in this issue - flight comment

IN THIS ISSUE:Operation Halo: The Griffons are back from HaitiFlight Safety on the Edge of the EnvelopeOperational Cause Factor Discussion

SUMMER 2004

IN THIS ISSUE:Operation Halo: The Griffons are back from HaitiFlight Safety on the Edge of the EnvelopeOperational Cause Factor Discussion

Table ofContentsThe Director’s Views on Flight Safety ................................................................1

DossierAn Opportunity Missed................................................................................................8Operation Halo: Return of the Falcons to Haiti........................................................12Safety at the Edge of the Envelope .............................................................................16

Regular ColumnsFrom the Flight Surgeon...............................................................................................2Editor’s Corner............................................................................................................11Maintainer’s Corner Tool Control — Are You Taking It Seriously Enough? ..............................................26Épilogue ......................................................................................................................28From the Investigator .................................................................................................33For Professionalism ....................................................................................................35

Lessons Learned“Supposed” Operating Procedures ...............................................................................3Behind schedule ............................................................................................................4Bad Habits Die Hard.....................................................................................................6Ready for Everything?.................................................................................................20Importance of Completed Paper Work…..................................................................22Lithuanian Landing ....................................................................................................24

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Cover page: Captains Aldo Cordisco (on the left) and Jeff Beaudry completing their mission planning during Operation Halo in front of a Griffon Helicopter.Photo by Master Corporal Pascal Dupuis, Operation Halo, 430 Squadron, April 2004.

DIRECTORATE OF FLIGHT SAFETY

Director of Flight SafetyColonel A.D. Hunter

EditorJacques Michaud

Art DirectionADM (PA) DMCS

THE CANADIAN FORCES FLIGHT SAFETY MAGAZINE

Flight Comment is producedfour times a year by theDirectorate of Flight Safety.The contents do not necessarilyreflect official policy and unlessotherwise stated should not beconstrued as regulations, ordersor directives. Contributions,comments and criticism arewelcome; the promotion offlight safety is best served by disseminating ideas andon–the–job experience.

Send submissions to:

Editor, Flight CommentDirectorate of Flight SafetyNDHQ/Chief of the Air StaffLabelle Building4210 Labelle StreetOttawa, Ontario Canada K1A 0K2

Telephone: (613) 992–0154 FAX: (613) 992–5187E–mail:[email protected]

Subscription orders should bedirected to: Publishing andDepository Services, PWGSC,Ottawa, ON K1A 0S5Telephone: 1-800 635–7943

Annual subscription rates: forCanada, $19.95, single issue,$5.50; for other countries,$19.95 US, single issue, $5.50US. Prices do not include GST.Payment should be made toReceiver General for Canada.This publication or its contentsmay not be reproduced withoutthe editor’s approval.

To contact DFS personnel onan URGENT Flight Safety issue,please call an investigator whois available 24 hours a day at1-888 WARN DFS (927-6337).The DFS web page atwww.airforce.forces.gc.ca/dfsoffers other points of contactin the DFS organization orwrite to [email protected].

ISSN 0015–3702A–JS–000–006/JP–000

corners and get aircraft on the ramp is huge. The practice ofperforming tasks from memoryvice referring to the technicalorders, omitting essential paper-work, and allowing unqualifiedpersonnel to complete mainte-nance tasks without the appropri-ate level of supervision are someof the shortcuts that we haveseen. These are not only unaccept-able flight safety practices, theyare illegal from an airworthinessperspective. Therefore, althoughthe temptation is there, it mustbe resisted as the consequencesare huge. In the past, aircrafthave been written off and liveshave been needlessly jeopardizedby cutting corners. I would askyou to remember this if and when this temptation arises.

Fatigue is a more insidious problemthat all members of the Air Forceteam face. Our more experiencedpersonnel are contending with aheavy workload as they try to getthe job done while simultaneouslytraining/ mentoring the largenumber of ab initio aircrew, main-tainers and ops support personnelthat are now in the system. Whilethere is nothing wrong with a bitof hard work, we are currently facing some unprecedented chal-lenges and we therefore have torealize that we all have our limits.There have been several seriousoccurrences in the recent pastwhere fatigue played a part.

While we all pride ourselveson ability to get things done,

we have to honour the threatthat fatigue poses to a safe

operation.

The Air Force is going throughsome tough times from a flight

safety perspective. It is thereforecrucial that we use the system'sbuilt in safety processes and avoidshortcuts and that we remain vigilant against the threat posed to a safe operation by fatigue.

In closing, I would like to mentiontwo key members of the flightsafety team who are moving onthis summer. Lieutenant-Colonel(LCol) Gary Hook, the 1 CADDivisional Flight Safety Officer will assume command of theCentral Flying School. LCol Hookhas had a huge influence on flightsafety within the Canadian Forces(CF). He has been a key element intoday's flight safety organizationby training and shaping the think-ing of flight safety personnel bothwithin the CF as well as foreignmilitaries. He will be replaced byLCol Peter Young who I would liketo welcome to the flight safetyteam. Chief Warrant Officer (CWO)Jacques Mercier, who has been theDFS CWO for the past three years, will be retiring from the CF afterover 37 years of dedicated service.CWO Mercier's dedication, passionfor flight safety and terrific senseof humour will be sorely missed by all of us at DFS. We wish CWOMercier all of the best in his retirement. In addition, a warmwelcome to his replacement, CWO Michel Bernier. ◆

Colonel Al Hunter, Director of Flight Safety

It is hard to believe but it hasbeen almost a year now since I

assumed the position of Directorof Flight Safety (DFS). Since thattime, I have had the opportunityto visit just about all Wings as well as most of the units withinthe Air Force. I continue to betremendously impressed with thequality of our people and the man-ner in which they continue to meetthe numerous challenges that weface. In addition, the enthusiasm ofthe ab initio aircrew, maintainers, controllers, and flight line supportpersonnel is truly amazing.

However, that is not to say thatthere are not some concerns. Inthe last issue of Flight Comment,Lieutenant-General Pennie outlinedthe serious flight safety challengesthat are currently facing the AirForce. These challenges include a high operations tempo, lowexperience levels, equipmentreplacement and modernizationprograms, and challenges associ-ated with various theatres ofoperation. The Air Force is doingwhat it can to mitigate this situa-tion; but there are two seriousthreats that are starting to becomenoticeable: shortcuts and fatigue.

The issue of shortcuts is currentlymanifesting itself within themaintenance community, but it isequally applicable to all parts ofthe Air Force. Given our currentsituation, the temptation to cut

Summer 2004 — Flight Comment 1

The Director’s Views on

FlightSafety

2 Flight Comment — Summer 2004

Hello from OP HALO in Haiti!With only one-days notice

I went from occupying my niceand comfortable Air Force cubicleat the Directorate of Flight Safety(DFS) to playing army in Haiti living in a tent. Who said youcan’t be at DFS and not be partof a Rapid Reaction Force!! As aresult, I did not have time togather my files and produce thearticle I had originally wanted to publish, however, there are flight safety lessons to belearned from our operation here in Haiti with our six CH146

Griffon’s from 430 Sqn. My pointwith this article is to refresheveryone’s minds on the signsand symptoms of heat illnessand to stress the point that itdoes not take much to becomeafflicted.

Operating in hot environments is now a routine aspect ofCanadian Forces (CF) deployedair operations, certainly withinthe last three years. We areoperating in and out of hot envi-ronments constantly. Heat stressinjury is a common diagnosisamongst CF personnel and aircrewcan be particularly susceptible asthey are often operating in someof the hottest environmentswithin our flight decks.

Heat exhaustion and heat strokeis a continuum of increasinglysevere heat illness caused bydehydration, electrolyte losses,and failure of the body’s ther-moregulatory mechanisms (i.e.the way your body manages itscore temperature). Heat exhaus-tion is an acute injury withhyperthermia (i.e. increased corebody temperature) due to dehy-dration. Heat stroke is extremehyperthermia with thermoregu-latory failure and profound cen-tral nervous system dysfunctionand even death.

Common signs and symptoms ofheat exhaustion include: fatigue,weakness, dizziness, nausea/vomit-ing, headache, muscle pain, profusesweating, increased heart rate, lowblood pressure, lack of coordination,agitation, and intense thirst. Thecommon signs and symptoms ofHeat Stroke are all of the previoussymptoms plus the following:exhaustion, confusion, disorienta-tion, coma, and hot flushed dryskin. The predisposing factors are:poor acclimatization to heat, poorphysical conditioning, salt or waterdepletion, obesity, acute febrile illness or gastrointestinal illness,alcohol/caffeine use, poor air circulation in environment, andheavy or restrictive clothing.

We have had four cases of heatinjury down here in Haiti and in all cases, the personnel becameaffected within 48 hours of arrivingin theatre. None were doing anyparticularly heavy work, just set-ting up their living spaces, etc. Allexperienced nausea and vomitingand all were surprised how little it took before they got knockeddown. All did well after resting for24–48 hours and returned to theirduties. So, check yourself, yourenvironment and your crew, andtake appropriate precaution inorder to mitigate the risks. ◆

Major Tarek Sardana, DFS 2-6, Flight Surgeon

“Heat exhaustion and

heat stroke is a continuum

of increasingly severe

heat illness caused by

dehydration, electrolyte

losses and failure of the

body’s thermoregulatory

mechanisms.”

HEAT STROKE

From the

FlightSurgeon


OPERATINGPRODECURES

SupposedTactical Fighter Controllers (TFC’s)

— some call us “wanna-be”fighter pilots. What we are is notimportant, but what we do is! Oneof the TFC’s main occupations is tomaintain a constant lookout duringthe simulated combat operationsand spot any possible flight safetyincidents before they happen.

One day, during a simulated aircombat exercise, I noticed an aircraftwith a transponder code of 1200 popup close to four CF-18 Hornet’s insimulated combat. For those of youthat do not know, 1200 is a codethat indicates that an aircraft is fly-ing under visual flight rules (VFR).This aircraft’s heading and altitudeindicated that he was flying in therestricted airspace reserved for ourCF-18’s. The aircraft was close to theengagement, however it was flyingaway from the fighters. I was con-vinced it was a civilian aircraft thathad gone astray!

Before knocking off the fight and losing precious training time,I decided to ask my missing CF-18what his “squawk” was. The pilotanswered “1200.” Intrigued, and nowreassured of my sanity,I asked him why he wassquawking a VFR code.“Because it is SquadronStandard OperatingProcedure (SOP) for adead man,” answeredthe pilot. I requestedthat our “dead” friendchange back to his previous code, and we agreed to discuss it on the ground.

Being 50 feet from the squadron andnot 50 miles like the CF-18, I had thechance to discuss the situation withthe Unit Flight Safety Officer (UFSO)at the squadron, who is also a pilot,before the Hornets landed. The con-fused look on his face to my requestfor information answered my ques-tion — either a 1200 code was not aSOP or there was a definite lack ofcommunication. Just then, in walkedthe pilot who said that he was con-vinced that the procedure was SOP.A decision to research the situationwas reached by both pilots, and thenext day the UFSO informed me thata “Dead Man” code of 1200 was NOTa squadron SOP and that it hadmerely been a misunderstandingbetween a junior and a senior pilot.End of story… not quite!!

Two weeks later, during a pre-mission brief, the pilot responsiblefor the exercise informed us that a“Dead Man” code of 1200 was to be used. Before I could even raisemy hand to comment on this repeatsituation, another pilot mentionedthat 1200 was inappropriate andsaid that a code that didn’t conflictwith civilian codes should be used.Another code was chosen and wewent off to play for yet another day.

People in the flying community have to discuss problems that havearisen so that they are not repeatedand so that information passes clearlyand rapidly- communicate, commu-nicate, communicate. Procedures areNOT SOP’s until they are written andpromulgated in the publications. ◆

Captain Stephen Hansen now servesin the United States at Tinker AirForces Base, Oklahoma.

“ ”

Photo by Corporal Kimberley Plikett, 1 AMS Wing Photo, 4 Wing Cold Lake.

It was the morning after the first leg of a transit to Argentina.

The Aurora crew had spent the night in Panama City, Panama at an American Air Force base, where the crew enjoyed the night in a hotel.Inevitably, the planned early departurewas slipping to the right. This was dueto late checkouts by some of the crew,the bus to the airfield showing up late,traffic, and most of all, an unplannedstop at the Naval Exchange store.

The crew, already thirty to forty-five minutes late, attempted to contact transient servicing for a start man, but had no luck. The daywas getting hot and muggy, and thecrew was trying to make up sometime. Subsequently, the on-boardcheck was carried out alone by acrewmember that, due to qualifica-tions, required full supervision.The checks were all completed and the aircraft was ready to start.

