CT114006 and CT114081 Tutor - Epilogue - Flight Safety Investigation Report
Report / June 21, 2001 / Project number: CT114006-CT114081 - A Category
Location: 35 NM South of London, Ontario
Status: Investigation Complete
The Flight Safety Investigation Report (FSIR) is available from DFS.
431 Air Demonstration (AD) Squadron was conducting a nine-plane media flight at London, Ontario on 21 June, 2001. At the time of the accident, aircraft #1 was leading aircraft #5 to rejoin on the remaining seven aircraft in formation. The two aircraft collided when approximately 300 feet behind the main formation while conducting the rejoin. Control of aircraft #1 was lost and the two occupants ejected successfully. The pilot sustained minor injuries and the passenger sustained more serious (defined as major) injuries. Control of aircraft #5 was maintained and it was flown back to London airport without further incident.
The collision between aircraft #1 and aircraft #5 occurred when pilot #5 purposely switched his primary focus to the main formation earlier than pilot #1 anticipated due to the interpretation of the non-standard rejoin directive given by pilot #1.
To address the main cause of this accident the following safety measures were taken: The 1 Canadian Air Division Flight Safety Officer provided a three-day, focused Crew Resource Management course in July 01 and again in December 01; Pilot #1 and pilot #5 each received a formation training/confidence flight with a Central Flying School Standards pilot prior to resuming normal Team formation flights; and, 431 (AD) Squadron flew numerous training flights prior to resuming air display flights on July 20, 2001. The requirement to maintain situational awareness of the other members of the formation was stressed.
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