Aviation accidents and incidents have the potential to cause the loss of lives and of valuable resources. It is therefore important to investigate such Flight Safety (FS) occurrences with the objective of quickly identifying effective measures that will either prevent or reduce the risk of similar occurrences.
Within DND, the Director of Flight Safety is appointed as the Airworthiness Investigative Authority (AIA), and is charged with investigating all matters concerning aviation safety (independently of the chain of command). The powers of the Airworthiness Investigative Authority are delegated from the Minister of National Defence, pursuant to the Aeronautics Act. The Chief of the Air Force Staff is responsible for flight safety policy in the Canadian Armed Forces (CAF).
While conducting an advanced clearhood training sortie in a CT156 Harvard II aircraft out of 2 Canadian Forces Flying Training School (2 CFFTS), a qualified flying instructor (QFI) and student pilot (SP) experienced a hard landing upon completion of a practice forced landing (PFL).
During a touch and go at Naval Air Station Key West just prior to the aircraft becoming airborne, the Loadmaster, who was seated in the rear of the cargo compartment, heard an electrical buzzing sound and observed an orange jet-like flame shoot across the cargo ramp floor.
Directorate of Flight Safety (DFS) has a mandate to champion a pro-active, effective, and innovative Flight Safety Program that enhances combat-effectiveness by preventing the accidental loss of aerospace resources. DFS fosters the safe execution of Canadian Forces aerospace operations through independent investigation of matters concerning aerospace safety, active participation in the airworthiness program and leadership of the Canadian Forces Flight Safety Program.
Endorsement by the Chief of the Defence Staff
The Defence Administrative Orders and Directives mandate commanding officers to “conduct their own general and specialist safety programs in accordance with the General Safety Program and specialist safety programs.” One vital specialist program that is well recognized nationally and internationally is the Canadian Armed Forces (CAF) Flight Safety Program.
The Flight Safety Program, which I strongly champion and support without reservation, reaches all elements of the CAF. Within the CAF, the Commander Royal Canadian Air Force is responsible for flight safety policy while the Director Flight Safety (DFS) administers the program as a whole on his behalf.
A capital element of the program stems from the Minister of National Defence designating DFS as the Airworthiness Investigative Authority as required by the Aeronautics Act. With this designation comes the authority and responsibility to investigate all matters concerning aviation safety, independently of the chain of command. Moreover, on Ministerial Direction, I have issued a CDS Order to the AIA delegating additional responsibilities to carry out this function within the Flight Safety and Airworthiness Programs.
With the introduction of unmanned aerial vehicles in different organizations of the CAF and the contracting out of many aircraft maintenance and support activities, a vigorous Flight Safety Program that spans to all elements of our organization is critical. Aviation assets, including aircraft and unmanned aerial vehicles, are expensive and hard to replace. Also, our personnel are critical to mission success. It is vital that our resources be well preserved through a pro-active flight safety program to ensure the operational viability of the CAF, at home and abroad. The program is a key component to support any operational deployment where aviation assets are involved.
I expect commanding officers involved with operating or supporting aviation assets to allocate the right balance of resources to have in place an effective Flight Safety Program. Furthermore, commanding officers have to demonstrate leadership and engagement in the program so our aviation assets are well protected.
Flight Safety (FS) Program
The aim of the FS Program is to prevent accidental loss of aviation resources while accomplishing the mission at an acceptable level of risk.
The FS Program is a program of safe behaviour, education, independent airworthiness investigation, promotion and analysis of matters concerning aviation safety. Personnel at every level are required to participate in and support the FS Program; it is directed at military and civilian personnel involved in CAF aviation activities and its’ contracted support elements.
A FS Program aligned with the roles and missions of the DND / CAF shall be established at each level of command where flying operations are supervised or supported. Understanding why safety occurrences happen and the implementation of suitable preventive measures (PMs) are key to an effective accident prevention program. Therefore, accidents and incidents representing a risk to aviation should be investigated.
