Investigation reports

Flight Safety Investigation report are produced under authority of the Minister of National Defence (MND) pursuant to section 4.2 (1)(n) and 4.2 (2) of the Aeronautics Act, and in accordance with the A-GA-135-003/AG-001, Airworthiness Investigation Manual (AIM).

The contents of the reports shall only be used for the sole purpose of accident prevention.  The reports are released under the authority of the Director of Flight Safety (DFS), National Defence Headquarters, pursuant to powers delegated to him by the MND as the Airworthiness Investigative Authority (AIA) for the Canadian Armed Forces under Part II, section 12 of the Aeronautics Act.

Recent and significant Flight Safety Investigations information are available on this page. The Flight Safety Information Management System (FSIMS) is the primary tool used by Flight Safety Specialist to store Flight Safety information and reports. You may contact your local Flight Safety representative to access any specific reports. For older and archived investigation reports or any public or additional queries contact DFS (dfs.dsv@forces.gc.ca).

For any media queries regarding the current DFS investigations, please contact the CAF Media Relations Office at mlo-blm@forces.gc.ca.

To quickly find a report click Ctrl-F to search with a keyword.

CT114071 Tutor - Crash Site

CT1140071 Tutor - Epilogue

The accident involved a CT114 Tutor aircraft from the Canadian Armed Forces Air Demonstration Team (Snowbirds) enroute to the Atlanta Air Show being held at the Atlanta Motor Speedway in Hampton, Georgia. The aircraft was destroyed upon impact and the pilot received minor injuries as a result of the ejection sequence. The investigation determined that the most probable cause of the CT114071 accident was a fuel delivery system failure within the engine.
June 26, 2020

Nose impact with hangar structure

CC15001 Airbus - Epilogue

On 18 October 2019 a CC150 Polaris was towed from the North ramp to 10 hangar. During the tow tractor change, while no tractor was attached, the aircraft started moving forward and over the chocks. The aircraft sustained very serious damage. The investigation could not positively determine the cause for the parking brake not holding the aircraft in position and recommends the use of approved chocks on all wheels and improved training for towing operations.
June 15, 2020

CH148822 Cyclone

CH148822 Cyclone - From the Investigator

The aircrew were tasked as part of Operation REASSURANCE to conduct a routine surface reconnaissance mission in the Ionian Sea followed by flight deck evolutions for aircrew proficiency upon recovery to HMCS Fredericton. During this final complex manoeuvring turn to close with the ship, the aircraft did not respond as the crew would have anticipated. This event occurred at a low altitude, was unrecoverable and the aircraft entered a high energy descent and impacted the water astern the ship. The aircraft was destroyed and all six occupants were fatally injured.
June 8, 2020

CT114161 - Tutor

CT114161 Tutor - From the investigator

The accident involved a CT114 Tutor aircraft from the Canadian Armed Forces Air Demonstration Team (Snowbirds). Shortly after take-off from Kamloops, BC, aircraft CT114161 was observed gaining altitude and departing the formation. Shortly thereafter, the aircraft initiated a left turn, followed shortly by an abrupt steep nose low attitude. The two occupants ejected the aircraft however one received serious injuries and the other received fatal injuries. The aircraft was destroyed on impact.
June 1, 2020

Hercules CC130J608

CC130J608 Paratrooper Accident - From The Investigator

The occurrence flight was part of Exercise Swift Response 2019, a joint multinational airborne field training exercise led by the United States. During the jump, a paratrooper on the starboard side became hung-up outside the aircraft and subsequently experienced a sudden static line failure which resulted in an uncontrolled descent. The paratrooper sustained fatal injuries.
June 17, 2019

CT114009 - Tutor

CT114009 Tutor - Epilogue

The occurrence involved a CT114 Tutor aircraft from the Canadian Armed Forces Air Demonstration Team (Snowbirds). The Tutor was flying at 600 ft. above ground level in a formation of 4 aircraft. One of the wingman aircraft was rolled into inverted flight as part of the setup for the Double-Take maneuver. Having rolled-out lower than normal in plane to the lead aircraft, the pilot lost visual contact with Lead.
April 26, 2019

CC138803 - Twin Otter

CC138803 Twin-Otter - Epilogue

The aircraft touched down on a smooth area of sea ice, but then bounced into the air after hitting an ice ridge perpendicular to the aircraft’s heading. The aircraft impacted the base of a larger ice ridge once it settled back onto the sea ice. The nose landing gear collapsed and the aircraft came to a stop shortly thereafter. The aircraft was very seriously damaged.
March 10, 2019

