CANADIAN FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FINAL REPORT FILE NUMBER: 1010-CC130323 (DFS 2-2) DATE OF REPORT: 12 November 2013 AIRCRAFT TYPE: CC130 - Hercules DATE/TIME: 21:34 UTC (17:34 local time) 27 October 2011 LOCATION: Near Igloolik, Nunavut CATEGORY: "A" Category Accident FSOMS NUMBER: 150074

This report was produced under authority of

the Minister of National Defence (MND) pursuant to section 4.2 of the Aeronautics Act, and in accordance with

A-GA-135-001/AA-001, Flight Safety for the Canadian Forces.

With the exception of Part 1, the contents of this report shall only be used for the purpose of accident prevention. This report was released

to the public under the authority of the Director of Flight Safety, National Defence Headquarters, pursuant to powers delegated to him

by the Minister of National Defence as the Airworthiness Investigative Authority for the Canadian Forces.

SYNOPSIS In response to a distress call from two men in a small open boat in Hecla Strait, northeast of Igloolik, Nunavut, a Search and Rescue (SAR) CC130 aircraft from Trenton, call-sign Rescue 323 (R-323) was dispatched, arriving on scene at 1505 hours (hrs) local time. After assessing the men to be hypothermic and unresponsive, three SAR Technicians (SAR Techs) jumped at 1734 hrs to provide assistance; weather conditions were extreme with 25-35 knot (kts) winds and 10-15 foot (ft) waves with sea ice present. The first SAR Tech landed in the water, swam to the raft that the men were by now in, and assisted them. The second SAR Tech and the SAR Tech Team Leader (TL) both landed separately in the water and, unable to swim to the raft, initiated their own survival procedures. Approximately four hrs later a CH149 helicopter hoisted the two men and the first two SAR Techs aboard unharmed. One hour later, the helicopter crew located the unresponsive body of the SAR Tech TL; he was floating free of his parachute harness face up with his life preserver inflated. The TL was flown to the Igloolik airport and transported to the Health Center where attempts to resuscitate him were unsuccessful. The circumstances surrounding the parachute jump were examined in order to improve the success of future open sea, cold water, parachute rescues. The investigation focussed on the TL’s descent, post-landing activities and plausible theories that led to his drowning. SAR Tech life support equipment and the regulations governing rescue activities, including pre-jump planning, safety activities and SAR Tech dispatch decision-making, were also examined. The investigation concluded that the TL drowned, although the exact drowning mechanism could not be identified. It is probable that with water entry into his constant wear flight suit, he became non-functional and unable to re-enter his raft. The inability to recognize the difficulties the SAR Tech team was to have getting to the men, the lack of established regulations and procedures concerning rescue swimming, and the selection of landing location were also causal. Contributing factors included gusty winds that affected the jumper exit point selection, parachute performance expectations and the lack of adequate equipment and training concerning SAR Tech activities on the water. The delegation of SAR risk management to the operator level without adequate regulation created the opportunity for an inappropriate jump decision. Finally, insufficient directives, training and experience of a rescue into arctic environmental conditions were also contributory to the mission’s outcome. The Royal Canadian Air Force (RCAF) has implemented 12 preventive measures, including amendments to operator manuals to address SAR Tech equipment and training. This report recommends an additional 35 preventive measures and further identifies 10 safety concerns aimed at improving current SAR Tech aviation life support and safety/rescue equipment as well as amending operating procedures and checklists.

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TABLE OF CONTENTS

1 FACTUAL INFORMATION........................................................................1

1.1 History of the Occurrence ..................................................................................1 1.2 Injury to Personnel............................................................................................10 1.3 Damage to Aircraft ............................................................................................10 1.4 Collateral Damage.............................................................................................10 1.5 Personnel Information ......................................................................................10 1.6 Aircraft Information...........................................................................................12 1.7 Meteorological Information ..............................................................................13 1.8 Aids to Navigation.............................................................................................14 1.9 Communications ...............................................................................................14 1.10 Aerodrome Information ....................................................................................16 1.11 Flight Recorders................................................................................................16 1.12 Wreckage and Impact Information...................................................................16 1.13 Medical ...............................................................................................................16 1.14 Fire, Explosives Devices, and Munitions ........................................................16 1.15 Survival Aspects ...............................................................................................17 1.16 Test and Research Activities ...........................................................................20 1.17 Organizational and Management Information ................................................21 1.18 Additional Information ......................................................................................21 1.19 Useful or Effective Investigation Techniques.................................................23

2 ANALYSIS ...............................................................................................24

2.1 General ...............................................................................................................24 2.2 TL’s Parachute Descent....................................................................................24 2.3 TL’s Post-Landing Activities ............................................................................25 2.4 SAR Tech Equipment........................................................................................30 2.5 Inter-Personnel Crew Gradient ........................................................................34 2.6 Safety Person Activities ...................................................................................35 2.7 Pre-Jump Planning............................................................................................35 2.8 Aircraft Captain’s SAR Tech Dispatch Decision ............................................47

3 CONCLUSIONS.......................................................................................48

3.1 Findings .............................................................................................................48 3.2 Cause..................................................................................................................55

4 PREVENTIVE MEASURES .....................................................................56

4.1 Preventive Measures Taken .............................................................................56 4.2 Preventive Measures Recommended..............................................................57 4.3 Other Safety Concerns .....................................................................................61 4.4 DFS Remarks .....................................................................................................62

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Annex A Jump Master Safety Check - Static Line.......................................A-1

Annex B Safety Person Duties and Responsibilities..................................B-1

Annex C Target and Recovery Locations Plot ............................................C-1

Annex D Pictures - Equipment......................................................................D-1

Annex E CWFS Operational Airworthiness Approval................................. E-1

Annex F Aircrew Information File................................................................. F-1

Annex G Equipment Found on TL at Recovery...........................................G-1

Annex H Mandatory Personal Equipment - In Water, Static Line ..............H-1

Annex I Abbreviations ....................................................................................I-1

1 FACTUAL INFORMATION

1.1 History of the Occurrence

1.1.1 On 26 October 2011, the day before the occurrence, two men in a small open aluminum boat became stranded in an ice-field approximately eight nautical miles (nm) southeast of Igloolik. By nightfall they had activated their SPOT1 beacon indicating their request for assistance.

1.1.2 In response, a CC130 aircraft, call sign Rescue 340 (R-340), from 435 Transport and Rescue Squadron (Sqn), Winnipeg, was tasked by the Joint Rescue Coordination Center (JRCC) Trenton to proceed to the Igloolik search area. It arrived on 27 October at 0424 hrs local2 over what the crew believed to be the distressed vessel that was identified by an intermittent light source. Under the light of para-flares a radio was dropped in the darkness, although the men failed to retrieve it. The boat appeared to be lodged in ice. At 0650 hrs R-340 proceeded to Iqaluit to refuel and then returned to the search area at 1150 hrs to find the boat had moved clear of the slushy ice-field into open water. Another radio and two separate Sea Raft Kit (SRK) bundles of two six-person rafts were dropped. The first two-bundle SRK landed long and drifted away from the boat while the second two-bundle SRK landed close to the boat; only one of the rafts inflated while the other remained in its container. The men in the boat retrieved the inflated raft and tied it to their boat. They were observed to pull the un-inflated SRK bundle into their boat.

1.1.3 R-340 established radio communication with the men who then reported that they were hungry, thirsty and sea sick. The men were informed that two rescue boats3 from their community would attempt to reach them. However, the crew of R-340 could not offer further assistance as their crew duty day limit would be reached upon landing. R-340 proceeded to Iqaluit as it was the closest suitable destination (1.5 hrs away). Though Hall Beach was closer, it was to become unsuitable for re-launch due to high winds. The seas at this time were estimated to be 10-15 ft swells with a long period between waves. The waves were not breaking but the wind, estimated to be 25-35 kts at the surface, caused some white foam to be visible from the air.

1.1.4 Meanwhile, anticipating the need for additional resources, the JRCC launched a CH149 helicopter, call sign R-915, from Gander at 0811 hrs and tasked a CC130 aircraft, call sign R-323 from 424 Transport and Rescue Sqn, Trenton, to support the rescue effort.