The FS Program is based on the following five fundamental principles:
- the main principle is the prevention of occurrences. Although cause factors are assigned to occurrences, this is only done to assist in the development of effective PMs;
- personnel involved in conducting and supporting flying operations are expected to freely and openly report all FS occurrences and FS concerns;
- in order to determine the cause of occurrences such that appropriate, effective PMs can be developed and implemented, personnel involved in conducting and supporting flying operations are expected to voluntarily acknowledge their own errors and omissions;
- in order to facilitate free and open reporting and voluntary acknowledgement of errors and omissions, the FS Program does not assign blame. Personnel involved in a FS occurrence are de-identified in the final report and the report itself cannot be used for legal, administrative, disciplinary or other proceedings; and
- the whole FS Program is based on the primacy of having a “just culture.” A “just culture” lies between a non-punitive culture and one of sanction and punishment. Free and open sharing of critical safety information between managers and operational personnel, without the threat of punitive action, represents the basis of a reporting culture. Personnel are able to report occurrences, hazards or safety concerns as they become aware of them, without fear of sanction or embarrassment. However, while a non-punitive environment is fundamental for a good reporting culture, the workforce must know and agree on what is acceptable and what is unacceptable behaviour. Negligence or wilful, deliberate deviations must not be tolerated by leadership. A ‘‘just culture’’ recognizes that, in certain circumstances, there may be a need for punitive action and defines the line between acceptable and unacceptable actions or activities.
The first known formal recognition of the need for a dedicated Flight Safety (FS) Organization occurred in mid 1942 when the RCAF Aircraft Accident Investigation Board (AIB) was formed under a Chief Inspector of Aircraft Accidents. This small cell of 16 people headed by a RAF Group Captain (later transferred to the RCAF) was expected to examine past aircraft accidents and to investigate new ones with a view to reducing non-operational losses. It was a very tall order and the war ended before much progress in accident prevention could be made. During the unsettled period of demobilization, the record of their efforts along with most of the staff, appears to have been lost. The designation AIB and a small staff of 6 survived, until the early 1950's when the Directorate of Flight Safety (DFS) was established and the strength increased.
With the establishment of DFS, the "AIB" still remained by far the major responsibility, but some long overdue recognition was intended to be given to education and prevention. Regrettably, this first slight shift of emphasis to learning from our mistakes was set back by the rapid RCAF expansion during the Korean conflict. How dearly this set back cost us is indicated by the 1953-57 losses of 476 aircraft and 405 people.
Regardless of the circumstances, such a destruction rate could not continue and in 1957-58, the then Chief of the Air Staff directed in no uncertain terms that the development of a positive and effective flight safety program had the highest priority. This declaration is considered by many to have been the first real break with the traditional air force syndrome of "press onward regardless".
The need for thoroughness in AIB investigations was if anything increased during the next 6 to 7 years. The very carefully selected and trained pilots and engineers were now expected to assist the President of the B of I in every way possible, particularly in finding the true cause(s) for aircraft accident so that corrective action could be taken: "In other words, treat the disease not the symptoms." How effective this FS program was is indicated by the fact that in 1958 we lost only 42 aircraft compared with 81 in 1957.
