2015 Annual Report - Airworthiness Investigative Authority and Flight Safety Program Activities

Report / July 16, 2016 / Project number: RCAF-DFS-2015-annual


This is the 11th 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 2015 with a statistical comparison to the previous 10 years.

As this is my third year as DFS, I wish to highlight the continued dedication and professionalism demonstrated by all FS personnel across the country. The FS Team at Wing and Unit level continues to bring about positive changes to the FS Program.

Overall, the year 2015 was a good year. The CAF suffered nine air accidents, none being a Category ‘A’. There was one major injury with no fatalities; which is trending well below the 10-year mean. The Air Cadets had two air accidents, one very serious and one serious, and experienced one ground accident. That being said, we need to remain vigilant and not lower our guard in light of all of these results as in some cases we came perilously close to a major accident.

The number of reported occurrences has increased (3195) slightly since 2014. This number of investigations continues to apply pressure on our Flight Safety Officers striving to complete the investigations in a timely manner. Although Units and Wings have made some headway over the last two years to reduce the backlog, I have initiated action that will rectify the issue by end of September 2016.

The FS Information Management System (FSIMS) collaborative project with the Information Management Group continues on track for the new version release scheduled in June 2016. This new software will enhance data capture, quality assurance of information and provide more flexible search and report features down to the unit level.

Analysis of the occurrence rate distribution continues to indicate an upward trend in the maintenance related stage of operations (table 15). This negative trend is at our highest level of concern and will be subject to detailed examination in order to identify the contributing factors and propose remedial measures. The fleet concerns associated to DRMIS will be an integral part of the analysis due to the additional workload pressures associated.

The Director and CWO of Flight Safety visited all Wings and numerous civilian facilities this year. There were 62 annual briefings presented in both official languages reaching approximately 7400 personnel. The main theme of the DFS annual briefings was ‘cutting corners’ and human factors. The presentation centered on the importance of everyone’s role in flight safety but stressed that FS is a leadership responsibility. One particular field that all levels of leadership must understand is the management and control of operational pressures. The DFS message is that excessive pressure and the perception that the mission is "No Fail" often leads to failure to follow procedures.

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


This report provides a synopsis of the activities carried out in 2015 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.



Governance changes to the MND designation of the AIA and changes to the CDS Order to the AIA were accomplished as a result of the amendments to the Aeronautics Act (AA). Additionally, Orders in Council (regulations) must be developed and put in place to properly exercise the powers available to the AIA and delegated investigators.


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. DFS conducted four FS surveys at contracted service provider sites (L3 MAS in Mirabel, QC; IMP Halifax, NS; Magellan Aerospace Toronto, ON; Cascade Aerospace in Abbotsford, BC;) and the FS staff at 1 Canadian Air Division conducted four assistance visits (12 Wing Shearwater, NS, 3 CFFTS in Portage la Prairie, MB and 2 locations in Kuwait).


During the calendar year, the AIA initiated 3195 investigations. Of those, DFS initiated seven investigations: three Class I investigations for the CC150 Polaris flight control delamination, CT114 Tutor tire explosion, CP140 Aurora runway excursion, as well as four Class II investigations for the CH139 Jet Ranger hard landing, CH124 Sea King engine failure and separate tire explosion and the Air Cadets L19 Superdog engine power loss and SZ23 Schweizer landing in trees. DFS completed 12 investigations in 2015.


Although units and wings have made significant efforts towards reducing the number of overdue occurrence reports, the FS Program continues to be affected by overdue investigation reports. As of 01 April 2016, 484 occurrence reports remained incomplete from 2015 or earlier. DFS is actively seeking a solution to resolve this matter as it has a direct impact on our prevention program.

The Defence Resource Management Information System (DRMIS) was discussed during the spring 2015 Airworthiness Review Board (ARB) as an issue affecting many fleets. Analysis of occurrence data has indicated a number of procedural and interface issues that have been identified as cause factors or preventive measures associated to flight safety occurrences. This combined to the 5-year increasing trend in maintenance related stage of operations requires additional in-depth analysis. The number of overdue occurrence reports related to the ACGP and Powered Flight Programs is of concern. Most of these reports will be closed without further investigation due to the time since the occurrence, the availability of any witnesses and the reduced likelihood of any lessons.



