Annual Report

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 Forces. They are prepared solely for the purpose of accident prevention and shall not be used for legal, administrative or disciplinary action.

The intent of the annual report is to provide a brief analysis of Flight Safety information for the chain of command and to Flight Safety staffs at all levels. The Annual Report describes the major occurrences of the year, provides statistics on key indicators, and gives a synopsis of significant trends identified.

The Annual Report Executive Summary is provided below. The full version of the report is available upon request to DFS at: dfs.dsv@forces.gc.ca

This is the 15th 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 Investigative Authority (AIA) and the activities overseen by the Director of Flight Safety (DFS) in relation to the FS Program for 2019 with some statistical comparison to the previous 10 years.

At first, I would like to focus on the professionalism and dedication demonstrated by all FS personnel across the country. The Wing and Unit Flight Safety Officers and their teams continue to influence positive changes from the floor and up as well as to provide counsel to the leadership. Their vigilance, involvement and initiatives have contributed directly to the good health and promotion of the FS Program.

In June 2019 there was a major occurrence which saw the loss of life of Bombardier Patrick Labrie while conducting paratroop jumps from the CC-130J over Cheshnegirovo, Bulgaria. During the jump, a paratrooper on the starboard side became hung outside the aircraft and subsequently experienced a sudden static line failure which resulted in an uncontrolled descent. At the time of writing this annual report, the Flight Safety Investigation Report has been concluded for this accident and is awaiting publication.

In October 2019, while preparing for an airshow at the Atlanta Air Show, Snowbird 5 experienced a loss of power. Efforts to recover the engine were unsuccessful and resulted in the decision of the pilot to eject from the aircraft. The aircraft crashed into a pasture. The pilot sustained minor injuries associated with the ejection sequence. No one was hurt or injured on the ground. The aircraft was completely destroyed.

The Flight Safety Information Management System (FSIMS) is declining in functionality and the basic capacity to provide the required statistics to give us a good picture of what’s happening out there is questionable at times. The software was developed internally within the department and its continued development is slow and challenged. This system does not meet the capacity of several “off the shelf” options available to support modern data analytics.

DFS continues to develop their network with other National Flight Safety organizations by participating in various national and international forums. The principle goal: to improve and strengthen our own FS program via an exchange of Flight Safety information, ideas on the prevention of accidents and to promote Flight Safety awareness by applying lessons learned by other militaries.

While Canada along with many of its partners has reduced its accident rates to historically low levels over the last decades, there is still more to be accomplished to achieve a zero accident rate. Many nations are now employing Flight Data Monitoring (FDM), also referred to as Military Flight Operations Quality Assurance (MFOQA) in some countries, as a means to predictively identify risks to aviation before an accident has to occur. FDM is the analysis of routine flight data to detect, measure, and mitigate hazards, while promoting the proper use of data for safety. The RCAF is embarking upon a program to implement this capability across those fleets with Flight Data Recorders capable of supporting this program.

Human Factors continues to be the largest cause factor assigned to accidents and incidents within the CAF. In some regards this is positive in that other cause factors like materiel are continuing to stay low and relatively under control. It speaks to the quality of the airworthiness program in putting forth reliable aircraft and operationally employing them with a judicious assessment of the risk. However, Human Factors should be within our grasp to control. To do so effectively one must appreciate the limitations to the human cognitive processes, physical limitations and cultural and personal biases. It is not enough to mandate through fear of retribution policies to avert human nature, such as the innate evolutionary favored tendency to cut corners. The Just Culture principles must continue to be embraced throughout the Chain of Command. Fairness in the eyes of the people doing the work, when managing human mishaps and behaviours that put safety at risk, continues to foster open reporting to enable a good safety culture.

There is rarely a new error. All the conditions for mistakes are known and all errors/lapses are falling into recurrent patterns: different people at different bases from different organizations keep on having the same issues. We must take every opportunity to learn from all incidents before they become serious accidents. Failure to learn and to adapt, even to the changing cultural demographics within our Forces means we are destined to repeat incidents and accidents again and again.

The Flight Safety Program is most successful in units and formations where the command elements have chosen to take leadership of the program. The Flight Safety team at all level serves to identify the risks such that the command teams may make appropriate decisions.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.

John Alexander
Colonel
Director of Flight Safety and
Airworthiness Investigation Authority