Over the next ten years, the overall trend was a gradual reduction in losses with the years 1963 and 1965 being slight aberrations (like 1982). It was during this period that a definite shift developed away from the long standing legal requirement for a Board of Inquiry convened under QR&O 21.56 to assign blame, except in the strong case (CFAO 24-6 para 2a) and recommend punishment. More important was the fact that none of the information given to an aircraft accident investigation could be used in disciplinary proceedings. With such a positive approach, the evolution of our "before the fact" aircraft accident prevention system was fairly rapid until 1965 when unification took place. At that time, the RCAF/DFS establishment was 31 but the combined strength of 34 was immediately cut to 24. This set back in manpower had no immediate degrading effect because those remaining in DFS had the opportunity to change priorities. More important, drastic philosophical changes that had not been possible under traditional sea, land and air concepts were introduced. The more significant developments during this period were:
- publications of CFP-135, Manual of Flight Safety for the Canadian Forces which for the first time laid out a comprehensive FS program plus the direction on how best to do it;
- acceptance and approval of the philosophy that information given to an investigation into an aircraft occurrence whether formal or otherwise be classed as "privileged" (QR&O See 8-CFP 135 Chap 15);
- expansion of the Flight Safety reporting system to include anything that might hazard aviation resources or the people involved; with specific emphasis on the importance of the so called incident;
- development of definitions which are realistic, understood and accepted over the longer term by most of the people involved. (This made comparisons meaningful.);
- re-establishment of to the need of FS staff officers to report the most senior individual at each level of command ( i.e. DFS reports to the office of the CDS); and
- probably the most important single step of all was elimination of the distasteful, derogatory word ERROR when assigning human cause factors.
These and other factors brought about a degree of stability in the total Flight Safety program that never existed before. People learned to trust the system more than in the past and expected it to help them do the job better (and safer). They in turn were willing to come forward and report candidly even when they were deeply involved. No other Air Force has such a philosophy or privilege of information which established a spirit of trust, the benefits of which are still being realized in the CAF. The principle of this philosophy has been recognized in the recent Canadian Aviation Safety Board Act (Bill C163 paras 26 & 30).
The formation of Air Command in 1975 while obviously necessary to consolidate and concentrate aviation efforts and resources did not improve the operation of the Flight Safety system: at least not initially. It added another level of command which compounded some of the command and control problems that already existed and it made it difficult to delineate responsibilities between NDHQ, AIRCOM and CFE. Flying units outside Air Command, such as 1 CAG and 444 Sqn in CFE and AETE an ADM(Mat) unit, posed particular problems which were eventually solved through assignment of responsibility for matters of Air Policy, Air Doctrine, Air Standards and Flight Safety to Commander Air Command for all flying units within the Canadian Forces. Of equal concern, during the early days of Air Command, was the heated controversy over the division of responsibility between Air Command Flight Safety staffs and DFS. While the dividing lines are still not absolute, there has developed a basic understanding and good working relationship. The Commander Air Command, who exercises control over the vast majority of air resources is the convening authority for all aircraft accident Boards of Inquiry, while NDHQ, through VCDS/DFS prepares the Closing Action Report and assigns the final cause factors. Air Command Senior Staff Officer Flight Safety and his staff oversee the day-to-day Flight Safety programs as administered by the Air Groups while DFS staff are responsible for accident investigation, Flight Safety prevention programs, specialist education, and statistical reporting, collection and analysis. The most recent development in the evolution of the CF Flight Safety system has been the expansion of the DFS mandate to include air weapons safety. This responsibility involves monitoring air weapons activities from weapon breakout, through the convoy process, the loading and the air delivery of the weapons. It also includes downloading, if necessary, and the return of the weapons to the storage area.
There have been a number positive steps taken over the years which influenced the program and helped to improve accident/incident statistics. The one significant, negative factor has been our inability to retain, as a result of the Access to Information Act, the "privilege" status for Flight Safety Board of Inquiry which did so much to foster trust in the system. The Boards are now provided the limited protection offered in the Access to information Act and the Privacy Act, but they, as an entity, can no longer be withheld. We have yet to feel the full impact of this policy; however, it has forced a rewrite of our manual and a restructuring of our accident-reporting format.
As the new millennium begins, it is fair to say that Flight Safety has come a long way since the disasters of the mid 50's. That there remains room for improvement is a given however, as the gap narrows between performance and expectation, every gain demands greater and greater effort. Flying is not risk-free and military flying even less so. Managing this risk in an ever changing environment is the task facing airmen of the future. A dynamic and responsive Flight Safety Program supported by all levels of command will assist in meeting this challenge.
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