2012 Annual Report on Flight Safety

Report / June 19, 2013 / Project number: RCAF-DFS-2012-annual

DIRECTOR COMMENTS

This is the 8th Annual Report on Flight Safety (FS) for DND/CF.  The report provides a synopsis of the investigations carried out by the Airworthiness Investigation Authority (AIA) and the activities of the Directorate of Flight Safety (DFS) for 2012. 

FS witnessed continued challenges this year due to personnel shortages at the supervisory level.  The FS Program bears the signs associated with overdue investigations reports and the impact of increased workload on staff at the wing and squadron levels.  The number of reported occurrences (3236) and the rate (247.2/10000 hours) represent an increase when compared to the previous year’s data.  The Program needs to remain focussed on core activities: investigate occurrences, recommend preventive measures (PMs) and monitor their implementation and effectiveness.  In these processes, the responsible FS officers shall ensure that lessons learned are captured and published in order to prevent accidental loss of personnel and critical resources.

The 2012 DFS briefing focused on the importance of proper supervision and communication.  With the decrease of experience levels throughout the RCAF, both in the air and on the ground, supervisors at all levels must remain vigilant to identify hazards early and to mitigate impact.  Following in the same vein, with the forecasted attrition of senior ranks of both officers and NCMs, proper communication and passage of critical knowledge is paramount.  Key FS issues were reported back to the Chief of the Air Force for awareness and action as necessary

The Program has continued to improve, with many important initiatives started or completed in 2012.  First, the Human Factors Analysis and Classification System (HFACS) model used to classify FS Personnel cause factors was comprehensively reviewed by DFS.  A proposal to modify the taxonomy while improving usability was developed and briefed to the FS Team.  When implemented later this year, the changes will facilitate investigator consistency in the assignment of cause factors for similar circumstances.  These needed changes will be promulgated in change 7 to A-GA-135-001/AA-001 Flight Safety for the Canadian Forces.  Second, a collaborative project with the Information Management Gp is underway to upgrade the current Flight Safety Occurrence Management System (FSOMS) to a future Flight Safety Information Management System (FSIMS), providing a next-generation statistical repository and analysis tool.  Third, the FS Course taught by 1 Cdn Air Div staff was further enhanced by the production of an improved qualification standard and course enhancements.

In the last year, two points were observed from an analysis of the 2012 FS data.  First, overdue occurrence reports continued to hinder the processing of effective PMs.  As of February 2012, the average completion time for FS reports was 65 days (twice the expected time).  As of the date of this report, 17.9% of reports remained incomplete for 2012.  The FS team will explore ways to streamline the review process to reduce overdue reports.  This is critical since the recommended PMs and their timely staffing by the chain of command is key to an effective FS Program.  Second, the number of near mid-air collisions in training areas continued to increase, despite efforts to reduce them.  This was noted in last year’s report but limited progress was achieved in resolving the issue, therefore near mid-air collisions continue to be of concern.  A renewed effort is required before an accident occurs.

J.C.Y. Choinière
Colonel
Director of Flight Safety

EXECUTIVE SUMMARY

This report provides a synopsis of the activities carried out in 2012 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.

Airworthiness Program

Investigations.  During the calendar year, the AIA initiated eight investigations and closed 12.  The DFS investigations were for seven CF accidents (one category 'A', two category 'B', and four category 'C') and one Air Cadet accident (category ‘B’) involving two aircraft.

Aeronautics Act Amendment.  A Bill entitled “Safeguarding Canada’s Seas and Skies Act – C-57” was introduced in Parliament in March 2013 that includes amendments to the Aeronautics Act that establishes the AIA for DND/CF.  Bill C-57 also includes amendments to four other acts; however, these acts are not related to DND/CF operations and are primarily in the Minister of Transport’s areas of responsibility.

Airworthiness Investigation Manual.  The amendment to the A-GA-135-003/AG-00 Airworthiness Investigation Manual (AIM) was postponed primarily due to the projected re-write and changes that will be required with the amended Aeronautics Act.  Pending successful completion of the Aeronautics Act amendments, this project will commence and form part of the AIA's governance.