The Director and the DFS Chief presented 62 annual briefings to different locations across Canada reaching more than 7400 personnel. The Directorate published three issues of Flight Comment magazine, five issues of the electronic FS newsletter Debriefing as well as five FS FLASH messages.


A total of 28 FS awards were handed out consisting of 9 Good Show awards and 19 For Professionalism awards. 39 FS coins were also handed out.


1 Cdn Air Div FS staff conducted six Flight Safety Courses (FSC) where 193 personnel were trained, including Air Cadets staff members, civilian contracted service providers, Army personnel, DND firefighters and two investigators from the Ukraine Armed Forces.


A draft of the A-GA-135-003/AG-001 Airworthiness Investigation Manual (AIM) was undertaken to reflect the changes to the AIA investigation processes, procedures and orders as a result of the recent AA amendments. This required a complete revision to the publication, which should be completed by summer 2016. Changes include updating the investigator training and certification requirements, 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 participated to various national and international forums intended to share FS information, exchange of ideas on the prevention of accident, and discussion on furtherance of safety awareness. The forums attended included the participation to the NATO Flight Safety Working Group (Bucharest, Romania), the Air Forces Flight Safety Committee (Europe) (Ljubljana, Slovenia), the International Society of Air Safety Investigator (ISASI) (Augsburg, Germany), and the CHC Safety & Quality Summit (Vancouver).

The provision of military assistance by Canada to Ukraine is done under the auspices of Op UNIFIER. In Feb 2015, as part of Op UNIFIER, a team of four FS personnel conducted a staff assistance visit of the FS organization and made recommendations to the Canadian Joint Operation Centre (CJOC). In the aftermath of that visit, Canada committed itself to train up to ten Ukraine Armed Forces personnel on the FSC in Winnipeg with English training provided beforehand as required. In the spring of 2015, four Ukraine Air Force officers attended English language training in St-Jean-sur-Richelieu and were scheduled to attend the FSC in 2016. Concurrently, in the fall of 2015, DFS has proposed to CJOC and the UAF an alternate plan to organize in Ukraine a customized FSC based on International Civil Aviation Organization Safety Management System standards. Planning is ongoing.



The overall flying hours indicate an increase (17.8%) from 125328 to 144519 compared to the previous year. This increase mainly affected helicopter, transport, fighter fleets with minor variations in the patrol and trainer fleets compared to the previous year.

Personnel reported 3195 occurrences divided almost equally between Air and Ground occurrences (50.2% and 49.8% respectively). This represents a very slight increase in the reported occurrences when compared to the previous year (3074) and remains slightly above the 10-year mean value of 3045.4. The occurrence-reporting rate decreased to 221 remaining above the 10-year mean of 220.8.


The CAF has experienced nine air accidents during 2015, none of them being a Category ‘A’. The breakdown of air accidents was one Category ‘B’ (CP140 Aurora) and eight Category ‘C’ (CT114 Tutor, CT155 Hawk, two CC130J Hercules, CF188 Hornet, CH139 Jet Ranger, CH146 Griffon, and CH149 Cormorant). The overall CAF Air Accident rate increased to 0.69 bringing it slightly above the 10-year mean of 0.62. The CAF had three ground accidents; one Category ‘B’ (CT114 Tutor) that suffered very serious damage when a main landing gear tire exploded due to over-inflation, and two Category ‘C’ (CH124 Sea King), one suffered serious damage due to main landing gear over-inflating and the other was discovered with cracked main gearbox transmission mounts. This amount represents a 50% increase from the previous year.

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 1.39 from last year. The Air Cadets had one Category ‘C’ (SZ23 Schweizer) Ground accident in 2015 when grass-cutting equipment came into contact with the parked aircraft.


The FS Information Management System (FSIMS) collaborative project with the Information Management Group continues on track for the new version release scheduled in June 2016. This new software will enhance occurrence and hazard data capture as many fields will validate the content for but not limited to: cell format, value against an upper and lower limit, according to the scale selected, or mandatory requirements to name a few. The application contains new search features and standardized reports available to all users. The desktop can be configured to display the user’s specific unit, or wing by selecting one of the pre-determined configurations or by selecting a user defined search query that can be named and saved as the users default view. Several structured reports produced periodically and distributed by DFS have been added to the application and they may be generated by any user at their choosing. The application contains the complete user manual as well as context sensitive help. The display language can be switched between English and French depending on the user’s language of choice. Migration of the existing historical FS database will ensure we continue to build on the lessons learned.

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