2011 Annual Report on Flight Safety

Report / May 14, 2012 / Project number: RCAF-DFS-2011-annual

This report provides a synopsis of the activities carried out in 2011 by the Airworthiness Investigative Authority (AIA) and the Directorate of Flight Safety (DFS) in relation to the Flight Safety (FS) Program of the Canadian Forces. 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.


Investigations. During the calendar year, the AIA initiated 11 investigations and closed 15. The investigations tasked by DFS were for eight accidents (three category 'A', one category 'B', and four category 'C'), and one incident (one category 'D'). These figures include two Air Cadet (categorized non-CF) investigations for two accidents (one category 'B' and one category 'C').

Aeronautics Act Amendment. The AIA obtained the Minister of National Defence's support to advance a Department of National Defence lead amendment to the Aeronautics Act. The amendment has for goal the securing of the appropriate powers for investigators to conduct investigations concerning aviation safety, particularly when civilians are involved in the occurrences. As of March 2012, the CF/DND internal administration for this initiative was completed and follow on steps should result in the projected introduction of the proposed amendment in the fall 2012 session of Parliament.

Airworthiness Investigation Manual. The A-GA-135-003/AG-00 Airworthiness Investigation Manual (AIM) was published in February 2010 with the procedures and processes outlined in the manual coming into effect 15 April 2010. Recent changes in the FS program and policy, notably the consolidation of FS training course, the AIA's policy with respect to Aircraft Recording Devices (ARDs) and the requirement for the AIA to delegate certain authorities to WFSOs have precipitated the requirement to amend this publication in these specific areas. The projected amendment completion is fall/winter 2012-13. The AIM is available on-line via the DFS website under Publications at http://www.airforce.forces.gc.ca/dfs-dsv/index-eng.asp.

Amendments to A-GA 135-001/AA-001. Amendment #4 of the A-GA 135-001/AA-001 Flight Safety for the Canadian Forces was released on 01 Apr 2011. The amendment covers changes relevant to the simplification of the FS strategic business model, the clarification of Air Cadet command structure, clarification of Good Show and For Pro staffing procedures, adjustment of the CF Aircraft definition, amendment of Hazard Report Form DND 2484, clarification of quarantine documentation and authority to lift quarantine, determination of For Tracking Purposes Only occurrence closure, adjustment of the Investigation Class Table. Amendment #5 of the A-GA 135-001/AA-001 was in draft form at the end of the year and is due for release in April 2012.

CVR/FDR Working Group. There were no meeting held during the period. The implementation policy remains focused at tackling one fleet per year for the next 10 years based on fleet prioritizations. A Small Capital Project was staffed, approved and funded to install an Alternate Means of Compliance CVR/FDR system on the CT114.


Promotion. DFS presented 41 annual briefings (33 English and eight French) at 26 locations across Canada as well as the Canadian contingent at Geilenkirchen, CDLS (London) and SHAPE HQ Belgium, and reached approximately 7500 personnel. DFS met with over 75 Commanding Officers and their Squadron Warrant Officers and visited eight air traffic control towers. DFS published three issues of Flight Comment magazine, one issue of On Target magazine, which focussed on new technologies, three issues of the electronic FS newsletter Debriefing and one FS Flash message. A total of 29 FS award submissions for individuals or groups were considered and resulted in the granting of two Good Show and 18 For Professionalism awards and nine recommendations for Commanders Commendations.

Surveys. DFS conducted five FS surveys with contracted organizations: Cascade Aerospace Ltd in Abbotsford, BC; Kelowna Flightcraft Limited in Kelowna, BC; Bell Helicopter represented by Alpine Aerotech Limited in Kelowna, BC; Orenda Aerospace Corporation in Mississauga, ON; and Vector Aerospace in Richmond, BC. The FS staff at the division level conducted surveys of 8, 9, 12, 14, 16, 17 and 19 Wings as well as 443 Sqn and 3CFFTS. A FS Staff Assistance Visit (SAV) to 1 Wing was completed. With over 50 visits to Sqns, supporting units, and contracted service providers, the FS staff was able to provide the chain of command (CoC) with effective feedback on the stressors affecting each unit, along with specific recommendations for improving FS prevention programs with the aim of reducing risk and FS accidents or incidents.

Training. A total of five Basic Flight Safety Courses and two Advanced Flight Safety Courses were conducted by 1 Cdn Air Div FS staff. They qualified 187 personnel, including Air Cadet staff members, civilian contracted service providers, Army personnel and DND firefighters. The Basic and Advanced Flight Safety courses have now been combined into a single Flight Safety Course. A trial course was conducted at the end of the year. Staffing is on-going for the approval of a new Training Standard and associated Training Plan.


Flying Hours and Reporting. Compared to 2010, the number of hours flown in the CF has increased by 1.9%, accompanied by a 4.2% reduction to the Air Cadet Glider Program (ACGP), and a 49% reduction of Unmanned Aerial Vehicles (UAV) due to a cessation of operations. Personnel reported 3,149 occurrences, of which 56.27% were classified as Air occurrences. When compared to last year, the rate remains virtually unchanged (207.87 compared to 208.27 in 2010).

Occurrence Breakdown. The CF had a less than favourable FS record for 2011. Major and minor injuries have increased, (one fatal, six serious, and 49 minor), a total of two aircraft were destroyed (one CT155 and one CH147 Chinook). The air accident rate for the CF has increased for the third year in a row to 0.96. This was attributable to three category 'A' accidents (one CT155 Hawk, one CH147 Chinook and one fatality) and 10 category 'C' accidents (two CH146, one CH139, one CC138 and six Pers injuries). The major injuries are predominantly associated with SAR Tech operations. The serious injuries rate is above the 10-year mean and should be investigated further. The major injuries rate is greater than the 10-year average rate of 0.66, and marks the fourth consecutive year above the mean. Although statistical data for the Air Cadet program show a decrease from last year's high (2.53 vs. 3.03) it remains above the previous 5-year mean (2.17) which is indicative of a negative tendency. The UAV accident rate was 0.0 and reportable UAV operations have now ceased.

Personnel Cause Factor. The DFS Human Factors specialist reviewed of the Human Factors Analysis and Classification System (HFACS) for assigning human errors in the Flight Safety Occurrence Management System (FSOMS). The resulting observations and recommendations which will also include amended definitions for the assignment of specific factors were briefed to DFS.

Cause Factor Analysis. An important part of the DFS prevention activities surround the data analysis and comparison to previous years. Cause Factor analysis is based on data from completed reports only as draft reports are subject to change. Preventive measures and their timely staffing and implementation by the chain of command are critical to an effective prevention program. Overdue occurrence reports have a detrimental effect on our ability to analyze and trend cause factors and the distribution of PM information. This year is particularly critical due to the amount that were overdue (509 of the 3149) at the time of the report (247 Air and 262 Ground).

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