CH146477 - Griffon

CH146477 Griffon - Epilogue

The crew of the CH146 Griffon was tasked to transport a replacement generator into a repeater antenna site within the 4 Wing Cold Lake Air Weapons Range. The main rotor blades made contact with the obstruction lights and support bracket at the top of the 96 foot tower.
December 13, 2018

CT156106 Harvard II

CT156106 Harvard II - Epilogue

A student pilot from 2 Canadian Forces Flying Training School conducting solo training on the CT156 Harvard II aircraft experienced the symptoms of a G induced almost-loss of consciousness (A-LOC).
October 24, 2018

ALSE Shop

CF188 Hornet ALSE - Epilogue

On 24 August 2018, it was discovered that an Aviation Life Support Equipment (ALSE) technician at 433 Tactical Fighter Squadron, at 3 Wing Bagotville, Quebec, had shared their Maintenance Release (Level A) personal identification number with technicians in the section, on numerous occasions, in order for other members in the ALSE shop to sign for, and certify as airworthy, ALSE equipment work processes within the unit.
August 24, 2018

CT155211 Hawk

CT155211 Hawk - Epilogue

A near mid-air collision occurred between the CT155 and a Thrush aerial application aircraft returning to Moose Jaw Municipal Airport, following an aerial application in some fields located to the west of Moose Jaw.
August 21, 2018

Bellanca scout

Bellanca Scout C-GSSV - Epilogue

The accident flight was part of the Air Cadet Gliding Program and in support of the summer glider pilot training. The aircraft sustained very serious damage and the pilot received minor injuries. The investigation did not reveal any evidence of technical issues with the aircraft and focused on human factors.
July 17, 2018

CH146432 Griffon

CH146432 Griffon- Epilogue

The occurrence involved a Griffon helicopter from 424 Transport and Rescue Squadron (search and rescue configuration) with a six person crew operating out of the Opa-Locka airport, near Miami, Florida.
February 28, 2018

The glider sustained very serious damage.

Schweizer 2-33A Glider C-GCLE - Epilogue

The accident took place during the summer Air Cadet Gliding Program at the Gimli Cadet Flying Training Center located at the Gimli Industrial Park Airport in Manitoba. The investigation identified shortcomings in the student pilot’s training management and several working and training environment issues including student/instructor ratio, course length and manning of key positions within the Chain of Command.
August 21, 2017

Cessna 172 (C-GAYE) accident site

Cessna 172 C-GAYE - Epilogue

The accident flight was part of the Air Cadet Power Scholarship Program and flown under contract by a civilian flight training unit. The purpose of this flight was to conduct pilot training.
August 2, 2017

G-suit

CF188796 Hornet - Epilogue

Two CF188 pilots (call signs Mig-1 and Mig-6) completed individual Maple Flag missions uneventfully in the Cold Lake Air Weapons Range and returned to base together as a two-ship formation.
June 20, 2017

Search and Rescue training parachute jump. Stock photo not related to the accident.

CC130338 SAR Technician - Epilogue

The accident occurred during a 435 (Transport and Rescue) Squadron CC130H Hercules search and rescue (SAR) training mission.
March 8, 2017

CT156 Harvard II accident site

CT156105 Harvard II - Epilogue

A CT156 Harvard II was operating out of 15 Wing Moose Jaw SK, with a two pilot crew from 2CFFTS. The mission was an instructional flight to practice visual sequences including basic aerobatics.
January 27, 2017

Accident site

CF188747 Hornet - Epilogue

The pilot of aircraft CF188747, using the call sign “Swift 32”, was part of a two-ship formation led by “Swift 31” for an air-to-ground training mission.
November 28, 2016

Glider impacted ground

Schweizer 2-33A Glider C-GFMB - Epilogue

On 15 August 2016, a cadet student pilot was conducting the eighth solo training flight under the Royal Canadian Air Cadet Gliding Program at Comox Airport.
August 15, 2016

A gear up landing was conducted.

CT156115 Harvard II - Epilogue

Two Harvard II Instructor Pilots (IP) from 15 Wing Moose Jaw (IP1- front seat and Aircraft Commander, IP2 - rear seat) were conducting a night cross country proficiency flight to Hillsboro Airport in Oregon, USA.
February 12, 2016

CP140103 accident site

CP140103 Aurora - Epilogue

The CP140 Aurora was taking off from 14 Wing Greenwood, Nova Scotia, on a transit mission to Iqaluit, Nunavut, in support of Operation Qimmiq.
August 27, 2015

The force of the explosion seriously damaged the aircraft.

