A-GA-135-001/AA-001 Chapter 1 Program Description

Manual / October 31, 2013

Change #7 -  November 1, 2013

References: A. 1016-17 (DFS), Service Level Agreement between DFS and DAER, 11 October 2013B.
B-GA-297-001/TS-000 Safety Orders for CF Air Weapons Systems
C. D-09-002-011/SG-000 Standard, Assessment of Ammunition Containers, Packages, and Palletized Unit Loads


1.  The Flight Safety (FS) Program is a force multiplier for the Canadian Forces (CF). FS contributes to mission accomplishment in the DND / CF through the elimination of the accidental loss of aviation resources.

2.  Orders and standards for operational and support personnel are, for the most part, developed out of concern for the safety of people and equipment. These standards represent levels of risk which are considered acceptable and practical for the full spectrum of DND / CF activities from peacetime training to wartime operations. It is understood that Commanders (Comds) in high intensity wartime action are likely to accept higher levels of risk than those considered acceptable in peacetime force generation activities. Risk management in the planning and execution of the DND / CF mission is fundamental to safe operations.


3.  The Chief of the Air Force Staff (C Air Force) and the Royal Canadian Air Force (RCAF) has been designated as the Airworthiness Authority (AA) for DND / CF. C Air Force retains as a residual responsibility the oversight of the FS Program across the full spectrum of DND / CF operations, at home or abroad. Therefore, the FS Program is applicable to:

a. all DND / CF units conducting flying operations or supporting flying operations;

b. any contracted organizations conducting or supporting flying operations, be it for maintenance support, logistics support or any other support role; and

c. independent airworthiness investigation activities as detailed in the A-GA-135-003/AG-001 Airworthiness Investigation Manual (AIM) and authorized by the AIA.

4.  The Director Flight Safety (DFS), as the Airworthiness Investigation Authority (AIA), monitors matters concerning aviation safety of all foreign military aircraft operating in Canada.


Flight Safety (FS)

5.  FS is a desired condition achieved by individuals and organizations through the systematic process of identifying and forecasting air operations risks and developing a proactive attitude for safe procedures, services, facilities and associated programs to minimize risks to air operations.

FS Program

6.  The FS Program is a program of safe behaviour, education, independent airworthiness investigation, promotion and analysis of matters concerning aviation safety. It is directed at military and civilian personnel involved in CF aviation and its contracted support elements.

The FS Program is responsible for the Air Weapons Safety Program as described at para 24.

FS Occurrence

7.  Any event that involved the operation of a CF and / or a military conveyance aircraft or activities in support to flying operations where safety of flight was compromised. To constitute an occurrence, the event may not necessarily have caused injuries to personnel or damage to materiel or property but had the potential to do so.

FS Unit

8.  A FS Unit is any unit / formation within the CF or contracted by the CF that is conducting flying or aircraft maintenance activities, or is coordinating closely or remotely flying or maintenance activities.

A FS Unit includes RCAF HQs, wings, squadrons and units, HMCS Ships with an MH HELAIRDET or UAS DET embarked, land forces garrisons that support flying operations, contracted flying training es-tablishments, National Defence Quality Assurance Regions’ (NDQAR) and work centres at all contractor facilities where CF aircraft are manu-factured, overhauled, inspected or repaired. For the FS unit, it implies that the Comd / executive manager and its supervisor will ensure proper oversight of flying operations within their area of responsibilities.

Safety of Flight (SoF)

9.  SoF is a desired mode of operation whereby the preparation of and conduct of a flight is done by following best possible maintenance and operational practices as well as approved procedures. Doing so will minimize, to the maximum extent possible, risks associated with flight operations.

FS Hazard

10.  An existing condition whereby there is possibility of adverse effect on health, property or SoF.

FS Risk

11.  A FS risk is the quantification or measurement of a FS hazard according to the quantitative probability and the qualitative severity of the hazard.

Military Conveyance Aircraft

12.  A military conveyance aircraft is any aircraft, including civilian registered aircraft, that is operated by or on behalf of the DND, the CF, or a visiting force.

Operating Unit

13.  This term refers to the unit under whose authority a flight has been authorized in accordance with B-GA-100-001/AA-000, National Defence Flying Orders.