1 A SPOT device is an inexpensive personal satellite tracking device offered by SPOT LLC. With a subscription, the device transmits the GPS position of the user to a web based map. A special feature enables the user to signal a (distress) request for help. This request is processed through GEOS Travel Safety Group in Montgomery, Texas, where notification eventually reached the JRCC. 2 Both Igloolik and Trenton are in the same time zone, Greenwich Mean Time - 4 hrs. Igloolik local time is used throughout this report unless otherwise specified. 3 Community rescue boats: these boats were simple open boats without any specialized rescue fittings.

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Figure 1: Map showing the SAR location.

1.1.5 The ten man crew of R-323 was scheduled for SAR standby duty. The crew had planned to conduct local flying training4 over southern Ontario to include parachuting by their three SAR Techs. The crew arrived at the Sqn between 0600 and 0700 hrs. At 0830 hrs the JRCC air controller called the aircraft captain to discuss R-323’s new tasking to fly to Igloolik. The crew was then briefed by the aircraft captain about the mission change; the aircraft was further prepared and fuel was uploaded to 60,000 lbs.

1.1.6 R-323 departed Trenton at 0945 hrs. During the transit portion of the flight, the SAR Techs had a meal and conducted equipment familiarization training for the junior SAR Tech Team Member (TM1) because he was unqualified on the CC130

4 Regulations permit the standby aircraft to be airborne while holding standby duties.

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aircraft5. They also prepared equipment for their mission. By 1505 hrs the crew of R-323 were overhead and had visual contact with the two men in distress. The crew saw a six person raft tied to the aluminum boat and noted the men had remained in their boat. Some radio frequencies were tried unsuccessfully before they finally established radio communication with the younger man. By 1524 hrs the crew of R-323 had determined the men to be nauseated and distressed and that they had not accessed the supplies in the SRK. The SAR Techs were concerned about the men’s condition and commenced dressing for a possible jump. By 1607 hrs, R-323 advised the JRCC that the SAR Techs were requesting approval to jump because the men could no longer be contacted by radio and the SAR Techs believed that the men were becoming hypothermic.

1.1.7 Simultaneously, the JRCC and the Igloolik community had dispatched two rescue boats to provide assistance; however, the boats had limited communication equipment and their progress soon became a concern. The JRCC changed R-323’s tasking to search for these boats in the vicinity of Neerlonakto and Igloolik Islands. Prior to leaving the men in distress, a marine radio marker was dropped to make it easier to return to the men’s location. R-323 transited approximately 15 miles where, after a short search, a single rescue boat (boat 1) was discovered. R-323 dropped a radio to boat 1 and communication was established. The crew of R-323 learned the other rescue boat (boat 2) had returned due to engine trouble and that boat 1, which was at this point on Igloolik Island, would remain on shore as it was no longer able to provide assistance.

1.1.8 The crew of R-323 attempted to determine R-915’s estimated time of arrival (ETA) to the SAR area by querying the JRCC on their status. At 1514 hrs, R-915 passed a progress estimate to the JRCC saying that they would land to refuel at Cape Dorset at 1844 hrs. Cape Dorset was the third of three en-route fuel stops the helicopter was required to complete during the transit to the SAR area. Because R-323 and R-915 were not in direct communication with one another, it was not until 1933 hrs, two hrs after the SAR Techs had jumped, that R-915 provided the JRCC with an ETA to the Igloolik area of 2133 hrs.

1.1.9 At 1641 hrs, JRCC approved R-323’s request to dispatch its SAR Techs by parachute into the water. At 1645 hrs, R-323 had returned overhead the men in distress and found them lying unresponsive in the six person raft, whose roof had partially collapsed, and their boat missing.

1.1.10 Concurrently the SAR Techs, led by the SAR Tech Team Lead (TL), made final preparations for the parachute jump. The TL occupied the aircraft’s port side SAR window station and wore his 190C helmet connected to the intercom so he could hear radio transmissions and communicate with the aircraft captain. Throughout the day as opportunities permitted, the SAR Techs had inspected and packed their gear, such as 5 TM1 was qualified to parachute and function as a SAR Tech when clear of the aircraft on the ground/water; however, he had not yet completed airframe specific training and a check ride on the CC130 aircraft. This was a work-up flight to that achievement.

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individual Life Raft Survival Kits (LRSK), CSAR-7 (A) parachutes and Life Preserver Yoke (LPY) assemblies, a food and water bundle, a message bundle and other SRKs. They discussed the equipment they would require and then packed their SAR Personal Equipment Lowering System bags (SARPELS), their extender bags, B-25 kits6 and rifle kits. Their plan was to rendezvous in the raft together. The TL briefed everyone to land upwind of the raft because of the unknown sea currents and winds that could be up to 55 kts.

1.1.11 Each SAR Tech’s gear was inspected by a fellow SAR Tech as each layer was added. The TM1 and SAR Tech Team Member 2 (TM2) inspected one another as they got dressed. TM1 checked the TL’s parachute harness connections and pointed out the main zipper of his dry suit was open a few inches (common for ventilation purposes). Later, TM2 assisted and confirmed the routing of the TL’s LRSK lanyard to be underneath his parachute harness to the quick release coupling (Fastex buckle) of his LPY. TM2 carried out the Jump Master Safety Check – Static Line7 on the TL. While waiting for the jump, TM1 attempted to tighten the TL’s LRSK attachment straps; however, the TL seemed content with the fitting of the LRSK and he focussed on overall jump preparations. Communications between the three were often conducted without the use of the aircraft intercommunication system because the TM2’s communication radio cord was unserviceable and the numerous communication cords combined with the equipment positioned on the aircraft floor made it awkward to keep the radio cords untangled. Later, TM1’s and TM2’s wearing of dive hoods and Pro-Tec helmets precluded the use of the intercommunication system.

1.1.12 To determine a suitable jumper exit point (JEP), wind drift indicator streamers (WDI) and a C-8 smoke marker were released over the target. The aircraft was manoeuvred by the aircraft captain to keep the WDI/smoke in view as the markers descended to the water’s surface. The TL lost sight of the WDI/smoke as they descended; however, the aircraft captain was able to observe the WDI/smoke all the way to the surface to the satisfaction of the TL. The aircraft captain manoeuvred the aircraft to fly into wind over the WDI/smoke and to the target8. The TL could not pick out the WDI and smoke marker, so he relied upon the aircraft captain to calculate the JEP, which was determined to be 45 seconds upwind of the target.

1.1.13 To increase the visibility of the target, another pass was made at 450 ft to drop a marine locator marker (MLM). On this pass, the aircraft captain directed the non-flying pilot to update the target position in the flight management system (FMS). During this pattern, TM2 noticed an anomaly with his SARPELS bag release system buckle and he called a stop-drop to reset the fitting. The aircraft climbed and flew a left hand pattern at 2,000 ft above the water in preparation for the jump. TM2 was still not satisfied with his SARPELS release system buckle adjustment and he called another stop drop to have it adjusted to his liking. TM2 made a third stop drop call to have a

6 B-25 Kit: extra winter wear style clothing. 7 Jump Master Safety Check – Static Line: the check is reproduced at Annex A. 8 Target: the six person raft with the men onboard is referred to by the crew as the target.

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strap on his swim fins re-attached. At this point, the TL coordinated with the aircraft captain for a longer run-in of four to five miles for the actual jump.

1.1.14 The aircraft captain called over the intercom on the final run-in to the target at thirty seconds prior to the jump. The TL disconnected from the aircraft intercom but he did not remove the boom microphone from his helmet9. The loadmaster (LM) received a ten second call from the flight deck and he raised his arm to alert the SAR Techs. When the flight deck called again, the loadmaster lowered his arm and shouted “go.” TM1 looked back at the TL to confirm it was OK and then he jumped followed by the TM2 and the TL. Amateur video of the jump showed three similar exits from the aircraft with three normal main parachute canopies inflated and descending. The video showed TM1 and TM2 flying their parachutes facing away from behind the aircraft toward the target and the TL flying his parachute facing the aircraft until they disappeared from sight. The jump occurred at 1734 hrs, 40 minutes after sunset.

1.1.15 After the jump, the aircraft was manoeuvred on several low passes in an attempt to see the SAR Techs in the water. The three main parachute canopies were observed in the water. Two were closer to the target and the third was further away upwind. Later, a steady light and two flashing strobe lights were observed. Subsequently, one individual in a one person raft was observed; however, it was too dark to determine any more details from the sea’s surface.

1.1.16 After the jump, the crew of R-323 dropped a night illumination flare and a two-bundle SRK near the target in case they would be of assistance. Three crew members of R-323 heard the radio transmission “Rescue 323, Team Lead” followed by radio silence. The flight deck crew tried to raise the SAR Techs on their radios but never received a response. At 1810 hrs, R-323’s on-station fuel was depleted, causing them to proceed to Iqaluit. As R-323 departed the area, they received a single distress beacon signal on their radio. Later at 1838 hrs, the JRCC informed R-323 they were now receiving two distress beacon signals from the SAR area. The CC130 aircraft continued to Iqaluit and landed without further incident. The aircraft captain determined that they could not return to the SAR area due to insufficient time remaining in their crew day10.

1.1.17 TM1 Parachute Jump and Rescue

1.1.17.1 TM1’s parachute exit was normal. He jumped four seconds after the loadmaster lowered his arm and shouted “go”. After leaving the aircraft he re-evaluated the on-board plan made with his colleagues to land upwind of the target. Once he completed his under canopy checks, he turned downwind and flew toward the target for as long as possible. He delayed his final turn into wind for the water landing to increase his proximity to the target. He estimated that he was 200 metres (m) from the target on

9 Boom Microphone Removal: Standard Manoeuvre Manual (SMM) 60-130-2605 Ch2 11 January 2011 Chapter 4 Section 3 paragraph 1.a. (3) directs the boom microphone to be removed before the jump. 10 Had R-323 been able to return to the area, their duties would have included morale support, radio relay activities (had the SAR Tech radios been functional), ETA updates, weather updates, location assistance for R-915, dispatch of additional night illumination flares and observation of further SAR Techs signals.

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water contact. During his descent he was able to disconnect his reserve static line, belly band and chest strap, although, performing these tasks was more difficult because he wore his three finger (lobster) mitts. He prepared for the water landing by lowering his SARPELS bag on its tether.

1.1.17.2 During his descent, TM1 observed the TL manoeuvre his canopy by moving his arms and turning his head. The TL was observed to be approximately 500 ft above the water surface.

1.1.17.3 As TM1 descended, he noticed the waves were much larger than expected. In the water, he released his main canopy even though activating the release was difficult with his three finger mitts and he removed his leg straps, which were difficult to clear from the LRSK. He then temporarily disconnected his LRSK tether from his LPY in an effort to clear himself from the SARPELS tether line that had entangled him. Eventually he used his personal Spyderco knife to cut the line entangling his body and equipment.

1.1.17.4 Once clear of the entanglement, he began swimming towards the target, which he initially could not see although he approximated its position based on the setting sun’s rays. He towed his LRSK in its valise and kept his SARPELS bag against his chest. He felt that his progress through the water was very poor. Later, he devised a swim and rest rhythm to take advantage of the large swells. He rested on the uphill side of the wave and used the downhill side to surf and swim in the direction of his target. After some practice, he was able to see the MLM and the target and adjust his course as he crested each wave. At times he whistled then listened for a response from the other team members, which he never received. He never actuated his rear helmet mounted strobe light but he initially activated his head lamp and then extinguished it as it illuminated spray/haze that reduced his ability to see the MLM and raft. Eventually he reached the SRK raft with the two men inside. He estimated the MLM was 20-30 m from the raft.

1.1.17.5 TM1 secured his LRSK (raft was not-inflated), SARPELS bag and fins to the outside of the raft. He boarded the water-filled raft and determined that the men11

inside could not provide assistance. The raft was void of most supplies but he found the air pump and used it to inflate the floor and the underinflated overhead arch structure. He bailed the raft but could not locate the radio dropped by R-340.

1.1.17.6 TM1 activated his Survivor Locator Beacon (SLB) and returned it to his LPY front pocket. He assessed the men and commenced a routine to aid their survival with the limited equipment he carried. Routinely, he tried to engage the men in conversation and he physically jostled them to promote circulation. The younger man had bare feet. These were wrapped in heat blankets but very shortly became wet and ineffective. TM1 retrieved the “bivy” bag holding his B-25 kit from his SARPELS bag but found it wet. He tried to enlist the support of the older man to keep the raft flaps closed and the raft dry; however, the man was unable to provide assistance.

11 Henceforth the men were casualties and required assistance.

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1.1.17.7 The six person raft had four apron flaps for shelter that could be closed with hook and pile fasteners. The two upwind flaps could not be closed because freezing spray had fouled the hook and pile fasteners; consequently, it was difficult to keep the wind and water out. Several attempts to improvise closure were tried, all without success, including use of the raft’s rescue line, use of clips from the rifle bag, rolling the flaps together and manually holding them closed.

1.1.17.8 During the night, TM1 estimates the wind speed and wave size increased. At one point, the inflated floor made an explosive sound and became distorted. On two separate occasions, the older man and the TM1 were individually tossed outside the raft. Without his fins, TM1 reacted quickly to swim to and re-enter the raft. Throughout the evening the muscles in his shoulders ached but he felt otherwise well. His three finger mitts kept his hands functional. At one point he opened the zipper of his dry suit to relieve himself; this resulted in water entering his suit.

1.1.17.9 When R-915 appeared, TM1 fired two red flares from his flare gun. The men stirred and he briefed them about use of the rescue hoist. Initially a fast rope from the helicopter was hooked to the raft but this was abandoned when it became tangled. The young man was hoisted to the helicopter followed by the older man and lastly TM1. TM1 was recovered at 2144 hrs; he had been on the water for 4.2 hrs.

1.1.18 TM2 Parachute Jump and Rescue

1.1.18.1 TM2’s parachute jump was normal. He jumped six seconds after the loadmaster lowered his arm and shouted “go”. His canopy opened marginally later than the others; therefore, he was lower and felt he set the pattern to the target12. He completed his wind, control and manoeuvring checks and continued to the target by referencing the sun’s rays, the MLM and the six person raft. During the descent he disconnected his reserve static line, his chest strap and his belly band according to procedure. He extended his SARPELS bag on the tether and felt the waves reach up to him; this caused him to turn into wind and land sooner than he had intended, approximately 200 m upwind of the target. Just before water entry, he noticed TM1 pass 50 ft above him, proceeding closer to the target. TM1 believed he was also 200 m from the target, but likely he was much closer to the target than TM2.

1.1.18.2 After water entry, TM2 allowed his still-inflated parachute to drag him in the direction of the target for a short period before releasing it and settling in the water. He began to remove his parachute harness and to intentionally clear his leg straps from his LRSK. While doing this he became fouled by the SARPELS tether line which began to drag him down and inhibited his ability to swim, so he cut the line with the knife from his SARPELS. While doing so, he inadvertently cut the tether connecting his LRSK to his LPY. No longer connected to the LRSK, he inflated it for access. While focussed on his LRSK, his SARPELS bag floated 15-20 ft away and he quickly kicked his Rocket

12 The parachute is flown in a circuit to the target with a downwind, base and final leg. The lowest jumper is the least able to manoeuvre and therefore determines the route and direction for base and final leg.

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fins13 to swim to the gear and secure it.

1.1.18.3 TM2 could not see the target from the water surface so he swam to its approximate location by triangulating the MLM (until it expired), R-323’s track overhead and the sun’s setting rays. He was towing his SARPELS equipment bags in one hand and his one person raft in the other. At times he took breaks climbing into the raft to observe R-323 fly overhead. After 20-30 minutes of swimming TM2 realized that he was swimming against the one person life raft sea anchor that had inadvertently deployed. He also felt that the sea’s large waves and the bulkiness of his gear made progress difficult. As a result, he believed that he would not make the target, which he thought was drifting downwind faster than he could swim. Once the light disappeared from the horizon, he no longer had a reference to guide him to the target.

1.1.18.4 TM2’s focus now changed to one of personal survival as he climbed into his raft. He tethered his SARPELS bag to one side of his raft and his extender bag to the other and secured his fins outside the raft. He wanted to keep his fins on for immediate use in case he was expelled from the raft; however, the raft aprons were not large enough to accommodate this need. The raft had not fully inflated via the automatic CO2 cartridge, a normal occurrence to accommodate use in warmer climates, so he manually added air. Furthermore, he activated his head light and cut his Pro-Tec helmet chin strap to be able to reach and activate the rear-mounted strobe light. Removing his helmet significantly cooled his head so he replaced it over his dive hood despite its tight fit. Although TM2 retrieved his radio and called “Rescue 323, this is SAR Tech (surname)” the radio appeared to not function. After removing his SLB from his SARPELS bag he had difficulty activating it as his thumbs were cold (the switch must be held down for two seconds). Once activated, he placed the SLB in the front pocket of his LPY. He did not inflate his LPY as his dry suit provided him with enough flotation by itself.

1.1.18.5 TM2 wrapped the apron flaps of his one person raft around him. The hook and pile fastener on each flap initially connected together but when re-opened caused the threads securing the fastener tape to the apron cloth to fail. To compensate he rolled the two pieces together to obtain a partial closure though water still entered his raft. The raft’s 1.3 litre tan bailing bucket was too small to keep up with the water ingress caused by the wind and waves so he used a dry bag as a larger bailing bucket. He reported that continuously bailing his raft throughout the night kept him active and significantly improved his level of comfort. He never saw his team mates on the water but occasionally he saw a light. He overlooked his option to manually inflate the raft’s floor.

1.1.18.6 TM2 saw R-915’s search light approaching and he observed a red flare and the helicopter crew hoisting the men and TM1 aboard. At this sight, TM2 activated the night side and then the day (smoke) end of his AP day/night flare. His hands were

13 SAR Techs can use either the Super Rocket or the Force fins. Some SAR Techs can swim with better efficiency with the Force fins. All would agree that the Force fins are easier to walk off the CC130 Hercules ramp during parachute jumps.

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cold and ineffective. The outside of his five finger gloves were covered in ice. He used his teeth to activate the flare gun’s catch that allowed him to insert the magazine into the gun. He fired multiple red flares, some of which were miss-aimed and shot into the high waves around him. The raft’s movement and the steep pitch of the waves in the dark made a clear shot difficult to achieve. The helicopter flashed its light at him; however, he did not notice. When the helicopter and SAR Tech arrived overhead, TM2 slipped into the water, moved away from his raft, donned the horse collar, and was hoisted aboard. During his time in the raft he was periodically struck by chunks of ice. He was picked up at 2206 hrs, 4.5 hrs after his jump.

1.1.19 CH149 Helicopter R-915 Rescue Actions

1.1.19.1 R-915’s transit from Gander to the SAR area was via Goose Bay, Kuujjuaq and Cape Dorset. R-915 was receiving two SLB signals as it arrived in the SAR area at 2126 hrs. The crew flew to the SLB located furthest away where they recovered the men and TM1. They next proceeded 1,700 ft east-northeast and slightly downwind of TM1’s location to the second SLB and retrieved TM2. In an attempt to locate the TL the crew slowly searched upwind where they passed an empty six person raft (SRK) and then saw an object flashing in the water. A SAR Tech was lowered to the water and the object was determined to be a flashing strobe light and helmet. Faced with a night search for the TL, the crew returned to the empty six person raft to re-search the area in the direction from the raft to the helmet.

1.1.19.2 Continuing southbound past the helmet, R-915 entered an ice-field of 45% slush with pieces of ice up to five ft in diameter. The aircraft captain faintly observed a reflection under the water and slush. As the helicopter taxied closer, the outline of the TL face-up in the water was seen with water washing over him. A SAR Tech was lowered via the rescue hoist to recover the TL. The TL was found floating at a 45º angle with his dive hood in place on his head and his LPY inflated. His five finger neoprene gloves were on and he was wearing his constant wear flight suit (CWFS). His Force fins were attached to his feet. There was no other personal survival equipment observed near him. The TL was hoisted aboard the helicopter in a horse collar at 2245 hrs. He had been in the water 5.2 hrs. Later, it was determined his SLB was in a CWFS pocket with the rubber band around its antenna, as it was stored when selected from the CC130 aircraft. As well, it was determined that the Fastex buckle and cloth tab used to connect his one person life raft to his LPY via a tether, had been torn away (see picture at Annex D). The waves at the time of recovery were 20-30 ft high and R-915 recorded wind gusts up to 47 kts with the aircraft pitching up to 15º while hovering stationary in the wind.

1.1.19.3 The flight to Igloolik’s airport took approximately 15 minutes where an initial examination of the TL determined his vital signs were absent. He was transferred by vehicle to the Igloolik Health Centre where attempts to warm and resuscitate him were unsuccessful.

1.1.19.4 The two rescued men had received basic assistance during their flight such that they were able to walk from the helicopter to a waiting vehicle.

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1.2 Injury to Personnel

Injuries Crew Passengers Others Total

Fatal 1 0 0 1 Serious 0 0 0 0 Minor 0 0 0 0 Total 1 0 0 1

Table 1: Injuries to Personnel

1.3 Damage to Aircraft

1.3.1 Nil.

1.4 Collateral Damage

1.4.1 The investigation received no indication of any claim against the Crown.

1.5 Personnel Information

Aircraft Captain

LM / Safety

Person 1

ACSO / Safety

Person 2 TM1 TM2 TL

Medical valid valid valid valid valid valid Aircraft Check Rides valid valid valid not valid14 valid valid Time on Duty - day of15 10.5 11.5 11.5 11.5 11.5 11.5 Time on Duty last 48 hrs 16.5 16.5 16 22.5 23.5 20.5 Flying hrs last 24 hrs16 10.2 10.2 10.2 7.7 7.7 7.7 Flying hrs last 48 hrs 10.2 10.2 10.2 11.3 13.2 9.5 Flying hrs last 30 days 44.3 33.2 49.2 51.5 49.4 20.4 Flying hrs Grand Total 1324.5 6559.9 394.8 133.9 161.4 1354.2

Table 2: Personnel Information

TM1 TM2 TL

Total: Static Line Jumps 61 67 123 Total: Night Jumps 2 2 8 Total: Water Jumps17 3 2 8 Total : Jumps Last 30 Days 15 21 2 Grand Total: Jumps 115 119 269

Table 3: SAR Tech Jump Information

14 TM1 completed his check ride on the CH146 helicopter the day before the occurrence. This was an introductory sortie to CC130 (fixed wing) operations. While not qualified to function as a SAR Tech on the aircraft, he was qualified to parachute and function as a SAR Tech when clear of the aircraft on the ground/water. 15 Time on Duty - Day of: this is the time from arriving at work until the jumpers were dispatched. 16 Flying hrs Last 24 hrs: the sortie was 10.2 hrs long; however, the jumpers were dispatched at 7.7 hrs. 17 Total Water Jumps: includes this jump on the day of the accident.

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1.5.1 Aircraft Captain

1.5.1.1 The aircraft captain was on his first tour. He upgraded to SAR Aircraft Commander in March 2011, two years after joining 424 Sqn.

1.5.2 Load Master (LM) / Safety Person 1 (SP1)

1.5.2.1 The LM was qualified on the CC130 at 424 Sqn since 1998 except for a 10 month period. His last proficiency check-ride was successfully completed in February 2011. The LM functions as the SP1; duties are described at Annex B.

1.5.3 Air Combat Systems Officer (ACSO) / Safety Person 2 (SP2)

1.5.3.1 The ACSO successfully completed his CC130 operational training in the spring of 2011 and his category check ride in September 2011. During the dispatch of jumpers he assisted the LM and TL as an additional SP.

1.5.4 SAR Tech Team Members

1.5.4.1 Both SAR Tech team members were experienced personnel who had transferred into the SAR Tech trade after completing their QL5A training (SAR Tech Qualification) in June 2011. Over the summer they moved to the Trenton area and commenced qualification activities on their respective aircraft. TM1 was qualified on the CH146 helicopter where he recently participated in a calm water rescue jump. He had started qualification training on the CC130 aircraft. TM2 was qualified on the CC130 aircraft and was previously a qualified Jump Master. He completed one water jump on his QL5A course prior to this occurrence. Both had received training on the use of the LRSK while at the Canadian Forces School of Search and Rescue (CFSSAR) in Comox. The training did not include wearing an LRSK during the (single) water jump completed on course.

1.5.5 SAR Tech Lead (TL)

1.5.5.1 The TL joined the CF in August 1998 as an infantryman. He re-mustered as a SAR Tech and during his initial training at CFSSAR he completed one water jump and 61 land jumps, graduating in June 2004.

1.5.5.2 His first assignment was to 442 Transport and Rescue Sqn, Comox, where he completed six rescue missions (climber injuries and a poisoning) from the CH149 helicopter and three parachute rescue missions from the CC115 aircraft. He completed 175 parachute jumps by the end of this tour. In July 2008, he transferred to 439 Combat Support Sqn, Bagotville, operating from the CH146 helicopter. During this tour he completed two medical evacuation flights and one SAR mission involving a hoist let down to an aircraft accident with two fatalities. Although there was no operational requirement to maintain a parachute qualification at 439 Sqn, he completed 10 free-fall parachute jumps. In May 2010 he completed a parachute re-qualification course that included five free-fall and 17 static line jumps; this included one night and one water jump.

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1.5.5.3 In July 2010 he was transferred to 424 Sqn in Trenton on the CH146 helicopter and CC130 aircraft. In December 2010 he completed 18 jumps at a jump concentration camp. In May 2011 he participated in parachute testing of the new bush suit and new SARPELS equipment. One of the test jumps was a static line jump from 3,500 ft into fresh water wearing a Pro-Tec helmet, the CWFS18, LPY and new SARPELS bag. This jump was conducted without wearing the LRSK. The following month, he participated in a CH146 helicopter search for an overturned canoe where no-one was found.

1.5.5.4 In the six months prior to the occurrence, the TL completed 11 free-fall and 11 static-line jumps. His last water jump prior to the occurrence took place for training on 17 August 2011. His last static-line jump prior to the occurrence was with full equipment to a confined area on land, also on 17 August 2011. His total of 269 jumps, including the occurrence jump, comprised eight water jumps, eight night jumps, 146 free-fall jumps and 123 static-line jumps.

1.5.5.5 A review of the TL’s training file showed him to be qualified on both the CC130 aircraft and CH146 helicopter. Both supervisors and peers respected the TL for the professional approach he consistently displayed concerning his work. He was well regarded and believed to have always followed regulations. This was reflected in his appointment to standards, where he was responsible for conducting assessments of other SAR Techs. A review of his training records revealed his LRSK user familiarization form could not be found; however, alternate documentation indicated he completed LRSK training in September 2010.

1.6 Aircraft Information

1.6.1 The CC130 Hercules is a four-engine fixed-wing turboprop aircraft that can carry up to 78 combat troops. The Hercules has a maximum range of 4,000 nm and a cruising speed of 300 kts. On the day of the occurrence, the interior was configured for SAR operations to include the installation of a static line system, various equipment containers and special SAR door platforms for both the left and right para-troop door positions. Each SAR door platform is fitted with an observation seat for the use of the SAR Techs or spotters. A SAR door window can be put in position after arrival in the SAR area. This window is a floor to ceiling acrylic glass fixture that enhances visibility out of the aircraft. The aircraft is unable to pressurize when using the SAR door windows but is otherwise unrestricted from operations. The TL used the port SAR door window to observe outside the aircraft.

1.6.2 When conducting parachute operations the aircraft is configured with rear ramp door open, 50% flaps and landing lights on. The aircraft is flown at a speed of approximately 130 kts, adjusted for aircraft weight.

18 CWFS Use Authorization: An Operational Airworthiness Exclusion (OAEX) was granted by a message from 1 CAD (162049Z MAY 11 UNCLAS COMD 1164) to allow the CWFS to be worn with other test equipment during parachute operations for the period 9 May to 31 July 2011.

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1.7 Meteorological Information

1.7.1 Aviation Weather

1.7.1.1 The Igloolik airport is 22 nm southwest of the jump location. The Terminal Area Forecast (TAF) for Igloolik (CYGT) issued at 1534 hrs local time on 27 October was as follows:

TAF CYGT 271934Z 2719/2721 18025G35KT P6SM FEW010 OVC 040 TEMPO 2719/2721 4SM –SN BLSN OVC 010 RMK NXT FCST WILL BE ISSUED AT 281145Z

1.7.1.2 The aviation weather observations recorded at CYGT at 1600 hrs (2000Z) and 1700 hrs (2100Z) were as follow:

CYGT 272000Z 18030G35KT 5SM BLSN FEW010 OVC035 M08/M10 A2970 RMK SC1ST7 SLP064 SKY9X T10841098 CYGT 272100Z 18025G30 10SM DRSN FEW10 BKN040 M08/M09 A2970 REBLSN RMK SC1SC6 -8.0/-13.8/0/12 MEDIUM PACK LAST OBS/NXT OBS 281000Z SLP065 57009 SKY89 T10801090

1.7.1.3 At 1700 hrs the winds were from 180 degrees true, 25 gusting to 30 kts. The visibility was 10 statute miles in drifting snow with 1 to 2 eights clouds at 1,000 ft above aerodrome elevation and 5 to 6 eights clouds at 4,000 ft above aerodrome elevation. The temperature was minus 8 degrees Celsius (ºC) and the dew point was minus 9ºC. The Igloolik altimeter setting was 29.70 inches.

1.7.2 Marine Forecasts

1.7.2.1 Two marine forecasts were issued on Thursday, 27 October, one at 0530 hrs and the other at 1730 hrs (local time), as follow:

FQCN17 CWNT 270930 (0530 hrs local) MARINE FORECAST FOR SOUTHERN NUNAVUT ISSUED BY ENVIRONMENT CANADA AT 5:30 A.M. EDT THURSDAY 27 OCTOBER 2011 FOR TODAY TONIGHT AND FRIDAY.

IGLOOLIK. FREEZING SPRAY WARNING IN EFFECT. WIND SOUTH 20 KNOTS INCREASING TO 30 EARLY THIS MORNING THEN

DIMINISHING TO SOUTHWEST 20 FRIDAY EVENING. A FEW FLURRIES BEGINNING AFTER MIDNIGHT AND ENDING FRIDAY EVENING. VISIBILITY 1 MILE OR LESS IN FLURRIES. FREEZING SPRAY BEGINNING THIS MORNING AND ENDING AFTER IDNIGHT. TEMPERATURE MINUS 10 RISING TO ZERO FRIDAY AFTERNOON.

FQCN17 CWNT 272130 (1730 hrs local) MARINE FORECAST FOR SOUTHERN NUNAVUT ISSUED BY ENVIRONMENT CANADA

AT 5:30 P.M. EDT THURSDAY 27 OCTOBER 2011 FOR TONIGHT AND FRIDAY. IGLOOLIK. FREEZING SPRAY WARNING IN EFFECT.

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WIND SOUTH 30 KNOTS DIMINISHING TO SOUTHWEST 20 FRIDAY EVENING. PERIODS OF LIGHT SNOW BEGINNING BEFORE MORNING AND ENDING FRIDAY AFTERNOON. VISIBILITY 1 MILE OR LESS IN SNOW. FREEZING SPRAY ENDING AFTER MIDNIGHT. TEMPERATURE NEAR MINUS 1.

1.7.3 Actual Marine Conditions

1.7.3.1 At the time of the jump, 1734 hrs, wave swells were approximately 10-15 ft in height with a longer interval between crests. Ice pieces were visible but covered less than 5% of the sea’s surface. The closest significant ice field was approximately two miles to the south of the target.

1.7.3.2 When the SAR Techs were hoisted from the water the waves were 20-30 ft high. TM1 and TM2 were located in an area of water with ice infrequently present, some of which included pieces five ft across. The TL was recovered from an area of slush and ice covering approximately 45% of the local sea’s surface. The CH149 helicopter pitched up to 15º in the gusting winds and recorded wind speeds in the hover up to 47 kts.

1.7.3.3 No forecast or observation of sea temperature exists for this location; however, sea ice formed near the area overnight as recorded by Environment Canada. The formation of sea ice indicates a sea temperature near -1.8ºC.

1.7.4 Tide

1.7.4.1 The closest station with a published high and low tide prediction19 for the area was Igloolik. On the day of the occurrence, low tide was at 1433 hrs and high tide was at 2107 hrs after which the next low tide was on 28 October at 0320 hrs. The tables indicate the tide height fluctuated approximately eight ft.

1.7.5 Sunset

1.7.5.1 The sun set on 27 October at 1654 hrs local time. Civil twilight20 ended at 1800 hrs local time.

1.8 Aids to Navigation

1.8.1 Not Applicable.

1.9 Communications

1.9.1 General

1.9.1.1 The CH149 helicopter used an aircraft-installed satellite phone to

19 Tidal Prediction: see http://www.tides.gc.ca/ and reference Igloolik station #5295. 20 Civil Twilight: the time from sunset until the sun is 6º below the horizon. In this period there is often enough light for objects to be seen without artificial illumination.

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communicate with JRCC.

1.9.1.2 The CC130 aircraft does not have a satellite phone capability. Communication with the JRCC was conducted by HF radio phone patch where the quality of the connections was reported as relatively good.

1.9.1.3 Communication between the CC130 aircraft and the SAR Techs following their jump was conducted via VHF aircraft radio and portable handheld radio. Both the TL and TM2 jumped with a rechargeable battery Motorola XTS 5000R Model II radio, model H18KEF9PW6AN, for use on the ground and water. The H in the serial number indicates the radio is a ruggedized version, submersible to two meters for two hrs. TM1 jumped without a radio.

1.9.1.4 The TL’s radio was not recovered. TM2’s radio was recovered and analysed at the Quality Engineering Test Establishment (QETE) in Ottawa.

1.9.1.5 All three SAR Techs jumped with a waterproof personal survival locator beacon (SLB) that is sometimes called a personal locator beacon (PLB). The ProFIND SLB 1000-200 transmits a line of sight signal on 121.5 and 243.0 MHz for homing and a 406 MHz signal for reception by the COSPAS-SARSAT satellite system. This SLB transmits a GPS fix accurate to within 100 m within five minutes of activation. The SLBs in use on the night of the occurrence were activated by raising a protective shield and firmly pressing a narrow button for two seconds. An alternative model to the ProFIND 1000-200 is the ProFIND 1000-200RD. This model is identical except that it is activated by pulling a lanyard.

1.9.1.6 The SAR Techs carried a handheld day/night flare and a personal flare gun with magazine capable of firing red or green flares.

1.9.2 Applicable SAR Tech Communication Procedures

1.9.2.1 “When a SAR Tech team has been dropped to a crash site, the team leader shall establish communications with the aircraft as soon as possible and give the team’s own status21.” Signals to establish the condition of jumpers and the survivors in the event radio communication cannot be established are as follow: two green flares – jumpers all right; two red flares - jumpers require assistance; one green flare – survivors; and, one red flare – no survivors22.

1.9.2.2 Prior to jumping from the aircraft the TL advised the aircraft captain of a back-up procedure for signalling the status of the SAR Techs. The TL advised if one PLB signal is received, we are OK; if two PLB signals are received, we are in distress. This method of signalling is not referenced in any publication but is a word of mouth procedure familiar to some 424 Sqn SAR Techs.

21 Drop Zone Communications: as quoted from SMM Chapter 8 Section 1 Paragraph 5. 22 Flare Signals: SMM Chapter 8 Section 2 Paragraph 9.

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1.10 Aerodrome Information

1.10.1 Not Applicable.

1.11 Flight Recorders

1.11.1 The CC130 aircraft was equipped with a cockpit voice recorder (CVR) that recorded two hours of information only, overwriting previously recorded information that was older than two hours. The CC130 aircraft was also equipped with a Flight Data Recorder (FDR) that recorded 25 continuous hours of information. Both the CVR and FDR were sent to the National Research Council Recorder Playback Facility in Ottawa for downloading, verification and analysis. The FDR and CVR information along with testimony and amateur video from the back of the aircraft assisted with reconstructing the location of the target and the jumper exit point.

1.11.2 The CH149 helicopter (R-915) provided flight path data for analysis through its external satellite software tracking system. A plot of the target and SAR Tech recovery locations is depicted at Annex C.

1.12 Wreckage and Impact Information

1.12.1 Nil.

1.13 Medical

1.13.1 Toxicology specimens were collected from the crew of R-323 (less the SAR Techs) when they returned to Trenton, approximately 24 hrs after the occurrence. Toxicology specimens from the surviving SAR Techs were obtained in Igloolik 28 October 2011 (exact time not recorded at the civilian hospital) 18-20 hrs after the jump occurred. The TM1 and TM2 were uninjured and returned to flying status.

1.13.2 An autopsy of the TL was completed in Ottawa on 31 October 2011. Toxicological specimens were collected for analysis and sent to the Armed Forces Medical Examiner System (AFMES) at Dover Air Force Base (AFB), DE. The Coroner's report and the Pathologist's report list the cause of death as drowning.

1.13.3 Toxicology results from AFMES for the crew of R-323, including TM1, TM2 and the TL, revealed nothing contributory.

1.14 Fire, Explosives Devices, and Munitions

1.14.1 The aircraft deployed an LUU-2B/B flare for night illumination after the SAR Techs jumped; the standard burn time is five minutes. A C8 Signal Smoke Drift Indicator (SSDI) was deployed with the WDI streamers; it has a standard burn time of eight to 10 minutes and a fall speed of 20 feet per second (fps). Ten C2 Marine Locator Markers (MLMs) were deployed to make the target more visible by emitting a flame and white smoke; each had a standard burn time of 13.5-20 minutes. The typical deployment altitude for the MLM is 300 ft above water level and it usually lands within

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500 ft of the target.

1.15 Survival Aspects

1.15.1 CSAR-7 (A) Parachute Assembly Description

1.15.1.1 The CSAR-7 (A) parachute assembly is an integrated pack and harness assembly weighing approximately 45 lbs. Both the main and reserve canopies are worn on the back. The main canopy is a semi-elliptical, nine cell, ram air canopy that is tangerine in colour, except for cell number two (on the parachutist’s left) which is black. The canopy is steerable and equipped with trim tabs. Maximum deployment weight below the canopy is 375 lbs. Forward speed is rated at 16-24 kts. Rate of descent in full flight is 12-16 feet per second (f/s); with 50% brakes this is reduced to 7-12 f/s. On the day of the occurrence the main canopy was deployed by the 14 ft 8” long static line.

1.15.1.2 The harness assembly is made of 1 3/4 inch black nylon webbing. The front of the harness is composed of two main lift webs running vertically up the body. A horizontal crossing chest strap connects the two vertical lift web straps. At chest level, on each main lift web, are two SARPELS attachment rings. The rings are used to attach SAR equipment for use after landing. On each side of this harness, just below the armpit, is a V-ring that is used to attach the LRSK attachment strap ejector fasteners.

1.15.1.3 An operating feature of the CSAR-7 (A) parachute is its ability to be steered directly to the target. Under training wind limits, SAR Techs are able to take advantage of the parachute’s ability to manoeuvre and its ability to travel into wind when the wind is less than the maximum forward generated speed of the canopy. This feature is known as penetration ability. A SAR Tech’s ability to reach the target is maximized when he exits at a judicious altitude to judge the gliding performance of his canopy, has an accurately calculated JEP and the jump is conducted under zero wind conditions that provide him with the maximum penetration ability.

1.15.2 Life Preserver Yoke – SAR (LPY)

1.15.2.1 The LPY was evaluated for use by the Transport Operational Test and Evaluation Flight (TOTEF) in a report dated 281255Z February 2005. The LPY is required to be inspected every 180 days by a qualified technician. A review of the TL’s LPY showed it was not due for an inspection until February 2012. Canadian Forces Technical Order (CFTO) C-22-100-003/MF-001 Part 2 paragraph 3 says the individual to whom the LPY is issued shall carry out a visual inspection prior to and after each time the LPY is worn. Paragraph 3 c specifically directs the user to check the security of all webbing and anchor strap assemblies. LPYs in use at the time of the occurrence did not have an individual serial number.

1.15.2.2 The SAR Tech life preserver has two 16 gram CO2 cartridges that are activated separately via beaded handles. The LPY is equipped with an oral inflation tube and an over-pressure relief valve. An accessory pocket is located on the front with a one-person life raft mating lanyard attachment. A yellow (webbing) quick release

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coupling (male Fastex buckle) is attached to the vest via a larks head loop through a black cloth (webbing) tab sewn to the lower neck opening area of the vest. The cloth tab is attached with black stitches in a box X pattern to the black backing material of the LPY. Each stitch when new has an average breaking strength of 10.9 lbs. There is no stated design strength specification for the LRSK to LPY cloth attachment tab.

1.15.2.3 An informal survey of SAR Tech users indicates the LPY is unlikely to be inflated prior to or after water entry due to the inherent buoyancy of their dry suit and other equipment. Should buoyancy be required, oral inflation is the likely method to be used because the amount of inflation is controlled and this saves the cartridges for an instantaneous unanticipated requirement. The survey found that inflation by the CO2 cartridges would be undertaken only in a state of urgency.

1.15.2.4 Examination of the TL’s LPY showed that both CO2 cartridges were discharged and the LRSK to LPY quick release coupling along with the black cloth attachment tab was missing. Of particular note, the backing cloth where the cloth tab was attached was undamaged.