CT114058 Tutor - Epilogue

A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency.
August 25, 2015

CH12428 on ramp

CH12428 Sea King - Epilogue

The CH124 Sea King was operating from 443 Squadron, in Pat Bay, BC, with a crew of four. 
May 11, 2015

Delamination of the RH Elevator trailing edge

CC15004 Airbus - Epilogue

On 8 May 2015 at 1510 hrs (L), the CC150 departed its base of operation for an air to air refueling mission in support of OP IMPACT.
May 8, 2015

Bell Jet Ranger C-FTHA

Bell 206B3 Jet Ranger C-FTHA - Epilogue

The accident aircraft, a Bell 206B Jet Ranger III helicopter, was on mission NAV 1 of the Phase III pilot training course out of 3 Canadian Forces Flight Training School in Portage la Prairie, Manitoba. The helicopter was crewed by a qualified flying instructor and a student pilot.
May 6, 2015

CH12424 Sea King

CH12424 Sea King - Epilogue

During an over water CH124 Sea King pilot conversion flight south of Vancouver Island, the crew, consisting of a maritime helicopter flight instructor, a student pilot, an air combat systems officer, and an airborne electronic systems operator, carried out various tactical manoeuvres in accordance with the maritime helicopter co-pilot training plan.
December 2, 2014

CH146485 Blade damage

CH146485 Griffon - Epilogue

427 Special Operations Aviation Squadron (SOAS) were on deployment to 12 Wing Shearwater, NS to conduct a Canadian Special Operations Forces Command (CANSOFCOM) Maritime Security Operations (MSO) training mission.
September 29, 2014

SZ2-33A accident site

Schweizer 2-33A Glider C-FYWL - Epilogue

This mission was the Cadet Pilot’s (CP’s) first flight of the day, and 6th solo flight of the Cadet Glider course.
August 13, 2014

Near Mid-Air collision

CT156 Harvard ll - CT114 Tutor - Epilogue

A near mid-air collision (NMAC) occurred southeast of 15 Wing, involving two locally-based RCAF high-performance aircraft.
April 15, 2014

CT156102 Accident site

CT156102 Harvard ll - Epilogue

While conducting an advanced clearhood training sortie in a Harvard II aircraft, a qualified flying instructor (QFI) and student pilot (SP), call sign Apache 11, experienced a hard landing upon completion of a practise forced landing (PFL).
January 24, 2014

Schweizer 2-33 Glider (C-GCLB) accident site

Schweizer 2-33 Glider C-GCLB - Epilogue

The solo pilot was conducting a familiarization flight under the Royal Canadian Air Cadet Gliding Program and had just regained currency after a 334-day break from his last glider flight. The aircraft struck two trees and came to rest on the roof of a convenience store approximately ½ a nautical mile west of the airfield. Damage to the glider was very serious. The pilot was extracted from the cockpit and transported to a local hospital for minor injuries.
September 8, 2013

CC15001 accident site

CC150 Polaris - Epilogue

A contractor technician was lockwiring the drainplug of the left no. 4 flap screwjack gearbox while another technician, who was concurrently working on the right main landing gear brake system, applied hydraulic power to the aircraft.
August 25, 2013

Engine Compressor

CH149906 Cormorant - Epilogue

Helicopter CH149906 was conducting a normal take off to a 10 foot hover.  Three seconds into the take off, at approximately three to four feet above ground, the crew heard a clunk followed by "Master Warning" and "Engine Fail" tones.
August 7, 2013

CH12435 accident site

CH12435 Sea King - Epilogue

The crew planned a night trainer in the local Shearwater area and boarded the aircraft during a hot refuel with engines running and rotors turning.
July 16, 2013

Cormorant CH149910

CH149910 Cormorant - Epilogue

A technician was carrying out a torque check and nut replacement of the bolted connection between the Main Gearbox (MGB) upper case and main case when a lock-ring stud failed in overload.
November 16, 2012

CC138804 Twin Otter accident site

CC138804 Twin Otter - Epilogue

While conducting austere airfield training, during the takeoff from the tundra near Horn Lake, southwest of Inuvik, NT, the Twin Otter aircraft’s nose landing gear collapsed.  There were no injuries among the four crew and two passengers.
August 23, 2012

