five, all serious. This is in line with the 10-year mean value. The Air Cadets had one very serious air accident, the rate being 0.7 which is the lowest seen in eight years, and one serious ground accident.

The number of reported occurrences (3095) created a vast amount of work for our Flight Safety Officers striving to complete the investigations in a timely manner. Overdue investigation reports (327) equate to 10.5% of the reports produced in 2013, an improvement of 5% over 2012. We shall continue to improve on those statistics, ideally to less than 5%. Overdue occurrence reports hinder the implementation of effective and timely Preventive Measures (PM). The flight safety staff must remain focused on core activities of investigating occurrences, recommending preventive measures and monitoring their implementation and effectiveness. Priority must be given to the accurate and timely capture of lessons learned and their prompt publishing in order to prevent accidental loss of personnel and critical resources. The decrease of experience levels and personnel shortages throughout the RCAF continues to affect both our operations in the air and on the ground.

The FS Program was enhanced in 2013 by the introduction of the revised Human Factors Analysis and Classification System (HFACS) model used to classify FS Personnel cause factors. This updated taxonomy helped in improving usability and standardizing data entry and analysis for Personnel cause factors. The FS Information Management System (FSIMS) collaborative project with the Information Management Group continues. This new version to be released in September 2015 will upgrade the capabilities of our dated FS Occurrence Management System (FSOMS) and provide a next-generation web-based statistical repository and analysis tool.

Amongst many key FS issues included in the 2013 DFS annual briefing, supervision and experience of personnel were first and foremost. For aircrew, the absorption of newly winged pilots and the ability of all pilots to maintain currencies were a cause for concern, more so with the planned YFR cuts projected to affect several fleets in 2014. The issue centered on qualifications versus currencies and the many pressures from the chain of command to preserve a high level of readiness throughout the RCAF. The challenge of the Wing Commanders and Commanding Officers is to find the right balance of force readiness, force generation, force employment that fit the current fiscal envelop while maintaining an acceptable level of safety.

For maintenance personnel, the ongoing restructure of the air maintenance trades caused gaps in experience that can only be mitigated by increased supervision. However, with the rapid movement through the ranks due to high technician attrition rates, the supervisory experience level continues to decrease and, as such, is increasing risk. Supervisors at all levels must remain vigilant to identify hazards early and to mitigate risk.

An additional point of the DFS annual briefing was to make personnel aware of their personal limitations, understanding that they need also to match their confidence level with their experience. This highlighted the need to carry out their duties in a manner and at a pace that they feel was safe.

Finally, key FS issues were reported back to the Commander RCAF for awareness and action as necessary.

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

Steve Charpentier
Director of Flight Safety


This report provides a synopsis of the activities carried out in 2013 by the AIA and DFS in relation to the FS Program of the CAF. It covers statistical data for the Air cadets Glider Program. 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.



During the calendar year, the AIA initiated 3095 investigations. Of those, DFS initiated five accident investigations: one Class I investigation for the CH124 Sea King dynamic rollover and four Class II investigations for the CH149 Cormorant engine failure, the CC150 Polaris technician injury, the Air Cadet SZ23 glider off-field landing and the CH149 Cormorant SAR Tech fall from the hoist harness. DFS completed seven investigations in 2013. A further three investigations were completed as of 1 April 2014.


The Bill Safeguarding Canada’s Seas and Skies Act (C-57), was re-introduced in Parliament in September 2013 under C-3. This bill includes the same amendments to the Aeronautics Act (AA) as were present in C-57. Once Bill C-3 is voted, the MND through the AIA will be able to carry out his statutory AA requirements to investigate all matters of military aviation safety by providing him the ability to fully investigate occurrences involving civilians. Bill C-3 also includes amendments to four other acts not related to DND/CAF operations but concerning primarily the responsibilities of the Minister of Transport.


The FS surveys are part of a continuous improvement effort and provide a platform from which the safety culture at each organization can be sampled regularly. DFS conducted three FS surveys at contracted service provider sites (Cascade Aerospace inAbbotsford, BC; Standard Aero in Winnipeg, MB; L3 MAS in Mirabel, QC) and the FS staff at the Division conducted six surveys of 4, 5, 8, 15, 17, and 19 Wing. The chain ofcommand (CoC) was debriefed on salient points.


The implementation policy for CVR/FDR as identified in the 2009 Airworthiness Advisory Board (AAB) remains focused at tackling one fleet per year for the next 10 years. Alternate Means of Compliance systems have been installed on three of four Contracted Flying Training and Support (CFTS) fleets (CT145 King Air, CT102 Grob, and CH139 Jet Ranger). Remaining legacy fleets found deficient with respect to CVR/FDR policy are expected to be upgraded with estimated life expectancy (ELE) extension funding if such plans are pursued. DFS continues to monitor the situation.



DFS presented 44 annual briefings across Canada. The briefings reached approximately 5200 personnel. The Directorate published four issues of Flight Comment magazine, four issues of the electronic FS newsletter Debriefing as well as two FS FLASH messages. DFS is in the process of enhancing its means of distribution by expanding the Flight Comment onto a digital medium.


