2014 Annual Report - Airworthiness Investigative Authority and Flight Safety Program's Activities

Report / June 17, 2015 / Project number: RCAF-DFS-2014-annual

DIRECTOR’S COMMENTS

This is the 10th annual report on Airworthiness and Flight Safety (FS) activities for the Department of National Defence/Canadian Armed Forces (DND/CAF) and the Air Cadets. The report provides a synopsis of the investigations and activities carried out by the Airworthiness Investigation Authority (AIA) and the activities overseen by the Director of Flight Safety (DFS) in relation to the FS Program for 2014 with a statistical comparison to the previous 10 years.

As this is my second year as DFS, I wish to highlight the continued dedication and professionalism demonstrated by all FS personnel across the country. The FS Team at Wing and Unit level continues to bring about positive changes to the FS Program.

Overall, the year 2014 was a very good year, in particular for the CAF. The number of hours flown by the CAF has decreased by 10% to 124,522 hours. The CAF air accident rate continued to decrease to .4, which is well below the 10-year mean of 0.60; the CAF suffered four air accidents, one being a category ‘A’. The CAF had two ground accidents; this number represents a 50% reduction from the previous year and is half of the 10-year mean value of 4. The number of major injuries, all serious, totaled five; this is in line with the 10-year mean value. The Air Cadets had three air accidents, two very serious and one serious. This resulting rate of 2.0 is slightly above the 10-year mean. There were no Air Cadets ground accidents.

The number of reported occurrences (3087) remained almost identical to 2013. The number of investigations maintains the pressure of last year on our Flight Safety Officers striving to complete the investigations in a timely manner. Overdue investigation reports (405) equate to 13.1% of the reports produced in 2014, this doesn’t include the 151 additional reports from previous years.

As I indicated in last year’s report, the FS Program continues to be affected by overdue investigations reports. Although DFS appealed to Unit and Wing FSO in 2012 for more diligence in the completion of their FS reports and the FS Program had reported a reduction in overdue of occurrence reports for 2013, we have lost ground last year in the effort. Overdue occurrence reports hinder the implementation of effective and timely Preventive Measures (PM). The FS staff must review the priorities and remain focused on core activities of investigating occurrences, recommending preventive measures and monitoring their implementation and effectiveness. Priority of effort must shift to the accurate and timely capture of lessons learned and their prompt publishing in order to prevent accidental loss of personnel and critical resources. As such, WComds and COs must endeavour to assign the right amount of resources to keep their FS programme at an acceptable status. DFS is working with the Wings to resolve the current issue and help them focus effort where it is most beneficial to the program. A poster included in the Flight Comment magazine says it all: Flight Safety Reports Overdue… Puts Flight Safety in The Queue! Given all the operational and training pressures we have in the RCAF, I believe it is essential that we maintain and possibly augment the effort towards the Flight Safety Program to protect resources and people. 2014 Annual Report – AIA and FS Program’s Activities

The FS Information Management System (FSIMS) collaborative project with the Information Management Group continues on track for the new version release scheduled in September 2015.

The Director and CWO of Flight Safety visited 64 different units and civilian facilities this year. 48 annual briefings were presented in both official languages reaching approximately 7258 personnel. The main theme of the DFS annual briefings centered on the need to ensure that no one is cutting corners and everyone is adhering to our established rules and regulations, thus making sure the acceptance of risk is done by the proper authority and not by the individual with a can-do attitude.

DFS also introduced a new FS coin recognition program this year. The FS coin is used to recognize a notable contribution to the FS Program by an individual’s particular actions or noteworthy dedication and conveys DFS’ appreciation to a worthy recipient that exemplifies the values of the FS Program. The coin is often awarded by DFS during its annual briefing to exemplify safe behaviour. A total of 35 FS coins were handed out this year.

Finally, key FS issues were reported back to the Commander RCAF for awareness and action as necessary.

Feedback and comments on this annual report are solicited and would be greatly appreciated. They should be forwarded to DFS at dfs.dsv@forces.gc.ca.

Steve Charpentier
Colonel
Director of Flight Safety

EXECUTIVE SUMMARY

This report provides a synopsis of the activities carried out in 2014 by the Airworthiness investigative Authority (AIA) and the Directorate of Flight Safety (DFS) in relation to the FS Program of the Canadian Armed Forces (CAF). It covers statistical data for the Air Cadets Glider Program. 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 INVESTIGATION AUTHORITY ACTIVITIES

INVESTIGATIONS

During the calendar year, the AIA initiated 3087 investigations. Of those, DFS initiated six accident investigations: two Class I investigations for the CT156 Harvard II ejection and the Air Cadets Cessna 152 loss of control in flight, as well as four Class II investigations for the CT156 Harvard II / CT114 Tutor near mid-air collision, CH 146 Griffon main rotor blade strike, CH124 Sea King inadvertent water landing, and the Air Cadet SZ23 Schweizer, glider rope break and hard landing. DFS completed five investigations in 2014.

AERONAUTICS ACT AMENDMENT

The Bill Safeguarding Canada’s Seas and Skies Act (C-3) received Royal assent on 16 December 2014. This bill includes the same amendments to the Aeronautics Act (AA) that allow the Minister of National Defence’s (MND) designate, the Airworthiness Investigative Authority, to carry out the statutory AA requirements to investigate all matters of military aviation safety by providing certain powers of investigation particularly for occurrence involving civilians. Most of the provisions in the amendment came into force on14 February 2015. Orders in Council (regulations) regarding these amendment provisions have yet to be completed. Bill C-3 did include amendments to four other acts not related to DND/CAF operations.