Schweizer 2-33A Gliders C-GFMC and C-FQMH accident site

Schweizer 2-33A C-GFMC - Schweizer 2-33A C-FQMH - Epilogue

Air Cadet glider familiarization flights were being conducted from the Netook airfield when the weather began to deteriorate.
August 14, 2012

Related Photo

CH146437 Griffon - Epilogue

On completion of a Basic Handling and Emergency training flight, Griffon CH146437 was attempting to conduct a descending, decelerating transition to the hover to a spot south of the fuel pumps with a right hand turn to a northerly heading.
July 5, 2012

Collapsed main wing jack

CC130617 Hercules-J - Epilogue

Early in the morning of 1 Jul 12 (0212Z), contracted personnel working on a CC150 Airbus in 10 Hangar heard a loud noise and noticed that the Hercules in the adjacent Bay 5 was rocking from side to side.
July 1, 2012

CC130342 Hercules - Fuselage burned through

CC130342 Hercules - Epilogue

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.
February 21, 2012

SAR Tech parchuting from CC130 aircraft

SAR Technician - A Cat - Epilogue

In response to a distress call from two men in a small open boat in Hecla Strait, northeast of Igloolik, Nunavut, a Search and Rescue (SAR) CC130 aircraft from Trenton, call-sign Rescue 323 (R-323) was dispatched, arriving on scene at 1505 hours (hrs) local time.
October 28, 2011

Post occurrence: Simulated position of Ramp FE

CH147204 Chinook - Epilogue

The flight of occurrence was a night mission to include hover, simulated slung load, dust-ball and pinnacle landing training.
January 24, 2010

CH147204 after the rotor blades have stopped

CH147204 Chinook - Epilogue

Aircraft CH147204 was on a training mission out of Kandahar airfield.  Subsequent to its departure, an aft rotor fixed droop stop was found on the ramp near where CH147204 was previously parked.
January 18, 2009

Information: Investigation report types

At the wing level, following the notification of a FS occurrence, Supplementary Reports are produced for minor or non-complex incidents, once the investigation by the Wing or Unit Flight Safety Officer is completed. Those reports are not made public and, therefore, not published on the DFS website.

In the case of occurrences investigated by DFS, the investigation will usually be classified as a Class I, or Class II, investigation depending on the aircraft damage level, the personnel casualty level, and the safety of flight compromise level.

DFS will document their investigation results in one of the following reports, depending on the class level:

  • For Class I or Class II level investigations (investigations of aircraft accidents and serious incidents): From the Investigator (FTI), Flight Safety Investigation Report (FSIR) and Epilogue;
  • For selected Class II or Class III level investigations (occurrences that are sufficiently complex to warrant a more thorough investigation than a normal Supplementary Report produced at the wing level, but that do not require the same degree of scrutiny that is required for Class 1): Enhanced Supplementary Report (ESR) and Epilogue.

From the Investigator (FTI)

The FTI summarizes information contained in the preliminary report issued by the investigation team after it completes the first phase of its work. Subject to the requirements for operations security, this summary will describe factual information and immediate safety actions taken, and provide an indication of the direction in which the investigation is proceeding.

The FTI is usually made public and posted on the DFS website within five weeks of the incident.

Flight Safety Investigation Report (FSIR)

Once the investigation is complete, the final FSIR is prepared. This is a comprehensive report on a specific flight safety occurrence that includes recommendations for preventive measures. The report will contain all conclusions and recommendations associated with the occurrence. It contains four sections - facts, analysis, conclusions and preventive measures - and is released to the public under the authority of the Director of the DFS.

The report closely parallels the internationally accepted International Civil Aviation Organization (ICAO) format.

The Report’s recommended preventive measures are provided to the chain of command and applicable action organizations for their consideration. DFS has no executive authority to direct the implementation of the preventive measures. If the investigation team uncovers information that the aviation community needs to be made aware of immediately, this information is communicated without delay.

The FSIR is usually posted on the DFS website within 12 to 18 months of the incident, depending on the complexity of the investigation.

Epilogue

The Epilogue summarizes the information contained in the FSIR. The Epilogue is made public and usually posted on the DFS website at the same time as the FSIR.

Enhanced Supplementary Report (ESR) and Epilogue

The ESR is to be used for Class II or selected Class III level investigations. The reporting requirements are the same as for the Supplementary Report (30 days) except that the investigation paragraph will be more detailed. This report will not be released to the public.

Once the Class II level investigation is closed, an Epilogue will be made public and posted on the DFS website, usually within six to 12 months from the incident.

Date modified: