Flight Safety Investigation reports
Flight Safety reports are produced under the authority of the Minister of National Defence (MND), pursuant to sections 4.2 (1)(n) and 4.2 (2) of the Aeronautics Act. Flight Safety reports are prepared solely for the purpose of aviation safety.
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 (firstname.lastname@example.org).
For any media queries regarding the current DFS investigations, please contact the CAF Media Relations Office at email@example.com.
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The accident aircraft, call sign “Outcast 903”, with a crew of six, was scheduled for two crew training missions based out of 9 Wing located at Gander International Airport (CYQX), N.L. The first training mission was scheduled in the afternoon and was primarily focused on overland Search and Rescue evolutions for the Flight Engineer Under Training.
April 6, 2022
The accident involved a CT145D King Air 350 from the 8 Wing Multi Engine Utility Flight (MEUF). The mission consisted of a multi-day cross country training and familiarization trip with three military aircrew members onboard. The accident happened on the first segment of the mission.
March 8, 2022
The Chinook was flying in concert with two CH146 Griffons in VMC (Visual Meteorological Conditions). Very shortly after touch down, the Flight Engineer (FE) called for the pilot to abort the landing. The pilot flying (PF) aborted the landing and started to climb the aircraft into a hover. The aircraft entered into an unstable flight regime shortly after with strong lateral oscillations causing the PF to initiate an emergency landing. Upon touch down, the FE called for an emergency egress whilst the PF initiated an emergency shutdown of the aircraft. Two of the front rotor blades made contact with the fuselage and the rear landing gear collapsed.
June 11, 2021
During the aircraft acceptance check for aircraft CH148805, avionics technicians inspected the #1 Power Distribution Unit as per the Fleet Work Instructions. Terminal wire lugs T1, T2 & T3 were found unsecured. A Foreign Object Damage (FOD) check was carried out and all missing hardware for T1 lug was located just below in its cover panel. The preventive measures recommend a publication amendment, and a design change to prevent the nuts at the terminal connections from backing off when subjected to vibrations.
May 13, 2021
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.
May 11, 2021
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.
April 22, 2021
The accident involved a CT114 Tutor aircraft from the Canadian Armed Forces Air Demonstration Team (Snowbirds). Following the take-off, a loss of engine thrust resulted from a bird ingestion. The pilot initiated a climb straight ahead and then elected to carry out a left-hand turn back towards the airport. The manoeuvre resulted in an aerodynamic stall halfway through the turn before the pilot gave the order to abandon the aircraft. Both occupants subsequently ejected and the aircraft was destroyed upon impact in a residential area. The passenger was fatally injured and the pilot received serious injuries.
January 29, 2021
A Near Mid Air Collision (NMAC) occurred between a CT156 Harvard II on a simulated minimum fuel Precision Approach Radar (PAR) and a formation of two CT155 Hawk aircraft on visual flight rules (VFR) downwind leg. A 4g pull was immediately initiated in order to avoid the Hawk formation, resulting in a separation of approximately 300 feet distance.
October 5, 2020
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
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
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.
February 26, 2020
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.
February 4, 2020
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.
January 28, 2020
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
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
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
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 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 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
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
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
The accident occurred during a 435 (Transport and Rescue) Squadron CC130H Hercules search and rescue (SAR) training mission.
March 8, 2017
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
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
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
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
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
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
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
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
The flight of occurrence was a night mission to include hover, simulated slung load, dust-ball and pinnacle landing training.
January 24, 2010
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.
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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