2001 1 Eng

EM-177 Epub(FltWinter)_LR 30/1/2001 16:35 Page a
WINTER 2001
IN THIS ISSUE:
Impressed by Experience
▼▼▼ ▼
Aerospace Life Support Equipment

It Almost Cost A Life
20-20 Hindsight
EM-177 Epub(FltWinter)_LR 30/1/2001 16:35 Page b
Table of Contents
1 .......................................................As I See It
2...............................Impressed by Experience
Directorate of Flight Safety
Director of Flight Safety
Col R.E.K. Harder
Editor
Capt T.C. Newman
Art Direction
DGPA–Creative Services
Translation
Coordinator
Official Languages
Printer
Tri–co
Ottawa, Ontario
8 ..................................Conversion Nightmare The Canadian Forces

11 ......................................Letters to the Editor Flight Safety Magazine
12..............Aerospace Life Support Equipment Flight Comment is produced 4 times a
year by the Directorate of Flight Safety.
14 .................................A Good Day for Traffic The contents do not necessarily reflect
official policy and unless otherwise
stated should not be construed as
regulations, orders or directives.
Contributions, comments and criticism

are welcome; the promotion of flight
safety is best served by disseminating
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ATT:
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Directorate of Flight Safety
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101 Colonel By Drive
Ottawa, Ontario Canada K1A 0K2
15 .....................................It Almost Cost a Life Telephone: (613) 995–7495
FAX: (613) 992–5187
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EM-177 Epub(FltWinter)_LR 30/1/2001 16:35 Page 1
Improved Analysis Clearly we need to look at our Because activities at each level affect
of Human Error own susceptibility to error with those below, it is helpful to look at
openness and understanding (and the organization from the top down.
I n the early years of flight safety
programmes, we saw dramatic
improvements in the aviation acci-
humour). There are some principles
that help us to understand and
Imperfect decisions of upper-level
management directly effect supervi-
reduce human error: sory practices, as well as the condi-
dent rate. In fact, this lasted through tions and actions of operators, main-
to the early 80’s, attributable partly • Error is applicable to everyone! —
tainors and support personnel. The
to improved attitudes, but largely regardless of age, race, height, sex,
organization allocates resources, and
to improvements in aircraft design, native language, national origin,
sets the operational tempo, time
materials, and better and more stan- rank or intelligence.
pressures, procedures, incentive sys-
dardized training. In the last two tems, and schedules. Supervisors
• The first step in understanding
decades, further reductions have know (or should know) the capabili-
error is to consider error apart
eluded us, but costs of accidents have ties of their people, decide which
from its consequences. This is
gone up at the same time that society people to assign to which jobs, and
important so we can look at
is becoming less tolerant of them. sometimes decide which missions
the error without emotion and
Furthermore, the majority of these will be undertaken.
defensiveness.
remaining accidents are caused by
what appears to be both our greatest • This approach attempts to enlist Looking one level lower, people
strength and our greatest weakness the people doing the work as sci- do not normally make mistakes or
— the human being. entists in the understanding of commit violations “out of the blue”.
their own mental processes by There are normally circumstances,
As a result we are looking at better or “pre-conditions” which either
encouraging openness.
ways to analyze the effects that peo- cause them to make the mistake or
ple have on accidents. Until now, we • And finally, once the defining
increase the likeliness of their mak-
have assigned personnel cause factors characteristics of any error type
ing it. This area is worth examining
such as “inattention” or “judgement”. are determined, counteracting
in a little more detail.
But how do you correct a problem strategies can be developed.
relating to inattention or judgement Medical or physiological conditions
As I noted earlier, accidents are nor-
except to remind people to exercise such as spatial disorientation, visual
mally caused by the whole system
better judgement or be more atten- illusions, G-induced loss of con-
of the organization. A way of looking
tive? What’s more, we have tended sciousness (G-LOC), hypoxia, physi-
at the human factors of the whole
to focus on the individual who made cal fatigue, and the myriad of phar-
organization has been devised by
the active failure, the one to whom macological and medical abnormali-
some behavioural psychologists at
the accident actually happened. But ties known to affect performance are
the UN Navy Safety Center which
current work in the area of accident equally important. If, for example,
we have found particularly useful; it
prevention has shown that an acci- an individual were suffering from
divides the human factors into:
dent does not happen to an individ- an inner ear infection, the likelihood
unsafe acts, preconditions for unsafe
ual, but to the organization — every of spatial disorientation occurring
acts, unsafe supervision, and organi-
layer of that organization has some- increases. Consequently, the medical
zational influences. In this way, we
how contributed. In fact, the individ- condition must be addressed within
look not only at the individuals
ual who was the direct cause is only the chain of events leading to an
involved in the final stages of an
the last (and least manageable) fail- accident.
accident, but also at the whole orga-
ure in a chain of events. If we want
nization that has affected the condi- In today’s complex environment,
to reduce accidents caused by people,
tions that allowed the accident to people usually work in teams.
we needed a new system, one that
ultimately occur.
steers us toward more effective continued on page 9
corrective action at all levels.
Flight Comment, no 1, 2001 1
Impressed by
s the guys in the back were little comments to the crews on how
A making fun of me, I once again
told John that we should turn back
it was just like a newbie to get lost.
At that point, we agreed that it would
a few miles to the last valley I could
be best just to head back to Stuart for
remember on the map and start
the night and resume covering our
again. He smiled and said nothing as
assigned search area in the morning.
he gave his head a nod indicating to
After a few more humorous attempts
me that he knew where we were and
at getting John to go back, he sur-
not to worry. It was a nice clear after-
prised me by heading over a ridge
noon and we had been searching the
into a new valley. The crew seemed
same mountain range for the past
indifferent at this point, except to
I promised myself that from few days. I figured that if he wasn’t
make encouraging remarks about
worried, then why should I be? After
that moment on, I would not John’s experience in SAR and his
all, he was a SAR veteran, full of sto-
time on the West Coast and that he
be intimidated or impressed ries and loved by all. I, on the other
surely must know where we were.
by another pilot’s experience hand, was a pipe liner, fairly new to
It did not take long before John was
the squadron and had still to earn
or skill if he attempted to over a few more valleys, and I knew
the trust and respect of many on the
that I would never recognize any fea-
endanger my or any crew helicopter side of the house.
tures being so far away from my last
member’s life. I tried to cover up the fact that I had known position.
no clue as to our location in the B.C.
We suddenly found ourselves over
mountains, but it was just as the guys
a valley with low-lying cloud below
in training said it would be, simply
us and I could not believe how much
look away once or lose track of a val-
altitude we had gained in such a
ley and you’re lost. The old Omega
short time. John still had the crew
and Loran were not accurate enough
worked up and I thought that I was
to be of any help, so I tried to recog-
the only one who was getting ner-
nize any feature to pinpoint our loca-
vous. I remembered another SAR
tion, but it all looked the same. John
pilot once telling me that if I felt
seemed to be in control, adding his
uncomfortable in flight, that there
2 Flight Comment, no 1, 2001

E xperience
would always be someone else on
the crew who felt the same and that
all I had to do was speak up and the
others would follow. At that point,
I told John that I thought that we
Silence soon took over again as
they informed us that since the
weather was down at Stuart, they
would be heading direct for Terrace
with their fuel sate. All thoughts of
I think the biggest shock I got was
not from the fact that John had just
lead his crew to death’s door, but on
shut down, one of the guys came
forward and congratulated John
could be in some trouble soon if the Twin Otter vectoring us to the on what a great job he had done of
we didn’t figure something out. airport vanished and no mention bringing us down. He went on to say
Sure enough, a few crewmembers of our situation was ever passed to that not many pilots on squadron
agreed and we finally got serious the Twin Otter crew. I think John could have brought us home safely
about our situation. felt guilty and did not want details if they found themselves in the same
of our little adventure passed all situation. I sat in amazement as the
As we kept climbing, hoping to get
over search headquarters and the cheers for John echoed the cabin and
visual over the next range, we found
squadron for fear of ridicule if could not help but wonder where
ourselves in the worst situation pos-
we ever made it back. this crewmember was for the past
sible. The flight engineer (FE)
two hours. I wanted to ask him who
echoed our thoughts about our We were circling with uncertainty
he thought got us into the situation
diminishing fuel state and that we when we spotted the only mountain
that required John’s skill and experi-
should think about putting down peak above the cloud layer. Upon
ence to bring us back in one piece.
somewhere. The problem with that examination of the map, we headed
was that we were now at over ten for the peak since it was within ten The following week, John was
thousand feet above sea level with a miles of Stuart. John handled the old downgraded to first officer and
solid layer below us. Not a reassuring Labrador like the seasoned pro he a re-evaluation of his IFR skills
feeling when you have no clue where was, as we descended the side of the were ordered. No reason was given,
you are or what is below you. The mountain barely maintaining VFR but I am certain our little trip was
Stuart airport did not have a preci- with the hope of breaking out. Our the cause. Rumours spread of who
sion approach, which eliminated the fuel situation was critical and we might have spoken out, but I
hope of shooting an ILS back to agreed to put down anywhere when promised myself that from that
solid ground. The FE had calculated we made it through. Visual again, I moment on, I would not be intim-
our VNE (Velocity Never Exceed quickly found our position and we idated or impressed by another
speed) for ten thousand feet to be decided to head for Stuart until our pilot’s experience or skill if he
around fifty-five knots. The blades low fuel light came on. Luckily, we attempted to endanger my or
overhead were struggling for dense made it without any further incident any crew member’s life.
air as they went around and I think and it was strongly recommended
I later went on to instruct at the
that it was at that point that the last by John that we keep our little trip
helicopter flight school for ab initio
comic on board realized we were no to ourselves. Being the new guy on
students and of all my SAR stories,
longer making fun of being uncer- the block, I wondered how many lit-
I made sure that they listened and
tain of our exact position. tle trips other guys had been on and
understood my little story about
though that this was all part and
Silence turned to cheers when my flight with John. ◆
parcel of being a SAR pilot.
we heard the crew of a SAR Twin
Otter calling the Stuart airport.