Air Weapons Capable Wing / Unit

14.  A wing / unit which uses ammunition, explosives and / or pyrotechnics in support of its role.

Air Weapons System

15.  A system containing armament computers, mechanical, electromechanical and electronic components, that is part of an aircraft’s permanent equipment or installed as a mission kit and is used to suspend, launch, release or fire ammunition / explosives and / or pyrotechnics in support of the mission being flown.

Air Weapons

16.  Air Weapons are any ammunition, explosives and / or pyrotechnics suspended, launched, released or fired from an aircraft; it includes any aircraft store, as described in para 8 below, that interfaces with the Air Weapons System including bombs, missiles, torpedoes, flares, pyrotechnics, survival kit air droppable (SKAD) (excluding the SKAD dropped as cargo), chaff and flares, releasable external fuel tanks from the time the load starts to the time it is unloaded from the aircraft, sonobuoys, airborne targets and banners, etc. This shall apply to both live and training weapons.

Aircraft Store

17.  An aircraft store is any device carried internally or externally and mounted on aircraft suspension and release equipment, whether or not the item is intended to be separated in flight from the aircraft. Aircraft stores are classified in two categories as follow:

a. Expendable store. Expendable store is an aircraft store normally separated from the aircraft in flight such as a missile, rocket, bomb, mine, torpedo, pyrotechnic device, sonobuoy, signal underwater sound device, survival kit (SKAD) or other similar item; and

b. Non-expendable store. Non-expendable store is an aircraft store that is not normally separated from the aircraft in flight such as a tank (fuel or spray), pod (refuelling, thrust augmentation, gun, electronic countermeasures, target designator, etc), multiple racks, target, cargo drop container, luggage / equipment carrier, drone or other similar item.

Aircraft fire detection and extinguishing systems, ejection and escape explosive charges, shielded mild detonating cord (SMDC) lines and aircraft hoisting systems are not considered Air Weapons. Although they all contain explosives, they do not interface with the armament system and are not considered Air Weapons; therefore, no armament implications.


18.  A chemical mixture of oxidizing and reducing agent capable of reacting exothermically. Such mixtures are used to produce light, heat, smoke or gas and may also be used to introduce delays into explosive trains.

Ammunition Container

19. A container specifically designed to facilitate the carriage of a specific class of ammunition required by one or more means of transport without intermediate reloading (ref C).

Ready-use Magazine

20. A building or fenced area used for storage of assembled and fuzed ammunition held ready for use (ref B). It used to be called ready-use facility.

Unit Ammunition and Explosive (A&E) Lock-up

21. A licensed storage for a limited quantity of small arms ammunition, pyrotechnics or other explosives required for a specific operational or training use (reference B). It used to be called ready-use lock-up.

Aim of FS Program

22.  The aim of the FS Program is to prevent accidental loss of aviation resources while accomplishing the mission at an acceptable level of risk.

Scope of FS Program

23.  The CF shall conduct flying operations in accordance with this publication. A FS Program consistent with the roles and missions of the DND / CF shall be established at each level of command where flying operations are supervised or supported. Personnel at every level are required to participate in and support the program. The FS Program is a program of safe behaviour, education, independent airworthiness investigation, promotion and analysis of matters concerning aviation safety. It is directed at military and civilian personnel involved in CF aviation and its contracted support elements. Since understanding why safety occurrences happen is the key to an effective accident prevention program, accidents and incidents representing a risk to aviation, or which could lead to the implementation of preventive measures (PMs), should be investigated.

Air Weapons Safety

24. Every unit with an air weapon capability shall ensure that their FS Program encompasses a vibrant Air Weapons Safety Program. Ref B publication remains the primary reference for air weapons related issues. As per reference A, DFS has accepted the oversight of air weapon safety occurrences as part of the FS Program in that it will capture through the Flight Safety Occurrence Management System (FSOMS) every weapon safety related occurrence involving operational air weapon activity from the moment that an air weapon is removed from a ready-use magazine or a unit A&E lock-up for operational use until its safe separation from the aircraft or return into either a ready-use magazine or a unit A&E lock-up.

25. Chapter 7 para 41 and 42 detail what weapon occurrences are FS related and reportable in FSOMS and explain how the other types of weapon safety occurrences with no safety implication shall be reported.