A total of 32 FS awards were handed out consisting of five Good Show, 17 For Professionalism awards and 10 Commanders Commendations.


1 Cdn Air Div FS staff conducted five Flight Safety Courses (FSC). 150 personnel were qualified including Air Cadet personnel, civilian contracted service providers, Army members, DND firefighters as well as two investigators from the Brazilian Aircraft Accident Investigation and Prevention Center. A survey was administered to course members having graduated at least one year ago and 68 personnel responded. The results provided interesting observations, which will be looked into for possible amendment(s) to the Quality Standard or adjustment(s) to the course training plan.


Work has been on-going to amend A-GA-135-003/AG-001 Airworthiness Investigation Manual (AIM) for a new edition to be released in 2014. This amendment will update the AIA’s policies and reflect changes made to training of FS officers and investigators. Pending successful completion of the AA amendments, appropriate changes to the AIM will be promulgated and become part of the AIA's governance.

An amendment of the A-GA-135-001/AA-001 Flight Safety for the Canadian Forces (Mod #7) was released on 01 November 2013. The majority of these changes were clerical in nature and the revised Human Factors Analysis and Classification System (HFACS) v3.0 model was promulgated. The model introduces new taxonomy designed to provide investigators consistency when assigning cause factors for similar circumstances.


The AIA continued to work closely with the following organizations: Aerospace Engineering Test Establishment (AETE), Quality Engineering Test Establishment(QETE), National Research Council (NRC), Defence Research and Development Canada (Toronto) DRDC(T), and Transportation Safety Board of Canada (TSB).

After the crash of a Canadian Coast Guard (CCG) helicopter, DFS was provided insight into the CCG's aircraft recovery, salvage and post-accident activities. Follow-on discussions with CCG led to DFS staff participation in CCG risk assessment activities concerning over water operations and aircrew life support equipment policies.

DFS participated to bilateral engagement with the Brazilian Air Force (BAF) in that two BAF students from the Brazilian Aircraft Accident Investigation and Prevention Center, CENIPA, attended the CAF FS course. Additional exchanges and training between DFS and CENIPA have been planned for 2014 and 2015.

AIA staff attended various forums intended to share FS information and exchange ideas on the prevention of accident and furtherance of safety awareness. The forums attended included the NATO FS Working Group and the Air Forces Flight Safety Committee (Europe), International Society of Air Safety Investigators, and Canadian Aviation Safety Officer Partnership.

The sharing of FS hazards and investigation resources was discussed at the System of Cooperation Among the American Air Forces (SICOFAA) Conference of the American Air Chiefs (CONJEFAMER) in Ottawa. A proposal was approved which recommended that shared lists of fleet and investigator contacts be kept to facilitate national and international accident investigations. The contact information will eventually be posted at the SICOFAA site at http://sicofaa.org/. A manual of accident investigation can befound on the site at http://sicofaa.org/files/archivos/documentos_normativos/manual_de_investigacion_de_accidentes_(SAR).pdf, and has been translated into English as a reference.


FLYING HOURS AND REPORTING In 2013, the number of hours flown in the CAF has increased by 2.94% to 137,799 hours. This was mainly due to an increase in flying hours for the helicopters CH146 Griffon and CH139 Jet Ranger, the trainer aircraft CT156 Harvard II as well as thetransport aircraft CC130J Hercules.

Personnel reported 3095 occurrences divided almost equally between Air and Ground occurrences (51.7% and 48.3% respectively). This represents a small decrease in the reporting rate in comparison to the previous year but remains above the 10-year mean of 213.8.


The CAF had a good FS record for 2013 with five air accidents, none being a category ‘A’. This was attributable to one category ‘B’ (CH124 Sea King), three category ‘C’ (CC130 Hercules), and one category 'C' (CT156 Harvard II). The air accident rate decreased to 0.4, which is well below the 10-year mean of 0.6. The CAF had four ground accidents; this number represents a 50% reduction from the previous year and is in line with the 10-year mean. The number of major injuries was limited to five, all serious, and is in line with the 10-year mean value.

Similarly, the Air Cadets had only one very serious Air accident involving a SZ23 Schweizer glider and one serious ground accident. Interestingly, the Air Cadet accident rate has gone down to a level not seen since 2004 (0.7) and is well below the 10-year mean of 2.3.


An important part of the DFS prevention activities surrounds the data analysis and comparison to previous years. Overdue occurrence reports have in the past had a detrimental effect on DFS’ ability to analyze and trend cause factors. Further, overdue reports delay the timely staffing and implementation of PMs, the keystone of an effective prevention program. In 2012, the FS Program reported that 16.1% of occurrence reports were overdue (509 of 3149). DFS appealed to Unit and Wing FSO for more diligence in the completion of their FS reports and the situation has improved. As of 27 May 2014, 10.5% of the 2013 occurrence reports were overdue (327 of 3095). There are still 141 overdue reports related to occurrences that took place prior to 2013. DFS will continue to monitor the situation.

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