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The crew once again tried to radiofor the start man, but still there wasno one available. A decision wasmade to continue the start withoutthe ground man. A normal start wascarried out and taxi clearance wasreceived. The brakes were releasedand an attempt was made to taxi,but the aircraft would not move.The pilot confirmed with the flightengineer (FE) that the chocks hadbeen removed, but he was not sure.The ground man, just prior toengine start, normally carries thisout and this is a flight deck checkprior to engine start. The flaps wereretracted to allow the aft observers

to check for the chocks, and it wasconfirmed that they were still inplace. A discussion ensued to decidethe best course of action and, sincethe crew was already behind sched-ule, it was decided to try to run overthe chocks. The attempt was madeand then aborted.

Another discussion took place, and a decision was made to stop #1 and#2 engines and exit the aircraft toremove the chocks. Upon exiting the aircraft, the FE noticed that a firebottle was located just right of thenose, approximately 25–30 feet infront of the #3 engine. It was in

a spot that was not in clear view ofthe pilot, and not noticed during the on-board check. The groundman also normally moves this afterthe start. It was determined that thebottle was of sufficient height that it would have contacted the #3 propresulting in major damage.

The crew dismissed the incident aslucky. Unfortunately, there was nofurther discussion of the incident. ◆

Sergeant Dan Murphy serves withthe Maritime Proving and EvaluationUnit of 14 Wing in Greenwood.

Story based on facts as related toSergeant Murphy by a third person.

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This is an example of what canhappen if one develops bad

habits that are allowed to continueunchecked. I was one of four pilotstaking a four-ship of Tutor aircraft to Mountainview for retirement. Wetook the first day to get to Toronto andspent the night there, as we were todo a four-ship flyby over Downsviewfor Canada Day celebrations. We allgot a good nights rest in anticipationfor the next day’s events. We woke upto a beautiful sunny day without acloud in the sky and we all commentedon how great the weather was to do a fly-by. The fly-by was planned for1300 hrs so we all arrived at the flyingbase of operations (FBO) around1000 hrs, which gave us plenty of time to brief and discuss the mission forthe day. After confirming the weather,frequencies, and timings we briefedthe trip and everyone was clear onwhat was supposed to happen. I wasthe deputy lead in the third aircraft.

We had a planned start time of1230 hrs so we all had time to complete our walk-around and beready to start in time. We all startednormally and got our clearance to

taxi out. We had already talked toAir Traffic Control (ATC) on thephone, so they were prepared for us.We started to taxi off the line inorder and, when it came my turn,I advanced the power to leave the lineas there was a bit of a hill to get over.A few seconds after advancing thepower I felt some rumbling. I pulledthe power to idle and checked myengine gauges, which were all indicat-ing normal. I attributed the rumblingto sticking brakes, which I had felt afew times in the past. I wasn’t in thesame aircraft as I had flown yesterday,so I didn’t know if it had had anyprevious problems, but the pilot hadn’t reported anything. I radioed to #4 of my suspected problem andhe replied that he had had sometrouble getting off the line as well.With this, I dismissed the problemand continued to taxi.

Being excited about the mission,I conducted my taxi checks withenthusiasm and was fully preparedto go. We were issued hold shortinstructions for the runway in useand we were all prepared for the

BAD ABITSHARDDIEinevitable “cleared immediate take-off”that comes with trying to depart afour-plane formation from Pearsonairport. We were cleared for take-offand all powered up to get into posi-tion quickly. When I powered up Iagain felt the rumbling noise and feltvibrations. This time I checked myengine instruments prior to reducingthe power and noticed that theExhaust Gas Temperature (EGT) wasrising and the RPM had fallen fromwhere it should have been, a clearindication that I had a compressorstall. I powered back and informedlead that I had to abort. I taxied backto the FBO without further incidentand shut down.

After shutting down the aircraft,I went to install the gear pins andappropriate covers and pins. When I went to cover the pitot tube, Ifound that I couldn’t find the pitotcover. This immediately gave me suspicion as to what had caused the compressor stall. I carried out a foreign object damage (FOD)crawl and found the first three stagesof the compressor were damagedand there were the telltale remnants


of orange “remove before flight”flags stuck in the stator guide veinsprior to the compressor. I hadindeed ingested the pitot cover.How could this have happened?

Well…it actually started approxi-mately three years ago when Istarted my pilot training on theTutor. There is a ledge just ahead of the intake that is formed by a v-shaped formation on the aircraft,which splits the airflow by the intake.This ledge served well as a resting-place for the pitot cover while I didup my parachute. The normal flowof events was that I placed the pitotcover on the ledge, did up my

parachute, then took the cover andplaced it in the appropriate stowagepouch. I did it in this order so as tosave climbing up to stow the cover,then climbing down to do up myparachute. There were times in thepast where I had forgotten the coveron the ledge but, either the groundcrew or I, had noticed the errorprior to engine start. This day wasan exception. My bad habit, com-bined with some inattention dueto excitement about the upcomingmission, had allowed me to miss thefact that I hadn’t stowed the pitotcover, which resulted in the destruc-tion of a 1/2 million-dollar engine.

But it could have been worse. Hadthe cover been ingested on departureinstead of immediately on start, itwould have led to an ejection and acrashed airplane.

It is important that in our line ofwork, we develop good practicesright from the commencement ofour training. We must continue tofoster good habits and seek out badones so that we can put an end tothem before they are allowed to causedamage to, or the loss of, valuableaviation resources. I have learnedthis lesson but, unfortunately, notwithout cost. ◆

Captain Damian Unrau serves with410 Squadron at 4 Wing Cold Lake.


There is a lot of unnecessary and distracting information

being forced upon people these daysand aircrew are probably subject toeven more of it than most. I expect,therefore, that in self-defence mostaircrew have adopted a fairly restric-tive filtering system, so that dealingwith the trivial does not interferewith getting at the important issues.Flight safety officers should remem-ber this reality when writing up inci-dent reports, because there will onlybe a slim window of opportunity tograb the reader’s attention and, if itis missed, it is likely gone forever.When that happens, the mostimportant reason for the existenceof incident reporting is gone with it.

For instance, take the followingGriffon incident (#111108) extracts,which concerns a rotor overspeed in Bosnia.

• Description: Suspected main rotor overspeed — crew was flying at 80–100 knots, approx 500 feet above ground (AGL.)The aircraft was crabbing at 45 degrees to the right in 65 knotsof wind, with gust of 85 knots,(60G85knots) when severe

turbulence occurred. The aircraftyawed to 90 degrees and lost andgained altitude at a rate of 1000 to 1500 feet per minute. The mainrotor rpm (RRPM) was seen toreach approx 106 percent with theRRPM warning light and cyclicposition centre light on. Severeturbulence continued for almostone minute before the crew wasable to find smoother air and landsafely at the nearest site, withoutfurther incident.

• Investigation: After landing,the crew downloaded the datafrom the aircraft Health & UsageMonitoring System. No condi-tions of overspeed were recorded.The crew carried out a detailedpre-flight inspection and returnto base without any further incident.

• Cause Factors: Environment —weather — in that strong andgusty winds caused a rapid accel-eration of the main rotor rpm.

• Preventive Measures:Brief all aircrew.

The current bee in my bonnet is theincorrect application of the environ-ment cause factor. In another closedincident, a window broke when agust of wind slammed the open andunattended pilot door shut and the

An Opportunity

MISSEDonly cause factor is environment/wind. I wondered, though, who leftit open? In the above-mentionedcase, I was quick to notice that thewhole incident was also attributedto the strong gusty winds that did,in fact, exist. However, I think youhave to dig a little deeper than thatand rule out other possibilities beforeyou can settle on “environment” as a cause factor. The A-GA-135 statesthat: “Environmental causes applyonly to those events where adequateand reasonable care and precautionswere exercised. Reasonable precau-tions include, but are not limited to:full use of forecast information, …”.

Right away, I wondered about whatforecast information was known bythe crew. Nothing in the investigationanswered that question but I thoughtthat 65G85 knots does not just comeout of nowhere, so there were severalpossibilities. At least three of thesewere: first: no area forecast available,second: crew was at a deployed loca-tion and could not get the forecast, orthird: crew did not check the forecast.I came away from reading this withmore ammunition for my crusade

OPERATIONAL CAUSE FACTOR DISSCUSION

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but had an inadequate appreciationof what really happened. Routinely,I review all Griffon incidents and,every once in a while, review the“higher interest” ones at the morning400 Squadron operations briefing.On the day I mentioned this one, Iwas just getting warmed up with myenvironment cause factor theme andgot as far as “What did the crew knowabout the weather?” when one of thepilots at the briefing broke in andtold us he was the aircraft commander(AC) in question. The tale he toldwas eye-watering. What follows is thenarrative he later wrote up, a storyhe called “Bumpy Ride” but thathardly does the tale justice. Read onto see what the AC had to say…

“In February 2003, our squadron wasdeployed to Banja Luka, Bosnia insupport of the Multi-NationalDivision North West. Essentially, wewere a taxi service for VIPs. The daystarted the same as others while inBanja Luka. We received our taskingthe previous night. This time we wereto fly our VIP to Sarajevo and twoother persons to Bugojno, a Dutchbase mid-way to Sarajevo, but offtrack and in the next valley over. Aweather call had been requested at0630 hrs, due to the long drive requiredif the weather was poor. As usual, theweather was less than ideal; the ceil-ings were right on the line with respectto making it over the mountainsenroute to Sarajevo. The most noteditem, however, was the forecast wind

— severe turbulence in the mountains.This wasn’t supposed to occur until wewere nearing the end of our mission.Regardless, based on the relatively lowceilings, the severe turbulence, and theknown dislike of flying by our passen-ger, I elected to cancel the mission.No problem. As expected, we wereasked if we could at the least get theVIP to Bugojno, which was halfway.Since I was still trying to get there with my other two passengers, I said itshouldn’t be a problem but told him toexpect a very bumpy ride. This madehim happy as it cut his drive in half.”(Major Lee Editorial Note: So far, sogood. The decision to go was basedon a shorter mission and the abilityto complete it before the onset of theforecast severe turbulence condition.)


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Dossier“As luck would have it, about thirtyminutes before our launch time, aSlovenian Bell 412, (a civilianGriffon) with weather radar onboard,had made it in from Sarajevo and theVIP caught wind of this fact. Whenwe arrived to pick him and the twoother passengers up, he said hewanted to try for Sarajevo as he had avery important meeting to attend. Itold him about our chances due to theweather and advised him that I hadanother mission to Bugojno, for myother passengers. “Essentially, he saidthat he was the priority and all elsewould have to wait.”

This is where I made my biggest mistake. I caved and agreed to try,warning him it was going to be abumpy ride and I couldn’t promisethat we could make it. The two Dutchpassengers weren’t too happy, butcame along in hopes of getting toBugojno on the return leg.

After take-off, we noted the winds onthe avionics management system to be60G85 knots, and we were making aground speed of approximately sixtyknots. Right away, I advised the VIP that we would have to land atBugojno for fuel, due to the winds.No complaints so far. In order to getto Bugojno from Banja Luka, we hadto take a small cut through a line ofmountains, which was approximatelyfifteen to twenty miles wide. As we

turned the first corner into a valley,perpendicular to the winds, we reallystarted to feel the turbulence. It wasbad, but nothing too extreme at the time.

Our second mistake was that we con-tinued. At that point, we hit severeturbulence, which sent us back andforth from 2000 feet per minute (fpm)up to 2000 fpm down. The aircraftwas already crabbing 45º to the rightand was being kicked 90º off of track.In order to control the rotor duringthe rapid changes on the VerticalSpeed Indicator, I had to pull in thecollective. Unfortunately, the ceilingswere only a couple of hundred feetabove us, and closing. We managed toarrest our rate of climb but at the costof over speeding the rotor. After somecolourful descriptions of our currentsituation from the entire crew, I man-aged to get us low enough and closeenough to a mountain that some of theturbulence subsided and we made anemergency landing at Novi Travnik, aDutch hospital camp. After a few hourson the ground to regain our composureand several phone calls and inspectionslater, we were able to get the aircraft

back to Banja Luka, hugging theground to avoid the worst of the winds.In comparison, it took us ninety min-utes to get to Novi Travnik and lessthan twenty minutes to get back.