Airworthiness Program

26.  The aim of the DND / CF Airworthiness Program is to establish and maintain an acceptable level of aviation safety. This compares favourably with the FS Program stated goal of preventing the accidental loss of aviation resources. While not integral to the FS Program, the Airworthiness Program is intended to provide a framework for the regulation of military aviation. In fact, the two programs collaborate on many fronts and share best practices for enhancing SoF. One of the primary objectives of the Airworthiness Program is to establish and maintain an acceptable level of safety for military aviation. When the roles of DFS and the AIA and the associated investigation aspects of these programs were compared, the close match allowed the overlap of the investigation responsibilities to become a single CF / DND activity.

Fundamental Principles

27.  The FS Program is based on the following five fundamental principles:

a. the main principle is the prevention of occurrences. Although cause factors are assigned to occurrences, this is only done to assist in the development of effective PMs;

b. personnel involved in conducting and supporting flying operations are expected to freely and openly report all FS occurrences and FS concerns;

c. in order to determine the cause of occurrences such that appropriate, effective PMs can be developed and implemented, personnel involved in conducting and supporting flying operations are expected to voluntarily acknowledge their own errors and omissions;

d. in order to facilitate free and open reporting and voluntary acknowledgement of errors and omissions, the FS Program does not assign blame. Personnel involved in a FS occurrence are de-identified in the final report and the report itself cannot be used for legal, administrative, disciplinary or other proceedings; and

e. the whole FS Program is based on the primacy of having a “just culture.” A “just culture” lies between a non-punitive culture and one of sanction and punishment. Free and open sharing of critical safety information between managers and operational personnel, without the threat of punitive action, represents the basis of a reporting culture. Personnel are able to report occurrences, hazards or safety concerns as they become aware of them, without fear of sanction or embarrassment. However, while a non-punitive environment is fundamental for a good reporting culture, the workforce must know and agree on what is acceptable and what is unacceptable behaviour. Negligence or wilful, deliberate deviations must not be tolerated by leadership. A ‘‘just culture’’ recognizes that, in certain circumstances, there may be a need for punitive action and defines the line between acceptable and unacceptable actions or activities.

Responsibility for FS Program

Overall Responsibility

28.  A large portion of the FS Program is based on the continuous monitoring of hazards, appropriate and independent investigation of aviation safety occurrences and thorough analysis of investigation findings so that the risk of recurrence can be reduced. The complete program involves pre-occurrence activities like education and promotion for the safe behaviour activity, risk management techniques designed to reduce the chances of an occurrence, post-occurrence activities including occurrence response procedures, investigations, occurrence analysis, formulation of PMs and feedback. Early involvement in capital acquisitions is essential to ensure FS issues are adequately considered.

29.  C Air Force is responsible for FS policy in DND / CF. FS policy is implemented by the chain of command at wings, bases and units. This policy also applies to NDQAR contracted facilities where CF aircraft are being manufactured, overhauled, inspected or repaired. Supervisors at all levels are responsible for establishing their own FS Programs.

Individual Responsibilities

30.  The success of the FS Program is reliant upon a commitment to it by all personnel associated with DND / CF flying operations. This commitment can only materialize if all personnel believe in the value of the program and understand that they have a responsibility to actively participate. In order to facilitate this, the individual shall be able to report any flight activity concerns and occurrences or propose better ways of doing business without fear of retribution.

31.  Personnel are responsible for:

a. immediately ceasing unsafe activities under one’s direct control;

b. notifying their supervisor and the FSO of the unsafe activity; and

c. formally identifying and reporting hazards.

It is the responsibility of each individual to cease unsafe activities, regardless of rank or position in the organization.

Unit Responsibilities

32.  The FS Program is designed to ensure that DND / CF flying activities remain safe while remaining operationally focused. The scope of the FS Program shall be such that individuals belonging to an organization conducting or supporting air operations will have a structured FS Program in place. Every unit conducting or supporting air operations shall have a flight safety program.