SURVEYS

The FS surveys are part of a continuous improvement effort and provide a platform from which the safety culture at each organization can be sampled regularly. DFS conducted three FS surveys at contracted service provider sites (Cascade Aerospace in Abbotsford, BC; Standard Aero in Winnipeg, MB; L3 MAS in Mirabel, QC) and the FS staff at the Division conducted seven surveys of 1, 3, 12, 14, and 19 Wing as well as CFBs Wainwright and Suffield. The chain of command (CoC) was debriefed on salient points.

FLIGHT SAFETY ACTIVITIES

PROMOTION

DFS presented 48 annual briefings to different locations across Canada reaching more than 7200 personnel. The Directorate published three issues of Flight Comment magazine, four issues of the electronic FS newsletter Debriefing as well as two FS FLASH messages.

AWARDS

A total of 32 FS awards were handed out consisting of 11 Good Show, 21 For Professionalism awards. 35 FS coins were also handed out.

TRAINING

1 Cdn Air Div FS staff conducted five Flight Safety Courses (FSC). 160 personnel were qualified including Air Cadet personnel, civilian contracted service providers, Army members, DND firefighters as well as two investigators from the Brazilian Aircraft Accident Investigation and Prevention Center.

AMENDMENTS TO FS/AIA DOCUMENTATION

The A-GA-135-003/AG-001 Airworthiness Investigation Manual (AIM) was updated with a new edition dated 30 December 2014, published 30 Mar 2015. Changes include documentation of the Investigative Airworthiness Clearance (IAC) process, updating the training requirements and delegated authorities for investigators, publishing an Investigator In Charge (IIC) checklist, publishing examples of AIA delegations and improving the examples to explain AIA policies and processes. This version does not include any changes as a result of the newly amended Aeronautics Act (dated February 7, 2015). The AIM will be revised subsequently as soon as the resultant required regulations of the Governor in Council are produced, likely by late 2016.

COOPERATION WITH OTHER AGENCIES

DFS participated to various national and international forums intended to share FS information, exchange of ideas on the prevention of accident, and discussion on furtherance of safety awareness. The forums attended included the participation to the NATO FS Working Group (Budapest, Hungary), the Air Forces Flight Safety Committee (Europe) (Vilnius, Slovenia), the System of Cooperation among the American Air Forces (SICOFAA) (Halifax), the International Society of Air Safety Investigator (ISASI) (Adelaide, Australia), and the CHC Safety & Quality Summit (Vancouver).

In support of the SICOFAA proceedings, DFS did a complete review of the document SICOFAA Military Aircraft Accident Investigation Manual. During the travel to Australia for ISASI, DFS visited the Royal Australian Air Force Directorate of Safety to discuss issues of common interest. Further, DFS participated to the bilateral engagement with the Brazilian Air Force aimed to strengthen the links with the RCAF. As such, two CAF officers visited the Brazilian Aeronautical Accident Investigation and Prevention Center in Brasilia, District Federal, Brazil with two Brazilian officers attending the 2-week FSC in Winnipeg in the Fall and one Canadian officer attending the 2-week Safety and Prevention course (CPAA) in the summer and another one attending the Accident Investigation (CIAA) in the Fall. Also, in collaboration with 1 Canadian Air Division A4 Maintenance, DFS published a poster on aircraft marshalling signals (C-05-010-019/DA-000) based on the recently amended STANAG 3117. The poster is supplemented by the signals contained in C-05-005-P06/AM-001 Servicing.

The AIA/DFS continued to work closely with the following organizations for the conduct of AIA activities: Aerospace Engineering Test Establishment (AETE), Quality Engineering Test Establishment (QETE), National Research Council (NRC), Defence Research and Development Canada (Toronto) DRDC(T), and Transportation Safety Board of Canada (TSB).

STATISTICS AND TREND ANALYSIS

FLYING HOURS AND REPORTING

In 2014, the number of hours flown in the CAF has decreased by 10% to 124,522 hours. The reduction affected all fleets except the CH139 Jet Ranger and CC115 Buffalo, which remained stable as well as the CH147 Chinook, which increased due to entry into service of the remaining Chinooks.

Personnel reported 3087 occurrences divided almost equally between Air and Ground occurrences (51.2% and 48.8% respectively). This represents a small decrease in the reporting rate in comparison to the previous year but remains above the 10-year mean of 216.7.

OCCURRENCE BREAKDOWN

The CAF had a good FS record for 2014 with four air accidents. This was attributable to one ‘A’ category (CT156 Harvard II), one category ‘B’ (CH146 Griffon), and two category 'C' (CT114 Tutor). The air accident rate decreased to 0.36, which is well below the 10-year mean of 0.6. The CAF had two ground accidents; this number represents a continued 50% reduction from the previous year and is below the 10-year mean of 4. The number of major injuries was limited to two serious, and is below the 10-year mean value of 3.5.

Similarly, the Air Cadets had three air accidents. This was attributable to two category ‘B’ accident (SZ23 Schweizer, and Cessna 150), and one category ‘C’ (SZ23 Schweizer). The Air Cadet Air accident rate increased to 2.0 from last year’s low but remains within one standard deviation of the mean.

OVERDUE INVESTIGATIONS

An important part of the DFS prevention activities surrounds the data analysis and comparison to previous years. The FS Program continues to be affected by overdue investigations reports. Although DFS appealed to Unit and Wing FSO for more diligence in the completion of their FS reports, we have since lost ground in the effort. As of the 01st of April, 16.9% of occurrence reports remained incomplete for 2014 (522 of 3087). This number does not include the 162 occurrences dating prior to 2014.

Overdue occurrence reports hinder the processing of effective PMs and their timely staffing by the CoC. The FS staff must remain focused on core activities of investigating occurrences, recommending PMs and monitoring their implementation and effectiveness. DFS has engaged the FS team and will continue to monitor the situation.

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