I learned a great deal that day. Thefirst lesson was to never second-guessmy decisions concerning weather.The second one was not to allowmyself to be pressured into flying amission, at least a non-critical one,in poor or unsafe conditions. On aside note, the VIP passenger admittedhe learned a lesson that day as well.He’ll never question an AC’s decisionwhen weather (more accurately turbulence) is concerned.”

For this incident, the preventivemeasure assigned was “Brief all aircrew”. This tale was related to the Bosnia pilots but that is as far as it went. That was a significantoversight for the rest of the Griffonpilot community, specifically, andfor all pilots in general. Anythingmore that might be said would beanti-climactic. Suffice to say that the opportunity to use this incidentto pass on an important message toall pilots was, for whatever reasons,missed. Make sure you don’t missyour opportunities. ◆

Major Ted Lee serves as Base FlightSafety Officer at Base Borden.

Captain Carl Stenhouse serves as apilot with 400 Squadron in Borden,1 Wing Kingston.

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E-mail from Sergent JocelynChagnon, 12 May 2004

Just a quick note with respect to the Spring issueof Flight Comment. Included in the magazine is

a poster of the Flight Safety Team for 2004. It is avery nice poster but unfortunately not very accu-rate in my opinion. What I mean is that as a NationalDefence Quality Assurance Region (NDQAR) here at SPAR Aerospace, I have a full plate monitoringflight safety concerns on numerous Canadian Hercswe have in house at any time. Beside our ownairplanes, we have other military Hercs belongingto the USCG, the USN, Mexico and Greece whichcan bring the total of aircraft in house to 11 planes,not counting any Tutor Snowbird’s conversion wemay have or our busy CC-130 component Repairand Overhaul line. I am also aware we have a

Editor’s

The Assistant Chief of the Air Staff, Major-General RichardBastien, presenting the Chief of the Air Staff Commendation toLieutenant-Colonel Gary Hook at the opening of the FS SingleIssue Seminar, Ottawa, 18 May 2004.

Kudos to LCol Hook for the CAS Commendation

As the Divisional Flight Safety Officer (DFSO),Lieutenant-Colonel (LCol) Gary Hook has had a

profound and lasting impact on the Flight Safetyculture of the Air Force. Under his guidance, theBasic and Advanced Flight Safety (FS) courses haveevolved to a highly sought after world class standard.The reputation of the course has spread, resultingin no less than fourteen different nations havingsent individuals to these courses. He has reachedout beyond the flight safety organization to spreadhis message. His superb briefing abilities have beendescribed as outstanding and inspirational. LColHook’s interest in the well being of the Air Force ismanifested in his continued efforts to maintain focuson FS and the balance with operational requirements.His background in the study of Human Factors (HF)is extensive and in his capacity as DFSO he has raisedthe awareness of the human element in operationsto the point where HF considerations have becomeinstitutionalized in the Air Force system. He hasbeen instrumental in the development of the HFAnd Classification System (HFACS). Not only willthis initiative contribute to a safer environment, itwill also enable the identification of systemic issues

multitude of NQARs across the country who performs the same duties for other DND aircrafttype once inducted for 3rd line repairs. Does itmean that we are not part of the team? I hope not.”

Sergent Jocelyn Chagnon, NDQAR SPAR Edmonton

Editor responds

Very good point, Sergeant. As you can appreciate, it is difficult to incorporate on one poster all organizations forming the Flight Safety (FS) team.When we will reproduce the next edition of theposter; we will look into the possibility of insert-ing the NDQARs and other members of the FSTeam like the Regional Glider Cadet Offices. ◆

Jacques Michaud, Editor

that affect the operational capability of the Air Force,thus creating a more effective organization.” ◆

Signed Lieutenant-General Ken Pennie, Chief of the Air Staff

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(THS) and nine others from 438 THShad completed their preparationsand training for Operation Halo.On 17 March, the advance party of 26 members and two CH-146Griffon helicopters arrived in Port-au-Prince to start the mission. On 28 March, the main body, consistingof 65 members and four Griffons,arrived in theatre. Although the per-sonnel were transported in Herculesand Polaris aircraft, the six CH-146helicopters, receiving the invaluableassistance of 438 THS, made thejourney from Valcartier to Port-au-Prince in 4 days, accumulating morethan 27 hours each.

Over the first few days, the reality of Haiti hit us right in the face.Not only did our crews have to cope

with a hostile environment with difficult living conditions, they hadto adapt to the unique flying condi-tions. These include the heat and thedensity altitude, the terrible air trafficcontrol service, flying obstacles (ie, non-indexed wires), the hugeamount of garbage at landing andtake-off sites and at the Port-au-Prince airport, kites, and theweather conditions unique to theWest Indies. Given the developmentand implementation of new operat-ing procedures and our integrationinto multinational flight operations,we had to have an accurate assess-ment of these conditions to allow us to adapt and to clearly identifyappropriate measures to mitigate the risks they represented.

We gradually adapted to this newenvironment. The personnel neededsome time to acclimatize to a signif-icant change in temperature (-20 to40°C), to get used to life in a tent,and to appreciate the hard rationsthat would be the norm for the restof our stay here. Another aspect thatneeded some adjustment was thenature of the mission, which is governed by Chapter VII of theUnited Nations (UN) Charter,requiring constant protection ofthe force. Consequently, the crewsmust constantly wear army fightingorder and fly wearing bulletproofvests, which increases the risks ofdehydration and the consequencesof the greenhouse effect. Greatervigilance and mutual monitoringwere the most effective measures.The personnel needed 24 to 48 hoursto make the adjustment and be ableto commence operations. And to dealwith the extreme heat, we built an“igloo” tent with several air condi-tioners where night flight crews andnight technicians could cool downduring the day.

It was hard to imagine that one day we would be asked to return

to Haiti to serve on another UnitedNations (UN) mission. Even thoughsome of our members have neverforgotten their experiences in 1997on Operation (OP) Constable, itcame as a bit of a surprise when we had to consider a possible returnto this Caribbean country. TheCanadian government’s positiveresponse to a request from the UNmade it very clear: the squadronwould be on its way. With unrivalledenthusiasm, the members of 430Tactical Helicopter Squadron quicklyanswered the call. Barely two weeksafter the order to deploy, 82 membersof 430 Tactical Helicopter Squadron

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As for the equipment, the CH-146displays good potential and performswell under these conditions. The expe-riences of OP Constable with theGriffon helped us prepare and traincrews and technicians. Required tooperate at the aircraft’s weight limits(11,900 lbs) and at a density altitudeof 2,500 feet above sea level at Port-au-Prince, the crews do not have alot of room to manoeuvre and mustbe extremely careful when control-ling the helicopter. One of the mostobvious signs of poor technique orskills is the amount of torque over-loads that occur under these condi-tions. Only one overload occurredin the 457 hours flown in theatrebetween 17 March 04 and the datethis article was written (3 May 04).

Another distinctive detail of thistheatre is the extremely limited airtraffic control service. Air trafficcontrol in the Port-au-Prince areaconsists of the controller on dutyvisually identifying the traffic.Although most approaching aircraftsidentify themselves, some do not andland without the permission of aircontrol. Thus, the actual control isexercised by all military aircraft thatclearly announce their intentions for

the benefit of everyone. The greatestdanger, however, is not necessarilythe lack of air traffic control but thecloseness of the airport to severalkites, some of which can attainheights of 700 feet. To face this challenge, the crews try not to flyover parks and large recreation areasused by kite-flying fans, and they jointhe circuit at higher altitudes thanrequired in order to steer clear of anyunannounced traffic approachingPort-au-Prince airport. According tothe mission’s operational requirements,a certain number of flights are to beconducted in the Port-au-Prince areawith night vision goggles (NVG).Close co-ordination between us andthe American forces (US Army andUS Marines) thus ensures that theairspace is shared safely. We need tomaintain constant vigilance becausewe are operating with civilian trafficthat does not see us. A fourth member of the crew, actually themission specialist, is essential onthese missions to help with thevisual detection of air traffic.

In addition to these unique conditions,there are challenges caused by theweather. Since we are in the rainyseason and thunderstorms occur

every day, we plan our flights inclose collaboration with our weathersection. The geography of the coun-try means that the altitude can rangefrom sea level to mountain chainsreaching a height of 8,000 feet. Thisgenerates a variety of weather condi-tions and requires special attention.Since the weather section is underthe same roof as flight operations,it can contact the crews in time in case of any changes that couldinfluence their flight.

The technicians must also adapt tothe heat and to sharing their facilitieswith civilian companies. The rampused is shared with several air com-panies that have up to 40 flights aday. Boundaries and strict control of access to our facilities, includingbarriers and guard posts, ensure pro-tection. In addition, two “WeatherHeaven” hangars help us protect aircraft undergoing repair or main-tenance. Even though aircraft in theatre should not require majorinspections, we still need to pay special attention to it to maintain agood serviceability rate. For example,it must be washed every night toremove salt, and special attentionmust be paid to the aircraft batteries


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the Task Force Haiti PublicAffairs Officer, reported onthe Department of NationalDefence Internet site that theGriffon helicopters from 430THS played a pivotal role inrelief efforts after torrentialstorms hit Haiti, causingmudslides and damagingtowns along the borderbetween Haiti and theDominican Republic. “In themountains, many roads werewashed out, so some of themost badly damaged areaswere accessible only by heli-copter. Haiti’s interior min-istry was estimating that thestorms had caused more than400 deaths.

The six Griffon helicoptersdeployed to Haiti onOperation HALO are Canada’sparticipation in the Multi-National Interim Force (MIF).430 THS works with theAmerican, Chilean and Frenchcontingents of the MIF aswell as the Canadians, providing services rangingfrom aerial coverage for thesoldiers of India Company, 2nd Battalion, The RoyalCanadian Regiment, to ferry-ing French soldiers to thenorthern city of Cap Haitien.” ◆

help of a thorough and continualrisk analysis. We quickly learned thatwe cannot do everything. Althoughthe missions may present us with anunexpected and excessive workloador with requests different from thoseearlier agreed upon, we have to bevery careful before accepting. In otherwords, we cannot maintain a “can-do”attitude at all costs. In such situations,control can be lost, emotions can tri-umph over reason, and security caneasily be breached. Since our experi-ences tend to vary from one day tothe next, it is important to absorbthe lessons and information that willhelp us improve our skills and avoidspecific situations. Consequently,we stage daily meetings with allflight personnel and some personnelfrom the maintenance and operationsteam to review events and share thelessons learned.

The members of 430 THS Falconsand the augmentees are proud oftheir ability to meet the challenges ofOP Halo and to demonstrate that airoperations can be carried out safelyin difficult environments. ◆

Lieutenant-Colonel Pierre St-Cyr,Commander Task Force Haiti Tactical Helicopter Detachment

on a daily basis. Batteries are lesseffective in such hot conditions.

Managing flight operations here isno different than managing opera-tions in garrison. However, the risksand inherent dangers of this type ofmission mean that our analysis ofeach situation must lead to the iden-tification of all possible mitigationmeasures. In an environment asnon-permissive as Haiti’s, each element is studied by both the crewconcerned and the flight supervisors.To facilitate the communication andintegration of information requiredby all flight supervisors, a newCommand Post concept is currentlybeing tried out. It allows us to cen-tralize and maintain all our infor-mation under one roof. This givesthe crews access to all the detailedinformation they need to plan theirmissions and the supervisors with allthe data required in risk analysis anddecision-making. The effectivenessof this concept is exceeding expecta-tions and represents an improvementin flight operations management.

Air operations can only be organizedand conducted in such rough andnon-permissive conditions with the


EdgeFlight safety and risk management

are key to operations at theAerospace Engineering TestEstablishment (AETE) in Cold Lake,Alberta. AETE is the CanadianForces Engineering Test andEvaluation (ET&E) centre and oftenprovides the first look at new aircraftsystems, stores, and expanded aircraftenvelopes. Colonel Bill Werny, theCommanding Officer of AETE, is thedesignated Canadian Forces (CF)Flight Test Authority and in thiscapacity must ensure that safety andrisk management come first in allaspects of flight test programs.

Within the past two decades, severalnew approaches have been producedin both the civilian and military sectors to improve safety by applyingmethodical approaches to risk man-agement. Most notable were the con-tributions of Professor James Reasonof the University of Manchester. Forthe past 25 years, Professor Reasonhas researched human error andorganizational processes and how

they contributed to the breakdownof well-defended technologies suchas aviation, nuclear power genera-tion, process plants, railways, marineoperations, financial services, andhealthcare institutions. He thendeveloped error classifications andmodels of system breakdown whichare now used by many organizations

Safety at the

NOTE: Adapted from Professor JamesReason's Swiss Cheese Model of Safety.

LATENT DEFENCEFLIGHT TEST POLICY

TEST PLANNING

LATENT DEFENCE

SAFETY REVIEW BOARD

LATENT DEFENCE

TEST EXECUTION

ACTIVE DEFENCE

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of the Envelope


and is known as the Swiss CheeseModel of flight safety. Succinctlystated, each layer is a defence againstor means of preventing an accident.However, each layer has holes and ifall of the holes line up at a giventime, an accident will occur.

The different layers are identified as either active or latent defences.The active layers are obvious — in

aviation they might be environment(weather, obstacles, traffic, etc),aircraft flight condition, and pilotactions. The latent layers are lessobvious. These could be mainte-nance policy, maintenance instruc-tions, training, parts procurementpolicies and methods, or aircrewtraining and proficiency. The latentdefence layers consist of policy,

orders, instructions, and planning,to name a few. One of the methodi-cal approaches to risk managementwas produced in Standard Practicefor System Safety (MIL-STD-882)and has been used by AETE for flighttest since the late 1980s. It has alsofound its way into Canadian ForcesTechnical Orders, namely Flight Safetyfor the Canadian Forces and theTechnical Airworthiness Manual,as well as 1 Canadian Air Division(CAD) orders.

AETE has executed many interestingflight test programs in the past fewyears: CF-18 Hornet Precision GuidedMunition (PGM) stores clearance,implementation of a CT-133 T-Birdejection seat test bed aircraft,

CC-130 Hercules AUP Glass Cockpit.

CH-149 Cormorant Icing Trials.

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DossierCC-130 Hercules AC DC electricalsystems upgrade and GroundCollision Avoidance System (GCAS),CP-140 Aurora electromagneticinterference (EMI) on the autopilotand electrical power control panels,CH-124 Sea King sudden loss ofpower investigation, and CH-149Cormorant icing trials. Each testprogram provided unique risks andchallenges that required carefulthought and planning prior flighttest execution.

Store clearance risks might entailexceeding an aircraft limit as theedges of the envelope are exploredor worse, un-damped flutter couldencountered which would quicklydestroy the aircraft. Designing,building, then flying the prototypeejection seat CT-133 aircraft hadrisks of flight path stability, potentialpitch excursions when firing theejection seat, or smoke in the cock-pit from the ejection of the rear seat.Modified complex CC-130 electricalsystems face risks of fire or loss ofelectrical power due to unknownsystem switching response. Ice trialson a helicopter could cause a rotorimbalance from ice build-up or iceshedding. The challenge is identify-ing the hazards, all of them, andreducing the list to only those thatcould be reasonably expected tooccur. Sound easy? Far from it.

The process used by AETE involvesfour distinct steps:

1. Identify:

Hazard: What bad things awaitthe unwary?

Causes: What could cause thesebad things to intrude on the testprogram?

Effect: How bad could it get,injury, loss of aircraft?

Unmitigated Effect Category

Unmitigated Probability

Unmitigated Risk Level

2. Minimizing procedures —What can be done to reduce theeffect if the hazard occurs and tominimize the probability of itoccurring?

3. Corrective actions — So itdoes occur, now what? You needto do something!

4. Once minimizing procedures aretaken into account, identify theprojected:

effect category

probability

risk level

The potential Effect of an event isdefined by four specific categories as follows:

1. Category I — CATASTROPHIC:May cause death, system loss, orsevere environmental damage;

2. Category II — CRITICAL:May cause severe injury, severeoccupational illness, or major system facility, or environmentaldamage;

3. Category III — MARGINAL:May cause minor injury, occupa-tional illness, or minor system/facility/environmental damage;and

4. Category IV — NEGLIGIBLE:There are no significant effects

The Probability of an event occurring is broken into five distinct areas defined as follows:

1. FREQUENT: Likely to occur frequently during the test;

2. PROBABLE: Will occur severaltimes during the test;

3. OCCASIONAL: Likely to occursome time during the test;

4. REMOTE: Unlikely, but possibleto occur during the test; and

5. IMPROBABLE: So unlikely thatit can be assumed that it may notoccur during the test.

The combinations of effect categoriesand probabilities is further catego-rized into risk levels culminating inthe following table which is used inMIL-STD-882 and most CanadianForces risk management documents:

Much of the flight testing conductedby AETE is on aircraft systems thatdon’t have an airworthiness clear-ance or are in flight regimes at theedge or even beyond the approvedenvelope. A flight test exclusion isrequired to allow the test to proceed.AETE, the Director of TechnicalAirworthiness (DTA), and theAircraft Engineering Office (AEO)consult and determine what limitsare required to accomplish the test.As well, a safety onion skin layerbeyond those limits is determined to allow for small excursions as thetarget limits are approached. Simplystated, the experts look at a limitbeyond the cleared envelope, apply a small margin for excursions, anddetermine if it can be approachedduring a methodical build-up andreached without causing damage orinjury. This is then documented inthe flight test exclusion which is, infact, the first step of a risk analysis.

For a CF-18 stores clearance project,one hazard is un-damped flutter incertain flight regimes with the newstore, or combinations of the newand existing stores, loaded onto theaircraft wing. Rapid onset of fluttercould destroy the aircraft. The testteam, consisting of qualified testpilots (QTP), flight test engineers(FTE), and subject matter experts(SME), analyze the hazard, andassign an effect level and probabilityto determine an unmitigated risklevel. Minimizing procedures would


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SOURCES: MIL-STD-882D, Standard Practice for System Safety C-05-005-001/AG-001, Technical Airworthiness Manual.

include a methodical build-up in the test matrix from benign to more dynamic test points, use ofan instrumented aircraft, and

monitoring the flight, real time,in AETE’s flight test control room.

The next critical step in the riskanalysis is identifying correctiveactions — that is, if things do gowrong, now what? We need to makesure that if the pilot and aircraft arehaving a bad day, things don’t getworse. The test team identifies stepsto ensure that safety infrastructureand support are in place in case,despite our best efforts, the hazardoccurs. Finally, the team looks at theminimizing procedures, determinesa projected effect and probability,and finally the projected, or resid-ual, risk level. If the residual risk istoo high, the team returns to squareone and starts over. Once all risksare identified and addressed in theRisk Assessment, a Safety ReviewBoard, chaired personally by the COAETE, as the Flight Test Authority, isheld with AETE’s Senior Test Pilot,

Senior Test Engineer, and the testteam to review the hazards, mini-mizing procedures, and residual riskbefore the program can continue.

Regardless of the aircraft type orsystems involved, AETE must ensurethat the right people and skill setsare assigned to the test program toguarantee success. AETE’s safetyprocess is systematic but we mustalways bear in mind that process isno substitute for Test and Evaluationexperience and sound judgment.Experienced QTPs, FTEs, and SMEsand our methodical approach ensurethat we continue to test new systemsand explore aircraft performancesafely at the edge of the envelope. ◆

Larry Dublenko, P.Eng.Aerospace Engineering Testing EstablishmentOfficer in Charge Avionic SystemsEvaluation

HAZARD SEVERITY CATEGORY

CATEGORY

PROBABILITY

CATEGORY ICATASTROPHICDeath or system/

Facility loss, severeenvironmental damage

CATEGORY IICRITICAL

Severe injury, occupationalillness, or major system/facility/environmental

damage

CATEGORY IIIMARGINAL

Minor injury, occupationalillness, or minor system/facility/environmental

damage

CATEGORY IVNEGLIGIBLENo significant

effects

FREQUENTLikely to occur frequently

during test

PROBABLEWill occur severaltimes during test

OCCASIONALLikely to occur

sometime during test

REMOTEUnlikely, but possibleto occur during test

IMPROBABLESo unlikely, assume it

may not occur durint test

EXTREMELYHIGH

EXTREMELYHIGH

EXTREMELYHIGH HIGH

HIGH

HIGHHIGH

MEDIUM

MEDIUM

MEDIUM

MEDIUMMEDIUMMEDIUM

LOW LOW LOW LOW

LOW

LOW

LOW

AETE CF-18 flying with MK82 bombs.

AETE CF-18 dropping MK82 bombs.


Iwas at home, on summer leave,when I received a phone call from

work. They wanted my passport as, it seemed, I would be replacing a suddenly repatriated squadronmember. Within four days, havingsaid my goodbyes, I found myselfon the way to the Persian Gulf.Once arrived, I made my way to mynew home, the HMCS Regina, tojoin the already embarked helicopterair detachment.

The next day, the ship put out to seaand I was scheduled for my first flightin the Arabian Gulf. This flight was a “door gun shoot” and it was specif-ically scheduled to give me my lastneeded qualification before reachingthe operating area. My immediatesurroundings were not new; I hadbeen at sea before and had donethese flights before, although neverin this neck of the woods; still, Iconsidered it an easy trip. During ourpre-flight brief, water was mentioned,but not stipulated. This detachment,already in theatre for a month, wasrelatively accustomed to flying in theharsh, hot environment. I was not, nordid I understand the effect it wouldhave on me. “Besides,” I thought,“this flight was short and onlyscheduled for ninety minutes.”

I observed other aircrew filling theirwater bottles, however I had not had

an opportunity yet to acquire a bottleof my own. I made a brief search yetwas unable to come up with anysuitable container. Flying stationshad been piped and the last thing I wanted to do was to delay my firstflight. I decided then, that I couldsurvive a short flight without waterand I would sort out the water bottle issue for the next flight.

Having spent the last fifteen hourssleeping and living in an air-condi-tioned space, the heat and humidityhit me like a hammer. The intensityof 40+ temperatures surprised me,but the hangar door was closing and I was already behind in my pre-flight checks. I carried on with myjob and wondered if I had made awise decision. I came to the samerationalization as earlier — it wasonly a short flight!

After adding a helmet, life vest,and the required dual layer clothing,I was sweating buckets inside theaircraft, even before take-off. As Iwas moving around the plane dur-ing the post take-off cabin check,I noticed sweat dripping from myhelmet. When the range had beencleared, the Tactical CoordinationOfficer (TACCO) and I proceeded tothe rear cabin to prepare for themachine gun shoot. By now, myflight suit was soaked; the TACCO

noticed and kindly offered me someof his water. I declined his offer, tooproud to admit that I was in anydiscomfort. When our task wascompleted, we cleaned up and wereon our way back to the ship for acrew change. I was in some discom-fort but I was relieved knowing thatI would soon have some water todrink on an air-conditioned ship.

During our return flight to the ship, we were re-tasked as a medicalevacuation (Medevac) flight. We hadthe only doctor afloat, so we were to land on an American ship andtransport a possible heart patient toour ship, the HMCS Regina. Oncewe landed on the American ship, myactivity level increased because ofthe refuelling, passenger brief, andthe physical effort of carrying a litter to our helicopter. I was nowconcerned for my own health as it was unbearably hot. Still today,I don’t understand why I did notrequest water from the Americans.I had stopped perspiring, yet I hardlynoticed as I was so preoccupied withconcern for our passenger’s comfort.

?Ready forEverything


As we were touching down on ourdeck for landing, I was nauseousand dizzy, and my peripheralvision was starting to grey. I feltthat I was in grave physical condi-tion, however there was no time

to interrupt as we needed to set down, shut the rotordown, and disembark ourpassenger to the sick bay.

Fortunately, there was ample helpand I was free to proceed inside.It was none too soon as I stumbledwhile crossing the deck and neededto be helped down the ladder, whereI was physically sick.

The short, ninety-minute flight hadturned into a three and a half hourflight, in 40-degree heat, withoutwater. I was definitely unprepared.I spent the next hour re-hydrating

and reflecting on how my pride,ignorance, and stupidity couldhave unnecessarily burdened thecrew and the already busy medicalstaff. For the rest of that deploy-ment I became inseparable frommy shiny, new, and very largewater bottle. ◆

Warrant Officer Don Mackieserves with 407 Squadron, 19 Wing Comox.


It all started with a briefing twohours before our scheduled take-

off time. The weather was forecastto be low ceilings and reduced visi-bility in light snow for the durationof our mission and for our landingtime. New to the squadron, I hadonly a year of experience as a co-pilot on the Aurora. The missiontoday was open ocean surveillance.It was something we were supposedto do the day before but, because of fuel discrepancies from the fuelgauge, the mission was delayed one day.