Management Responsibilities

33.  Management responsibilities are as follow:

a. immediately ceasing activities that are deemed unsafe or where an unacceptable risk exists;

b. notifying higher authorities of unacceptable risks and the actions taken to mitigate them or of the need to seek additional resources to mitigate them;

c. reviewing and accepting / rejecting the risk as per the authority delegated from the Airworthiness Authority (AA), the Operational Airworthiness Authority (OAA) and the Technical Airworthiness Authority (TAA);

d. establishing the unit’s risk control strategy;

e. measuring and reporting on the effectiveness of risk management activities within the unit; and

f. promoting risk management activities at the unit and formation level.

FSO Responsibilities

34.  The FSO is responsible for:

a. consulting and being aware of the unit’s risk assessment criteria;

b. immediately notifying the CO of any unsafe activities and unacceptable risks. In these cases the FSO must seek an order from an appropriate authority to cease the activity until the problem can be assessed and either resolved or mitigated to an acceptable level; and

c. carrying out independent airworthiness investigation activities as detailed in the AIM and authorized by the AIA.



35.  Within the Airworthiness Program, DFS is named as the AIA and charged with independently investigating all matters concerning aviation safety. Details of the powers delegated from the MND, using powers within the Aeronautics Act, to the AIA and then onward to all airworthiness investigations are laid out in the AIM. Of note, all activities carried out for flight safety airworthiness investigations are carried out on behalf of the AIA / DFS. The FS Program integrates the investigation portion of the CF/DND Airworthiness Program within its activities which are detailed in Chapters 7-11 of this manual and with the occurrence investigation techniques outlined in the A-GA-135-002/AA-001 Occurrence Investigation Techniques for the Canadian Forces.

36.  The Airworthiness Program contributes to aviation safety by influencing areas related to aeronautical products and their operation. The DND / CF Airworthiness Program is mandated by the Minister of National Defence (MND) as detailed in DAOD 2015-0 and DAOD 2015-1 and amplified in A-GA-005-000/AG-001 DND / CF Airworthiness Program. The elements of an effective airworthiness program consist of a full range of aviation activities including design, manufacture, maintenance, materiel support, facilities, personnel and operations.

Airworthiness Program Authorities

Airworthiness Authority

37.  The AA is responsible for the development, promotion, supervision and management of an Airworthiness Program for the DND / CF. This includes the appointment of competent individuals to fill the positions of OAA and AIA as described below, and in consultation with the Assistant Deputy Minister (Materiel) (ADM (Mat)), the appointment of a competent individual as Technical Airworthiness Authority. C Air Force is the AA for DND / CF. Of note, the AA is charged with ensuring the AIA is not impeded in any way in its’ investigation of matters concerning aviation safety.

Technical Airworthiness Authority

38.  The TAA is responsible for the regulation of the technical airworthiness aspects of the design, manufacture, maintenance and materiel support of aeronautical products and the determination of the airworthiness acceptability of those products prior to operational service. The Director General of Aerospace Equipment and Program Management (DGAEPM) is the TAA for DND / CF.

Operational Airworthiness Authority

39.  The OAA is responsible for the regulation of all flying operations. This includes responsibility for operational procedures; flight standards; operator training, qualification and licensing; aerospace control operations; and operational airworthiness clearance of aeronautical products prior to operational service. The Comd of 1 Canadian Air Division (Comd 1 Cdn Air Div) is the OAA for DND / CF.

Airworthiness Investigative Authority

40.  The AIA is responsible for regulating the airworthiness investigation aspects of the FS Program. The AIA is responsible for investigations. The AIA is also responsible for monitoring the Technical and Operational Airworthiness Programs to identify deficiencies. DFS is the AIA for DND / CF. Of note, the AA is charged with ensuring the AIA is not impeded in any way in the investigation of matters concerning aviation safety.

Airworthiness Program Principles

41.  The DND / CF Airworthiness Program is based on the fundamental principles that airworthiness-related activities are:

a. completed to accepted standards;

b. performed by authorized individuals;

c. accomplished within accredited organizations; and

d. performed using approved procedures.

