Flight safety: Identifying what went wrong

Avatar for Tim DunneBy Tim Dunne | June 12, 2020

Estimated reading time 10 minutes, 5 seconds.

The 117-year history of powered aviation has led to the creation of a multitude of specialized aircraft, from small ultralights to the 850-passenger Airbus A380-800, the largest passenger aircraft ever made to date. While continuous research, development and experimentation has made flight higher, faster and safer, it’s also true that incidents, accidents and tragedy can still befall aviators and passengers.

CF Snowbirds Photo
The Directorate of Flight Safety is the military equivalent of the Transportation Safety Board of Canada, in that it investigates and researches all crash incidents involving RCAF aircraft. CF Snowbirds Photo

This was the fate of seven Canadian military personnel in less than three weeks. Two Royal Canadian Navy officers of HMCS Fredericton and four RCAF aircrew of 423 Maritime Helicopter Squadron assigned to that ship died on April 29, when their CH-148 Cyclone maritime helicopter crashed into the Ionian Sea. Then, on May 17, Capt Jennifer Casey died when the CT-114 Tutor aircraft in which she was a passenger crashed in Kamloops, B.C.

The April 29 accident involved the recently-acquired Cyclone, the eagerly-anticipated replacement for the half-century-old CH-124 Sea King helicopter. The 58-year-old Tutor flown by the Snowbirds aerobatic team, conversely, is the oldest aircraft in the Canadian military inventory.

All significant aircraft accidents in Canada are investigated. The Transportation Safety Board of Canada (TSB) conducts inquiries into incidents involving civilian aircraft, while its military equivalent is the Directorate of Flight Safety (DFS) at Department of National Defence (DND) headquarters, headed by Col John Alexander.

The DFS mandate is “to champion a pro-active and innovative Flight Safety Program to enhance combat-effectiveness through the prevention of the accidental loss of aerospace resources,” and it “fosters the safe execution of operations through independent investigations, active participation in the airworthiness program and leadership in the Flight Safety Program.”

Historically, the flight safety program began following the Second World War. The data from flying operations of the 1950s indicated that the RCAF was losing a lot of aircraft and a lot of personnel, both on the ground and in the air. That’s why and when the flight safety program had its genesis.

The Canadian military’s level of accident acceptability is exactingly comprehensive.

“Every investigation is done differently,” explained Alexander. “We have four graduated levels of investigation. The lowest level, Class 4, will generally encompass most of your Category D and E level accidents. Those are done at the Wing and squadron levels. We have trained flight safety personnel at all our RCAF Wings and flying units who can do these investigations within a 30-day turnaround.”

Like class 4 investigations, class 3 are conducted by the assigned Wing or Formation Flight Safety Officers (FSO) which assign and authorize the Investigator in Charge and supporting investigation team. The investigation report is submitted to and released by the FSO.

“Class 2 investigations, the second-highest, will usually result in what we call an enhanced supplementary report. This is a more streamlined report that can be produced more quickly than the typical full, or Class 1, flight safety investigation.

“A Class 1 investigation looks at Category A and Category B accidents which involve loss of life or major injury and perhaps loss of the airframe. A Category B accident may have major injuries with serious damage to an airframe where multiple major components are damaged. This would bump that incident up to a higher-level investigation that would be undertaken by DFS.”

HMCS Fredericton sails away from Halifax along with its embarked CH-148 Cyclone helicopter on Jan. 20. Royal Canadian Navy Photo
Two Royal Canadian Navy officers of HMCS Fredericton and four RCAF aircrew of 423 Maritime Helicopter Squadron assigned to that ship died on April 29, when their CH-148 Cyclone maritime helicopter crashed into the Ionian Sea. Royal Canadian Navy Photo

Over the past five years, there has been an average of 2,920 investigations annually, of which 99.8 per cent were Class 3 or 4 conducted at the Wing and squadron level. Only 0.2 per cent, averaging six investigations annually, were the more serious Class I and II investigations where the level of damage ranged from major damage to loss of an aircraft, or serious to fatal injuries.

All contribute to the directorate’s collection of lessons learned.

The 25-member DFS is divided into two sections: Promotion & Education and Investigations. The former produces informational and educational materials such as Flight Safety Comment magazine, flight safety posters and informational literature, and conducts statistical and data analysis. They examine and evaluate flight safety-related data across the whole of the RCAF on a daily basis. The vast majority are Category D and E where only minor or no damage is done, but the potential for greater damage or injury is recognized.

“It could be something as innocuous as someone bumping into an aircraft or dropping a tool on an aircraft that causes a dent or a scratch on the paint,” Alexander noted. “This is registered as a Category D. That is the nature of most of the incidents.

“So with the D and E categories, if you can prevent those from happening and learn from those incidents, you can prevent those increasingly dangerous and significant incidents, the ones causing serious damage to airframes and our personnel.”

The investigation

The DFS Investigations division observes the individual fleets of aircraft and becomes the investigator-in-charge of the Flight Safety Investigation Team responding to a serious accident or incident. The team composition is contingent on the nature of the accident.

Typically, an investigation team will comprise a pilot, an aerospace engineering officer, a photographer, a custodian for the often-enormous amount of material which investigators collect, and other specialists, including the original equipment manufacturer, as necessary. The Flight Safety Investigation Team can incorporate both military and civilian subject matter experts to provide insight and analysis on any particular issue relating to the investigation.

Col John Alexander, pictured, is the head of the Directorate of Flight Safety. Canadian Armed Forces Photo

“The team endeavours to discover that last layer of defence that didn’t respond the way it should and then works their way backwards to determine if there are also other layers, circumstances and factors that can be identified and rectified,” Alexander explained.

“We begin by collecting perishable evidence. If you have a wreckage in the field you want to capture photographs, oil samples and fuel samples as quickly as possible before they permeate into the soil.  Those are perishable things that we need right away.”

In general, the team looks at mechanical, maintenance and human factors. The human element consumes most of their attention.

Ultimately, the Flight Safety Investigation Team analyzes the timeline leading up to the event to draw lessons learned, to develop preventive measures and prevent any repetition. Similar to the civilian TSB, the team does not and cannot assign responsibility for the accident, nor determine liability and/or assign blame.

Flight safety investigations can take up to a year and longer. They differ from criminal investigations with their statutory rights under the Canadian Charter of Rights and Freedoms and the Criminal Code. The Aeronautics Act of Canada provides privilege of an individual’s witness statement. The accident report summarizes individual statements to protect identity and eliminates anything that can refer to witness statements. They go to great lengths to remove even an individual’s gender identification.

Flight safety reports used to remain classified, but no longer.

“It’s challenging in today’s media world,” Alexander noted. “Folks always want to have an answer right away about what went wrong. The challenging part for us is to ensure we understand the events correctly and get the information out to the communities as quickly as we can to prevent it from happening again.”

Flight safety investigation budgets are not unlimited, but, “We are funded every year for a certain amount. However, if we have a major accident that’s going to be fairly taxing and difficult, those funds are provided to make it happen.”

“As a pilot, I am very motivated both personally and professionally,” concluded Alexander. “These are my comrades and my friends flying these aircraft. You will always want to get to the bottom of what’s happened in an incident or accident to prevent it from happening again.”

Tim Dunne is a retired military public affairs officer with 37 years service in Canada, the United States, eastern and western Europe, the Middle East and Africa. He has served with both the United Nations and NATO. In his retirement he is a professor of communication studies at Mount Saint Vincent University and a military, defence and security analyst and writer.

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