Getting Home Early for

Christmas With the successful run completed,
both techs had their heads up the
The final result of this was that the
engines flamed out while the air-
afterburner trying to discern what craft was on the runway preparing
might have been ejected from the for its take-off roll. The flight was
back-end. Best guess ran to a rag aborted and a catastrophe was
that may have been wedged between averted.
the bypass ducts, accounting for its
fiery state. Working on the philoso- Lessons Learned
phy that one can never do too much, Five minutes saved is never five
it was decided to tow the aircraft minutes saved. Always record
back in and have a closer look with everything that is a pertinent main-
strong flashlights. The most experi- tenance action. This is a problem
enced technician, intent upon con- that crops up constantly, informa-
current activity, would complete the tion passed on verbally, assumptions
hristmas in Germany is full of
C good cheer and hail-fellows
well met. Christmas Eve found F-18
run on the second aircraft. In the
hangar, the less experienced fitter
was under the impression that the
made, and the good old halo effect.
This was a tasking that started off
with the best of intentions. A prob-
Phase busy as always attempting to flame holder may be missing a piece lem was observed, and a plan of
complete two inspections. Both of material. Working under that action was devised. Unfortunately
aircraft required run-ups for leak assumption, the decision was made the plan forgot that the most
checks. With the completion of to change the engine, not a labour- important step, a successful conclu-
paperwork, and assuming there intensive project on the F-18. sion, does not necessarily entail
would be no problems, the skeleton everyone getting home early for the
The engine change was in the pre-
crews hoped to be at home for the holidays. Secondly, the crew that day
liminary stage of opening cowlings
holidays by the early afternoon, and was at the barest minimum. This
and pulling circuit breakers, notably
anticipation was driving this goal. added to the perception of pressing
those that cut off fuel to the engines.
Both aircraft were towed out, and, It was at this time that the more that existed. Doing the job these
as they were only low power run- experienced technician appeared. days with fewer personnel and
ups, they could be completed Upon further consultation, and a bit resources is a problem that all
unchained on the taxiway by of head slapping, it was concluded supervisors must be aware of. Part
Snags/Phase. As with any plan that that the flame holder was normally of this awareness entails realizing
assures success without amend- shaped like this, and in fact, the that completing maintenance
ments, there was an immediate engine was serviceable. The paper- actions quickly does not necessarily
problem. Immediately upon start- work, which up until this time had translate into better. Finally, if it’s
up, a fiery object exited the left- been used to record all the mainte- written down, at least it can be
hand engine. The conversation nance activity, was ripped up and questioned and confirmed. There
between the run-up person and everything was put back to its prop- are constants in society that always
the ground man decided to press er state. Everything, that is, except put pressures on the flying world;
on with the leak run and shut for the circuit breakers which con- there will always be holidays…
down to check out the situation. trolled the fuel to the engines. funerals too. ◆

TEACHING
TEACHING A
A LESSON
LESSON
am needed a lesson and I was the he would head the glider straight
S one who would teach it to him.
After all, I was the gliding instructor
seldom gives lots of height to work
with and a pilot had to know when
to stop his 360º turns and other
for the landing area since we would
be low in the circuit. However, not
who got Cathy over the hump, when maneuvers. A pilot has to be in taking control at that point was
the other instructors had all but position to join the circuit at mid- another mistake. Sam, coming out
given up. At the top of winch field with sufficient height and the of the turn, continued as if the situ-
launch, Cathy insisted on handing correct distance from the landing ation was normal and proceeded
control to the instructor, as soon as site. This afternoon, we reached with the circuit. Again, I did noth-
she encountered a little negative “G”, 1100’ with a light breeze blowing ing! I suggested to Sam we cut off
put in place to take pressure over straight down the runway. some of the circuit. As we proceed-
the nose hook and initiate a cable ed over the trees, I noticed our sink
Several flights prior, Sam appeared
release. Aware of this peculiar rate increase. Sam was pulling the
to be getting the hang of it. After a
behaviour and knowledgeable of the nose up as if to avoid the trees. At
few turns and gentle stalls, we were
glider flight characteristics, I devised that moment I took control, proba-
heading downwind slightly outside
a plan. Cathy was seated in the front bly three to five feet over the 30-foot
the circuit mid-field entry point of
seat of the 2-33A and initiated the trees. I felt as if I could touch them.
800’. I was thinking that this was a
launch sequence and climb-out. At As we passed over the edge of the
prime time to challenge if Sam was
the precise moment of experiencing tree line, the glider was all but stalled
learning anything from the previous
negative “G,” Cathy urgently and settled to the ground like a
concepts. I know that students
announced “Sir, you have control.” falling leaf rolling three or four feet
will initiate almost any action an
My plan and answer was a simple and then stopping one foot from
instructor might ask. I asked Sam
“No.” Cathy, having never flown an embankment. The heat from
to initiate a 360° turn to the right
with me and perhaps expecting the trees must have provided just
and away from the airfield. This is a
some serious situation to develop, enough lift to get us over the tops.
“No-No” at this height and distance
immediately grabbed the joystick,
and the student should decline the My complacency and poor judge-
released the winch cable, and con-
suggestion. While thinking I would ment almost resulted in a serious
tinued the flight. Cathy was on her
allow Sam to turn 90° and then take accident. It was a lesson I have never
way to becoming a successful pilot.
control, Sam had quickly initiated forgotten. Sam finally received a
Sam, on the other hand, had diffi- an uncoordinated steep turn and license, but never flew after that
culty judging height and appropri- was past the 180° point before I summer. ◆
ately judging when to join the cir- could react. At this point, I decided Maj. Lomond
cuit. Glider launching off of a winch to allow him to continue, assuming

Change of Plans
light safety will most likely get aircraft had developed. The problem we continued to veer left, ever closer
F your attention when you least
expect it to. Such was the case for
could not be rectified until late in
the afternoon, which meant training
to the runway edge. I then inserted
right rudder, which straightened us
myself and my crew on a local for the day would be cancelled. out immediately. With coordinated
Search and Rescue (SAR) trainer reversing and careful use of the
With only a few hours left in the
near Winnipeg. The day started out brakes we came to a stop. While our
day, the servicing crew gave us the
as any other with each crewmember gear was being loaded we could see
good news that the aircraft was
taking care of their assigned duties just how slippery the ramp and run-
ready to go. We decided to complete
to enable us to launch within our way were by watching our crewmem-
our proposed training, but, since we
30-minute posture in the event of bers struggle to stay on their feet; it
were time restricted, we opted to
an actual callout. Our assigned area was completely ice-covered. Once the
train in Gimli. Since it is an ideal
of responsibility seemed to be quiet gear was loaded we taxied and took
place to train due to its close prox-
for the time being, so we decided to off without incident.
imity to Winnipeg, the SAR pilots at
carry out SAR training consisting of
our squadron are very familiar with Slippery runway conditions were
various equipment and personnel
Gimli. With the plan set in motion factored into our morning planning
paradrops. A discussion on choos-
we checked the weather, filed a VFR but in the afternoon they were
ing an aerodrome where this train-
flight plan, and set off for Gimli — ignored. The runway condition was
ing could be carried out took place.
without considering the runway overlooked due to the false sense of
The weather was not a factor since conditions! urgency to complete our training in
it was CAVOK but a system had the time allotted and the false sense
We completed the paradrops with-
passed through the previous night of security of going to a place with
out incident and set up for a normal
leaving most runways very slippery. which we were very familiar.
landing to pick up our gear and
The condition of the runway is a Important lessons were learned that
personnel. After touchdown, I went
very important aspect to consider if day. Never become complacent and
for the nose wheel steering which
you are planning to operate an air- do not let a change of plans, change
we use to steer the aircraft during
craft on the airfield. It can seriously your planning!! ◆
low speed ground operations. The
affect how the aircraft will handle Capt. D.R. Bjerke
aircraft started to veer to the left.
during takeoff, landing, and taxi.
Increasing my input on the nose
After all factors were taken into wheel steering had no effect and
account we decided to go to
Saskatoon where the runways were
reported to be 100% bare and dry.
When we arrived at the servicing
desk to sign out the aircraft we were
informed that a problem with the

LESSONS
LEARNED
t was a beautiful day throughout
I the Maritimes and my CC144
Challenger crew were setting out
from Ottawa on a two-day trainer
down East. Things went smoothly
until we approached Shearwater, our feed line to the RH engine, and a demands of manoeuvering the
intended destination for the night. RH engine failure. This also gener- aircraft into the proper stabilized
ated a fire because the torn fuel feed approach window on short final
As a final approach for the day, and,
line allowed residual fuel to travel (approximately 200’AGL) left little
in order to maximize the training
along the aircraft skin to the APU time for the pilot flying to mentally
benefit, a TACAN approach was to
exhaust where it was ignited. This prepare for the flapless landing.
be flown to the non-active runway,
fire forced the crew to complete an Landing and take-off are the most
and then the aircraft would circle in
urgent, flapless, single-engine crash demanding phases of flight and they
a flapless configuration to the active
landing. Due to the missing gear, should not be attempted unless all
runway for a flapless, full stop land-
shortly after touchdown the aircraft flying crew have had appropriate
ing. The weather was VFR and
departed the runway and eventually time to mentally prepare for the
therefore not a factor.
came to rest against a chain-link potential challenges ahead.
The flapless TACAN approach was fence at the edge of the airfield
Most importantly, trust your
completed to circling minimums approximately 6000’ from the
instincts. If you don’t like what
and then the aircraft was visually landing threshold.
you see — take action. As the train-
positioned on a downwind leg for
Many lessons were learned from this ing pilot on this ill-fated flight, I
a flapless, full stop landing to the
accident. We learned to keep training was not particularly comfortable
active runway. Unfortunately the
sequences simple and realistic. Avoid with the excessive maneuvering on
pilot flying did not provide ade-
the temptation to combine different final but the pilot flying was doing
quate lateral spacing on downwind
elements of training in one sequence a very reasonable job of trying to
and therefore the aircraft overshot
(in this case, a circling approach with re-stabilize the approach. What I
the extended runway centerline dur-
a flapless full stop landing) as you failed to consider was what state
ing the final turn. Fairly aggressive
run the risk of vastly increasing the of mind the pilot flying would be
maneuvering brought the aircraft
level of difficulty of the sequence in on very short final. After all that
back into a reasonably stabilized
without realizing it. If you still must manoeuvering on final was he truly
approach by approximately
combine sequences to meet training mentally prepared for the flapless
200’AGL. The very rushed short
commitments, then make sure they full stop landing ahead? Probably
final and flare resulted in two hard
are thoroughly briefed. not, and as such, I should have
bounces before an overshoot was
called for an overshoot!
performed. As the aircraft climbed We also realized we should have
to circuit altitude, tower informed insisted on a stabilized approach. As I look back on this accident,
us that the right-hand (RH) gear If the approach for landing is not an increased emphasis on any
looked damaged. A series of low stabilized on heading, altitude, and one of these three points may
passes were flown by the Control airspeed by 1000’AGL, seriously have averted this accident and
Tower to try and clarify the position consider overshooting and re- the loss of a valuable resource. ◆
of the gear, but on the fourth such attempting the approach. This phi- Capt. Fitzsimmons
pass the RH main gear departed the losophy will ensure that pilot work-
aircraft. Several other complications load remains appropriately balanced
ensued as a result of the missing between the approach itself and the
gear. These included a torn RH fuel landing phase. In our case, the

Conversion Nightmare
rior to the avionics update on Between the pilots there was proba-
P the CC130 fleet, we operated
E-model C130’s with cockpit instru-
bly at least 10,000 hours and the
navigator had more than 5,000
craft approached the airport and was
handed off to the final controller, the
final controller announced what the
mentation from the 1950’s. This hours, all on type. The crew then minimums for the approach were and
included altimeters that only had an walked to the aircraft, all of them that the altimeter setting was 992 mil-
inches sub-scale. During operations looking forward to spending some libars. It was at this point that the
overseas, where altimeter settings are time on TD. The crew day for this crew had finally realized their mistake
given in millibars, the crews would mission was a standard 16 hours, not and requested an inches setting for
either carry with them conversion a maximum crew day but certainly a their altimeter in order to shoot the
charts for millibars to inches or they challenging one given the overnight approach. The aircraft then landed
would request inches settings for hours of flying. Enroute, the trip without further incident but plenty
their altimeters from ATC. went without hiccups; there was the was said in the debrief.
standard stop for fuel and a final
The mission was a routine re-supply This incident seems harmless enough
weather check in Gander, Nfld. Then
of troops in Europe, not an unusual taken in the context above, but think
the uneventful but busy trip across
sortie for the experienced crew of about the consequences if everything
the ocean towards Europe.
the C130. It was to depart Trenton in had compounded against the crew.
the afternoon and arrive in Europe By the time the aircraft coasted in The crew flew around on radar vec-
the next morning. The mission over England, the crew had been tors with at least a 200’ error due to
began as any other in the C130, with awake about 24 hours, but this was the mistake in the altimeter setting.
a good check of the weather along nothing new for the experienced ATC asked why the aircraft was low,
the route and at the final destina- crew. Approaching Lyneham, the but in such an ambiguous fashion,
tion. The briefing was thorough and activity level picked up as the aircraft the crew did not understand the
covered all aspects of the mission. was picked off for radar vectors for meaning. Now, what if the precision
The destination weather was not the approach. During these vectors, approach in Lyneham was down and
great, but suitable, and the alternate’s the aircraft was cleared “to maintain the crew elected to fly a non-precision
weather was good. The general influ- 3000’ on 992.” Without hesitation the approach. Had the crew not picked
ence over our destination was a low crew began their descent and called up the mistake on the altimeter set-
pressure that was causing some 2992 set throughout the cockpit ting in time, they could have leveled
lower ceilings (remember this a little (remember that low pressure over 200’ below the safe altitude for the
later on). England). Once the aircraft leveled at approach. If you then allow the pilot
3000’, ATC came back with “for vec- to make a mistake and fly 100’ below
Next was the crew briefing, standard
tors steer heading — and confirm minimums for the approach on top
for any C130 departure. The AC
level at 3000’”. The co-pilot read back of the 200’ error, they could have
started the briefing and covered all
the heading and confirmed that we impacted a tower on approach and
of the finer points, including desti-
were maintaining 3000’. The crew killed everyone onboard. The critical
nation weather and the influencing
never queried this ambiguous ques- mistakes here are crew complacency
low pressure. The trip was autho-
tion as they happily flew the radar and fatigue, which nearly led to a
rized without hesitation, and the
vectors they were given. As the air- fatal accident. ◆
crew was seen as very experienced.

Continued from page 1
Anywhere communication between Finally, the actual actions of the per- of corrective action. That is why we
individuals is required, there is son who causes the mishap must be are moving toward replacing the old
potential for miscommunication, or evaluated. The unsafe acts committed Personnel cause factors with this sys-
simply poor resource management by personnel generally take on two tem. It will help us to better under-
to result in an accident. Another forms, errors and violations. The first, stand the whole situation leading to
aspect considered in the analysis is errors, are not surprising given the an accident or potential accident,
a person’s readiness to perform at fact that human beings by their very especially if everyone reports inci-
optimal levels — sufficiency of nature make errors. Consequently, dents and hazards to prevent them
sleep, medication, exercise, etc. errors are seen in most mishaps — from turning into accidents. An
often as that last fatal flaw before a open, non-threatening environment,
Environmental conditions are con-
mishap occurs. Violations, on the where information flows freely is the
ducive to accidents as well. A person
other hand, represent the willful dis- best defence. This new analysis of
who is working at night on the flight
regard for the rules and typically human error will help us analyze
line and does not see the tool he/she
occur less frequently. that information and maximize the
left behind in the engine compart-
likelihood of preventing the next
ment has fallen prey to his environ- The categories being assigned under
accident. ◆
ment. We also consider equipment, these new Human factors Analysis
space and layout. This involves within FSIS not only leads to an Col. R.E.K. Harder
analysis of the whole organization, Director of Flight Safety
working in confined, obstructed,
or inaccessible workspaces. but also point toward some kind
Improved Analysis of Human Error Flowchart
ORGANIZATIONAL INFLUENCES
Resource Organizational Organizational

Management Climate Process
SUPERVISION
Inadequate Planned Inappropriate Failed to Correct Problem Supervisory Violations

Supervision Operations
PRECONDITIONS FOR UNSAFE ACTS
Substandard Conditions Substandard Practices

of the Personnel Working Conditions
of the Personnel
Adverse Physical/ Interpersonal

Adverse Mental Readiness Equipment Workspace Environment
Physiological Mental Resource
States
States Limitations Management
Personal Qualification Training
UNSAFE ACTS
Errors Violations
Skill-Based Perceptual
Decision Errors Routine Exceptional
Errors Errors
Attention/ Knowledge/ Skill/

Memory Rule Technique

Where Will You Be

When CRM Breaks Down?
t was going to be an easy workday (since we were above 10,000 feet). I or St. Pete, thus closing the majority
I in the C-5 Galaxy. Takeoff was at
0800 local from Charleston AFB,
worked to find an airfield and worked
with the panel FE’s. I checked with
of either airfield. Great, I can see the
camera crews and media attention
South Carolina. We were enroute to the two LM’s with the passengers; now…
South America. A “short” 16-hour they were fine and no fumes were
While we descended through 15,000
day with planned stops in Panama present, yet.
feet, the chief FE had isolated the
and then on to Puerto Rico for
Another problem entered the scenario fumes and he thought the air condi-
the night.
— it was the first of January, New tioning system was moving the fumes
The crew was a basic C-5 crew, Year’s Day and all USAF airfields in up from the cargo compartment.
consisting of two pilots, two flight Florida (the closest land) were closed. At this point, the theory was a cargo
engineers (FE) and one student flight Our best airfield with hospitals and hazard spill or leakage. The ventila-
engineer, along with three loadmas- crash response (if required) was tion checklist relies heavily on using
ters (LM). Onboard this trip was the either Tampa International or St. the air conditioning fans to circulate
usual load of 110,000 pounds of mis- Petersburg. MacDill AFB was very air and clear the area — that will not
cellaneous cargo and 40 passengers close to both of these airfields and we work now, it seems, and we enter into
returning home to Panama after the were desperately trying to get permis- uncharted territory from the C-5
Christmas holidays. sion to land at MacDill AFB. AOI’s (aircraft operating instructions).
About 20 minutes after levelling off at The Chief FE was now reporting We were now below 10,000 feet
35,000 feet over the Gulf of Mexico, I the fumes were getting worse by and almost fully depressurized. The
settled into my box breakfast. Shortly the minute, even with the ventilation passengers were still fine, although
thereafter, the chief engineer who was process underway (while pressur- wide-eyed with no fumes present
eating in the aft flight deck, came for- ized). The passengers were still fine, yet, but the LM’s could smell the
ward and reported a terrible odour. but the cargo compartment (lower fumes from the cargo. The FE’s
The chief was known as a jokester, deck) was also saturated with the were trying everything in their
so the pilots and the FE at the panel fumes. The FE’s now decided power to get fresh air into the system
joked about who inappropriately (appropriately) to depressurize the and bypass the cargo compartment.
used the flight deck latrine. aircraft to be able to more adequately Attempts had reduced the fume
ventilate. The other pilot and I were spreading, but the fumes were still
The chief FE said the fumes were real trading off flying duties as required, very heavy in the cargo compartment
and smelled toxic — “like burning and he was coordinating with Air said the chief FE.
plastic or burning chemicals.” The Traffic Control for the descent,
crew donned oxygen masks. The pas- The other pilot and I were now fully
updating destinations, emergency
senger compartment (located aft of engrossed in gaining clearance to
status, etc. I was fully engrossed in
the wing on the upper deck of the land at MacDill and having crash
opening MacDill or arranging an
C-5) was yet unaffected by the odour. crews and medical people ready for
alternate airfield. I heard something
The chief FE, with a portable oxygen our arrival if possible. The back-up
about depressurizing and concurred
mask, kept searching for the fume plan was St. Pete, with less traffic
with a nod of the head while I was
source with the aft flight deck LM than Tampa during this part of the
talking to MacDill command post
while the pilots and panel FE’s day. The landing plan was set and
to get the airfield open.
worked to descend, clear the air now the pilots could focus more on
in the plane, and land. Why the intent on opening MacDill the fumes while we awaited landing
when two other airfields were readily clearance. We were only 30 miles
Here is the point where our crews available? Well, a C-5 is a large and out and descending through 7,000
(and my) CRM breaks down, specif- heavy aircraft; it requires certain feet. I reassessed the situation inside
ically the “M” — Management. Both taxiways and hard surfaces to land the aircraft — finally again. The
pilots were focused on the descent and manoeuvre on the ground. The FE’s said we were unpressurized and
and locating an appropriate airfield. only taxi routes for the C-5 clear of trying to ventilate as much as possi-
The two FE’s at the panel were traffic, we were informed, were to ble without the cargo fans operat-
working to ventilate the aircraft land and remain on the runway — ing. It sounded like a viable set-up
while the aircraft was pressurized regardless of which airfield, Tampa and the passengers were still okay.

The Wing Commander of MacDill Because of this fact alone, the effects with enough tricks and experience
was now on the airfield in his staff of the break down in communication to keep you out of trouble. But,
car surveying the runway for us, we between the pilots, LM’s and FE’s remember these lessons from my
were told. We obtained landing per- were minimal. From the moment we experience; first, ensure, as much as
mission just as we passed overhead descended from 20,000 feet until possible, everyone understands the
MacDill. We performed a quick turn short final to MacDill, I as the AC, problems, the situation and their
and set up on a nice final to MacDill was only minimally involved with the duties and goals; second, keep
with a huge sigh of relief from ATC, trouble shooting and passenger con- everyone abreast of plan changes
Tampa Int’l and St. Petersburg air- cerns. Training of the aircrew and and major occurrences that could
port. After landing, we exited the experience took over. Everything just modify the plan; and, finally, devel-
airfield and opened up every win- happened to come together on short op a game plan, execute and revise
dow, hatch, and door to ventilate. final at MacDill. as required with everyone (as much
Thankfully, the passengers were fine as possible) in the loop.
There are some minor things I would
— they were already asking when
do differently, but one I would defi- You are probably wondering what
we would depart to Panama.
nitely change. If you noticed, the the cause was? Well, after three days
Looking back on the whole event, chief FE was doing a lot of moving of research, special maintenance
CRM wasn’t too bad. But there were around the aircraft. I just assumed he teams and cargo handlers going
some definite points to learn from was on oxygen the whole time, but through all of the cargo, the offend-
my experience. I was lucky in the fact I was wrong. The only way to know ing item was finally found. The main
that my crew was very experienced. if the fumes were still there was to air conditioning fan from the cargo
The FE’s worked very well together smell them, and he was only on oxy- compartment to the aft flight deck
keeping each other informed and gen for part of the time. I would and crew compartment had been
working to properly identify the have ensured everyone was on oxy- layered with dirt, grease, and oil
problem, and then ventilate the air- gen. The passengers should have from years of use. This build-up
craft. The LM’s worked very well to had oxygen readily available with finally started to burn as the fan
secure the passengers, properly brief the masks deployed and ready for turned and that was the source of the
them for an emergency landing and passenger use, if required. odour. The ventilation procedures
egress, as well as keep them calm rely heavily on this fan to ventilate
Luck was on our side that day. In a
and updated about our problem the aircraft with the outside air. As
situation like this, it is impossible to
and our destination. long as we complied with the proce-
keep abreast of everything going on.
dures, the odour was still present. ◆
Hopefully your CRM bag is filled
Letters to the Editor

Hi Captain Vogel, just finished three years as the head and even when I told them that FT
of the terminology section here. So, stood for Flight Test, none got it right.
Congratulations and thank you for I have declared him disqualified and Michael Phelan
your response. You are right, DFTE you get the official honours. Analyst, Life Cycle Product
stands for Designated Flight Test Management
Without diminishing your achieve-
Examiner. Technically, you are the Directorate Information Resource
ment, I think the fact that it took
second person to get it right, but the Product Management (DIRPM)
almost eight months to get the
first person had an unfair advan- National Defence
answer proves my point: our use of
tage. Besides having many years as a
acronyms is counter productive.
high time military pilot of many
Many other people took a guess,
fixed and rotary wing aircraft, he

ALSE Aerospace Life Support E
t’s near the end of the second day reasons for this, ones that at first may you will get no argument from me
I of our regular Aerospace Life
Support Equipment (ALSE) Project
not be obvious. The CF ALSE pro-
curement approach and process often
on that point. So why bother enunci-
ating requirements and evaluating
Review Meeting (PRM). The room need some explanation. You may not products?
is stuffy; emotion is high, and I can like it but at least there is a funda- The ALSE procurement process
sense that the time is ripe — it’s mental procedure to be applied. stresses the question, “what is the
about time that someone launched Furthermore, it is significant to note requirement”? Too often ALSE
us into a philosophical debate that the way in which we authorize staff asks operational staff what the
about why ALSE in the CF seems so ALSE use is very similar to proce- requirement is and it is surprising to
neglected and why it takes so long dures in place in the USAF, USN and see the diversity in responses. Unless
to acquire new and better ALSE for other foreign military users of ALSE. we have a clear, concise, statement
our aircrew. “Why don’t we just buy of operational need, we may end up
First, let’s examine the need to con-
it off-the-shelf? It’s faster than wait- buying equipment that doesn’t serve
duct independent test and evaluation
ing for NDHQ to approve new kit. our aircrew well, if at all.
(T&E) of ALSE. The idea that off-
Our Wing Commander can just
the-shelf is the fastest and best Let us assume that the requirement
authorize local procurement —
method of procurement has been has been established. Rather than
nothing wrong with that, is there?”
debated in depth — it currently is simply making a direct acquisition,
We in the ALSE community have the fastest, but is it really the best? the CF has always insisted on evalu-
heard this many times before. And In many cases industry has taken the ating manufacturer’s products. The
I have to admit that on the surface, lead in new product development — rationale for this is sound — manu-
some of the complaints being voiced facturer’s statements about their
from the field have merit. Approval products cannot be accepted at face
and procurement of new ALSE value. This is not always or only
does take a long time — because of exaggeration or even
sometimes far too misrepresentation of their product
long. However, capability. Sometimes it’s due to
there are limited understanding of the
PROTECTIVE EQUIPMENT

t Equipment
application and the environment of (Aerospace Life Support Equipment from inadequate acquisition are
use, that is, the complete require- Management). Unfortunately, it is blamed on the LCMM’s in Ottawa
ment. In the ALSE community, we rare to find an ALSEO who can give — which is not only wrong, but
have seen this far too often. In fact, ALSEO duties at the squadron level unfair as well.
in many cases the testing that orga- the priority they’d like to. ALSEO’s
On a final note, I want to stress that
nizations such as DCIEM, QETE, often complain that their CO’s don’t
there are many people working very
and AETE conduct is far more give them the support that they
hard behind the scenes to ensure
extensive than that which original need. The result — the brand new
that our aircrew are equipped with
equipment manufacturers them- squadron ALSEO’s (probably a
the best ALSE that is available.
selves conduct. The moral of the Lieutenant) major objective at work
Research and Development organi-
story — “buyer beware” by knowing becomes a burning desire to get rid
zations such as DCIEM have made
precisely what you need and ensur- of this secondary duty. A weak
great strides in developing ALSE
ing your needs will be satisfied. Yes, ALSEO network results in staff offi-
that is the envy of other military
T&E adds time to the procurement cers at higher headquarters and indi-
forces. The STING G-suit is but
cycle, but omitting this step can be viduals at T&E establishments not
one example of Canadian-devel-
costly and dangerous. It is worthy of receiving good operational feedback.
oped ALSE that has set the standard
note that DND organizations And good operational feedback is
in acceleration protective garmen-
involved in T&E are frequently asked essential in ensuring that we get the
try. The level of protection afforded
to conduct independent third party proper ALSE out to aircrew for any
to our aircrew has been steadily
evaluations for civilian clients. given operational environment.
improving and some exciting new
Next, the question of why ALSE ALSE tends to be an after-thought advancements are being made. Yes
seems to be neglected relative to in capital procurement. This trend the system is slow, but procurement
other equipment used by aircrew. was seen years ago with the CF-18 without proper independent testing
This perception is shared by many acquisition and has not improved is not the answer. As I write this
in the ALSE community. How is it much in the two decades since this article, a new and radical change to
that the people using it on a daily project. Identifying, evaluating, and the way in which ALSE is managed
basis neglect the equipment that integrating ALSE for new weapon in the CF is being contemplated
could save someone’s life? Clearly, systems are typically addressed late (Integrated Logistics Management
the attention that ALSE gets at all in those procurement programs. Services For Aviation Life Support
levels needs to be heightened. My The result often is panic-mode Equipment) that will rely more
contact with NDHQ and 1CAD decisions being made with failure heavily on contractor support. With
staff suggests that there is a great to meet the needs of our aircrew. this change, it will be more impor-
desire to elevate ALSE issues to Recent projects such as the Harvard tant than ever for ALSEO’s,
required levels, however these peo- II and Griffon are examples of this squadron COs, and indeed all air-
ple are meeting with limited success problem. Clearly, this way of doing crew to take a proactive role in
in that regard. I believe that not business must change. Project man- ALSE issues. The need to make wise,
much will change until there is agement staff must consider and well informed decisions in ALSE
a strengthening of the ALSEO plan for ALSE acquisition. ALSE is procurement could thrive only with
system at the squadron and wing part of the weapon system and must good support from the end users. ◆
level. ALSEO’s are trained and be treated just like the aircraft, the Major Zenon D. Myshkevich
appointed to conduct important weapons, and the spares. Too often
jobs as outlined in CFAO 55-16 follow-on ALSE problems stemming

A Good Day Kings doing hover work on the heli-
for Traffic port, which is adjacent to taxiway

Alpha. I am quite busy, to say the
least, but I was excited by the chal-
lenge, and expected it to die off at
any time.
Unfortunately, this did not happen.
The traffic continued to grow with a
couple of overflights through the
zone, more Cessnas and Sea Kings
arriving and departing, a Medevac
helicopter coming inbound to the
harbourfront landing pad, and
some media aircraft requesting to
fly over the harbour to film the war-
ships alongside. To put it simply,
I was controlling a lot of aircraft,
all within my 5 NM zone, in an
t was a beautiful, sunny day in
I June 1998 — the first nice day
we had had in a few days, so we
example, when the number of light
aircraft starts to interfere with heli-
copter operations, we give the Sea
extremely complex traffic scenario.
I realized I was getting mentally
fatigued but was sure that it would
knew it would be a busy traffic day. Kings the option of doing circuits to slow down any minute and that I
In addition to our locally based traf- the parallel taxiway. The Cessnas do would be able to take a “breather” as
fic, we had several multi-national right-hand circuits to runway 34, soon as I landed several aircraft. But
helicopters visiting the Wing who the Sea Kings do left-hand circuits as each landed, two more showed
were looking for some airfield train- to the parallel taxiway Alpha, and up and I began to struggle with
ing while their warships were along- the wake turbulence problems, plus holding onto the air picture. I was
side. Everybody knew it would be the circuit congestion problems, are talking continuously to aircraft and
a good day for traffic. solved. But, now the controller is felt that if I let down my guard for
working two separate circuits, which even a second, I would lose the air
As expected, the traffic picked up
requires much more concentration. picture. I became so focused, that
fairly early and remained fairly
steady all day. As is usually the case, On this particular day, there were I completely lost all appreciation
there were spurts of moderate traf- quite a lot of Cessnas coming and of time and failed to see any option
fic with launches and recoveries, fol- going, so, in order to better accom- but to continue. I was sure it would
lowed by lulls of low activity with modate the Sea Kings, this was the either slow down, or a supervisor
one or two aircraft operating on the solution I chose. As the day went would come up to the tower to give
airfield. The traffic wasn’t out of the on, the number of aircraft contin- me a break. I considered calling, but
ordinary — Cessna’s and Sea Kings ued to grow. Several of the foreign was so afraid of losing situational
departing for various training areas aircraft decided to join the heli- awareness that I just decided to
and then returning to the base for a copter pattern on taxiway Alpha, carry on. It was three hours later
few circuits to a landing. Also, the and, in addition to the arriving and when the break in intensity came.
Waterbird Sea King was doing train- departing Cessnas, there were a cou- Because my senses were so acute
ing on a lake east of runway 34. ple of them that went up into the due to the duration of the heavy
circuit, and a few Sea Kings elected traffic, I responded to every call as
One interesting thing about work-
to do on-field operations. So, now I if there were 10 more to follow. I
ing with helicopters is the flexibility
am running a fixed wing pattern off didn’t realize the traffic had slowed
a controller has in what we can do
of the runway, a helicopter pattern down and was waiting for the next
with them. This can, as I found out,
off of the taxiway, and a Sea King aircraft to call with each transmis-
be a double-edged sword in that it
pattern off of Morris Lake (immedi- sion. A Cessna called final for the
solves some problems, but can
ately adjacent to runway 34). There touch-and-go to runway 34 to
increase the complexity of the sce-
is also a slung load Sea King pattern which I responded with a clearance.
nario quite dramatically, creating a
off of a different taxiway, and Sea Another aircraft called in for some-
whole new set of problems. For
thing and I immediately responded, — “Know my limitations.” I found another member of the crew to call
diverting my attention away from out after the fact that I had worked on my behalf.
runway 34. That call was followed 15–20 aircraft continuously for over
Thirdly — “Adjust my technique.”
by a request from the Waterbird Sea three hours in an extremely com-
Although the traffic had slowed
King, to proceed across the active plex scenario. I knew I was fatigued
down, I continued to control at a
runway for a landing at the North and I knew I was struggling, but I
level well above what was required.
Gate. I scanned the runway, didn’t didn’t consider restricting the num-
There was no urgency when the Sea
see the Cessna and cleared the Sea ber of aircraft to a number I could
King requested to cross the runway;
King across. As the Sea King handle until I could recover.
I had plenty of time to verify the
approached the runway, I saw the
Secondly — “Know my options.” position of the Cessna. But, not see-
Cessna emerge from behind the
Once I realized that I was getting ing him in a quick runway scan, I
beam in the tower window, and lift
fatigued mentally, I should have cleared the Sea King across in antici-
off (about 4000’ down the runway
looked at my options. The only one pation of many more calls to follow.
from the Sea King). I immediately
I could see was reactive rather than
advised both aircraft of the other, Lastly — I put undue pressure on
pro-active; let the traffic slow down
they responded “visual” and contin- myself to handle everything on my
or the supervisor show up rather
ued without further incident. own rather than calling on other
than calling for him. Although I was
members of the team to help me. ◆
This incident drove home some too focused and too busy to call
very important points to me. Firstly myself, I could easily have asked
It Almost Cost a Life

for the aircraft to land, be loaded cockpit and told him to activate
with the SKAD, fueled, and proceed the switch. I checked the one side I
to the search area. was going to load and verified that
indeed the hooks had opened. I
As the aircraft rolled in, I noticed didn’t check the other side of the
that it already carried a photo pod aircraft as I had no intention of
on the wing rack. I made a mental loading it. We loaded the SKAD
note and began my pre-load check- and signed the paperwork.
list. I gathered up my augmentee
FB Summerside was regularly
C tasked to provide aircraft for fish
patrols, coastal patrols and SAR mis-
loader and began the loading func-
tionals for the SKAD upload. Early
When the aircrew arrived, my
augmentee was tasked as part of
the start crew. Part of his job was to
on in this procedure, it became
sions. The CP-121 Tracker was tasked obvious that this individual was not pull pins prior to the pilot’s arrival.
with these missions and based at very comfortable or knowledgeable When he reached the side with the
St. John’s airport in Newfoundland. with his task. Realizing the limited loaded photo pod, he pulled the pin
As an air weapons technician, I was experience of this technician, I (it seemed harder to come out than
tasked along with an augmentee decided to follow him around and usual) and the photo pod, weighing
loader to provide air weapons support. help him with his responsibilities, close to 300 pounds and costing
This included loading/unloading and ensure that he followed my $750,000, dropped, missing him
SKAD’s (survival kit, air dropable), instructions. As his major responsi- by inches.
photo pods, and pyrotechnics on bility was cockpit switches, I found
Looking back, I now realize the
the aircraft. myself going in and out of the air-
importance of maintaining situa-
On one particular day, a second aircraft as he had difficulty locating
tional awareness. My thinking was
craft arrived. While enroute, the air- the various switches.
channeled into ensuring that the
craft was tasked to conduct a SAR When we reached the point in the augmentee loader did his job. I lost
operation, which required the upload checklist, which called for an emer- focus on the overall task, and it
of a SKAD, as per SOP’s. The plan was gency jettison check, I was in the almost cost a life. ◆
Safe Beginnings
Mean Safe Endings
his is an account of a trip that I individuals. It prompted us to do a it is for a reason. Believing that it is
T was tasked with as a loadmaster
shortly after my arrival to one of
full kit inspection of everyone and
this was going to delay us by at least
okay is an excuse for disaster, and
UEO’s must be vigilant in ensuring
our transport squadrons. In June of one hour. It was at this point that that a full inspection is carried out.
1997, I was tasked to be a restricted we had to deal with the chalk com- LM’s must be willing to take the
Load Master (LM) on a long-range mander, who was more than a little time to complete inspections
trainer to western Canada and then upset at the thought of us doing a regardless of the time it may take.
down to the United States and full inspection since they had Just one last note for personnel
South America. The first leg was to already done so back at their unit. traveling on any aircraft — it’s not
fly from Trenton to the East Coast This was easily solved with the full that you’re not trusted (that was
to pick up 60 ground troops and backing of the aircraft commander. some people’s response to being
take them to Medicine Hat, Alberta. inspected), but, if even one person
We gave all of the passengers the
has dangerous cargo on them, it cre-
We arrived at the airport at approxi- opportunity to turn in the different
ates the sense that others do as well,
mately 1600Z and were scheduled dangerous cargo items we listed for
therefore everyone must be inspect-
to take off at approximately 1730Z. them and then we proceeded with
ed. If in doubt, we ask; it will always
The other LM and I met with their the checking of their kit. The amount
be to the passenger’s benefit. ◆
Unit Emplaning Officer (UEO) and of things we found was too much
were informed that the passengers to list in this article but some of the
were going to be late by at least things we found were: hexamine
30–45 minutes. We confirmed with tablets in a pouch with ronson
the UEO that all of the passengers lighter fluid and strike anywhere
had been briefed and checked for matches, lithium batteries just
any dangerous cargo they might be thrown in a rucksack, numerous
bringing with them in their person- bottles of lighter fluid, matches
al kit. As a rule, we always do a spot in about every pouch. Some troops
check of approximately 10%. even had their own mountain
stoves with naphtha still in it.
Shortly thereafter, the passengers
showed up. They proceeded to the This inspection took almost one
aircraft where we randomly took ten and a half hours. There were several
individuals and their kit aside for an things that could have prevented
inspection prior to loading the air- this need right from the beginning,
craft. As we were about to start this, but the biggest thing that could have
the front-end crew were asking us ensured a smooth trip was that pas-
how long it would take to complete sengers need to know that their
the inspections; we wouldn’t know safety is first and foremost, and
until it was complete! Once we when they are asked to leave
started, we found dangerous cargo behind the items that are
in just about all of the kit of the ten considered dangerous cargo,

TRAIN AS WE FIGHT
O n a recent exercise during a
troop move, we experienced
an aircraft event that, of itself, was
the wind for a two-stage approach
over the tall pines.” On short final
we confirmed that there were no
time), was completely preventable
without compromising the mission.
I believe the contributing factor
minor. However, the situation sur- other obstacles and noted that the (aside from the torque sensing
rounding it was potentially danger- ground was quite uneven with many problems of the Griffon) was that
ous, and the risk level could have small, undulating hills and valleys, we were looking into a bright, post-
been reduced. and further briefed our landing spot sunset sky and could not easily see
atop one of the hills. Once clear of the ground below. Furthermore,
The mission was simple — pick up
the barrier, we began our descent I did not anticipate the sudden
eight troops with rucksacks and
and were given a “steady down” by “steady down,” and had to abruptly
drop them off to let them play for
the flight engineer at approximately stop our descent. The winds were
a while. We were then to pick up the
ten feet to reposition for tail rotor not excessive, so perhaps an out of
commander for a tour of the exer-
clearance. To arrest our descent, the wind approach would have been
cise area, return, refuel, and wait
collective was checked up. The preferable. An easterly approach
for the troop extraction time.
Aircraft Commander called “no path would have put the bright sky
We departed for the initial pick-up more power” and there was a subse- behind us, taken the tall pines out of
just a little after sunset; flew our quent torque spike to 100.5% — the picture, but given us a tail wind
route to the pick-up zone, landed enough to make the overtorque at about our four o’clock position.
and took off with eight troops on light flicker on and then off. We In addition, a single stage approach
board. This put our all-up-weight at continued with the landing, off- might have been possible.
11,500 lbs., quite close to our maxi- loaded, and returned to base.
This may have come up had a more
mum gross of 11,900 lbs. We pro- Unfortunately the commander
thorough confined area briefing
ceeded to the given grid to find a would not get his ride that night.
been conducted. In efforts to be
suitable landing zone. Conditions at We were, however, ready for the
tactical and spend a minimum time
the time were southwesterly winds extraction after the necessary paper-
circling the landing zone (“Train as
at five to ten knots, sky clear with work and visual inspection were
we Fight”), the maneuver was car-
the sunset about 15-20 minutes completed.
ried out quickly and thus the subse-
prior. This left the sky bright, yet
In looking back — what was the quent overtorque. As previously
the ground quite dark — unsuitable
problem? The overtorque, and the mentioned, the results of the above
conditions for night visions goggles.
commander not getting his ride events were minor, nonetheless,
We identified a suitable area, con- were really small items and conse- the mission could have been safer
ducted a quick crew brief — some- quences of a bigger picture. A pic- and more complete had an extra
thing like “we’re downwind now, ture that was potentially dangerous minute been taken and a little
we’ll conduct a 180-degree turn into and, I believe (as flying pilot at the more foresight used. ◆

Maritime Patrol’s
Flight Safety Record: Good Enough?
haphazard or incomplete manner,
lacking in training and documenta-
tion. Certainly the typical young
instructor has a limited experience
pool to draw on. Teaching 90% of
90% to successive generations of MP
he Maritime Patrol mission is aviators will quickly see us losing the
T demanding. Large aircraft,
variable weather, long distances and
magazines, videos etc. with the aim
of preventing a recurrence. Many
of us have read incidents of various
hard-learned lessons of the past.
There are positive initiatives that
low-level operations, not to mention kinds and walked away scratching
can and do make a difference.
the potential for hostile action, all our heads wondering how a crew
At a time when many nations are
demand the best from MPA aircrew. could possible have put themselves
upgrading their MP aircraft, a timely
Yet, despite the demands, it can be in that position, and how certainly
upgrade of simulators to current
seen that this branch of military we never would. Unfortunately, year
commercial standards can allow the
aviation has achieved a creditable after year similar situations arise.
more realistic practice of demanding
flight safety record. In the major The air show or air-show practice
emergency procedures. Simulators
countries that operate MP aircraft, that got out of hand, the inappro-
are also excellent for drilling the
there exists a variety of operational priate application of power in an
fundamentals of Cockpit Resource
styles, missions and even operational asymmetric situation, either in the
Management (CRM) and honing
authorities, with many nations air or on the ground, or the overly
the critical crosscheck and backup
operating their MPA fleets as Navy, aggressive G application which
roles that all crewmembers must
Air Force, Coast Guard or Customs led to structural failure and
have. It was a tactical compartment
entities. What is evident, however, ditching are examples.
crew member’s alertness in holler-
is a common thread of training,
When we look to prevent these ing “altitude!” to a flight deck that
professionalism and sound opera-
and similar events we often turn recently prevented a tragedy on a
tional practices, which ensure their
to a familiar cast of cause factors. routine night ASW exercise. We can
continuing safe operation.
Supervision, training, knowledge utilize tools such as Operational
Most nations’ Military air arms and/or experience are very common Risk Management to carefully ana-
have in place a process to review themes. We are familiar with the lyze roles, flight profiles and proce-
and analyze system failures that issues surrounding loss of experi- dures to see if they are in fact the
result in accidents or incidents. enced personnel and reduced flying best way to accomplish the mission.
They are often called Flight Safety rates. Have we really hoisted aboard Those countries that have a multi-
organizations and can operate in the notion that we can’t expect peo- engine phase in their pilot training
parallel to airworthiness bodies ple to upgrade as quickly or as com- can utilize this period to emphasize
and/or the chain of command. pletely as in the past, when an over- Crew Resource Management prior
Independence is usually granted to abundance of purely operational to the individual showing up on
the Flight Safety function in order experience kept us all busy? Often a squadron. Training or standards
that it can concentrate on its prima- junior MP aviators have only been personnel need the consistent sup-
ry objective: reducing the accidental exposed to certain specific roles. port of senior leaders to provide the
loss of aviation resources. By a vari- Other skills may have been paid essential time, on ground-training
ety of means this organization col- only lip service in order to maintain days, to effectively impart lessons
lects and analyzes data to determine an appearance of relevance to politi- concerning tactics, procedures and
trends and prevent accidents and cal or military masters. Hazards are safe and effective ways to complete
incidents. This information is then also present when new equipment the mission.
distributed via e-mail, messages, or roles are being introduced in a

Utilizing examples from other ing to after that long deployment In years past, the MPA community
countries can assist in increasing the or all-night flight. On another front, worldwide went about its business
flight safety knowledge and aware- an offshoot of CRM of interest to in a largely unsung manner. That
ness of all MP aviators. Furthermore MP aircrew is the relatively new has changed and MPA are likely to
the experiences of fellow aviators HPIM. Human Performance in find themselves in the vanguard of
should not be disregarded on Wings Maintenance is an initiative to highly visible operations. The mid-
or Bases where MPA are not the sole recognize and mitigate many of air collision of two MPA a few years
occupants. These professionals are the same types of cause factors ago and the recent successful ditching
also in the business of safe mission that recur in aircrew incidents, of a severely damaged one indicate
accomplishment and routine cross- and are shared in the maintenance that despite our best efforts there will
pollination of ideas can yield great hangar. In many ways maintenance always be risks. By analyzing our
safety initiatives and reveal common organizations are affected by the weaknesses, rigorously auditing our
problems. MPA aircrew also need same restraints as the aircrew. procedures and selecting only the
to play an active role on their home Knowledge of training, spares, most capable supervisors, the MPA
bases, attending the necessary meet- and experience level concerns of community can continue its tradition
ings that deal with bird control, ATC your maintenance team is essential of mission accomplishment in a safe
concerns, snow and ice control and to planning safe operations, and effective manner. The AIM:
the like. All of these items make up particularly on deployments. Safe mission accomplishment. ◆
the environment you will be return- Major Al Harvey, CF
Corporate Knowledge
he unit had just lost 50% of its CF101. As the tow mule drove over
T technicians due to retirement.
Recruiting had just begun the year
the hangar door rail, the four bolts
holding the hitch onto the mule
The driver jumped off of the mule
and ran to the aircraft with a chock
to stop the aircraft. The mule drove
before for the first time in ten years. sheared. toward all of the aircraft parked in
This unit was just awarded the the hangar. The wing person ran
“transient servicing” award for toward the mule and stopped it
the Canadian Forces for before it hit anything.
the third year in a row.
It was 2300 hours on The brake person yelled
a summer night and “pull the handle on the
the weather was left.” The brakeman saw
seasonally warm one marked drag chute.
and clear. He said he couldn’t find
it. The brakeman yelled at him
Transient servicing had just to pull it so he did. The tail man
towed 15 aircraft into the hangar dodged the drag chute and yelled
and this tow job was the last one. “pull the other one.” The brake per-
The hangar would only fit one more The CF101 rolled towards the wall. son found it and did. The aircraft
aircraft. The tow crew chief had The crew chief yelled “brakes.” The stopped in time. No damage, no
23 years experience, and the driver, brake person applied pressure to the injuries.
wing walkers, and tail man all had tow brakes but the aircraft did not
22 years experience. The only person stop. At the same time, the driver God protects drunks and fools.
ever to work on a CF101 was the tail applied brakes to the mule and They weren’t drinking at the time.
person. The brake person had six stopped it but left it in gear. The This is an old story but a true one.
months experience and had towed crew chief yelled “brakes” again. We are now downsizing. People are
many types of aircraft, but never a The brake person was still trying. retiring. We haven’t recruited for
years. Sound familiar? ◆

20-20 Hindsight
n August, 1996 I was the aircraft before. This plane makes all kinds of
I commander on a redeployment
from Tinker Air Force Base,
noises, though.” Then John observes,
“Well, no one up there seems con-
more important that all agencies
involved learn from it instead.
The investigation revealed that the
Oklahoma to Geilenkirchen, cerned.” After a little more thought
tire actually had shredded on take-
Germany. We were in a NATO I concluded, “It could have been the
off at Goose Bay. There they found
E-3A with an international crew of wheels bottoming out on the struts
pieces of shredded tire approxi-
30. The flight deck was comprised on lift-off.” And then we settled into
mately 5,000 feet down the runway.
of an augmented crew. our usual pre-nap magazines and
At Geilenkirchen they found no
books. The remainder of the flight
Having flown the first leg of our shredding on the runway. Therefore,
was uneventful as well as the land-
flight from Tinker Air Force Base they based their assumption on the
ing back at NATO Geilenkirchen.
to Goose Bay, Canada, the second more obvious findings.
half of our crew went in to file their After landing, Maintenance came out
There were several possible conse-
flight plan and the engineers did and asked the crew if they knew that
quences of flying with a shredded
their usual walk around. I remained a tire was shredded? We were all sur-
tire. The hydraulic lines could rup-
on board to keep an eye on things prised, but we were not sure when it
ture and result in a fire. In our case,
in the cockpit. When the other half occurred. No one “felt” anything.
we were lucky; the tubing had only
of our crew was ready to take over,
After a deployment, it is usual for been bent.
I retired to the back of the aircraft
the people on board to help unload
(my first “bad judgement call”) as On a more personal note, we dis-
all of our baggage onto the waiting
someone else wanted to be in the cussed some of the judgement errors
truck. Instead, we all had a look at
jump seat. on my part. First, even though we
the shredded tire and examined the
were an augmented crew, I still had
My buddy John, a weapons con- wheel well first (mistake #2). Then
signed for the aircraft and I was ulti-
troller, and I strapped in for takeoff. we proceeded to unload the aircraft
mately responsible. I should always
Everything seemed ops normal dur- and then go on to the squadron.
remain in the cockpit, even if only in
ing the takeoff roll except for a
Several days after the incident, I the jump seat. Once on the ground,
slight “thunk” right about lift off.
received a call from the safety office when there is a shredded tire, all per-
I turned to John and asked, “What
to come in and discuss their find- sonnel should remain clear of the
was that?” and John replied, “You’re
ings about the “shredded tire inci- tire. There is a possibility of a hot tire
the pilot, you tell me what that was.”
dent.” The safety officer greeted me exploding which could result in trag-
“I’m always up front on takeoff,
and made a point of telling me that ic consequences. Fortunately, I was
how should I know what sounds are
there was nothing to be gained from able to learn from this incidence
normal!” To which John said, “Well,
this particular incident by finger with 20-20 hindsight. ◆
I don’t know, I’ve never heard that
pointing. Rather, he stressed, it was

Trouble
Finds You
h, The Prairies; open spaces, flat
A ground, cloudless skies… noth-
ing to worry about on a fine VFR
might be possible to bypass
Medicine Hat and go directly to
Moose Jaw thus saving an hour in
that the navigator determined that
with the planned alteration to a
more northerly track, the drifting
day… or so we thought! our crew day. The Sea King altered north and the GHARS error that
about 20 degrees to the north to we were well north of track, in fact,
Our crew was ferrying a Sea King
take up a more direct route to far enough north that we had just
back to Shearwater from Victoria,
Moose Jaw. Another fuel reading on entered the Suffield Range… a
BC. The first day through the
the half-hour would confirm either restricted area! Now we were only a
Rockies to Calgary was uneventful
direct to “The Jaw” or to Medicine mile or two in at the very southwest
except that the engines were not
Hat as originally planned. corner but, we had, albeit inadver-
performing to 100% and would
tently, entered a restricted area.
need a tuning and topping at the With the great weather and ceilings
first opportunity. Day two would the aircraft captain decided to tune We immediately turned south and
see us through to Winnipeg with gas up the engines. For the next 15 min- exited with great speed (Sea King
stops in Medicine Hat and Moose utes, both pilots and the navigator mind you) and were clear of the
Jaw. The first leg out of Calgary was became busy with monitoring Range in about five minutes. Shortly
to Medicine Hat...a flight of about engine settings and adjusting the after that Medicine Hat FSS called
1.2 hours. The route was clear and topping screws. With all three heads to ask if we were aware of the Range
simple… basically follow the Trans inside the cockpit and busy, nobody and that the army was very con-
Canada Highway. There was the noticed that we were drifting north cerned about our transgression. Yep,
Army Range at Suffield but we’d be of track and that our Gyro Heading we messed up. The crew was busy,
well south of that… no problems. and Reference System (GHARS) had situational awareness was down and
We left Calgary at 0815; it was driz- developed a 20 degree error. Once our compass system failed us. All this
zly and ceilings were about 1000 the engine calibrations were done combined to make a routine VFR
feet. Twenty minutes east and the the crew got back to their map read- transit a bit of a nightmare. Trouble
skies began to clear and by 0900 we ing and fuel monitoring. It was then will find you if you are not always
were in severe clear and enjoying diligent. It certainly found us! ◆
the Alberta geography at 500 feet. Major Whitehead
With a tail wind and
good fuel consump-
tion the navigator
figured that it
Photo by Mike Reyno/Skytech Images

You Can Never Be Too

Sure
n October 1993, an F104 crashed

I on a hill 6500’ high north of
Aviano Air Base in Italy. The pilot
was killed. The pilot had 600 flying
hours total and 300 hours on type.
His flying proficiency was very low
(50 hours flown in the last six attempting to use a standard proce- and assess my situation. I cleared
months) because he was posted dure for F104 pilots that requires that hill by less than 1500 feet (I
to a desk job at Base Ops. manoeuvring in such a way as to found that out later!)
The flight safety investigation found intercept the IAF properly aligned,
so as not to have to enter the hold- Two reasons why I decided to abort
that the pilot got disoriented while
ing pattern and waste time. the instrument procedure were that
attempting to fly the Hi-Tacan pro-
firstly, I knew that my proficiency
cedure for Runway 05 and inter- Well, this is a happy ending story was very low and secondly, after
cepted the Initial Approach Fix because that pilot is me, and I didn’t being questioned twice in a few
(IAF) on a position 180 degrees crash on that hill. Why? Because an minutes about my position made
from the correct one (he had mis- ATC controller at Padova Radar, me think that something was
taken the point with the tail of his who was not too busy monitoring wrong. I flew back to my home
RMI). He started a descent from a the traffic on the airways, noticed base, asked for a PAR to a full stop,
wrong position and entered IMC something strange about my air- and I went right away to my
at 10,000 feet and impacted the plane. He called the controller at squadron commander to tell him
hill soon after. Aviano Approach and asked him to what had just happened. When all
Aviano Approach didn’t have radar query me about my position. My the clues pointed to something
so the ATC controller had to rely on answer was that everything was cor- being wrong, I decided to double
the pilot’s position reports to moni- rect. He asked again a minute later check…you can never be too sure! ◆
tor the progress of the approach. and at that point I decided to plug
By: Major Antonio Vianello
The pilot got disoriented while in the afterburner, climb on top,