The pre-flight and all-station checkswere going well, so we were able todepart on time for what shouldhave been a routine mission for thecrew. As in any good organization,we tried to maximize every hour of

flight. After changing from AirTraffic Control (ATC) to an opera-tional frequency, my AircraftCommander (AC) decided to showme an emergency high-speed descentto get into our surveillance areaquickly. This procedure involvedlowering the landing gear toincrease drag, thus achieving agreater rate of descent. As we levelledoff at our pre-briefed altitude, westarted cleaning off the aircraft toproceed with the mission. The land-ing gear has a speed restriction dur-ing retraction of 190 knots. As part

of the cleaning, the landing gear was retracted momentarily and re-extended above that speed for a second. After discussing with theFlight Engineer (FE) and the AC,we decided to bring the landinggear back up.

As we were getting closer to home,the weather seemed to be gettingworse. When we listened to theautomated terminal informationsystem (ATIS), the weather wasreported as a 200-foot ceiling and1/2-mile visibility, with a snow-


IMPORTANCECompletedPaperwork

ofIMPORTANCE

CompletedPaperwork

of

covered runway. Talking with ATC, itappeared we had two choices: gettingwide vectors for the runway or beingput in a holding pattern to wait forthe snow-ploughs to complete theirwork. We elected for the wide vectorin the heavy snow. We used an extrathirty minutes of fuel but, finally,were vectored for final approach.As we brought the gear down for the pre-landing check, we noticedthat we had an unsafe nose-gearindication. At this time, we requesteda block of airspace between two radials to complete our emergency

procedures. It was then that wenoticed our fuel was approachingthe minimum needed to get to ouralternate aerodrome. The gearfinally came down and we landedsafely without further incident.

Now it was time for the paper work!The AC started to do a Flight SafetyInitial Report, which was completedin several minutes. Everythingseemed to be in order, so we wenthome for the weekend. When wecame back on Monday morning,I heard another pilot talking aboutthe landing gear problem he hadduring his flight the previous day.I was surprised that he had the sameproblem as we had three days ago,so I asked him which tail number hehad. It was the same aircraft but, tomy surprise, he was not aware of theproblem we had. He should have

read it in the maintenance bookwhen he signed out the aircraftbefore the flight. After a short inves-tigation, we found out that the ACdid fill out the Flight Safety initialform but forgot to leave it with the maintenance desk. He also had improperly filled out the unser-viceability form, so the technicianhad no way of knowing that theyhad to re-adjust the nose-gear landing switch.

The second incident would not havehappened if the paper work hadbeen done properly. In this case,no accident resulted from theseerrors, but we should remind our-selves that the extra fifteen minutescould mean a lot for the mainte-nance crew and the ensuing pilotsthat will try to see a trend of prob-lems in the maintenance book.So remember, no job is completeuntil the paper work is done. ◆

Captain Sylvain Lavigne serves with404 Squadron, 14 Wing Greenwood. Ph

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Photo by Corporal Henry Wall, NSU photographer, Arabian Gulf Region, 06 June 2003.

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It had already been a long day,and it was about to get longer.

Our mission was to drop off charita-ble goods in Vilnius, Lithuania.Our departure point was Keflavik,Iceland, and our final destination forthe night was Copenhagen, Denmark.The weather in Vilnius was down toa ceiling of 100 feet, with a visibilityof only one quarter of a mile. Thewinds were quartering from theright, and seemed to veer toward aright crosswind on descent.

I was a level two first officer (FO)and I was flying a pilot-monitoredapproach (PMA) from the right seat.This was the standard instrumentapproach in Hercules operations, andthe experienced aircraft commander(AC) and I had both flown many ofthem. The advantage of this approachlies in the left seat pilot’s ability toscan for visual references while cross-checking the instruments, and thusmake an easier transition to landing.Further, this approach afforded anopportunity for a “continue” call, andfor flying the approach an additional100 feet below minimums. In the caseof the approach we were now on (the ILS 07 in Vilnius), this meantwe could fly to 100 feet above ground(AGL). In the remarks portion ofthe approach brief, the requirementfor a “continue” call was briefed as a likelihood, and the criteria for the“continue” call were reviewed. Theapproach had to be stabilized, and onthe numbers. I thought to myself…“small corrections only, get mypower setting early, keep my cross-check going, and hold that attitude.”

Once established on the localizer, theapproach was generally smooth, butdrifting left of the on-course. Withthe initial drift left, a three-degree

heading change to the right was initiated and the left-seat pilotprompted “drifting left.” The rate of drift was slowed, but not arrested.We now approached “a dot left” onthe horizontal situation indicator(HSI). Another prompt “turn right”came from the left-seat pilot as I rolled another three degrees to theright. We had just crossed the finalapproach fix (FAF) inbound andwere steady on both airspeed andglide-slope. The drift was nowarrested and further correction tothe right was needed. Unsatisfiedwith my lack of aggressiveness, andhaving twice prompted me, the left-seat pilot took control of the aircraftas I rolled out on the next headingchange. Stating, “I have control,”he continued the corrective turn and brought us aggressively throughthe localizer.

At this point, the approach becamenon-standard, and crew resourcemanagement (CRM) broke down.Unclear on the AC’s expectationsand passing through 400 feet AGL,I began scanning outside the cockpitfor the runway environment. Passingthrough 300 feet AGL, the left-seatpilot returned aircraft control to me,stating, “You have control.” With myinstrument cross-check broken andonly seconds to go until decisionheight (DH), I held the attitudesteady. I called “100 feet above” aswe continued toward our DH, and I braced myself for the overshoot.To my astonishment, the left-seatpilot called “continue” as I called“Decision Height.” We had not metthe criteria for a stabilized approach,a parameter necessary for a continuecall. Prior to 100 feet AGL, theapproach lights came into view andthe left-seat pilot again took control.

Now right of centreline, he bankedhard to the left, then to the right, andsmoothly touched down for landing.We were safely on the runway andthe blankets and school supplies hadreached their destination, but …hadwe done our job correctly and in thespirit of flight safety?

Obviously the answer is NO! Inchallenging weather and well intoour crew day, we had deviated fromnormal approach procedures andsacrificed flight deck coordination.I had allowed the aircraft to drifttoward one dot left of the localizer,and lacked the necessary aggressive-ness in correcting for drift. My pre-disposition for a stabilized approachthrough small corrections did notserve me well on this day. Deviationsleft of the localizer lead to twoprompts from the AC, and that leadto three control transfers inside theFAF. In turn, the control transfers,and deviation from normal PMAprocedures, lead to a breakdown inCRM with potentially dangerousresults. As well as creating seriousconfusion with respect to pilotduties, we prosecuted a “continue”call without the necessary parame-ters to do so. That we landed safelyis certainly indicative of pilot skill,but that a landing was attemptedfrom such an approach is the princi-ple issue. Aircrew coordination andCRM had broken down when theywere needed most, and standardprocedures during a critical phase offlight were sacrificed. This incidenthad potentially serious flight safetyramifications, and the lessonslearned should not be lost in theaftermath of a successful landing. ◆

Captain Jack Simpson now serveswith 440 Transport Squadron,Yellowknife, 17 Wing Winnipeg.


TOOL CONTROL —ARE YOU TAKING IT SERIOUSLY ENOUGH?

The Canadian Forces Tool Control System (CFTCS) is neither new nor revolutionary. The same system is in effect on each Wing and unit where Canadian Forces (CF) main-tenance personnel maintain and service aircraft. Tool Control (TC) has to be learned onlyonce, and is truly a universal system. Why then are there concerns within the Flight Safetyorganization that tool control, a very user-friendly system, is not being taken seriously by CF maintenance personnel?

Air Force. There were severalreasons why such a system madesense for the CF. First, there werelarge numbers of tools left inaircraft undergoing maintenanceor servicing. Second, these toolscould not be traced back to theirowners, whether military orcivilian (contractors). And, last, it was a cost-saving measure.Even though the last two issuesseem to have been solved, thefirst issue, however, still appearsto be a problem, albeit on asmaller scale. More on that subject later.

CFTCS radically changed the waytechnicians had to work: Toolswere now grouped around thejob rather than around theworker, and records were keptas to which tool kits were usedon which aircraft. Before CFTCS,a technician just grabbed histoolbox and went to work on theaircraft. Although it was possibleto find out who worked on theaircraft (through 349’s), it wasimpossible to find out who wasthe owner of a found tool. Thenew designs of the tool kits andcabinets made it easier for per-sonnel to ensure each tool wasreturned to its respective con-tainer. That was nearly impossiblewith individual toolboxes. (If you

have one at home or in thetrunk of your car, you knowwhat I mean.) CFTCS, althoughstandardized across the CF,remains flexible enough so thatit can be adapted to the variousfleets and operations that makeup the Canadian Air Force.

One of the main purposes of the implementation of CFTCSwas to improve flight safety. By controlling the number oftools used on an aircraft, itstands to reason that fewertools would be left behind once the job was completed.Unfortunately, we have no sta-tistics to prove that. The onlystatistics available concerns lost tools reported throughCFTCS and the Flight SafetyInformation System (FSIS).

As you can see in Table 1, there isa significant difference betweenwhat is being reported in CFTCSand FSIS. There could be severalreasons for the discrepancy. Onethat comes to mind is that notevery lost tool will result in aFlight Safety Incident. A tool lost in an aircraft in periodicmaintenance, for example,would not require a FS incidentreport, as long as the aircraft isstill in maintenance when thetool was found missing.

CORNERMAINTAINER’S

Alittle bit of history will helpwith understanding why the

CF adopted a Tool Control System.Not that long ago, technicianswere issued with their own tool-boxes. I remember, as a youngprivate, being issued a toolboxwhen I was sent to a maintenanceorganization for on-job training(OJT). I also clearly rememberturning in our toolboxes whenTC was implemented, in the early1980’s. When I was first issuedmy tools, a list was made of allthe items in the box. Strangelyenough, though, when I returnedthe tools, some were missing andothers I had never signed for inthe first place had appeared.And the worst part is that noone seemed to care. The extratools were put to other use, themissing ones were written off.I’m still wondering if any ofthese tools were left in an air-craft. The good news is that this fleet is no longer flying–notbecause of me; it has been takenout of service! As you can see,the ‘one-technician-one-toolbox’system was not very safe.

The solution was the CanadianForces Tool Control System,which was first introduced tothe CF in 1974. The concept hadbeen borrowed from the Royal

Are you confident that you didnot leave any tools behind? Doyou officially report a missingtool right away, even if it meansgrounding an aircraft to do aFOD check?

If the answer is ‘no’ to any ofthese questions, it is high timethat you start taking tool controlseriously before your carelessnessresults in the loss of life or aircraft.

Further information on theCFTCS can be found in the C-05-005-021/AM-000,Maintenance Policy, Tool Control System, 2001-01-31. ◆

Sergeant Anne Gale, DFS 2-5-2-2

Special thanks to Warrant OfficerNickerson from the Aerospace andEngineering Support Squadron for hishelp in researching data for this article.

The numbers in the table abovedo not seem very important whenyou consider there are approxi-mately 2000 tool kits and 1500tool pouches in the system. But remember this:

“Only one tool, left in a critical area, is needed to bring down a state-of-the-art aircraft and its crew.”

This is the main reason why toolcontrol is so important. This isalso why you should take toolcontrol seriously by:

• ensuring all tools you take to an aircraft are serviceable;

• ensuring all tools are putback in their respective tool kits; and

• reporting missing toolswithout delay so a ForgienObject Damage (FOD) checkcan be carried out beforethe aircraft goes flying.

Many of the lost tool incidentsreported in FSIS concerns foundtools rather than lost tools–atleast those are being reported.As seen in Table 1, there were 47 lost tools involving aircraft in 2003. However, maybe 2 ofthese were reported in FSIS.Here is a list of the 7 FSIS reports:

• One report was the resultof an audit (2 tools missingfrom tool crib).

• Another aircraft was goneon a cross-country flightbefore someone noticed a tool was missing from atool kit.

• One aircraft went flyingbefore it was discovered atool had not been returnedto tool crib.

• Three tools were foundduring maintenance (three separate reports).

• A tool from a tool pouchwas found on the groundduring an aircraft start.

I suspect in the first two incidents,where the tools were foundmissing following a tool kit ortool crib check, the tools werediscovered missing when theywere needed for another job and they were not in their place.Hence the questions: Are you, thetechnicians, taking tool controlseriously enough? Do you checkthe tool pouches, kits or benchescarefully (not a quick cursory look)after each job on an aircraft?


Lost tools(aircraftinvolved)reportedin CFTCS

148

40

47

Lost toolsreportedin FSIS

11

15

7

2001

2002

2003

Table 1: Lost Tools by Year.

CF-18 Electrical Toolkit.


