IN THIS ISSUEflightcomment.ca/wp-content/uploads/2006/03/2006-2-eng.pdf · 3. Flight Comment —...

IN THIS ISSUE:NOTAMs: Do You Really Have Them All? (Part 2)

Thumbs Up: A Lesson in Hoist SafetyHelicopter Ground Resonance

ISSUE 2 2006

IN THIS ISSUE:NOTAMs: Do You Really Have Them All? (Part 2)

Thumbs Up: A Lesson in Hoist SafetyHelicopter Ground Resonance

There is said to be an ancientChinese curse: “May you live ininteresting times!” It seems to me that for the Canadian Forces,times are getting more and moreinteresting every day. Our flyingoperations face ever increasingchallenges, as our operationaltempo remains high and newdemands appear almost daily.Procurement programs for newcapabilities have been announcedand some of these are likely tobe introduced to the flight linewith a rapidity not seen since the1950s. As if all that were notenough, the air force’s direct sup-port to operational theatres, suchas Afghanistan, is very likely toincrease. While Canada has neverbeen a neutral country, it hasbeen quite a while since we havebeen so overtly engaged on theinternational scene, and therecan be no doubt that Canadianairpower will figure more andmore prominently in upcomingcombat and security operations.The challenge this poses for theflight safety program is to con-tinue to contribute effectively to force protection and missionaccomplishment.

Some might question the utilityof flight safety as we becomemore involved in direct supportto combat operations, or indeed,in combat operations proper.This is certainly an area that Iwant to address, because therecould possibly be some miscon-ceptions out there about the role

flight safety should play. What isthe perception at the coalface?Am I going to find myself in thesituation of the US Army’s Directorof Army Safety, who was told by a front-line trooper in Iraq that,“we need to start [fixing things]by disbanding the Safety Center!”If flight safety were to be seen asa barrier to mission accomplish-ment, then we would have gottensomething wrong, somewhere.

The purpose of the CanadianForces’ Flight Safety program is toprevent accidental loss of aviationresources. Period. This very simpleand direct statement makes no distinction between wartime andpeacetime. No matter the situation,the purpose of the program doesnot change. The flight safety pro-gram is not a peacetime construct;rather, it exists to ensure that com-bat capability will be available toaccomplish future missions, and thisremains true in peace or in war.Consider this: in every war whereair power has been employed, acci-dental losses have exceeded com-bat losses by a very wide margin.To take a recent example, do yourealize that from 2002 through2005, the US Army lost 24 aircraftto hostile action, while losing 94due to accidents? That’s a lot of air-power no longer available for thefight! Seen in this light, an activeflight safety program is a vital forceprotection measure that no com-mander can do without.

Force protection — it is not a newconcept. In July 1942, the Accident

Investigation Manual used by theRCAF stated that the purpose ofaccident investigation was, “toreduce the wastage of personneland material by careful examina-tion of all the contributory causes.”Sound familiar? However, progresswas slow. As Group Captain R.D.Schultz (the first DFS of the unifiedCF) put it; flight safety “was setback (or worse) with the beginningof the Korean conflict and the veryrapid build up of the air force.” All the bad aspects of “press-onregardless” attitudes crept back inand in fact some new unproductivebut deadly wrinkles were added.”In other words, a cavalier approachto taking risk, born of a fatalisticwartime experience, imbued theculture of the RCAF in the early1950s. The command structure ofthe air force realized that thingshad to change, that the air forcecould not survive its unacceptableloss rate, and so started us on thepath that led to the flight safetyprogram we have today.

Certainly, for Canada’s air force, fly-ing in challenging operational con-ditions is nothing new. Whateverour aircraft type or community, wehave all had to accomplish difficultmissions in the face of known andunknown risks. More and more, wehave taken a deliberate and rea-soned approach to managing therisks of flight operations, and it haspaid off. As the operational chal-lenge increases, the key to avoidingunnecessary losses will be in man-aging the risks appropriately to thesituation, and ensuring that risksare consciously accepted at theappropriate level of command. Theflight safety program can play agreater part in giving you the toolsto do that, but my sense is that wehave to do some further workbefore we can realize our fullpotential for force protection. Ithink the journey towards that goalis going to be interesting, and notjust in the ancient Chinese sense.

May you live in interesting times,and survive to talk about them!

Strive for perfection and cope wellwith what reality deals out. ◆

1 Flight Comment — Issue 2 2006

FlightSafety

FlightSafety

Views onViews onDirector of Flight SafetyDirector of Flight Safety

By Colonel Chris Shelley, Director of Flight Safety

Issue 2 2006 — Flight Comment 3

Table of

ContentsDossiers

On the Dials — NOTAMs: Do You Really Have Them All? (Part 2) ...................15Helicopter Ground Resonance.........................................................19Eurocontrol: Lack of ‘just culture’ leads to poor incident reporting, jeopardising aviation safety ............................................22

Regular ColumnsDirector of Flight Safety – Views on Flight Safety ............................1Good Show...........................................................................................3From the Flight Surgeon — Errare Humanum Est or Human Factors 101 ..............................5The Editor’s Corner..........................................................................12Maintainer’s Corner — Blue Threat – Red Threat in Aviation Maintenance ....................23Epilogue ............................................................................................25From the Investigator .......................................................................30For Professionalism............................................................................34

Lessons LearnedOn One Hand…On The Other Hand…Do You Have an Out?........7We Can Land Anywhere! ....................................................................8Flying with the Leans .........................................................................9Thumbs Up — A Lesson in Hoist Safety.........................................11Hoping for a Break is Not as Good as Making a Break — A Lesson in Timely Decision Making!........................................13

Cover Page: Pilot training on the Harvard near Moose Jaw.

DIRECTORATE OF FLIGHT SAFETY

Director of Flight SafetyColonel C. R. Shelley

EditorCaptain Rob Burt

GraphicsCorporal Eric Jacques

THE CANADIAN FORCES FLIGHT SAFETY MAGAZINE

Flight Comment is producedthree 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 StaffPearkes Building101 Colonel By DriveOttawa, Ontario Canada K1A 0K2

Telephone: (613) 992–0198 FAX: (613) 992–5187E–mail: [email protected]

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

Annual subscription rates: forCanada, $19.95, single issue,$7.95; for other countries,$19.95 US, single issue, $7.95US. 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–000Art Direction: ADM (PA) DMCSCS05-0274

FLIGHT COM

MENT —

ISSUE 2 2006

Administrator

Text Box

Photo: Ken Lin, www.aviography.com


Corporal Jamie Jordan

In June 2005 Corporal Jordan was working on an ASEsnag found during a post periodic inspection test flight

of Sea King CH124A440. Corporal Jordan was tasked tocarry out a basic flight control rigging check in prepara-tion for AVS technicians to check the automated flightcontrol computer system.

During the installation of the flight control rigging pins heencountered significant resistance while inserting a riggingpin through the mixing unit. Closer examination revealedthat the mixing unit, which is mounted laterally, was ableto move well beyond tolerance from side to side on itsshaft. Corporal Jordan informed his supervisor of the find.With a maintenance test flight crew, the supervisor testedthe unit but could not duplicate the snag.

Still concerned there was a problem, Corporal Jordan con-vinced his supervisors to let him remove the mixing unit,even though this would delay a test flight a further threedays. With the unit removed, the two main bearings sup-porting the mixing unit’s lateral shaft were found un-staked, worn and able to move within their own flanges.The severe deterioration of the bearings permitted themixing unit to tilt internally thus giving the impressionthat it was operating within normal parameters and thusdisguising the fault.

The mixing unit is a critical component of the helicopter.Ten flight control rods and nine bell cranks are all mountedon the mixing unit’s lateral shaft. Through these rods andcranks the unit integrates collective pitch control move-ments with the lateral, fore-and-aft and directional systeminputs and allows the controls to move the main rotor headprimary servo cylinders simultaneously in the same direc-tion and to change the pitch on the rotary rudder blades.

Corporal Jordan’s, technical ability, steadfast determina-tion, and unwavering tenacity resulted in the detection

For Excellence in Flight SafetyGood Sh w

and elimination of what could have developed into a catastrophic flight control failure. In the face of opera-tional pressures and the apparent serviceability of the part, Corporal Jordan persisted. Trusting his instincts and training he ensured the serviceability of a critical flight control component and, in so doing, ensured thesafety of an aircraft and those who would fly in it. ◆

Corporal Jamie Jordan is an aviation technician serving with 12 Air Maintenance Squadron, 12 Wing Shearwater.

For Excellence in Flight SafetyGood Sh w


Corporal Christopher Bonnier

During a routine post flight discussion, CorporalBonnier, a new Aviation Systems journeyman

employed at first line CC-115 Buffalo maintenance at 19 Wing Comox, learned of a possible navigational sys-tems anomaly. With the bearing pointer source selectedto GPS, the track bar was also displaying GPS data no matter what the equipment setting. The result wouldleave aircrew believing they were getting track bar data from VOR/ILS receivers, an authorized precisionapproach aid, when in fact they would be receiving datafrom the GPS that is not certified or flight checked forprecision approaches. At the time, the crew were not certain the observation constituted an unserviceablilityand the matter could have been dropped at that point.

On his own initiative, Corporal Bonnier researched the schematics of the system, liaised further with air-crew and instructors on the BuffaloTechnical Training Flight and eventuallyuncovered a design problem in a junc-tion box that generated the extremelyhazardous functionality observed. Heimmediately raised an unsatisfactorycondition report and notified the chainof command of the possible risks. Anaircrew information file was circulatedand crews were briefed.

Upon receiving the report, avionics subject matter experts visited Comox to research the problem. By that time,Corporal Bonnier had already deter-mined what modifications wererequired and he demonstrated both the problem and the fix to the avionics

team. His proposed changes were released as a fleet modification instruction and were adopted fleet widewithin three months of the first report.

Corporal Bonnier demonstrated outstanding technicalknowledge and determination in addressing a fault thatwould result in Buffalo aircrew flying approaches withincorrect, uncertified navigational information. His find and fix with respect to the CC-115 navigation suite, prevented what would have undoubtedly been a catastrophic flight safety occurrence. ◆

Corporal Christopher Bonnier is an aviation technician serving at 442 Transport and RescueSquadron, 19 Wing Comox.


It must be “Pilot Error”

Errare humanum est. To err ishuman. That is a fact of life,

and it will not change in thenear future. All right then, let’spack our things and go home.The pilot was flying, and the aircraft crashed. So it must be“Pilot Error”. Or is it?

Yes, human error continues toplague modern aviation, bothmilitary and civilian. Yet, simplywriting off aviation mishaps as“Pilot Error”, or even “TechnicianError” or “Controller Error”, is asimplistic, if not naive, approachto mishap causation. Mishapscannot be attributed to a singlecause, or in most instances,even a single individual. Rather,accidents are the end result of amyriad of latent and active fail-ures, the overall cause factors.

“Personnel” as cause factorA cause factor could be definedas being any event, condition,or circumstance the presence orabsence of which, within reason,increases the likelihood of aflight safety occurrence. If werefine it a little more, looking at “personnel” cause factors, asopposed to material or environ-

cumstances or errors associatedwith the individuals, or condi-tions present anywhere in thesupervisory chain of command or the system of management ofthe individuals, which predisposeto the tragic sequence of eventscharacteristic of an accident. Forexample, it is not difficult tounderstand how tasking crews at the expense of quality crewrest, can lead to fatigue and ulti-mately errors (active failures) inthe cockpit. Viewed from thisperspective then, the “unsafeacts” of aircrew are the endresult of a chain of causes origi-nating in other parts (often theupper echelons) of the organiza-tion. Latent causes contribute tothe final sequence of events ofthe occurrence or hazard by pre-disposing it to happen. Thoughthey are not the direct cause,they can have as much of animpact on the negative outcomeas the direct cause, or active fail-ure. The problem is that theselatent failures may lie dormant or undetected for hours, days,weeks, or longer until one day an“unsafe act” occurs or an “unsafecondition” is recognized, whichcan bite the individual who thenmakes the active failure.

Errare Humanum Estor Human Factors 101

mental cause factors, is lookinga “Human Factors” per se.

When an accident or unsafecondition involves personnel,the study of “Human Factors”comes into play and has shownthat there are two general cate-gories for the causes associatedwith the situation. These cate-gories are referred to as “active”and “latent” causes. FlightSafety investigations need toidentify both the active andlatent causes for occurrencesand hazards so that effectivepreventive measures can beimplemented to reduce the likelihood of recurrence.

“Active” and “latent” causesActive failures (or causes) areerrors, events or conditionsdirectly related to the occur-rence. Usually active causes arethe last action leading to thecondition or act. They are tradi-tionally referred to as “PilotError” or something similar, i.e. the so-called “unsafe acts”committed last by individuals,often with immediate and tragic consequences.

Latent failures (or causes) are,on the other hand, events, cir-

Fact: In this day and age, when asked: “In your opinion, what would you say caused or contributed to thisaccident?”, more often than not aircrew and ground crew alike, as well as witnesses, stakeholders or out-side observers, still throw on the table, often without hesitation, the archaic expression: “Pilot Error”!

From theFlight Surgeon From theFlight Surgeon

By Major Martin Clavet, Flight Surgeon, Directorate of Flight Safety

Looking at the “Human Factor”causal model as a whole, it canbe seen that active cause factorscan be the end product of a long chain, the roots of whichoriginate in other parts of theorganization (latent causes). Forinstance, latent failures such asfatigue, complacency, illness,and the loss of situationalawareness (SA) all effect per-formance but can be easily over-looked. Likewise, supervisorypractices can promote unsafeconditions within operators andultimately unsafe acts will occur.

But the idea is not to stop at the supervisory level either, theorganization itself can impactperformance at all levels. Forinstance, funding could be cutand as a result training and flighttime is restrained. Supervisors aretherefore left with tasking “less-proficient” aircrew with, some-times, complex missions. Notsurprisingly, causal factors suchas task saturation and the loss ofSA will begin to appear and con-sequently performance in thecockpit will suffer. As such, causalfactors at all levels must beaddressed if any mishap investi-gation and prevention system isgoing to work.

The purpose of flight safetyinvestigations is to identifythese active and latent failuresin order to understand why themishap occurred and how itmight be prevented from hap-pening again in the future. Thegoal is to prevent future acci-dents through the careful deter-mination of cause and theformulation of recommendedpreventive measures to mitigatethe active and latent failures.


Going back to this “Human Factors” thing…Human Factors means a varietyof things to a variety of people.A human engineer might tellyou it has to do with crew station design an anthropometry.A physiologist might emphasizethe effects of flight, such as alti-tude, cold, acceleration or move-ments along a 3-axis referencesystem, on bodily processes. Apsychologist might tell you thatHuman Factors has to do withinformation processing, emotionand motivation. A sociologistwill tell you that it concerns per-sonality, life event stresses andsocial relationships. A life supportspecialist might emphasize egresssystems and life support equip-ment. In fact, Human Factorsincludes all that, and even more,which affects human behaviour.

In relation to the Human Factoraspects of aircraft accidents, thissuggests that so-called “PilotError” accidents can be described,if not explained, in terms ofanomalies or deficiencies withinone or more of these categoriesof attributes.

A comprehensive study ofHuman Factors would thereforeinclude the physical, physiologi-cal, psychological, psychosocialand pathological attributes ofhumans in the context of theirinfluence on the interface of thehuman with the environment.

The environment includes herefactors external to the personthat determine or modify humanbehaviour. It also includes thetotal organizational system

design to prepare the person tocope with the external demands.

The interface of the human withthe environment consists of thecrucial human and environmentinteractions that proved to beincompatible and ended in anaccident.

Wisdom at last…Statistics suggest that the great-est single cause of aircraft acci-dents and incidents is humanfailure. The human is present atall levels where flight safety isconcerned: in the aircraft, on theflight line, in the controltower… even at decision-makinglevel in the office. The key rolethat the human plays explainswhy the Human Factor, not the“Pilot Error”, by itself or in com-bination with other factors, ispresent in as much as 80% of airaccidents (if not 100%!).Numbers do obviously dependon the statistical source andhow one looks at things;nonetheless, they are huge andcannot be overlooked.

To minimize the reality, impor-tance and salient role that HumanFactors have in the investigationof aircraft accidents by the sim-plistic expression “Pilot Error”would be not only fallacious but also missing the point.

Errare humanum est. To err ishuman. And one would err ifone kept referring to “Pilot Error”as the all inclusive bin intowhich we could shove anythingthat goes wrong on the humanside of the house when aircraftaccidents and tragedy occur. ◆

Life is about choices and so is the aviation business. Making

a bad choice usually has a bad out-come. Here’s the story of my fork in the road.

In the spring of 2005 I was attached toa Sea King HelAirDet operating withmultiple warships off the coast ofNorfolk, Virginia. It was about 45minutes to official night and veryhazy. The forecast called for clear skieswith a slight chance of patchy fog nearthe coast. Our position at the time was135 miles from Oceana, Virginia.

The sortie began with a passengertransfer from our Destroyer (DDH)to a Frigate (FFH) about 18 milesaway. After leaving the FFH we flew20 miles to the South to conduct apreplanned anti-submarine warfareserial with a French sub. After 30minutes of ping time on the sub,and while in the hover at 40 feet, we noticed the ceiling coming down.We called our DDH and asked forthe latest actual. Our first call wasunanswered. We decided to breakdip and climb a little for better line-of-sight reception. We called againregarding the weather at the ship.The answer this time was “Standby”.As we believed the DDH to be only25 miles or 15 minutes away we notconcerned about the reduced ceiling.Five minutes later the DDH calledback “The ship is looking for betterweather”. With 40 minutes of fuel,fog forming at a rapid rate, the sunstarting to set, 135 miles from shore,and our ship in the clag the temper-ature in the helo suddenly felt warmer.

The next radio call came from ourCommanding Officer on the DDHwho wanted us to return to the ship.That was it; we were heading back to the DDH hoping that they wouldfind weather good enough for recov-ery. Or was that it? Was that our onlychoice? While we waited for word

that the DDH had found clear air wethought about other options, otherchoices. We knew that the FFH thatwe had done the transfer to wasapproximately 20 miles to our North.We called them for a weather sitrepand they reported a 500-foot ceilingwith 10 miles visibility, but dropping.We were at the fork! There was achoice and we had to make one. Our options were dwindling fast. We realized that we may not findour DDH in the fog, and if we did, it would probably require a belowlimits approach to the ship — essen-tially an emergency procedure. Withthat in mind we opted for the FFH.We’d get fuel and then go look forour DDH.

After we fuelled up on the FFH, wedeparted and hit a solid wall of fog.Not only that, but it was gettingdark. We called our DDH for a posi-tion report and found out that theywere not 25 miles away as previouslythought, but 68 miles away and stilllooking for better weather. Thirtyminutes later with about 5 minutesof daylight left, we broke out of thefog just in time to see our DDH alsobreak out of fog. Three minutes aftersetting down night arrived and sodid the fog — it lasted for 3 dayswith 50 yards of visibility.

As the aircraft captain, straying fromthe direction of the CO, I believed that I would be reprimanded for mychoice. I was not reprimanded, insteadthe crew and I were congratulated forhaving found another option and forchoosing it. I shudder to think whatwould have happened if we had gonewith option one.

Often life points you in one direc-tion and we obediently head thatway, but this lesson taught me toseek out choice, to consider what life readily offers and to also rootaround for the less apparent. Whenthe road ahead looks bumpy don’tjust slow down, look around fordetours or alternate routes. You do have an out! ◆

On One Hand…

On The Other Hand…


By Captain Scott Young, 423 Maritime Helicopter Squadron,12 Wing Shearwater

Do YouHave anDo YouHave an

Out?


Anyone remember the Twin Huey?Well I do and I won’t forget this

lesson. With the many new pilotsthat are being trained yearly as TacHel aviators this story could apply to just about any new OTU grad.

I was on a cross-country trainer tothe Maritimes. We had a combinedmission — compassionate — due to an illness in the family, we wereflying a squadron member home fora couple of days and — training —operating in a new and unfamiliararea we would practice some of theskills recently taught on OTU.

After an easy first day we arrived inthe Gaspe area. With our compassion-ate passenger delivered home and agood night’s rest it was down to busi-ness. For the next two days we woulddo some IFR training and some nightflying before returning to pick up ourpassenger for the ride home.

It was a nice sunny Septembermorning and we were enjoying our flight along the Gaspe coastline.We spotted a sizeable rock up aheadand decided to try and land on it.

I was new, wet behind the ears. I thought to myself, we must do this all the time, we’re in a helicop-ter, this is thrilling — we can landanywhere!

Now, looking back, there were a couple of clues that it probably wasn’t the best move:

There was a blue duck symbol (birdsanctuary) on the chart that corre-sponded with the location of the rock.

On short final there were four hun-dred or so birds lifting off to get outof our way.

It was a really cool rock — if you’reever out that way it is called RochePerce — a well-known, well-adver-tised bird watching location. As amatter of fact, the tour boat operator

who was pointing out the variousspecies to his bird enthusiasts wasnow pointing at us.

When we got back to Base we foundout (okay it was pointed out) that the Squadron had some very specificregulations regarding off-airfieldlandings and combined with thatbird sanctuary thing, that we hadbroken a few rules in landing on thatcool rock. We suffered a few minorpunishments and some bruised egos,but the lessons remain fresh:

• If you’re new, don’t be afraid to ask a question or two or; don’t beafraid to point out the chart nota-tions or; don’t be afraid to pointout the thousand or so birds.

• If you’re going somewhere new, plan ahead, read the charts, pick up a brochure?

• Know the Squadron’s proceduresand regulations.

• Don’t bird watch in a helicopter. ◆

ANYWHERE!We Can Land

By Captain Marcel Rochat, 403 Squadron, Canadian Forces Base Gagetown

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asic instrument flying saved mylife! Without it I wouldn’t be the oldpilot I am today, telling you this story.Though it occurred a long time ago, I believe it to be of value regardless ofwhat aircraft type you fly.

The task for the day was to fly toEngland to pick up one of our air-craft that had been left there forrepairs. We were to fly down in oneand return in formation with both.As usual the weather was poor, inother words, we would be IMC forthe majority of the transit and wouldbe doing instrument approaches forlanding — no big deal! I was verycomfortable flying in IMC, and information, and having done thatmany times before, wasn’t at all concerned with combining the two.The flight to England was uneventfuleven though the weather was downto minimums. Before heading backto Germany we had the standardformation briefing, including all thecontingencies given the IFR weatherfor the day. I was “on the wing” so Ididn’t feel it necessary to clutter upthe cockpit with charts and pubs,after all, I was plenty familiar withhome base. It was to be a 75-minuteflight. The take-off and enroute por-tion were uneventful, but after anhour IMC and in close formation, Icould have used a break. I was look-ing forward to getting on the ground.

We were cleared for the HI-TACANapproach, which I knew wouldrequire a long level turn to the right to reach the initial approachfix, followed by a short descendingstraight portion and then anotherlong descending turn to the left onto final. After this snaking wewould then configure for landingand complete the final approach.

The weather was down to limitsagain. We started the first turn, noproblem, but then I expected thestraight portion before starting theleft turn — why was my lead turningleft so soon? I crosschecked my atti-tude indicator (AI) and that was whenI realized I had a problem! I had acase of “the leans”! We were in factwings level, but I felt as if I was in a steep turn to the left. My internalgyros must have toppled during theroll out, but who cares, right then Ineeded to get my brain “caged” again.I had heard about, and actually feltthis sensation before, and I knew thatall I had to do was take a few morepeeks at my AI and I would be OK.Right then we must have started theleft turn onto final because the sensa-tions I was feeling got worse. I triedto tell myself not to worry about it, Ihave been in close formation nearlyupside down and I’ve never had aproblem with that, in fact, I enjoyedit. The sensation seemed to subsideslightly, I took a peek inside and wewere now level on the AI, but I stillfelt like we were in a 90-degree turnto the left. It occurred to me that wewould soon be selecting gear down,followed immediately by the flapsdown selection — both of which Ihad never done while in a 90-degreebank turn. I started to perspire and a sense of panic began to well up. Tostay in formation my control inputswere getting more and more erratic.I had a decision to make, stay on mylead’s wing for the landing and risk a possible mid-air, or break away tosort things out on my own? I’m notsure how I made the decision, but Imade one and what occurred afterthat, words cannot completely

describe. Remember the formationwas in fact wings level when I initi-ated the break away and I had putmyself in a real unusual, nose lowattitude in IMC with severe “leans”. I remember hearing my voice insidemy helmet coaching me to believeand trust the instruments and toignore what my senses were tellingme. I did eventually recover, talk to ATC, and get vectors for a PARapproach and landing.

This is where I thank God and myinstrument flight instructors inMoose Jaw for drilling into me the“Centralize, Analyze, Recover” andall the other basic instrument flightcrosscheck skills which I had to callupon. Even now, with 6000 hours, I look back and this still ranks as the most significant emotional (near-death) experience of my career.

Here are the take-aways:

• If IMC and you really don’t haveto fly in formation for extendedperiods of time — don’t.

• Always have your charts & pubsreadily available even if you don’texpect to need them. I recall notbeing able to pull the approachplate out of my pocket while I was fighting to keep the wingslevel. Fortunately for me, the PAR approach was available.

• Swallow your pride and commu-nicate to your lead that you areexperiencing a problem.

• You may fly by the seat of yourpants some of the time, but youmust trust your instruments all of the time.

• Near-death experiences never healcompletely — try not to have one.

• Just because its never happened to you doesn’t mean that it neverwill. ◆

BBy Captain Gerhard Proksch, CANSOFCOM, Canadian Forces Base Petawawa


the hoist. Once I finished puttingthe horse collar around the diver,who was over six feet tall and weightabout 250 pounds, I gave the signalto raise by patting my head. At thatpoint, the hoist operator started toraise the hoist, but with so muchcable in the water I didn’t realize wewere being reeled in, so I signalledagain but used the thumbs up — itmeans the same thing. What I failedto notice was that I had just stuckmy thumb in a loop that was aboutto close. Before I could react, thecable cinched around my thumb.My weight, the weight of the diverand all the gear was now bearing on my thumb. I could feel the cable cutting through my thumb. I attempted to wave off the hoist but failed. Seconds later, the cableripped my glove and my thumbfrom my right hand. I rememberbriefly falling back into the waterand looking for my thumb but I

couldn’t see it. The hoist operatorknew that that something had goneterribly wrong, but the only thing he could do was to hoist the diverand I back into the Sea King. As were-entered the helicopter I rememberseeing the hoist operator’s face turnfrom a healthy pink to a sickly green.It’s about at that time that I startedto feel the pain.

My thumb was gone and there wasno way to recover it; I knew that was bad. It also occurred to me thatwe were in the middle of nowhere; I knew that was bad too. I wasn’thaving a great day! But to the creditof my crew and the ship’s company,they settled me down and had meon a medevac to Guam within 45minutes of the accident. That’s whenthings started to look up. As theywere loading me on the helo some-one told me that they had my sev-ered thumb. I thought that I musthave misunderstood, but then they

March fifth 2002, I’m on theoperating table in Guam

waiting for a doctor to reattach myright thumb. My right hand is mydominant hand but the only thing I can think about is the accidentthat lead me here.

Six hours earlier, 300 nautical milesEast of Guam, our Sea King lifted offHMCS Ottawa to conduct a routinediver deployment with three of theships divers. We had briefed thecrew and the divers and everyonewas straight on the who and whatof the mission.

Everything was going as per theplan. It was my turn to be harnessman and be lowered into the waterto retrieve the divers. Once in thewater I proceeded to hook up thefirst diver. No real difficulty, butthere was a noticeable sea swellwhich forced the hoist operator toleave me 10 to 15 feet of slack on

A Lesson in Hoist Safety

ThumbsA Lesson in Hoist Safety

Thumbs UPUP

By Captain Yves Soulard, Canadian Forces Air Navigation School, Winnipeg


CornerTheEditor’sCornerTheEditor’s

What’s New Pussycat?I have a lot of explaining to do with respect to Flight Comment:

What happened to the Winter 2006 issue? — In the Fall 2005 Issue I lamentedmy inability to align the issues with the seasons and proposed a governmentintervention to realign the seasons to correspond to my lack of time appre-ciation. Well no response, but thankfully global warming saved the day andwinter was cancelled here in Canada — alas no winter — no winter issue.

What happened to the Spring and Summer issues? — Seasonal adjustmentdisorder (SAD). With the cancellation of winter we slipped into a long drearyperiod of rain, drizzle and fog. With the resultant vitamin D deficiency I justcouldn’t motivate myself — alas no energy, no interest — no Spring issue.As for Summer issue, who cares, everyone went on vacation!

With this kind of chaos, i.e., global warming, climate change, SAD, anunprecedented rise in the Canadian dollar, etc changes were necessary:

This list is not exhaustive, so keep your eyes peeled for other tweaking.

Ultimately, the goal is to produce a top quality flight safety publication thatprovides those in the business of aviation with the tools and lessons to flysafe. You are cordially invited to contribute to this endeavour. Our websitehas a survey that solicits your opinions on Flight Comment, Debriefing, thewebsite itself, etc. Fill it in at: http://www.airforce.forces.ca/dfs/docs/home/new_e.asp. With readers in at least forty countries I think that there’s lots we can learn from each other. ◆

Fly safe.

• We are only producingthree, instead of four, issuesof Flight Comment annually.

• If I can locate the content,the issues will be larger.

• The magazine is now fullcolour.

• A great column, On theDials, has been resurrectedby the Instrument CheckPilot Flight. Part II of theirfirst article on NOTAMSappears in this issue.

• We have a new DFS. He’s #1, soI put him on page one. Hopefullythis will help my evaluation!

• The Table of Contents moved topage 2.

• New banners for the From theFlight Surgeon and the On theDials articles.

• The price per issue has increased,but the annual subscriptionremains at the same low price.

• Each Good Show award has itsown page.

showed it to me. It was a thumb,and I was missing one, so it seemedlike a good match. Apparently, whenmy glove came off, it fell right besidethe diver I was hoisting. Not knowingthat my thumb was inside, he pickedit up figuring that I would need itlater — little did he know how truethat innocent thought was! When hegot back into the helo, he noticedsomething fall from the glove. It wasmy thumb, the one I had misplacedonly a few short moments ago.

The operation was a success. Thedoctor, who happened to be a handsurgeon, managed to reattach my little friend — it’s a little shorter thanbefore. Physiotherapy followed and I was able to regain my full categorywithin 2 months of the accident andto resume full flying duties. Sincethat time, when hoisting I signal bypatting my head. ◆

It was a long September weekend;our mission was to transit 2 gliders

on tow with 2 tow planes north toprovide some local familiarizationflying to some northern cadetsquadrons. We would depart St-Jean, PQ enroute to Mont-Laurier,PQ. Standard stuff, as with everypre-flight, we crew briefed the tripincluding weather and in this case atransit check for a junior instructor.As the more senior instructor, I wasconducting the check ride-out fromthe second glider.

We strapped in and the two forma-tions took off expecting a total triptime of about 2.5 hours. About onehour in we encountered rain show-ers that had moved in sooner thanpredicted. We quickly diverted to afamiliar enroute airport from whichwe could still achieve the mission of providing cadets with some

familiarization flying. Our flight lead,in the tow plane, called up the FlightService Station and got anotherweather briefing which called fornicer weather in a few hours. Withthat window of hope we decided tosit it out there and re-evaluate thesituation in a couple of hours.

The weatherman was right and itcleared, but another update showedsome TCU’s in the forecast. We talkedit over and decided to continue north.To avoid turbulence below the devel-oping clouds, we flew at 9500 to10000 feet throughout the flight. As we approached our destination,or more precisely about 20 miles out,a scattered cloud layer below us wasbeginning to be not so scattered. Wetalked that out and, as the weatherwas supposed to be scattered overMont Laurier, we decided to presson. As we got closer, all the holesfilled in and now we had a solid

Hoping for

a Break is

as Good

as Making

a Break

NOT

A LESSON IN TIMELY DECISION MAKING


By Captain Theodoros Foulidis, Regional Cadet Support Unit, St-Jean

After holding our breaths for thedrama of friends and colleaguesmaking a 4500 foot descent throughcloud we returned to focus on oursituation. We realized that we werenow tight for fuel for the trip homeand there were no options inbetween. As a crew, we decided thatwe too would release and make thedescent through the layer…

I’ve written this story so the outcomewas positive, but for 30-40 minutesof what seemed like a perfect start to


a long weekend in September I wasn’tso sure. Neither of us realized thatwe were heading ourselves down adead end path, neither of us fullyperceived the threat that the weatherposed that day, and neither of uswanted to end the mission beforeaccomplishment as long as there was hope that we could make it.From that day forward, I decidednot to hope for or count on a breakin life, I decided I would make myown breaks! ◆

layer of overcast below us. Pushinginto 40 knot headwinds we pressedon hoping for some breaks overheadthe airfield. The tow planes, usingtheir onboard GPS, let us know that we were overhead destinationbut there were no holes, no breaks,we couldn’t get down!

As we circled we realized that wehad become a tow plane/glider twolayers and the weather was closing inon us from the top and the bottom!With dwindling options, we decidedto head back home to St-Jean, butbefore we turned the lead formationinadvertently entered cloud at 8500feet and the glider released. The leadtow plane descended and broke outat 4000 feet. We, the second forma-tion, circled overhead awaited wordfrom the released glider. A few silent,scary minutes passed before theyradioed breaking out at 4000 feet andthen declaring that they had landed.

Photo: Captain Brian Cole


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In the last issue of “On the Dials”, we began to investigate just what

exactly was involved with checking“All the NOTAMs”. More particularlywe focused on what the purpose ofNOTAMs were followed by a more in depth discussion of aerodrome,enroute, vendor, and databaseNOTAMs. Part 2 of “NOTAMs, Do you really have them all?” takesyour NOTAM search to the next level as we focus more on tacklinggeographic regional NOTAMs and the intimidating U.S. NOTAM systemnuances. More to the point, what are ASHTAMs, Attention Notices,Temporary Flight Restrictions, SpecialNotices, and the very elusive “NoticeTo Airman Publication”.

On December 15th, 1989, a KLMBoeing 747-400 descending for landingin Anchorage, Alaska, was about 70 nmnorth of the city and entered a lightcloud while descending through FL260.Shortly thereafter things got dark andthe cloud started to sparkle “like fire-flies in the dark”. The Captain ordereda climb to get out of the cloud butshortly after climb power was addedand the aircraft began it’s climb, all

four engines quit. The aircraft stallwarning and stick shaker followedshortly thereafter and all airspeedindications were lost. The aircraft had inadvertently flown through avolcanic ash cloud from Mt. Redoubt,a volcano about 120 miles southwestof Anchorage, which in turn had failedall four engines and caused approxi-mately $80 million worth of damage.

Volcanic Ash Advisories/NOTAMs (ASHTAMs):

As many pilots have found, volcanicash can have catastrophic effects onan aircraft. While volcanic ash mayappear soft and fluffy, it is in fact very abrasive and flying through itcan have similar effects to sandblast-ing your aircraft. In addition to clog-ging and ultimately failing engines,volcanic ash has been known to clogports (including pitot-static tubes),glaze cockpit windows, damage flightcontrol surfaces, and wreck havocwith aircraft environmental and electrical systems.

Ok, so who would intentionally flythrough a volcanic ash cloud? Well,during day VMC you might be ableto see the plum of smoke and ashspewing from the volcano but didyou know that that same ash can be carried hundreds of miles by thewinds aloft and can even be embed-ded in regular clouds. And to makematters worse, volcanic ash cloudsare not picked up on normal radarscopes so you may not even knowyou’re flying in an ash cloud until it’s too late.

So, how do you avoid such a deadlymenace? Aside from visually avoid-ing these clouds, the best option isto check the Volcanic Ash NOTAMs(ASHTAMs).

Since 1995, nine volcanic observato-ries have been monitoring volcanicactivities worldwide. This informa-tion is then made available to aircrewthrough the ASHTAM advisory sys-tem. One such advisory source is theU.S. National Oceanic & AtmosphericAdministration volcanic activitywebsite, http://www.ssd.noaa.gov/VAAC/, where worldwide volcanic

On the DialsOn the Dials

Information for IFR FlightInformation for IFR Flight

By Major Kevin McGowan, United States Air Force exchange officer, Central Flying School, 17 Wing Winnipeg

NOTAMs: Do You Really Have Them All? (Part 2)

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ash advisories and related materialsare posted. On the other hand, ifyou’re one of the many pilots whonever leave Canada, then you canclick on the “Volcanic Ash” buttonfound on the NavCanada NOTAMwebsite (http://www.flightplanning.navcanada.ca/) and get the ASHTAMsthat may affect your flight here inCanada.

With this being said, do you need toadd an ASHTAM check to your dailypre-flight routine? No, probably not,especially if you’re not flying anywherenear any volcanoes. But then if thischeck is not part of your regular pre-flight routine, you may want to addit to your pre-flight checklist forwhen you’re away from home station.

Attention Notices:

Attention Notices are deemed perti-nent to operations within certainregions of the globe but often tendto be overlooked by most aviators.Included in these NOTAMs might be region-wide announcements(such as new regional procedures,no-fly zones, and shoot down areas,etc.) that don’t really apply to a specific ARTCC and are thus notincluded in the normal ARTCC orenroute NOTAMs.

Excerpt from DoD ATTE and ATTP Notices

Oftentimes, there aren’t very manyNOTAMs in this file and there prob-ably won’t be anything of value, butyou never know. Just click on the“Attention Notices” button on theDoD NOTAM website’s main page(https://www.notams.jcs.mil/) ortype in the specific designator forthe region you want (ATTA for

Attention ALL, ATTN for AttentionNorth America, ATTE for AttentionEurope, ATTP for Attention Pacific,and ATTC for Attention Central/South America) in the ICAONOTAM Retrieval Form.

Temporary FlightRestrictions and SpecialNotices:

Here’s where it starts getting compli-cated as it deals with the U.S. NOTAMsystem. We’ve all heard the phrase,“information is power”, well, theU.S. takes this to the extreme andprovides so much information thatit can be intimidating. As a result,many pilots choose to avoid thesepages and pages of NOTAMs andthen hope for the best.Unfortunately, many pilots, especiallythose operating under VFR withinU.S. airspace discover all too latethat this course of action can lead

to not only violations but also incar-ceration, loss of aircraft, loss of aero-nautical ratings, and under extremecases, being shot down. The FAAtakes it’s airspace and proceduresvery seriously and they expect allpilots operating aircraft within thisairspace to be aware of their rules(something that is actually requiredby ICAO regulations).


So, now that I’ve gotten your atten-tion, what are Temporary FlightRestrictions (TFRs) and SpecialNotices and how do I proceed fromhere? Well, for starters, get the FlightData Center (FDC) NOTAMs. Theseare regulatory changes and advisoriesthat have been issued and are kepton file until they’re either cancelledor published in the FAR/AIM orNotice to Airmen Publication(NTAP). They include things likeamendments to charts, temporaryand combat zone flight restrictions,and certain changes to the FederalAviation Regulations (FARs). TheseNOTAMs tend to be plentiful andrather dry reading. Although most ofthe stuff won’t apply to your specificflight, there is a good chance thatone or two little tidbits will. Legally,you’re responsible for knowing thesetidbits so be sure to include this inyour NOTAM search. The FDCNOTAMs (including TFRs andSpecial Notices) can be obtained by asking the local Flight ServiceStation (FSS) for them via phone(800-WX-BRIEF while in the U.S. or 866-WX-BRIEF in Canada) or byclicking on the “FDC Notices” buttonon the main DoD NOTAM web page(https://www.notams.jcs.mil).

The Temporary Flight Restrictions(TFR’s) are NOTAMs contained withinthe FDC and ARTCC NOTAMs thatrestrict flight over certain locations.These temporarily restricted airspacesare not printed on any chart so you’llhave to transfer the NOTAM to yourcharts. Many of these areas are placeswhere disaster clean up or fire fighting

efforts are in progress. Many others areinfrastructure, government, or militaryfacilities that are included for nationalsecurity reasons or airspace closuredue to a Presidential or VIP visit.

Luckily, the TFRs are included in theNOTAMS you download for eachARTCC. They’re also available byclicking on the “ARTCC TFRs” button(although this will give you ALL theTFRs for the U.S.) but they are notincluded in the FDC NOTAMsreturned when you click on the“FDC Notices” button. You can alsoaccess a specific ARTCC’s TFRs byusing the “DINS ARTCC Notices, TFRsand Special Notice Page” located onthe bottom of the main page. Fromhere select “All Center Notices” or“TFRs Only”, select the ARTCC(s)you want the notices for, and thenclick on the “View Notices” button. I would also recommend clicking on the “Include Regulatory Notices”option to ensure you don’t forgetthese important NOTAMs. Eitherway, violating these restrictions mightconstitute a significant safety risk,possible interception by heavily armedcombat aircraft, or the dreaded “Callthis number when you land” radiocall from ATC. Read and heed as it’snot really worth the risk.

During your NOTAM search you’realso bound to find Special Notices.Special Notices are also regulatory innature but don’t necessarily meet thecriteria for a standard FDC or FacilityNOTAM. These are typically new or

modified procedures or restrictions,or the reissuing of previously pub-lished procedures or restrictions thatthe FAA wants to draw special atten-tion to. These Notices will be spreadout in each applicable section butmostly in the FDC NOTAM section.

Notice to AirmenPublication:The NTAP is an elusive “catch-all”document that’s published every 28days. Unfortunately, due to budget cutsand advances in technology, you mayonly find this document online nowand all pilots are responsible for com-plying with the contents. The NTAPis designed to contain NOTAMs thatwill be in effect for extended periodsof time (at least 7 days past the expira-tion date of the NTAP it is publishedin) and to advertise future specialairspace procedures around predictedhigh volume areas or special events.It’s also meant to be a means of remov-ing long running NOTAMs from thenormal NOTAM system to reducecongestion without cancelling them.NOTAMs contained within this doc-ument tend to focus on flight withinU.S. airspace but may include criticalNOTAMs that may affect U.S. andforeign aircraft flying outside U.S. air-space that the FAA deems importantenough to draw extra attention to.

Excerpt from NTAPInternational NOTAMs section

This document can be found throughthe FAA website (http://www.faa.gov/NTAP/) or through the DoD NOTAM

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website by clicking on the “Notice to Airmen Part 1” link on the rightside of the page. Even though it says “Part I”, it is in fact the entiredocument and is broken down into 7 sections:

1. General Information — Foreword and other NTAPBackground Information

2. Special Events3. Sporting Events4. Part 1 — Airway; Airport/

Facilities/Procedural; and General FDC NOTAMs

5. Part 2 — Revisions to MEAs and Changeover Points

6. Part 3 — International Notices to Airman

7. Part 4 — Graphic Notices

While the special and sportingevents procedures/restrictions maybe listed in the ARTCC NOTAMswhen they go into effect, many ofthe Parts 1 to 4 items are not foundanywhere else. For example, theInternational NOTAMs are noticesthat might affect your decision tooperate in foreign airspace and willinclude procedural changes or evenwarnings from foreign governments.

The Graphic Notices section, on theother hand, focuses on U.S. airspaceand is filled with a very wide assort-ment of need to know information(such as new airspace, new or modi-fied procedures, navigation sources,airport lighting, etc.). If you haven’ttaken the time to read this sectionbefore now, I would highly recom-mend sitting down and readingthrough it… It doesn’t take too long to check but it is one extraresource to devote some time tobefore stepping to go fly.

Oh, and by the way, if you call anFSS (1-800-WX-BRIEF) while in

the U.S., you’ll need to specificallyrequest the NOTAMs from this pub-lication as they won’t typically givethem to you right away. They won’tgive you the NOTAMs for SpecialIAPs that you may be certified to flyeither unless you specifically requestthem. Also, if you attempt to call anFSS in Canada (1-866-WX-BRIEF)in preparation for your flight to theU.S., don’t bother asking for theNOTAMs from the NTAP becausethey don’t have access to it.

All right, so there you have it. Never knew how involved checkingthe NOTAMs really was, did you? I realize that this all sounds veryintimidating and perhaps evenrestrictive but ARTCC expects you to know this information and theywill hold you accountable if you violate it. Now granted, in mostplaces we fly, we operate under IFR and ATC will keep us out oftrouble… or will they? Are you willing to take that chance?

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When it comes right down to it,completing a thorough NOTAMcheck isn’t that hard. Run through it a couple of times to get it down to a routine and then it becomes justthat, routine. In the end, while gettingNOTAMs has become more difficult,it is no less important to the accom-plishment of the mission. MissionAccomplishment, particularly inpeacetime, includes getting every-thing and everyone to their destina-tion in one piece. Fly Safe! ◆

This article (Parts 1 and 2), as well asmany other IFR related articles writtenby the CF Instrument Check Pilot FlightStaff are available online athttp://www.icpschool.com/track.html.Furthermore, extensive flight planningresources are available online athttp://www.icpschool.com/planning.html.

Photo Copyright Juan Carlos Guerra Aviation Photography of Mexico


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GROUND RESONANCEGROUND RESONANCEBy Curt Lewis and John H. Darbo

Ground resonance is one of themost dangerous situations a

helicopter pilot can face. This emer-gency situation can result in theentire hull being ripped apart by theaircraft’s own extreme oscillations.Ground resonance can be safely prevented, every pilot should knowwhat the causes are, what to do if it does occur, and how to prevent an incident.

HELICOPTER HELICOPTER

Ground resonance develops when therotor blades move out of phase witheach other and cause the rotor disc to become unbalanced. Ground reso-nance only occurs on helicopters witha fully articulated rotor system suchas the Chinook, TH-55, OH-6 andMD500. Go to this INTERNET site tosee a CH-47 destroy itself in groundresonance: http://video.google.com/videoplay?docid=-7722389053980760993&pl=true

On a fully articulated system theindividual rotor blades use a lead-lag hinge at the rotor hub to allow ablade to catch up or slow down alongits path to be in sync with the otherblades. The term “fully-articulated”means that the rotor head allows theblade to move in three independentplanes. A horizontal hinge pin allows

the blade to move up and down. Thisis known as “flapping”. Componentswithin the pitch varying housingallow the blade to rotate about itsspan (the distance from end-to-end).This is known as “feathering”. A ver-tical hinge pin allows the blade toswing forward and aft with respectto rotor-head rotation. This is knownas “leading and lagging” (hunting) .The vertical hinge pin has also beencalled the “drag hinge”. (see Figure 1)

Photo: Master Corporal Charles Barber


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It is the drag hinge that allows anygiven pair of blades to either getcloser to or farther away from eachother. When the pair of blades gettoo close or too far away, the bladesgo out of sync and the balance of theentire rotor disk becomes off center.When they fall out of sync this cre-ates oscillations within the aircraft.This is because the center of gravityof the main rotor, acting as a fly-wheel, is displaced from in line withthe axis of rotation, or the main rotorshaft., causing a “wobble.” In flightthis causes no ill effect, however, ifthe skids or wheels are touching the

ground, especially lightly, the wobblebecomes exaggerated. If the frequencyof these oscillations matches thehelicopter’s natural frequency, thenground resonance occurs. As eachoscillation occurs, within secondsthe amplitude increases until the aircraft has a hull breach.

Many modern helicopters imple-ment measures to prevent groundresonance. The U.S. Federal AviationAdministration defines ground reso-nance prevention as :

(a) The reliability of the means forpreventing ground resonance must beshown either by analysis and tests, orreliable service experience, or by show-ing through analysis or tests that mal-function or failure of a single meanswill not cause ground resonance.

(b) The probable range of variations,during service, of the damping actionof the ground resonance preventionmeans must be established and must be investigated during the testrequired by 14 CFR Sec. 27.241 (U S).

Common factors that may cause oraggravate ground resonance are:

• Unbalanced rotor head or blades

• Faulty blade tracking

• Damaged or malfunctioning lead-lag dampers

• Uneven oleo struts or tire pressures

• One-skid/wheel landing

• Hard landing or running takeoff/landing over rough ground

• Takeoff from, landing on or lightlytouching, a pitching ship's deck

Being able to dampen the vibrationsis the key to prevention. Implement-ation of shock struts, lead lag dampers,and properly inflated tires are among

the solutions. One type of damper isdescribed in the following quote fromheli-chair.com. “Ground resonance ismitigated…by employing the use ofdamping vibration isolators to attachthe landing gear to the airframe. Thedampers are tuned to absorb energyat the proper frequencies of groundresonance and typically can preventthis destructive event.” Proper main-tenance of dampers is critical forsafe flight. (see Figure 2)

Ground resonance most often occurswhen a helicopter is attempting toset down although it can occur while

sitting on the ground although therotor must be turning. The first stepoccurs when either the right or leftskid or wheel touches down beforethe other side. The shaft normally isperpendicular with the hull of thehelicopter but in this case it becomestilted to one side of the aircraft,causing an out-of-balance condition.This loss of balance causes the rotorblades to fall out of their naturalsynchronization. This initial contactsends a shock to the main rotor shaftand throws off its center of gravity.

Damping Vibration Isolators

Figure 1

Figure 2

Drag Hinge

http://video.google.com/videoplay?docid=-7722389053980760993&pl=true

Also poorly maintained shock strutsor low tire pressure can induceground resonance. Landing gearshock absorbers between the aircraftbody and landing skids are designedto attenuate any divergent vibration.

Various engineering arrangements areuseful in intervening in the resonancescenario. For example a Rotor HubVibration Absorber may be used tocounteract divergent excitationvibrations in the rotor mast. Theresonator acts on excitation loads attheir source. A weight is located onthe rotor hub axis and is held in placeby 3 springs allowing it to vibrate.The weight/springs system is excited

by the periodic cyclic loads on therotor hub, and responds at the exci-tation frequency by counteractingthe excitation load. (see Figure 3)

Another engineering intervention isa Cabin Resonators system, used tocancel out vibrations at the aircraftnatural frequency, which is normallynear three (3) Hertz . The cabin res-onator acts on a principle of physicscalled the resonator principle. It actsby damping the aircraft vibration atthe attachment point, thereby reduc-ing the vibration level. (see Figure 4)

Predicting ground resonance is difficult but possible. As the lastintervention strategy the pilot mustknow what to do during a groundresonance emergency. If the pilot hasmaintained the rotor RPM withinthe normal operating range aftertouchdown, breaking contact withthe ground is the best way to breakfree of a ground resonance incident.If there is not enough rotor energy(RPM) present then shutting down

Figure 3


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This article was published with permission from the Flight SafetyInformation Journal. It originallyappeard in the 2 May 2006 edition.See www.fsinfo.org

The Canadian Aeronautics andSpace Journal has an excellentreport on this topic athttp://pubs.nrc-cnrc.gc.ca/casj/q02-021.html.

The American Institute of Aeronauticsand Astronautics publishes a relatedarticle “Influence of landing geardesign on helicopter ground reso-nance”. It is available online for afee at http://www.aiia.org.

Figure 4


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Eurocontrol bemoans reluctanceof staff to report lapses

Eurocontrol’s efforts to reduceair traffic management (ATM)-related fatalities are beinghampered by the lack of a “just culture” in mostmember states, leavingrisks to go undetecteduntil they are exposedby an accident.

Although Eurocontrolset up a centralised ATMincident reporting anddata sharing system severalyears ago, safety chiefs areconvinced it is not working.

They believe the failure of manyEuropean countries to protect thesafety data reporting systems, andthose who submit reports, from thelaw means that no-one dare use them.

A crucial pillar of Eurocontrol’sEuropean Safety Programme (ESP)is a robust incident reporting anddata sharing system, says ESP man-ager Tony Licu. The fundamentalenabler for an effective incidentreporting system, he says, is a “justculture data sharing agreement”.According to Dragica Stankovic,who has joined Licu’s team from the International Air TransportAssociation, this culture is absentfrom most European countries.

Reporting systems have worked well in the airlines for years, but

in a state-controlled sector like ATM there was no such system until Eurocontrol set one up, andeven now the reporting rate is lowand does not reflect reality, says Dr Erik Merckx, the agency’s head of safety enhancement.

At Eurocontrol a just culture isdefined as one in which “front-lineoperators or others are not punishedfor actions, omissions or decisionstaken by them that are commensuratewith their experience or training,but where gross negligence, wilfulviolations and destructive acts arenot tolerated”.

Eurocontrol safety regulatoryrequirements, embodied under

European Single European Skylegislation, are supposed to put

pressure on states to makethe necessary adjustments

to their national laws toprotect open reporting by removing the fear ofpunishment or criminalprosecution from thosewho report on uninten-tional mistakes, errors,incidents, or on systems

that are not working asthey should be.

The Danish parliamentpassed a law in 2002 that

facilitated non-punitive, strictlyconfidential reporting after it hadbecome apparent that there was afailure to report loss of separationincidents in Danish airspace becauseindividuals feared career and legalconsequences.

Licu says he is trying to raise aware-ness of the need for action like this toimprove the quantity of ATM inci-dent reporting. Eurocontrol wantsthe ESP to be fully operational byDecember 2008, says Licu, but it willbe partially disabled unless memberstates make the changes necessary tosupport a just culture. ◆

This article was used with the permission of Flight International. It was published on 30 May 2006.

EUROCONTROL:LACK OF 'JUST CULTURE' LEADS TO POOR INCIDENT

REPORTING, JEOPARDISING AVIATION SAFETY

EUROCONTROL:

JustcultureJustcultureJustculture


By Chief Warrant Officer Michel Bernier, Directorate of Flight Safety

I travel across the country and abroad, learning with you about the dos and don’ts as we go over the history of incidents and accidents.

the red threat (the enemy) andthe blue threat (CRM — cockpitresource management) in check.

Technicians are trained to rec-ognize red threats (snags, bethey ACS, AVS or AVN related)and we are good at that; how-ever, we are not very good atrecognizing what I call theblue threat and how it affectsus on a daily basis!

For ground crew, the mission isto provide rubber on the ramp.The red threat is the component

that has an inherent designflaw; the component that willfail at an unpredictable time.Technicians do their best toidentify them early enough toprevent catastrophes. But inthe process we too often losesight of the blue threats.

Blue threats are always presenton a daily bases and can takemany forms as we too oftendiscover in 99% of our investi-gations.

Blue threats can take manyshapes and forms, they includethe following:

• Losing focus, due to a per-son taking you away from a task at a crucial moment;

• Pressure due to a personrushing you at the wrongtime, i.e. an impatient crewchief, or aircrew pacing backand forth in the servicingarea, or even a fellowworker pressuring you to do job faster;

• The weather, e.g., you’reworking outside and it’sfreezing, it’s too hot, it’sraining, or the mosquitoesand the black flies are driv-ing you nuts;

• Task saturation due to thenumber of subordinates (too many to manage);

Through our discussions onething sticks out. We never

come up with new threats.

Everyone in the aeronauticalindustry accomplishes the mis-sion using a combination ofairmanship and leadership skills.Our next challenge is to teachour work force how to keepthe red and the blue threats in check.

Let me explain!

For aircrew, the mission is todeliver steel to target keeping

CORNERM A I N TA I N E R ’ S BLUE THREAT — RED THREATin Aviation Maintenance

Photo: Master Corporal Michel Durand

• Your “Can Do” attitude, asyou’re the only one withexpertise and constantlyhave to manage too manysnags at once;

• The people pleaser, the tech that can’t say “no” or “enough is enough”;

• Your shift is almost over, you have an importantappointment and no one isthere to take your debrief;

• You have done the job somany times that you areoverconfident;

• You’re not getting properrest and you are chronicallytired;

• Your technical publicationsare vague and/or the trans-lation to French is bad;

• You don’t have enough bodies to do the task;

• You don’t have the propertools to do the job;

• You have something on your mind; e.g. caught in a family crisis, posting, etc.;

• You do not know how to be a supervisor because

you still have your tool box attached at the hip;

• You do not know how to be a supervisor because you don’t remember what a toolbox looks like, e.g.you’re stuck behind the snagor servicing desk when youshould be walking the floorto see what’s happening.

Keeping blue threats in check isvery much a leadership respon-sibility. We need to learn toslow down in order to avoidrepeating the same old mistakes.

If we can’t slow down due toops tempo, then the risk shouldbe formally assessed by leader-ship at the right level withinthat organization. ◆


Photo: Sergeant Joanne Stoeckl

Photo: Master Corporal Marc Gauvin


TYPE: SZ2-33A Schweizer C-GFMCLOCATION: Olds, AlbertaDATE: 01 May 2005

EPILOGUE

The mission was a winch launch and circuit fortwo qualified glider pilots. Immediately after

becoming airborne, at approximately fifteen feetabove ground level, the aircrew felt a loss of powerfrom the winch. The pilot manually released thetow cable and lowered the nose of the glider in an attempt to land straight ahead. As the gliderover-flew the tow-rope, the winch motor acceler-ated and the recovery parachute blossomed. Theparachute became entangled with the tail wheel ofthe glider and as the winch surged it pulled on thetail-wheel which caused the glider to complete alow-level, 360-degree rotation about its lateral axis.The glider impacted the ground in a flat attitudewith very little forward speed. The entire sequence,from beginning of the winch launch until groundimpact, lasted between 10-15 seconds. Both glideroccupants were treated and released from a localhospital with only minor injuries.

Investigation revealed that the winch had not beenoperating at optimum performance throughout theday. The spark plugs had become increasingly fouleddue to a leaking power valve. The normal mainte-nance inspections did not pick-up this progressivebreakdown. Discussion is on-going with respect totreating winch engines as ‘airworthiness’ assets.

The investigation also noted that after the momen-tary power loss the winch operator focussed hisattention from the glider to the winch, then back tothe glider. This delay in reducing the winch engine toidle and applying the cable brake was a contributingfactor to this accident. A National Pilot InformationFile was issued which states, “At any time that awinch experiences a momentary power loss, theimmediate action shall be to close the winch throttleand apply the cable brake.” Recommendations alsoaddress winch operator training. ◆


TYPE: CF188732 HornetLOCATION: Cold Lake Air Weapons

Range, AlbertaDATE: 26 May 2003

EPILOGUE

The accident aircraft was number three of a fourplane formation launched from 4 Wing, Cold

Lake, Alberta, to participate in a Maple Flag mis-sion. The four aircraft had completed their simu-lated weapons delivery and were flying relativelylevel at about 480 knots indicated airspeed and3000 feet above ground level in a “card” forma-tion. Just prior to the accident, the number twoaircraft had moved from a 6000 — 9000 foot lineabreast position to tight formation on the lead aircraft to inspect it for a possible gear problem.This put the leading element about 1.2 nauticalmiles directly in front and slightly above the acci-dent aircraft. When number three reached theapproximate point in space where the lead ele-ment of aircraft had rejoined, it began a very fastnegative G “barrel” roll to the right, completing a full roll in 3.5 seconds. Although the aircraft rollrate momentarily stopped at wings level, shortlythereafter the negative G continued and the roll to the right resumed. At about this time, with theaircraft in a negative G regime, the pilot ejected.The pilot sustained fatal injuries during the ejec-tion process. The aircraft continued to roll undernegative G, nosed down and impacted the groundbasically inverted at about 45 degrees of pitch andat a high velocity. The aircraft was destroyed onground impact.

The CF-188 is not equipped with a flight datarecorder (FDR) or a cockpit voice recorder (CVR).However, the aircraft was equipped with an AirCombat Manoeuvring Instrumentation (ACMI) pod, which recorded the aircraft’s flight path allthe way to impact. The data recovered from theACMI, although containing a limited number ofparameters, was used extensively to corroboratethe investigators’ research and analysis.

The cause of this accident could not be determinedwith certainty because of the lack of sufficientdata due to the absence of a crash worthy CVR/FDR

and the amount of destruction sustained by the aircraft upon impact. The investigation teambelieves the accident flight profile was created bya flight control malfunction of the left horizontalstabilator which abruptly deflected to a full trail-ing edge down position, sending the aircraft intoa violent, high negative G barrel roll to the right.It is believed the pilot was able to momentarilystop the aircraft’s rolling motion near wings level,however, as described above, by the time the ejection was initiated, the aircraft had resumedthe negative G roll to the right.

The pilot was fatally injured during the ejectionsequence. A number of deficiencies were revealedwith the CF-188 escape system, both in terms ofsystem limitations, as well as training and proce-dures used by operators. The escape system isnow undergoing a modernization program.

The preventive measures and recommendationsfor this accident include pilot checklist and train-ing amendments, acquiring an FDR/CVR system,further recommendations for the escape systemmodernization, and Aircrew Life SupportEquipment upgrades. ◆


TYPE: SZ2-33A Schweizer C-GFMELOCATION: Picton, OntarioDATE: 31 July 2003

The standards instructor pilot (IP) and the AirCadet student were participating in the Central

Region Air Cadet Gliding School Program. Theflight was the student’s pre-solo check ride andrequired the student to fly the entire flight withminimal verbal input from the IP. Shortly after takeoff, a significant amount of slack developed in thetow-cable. The IP took control of the glider andafter a quick re-assessment of the situation, thepilot believed the potential existed to snap thecable, upset the tow-plane, or have the cable back-release from the glider. The IP elected to releasethe tow-cable at approximately 50 feet above thetreetops. The glider climbed to 100 feet at whichpoint the IP set up for an approach to the only use-able field amongst the departure-end trees. Justprior to touchdown, the glider’s left wing struck a large tree 12 feet above the ground. The glider

came to rest in an upright position on the ground,oriented 160 degrees to the left of its final flightpath. The student and IP exited the aircraft unin-jured and contacted an overhead tow-plane viaradio. The aircraft received “A” Category damage.

This accident was the result of a premature tow-roperelease due to a significant slack cable situationand subsequent landing in an unprepared alternatefield. The slack situation developed because thestudent pilot was allowed to place the glider in a precarious position. Finally, not all possible slackreduction techniques were utilized prior to releasingfrom the tow plane.

This accident was one of seven gliding accidents thatoccurred during the summer of 2003. This was anunusually high number of accidents for the Air CadetGliding Program. While it was recognized that thesafety record of this organization was excellent,this rate of accidents was still cause for significantconcern. Accordingly, a Glider Program Standardsand Evaluation Team (SET) was established in 2004 byComd 1 Cdn Air Div. This SET has rectified a numberof the problems identified. ◆

EPILOGUE

TYPE: SZ2-33 Schweizer C-FARDLOCATION: Trois-Rivières, QuebecDATE: 31 October 2004

Two gliders were re-positioned from the mainrunway at Trois-Rivières to a nearby grass strip

where gliding activities were to be conducted forthe day. A runway inspection of the grass strip wasnot conducted and the first glider was forced toland in the middle of the strip due to a puddle ofwater. Shortly after, the second glider was inboundfor landing and the launch control officer (LCO) feltpressured to remove the obstructing glider from thegrass strip. The LCO asked a nearby instructor pilot(IP) to take a student pilot (SP) for an instructionaltrip. The crew quickly completed the pre-flightinspection and launched in challenging wind con-ditions without conducting a pre-flight briefing.The launch was not manned by the required num-ber of personnel.

The SP flew the take off, and the IP initiated thecable release at 600 ft AGL on the upwind leg.During the downwind leg, the glider drifted towardsthe runway and the turn to base leg started late.The IP took control of the glider on the base leg as

the glider overshot the runway centerline to thesouth. The IP increased the angle of bank (AOB) to at least 45 degrees in an attempt to realign theaircraft with the runway. The glider then headedtowards nearby trees and the IP entered a left turnduring the final stages of landing. The aircraft’s left wing struck the ground first followed by thetail wheel, it then skidded along the grass for 30 meters prior to coming to rest.

The investigation focused on the procedures used atthe Trois-Rivières gliding site and on human factors.The cause of this accident was that the aircraft wasplaced in a position from which it could not belanded safely. The weather conditions at the timeof the accident were very challenging and the air-field environment at this particular landing stripleave few viable options to safely compensate forerrors in judgement.

Recommended safety actions included the use ofthis accident as a case study for cadet instructortraining and in the air cadet Human Performancein Aviation program. As well, the Eastern RegionGliding School has modified their local gliding procedures to include a full operations briefing at the grass strip prior to continuing with flyingoperations. It is also recommended that the ERGSreview their procedures when re-positioning thegliders from the main runway. ◆


EPILOGUE


TYPE: CF188933 HornetLOCATION: Tinker AFB,

Oklahoma, USA DATE: 13 January 2005

EPILOGUE

The Pilot in Command (PIC) and second pilotwere enroute from Cold Lake, Alberta, to Naval

Air Station Key West, Florida as part of an exercisedeployment. An enroute fuel stop was planned atTinker Air Force Base (AFB), Oklahoma. Approximately100 Nautical Miles (NM) from Tinker and at an alti-tude of 39,000 feet, the crew experienced indica-tions of right engine oil pressure fluctuations. Thechecklist items were actioned and the right enginewas shut down. The crew declared an emergencyand began their descent.

The crew planned for an arrested landing via avisual straight in approach to runway 12. Within 2 NM of touchdown and unable to visually identifythe Bak 12 arrestor cable on the runway, the PICdecided to land at the runway threshold. Just priorto touchdown, the aircraft’s arrestor hook caught

the E-5 arrestor gear in the undershoot area ofrunway 12, 70’ before the threshold. The aircraft’smain landing gear then touched down prior to therunway threshold. After encountering difficultywith directional control, the PIC used emergencybraking to bring the aircraft to a halt on runway12, 7500’ from the threshold. After conducting anormal shutdown, both pilots egressed uninjured.The aircraft sustained “D” category damage; the E-5arrestor cable and runway also sustained damage.

The Flight Safety Investigation revealed that the CF-188crew were unaware that the tail-hook touchdownpoint can be over 500 feet prior to the intended aim-point (depending on variables such as glide path angle, and angle of attack). Recommendationsinclude amending manuals to ensure aircrew areaware of the difference in touchdown points.

The engine oil pressure fluctuations were caused by a faulty connector which had failed due to acracked oil pressure transmitter bracket. False oilpressure indications have resulted in approximately15 single-engine landings over the past five years.Recommendations include a re-design of the trans-mitter bracket, and modifications to the inspectionprocedures. ◆

TYPE: CH12438 Sea KingLOCATION: 30 NM East of

Aalborg, DenmarkDATE: 02 February 2006

The five crewmembers onboard the Sea King helicopter were returning to Her Majesty’s

Canadian Ship ATHABASKAN after having com-pleted circuit training at Aarhus, Denmark, whenthe accident occurred. On completion of one radarcontrolled approach to the ATHABASKAN, thecrew commenced an overshoot and entered thevisual circuit to land. On short final, at approxi-mately 30 meters on the ATHABASKAN’s port quarter, the helicopter’s rear fuselage and tail rotor contacted the water. The helicopter pitchedforward, became airborne again, and began toyaw right. The helicopter then impacted the waterin a near level attitude and, while still yawingright, rolled left. Water flooded the helicopteralmost immediately as it rolled inverted. All fivecrewmembers then egressed and were recoveredto the ATHABASKAN by zodiac within approximately

FROM THE INVESTIGATOR15 minutes. Four crewmembers encountered diffi-culties while egressing the inverted helicopter. Onecrewmember received minor injuries. The aircraftsustained “A” category damage after sinking in 16 meters of water one hour after the accident.

The preliminary investigation has indicated thatthe helicopter suffered no mechanical problemprior to impact. The investigation will focus onAerospace Life Support Equipment and human factors. Human factors investigation is focused onhuman night vision capabilities and organizationalissues such as currency and training. ◆



TYPE: CU161009 SperwerLOCATION: Kandahar, AfghanistanDATE: 06 May 2006

FROM THE INVESTIGATOR

TYPE: CC130311 HerculesLOCATION: CFS Alert, NunavutDATE: 25 April 2006


The five crewmembers aboard the Hercules air-craft were arriving in Alert on a fuel re-supply

mission in support of Operation Boxtop. Followinga Radar Approach to runway 23 True, the aircraftlanded long and the crew experienced difficulty inmaintaining runway centreline control. Decelerationefforts were reduced while efforts to regain direc-

tional control were attempted. The aircraft departedthe end of the runway, coming to rest approxi-mately 80 feet beyond the runway threshold. There were no injuries and the aircraft sustained‘D’ catgegory damage.

The Alert runway was covered with hard-packedsnow and ice at the time of the incident and thecrew was authorized to conduct an overweightlanding. The preliminary investigation did notreveal any mechanical problems associated with the aircraft prior to runway departure. The investi -gation will focus on the human factors element of flying oper ations to include crew proficiency and training. ◆

The accident occurred during a day mission conducted in the vicinity of Kandahar Airfield

in support of Op ARCHER. During the recoveryphase of flight, the parachute failed to deploy. The air vehicle (AV) descended freely, impacted the ground at high speed and exploded. The AVwas consumed by post-impact fire and sustained ‘A’ category damage. There were no injuries.

The flight was without incident up to the recoveryphase at which point the parachute failed to deploy.The investigation will focus on areas associated withparachute system design and parachute rigging. ◆


TYPE: CH149914 CormorantLOCATION: Chedabucto Bay,

near Canso, Nova ScotiaDATE: 13 July 2006


The accident involved a Cormorant Search andRescue (SAR) helicopter with a crew of seven.

The crew had assumed SAR standby duties and wasauthorized to conduct a training mission to practicenight boat hoists from the fishing vessel Four SistersNo. 1, a member of the Canadian Coast GuardAuxiliary. The cockpit crew consisted of a co-pilotin the left pilot seat, a pilot acting as AircraftCommander (AAC) in the right pilot seat and apilot who was the actual Aircraft Commander (AC)seated in the cockpit jump seat. The remainder ofthe crew occupied the cabin area. They comprisedof a Flight Engineer (FE), a Flight Engineer undertraining (FEUT), a SAR Tech Team Lead (SAR TechTL) and a SAR Tech Team Member (SAR Tech TM).

The crew departed Greenwood, NS at 2120L hrsand completed an uneventful transit to the PortHawkesbury, NS airport, where they stopped toconduct a required tail-rotor inspection. While onthe ground in Port Hawkesbury, the crew contactedFour Sisters No. 1 to confirm that the weather inthe area was suitable for the training scenario. The Captain of the Four Sisters No. 1 stated thatthe weather was clear, visibility was good and thewater was calm.

The aircraft departed Port Hawkesbury just beforemidnight on 12 July 2006 to rendezvous with theFour Sisters No. 1 at approximately 2 nautical miles

(NM) north of Canso, NS on Chedabucto Bay. Afterlocating the ship, the helicopter used the “Over WaterTransition Down” procedure and proceeded to the“rest” position, which is 100 ft above the water anda safe distance from the ship just off the hoistingposition from which the crew would start the boathoisting procedure.

At this point, the helicopter descended to 60 feetand the AC directed the flying pilot to go-around.The pilot acknowledged the go-around commandand initiated the go-around procedure. During theovershoot attempt, the helicopter entered a nose-low attitude and seconds later the aircraft impactedthe water at approx 30 to 50 knots in an 18 degreenose-down attitude with maximum torque beingdeveloped by the main rotor. Upon water impact,the front portion of the aircraft was destroyed whilethe cabin area aft of the forward part of the cargodoor remained relatively intact; the aircraft immedi-ately filled with water and rolled inverted. The crewof Four Sisters No. 1 made a “Mayday” call atapproximately 0030L hrs 13 July 2006. The aircraft sustained “A” category damage.

The three pilots and the SAR Tech TL were injured but survived the crash. The two flight engineers andthe SAR Tech TM were unable to egress the aircraftand did not survive.

No pertinent technical deficiencies have been discovered to date and the investigation is focussingon environmental and human factors. Several humanfactors need to be further examined including: proficiency, crew resource management, situationalawareness, crew pairing, use of night vision gogglesand organizational issues such as currency and training. Additionally, several Aviation Life SupportEquipment and egress issues will be investigated. ◆

TYPE: SZ2-33A Schweizer C-FACYLOCATION: Valcartier, QuebecDATE: 10 September 2006


The accident glider pilot was participating in theAir Cadet fall familiarization gliding program.

The cadet had recently graduated from the summerAir Cadet Gliding Program and was in the processof building up gliding time. Runway 04 is dividedinto two landing lanes with lane 1 being the leftlane (near the trees). The gliders were landing onlane 1 of runway 04.

On the day of the accident the pilot had alreadyflown three dual trips and seven solo trips. The accident occurred on the eighth solo flight ofthe day. The aero-tow and upper air work of theaccident flight were uneventful. On final approachthe pilot encountered a left crosswind whichrequired the application of a sideslip (left wingdown with application of right rudder) to maintain

the centre-line of the runway. The left crosswindabruptly ceased as the glider descended below the height of the trees that line the left side of the runway. This caused the glider to drift lefttowards the forested area and lose airspeed. The glider also encountered some downdrafts. The pilot attempted to correct back to the runwaycentre-line, however, the glider’s left wing con-tacted some trees at 23 feet above ground level.The glider pivoted 90 degrees to the left and fell almost vertically. The pilot sufferred seriousinjuries. The glider sustained ‘B’ category damage.

The investigation is focussing on the proximity ofthe trees to the landing area and the localizedwind shear phenomenon that is well known byValcartier pilots. The proximity of the trees to thelanding area allows for only 18 feet of clearancebetween the glider’s wingtip and the trees whenlanding on lane 1. The condition which is conduciveto the development of wind shear is a left crosswindon runway 04, or a right crosswind on runway 22.

Immediate preventive measures include moving the main landing area to lane 2 which is furtherfrom the tree line. All pilots will be briefed on thelocal wind shear phenomenon, and this informa-tion will included in the Regional Flying Orders. ◆



For Professionalism

For Commendable Performance in Flight Safety

CORPORAL LENA WAGNER

In March 2004, while conducting preventativesecond-line maintenance on a new modernizedCF-188 Hornet control stick grip, Corporal Wagnernoticed that the internal Electro-MagneticInterference (EMI) shielding was not within spec-ifications. She repaired the unit and returned itto service. Within a couple of weeks she discov-ered the same deficiencies on a second stick grip.

Concerned that there may be similar defectswith the remainder of the fleet’s modernizedstick grips, she proactively drew two additionalunits from supply in order to prove or disproveher concern. Indeed, both of these units had thesame defects. Corporal Wagner immediatelyquarantined the stick grips and briefed her chainof command. An Operational Restriction of allmodernized CF-188 aircraft was initiated pend-ing the findings of a Special Inspection (SI).

Sacrificing several personal commitments,Corporal Wagner worked diligently over a two-week period to conduct the SI. She discovered,recorded, and rectified defects found on 100% of the 40 modernized stick grips. Unserviceableconditions included improper EMI shielding,heavy internal FOD from previous maintenance

actions and/orunserviceableswitches. Hadthese defectsgone unno-ticed therecould havebeen seriousramificationssuch as, pre-mature releaseof selectedand armedweapons,inadvertent engagement of nose wheel steering,or adverse control inputs to the longitudinal andlateral aircraft trim actuators. With a Hornet con-ducting ops at low altitude the last of these couldhave lead to uncommanded roll with potentiallyfatal consequences.

Corporal Wagner’s attention to detail, foresightand dedication prevented a variety of stick gripdefects, in modernized CF-188s, from becoming a serious aircraft or weapons accident. ◆

Corporal Lena Wagner is an avionics technician serving with 1 Air Maintenance Squadron, 4 Wing Cold Lake.

MASTER CORPORAL DAVE REES During a Standing NATO Maritime Groupdeployment on HMCS Halifax in November 2005, Master Corporal Rees was replacing a main gearbox high-speed shaft input seal on aSea King when he noticed metal filings in thearea of the rotor brake assembly. Investigatingfurther, he found the assembly mounting nutsloose allowing the rotor brake assembly to leanagainst the rotor brake disc. He also found thatthe brake lining puck in the left-hand brakehousing was completely worn away, rendering it unserviceable and extremely dangerous.

Master Corporal Rees’ attention to detail, initia-tive and awareness in finding and repairing a faultin an area he was not required to inspect pre-vented a potential serious in-flight emergency. ◆

Master Corporal Dave Rees is an aviation technician serving with 423 Maritime Helicopter Squadron, 12 Wing Shearwater.

For Professionalism



MASTER CORPORAL DENIS CLOUTIER

While conducting a25-hour 30-dayinspection on Griffon146408, MasterCorporal Cloutier wasexamining the mainrotor head and flightcontrols system whenhe noticed that bothdrive links were justslightly out of posi-tion. Upon closerinvestigation, heobserved that bothdrive link washerswere actually missing.These washers aligneach of the drivelinks and prevent thedrive link-bearingend from wearinginto the swashplate.

In this case, due to the damage, one on the twodrive links had to be completely replaced.

The ensuing investigation revealed that thesewashers had been missing since the completionof the 2500-hour inspection, 210 operatinghours ago. During that time the aircraft hadundergone two separate 100-hour inspections,many 25-hour/30-day inspections and untold pre-flights without the fault being detected.Because the drive links have a normal operatinglife of 5000 hours it is probable that the deterio-ration of the bearings would have progressedunnoticed for some time.

Had Master Corporal Cloutier not taken theextra time to investigate this slight anomaly, and uncover the missing parts, the continuingdamage to the drive links may have progressedsufficiently to lead to a catastrophic flight con-trol failure with equally catastrophic results foraircraft and crew. ◆

Master Corporal Denis Cloutier is an aviation technicianwith 408 Tactical Helicopter Squadron, Canadian ForcesBase Edmonton.

MASTER CORPORAL STEPHEN CHAPPELL

Master Corporal Chappell was performing a 25-hour/30-day inspection on a Griffon when he noticed a very small and faint, dark spot on a large wire bundle concealed deep within thenose compartment. The wire bundle is locatedbehind the cockpit console and is barely visiblebehind numerous other components.

In order to conduct a more detailed investiga-tion, Master Corporal Chappell removed most of the components in the mid-electronics shelf.Upon reaching the area of concern, it becameapparent that the spot was the result of severalwires having rubbed through their protectiveshielding and having subsequently arced on anadjacent control box. This arcing could easilyhave caused an electrical fire in an area notaccessible to the aircrew while in flight.

The combination of Master Corporal Chappell’skeen eye, attention to detail and diligence,resulted in the discovery and repair of a significant

flight safety hazard that, unfound, would havejeopardized the safety of the aircraft and crew. ◆

Master Corporal Stephen Chappell is an avionics technician serving with 408 Tactical Helicopter Squadron, Canadian Forces Base Edmonton.

CORPORAL TROY GRAHAM

While deployed to 443 Maritime HelicopterSquadron to carry out a recertification of theNon-Destructive Testing (NDT) Operators forUltrasonic Inspections on the CH-124 Sea King,Cpl Graham was notified that two additionalindividuals required recertification in LiquidPenetrant Inspections (LPI) prior to a HELAIRDETdeployment to sea. As this was not part of theinitial request, Cpl Graham did not bring thenecessary equipment and resources to carry thisout but quickly ascertained that a Squadronemploying Sea King NDT operators should haveall the necessary equipment to carry out therequested extra training. While setting up for theLiquid Penetrant training, Cpl Graham noticedthat a vital piece of test equipment, a Radiometer,was not a part of the resources available at theSquadron. A radiometer is utilized to verify thatthe Ultraviolet Lamp meets the current writtenstandards prior to an inspection being carried out.Cpl Graham immediately ceased training until theappropriate test equipment could be acquired,as this is an essential quality control step prior tocarrying out any LPI examination. Cpl Grahamalso realized that the inspections being carriedout at that unit were not in compliance with thewritten procedures, as the serviceability of theUltraviolet Lamps could not be verified withoutthis type of meter. Cpl Graham provided 443 Sqn


MASTER CORPORAL HORST HENSEL

Master Corporal Hensel was assigned to assistwith a 600-hour inspection on a Griffon helicopterin order to complete his pre-type training courserequirements. Not having previous rotary-wingexperience he often used his free time to walk-around the helicopter to increase his familiarityand type knowledge.

During one of these walk-arounds MasterCorporal Hensel perceived a problem that heimmediately reported to the snags desk coordi-nator. Ten feet above the ground, the tail rotorretaining nut lock did not appear locked down.This nut is less than two inches in diameter andits locks are only one-eighth inch indentations.On inspection, the tail rotor retaining nut lockwas indeed not secure. Records showed that thetail rotor assembly had been installed, checked,independently checked and pre-flight checked.The aircraft had been ground run and was beingprepared for flight. Had this situation gone

unnoticed the retaining nut could have backedoff creating the potential for a failure or eventhe complete loss of the tail rotor.

A potential for catastrophe was avertedthrough the attention to detail, dedication,professionalism and overall airmanship ofMaster Corporal Hensel. ◆

Master Corporal Horst Hensel is an aviation technicianserving with 408 Tactical Helicopter Squadron,Canadian Forces Base Edmonton.

with all the necessary information to acquire aradiometer and later followed up on the statusof this equipment. The NDT Operators carry outLPI on secondary and tertiary structures and alsohold an additional qualification, for deployments,on a primary structure, the T-58 forward enginemount. This engine mount is critical and its fail-ure could cause catastrophic loss of the engineand aircraft.

Cpl Graham’s diligence in carrying out the extrasteps of verifying test equipment resources andamending local work processes has allowed theSquadron to comply with the inspection tech-niques standard. As this is a vital quality controlstep, and had Cpl Graham not intervened, therewas a definite potential that a critical crack mayhave gone undetected. ◆

Corporal Troy Graham is a non-destructive testing technician serving with 19 Air Maintenance Squadron, 19 Wing Comox.

For Professionalism



PRIVATE MYCAEL MCGRAW

While carrying out a Bcheck on Aurora 140103 on15 February 2006, PrivateMcGraw noticed somethingabnormal under and justright of the rear dinettewindow along the fuselageof the aircraft, approxi-mately seven feet above his head. He investigatedfurther and discovered thatthree rivets along one of

the main airframe formers had lifted away fromthe aircraft skin. Closer inspection on his partrevealed a white powdery substance bleedingfrom around the rivet holes. When he touchedthe rivets the heads fell off. The rivet heads had

been sheared for some time and had causedminor damage to the aircraft skin allowing corrosion to rapidly advance in that area. The adjacent rivets also required replacement.