1.15.3 Life Raft Survival Kit (LRSK)

1.15.3.1 The LRSK is comprised of a valise containing a one person life-raft, survival equipment and a flotation pad. The life-raft is tethered to the user via a six ft lanyard that also functions as a means to activate a CO2 cartridge that inflates the raft. The LRSK is designed to inflate the one person raft as the parachute harness is removed in the water.

1.15.3.2 An LRSK was involved in an occurrence in May 2009 in which the valise was not held securely below the parachute pack tray. Consequently, in July 2009, all SAR units were prohibited from attaching the LRSK to the parachute below the parachute pack tray. The incident was addressed by the addition of a container leg strap where the parachute leg straps pass through a strap on the LRSK case. 1 Canadian Air Division (1 CAD) issued provisional approval for operational and training use of the modified LRSK with the CSAR-7 (A) parachute on 18 October 2010 via 181541Z OCT 10 UNCLAS COMD 1086 message. Final operational airworthiness clearance (OAC) was issued via message 282014Z OCT 11 UNCLAS COMD 1329.

1.15.3.3 Both messages instructed SAR units to review and complete training procedures about how to wear the modified LRSK as identified in the 01 August 2010 TRSET Website SAR Tech LRSK User Guide.

1.15.4 One Person Life Raft

1.15.4.1 The one person life raft assembly consists of an integrated single buoyancy chamber with a pneumatic inflatable floor, two inflation tubes, protective hood and apron, five handles, a water pocket, a charged CO2 cylinder and a sea anchor. The raft is inflated by activating the CO2 cylinder by pulling the tether from the LRSK. The sea anchor is made of nylon and is 12 inches in diameter and attaches to the raft via a 25 ft bridle so that the user faces downwind. The protective hood and apron

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closes with a hook and pile fastener system that is designed to offer anti-exposure protection. The raft is equipped with either a 1.3 or 1.6 litre collapsible bailing bucket and the raft floor must be inflated manually. The raft is designed to under-inflate to preclude over-inflation and catastrophic failure in warm climatic conditions. A warning in the technical instructions states, “over-inflating the floor can make the raft float high, reducing its stability and increasing its chances of capsizing in rough seas.” (See picture at Annex D.)

1.15.5 Sea Rescue Kit (SRK)

1.15.5.1 The SRK system replaced the Survival Kit Air Droppable (SKAD) and received OAC in April 2006. Prior to deployment, the SRK looks similar to an orange style duffle bag and weighs approximately 90 lbs. Upon proper deployment, a pin preventing inflation is removed from the water activation device. Once water surrounds the water activation device, a capsule dissolves allowing a striker to open a CO2 cartridge causing the six person raft to inflate. Multiple SRKs may be linked together via 280 ft links of floating rope.

1.15.5.2 Equipment in the SRK includes a hook knife, flashlight, fleece socks, fleece mitts, fleece balaclava, fleece jackets, first aid kit, signalling mirror, 12 x 125 ml water sachets, rations, whistle, lip balm, thermal blanket, sunscreen, water bags, bellows bag, sponge, hand pump, leak stoppers and a SAR emergency radio. The SRK requires an inspection every six months.

1.15.5.3 The six person life raft is composed of twin superimposed circular buoyancy chambers, an inflatable boarding ramp, a footstep ladder, a manually inflated floor and an automatically erected arch structure and canopy. It has four water ballast pockets, a sea anchor and an automatically activated internal and external light. The six person raft is 88 inches in diameter and 46 inches high. The raft is designed to under-inflate to preclude over-inflation and catastrophic failure in warm climatic conditions. A warning in the technical instructions also states, “over inflating the floor can make the raft float high, reducing its stability and increasing its chances of capsizing in rough seas.”

1.15.6 Dry Suits

1.15.6.1 TM1 and TM2 wore Whites dry suits, proper suits for the chosen environment, made of water impermeable fabric with traditional latex neck and wrist seals. The TL had his Whites dry suit onboard the aircraft but he wore a very different suit, the Mustang MSD575, referred to by the CF as the Constant Wear Flight Suit.

1.15.6.2 TM1 and TM2’s Whites dry suits were determined to be undamaged following the occurrence.

1.15.6.3 These dry suits are to be inspected by the SAR Tech prior to and after use. There is no CF-prescribed inspection cycle or periodic leak testing requirement and there are no maintenance records kept concerning when inspections are to be completed or if rectifications have been undertaken. This is in contrast to dry or

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immersion suits that are worn for safety purposes by other aircrew, such as pilots, flight engineers, and airborne electronic sensor operators, for unplanned water landings or crashes; these are required to be maintained in accordance with CF-prescribed technical orders and they have inspection cycles, inspection criteria and records that are kept of all maintenance performed.

1.15.7 Constant Wear Flight Suit (CWFS)

1.15.7.1 The Mustang MSD575 CWFS received OAC for use in message 042033Z AUG 10 UNCLAS COMD 1025 (see Annex E). The CWFS was approved for use by SAR Techs at 424 Sqn when conducting operations, other than diving, from the CH146 helicopter. The CWFS was designed to be worn during flight so a SAR Tech would not have to change from his usual cloth flight suit to an ensemble appropriate for a marine environment. The CWFS has neoprene wrist seals and an adjustable neck seal for comfort that requires the user to tighten prior to water entry. The manufacturer has designed specific insulating undergarments for wear under this suit to maximize thermal protection; however, the CF did not procure these items.

1.15.7.2 A different dry suit in CF use, called the MSF751 Constant Wear Immersion Suit (CWIS), has a similar style of wrist seal and neck seal system used on the CWFS. The MSF751 (CWIS) received provisional OAC for use on the CH124, CH146 and CH149 helicopter in message 312052Z OCT 11 UNCLAS COMD1333. In 2005, testing of the CWIS wrist and neck seals revealed that they allowed 350 millilitres (ml) of water per hour into the suit if the liner was dry and 280 ml of water per hour if it was wet.

1.15.7.3 After the TL was recovered, the CFWS was cut from the neck to the wrists and down to the navel area to facilitate the resuscitation efforts. His undergarments were found to be wet throughout and completely frozen from the chest to the navel area. A significant yet unquantified amount of pooled water was observed in the CWFS as the suit was cut away. The TL’s CWFS was shipped to the Defence Research and Development Canada (DRDC), Toronto, for analysis and then to QETE for further tests.

1.15.7.4 The CWFS is to be inspected by the SAR Tech prior to and after use. Like the White’s dry suit, there is no CF-prescribed inspection cycle or leak testing requirement and there are no maintenance records kept on inspections or rectifications undertaken for the CWFS. This is in contrast to other aircrew dry or immersion suits that are maintained in accordance with CF-prescribed technical orders and have inspection cycles, inspection criteria and records kept of all maintenance performed.

1.15.7.5 For a list of the TL’s equipment as found at recovery, see Annex G.

1.16 Test and Research Activities

1.16.1 The TL’s SLB was tested and found to be serviceable. During testing of the other SLBs, one that functioned on the night of the occurrence was found to no longer broadcast a receivable signal.

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1.16.2 The TL’s CWFS and LPY were analysed by QETE together with DRDC.

1.16.3 QETE was also tasked to conduct performance testing on TM2’s portable handheld radio, Motorola XTS 5000R Model II radio.

1.17 Organizational and Management Information

1.17.1 Canada is divided into three Search and Rescue Regions (SRR), each with its own JRCC. Co-located with JRCC Trenton is the Canadian Mission Control Centre (CMCC), the focal point for the receipt of all distress beacon messages from national and international sources in accordance with procedures prescribed in national agreements. CMCC alerts the appropriate JRCC with any active beacons that are occurring within their applicable SRR. The resolution of a SAR incident commences with the receipt of the initial alert and continues with the JRCC’s effective co-ordination of SAR unit activity.

1.17.2 The primary SAR Sqns located within the Trenton SAR Region (for the Igloolik area) are 435 Sqn at Winnipeg and 424 Sqn at Trenton. 424 Sqn is composed of flight crews (including SAR Techs), administrative staff and maintenance personnel to operate both the CC130 aircraft and CH146 helicopter. Virtually any CF air asset can be tasked for SAR. This is why R-915 from 103 Search and Rescue Sqn, Gander, was tasked by JRCC Trenton even though it was a JRCC Halifax resource.

1.17.3 The authority to deploy the SAR Techs by parachute rests with three persons, each with increasing authority to deny the jump. Initially, the TL on board the aircraft must request authority to jump when he believes it is the best course of action. Next, the aircraft captain must endorse the request. Finally, the JRCC air controller must approve the request.