I LEARNED ABOUT
FLYING FROM THAT
t was day two of a three-day long-
I range trainer as part of my Twin
Otter operational training. Long
Ready for
flight...
range trainer is a bit of a misnomer
in the Twin Otter world, as it took
us a whole day to make it to Calgary
from Yellowknife. All airspeed jokes
aside, myself and the other pilot in
training were getting comfortable
with the aircraft and were starting to
have some fun now, applying what
we learned to enroute operations.
The first leg of the day we planned
to go IFR to Cold Lake and stay the
night. The weather was not terrible,
but there were local snow showers
and broken cloud based at 3000 feet. takeoff ability, our lightweight, and sometimes, but if you are not expect-
While we flight planned, the flight my momentary hesitation, we were ing to see something wrong, chances
engineer went outside and per- airborne. The aircraft commander in are you won’t. Visually confirm each
formed his pre-flight checks. Once the right seat confirmed that his air- item in your check.
he was done he replaced the pitot speed was working and that the air-
Thirdly, speak up! When I noticed the
covers and engine inlet covers, as craft felt normal then took control.
lack of airspeed, I should have called
heavy, wet snowflakes were starting There was still several thousand feet
it out immediately. An abort may turn
to fall. At this point it is important to of runway remaining, but a rushed,
out to be unnecessary, but it is far
mention that the large red “remove overweight landing is not always the
less embarrassing then running off
before flight” flag had ripped off one best idea. We elected to remain VFR
a runway, or worse.
of the pitot covers the night before. and returned for the visual approach.
All that remained was the leather While airborne we analyzed the The incident was well handled by the
cover, and it was this that was placed problem and on a hunch I looked aircraft commander and was a good
over the pitot tube to protect it from out my window — there was the lesson for me. The most important
the falling snow. pitot cover snugly in place on the thing to do is relax. Don’t run through
left-hand pitot tube! The pitot heat red pages too fast for your crew to
Flight planning finished, we hurried
circuit breaker was pulled and we follow through. When an incident
out to the aircraft. The quicker we
landed without further incident. occurs, follow the old adage: aviate,
got going, less were the chances of us
navigate, and communicate — fly
having to spend time de-icing. The What went wrong? Many things: First-
the aircraft first. Make sure that there
covers were removed, engines started, ly, the flag attached to the pitot cover
is always someone looking outside.
clearance received, and off we taxied. had been gradually coming apart for
Have someone concentrate on the
some time. It was meant to be replaced,
Takeoff procedure in the Twin Otter flying — and only the flying — while
but came apart before that happened.
calls for a 60-knot airspeed check to the rest of the crew concentrates on
Unfortunately, we didn’t pay parti-
confirm that both airspeed indicators the emergency. Calgary is a busy air-
cular attention to it on the trip.
are working properly. When the airport and the weather wasn’t perfect,
craft commander called “60 knots” Secondly, four aircrew walked out but when you prioritize your actions
off his airspeed indicator, I glanced to the plane, and not a single one things go a lot smoother — as did
down at my airspeed to see it flicker- noticed the pitot cover was still in the rest of our long-range trainer. ◆
ing right around the zero mark. place. Scanning an aircraft during
Lieutenant Crouch
Because of the Twin Otters short the last-chance check may work
MAINTAINER’S
CORNER
W elcome to the newest section of the Flight Comment Magazine. This page is dedicated to the men and
women of the Canadian Armed Forces who specialize in keeping our fleets in flying order.
The aim of this page is to provide a means of sharing trends and concerns developing in the maintenance
world. The intent is not to focus on any particular fleet but to discuss as many subjects as possible.
Throughout the year various maintenance issues will be tackled. Your participation is welcomed. If you have
anecdotes, photos, or article ideas forward them to DFS for review and possible inclusion in the magazine.
Send your submissions to Sgt Anne Gale, DFS 2-5-3, via e-mail or regular mail.
THE ROUTINE attention, fatigue, training, and inat- caused because the tow crew didn’t
tention). Also, 6 technicians were have clear directions as to where
TOW JOB... NOT! injured to various degrees. A lot of the aircraft was supposed to go.
“Not another tow job? Isn’t there additional maintenance resulted • Do a “pre-flight” — ensure
from these incidents. So, to save crew, equipment, and aircraft
anyone else to do it this time? I just
us the extra work (not to mention are ready for the move. Does
came back from one.” How many the crew know their area of
people have these thoughts when headaches when filling out the
responsibilities and where the
they are told they have to do a tow paper work) why not start treating aircraft is going? Is the mule
job? It’s a no-brainer, a boring job… the tow job likes any other mainte- serviceable? Review basic
or so we thought!!! nance action: lets take the time to emergency procedures.
prepare for it. Remember the fol-
Tow jobs have become routine and • Cover all the bases: wing tips,
lowing points for your next tow job: tail, AMSE around the aircraft,
we are not taking the time to pre- etc. It’s easier to ask for additional
• If you’re a crew chief, know the
pare before we connect the mule members of your crew and their spotters in congested areas than
to the aircraft. In 2000, there have qualifications. If you’re a crew reporting an incident to the boss!
been 37 towing mishaps; that’s 3 a member and you are not sure • Once the aircraft is parked,
month! Four are still under investi- of certain procedures, ask. Better ensure it is secured.
gation, but out of the remaining 33, to ask then try to explain an
22 were caused by personnel factors accident later. • If you think it may not be safe to
move the aircraft — SPEAK UP!
(carelessness, expectancy, compla- • Confirm the intended parking spot
cency, information/communication, before you start towing and inform It seems like a lot but it only takes
judgement, technique, channelized the crew. Many incidents were a minute to run through these steps.
A little bit of prevention will save
you tons of work later. ◆

No Potential for
Severe Weather
few years ago the day started
A as per normal in the weather
office. A ridge of high pressure
However, at 1215 a second call was
received on metro from the CF5’s
now reporting the original line had
dominated the weather picture with developed into CB’s with the tops
the temperature expected to reach reaching 40,000 feet. The weather
28 degrees Celsius. Prior to the radar had by now painted that line
scheduled morning briefings all of CB’s and the motion previously
preparations were progressing nor- reported was indeed correct. In fact,
mally. A daily check of the stability the cells would reach the base in one
indices indicated no potential hour and fifteen minutes. By now,
for severe weather. time was of the essence. Without
any further delay, I issued a weather
By 0930 the aircrew briefings were
warning for thunderstorms with
complete and it was time to settle
a real threat of hail. I subsequently
into the office routine. It was just
briefed the Base Operations Officer
another quiet day at the office until
and he immediately had the aircraft
1130 at which time a call was heard
towed into the hangar. This turned
on metro from two CF5’s enroute to
out to be an extremely wise deci-
the range. They reported a line of
sion. At 1340 the weather report
TCU’s, which appeared to be devel-
showed a ceiling of 1000 feet with
oping rapidly 40 NM northwest of
heavy thundershowers, moderate
the base with a southeasterly
rain showers, and hail. The size
motion. This was not previously
of the hail was marble size and
forecasted and nothing was showing
it lasted for ten minutes.
on the weather radar. I immediately
contacted the forecasting centre This situation demonstrated the
and informed the forecaster of the utmost importance of timely PIREPs.
PIREPs I had received. He promptly Without that early warning, I doubt
told me of the weather situation very much that this severe weather
and of the lack of support for any situation would have been detected
convective activity. soon enough to avoid damaging
aircraft. ◆
MWO Houde

From the Investigator
TYPE: CT114172 Tutor (#4) As the second element was positioning for the rejoin,
CT114006 Tutor (#1) Snowbird Lead called a speed reduction and “easing
right” into a turn. The number four aircraft overshot
DATE: 04 September 2000 Snowbird Lead aircraft and attempted to regain
position by moving backwards. During this manoeu-
LOCATION: Toronto ON vre, number four’s left elevator and tail contacted
Snowbird Lead’s left wing leading
edge and left belly smoke tank.
The number four aircraft left the
formation and recovered at
Pearson International Airport.
Snowbird Lead co-ordinated the
recovery of the remaining aircraft
and all recovered at Pearson
without further incident.
The number four aircraft sus-
tained damage to the fibreglass
cover at the top of the ‘T’ tail with
contact marks and torn metal
found on the left elevator and tail
section. The Lead aircraft had
contact marks and dents on the
left belly tank and a torn left wing
he accident occurred after the 9 plane leading edge.
T formation of 431 Air Demonstration (AD)
Squadron had departed Pearson International
The investigation is being conducted by DFS
in Ottawa. ◆
airport to fly a display for the Canadian National
Air Show in Toronto. The aircraft directly
involved were Snowbird Lead (114006) and the
number four aircraft (114172) of the formation.
The departure from Pearson was conducted as
three separate elements of three aircraft, each in
“Vic” formation. The number four aircraft was
lead aircraft of the second element. The briefed
rejoin was to be completed shortly after take-off
with the first two elements rejoining as depicted
below:
3 2
4
7 6

For Professionalism
Corporal Arsenault and Corporal Turgeon from 413

(T&R) Squadron, Greenwood were proceeding from
the ramp of #10 Hangar toward the servicing area when
Corporal Turgeon noticed what appeared to be a piece
of FOD. Retrieving the item, he recognized it to be the
remaining portion of a broken fastener. Consulting
Corporal Arsenault, an experienced AVN technician
on the Labrador aircraft, she immediately determined it
to be the shank of a Droop Stop stud on the Aft Rotor
Head of aircraft CH113304. Furthermore, a second stud
was found sheared wedged in place by the Droop Stop
block, making it very difficult for technicians to see.
Corporal Arsenault and Corporal Turgeon are highly
CORPORAL ANDRE TURGEON
commended for their attention to detail, immediate
response, and perseverance in preventing a very serious CORPORAL MURIEL ARSENAULT
flight incident during start up or shut down. If left unde-
tected this could have progressed into a very serious inci-
dent where there was potential for a tunnel strike by Aft
Rotor Head blades during a start up or shut down.
Corporal Arsenault and Corporal Turgeon’s actions pre-
vented possible airframe damage and/or personal injury.
CORPORAL J.P. LESPERANCE
In April 1999, In June 1999, while carrying out a before-flight check

Corporal Lesperance on aircraft #188766, Corporal Lesperance discovered
was conducting an a nut missing on the left main landing gear door
after-flight check on uplock hook assembly. Even though the landing gear
aircraft #188736. He door is inspected after and before each flight, the
noticed an unusual emphasis is put on the roller assembly. The uplock
number of washers hook is not specifically identified as an inspection
under the nut of the item. The area is confined and the nut is very difficult
left trailing edge flap servo bolt. Further investiga- to see. Corporal Lesperance’s thoroughness
tion revealed that a bushing had been omitted dur- possibly averted a serious in-flight emergency.
ing the last periodic inspection carried out 1.9 flight Corporal Lesperance’s diligence and attention to
hours earlier. Corporal Lesperance’s only clue that detail resulted in the discovery of serious unservice-
something was wrong was the excessive amount of abilities. These two incidents could have resulted
washers on the bolt; the bushing is not visible within serious and extensive damage on the aircraft
out partly disassembling the servo attachment bolt. and potential flight control problems. Corporal
Over time, abnormal wear on the hinge point could Lesperance demonstrated a dedication that
have caused extensive damage to the aircraft. exemplifies professionalism.
Furthermore, serious flight control problems may
have resulted had this problem gone undetected.

For Professionalism
smoke was excessive for an otherwise ordinary land-

ing. The aircrew wished to continue with their local
training mission, but through Cpl Watters insistence,
they decided to exit the runway and carry out
a visual inspection. The inspection revealed a dan-
gerously soft tire on the left main landing gear.
Consequently, the aircrew terminated their training
and taxied to the ramp without further incident.
Cpl Watters displayed adept Crew Resource
Management through her surveillance of not only
ground traffic but air traffic as well. Her assertive-
CORPORAL SHANNON WATTERS ness that there was indeed a problem with the air-
craft and encouragement to initiate an inspection,
On 10 July 1999, during her tour of duty as Ground which ultimately led to the decision to abort the
Controller, Cpl Watters observed an inordinate training mission, averted a possible airfield disaster.
amount of smoke coming from the main landing Cpl Watters attention to all aspects of her duties,
gear of a CC130 aircraft that had just completed a and her insistence that the aircrew check the situa-
full stop landing. Although the smoke dissipated tion out may well have prevented a serious aircraft
quickly, Cpl Watters was certain that the amount of incident.
MASTER CORPORAL MIKE STACEY
MCpl Stacey, an Aviation Technician with 442 (T&R)

Squadron, was tasked to conduct a primary inspection
on a Buffalo aircraft. During his inspection, MCpl Stacey
discovered that the brake unit felt loose but was told by
more experienced technicians that this was normal for
this aircraft and not to worry. A short time later, he again
ran into this problem and decided to investigate further.
On his own, MCpl Stacey went to the component shop
to learn how the brakes were built up. After researching
the CFTO’s he realized that the two bolts that hold the
torque plate to the piston housing must be torqued to
60-inch pounds and then lockwired thereby preventing
any movement of the two halves. All Squadron aircraft As a result of MCpl Stacey’s outstanding professionalism,
were checked, and at least one brake unit on each air- perseverance, and superior dedication a serious hazard
frame was found to be loose. In addition, four of the was identified and rectified. His attention to detail and
seven brake units sent as replacements had the same refusal to accept the “norm” clearly averted the potential
problem. for a serious incident.