ÉPILOGUE

“The loss of Sea King CH12422 (c/s Bishop 22) offHawaii on 23 June 2000 proved to be a calamitousevent which resulted in the loss of a valuable mili-tary helicopter; the impact of this accident was softened somewhat in that the aircrew were able to evacuate the aircraft prior to its sinking. As withso many aviation accidents, however, the true storyoften lies in a host of contributing factors that even-tually distort the delicate balance encompassingman, machine, and the environment.

Surprisingly, the Canadian Forces (CF) Flight Safetyprogram, through an Epilogue article published in the Summer 2003 edition of Flight Comment,chose to focus attention on an aircraft serviceabilityissue rather than highlight the succession of con-tributing factors that combined to influence theeventual ditching decision. Regrettably, not onlydoes such hypothetical musing challenge past flightsafety program precepts but, more importantly, it ignores the constructive lessons to be gleanedfrom such a classic aviation case study.

As often happens in aviation mishaps, the crew of Bishop 22 found themselves victims of a pre-accident sequence of events, of which each individ-ual event was a contributory factor to the finalditching outcome. I this case, it was the cumulativeeffect of a recognized Sea King Main Gear Box(MGB) overtemp condition, a potentially cata-strophic MGB emergency situation, and a relativelyinexperienced Maritime Helicopter (MH) crew.

Throughout the 1990s, the Sea King fleet experi-enced an epidemic of overtemp conditions involvingthe antiquated 21000 series MGB. Anticipating that the cancelled Maritime Helicopter Project soonwould resume, it was decided to delay implementa-tion of a costly 24000 MGB upgrade project.Unfortunately, fiscal and political realities soon indi-cated that a new MH aircraft was not in the imme-diate offing, thus it was decided to implement theMGB upgrade project over a prolonged time span.Despite an increasing frequency of MGB overtemp

situations, the risk mitigation factor was rationalizedthrough the belief that by retarding the number oneengine to ground idle, it was possible to resolve theovertemp condition. This mysterious procedural rem-edy had been discovered by accident and, even moreincredibly, was a power train technique unable to besubstantiated by either military or civilian Sikorsky aircraft engineers. In short, aircrew understood thatan inherent MGB overtemp problem resided withinthe Sea King fleet, yet they were expected to believethat a somewhat mystifying engine handling procedure should alleviate the situation.

Operating from HMCS PROTECTEUR during Exercise(EX) RIMPAC, CH12422 had experienced continualMGB problems, as evidenced by a substantial MGBoil loss situation at Hickam Air Force Base a weekearlier. While running at night prior to returning to PROTECTEUR at sea, the aircrew noted an MGBcaution light that subsequently confirmed a substan-tial quantity of transmission oil lying on the airporttarmac. Luckily, a second Sea King maintenancedetachment alongside in Hawaii was able to repairthe major MGB unserviceability, eventually allowingthe aircraft to rejoin the ship later the next day. Had the massive oil-loss occurred during the transitback to the ship the previous night, it is most proba-ble that the crew would have been forced into anarduous night ditching situation under extremelydifficult and dangerous circumstances. As could beexpected, aircrew suspicions concerning the status ofthe Bishop 22 MGB became even more magnifiedwith this latest development.

As the crew settled into the hover on that fatefulJune day, it is worthwhile to note their level of expe-rience. Although the Aircraft Captain (AC) was anexperienced multi-tour Sea King pilot and mainte-nance test pilot, the other three crewmembers werenovice naval aviators experiencing their first seacruise. Normally it would be customary to have aminimum of two experienced crewmembers on eachcrew, ideally with one located in the cockpit (pilot)and a second veteran aviator in the rear cabin area

TYPE: Seaking CH12422 LOCATION: 150 NM South of

Honolulu, HawaiiDATE: 23 June 2000

BISHOP 22A Second Perspective

The Summer 2003 edition of Flight Comment included the Epilogue article to the Flight SafetyInvestigation of CH12422’s ditching off the coast of Hawaii, 23 Jun 00. In response to this article, the

Directorate of Flight Safety (DFS) received the following letter which indicated that some relevant factorsmay have been omitted in the original Epilogue article, possibly better explaining how the stage was set forCH12422’s ditching. Major Brian Northrup’s letter has been published here in its entirety.

(Navigator/AESOP). Although all of the aircrew per-formed admirably during the actual ditching emer-gency, it is conceivable that a second experiencedaviator may have offered additional input that mayhave influenced the eventual decision-making chainof events. Unfortunately, post Force Reduction Plan(FRP) minimum air force personnel establishmentsand low experience levels had savaged Sea KingHELAIRDET manning plots, causing considerableconcern at all supervisory levels. Neither aircrew normaintenance crews were immune to the challengeof conducting embarked naval aviation operationswith below average at-sea operational expertise.

And so the stage was set for the Bishop 22 overtempscenario. While in the hover, an MGB oil hot cautionlight confirmed an MGB oil temperature readingpegged at the maximum 150-degree gauge temper-ature limit. A cursory aircraft inspection while raising the SONAR dome eliminated any otherabnormalities or evidence of MGB fluid leakage.Faced with a 20-minute transit to PROTECTEUR anda transmission temperature indicating well beyondlimits, the AC elected to depart the hover andattempt a low level transit back to the ship. Thenagging problem for the pilot, however, was justhow hot was the transmission fluid, based on theknowledge that the oil temperature light illuminateswhen the oil cooler is no longer able to maintainMGB oil temperature below a safe 120 degrees? Asthe pilot was well aware, extreme oil temperaturescould dramatically reduce oil viscosity properties andbegin to destroy system seals and other vulnerableparts of the transmission system.

Shortly after leaving the hover, the crew observedfluctuating and slowly decreasing oil pressure gaugeindications that forced the AC back into the hoverfor a situational reassessment. While in the hover, a distinct welding odour, coupled with abnormallyhot air emanating from the MGB area behind thepilot’s head, precipitated the decision to ditch theaircraft prior to an expected catastrophic failure.

Once settled on the ocean surface, the aircraft had to be shut down based on danger of the rotor blades striking the water due to ambient sea conditions.

Could Bishop 22 have made it back to PROTECTEURsafely? — Possibly and possibly not. From a FlightSafety perspective, it is suggested that the true valuein relating the Bishop 22 story lies in identifying the classic pre-accident factors that combined toinfluence the ultimate ditching decision. Rather than surmising that the aircraft still may have beenserviceable and capable of recovering onboard ship,a review of the pre-accident sequence of eventswould highlight how aviation disasters often are preordained through earlier decisions and eventsthat occur far distant from the actual accident site.”

Major Brian Northrup, 443 Maritime Helicopter Squadron,Patricia Bay, 12 Wing Shearwater.

DFS Comments:On occasions, the message is not made as clear as it was intended to be, as was indicatedto me in this case. My thanks to Major BrianNorthrup, 443 (MH) Sqn, for pointing that out.

The major lesson here is that the MH communitywas not given comprehensive, unambiguousdirection with respect to dealing with MGBovertemp conditions. Although documentedevidence supporting the use of the #1SSL proce-dure was compelling, the CF did not make itmandatory. As a result, pilots were given thelatitude to decide for themselves whether ornot to use the #1 SSL procedure even though its success, when it was used, was 100%. As isevident in Maj Northrup’s letter, the CF alsofailed to advise all crews of the success of thisprocedure. This lead the investigators to con-clude that, had the #1 SSL procedure been mademandatory, the crew would have employed this procedure. Given the success rate of thisprocedure, it was further concluded that it washighly likely that the aircrew would not havebeen forced into a ditching situation. In short,the system did not give this crew all of the tools necessary to operate the aircraft at anacceptable level of risk.

Please refer to this or any other FSIR on the DFS website for complete analysis, conclusions,and recommendations. You may access the DFS website via the Defence Wide AreaNetwork Intranet (airforce.dwan.dnd.ca/dfs) orthe Internet (www.airforce.forces.gc.ca/dfs/). ◆

Colonel Al Hunter, Director of Flight Safety



ÉPILOGUE

TYPE: Griffon CH146408 LOCATION: Cold Lake, AlbertaDATE: 06 November 2003

The 408 Tactical Helicopter Squadron crew was conducting an advanced Night Vision

Goggles (NVG) training mission in the Cold LakeAir Weapons Range (CLAWR). At the end of the 50 feet Above Ground Level (AGL) navigation leg,the aircraft commander (AC) gave a simulated no.2 Engine Fire. The First Officer (FO) selected a land-ing area which appeared to be approprite but wasfrozen muskeg. A seating check was performed inaccordance with CH-146 Standard ManoeuvreManual but after a few seconds the aircraft settledabout 12 inches with a 5 degree left roll. The FOimmediately increased power and the AC took control. Not realizing that the left skid shoe wascaught under the ice surface, the AC increased the power further, applied full aft and right cyclicbefore the aircraft broke free and stabilized in a 4 foot hover. The crew recovered the aircraft in aprepared landing area and found damage on the underside of the Griffon. The damage was initiallyassessed as B Cat but was later downgraded to D Cat.

The crew was experiencedand conducted the selectionof the emergency landingarea in accodance with estab-lished procedures. The investi-gation confirmed that theaircraft was fully serviceableand it was not equipped with skis.

417 Combat Support (CS) Sqn, a unit of 4 Wing,operates the CH-146 Griffon in the CLAWR on adaily basis. They operate the CH-146 with skisinstalled all year round. In addition, landings arerestricted to hard ground surfaces such as gravel,rock formations or helicopter landing pads due to problems with muskeg and other wet landingareas. The frozen muskeg area where the incidentcrew landed was identified by 417 (CS) Sqn as anunsuitable landing site.

This occurrence illustrates the risks involved inoperating in unfamiliar terrain. The unsuitability of the landing area for the simulated emergencycould not be detected visually prior to landing.Because the Detachment Operations brief did notinclude information on terrain conditions in theCLAWR area, the unit had not implemented mea-sures to compensate for the wet terrain to preventthis occurrence.

As it is often the case, this was not a new occurrence.A very similar event occurred in the CLAWR a fewyears ago which prompted the implementation ofthe preventive measures mentioned above. It isbelieve that these measures would have beeneffective in preventive the damage sustained by CH146408. ◆

ÉPILOGUE

The mission for the pilot of the accident aircraftwas to conduct an Instrument Flight Rules (IFR)

cross-country to Toronto. Shortly after the aircraftlifted off runway 29 (R29) at Bagotville, yellow,acrid smoke began to fill the cockpit. The landinggear and flaps were selected up and although thegear indicators showed three wheels “up andlocked”, the light remained on in the gear selec-tion handle indicating the gear doors were notcompletely closed. The pilot selected the geardown while carrying out the emergency proce-dures for smoke in the cockpit. While informingAir Traffic Control (ATC) and Squadron operationsof the situation, several system advisories werenoted. During the approach end engagement on

R36, the arrestorgear failed damagingthe aircraft’s rightside but a successfulovershoot was con-ducted. The aircraftwas successfullylanded on R29 (with-out the arrestor gearup) and was taxiedoff the active run-way without furtherincident. There wereno injuries in thisaccident but the aircraft sustained C category damage.

The investigation revealed that the aircraft experi-enced multiple failures after take-off because theFlow Temperature Limiting Anti Ice ModulatingValve did not function correctly; this caused the Environmental Control System (ECS) system to overheat which in turn caused the damage and thesmoke in the cockpit. The ECS Flow TemperatureLimiting Modulating Valve did not function properly because an unserviceable one had beenre-installed during maintenance.

The Pilot distracted by multiple emergencies andstepped on radio transmissions, forgot his landingflap and flew the approach at a speed in excess ofthe arrester cable limits. ◆


TYPE: Hornet CF188906 LOCATION: Bagotville, QuebecDATE: 31 July 2001


TYPE: Griffon CH146400 LOCATION: Petawawa, OntarioDATE: 25 August 2003

ÉPILOGUE

The aircraft was being towed from parking spotno. 07 to inside the hangar. Shortly after the

aircraft had crossed the hangar threshold the frontright hand cross tube broke at the top of the saddleassembly. As the aircraft fell, the tow bar struckand damaged the aircraft just below the right pilotdoor. The skin and web were punctured 1.5 inchvertically by 4 inches horizontally at station 37 andwaterline 18.5. The damage to the aircraft belly

was initially assessed as C Category, but was laterdowngraded to D Category ground incident follow-ing further examination and evaluation.

The entire skid gear assembly has been sent to theQuality Engineering Testing Establishment (QETE)Hull for testing. The mechanism for the cross tubefailure was assessed as fatigue cracking followed by overload. The relative small size of the fatiguecrack with respect to the overall fracture area suggest that overloading on the cross tube at finalfailure was high. Fatigue crack growth was attrib-uted to a combination of high and normal loads.No material contributing factors were identified.

