CT114172 Tutor and CT114006 Tutor - Epilogue - Flight Safety Investigation Report
Report / September 4, 2000 / Project number: CT114172-CT114006 - C Category
Location: Toronto, Ontario
Status: Investigation Complete
The Flight Safety Investigation Report (FSIR) is available from DFS.
The accident occurred after the 9 plane formation of 431 Air Demonstration (AD) Squadron had departed Pearson International Airport (PIA) to fly a display for the Canadian National Air Show in Toronto. The aircraft directly involved were Snowbird Lead (114006) and the number four aircraft (114172) of the formation. The departure from PIA was conducted as three separate elements of three aircraft, each in "Vic" formation. The number four aircraft was lead aircraft of the second element. The briefed rejoin was to be completed shortly after take-off with the first two elements rejoining as depicted below:
As the second element was positioning for the rejoin, Snowbird Lead called a speed reduction and "easing right" into a turn. The number four aircraft overshot the Lead aircraft by passing below and past by approximately 50 feet. The pilot of number 4 then attempted to regain the ideal position by moving backwards. During this manoeuvre, number four's left elevator and tail contacted Lead's left wing leading edge and left belly smoke tank.
The number four aircraft departed the formation and recovered at PIA. Snowbird Lead co-ordinated the recovery of the remaining aircraft and all recovered at PIA without further incident.
The number four aircraft sustained damage to the fibreglass cover at the top of the 'T' tail with contact marks and torn metal found on the left elevator and tail section. The Lead aircraft had contact marks and dents on the left belly tank and a torn left wing leading edge.
The investigation found that, although aware of the proper overshoot procedure, the pilot of aircraft #4 elected to attempt to salvage this overshoot with a non-standard manoeuvre.
Also, during Snowbird training/work-ups, straight-ahead rejoins and overshoots were briefed but were not practised as discrete manoeuvres and 431 Squadron SOP's did not clearly define overshoot procedures.
431 Squadron has initiated the following safety measures:
Squadron SOP's have been modified such that; the various procedures for overshoots are described; radio procedures are specified for rejoins and overshoots; there are detailed instructions specifying the rejoin sequence of aircraft; rejoin spacing will be increased from a position the Snowbirds refer to as "route" to "wider than route" to reduce the probability of collision until the formation is stabilised; formations with elements of three aircraft joining on three aircraft will not occur over populated areas; and rejoins in "Vic" formation in high-density international environments will be to a "trail" position of 500 to 1000 feet until the lead pilot calls the formation into tight formation.
431 Squadron training programs have been modified to include a straight-ahead overshoot/rejoin for aircraft rejoining from a line astern position. Also, greater detail on speeds, flight patterns and radio procedures are being provided in formation briefings with respect to take-offs, re-joins and overshoots in high-density airspace.
The investigation also recommended that 15 Wing review it's Flight Surgeon support to 431 Squadron in the event of a Flight Safety mishap while deployed and 431 Squadron should then develop an applicable SOP. Also, 1 CAD investigate the establishment of a method for all CF deployed flying units to have access to Flight Surgeon support/advise if required.
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