Amendments to A-GA 135-001/AA-001.  Amendments 5 and 6 of the A-GA 135-001/AA-001 Flight Safety for the Canadian Forces were released respectively on 31 Mar 2012 and 04 Sep 2012.  Most of these changes were clerical in nature except to the FS command and control table in Chapter 2 and related text, including land and naval assets as well as contractor FS responsibilities.  It also clarified definitions and procedures in relation to aircraft recording devices.

CVR/FDR Working Group.  As identified in the 2009 AAB, the implementation policy remains focused at tackling one fleet per year for the next 10 years.  Three of four CFTS fleets have installed Alternate Means of Compliance systems.  The CT114 Tutor project has halted due to new cost predictions found in excess of approved funding.  DAR will pursue MP funding for CC115 Buffalo and CC138 Twin Otter during FY 2014/15.  DND is awaiting estimates for the CT155 Hawk, and CT156 Harvard II.  Finally CF188 Hornet, CP140 Aurora and CH146 Griffon upgrade are expected to be included with an estimated life expectancy (ELE) extension funding if such plans are pursued.  DFS continues to monitor the situation.

Flight Safety Program

Promotion.  DFS presented 41 annual briefings (33 English and eight French) at 26 locations across Canada and at the Canadian Contingent at Geilenkirchen, CDLS (London) and SHAPE HQ Belgium.  The briefings were attended by approximately 7400 personnel.  DFS personally met with over 75 Commanding Officers and their Squadron Warrant Officers as well as visited seven air traffic control towers.  Concurrently, the Directorate published four issues of Flight Comment magazine and four issues of the electronic FS newsletter Debriefing.  There were two FS Flash messages released during 2012.  A decision was made to discontinue the production of the On Target magazine in favour of producing the fourth edition of Flight Comment which could focus on a single topic if necessary.  A total of 25 FS award submissions for individuals or groups were considered, resulting in the granting of three Good Show and 19 For Professionalism awards and five recommendations for a commander’s commendation.

Surveys.  DFS conducted three FS surveys at contracted service provider sites as part of the DFS contracted service provider visit program.  The 1 Cdn Air Div FS staff conducted surveys of seven wings and 3 CFFTS in addition to a FS SAV at 1 Wing.  With over 50 visits to Sqns, supporting units, and contracted service providers, the FS staff provided the 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 and incidents.

Training.  A total of five FS courses (FSC) were conducted by 1 Cdn Air Div FS staff.  They qualified 162 personnel, including Air Cadet staff members, civilian contracted service providers, army personnel and DND firefighters.  A survey of graduates will be conducted approximately 12 months after completion on the course to assist in tailoring instruction.  The Specialty Specification Codes remain to be amended to enable the tracking of these qualifications.

Statistics and Data Analysis

Flying Hours and Reporting. Compared to 2011, the number of hours flown in the CF has decreased by 13.9%.  Personnel reported 3,236 occurrences, of which 54.9% were classified as air occurrences.  When compared to last year, the reporting rate increased significantly to a 10 year high of 247.2.  The increase is, however, proportionally higher in the No Damage/No Injury category.

Occurrence Breakdown.  The CF had a fortuitous FS record for 2012.  Major and minor injuries decreased (no fatalities, no aircraft destroyed, 3 serious, and 49 minor injuries).  The air accident rate for the CF also decreased significantly to 0.43 and is below the 10-year mean of 0.64.  This was attributable to one category ‘A’ (CC130 Hercules), one category 'B' (CH146 Griffon) and two category 'C' (one CH146 Griffon, one CC138 Twin Otter) accidents.

Personnel Cause Factor.  The Human Factors Analysis and Classification System (HFACS) model was reviewed.  The taxonomy was modified significantly to provide investigators consistency when assigning cause factors for similar circumstances.  It is definitely more user friendly.  These long-awaited changes will be promulgated in change 7 to A-GA-135-001/AA-001 amendment to be published in the summer of 2013.

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.  Last year, the FS Program saw a large number of overdue occurrence reports (509 of 3149).  This was initially thought to be related to when the annual report queries were conducted in Mar 12.  This year, the queries were specifically delayed in order to provide the opportunity for units and wings to complete their occurrence reports.  As of 24 May, 18% of the 2012 occurrence reports were still overdue (575 of the 3236).  As well, there were 122 additional overdue occurrences related to years prior to 2102.  This issue must be addressed under a separate venue.

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