The overload was most likely caused by the towingof the aircraft. The investigation also revealed thatthere were no diversion from normal towing proce-

dures and, other than crossing of thethreshold of the hangar, the towing operation was smooth and unobstructed.The entrance of the hangar does nothave any significant obstruction thatwould induced abnormal loading on the skid gear.

QETE also recommended that a periodicinspection of the cross tube be includedin the maintenance cycle.

An Unsatisfactory Condition Report hasbeen raised by the unit of occurrence to address the deficiency of the towingsystem. The Land Aviation and TestingEstablishment has recently been tasked to evaluate an improved CH-146 Griffontowing system. The results should beavailable this fall.

This incident is a further illustration ofthe inadequacy of the Griffon towing

system. It hascaused personnelinjuries in the pastas well as othermaterial damage.It is also a reminderthat until a newtowing system is adopted, all personnel mustexercice vigilanceand care whentowing the Griffon helicopter. ◆


FROM THE INVESTIGATOR

TYPE: Griffon CH146493LOCATION: In the vicinity of

Goose Bay, LabradorDATE: 29 March 2004

CH146493 was conducting a scheduled trainingmission for the co-pilot who needed simulated

emergency practice. The emergency selected forthe training was: “Governor Failure High Side”.The co-pilot, flying in the left seat, was at the con-trols, with the pilot performing “non-flying pilot”duties. The emergency was briefed among thecrew, followed by a simulation.

The emergency simulation was correctly initiatedby the co-pilot raising the collective. The non-flyingpilot then lowered the collective to regain singleengine parameters in anticipation of switching the governor to manual. After identifying the governor switch and hearing “Confirmed” fromthe Flight Engineer (FE), the non-flying pilotselected the governor switch to manual.

Shortly thereafter, the “Engine 2 Out” and the “Fire 2 Pull” lights came on and the aircraft experi-enced a power loss of the no. 2 engine. The pilottook the controls and the crew executed a “No. 2Engine Fire” emergency procedure successfully landing on a snowmobile trail just outside the Base.Following shut down, the crew noticed extensivedamage inside the no. 2 engine compartment con-sisting of burnt paint chips and metal discolorationcaused by excessive heat.

The investigation later revealed extensive heatdamage to the no. 02 stage of the Free WheelingTurbine (as shown in the photo). Nearly all the tur-bine blades were missing 20 to 50 % of their tips.Also, damage was observed on the inside of theexhaust duct, the air by-pass duct and both tailrotor blades had dents, nicks and scratch damage.The damage is consistent with Category C.

The likely cause of the occurrence is the failure toroll the no. 2 throttle to idle prior to moving thegovernor switch to manual. The investigation is on-going and will focus on crew procedures, crew communications and Crew ResourcesManagement. ◆


FROM THE INVESTIGATOR

TYPE: Hawk CT155202 LOCATION: 1 Mile North of 15 Wing,

Moose Jaw, SaskatchewanDATE: 14 May 2004

The mission was a navigation trip and part of aconversion syllabus designed to familiarize the

Royal Air Force (RAF) student with the NATO FlyingTraining in Canada (NFTC) Hawk’s variant. With thearea portion completed, the crew was conductingsome proficiency flying at 15 Wing. The InstructorPilot (IP) had just taken control and as the aircraftapproached the departure end of Runway 29R, a bird was observed just left of the nose. Bothcrewmembers heard a “thump”, felt vibrations and noted a change in engine pitch. This was followed immediately by audio and caption engine warnings (T6NL&ECA) and high enginetemperature indication (660 C).

The IP traded altitude for airspeed, confirmed thatengine temperatures remained high, reduced throt-tle to idle and told the student to “prepare to aban-don the aircraft”. The aircraft reached a maximumaltitude of approximately 3700 Mean Sea Level(1700 AGL). When the aircraft descended through3000 MSL the IP transmitted his intention to eject toMoose Jaw tower. After confirming the student wasready, the IP ordered and initiated ejection.

Both occupants cleared the aircraft and descendedunder parachutes but for less than 30 seconds priorto landing. One crewmember was seriously injuredin the sequence and the other received minorinjuries. The aircraft was completely destroyedwhen it crashed about seven seconds later in afarmer’s field.

The investigation is on going and focusing on awide range of issues including the aspects of lowand slow speed (below 300 Knots Indicated AirSpeed) engine failure in the CT-155 and ejection criteria. Also, the investigation will examine engineperformance after bird ingestion and aircrew lifesupport equipment. ◆


For Professionalism

CORPORAL MIKE GALLANT

On 16 July 2002, Corporal Gallant was tasked tocarry out an Avionics (AVN) Before Flight Inspection(“B” Check) on Sea King CH12428. During his inspec-tion of the Flight Control rods, located in the elec-tronics bay (E Bay), he noticed a cotter pin missingfrom the collective pitch control rod. He immedi-ately notified his supervisor and initiated a flightsafety investigation. Corporal Gallant was notrequired to inspect the E Bay as part of the AVNcheck but did so under his own initiative. The samearea was inspected by others during the previous“A” check but did not reveal any unserviceability.

If left undetected, the missing cotter pin could haveallowed the castellated nut to loosen and fall off,disconnecting the collective pitch rod. This chain ofevents presented high potential for a catastrophicflight occurrence.

Although the E Bay is adifficult area to inspect,his initiative and keeneye for detail whileinspecting the compo-nent is commendable.Corporal Gallant’s profes-sionalism averted apotentially dangerous situation that could haveseriously endangeredboth aircrew and the aircraft. ◆

Corporal Mike Gallant has been promoted to MasterCorporal and still serves with 12 Air MaintenanceSquadron, 12 Wing Shearwater.

calibrated during its lastannual calibration, PrivateWest contacted the WingCalibration Coordinatorfor follow up. The WingCalibration Coordinatorcontacted the CalibrationCentre in Esquimalt andupon investigation, dis-covered that an impropermethod was used to calibrate the torquewrench during annual calibration. The othertorque wrenches on the Wing, which potentiallycould also have been incorrectly calibrated, wereinspected locally and all were found serviceable.

Private West’s strong technical knowledge and outstanding persistence prevented the potential for a very serious accident by having incorrectlytorqued components installed on aircraft. His excel-lent knowledge of reporting procedures allowed theappropriate authorities to be informed, thereby pre-venting any further occurrences. Private West shouldbe highly commended for his vigilance and persever-ance in pursuing a seemingly small discrepancy,which could have had very serious ramifications. ◆

Private Robert West has been promoted to Corporal and still serves with 19 Air Maintenance Squadron, 19 Wing Comox.

PRIVATE ROBERT WEST

Private West was conducting a quarterly inspectionof a torque wrench from the 19 Air MaintenanceShop component shop when he discovered thetorque wrench was reading a significantly lowervalue than what he had set. He rechecked the discrepancy, then requested a senior technician to confirm his finding. Upon checking the torquewrench, the senior technician determined it to bewithin specification. Private West noticed that thesenior technician had read the torque wrenchincorrectly. On this particular torque wrench, thenumerical value is physically offset from the actualtorque indication line. If a technician incorrectlyuses the numerical value adjacent to the indicationline as the torque value, the wrench will read alower torque value from what is actually beingapplied. Private West immediately explained theproblem to the senior technician and pointed outthat, as a result, there was a good possibility thataircraft components had been repaired with incorrect (low) torque values.

Private West immediately notified the Unit FlightSafety Officer, quarantined the torque wrench andinformed the Component Shop of the problem. Allaircraft components, which had been repaired withthat torque wrench, were located and re-torquedwith a serviceable wrench. Considering the possibilitythat the torque wrench may have been improperly


CORPORAL AUSTIN COLE

On 3rd October 2003, Corporal Cole, a 514 AviationTechnician, was tasked to assist with the beforeflight check on Seaking CH12441 (B). During thecheck of the port side airframe, Corporal Colenoticed the landing gear drag link assembly boltappeared different than the starboard side draglink bolt. After consulting the applicable CanadianForces Technical Order, Corporal Cole determinedthat an incorrect bolt was installed in the drag linkassembly. He then made a major entry in the aircraft servicing set and initiated a Flight SafetyIncident Report on this observation.

Failure of this drag link assembly bolt has thepotential to render the Main Landing Gear systemcompletely inoperable, possibly leading to a serious incident or accident

Corporal Cole’s initiativeand outstanding attentionto detail, while assistingwith carrying out thebefore flight check, is considered exceptional for someone with limitedexperience and exposureto the Sea King fleet.Corporal Cole is to be commended for his timelyactions in eliminating this potential flight safetyhazard. ◆

Corporal Austin Cole is still serving with 12 AirMaintenance Squadron, 12 Wing Shearwater.

CORPORAL MIKE SNELGROVE

On the 13th of November 2003, Corporal Snelgrovewas tasked with carrying out his first training highpower Class II Engine Run Up, on aircraft 188918.Following the run, while carrying out the post runinspection, Corporal Snelgrove noticed smoke ema-nating from the front inboard area of the engineand a predominant fuel smell from the enginecompartment. Concerned, Corporal Snelgroveattempted to isolate the source in the bay, to noavail. He then proceeded to the top of the aircraft,where Corporal Snelgrove noted smoke wafting upfrom around the front of the speed brake area.Taking initiative, he alerted ‘Man’ 1 to stand bywith a fire extinguisher and conducted a thoroughinspection under and around the speed brake, dis-covering the aft-most dorsal panel exceedingly hot.

Corporal Snelgrove immediately opened the dorsal panel, attempting to further identify theheat source. No leak or damage could be readilylocated. Corporal Snelgrove raised a CF-349 andpassed the aircraft on to Snags. During the subse-quent investigation, the cause was identified as an

improperly installedenvironmental controlsystem (ECS) clamp whichunseated a fuel ventline, dumping raw fuelon the ECS duct whichducted hot engine bleedair to the ECS system.Due to the inaccessibilityof the duct and line, it was impossible to discover the fault without the use of the boroscope equipment.

Thanks to CorporalSnelgrove’s outstandingdedication, professional-ism, and extraordinaryvigilance above andbeyond, a possible cata-strophic failure was avoided. ◆

Corporal Mike Snelgrove serves with 410 Tactical FighterOperational Training Squadron, 4 Wing Cold Lake.

For Professionalism


CORPORAL HARRIS GOODYEAR

In the course of his duties Corporal Goodyear wasrequested to carry out non-destructive testinginspections on a phase aircraft. Looking through thevarious special inspections required, he noticed thatthe CF-349 calling up NS-459 had been signed off asnot applicable. Usually when this occurs a technicianwill proceed with his other work, but CorporalGoodyear made inquiries as to why this inspectionhad been called up, and then signed off as notapplicable. The phase supervisor had noted in thespecial inspection description that if modificationCD-140 had been carried out on an aircraft, then thespecial inspection would not be required. Using DataManagement System/Maintenance Records Set toquery the aircraft records for outstanding mods, CD-140 did not appear, so the phase supervisorreached the conclusion that it had been done andtherefore the special inspection was not required.

Corporal Goodyear was not convinced that the information was interpreted correctly, and dugdeeper. Through further research, he discovered that modification CF-140 was not applicable to thisaircraft, and therefore wouldn’t have appeared onthe list of outstanding modifications. CorporalGoodyear explained the situation to the SquadronAircraft Maintenance Control and Records Officerand Phase Supervisor, and as a result the CF349 forNS-459 was re-opened and the special inspectionwas carried out.

Corporal Goodyearapplied excellent workethic and his knowledgeof the critical nature ofnon-destructive testinginspections in this situa-tion. He took the time toresearch and rectify themisunderstanding thatcould have resulted inextensive fatigue damageto an aircraft. Not onlythat, but by bringing thisto the attention of hissupervisor, a fleet-widerecord check was insti-tuted that discoveredtwo more aircraft that had been interpreted in thesame manner. This situation and the interrelation ofthe special inspection and modifications have nowbeen highlighted on the CF-18 fleet, and futureoccurrences should be eliminated.

Not performing this particular special inspection ina timely manner would not likely have resulted inan accident. However, there was potential for seri-ous and costly preventable damage to the aircraft.Corporal Goodyear’s thoroughness and adherenceto non-destructive testing principles has potentiallysaved aviation resources. ◆

Corporal Harris Goodyear serves with 1 Air MaintenanceSquadron, 4 Wing Cold Lake.

