Investigation reports

Recent and significant Flight Safety Investigations information are available on this page. For any additional queries contact DFS (dfs.dsv@forces.gc.ca).

Flight Safety reports are produced under the authority of the Minister of National Defence pursuant to Section 4.2 of the Aeronautics Act, and in accordance with A‑GA‑135‑001/AA‑001, Flight Safety for the Canadian Armed Forces. They are prepared solely for the purpose of accident prevention and shall not be used for legal, administrative, or disciplinary action. The analysis, findings and cause factors, and recommendations contained within Flight Safety reports form the opinion of the Airworthiness Investigative Authority and as such are neither competent nor compellable within a court of law.

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

Nose impact with hangar structure

CC15001 Airbus - From the investigator

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.
October 18, 2019

CT114071 - Tutor

CT1140071 Tutor - From the investigator

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.
October 13, 2019

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 - From the investigator

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 - From the investigator

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 - From the investigator

The crew of the CH146 Griffon was tasked to transport a replacement generator into a repeater antenna site within the 4 Wing Cold Lake training area. 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 - From the investigator

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

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

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

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

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.

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