Airworthiness Program Roles

42.  A regulatory approach is the most common method employed to implement the concepts and principles of any airworthiness program. A regulatory approach means to control by rule and involves using regulations, orders, directives and standards to control airworthiness-related activities. A regulatory approach for controlling airworthiness activities has the following three distinct roles:

a. Regulator. The regulator develops the airworthiness instrument (rules and standards) for the engineering, manufacture, maintenance, materiel support and operation of aeronautical products and ensures compliance (e.g. Transport Canada for civil aviation);

b. Implementer. The implementer conducts the aviation activities associated with the engineering, manufacture, maintenance, materiel support and operation of aeronautical products (e.g. airlines, manufacturers and maintenance organizations for civil aviation); and

c. Investigator. The investigator investigates airworthiness-related safety occurrences and aviation safety issues. The investigator is normally independent from the regulator and implementer. The investigator is also empowered to investigate the role that the regulator and implementer may have had in any aviation occurrence (e.g. Transportation Safety Board (TSB) for civil aviation). DFS is the designated AIA for this program and fulfils the investigator role as described.

43.  Unlike civil aviation, where the airworthiness regulator, implementer and investigator are totally independent, the Aeronautics Act has assigned DND a self-regulating and self-investigating responsibility for airworthiness.

Risk Management

44.  The Airworthiness Risk Management (ARM) process ensures that conflicts between aviation safety, mission accomplishment and resource expenditures are balanced. As promulgated in A-GA-005-000/AG-001 DND / CF Airworthiness Program overall responsibility for managing risks rests with COs, DND / CF managers at all levels, and designated contractor representatives. The identification / recognition of hazards is a responsibility shared by all DND / CF personnel or supporting personnel.

45.  Due to the inherent dangers associated with operating military aircraft, a certain acceptance of risk to safety is often required. The decision to accept risk must be controlled, balanced and approved at the appropriate level. The ARM process provides a logical and systematic means of identifying and controlling safety risks in the decision-making process.

46.  Aviation safety-related risk is a primary concern of the Airworthiness Program and the FS Program. Other forms of risk, such as operational, financial and legal, may also be factors in any decision-making process and may at times conflict with aviation safety goals. The ARM process provides a means to assess and proactively balance airworthiness risk against both mission accomplishment and available financial resources. All personnel associated with aviation, from the pilot-in-command (PIC) of an aircraft to the technician troubleshooting an unserviceability on the hangar floor, will be required to make a decision, at some point, involving some degree of airworthiness risk assessment. Adoption of a standardized ARM methodology enhances the quality of these decisions.

FS Strategic Processes

47.  A strategic level conceptual model of FS-related processes for the FS Program is provided at Annex A. It describes in a comprehensive manner all the FS processes irrespective of the organizations responsible to execute them. Many organizations or activities contribute directly or indirectly to the processes described in the model’s three management pillars in the form of Resilience Management, Risk Management and FS Program Management. DFS is the champion of the FS Program for the DND / CF, and maintains close liaison with the organizations carrying out the strategic FS processes. DFS, as the AIA, is responsible to the Minister of National Defence (MND) for FS investigations.

48.  Resilience and Risk Management represent the pillars to which most of the critical FS processes and activities gravitate. Resilience Management is considered a proactive form of accident prevention because it reduces the potential or severity of threats to air operations. Risk Management on the other hand is more reactive in that the associated activities are in response to newly identified hazards.



1. The strategic FS model provides a high level framework and describes the processes involved in the flight safety program. Accident prevention processes can be derived by inverting Reason’s Swiss Cheese model of Accident Causation. Accidents occur because weaknesses or "windows of opportunity" open and align in all levels of the operation, allowing a chain of events to cause an accident. Accidents can be prevented by adding layers of defences through resilience management and patching holes in these defences through risk/hazard management.


2.  Appendix 1 to this annex is a graphical depiction of the FS business processes. They are regrouped as follows:

a. Resilience Management. Resilience management is the process of making the equipment, procedures and personnel resilient to accident-causing conditions, and thus protect operations from unknown hazards.

(1) Equipment Resilience Activities. CF airworthiness organizations employ tools and methods to ensure aircraft and related equipment are acceptable for the operations and flying environment. FS data is provided to improve Design, Modification, and Maintenance airworthiness on current and new aircraft so that the flying operations can better withstand unknown hazards.

(2) Procedures Resilience Activities. CF flying procedures are monitored to ensure that air operations are being conducted in a safe manner. FS surveys are conducted, rules and regulations are reviewed, and periodic inspections are performed in order to continually improve all associated procedures.

(3) Personnel Resilience Activities. Personnel are trained to be capable of dealing with known and unknown threats to flight safety. Occurrences, hazards, trends, and many other forms of flight safety data are disseminated to all personnel involved with the support or conduct of air operations so they can better understand the situations and circumstances that can compromise flight safety. This is supported by a comprehensive awards program to encourage safe behaviour throughout the organization.

b. Program Management. The FS Program provides the administrative framework for the Resilience and Risk Management processes. Program Management includes development of the FS Program, policies and procedures, relevant training and education, and activities that provide feedback to the chain of command. Program Management does not directly prevent accidents, but supports Resilience and Risk Management in doing so.

c. Risk Management. Risk management is the systematic process of identifying risks, assessing their implications, deciding on a course of action, and evaluating the results. Known risks are those that have been identified and analyzed. Unknown risks, by their nature, cannot be managed, and thus are addressed through resilience management.

(1) Identify Hazards. The principle means of identifying hazards is through occurrence investigation, hazard reporting, and trend analysis. A comprehensive reporting system is required to track hazards from initial identification until resolution of any preventive measures.

(2) Investigate Hazards. Based on the preliminary information captured when the hazard or occurrence was reported, the nature of the hazard and its severity will be used to determine the level of the investigation and resources that should be employed.

(3) Analyze Risk. All available information is systematically reviewed to determine how often specified events may occur and the magnitude of their consequences. Commanders at all levels review investigations within their sphere of responsibility, the associated proposed PM, then make documented decisions on how they will address the hazards.

(4) Mitigate Risk. Hazards, whenever possible, are corrected by implementing one or more FS PM. It is critical that the various stages and levels of implementation be tracked and monitored to ensure complete staffing, either full implementation, partial implementation or no implementation (refusal). The latter two options must be endorsed at the proper level in the chain of command and supported by an appropriate record of Airworthiness Risk Management.


3. Appendix 2 describes the interrelationship between the individuals involved in FS and the FS information flow. It represents the major types of information used for flight safety management (Hazards, Risk, PM, etc.) and the relationships that the entities have with each other as the data / information flows through the FS system.

4. The information model descriptors are:

a. Persons Involved in Air Operations. These personnel include aircrew, groundcrew, maintainers, air traffic personnel, contractors, as well as any other Air Force, Navy, or Army personnel involved with flying operations. They are responsible for identifying and reporting any hazard to flight safety that they find.

b. FS Staff. FS Staff include Unit Flight Safety Officers (UFSOs), Wing Flight Safety Officers (WFSOs), Division Flight Safety Officers (Div FSOs), DFS Flight Safety Officers, and deputies at all levels. They are responsible for validating and investigating reported hazards, for analyzing the hazard risk potential and for proposing possible PM. FSOs and their assistants (FS Non-Commissioned Members, FSO Specialist (Weapons) (FSOS (W), etc.) operate within a FS functional chain of command. As advisors to their respective supervisors, all tiers of FS (deployments, unit, wing, air div, contracted unit and DFS ) work in a cooperative and functional Chain of Command IAW direction set in this publication.

c. Chain of Command. Chain of command include unit commanding officers, wing commanders, division commander, and supervisors at all levels. These persons are responsible for evaluating the hazards within their organizations, and either formally accepting the risk, or mitigating the risk by implementing PM. By extension, the senior management of contracted organizations have an equivalent chain of command.

d. Action Agencies. Once the Chain of Command has confirmed the risks associated with certain hazards, they will task Action Agencies to complete PM. These Action Agencies will notify FS Staff when their assigned PM have been completed, as well as provide status reports along the way.


5. The FS Program achieves the aim of preventing accidental loss of aviation resources while accomplishing the mission at an acceptable level of risk. This is done by managing the risks associated with air operations, and by making the organization resilient to unknown hazards. Some of the FS processes in the FS business model are the direct responsibility of the Airworthiness Investigative Authority while others are the responsibility of organizations and personnel directly and indirectly supporting air operations.

6. The FS Occurrence Management System (FSOMS) supports the FS Program by recording all factual data related to FS occurrences and hazards. It details investigation results including assigned cause factors, recommended PM and disposition of these PM. The collection of data and its systematic analysis helps in the prevention of accidents and the control of risk in a manner that is measurable.



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