CORPORAL DALE WARREN

On 17 April 2003, Corporal Warren was conductinga pre-flight inspection of Griffon CH146460 inpreparation for a mission during Exercise ResoluteWarrior in Wainwright, Alberta. During the con-duct of pre-flight he noticed that a screw appearedto be contacting one of the oil cooler lines. Closerinspection revealed that it was indeed contactingthe line and that the line was significantly wornpast allowable tolerances. Had the damage notbeen detected the line would have worn throughcausing loss of lubricating oil from the Cbox. Afternotifying maintenance section of this unservicea-bility a fleet wide Special Inspection was initiated.As a result, a significant number of Griffon helicopters were found with the same damage.

Corporal Warren is to be commended for hisexemplary level of dili-gence and professionalismexhibited during a fielddeployment. His proficientattention to detail whileperforming his dutiesundoubtedly preventedwhat certainly could have resulted in anextremely serious in-flight emergency. ◆

Corporal Dale Warren serveswith 408 Tactical HelicopterSquadron, Edmonton, 1 Wing Kingston.


For Professionalism

CAPTAIN GLEN ENGEBRETSON

On 01 November 2003, Crew 3 of 407 MaritimePatrol Squadron was preparing to start engines toembark on a seven hour maritime patrol. Just beforethe Pre-Start Check, Captain Engebretson, the CrewTactical Navigator, queried the flight deck as towhat system they had just turned on. He furtherclarified by stating that whatever switch had justbeen selected had created an abnormal vibration in the tactical compartment. With all of the noiseand vibration associated with the Aurora, he wasadamant that this particular vibration was abnor-mal. Upon further investigation it was determinedthat the vibration could only be felt when the #3Tank Fuel Boost pump was selected on, and that thevibration was predominantly localized at his flightstation. A technician was called on board the aircraft and in the course of investigation it wasdetermined that the #3 Fuel Boost pump impellorhad come loose which would have inevitably led toa failure of the Fuel Boost Pump and compromisedengine performance.

Captain Engebretson is aNavigator who is notfamiliar with the Auroraaircraft main systemmaintenance require-ments. However, hisattention to detail cou-pled with his decisiveactions and persistence,demonstrated his out-standing professionalism.His exemplary vigilancewas instrumental in preventing a potentiallyhazardous in-flight emergency that couldhave developed into a disastrous situation. ◆

Captain Glen Engebretson serves with 407 MaritimePatrol Squadron, 19 Wing Comox.

PRIVATE JEAN-PIERRE BOIVIN

On the 16th of May 2003, Private Boivin enthusiasti-cally volunteered to partake in the de-snaggingand ground maintenance run of a CF-18 Hornet.During the engine run up Private Boivin noticedthat the tail hook flag had separated from itsbraided attachment and was being blown forwardtowards the right engine intake. Since the groundcrew had not seen this, he immediately notifiedthe run up supervisor, who instructed the run uptechnician to shut down the right engine. PrivateBoivin’s quick and decisive action was instrumentalin preventing foreign object damage from beingingested into the right engine.

Despite his lack of experience, Private Boivin exhibited professionalism and dedication to safe operations beyond his years. His immediate actions averted a serious flight safety incident. In recognition he is awarded this flight safety For Professionalism award. ◆

Private Jean-Pierre Boivin serves with 416 Tactical FighterSquadron, 4 Wing Cold Lake.


PRIVATE GRANT POUPORE

During a deployment with 427 Squadron on 20 November 2002, Private Poupore discovered apotentially dangerous fault on a Griffon helicopter.As an apprentice Aviation Technician, PrivatePoupore was tasked to assist his crew with a 25-hour inspection. Upon removal of the #1 and #2engine intakes, he proceeded with an inspection ofthe engine wiring. It was then that Private Pouporenoticed an improperly positioned engine-wiringclamp on the #2 engine.

Having discovered this poorly positioned wiringclamp, Private Poupore immediately summoned his supervisor and continued with a detailedinspection of the engine. He then discovered thatthis wiring clamp had worn a hole approximately0.75 inches deep through the underside of the #2 engine fuel line outer protective sheath. Theclamp had been rubbing on the fuel line tubingabove the Automatic Fuel Control Unit, apparentlyfor some time. Had this fault gone undetectedmuch longer it may have resulted in fuel spillingover a hot running engine. For such an incident to occur in flight, the results would have been catastrophic.

Private Poupore demonstrated an ability to workwith minor supervision, even as an apprentice. He quickly discovered the fault with the poorly

positioned engine-wiring clamp and on his owninitiative, investigated further. This attention todetail enabled him to discover the damage to the fuel line even though it was in a in such anobscure location. Private Poupore’s keen eye and completeness of work likely prevented apotentially catastrophic in-flight emergency. ◆

Private Grant Poupore serves with 427 TacticalHelicopter Squadron, Petawawa,1 Wing Kingston.

when in fact it was theright hand fire bottle,which had come due andfor which the work hadbeen completed. As aresult, the left hand cartridges had been in service approximately one and one-half monthsbeyond their expiry date.Additionally, the righthand fire bottle and cartridges were replacedapproximately four yearsearlier than necessary.

Master Corporal Fitz-Gerald is awardedthe For Professionalism award. He identified,through diligence and attention to detail a criticalerror with aircraft servicing records. This errorcould have gone completely undetected andresulted in danger to crews and aircraft. ◆

Master Corporal Douglas Fitz-Gerald serves with 427 Tactical Helicopter Squadron, Petawawa,1 Wing Kingston.

MASTER CORPORAL DOUGLAS FITZ-GERALD

On 7 May 2003 Master Corporal Fitz-Gerald, anAviation Technician employed in the AircraftMaintenance Control and Records Officer section at 427 Squadron was verifying the maintenancerecords for a recently installed fire-extinguishingbottle on a Griffon helicopter. While doing so,Master Corporal Fitz-Gerald identified a discrep-ancy regarding the expiration dates for the righthand fire bottle’s explosive cartridges

While confirming the expiration date on the installedcartridges, Master Corporal Fitz-Gerald discoveredthat the other bottle’s cartridges on the left handside were actually expired, contrary to maintenancerecords. Confirmation was made by verifying theinstalled component’s serial numbers. Upon discov-ery of this discrepancy, Master Corporal Fitz-Geraldinformed maintenance personnel of the necessity toreplace the expired left hand cartridges.

The flight safety investigation revealed that the left hand bottle and expired cartridges werereportedly replaced eleven months earlier on 31 May 2002. This paperwork was entered in error,


For Professionalism

Mathews energized the extinguisher and remainedin position to ensure Master Corporal Lehtinen’ssafety. Master Corporal Lehtinen aggressivelyfought the fire, which was burning just behindtwo AIM-7 missiles, until it was extinguished. Hethen ran to and climbed the boarding ladder tothe cockpit. Quickly he shut down the restartedAPU and turned off the master power switch toensure that there would be no re-ignition of thefire. By this time, base fire fighting units arrivedand inspected the aircraft to ensure there were no internal fires and no chance of a flare-up.

In disregard of their own safety, Master Corporal’sLehtinen and Mathews’ instinctive response in acritical situation prevented the possible destructionof one or more CF-18 Hornet as well as the poten-tial loss of life or serious injury of the fifteen otherpersonnel manning the QRA. These two individualsare commended for their outstanding display ofbravery, quick thinking and decisive action. ◆

Master Corporal Aron Lehtinen and Master CorporalChuck Mathews serve with 441 Tactical Fighter Squadron,4 Wing Cold Lake.

MASTER CORPORAL ARON LEHTINEN MASTER CORPORAL CHUCK MATHEWS

On Wednesday, 4 June 2003, Master Corporal’sLehtinen and Mathews were standing outside theQuick Reaction Alert (QRA) facility in Comox. Therewas a fully loaded Operation Noble Eagle Hornetin each of the four hangar bays. An air sovereigntyalert practice scramble start involving two aircraftwas in progress when Master Corporal Lehtinenheard the auxiliary power unit (APU) on one jet cutout shortly after the #1 engine began to turn over.He proceeded into the hangar and saw the techni-cian in the ‘man one’ position signalling the pilotthat there was a fire. Initially he suspected that theAPU was ‘torching’, as is often the case in situationsof early APU shutdown followed by a quick restartattempt, however he soon noticed that the entireunderside of the tail section was in flames. At thispoint, the pilot abandoned the aircraft and moveda safe distance outside of the hangar. MasterCorporal Lehtinen and Master Corporal Mathewsimmediately rolled a portable fire extinguisher tothe rear of the involved aircraft. Master Corporal


CAPTAIN LYNE BRAGAGNOLO MISTER MICK LEBOLDUS

On 8 August 2003, Mister Leboldus was conductingan NATO Flying Training in Canada test flight, andCaptain Bragaganolo was acting as the inner runway tower controller.

A Hawk IP had returned from a low-level navigationmission and requested a practice forced landing(PFL) to the inner runway. Captain Bragagnolosequenced the aircraft and when required requestedthe pilot confirm the gear down as per the standardoperating procedures (SOPs). The pilot respondedthat the gear was down. As the Hawk neared thefinal stage of the PFL Captain Bragagnolo conducteda visual confirmation of the gear even though notrequired by regulation. Additionally, the Hawk PFLpattern is very dynamic, with a steep final approach,making it difficult to confirm the gear from tower.However, Captain Bragagnolo did not see any gearand requested the pilot reconfirm that the gearwas down to which the pilot again responded thatthe gear was down

At this time, Mister Mick Leboldus was holdingshort of the runway, awaiting take-off clearance,and heard tower ask the Hawk pilot, a secondtime, to confirm the gear was down. MisterLeboldus then heard the pilot reply that the gear was down, however, when he looked at the aircraft on short final he clearly saw that thegear was in fact not down. Captain Bragagnolosimultaneously confirmed that the gear was notdown and both Mister Leboldus and CaptainBragagnolo directed the Hawk pilot to overshoot.The pilot overshot and eventually landed withoutfurther incident.

Mister Leboldus and Captain Bragagnolo’s exceptional situational awareness and quick decision making prevented a Hawk gear up land-ing and potential accident with possible injuries topersonnel and loss of materiel resources. MisterLeboldus and Captain Bragagnolo are deserving of the flight safety For Professionalism award. ◆

Captain Lyne Bragagnolo and Mr Mick Leboldus servewith the NATO Flight Training in Canada, 15 WingMoose Jaw.


For Professionalism

Air National Guard Base at Syracuse, New York. A quick calculation by the flight crew confirmedthat they had just enough fuel to make the transitto Syracuse with the gear down, providing theycould climb to 20,000 feet. Despite repeatedrequests from Air Traffic Control to accept a loweraltitude, the flight crew insisted that they neededto climb to 20,000 feet. Upon arrival at Syracuse,Captain Griswold conducted a minimum fuel pene-tration to a five-mile Instrument Landing Systemapproach and successfully conducted an arrestedlanding. Both Captain Griswold and Major Argueshould be commended for their quick decision-making and crew coordination. Their timely decisionto go around at KBUF prevented the loss of controlof aircraft 912 and the possible closure of the onlyavailable runway at an international airport. Theirexcellent coordination with different Air TrafficControl agencies allowed them to successfullyrecover aircraft 912 and prevented this incidentfrom becoming an accident. ◆

Major John Argue and Captain Nicholas Griswold servewith 416 Tactical Fighter Squadron, 4 Wing Cold Lake.

MAJOR JOHN ARGUE CAPTAIN NICHOLAS GRISWOLD

Aircraft 912 was number 2 in a 4 plane CF-18 Hornetformation that was on route from Thunder Bay,Ontario (CYQT) to Buffalo Niagara International,New York (KBUF) on Saturday 04 October 2003. At the time of arrival at KBUF the runway in usewas runway 23 with a 15–20 knot crosswind fromthe right. The formation lead requested and wasvectored to initial for the overhead pattern. Upontouchdown, the number 2 aircraft experienced apull to the right and received indications that theyhad a planing link failure on the right hand mainlanding gear. Captain Griswold, the front seat pilot,initiated a go around at the same time that MajorArgue, the backseat pilot, was calling for a goaround. The number 3 aircraft landed without incident and the number 4 aircraft, upon therequest of Major Argue, carried out a low approachand formed up with the incident aircraft to con-duct a visual inspection of the right hand mainlanding gear. Upon inspection it was evident thatthe connectingrod on the righthand main land-ing gear was bentand that the tirewas not alignedappropriately fora normal landing.At the time of theincident KBUF hadonly one runwayavailable for oper-ations and therewas no cableavailable to con-duct an arrestedlanding.

At the request ofCaptain Griswold,Air Traffic Controlinformed aircraft912 that the clos-est airfield with a cable was the

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