On 22 February 00, Cpl Huculak was tasked to carry out the her perseverance, would not have been carried onto all
cockpit survey phase of the periodic inspection on aircraft unit aircraft.
CF-188780, her first periodic inspection. She discovered that
MCpl Monpetit’s dedicated and intense research was
the IFF Emergency Bail Out tone switch was in the “disable”
instrumental in discovering the other six fleet aircraft with
position. Unfamiliar with this switch, she investigated with
the IFF Emergency Bail Out Tone switch modification still
the MOD/SI coordinator, MCpl Monpetit, to determine if
embodied and with the switches in the “disable” position.
the aircraft was properly modified.
His research and effort in this case was well above what
Their investigation revealed that this modification was would be normally expected in the everyday performance
only to be carried out on aircraft flying in operational the- of his job.
atres. CF-188780 should have been demodified on return
These two individuals detected, investigated and took
to Canada, because, with the switch in the “disable” posi-
immediate steps to correct a serious problem to the
tion, the bail out tone would not have functioned on ejec-
CF-188 fleet. This could have resulted in delayed recovery
tion. Her closer examination of the other aircraft in peri-
of an ejected pilot in Canada, or enemy detection of an
odic inspection, CF-188798, indicated it was also modified
ejection in a theatre of operations.
incorrectly so that the IFF Emergency Bail Out Tone could
not be disabled. MCpl Monpetit conducted further inves-
tigation and discovered six other CF-188 aircraft at 3 and
4 Wing and AETE with the modification still in place and
with the switches in the “disable” position.
Cpl Huculak’s discovery showed exceptional attention to
detail and an unwillingness to allow a seemingly minor
problem to go uninvestigated. Her unwillingness to stop
CORPORAL PATTY HUCULAK
with only her area of responsibility ensured that both
periodic inspection aircraft were closely examined. This MASTER CORPORAL
discovery could have been easily overlooked, and without FRANK MONPETIT
PRIVATE GILLES FRENETTE orange and green drive links were installed improp-
erly. The washer on the swash plate stud was found
On 01 June 1999, Pte installed under the nut. Pte Frenette correctly uti-
Frenette, a 514 Aviation lized CFTO references and ensured the aircraft was
technician, noticed an returned to service.
accumulation of fuel on
the hanger floor from On 29 September 1999, Pte Frenette was conducting a
Aircraft #478. He took 600-hour inspection on the CH146. While inspecting
the initiative to inspect the number one engine AFCU forward drain line, he
the area and, upon noticed an anomaly on the drain line. On further
investigation, found inspection he noticed that the line was chaffed. If
that the #1 engine pres- this had gone unnoticed, there was potential for seri-
sure switch required ous damage. Further inspections on other squadron
replacement. The aircraft was returned to service aircraft indicated the same chaffing problem.
without further incident. Pte Frenette has shown his professionalism, dedication
On 16 July 1999, Pte Frenette was conducting and loyalty to his unit and the Canadian Forces as
a 25-hour inspection on Aircraft #497. While a whole, and his awareness surely contributed to
conducting this inspection, he noticed that the averting very serious hazards.

For Professionalism
MASTER CORPORAL JEFF WALLACE
investigated further by removing the forward cowl-

ing and gaining access to visually inspect the area
in which the pin had been found.
A detailed inspection was conducted and it resulted
in that the pin found was one of two pins attaching
the collective lever assy to the swashplate and sup-
port assy. He immediately informed his supervisor
of the situation. As a result of the severity of the
snag all 408 squadron aircraft were grounded and
a local special inspection was immediately carried
out. Further examination revealed that the wrong
bolt had been used to install the pin and during
removal only two threads held the bolt in the insert.
All other aircraft checked had wrong bolts installed.
Had the flight proceeded, and the collective lever
On 22 February 2000 Master Corporal Jeff Wallace broken free in flight, the result could have been cat-
was the Flight Engineer scheduled for a local train- astrophic. If it had not been for Master Corporal
ing trip on aircraft #CH146431. During his pre- Wallace’s attention to detail and technical expertise
flight he noticed a pin sitting by the transmission this incident may have gone unnoticed and possibly
filler cap scupper drain. Master Corporal Wallace resulted in a serious accident.
PRIVATE PATRICK McVEIGH
On 15 March 1999, Pte McVeigh was tasked to start cians and is to be commended for the professionalism
a transient RAF Tornado. A second Tornado start was and dedication he displayed.
being performed concurrently on an adjacent parking
spot. The starts were without incident until Pte McVeigh
observed that a refueling access door panel was open on
the nearby aircraft. Using hand signals he communicated
with the commander of his aircraft who in turn alerted
the other aircrew. A crewmember appraised the situa-
tion, exited the aircraft and secured the open panel.
Pte McVeigh’s alertness and quick response with decisive
actions were instrumental in preventing damage to an
aircraft. Although not familiar with the Tornado aircraft,
Pte McVeigh was able to ascertain the criticality of this
access door and ensure that the potential loss of an air-
craft panel was averted. He demonstrated to a foreign
ally the commitment to the task at hand of CF techni-

SERGEANT KIM BLAKE
On the night of 22 engine was started and the other cargo door (starboard)
March 2000, Sergeant was pinned open, Sergeant Blake compared the two doors
K. Blake’s superior pro- and found there was a discrepancy between the two.
fessional attitude averted
After informing the pilots of the problem, Sergeant Blake
the possibility of an air-
recommended shutdown due to the unserviceability of
craft accident or serious
the aircraft. After shutdown, further investigation revealed
incident. While com-
that the bottom track of the cargo door guide securing
pleting a post engine
hardware was broken off. This caused the looseness of the
start check on a CH146
cargo door and the more than normal aft positioning.
Griffon helicopter for a
night vision goggles If this unserviceability had gone unnoticed the potential
training mission with loss of aviation resources or life may have occurred if the
troops, Sergeant Blake cargo door had departed during flight. Sergeant Blake is
noticed that the port to be commended for his attention to detail and superior
cargo door was too far knowledge of aircraft systems that enabled him to notice
aft. Additionally, the aft portion of the door was loose an unserviceability that could have easily been missed.
while the door was pinned fully open. After the second
SERGEANT CLAUDE POTHIER
Sergeant Claude broken electrical wire, and a second wire that had
Pothier was become disconnected from the terminal board and
conducting a arced as it came in contact with the aircraft skin.
routine pre- At this point, Sergeant Pothier immediately notified
flight inspection the servicing crew.
a CP-140
The technicians were initially unable to locate the
Aurora when he
terminal board and faulty wires due to their con-
noticed a small
cealed location. Sergeant Pothier then crawled into
piece of plastic
the well for a second time and successfully pointed
lying on the
out the area of interest. Further investigation
bottom of the
revealed that the terminal board cover had broken
Doppler well.
off and that the disconnected wire feeds the radiant
On retrieval of
floor heating, a system that requires considerable
the FOD, it was
amperage. Hanging freely with no support, this
discovered that
live wire presented a grave fire hazard.
the plastic piece
was in fact a terminal board cover. Determined Sergeant Pothier’s exceptional attention to detail and
to locate the origin of the cover, Sergeant professional actions resulted in the detection of a
Pothier promptly proceeded into the tight con- critical unserviceability and prevented an aircraft
fines of the Doppler well. There, he discovered with a dangerous condition from going airborne.
the terminal board with the missing cover, a

FOD Walk or Talk Walk

remember the morning in ques- ourselves heading for the canteen So there we were out again, but
I tion well because it was a Friday
morning. Spring had sprung, the
for that well deserved morning cof-
fee. I noticed that some people had
this time it was made very clear to
leave all coffee cups behind and to
sun was out, and even though we their coffee in hand on the FOD pay more attention to the ground.
had a little wind coming from the walk, something I thought I would Strangely, no one talked during the
west, being outside felt nice; the definitely do one morning. Why walk, and all of us were looking
temperature was around zero wait until after the walk after all? down at the tarmac.
degrees Celsius. I can hold my coffee in one hand
Needless to say, even though I
and pick up FOD with the other.
At just about 0745, the call was made was not alone in this, I felt a little
over the P.A., like every working day, Not even ten minutes after we came responsible when I thought about
that it was time for our usual morn- in, we heard a P.A. announcement the way I had behaved. It made me
ing FOD walk. This meant that it calling a meeting for all personnel. realize that even though the task is
was time to get out to the flight line, That seemed unusual because all the done every morning, it takes all but
form a line which is usually com- meetings were usually held in the five minutes of the day, so it should
posed of 30–35 people (which curi- afternoon. To our disbelief, we were be done correctly and with profes-
ously can go up to as many as 50 told by the Sergeant in charge of the sionalism. From then on, I decided
when the weather is at its best!) and FOD walk that we had to go out to pay more attention to the FOD
wait for the Sergeant in charge of the and do it again! He explained that walk and wait for coffee-time in the
walk to give the go-ahead. Like most he had just been on the phone with canteen to chat with co-workers. ◆
of us should know, the goal is to pick the UFSO who had watched the
up what most aircraft engines, par- FOD walk from the second floor
ticularly low intake jet engines, like office of the hangar. The UFSO
to ingest for food (or course, I mean had said that if we are to carry out
FOD). a FOD walk the way we had done it,
we might as well not do it, because
The area that we have to cover is
it was useless.
about 75 meters wide for a distance
of about 300 meters, and the whole
process takes no more than five
minutes. Everyone seemed cheerful
given the Friday morning and the
nice forecast that was being
announced for the weekend. To
top it all off, my favourite hockey
team had won a big game the night
before, and I was eager to share with
my co-workers all the details about
important plays that had helped the
team win the game. With this in
mind, I squeezed myself between
two hockey fans and started to chat
with them about the now famous
outcome of the game. The Sergeant
in charge gave the OK to start walk-
ing, so we did. We were still talking
about the game when we found

2001 1 Eng

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EM-177 Epub(FltWinter)_LR 30/1/2001 16:35 Page a

Aerospace Life Support Equipment

8 ..................................Conversion Nightmare The Canadian Forces

Contributions, comments and criticism

20.............................................20-20 Hindsight Subscription orders

2 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 3

Getting Home Early for

4 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 5

6 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 7

8 Flight Comment, no 1, 2001

Continued from page 1

Improved Analysis of Human Error Flowchart

Resource Organizational Organizational

Inadequate Planned Inappropriate Failed to Correct Problem Supervisory Violations

PRECONDITIONS FOR UNSAFE ACTS

Substandard Conditions Substandard Practices

Adverse Physical/ Interpersonal

Personal Qualification Training

Attention/ Knowledge/ Skill/

Flight Comment, no 1, 2001 9

Where Will You Be

10 Flight Comment, no 1, 2001

Letters to the Editor

Flight Comment, no 1, 2001 11

ALSE Aerospace Life Support E

12 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 13

A Good Day Kings doing hover work on the heli-

for Traffic port, which is adjacent to taxiway

It Almost Cost a Life

16 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 17

18 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 19

20 Flight Comment, no 1, 2001

Photo by Mike Reyno/Skytech Images

Flight Comment, no 1, 2001 21

You Can Never Be Too

n October 1993, an F104 crashed

22 Flight Comment, no 1, 2001

24 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 25

From the Investigator

26 Flight Comment, no 1, 2001

Corporal Arsenault and Corporal Turgeon from 413

CORPORAL J.P. LESPERANCE

In April 1999, In June 1999, while carrying out a before-flight check

Flight Comment, no 1, 2001 27

smoke was excessive for an otherwise ordinary land-

MASTER CORPORAL MIKE STACEY

MCpl Stacey, an Aviation Technician with 442 (T&R)

28 Flight Comment, no 1, 2001

Flight Comment, no 1, 2001 29

MASTER CORPORAL JEFF WALLACE

investigated further by removing the forward cowl-

PRIVATE PATRICK McVEIGH

30 Flight Comment, no 1, 2001

SERGEANT KIM BLAKE

SERGEANT CLAUDE POTHIER