Private McGraw immediately informed the maintenance control office of his findings,processed the proper reporting documentationand recommended that ACS Techs carry out amore extensive and in-depth inspection to see if there was sub-surface damage.

Private McGraw’s superior attention to detail during a B-check arrested an advancing threat tothe structural integrity of an aircraft. In detectingthe corrosion Private McGraw prevented moreextensive sub-surface damage and averted thepossibility of a catastrophic inflight failure. ◆

Private Mycael McGraw is an aviation technician servingwith 14 Air Maintenance Squadron, 14 Wing Greenwood.

CORPORAL KEVIN JOHNSON

While carrying out a routine teardown of a CC-115 Buffalo propeller for a leak at the propellerblade root, Corporal Johnson realized the guidesleeve within the dome assembly was loose. Theguide sleeve is normally held motionless duringthe removal of the pitch lock assembly and is notpart of the prescribed teardown inspection pro-cedures. Upon further inspection, he determinedthat the guide sleeve-locking ring, located in anobscure and hard to inspect area of the dome,had broken into multiple pieces, essentiallybecoming FOD in the dome assembly.

Because the Squadron does not carry out repairson the dome assembly, the Life Cycle MaintenanceManager was promptly informed of the situationand the propeller was shipped to third line forrepair and further investigation.

Through careful attention to detail and pride inwork, Corporal Johnson was able to detect a sig-nificant defect in the propeller dome assembly.This defect had the potential to cause an in-flightfailure of the component, possibly resulting in anengine shutdown. Corporal Johnson’s diligence,and professionalism is an essential ingredient in maintaining 442 Squadron’s search and rescue capability. ◆

Corporal Kevin Johnson is an aviation technician servingwith 442 Search and Rescue Squadron, 19 Wing Comox.

PRIVATE DAN STASIUK

In February 2006, eight Tutor aircraft had justlanded on runway 29L at 15 Wing Moose Jaw. They were rolling to exit the runway at taxiway“Bravo” when a Harvard aircraft, at the post for runway 29L, requested take-off clearance. The Harvard was told “negative, taxi to position andwait”, which the pilot read back. The aerodromecontroller was scanning the runway waiting for theremaining Tutors to exit. Private Stasiuk, the dutyground controller, noticed that the Harvard aircrafthad started its take-off roll and was already over1000 feet down the runway with three Tutors notyet exited. Private Stasiuk immediately alerted theAerodrome Controller who instructed the Harvardto abort the take-off in sufficient time to avert apotential disaster.

Though the runway was under the aerodromecontroller’s supervision, Private Stasiuk’s vigi-lance and scanning skills permitted a quick and

critical intervention likely saving aircraft andlives. Private Stasiuk’s actions represent theimportance of, and the need for, a teamapproach in ensuring aviation safety. ◆

Private Dan Stasiuk is a ground controller serving with 15 Wing Moose Jaw.

MASTER CORPORAL GARY KEIR

In November 2005, Master Corporal Keir waspaged for a search and rescue (SAR) mission withthe standby Hercules. On reviewing the AircraftBasic Weight Change Record form, he noticedthat there was a discrepancy in the aircraft’s basicindex number. Though assured correct by theservicing desk controller, Master Corporal Keircontinued to research the problem concludingthat the basic weight index was high comparedto the other 413 Squadron Hercules aircraft having roughly the same configuration.

Master Corporal Keir informed the aircraft com-mander of his findings. He quickly computed theaircraft’s weight and balance and found that thecentre of gravity (C of G) showed tail heavy. Ofnote, during SAR operations a partially completedweight and balance template is used in order tosave time. It is neither routine nor necessary forthe loadmaster to produce one for every mission.In fact, this particular aircraft had been flownseveral times prior to the error being found. Hethen searched maintenance record set changerecords and discovered that the third-line con-tractor had removed an item from compartment“O” but had not subtracted the moment figure.This explained the inflated basic index figure.

With the index starting point already high, hada fuel load of between 60,000 to 62,000 lbs beenrequired, the aircraft’s C of G would have beenpushed well outof limits for take-off. This wouldhave resulted in the aircrafthaving to bedefueled thusdelaying andjeopardizing the SAR missionresponse time.Master CorporalKeir’s experience,eye for detail andtenacity ensuredthe safety andeffectiveness of acritical search andrescue asset. ◆

Master CorporalGary Keir is flightengineer servingwith 413 Transportand RescueSquadron, 14 WingGreenwood.


For Professionalism



PRIVATE BERNIE WALTON

In October 2005, Private Walton, an Avionics SystemsTechnician was tasked to fix an unserviceable jumplight on Hercules CC130305. While performing the repair, he observed that part of the ramp railassembly was missing. Private Walton immediatelyalerted the Flight Engineer and his supervisors andthe scheduled mission was cancelled.

The pursuant flight safety investigation revealedthat the missing component had departed the air-craft due to a hung load during a heavy equipmentdrop conducted several days earlier. Private Walton’skeen observation had been missed by several air-crew and by more experienced technicians duringtheir checks. Private Walton got qualified as a jour-neyman only a few weeks before. Private Walton’sunfamiliarity with the aircraft structure, the obscurelocation of the damage, and his relative inexperi-ence makes his observation all the more remarkable.

This incident revealed the potential for serious personnel injury and equipment damage and

ultimately resulted in 8 Wing revisiting their heavyequipment drop procedures. Private Walton’s actionsundoubtedly averted further aircraft damage andpotentially the catastrophic loss of a CC-130 Hercules,aircrew lives and the lives of ground troops. ◆

Corporal Bernie Walton is an avionics systems technician deployed to Camp Mirage.

SERGEANT LOWELL O’KEEFE

In October 2005, Sergeant O’Keefe, a flight engi-neer (FE) on the CP-140 Aurora, was conductingan external pre-flight inspection when he noticeda crack on the nose wheel steering cylinder nut.The nose gear area had accumulated dust anddirt over time, masking this particular crack. Many technicians and FEs who had worked inand inspected this area had missed this defect.Although the FE external pre-flight inspection ofthe nose wheel area includes several steps, there is no mention to inspect the nose wheel cylinder.

Closer inspection revealed that the crack was 8 inches long. The nose wheel cylinder nut, normally installed with 800-1000 inch lbs oftorque, required very minimal force to beremoved indicating failure was likely imminent.

Following testing at the Quality Engineering TestEstablishment, it was determined that the fault inthe nut was a progressive fatigue crack that hadbeen present for quite some time. In light of thisincident, nose wheel steering cylinder nuts are nowinspected for fatigue cracks at 3rd line overhaul.

Sergeant O’Keefe’s thoroughness and keen eyeaverted a serious incident or even accident andthis discovery has enhanced the inspectionregime fleet wide. ◆

Sergeant Lowell O’Keefe is a flight engineer serving with 404 Squadron, 14 Wing Greenwood.

Tearsheet - Mission Planning Checklist (As Required Depending Upon Route) General: AIF, Aircraft & Aircrew Publications Customs (Notify and Verify Entry Requirements)

File Flight Plan (Acknowledgment Message) Aircraft Performance (Takeoff & Departure Data)

Weather: (In Accordance With B-GA-100, NA)

Departure Weather Destination Weather Alternate Weather (Departure Alternate, Arrival Alternate) Enroute Weather (Charts, Hazards, Volcanic Ash, ETP, PSR)

NOTAMs:

Aerodrome (Departure, Arrival, Departure & Arrival Alternate Aerodromes) Enroute (ARTCC, Airspace, RVSM, RNP, NAVAID, GPS, Volcanic Ash, etc.) Vendor Specific (FMS, Enroute Charts, IAPs) Change Notices (PCN for AP & GP, TCN for DoD IAP, CN for DoT/FAA IAP) Specials (Special Notices, Temporary Flight Restrictions, Attention Notices)

Diplomatic Clearances: (Verify for next and all subsequent flights)

General Info (Valid Times and Dates, Tail Number, Call Sign) Hazardous Cargo (Special DIPs, Special Routing) Departure (Departure DIP, Slot Time, Departure Window) Enroute (Overflight DIP, National Entry / Exit Waypoints and Times) Destination (Landing & Departure DIP, Arrival and Departure Window)

Route:

Slot Time Route Verification (Verify Flight Plan & Jetplan Route against charts) Preferred Routing (GPH 205, GPH 270, RAF Planning Handbook) National Procedures (GPH 270, Airspace Restrictions / Procedures, etc.)

Airfield Study: (Departure, Arrival, Alternate Aerodromes)

Restrictions (Flight Supplement(s), AP) PN, PPR, Operating Hours, Preferred Arrival / Departure Routing, Fuel, etc. Approach Review / Selection (DND, TC, DoD, Host Nation, Jeppesen, RCAP) NA, and Terrain Study (OPC, GNC, JNC, TPC, VNC, Sectional, VTA) RWY, TWY, Apron (Width, PLR, PCN, LCN, Condition, Obstacles, etc.) Security (Airport Security, Area Stability, etc.) Ethnic / Regional Customs & Behaviours (Alcohol, Attire, Behaviour, etc.) Local Knowledge (Airfield Data Reports, Airfield Familiarization Manual, etc.)

NOTAMs: NavCanada: http://www.flightplanning.navcanada.ca DoD: https://www.notams.jcs.mil FAA NTAP: http://www.faa.gov/NTAP/ GPS: http://www.navcen.uscg.gov/ADO/GpsActiveNanu.asp Jeppesen NavData: http://www.jeppesen.com/wlcs/index.jsp?section=resources&content=publications_notam.html Jeppesen Chart: http://www.jeppesen.com/wlcs/index.jsp?section=resources&content=publications_notam.html RAF: http://www.ais.org.uk/aes/login.jsp RAAF: http://www.airservicesaustralia.com/brief/ Canadian Ash: http://www.flightplanning.navcanada.ca Worldwide Ash: http://www.ssd.noaa.gov/VAAC/

WEATHER: NavCanada: http://www.flightplanning.navcanada.ca ADDS Icing Products for CONUS and S. Canada http://adds.aviationweather.noaa.gov/icing/ NOAA: http://aviationweather.gov U.S. ASOS: http://www.faa.gov/asos/index.htm U.S. Duats: http://www.duats.com Int’l Weather: http://www.aviationweatherbrief.com

PLANNING:

DND DFLIP http://1cadgeo.winnipeg.mil.ca/DFLIP/launch.pdf GPH 270, DoD IAP http://164.214.2.62/products/digitalaero/index.html FAA/DoT IAP http://www.naco.faa.gov/ CARs http://www.tc.gc.ca/CivilAviation/RegServ/affairs/cars/menu.htm TC AIM http://www.tc.gc.ca/CivilAviation/publications/tp14371/menu.htm FAA FARs http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgFAR.nsf/MainFrame?OpenFrameSet FAA AIM http://www.faa.gov/ATpubs/AIM/index.htm Jetplan http://www.jetplan.com/ FAA’s Int’l FIM http://www.faa.gov/ats/aat/ifim/ Host Nation Regs http://www.eurocontrol.int/ais/links/world.htm

NOTAMS: (As Required For Route Of Flight and Materials Used) Aerodrome Departure, Arrival, Departure & Arrival Alternates Enroute ARTCC, Airspace, RVSM, RNP, NAVAID, GPS, ASHTAM, etc. Vendor Specific (Jeppesen, Host Nation) FMS, Enroute Charts, IAPs Change Notices PCN for AP & GP, TCN for DoD IAP, CN for DoT/FAA IAP Specials / Miscellaneous Special Notices, Temporary Flight Restrictions, Attention Notices, FAA NTAP

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