1.17.4 The JRCC air controller authorizes the dispatch of the jumpers only when he believes it is the most effective method of resolving the situation. The JRCC air controller does not assess the risk of the jump nor is he able to order the jump to take place without the concurrence of the aircraft captain and the TL. Once the jump receives JRCC approval, risk mitigation concerning the jump and subsequent rescue is the responsibility of the aircraft captain and the TL. The SMM 60-130-2605 (SMM) CH 2: 11 January 2011, Chapter 2 Section 1 paragraph 2 states that, “…The deployment of the team shall be authorized, unless it can be conclusively established that no assistance is required or that the lives of the SAR Techs will be placed in undue jeopardy.”

1.18 Additional Information

1.18.1 Jumper Exit Point (JEP) Determination

1.18.1.1 Computation of drift for static line parachuting shall be made for all premeditated jumps. Computation of drift will be calculated by the use of an approved drift indicator that is designed to duplicate the average descent of a 200-pound jumper.

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1.18.1.2 To calculate drift for a static line parachute jump under normal circumstances, a drift indicator is released by the TL when the aircraft is directly over the intended target. After the first drift indicator has reached the ground and its position has been noted, the pilot sets up a rectangular pattern, the final approach of which will be directly over the first indicator and the intended target in that order. This pattern aligns the aircraft on final approach on an into-wind heading. As the aircraft passes over the first drift indicator and then over the target, the TL notes the distance between the drift indicator and the target and then releases a second drift indicator at the same distance beyond the target to establish the jumper exit point.

1.18.1.3 To minimize error, precise altitude and airspeed must be maintained during the drift assessment and personnel dropping procedures. The pilot shall follow course instructions from the TL throughout the drop operation, provided safety of flight is not jeopardized. The pilot will notify the TL when turning on the base and final leg of all patterns. The parachute jump should take place within a few minutes of the release of the last drift indicator23.

1.18.2 SRK Aircraft Flight Patterns

1.18.2.1 To determine if an upwind or downwind drop is required, the drift of the target must be assessed. When survivors are in the water, an upwind drop should be considered. When survivors are in a boat or life-raft with a high free board, a downwind drop may be required24.

1.18.3 SAR Tech Currency Requirements on 27 October 2011

1.18.3.1 1 CAD Orders Volume 5, 5-503, Annex E regulates SAR Tech qualification and currency requirements. Paragraph 5 indicates that SAR Tech currency requirements for fixed wing operations include quarterly, semi-annual and annual parachute events. There is no requirement for a water parachute jump.

1.18.3.2 Paragraph 8 identifies continuation training topics stating that, amongst other things, a live parachute water jump, swimming and water rescue training should be included.

1.18.4 Parachuting Operational Jump Regulations on 27 October 2011

1.18.4.1 A specific SAR Tech Aircrew Information File (AIF) is maintained to pass information and regulations to SAR Techs prior to this information being established in permanent orders. AIF 62 concerning the approval and conditions under which to use the CWFS was initialled by the TL (see document at Annex F).

1.18.4.2 Night Live Parachute Jumps: flare illumination is essential both for the jumpers’ exit from the aircraft to allow them to check their canopy as well as for their

23 Drift Assessment Reference: SMM CH 2: 11 January 2011 Chapter 2, Section 1 Paragraph 5 and 6. 24 SMM Chapter 2, Section 3 Paragraph 13 (Notes) Paragraph 4.

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landing in the drop zone25.

1.18.4.3 The maximum surface wind speed for operational jumps shall be at the discretion of the team leader26. The maximum surface wind for training water jumps is 20 kts27.

1.18.4.4 Operational jumps shall not be carried out at altitudes less than 1,200 ft above water level (AWL)28.

1.18.4.5 A review of orders and guidance documents determined there to be no regulation of operational jumps and ice conditions, freezing spray, sea state, sea temperature, wind, gusts, density altitude, ceiling, air temperature, natural illumination levels or weather restrictions to visibility.

1.18.4.6 A review of orders and guidance documents and supporting testimony indicated that there is no guidance or required training for SAR Techs to conduct surface swimming in large seas or arctic conditions.

1.18.4.7 CFSSAR alerts course members to the warning concerning one person raft stability and over-inflation of the floor; however, the investigation found that this information may not be well known among users.

1.18.4.8 A review of the SMM for water jump planning considerations shows instructions for SRK drops but no guidance for parachutists when considering the need to land upwind or downwind of the target.

1.19 Useful or Effective Investigation Techniques

1.19.1 Parachute Exit Video Camera Data

1.19.1.1 Two supernumerary crew members shot limited cell phone video of the SAR Techs commencing approximately one minute before the jump until the parachutes disappeared from behind the aircraft. The video proved to be a valuable aid to the investigation. The video showed the order of the jump, state of dress, use of equipment and the extent of the loosened LRSK attachment strap on the TL.

25 SMM Chapter 2, Section 7 Paragraph 1. 26 SMM Chapter 1, Section 1 Paragraph 7. 27 1 Canadian Air Division Order Volume 5 5-401 Annex A, Paragraph 1 c. 28 SMM Chapter 1 Section 1 paragraph 7.

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2 ANALYSIS

2.1 General

2.1.1 The National objective of SAR is to prevent loss of life and injury through SAR alerting, responding and aiding29. Since the men in distress had made a bona fide request for assistance, the rescuers were required to assess the men’s condition from the air using all means available and to determine whether the men required physical assistance or not. A successful rescue requires the rescuers to reach the casualties, to provide suitable aid and to be extricated from the hazardous environment. In this case, an unmitigated hazard to CF aviation resources (the SAR Techs) was created by the decision to undertake a parachute rescue in extreme environmental conditions without an adequate extraction plan.

2.1.2 It is accepted and understood that some of the same decisions and actions could have been made by a similar or even senior SAR crew. In this occurrence, the aircraft captain and the SAR Techs believed they were accepting a certain risk, which proved to be much greater than they anticipated; it resulted in TM1 having limited resources, TM2 being unable to provide assistance, and the death of the TL. The circumstances before, during and after the parachute jump to the sea were examined to identify issues for resolution in order to improve the success of future open sea, cold water, parachute rescues.

2.2 TL’s Parachute Descent

2.2.1 The investigation determined that at the JEP the aircraft was at 2,100 ft mean seal level (MSL) at 136 kts indicated airspeed (IAS)30 and the winds at this altitude were 228º true (T) at 41 kts. The JEP was 7,700 ft upwind of the target and required a return track to the target of 010ºT. The video showed the TL exited the aircraft 10 seconds after the LM received the signal from the flight deck, which placed the TL’s JEP at 9,400 ft upwind of the target.

2.2.2 The TL’s exit from the aircraft was normal and he was observed to manoeuvre a fully inflated main parachute during the descent. The autopsy showed he had sustained no injuries to indicate that he fell free from the parachute. His dive hood was not worn under his helmet when he departed the aircraft but it was on his head when he was recovered. It is unlikely that the dive hood was placed on his head during his descent because he would have been occupied completing his under canopy checks and manoeuvring his parachute. The dive hood had to be placed on his head, only after he landed in the water; therefore, the investigation concluded he was conscious and functional on the water’s surface after the parachute descent.

2.2.3 The TL intended to land upwind of the target. He was observed to fly his parachute into wind after exiting the aircraft until he disappeared from sight. The video showed his parachute was fully inflated approximately seven seconds after his exit, 29 National SAR Manual, Chapter 1 article 1.4. 30 Ground Speed was determined to be 101 kts or 170 fps.

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from where he would have had at least 100 seconds of descent time. Had he immediately turned downwind and travelled with the wind for the entire descent, it was estimated that he would have landed 800 ft short of the target31. The distance to the target from the JEP was likely significant when compared to training scenarios conducted in lighter winds32. As well, there would have been few discriminating features over the water leading him to the target, which was difficult to see given the twilight. For as long as he faced into the wind, the target would have been over his shoulder behind him complicating efforts to track to it. The MLM would have been easy to spot except when it was in a wave trough or hidden behind a wave as the slant angle to it diminished during the TL’s descent. The TL would also have had to perform some under canopy checks into wind and he would have had to turn into wind prior to landing, reducing his ability to cover the distance to the target. To reach the 800 ft distance from the target, the TL would have had to conduct a downwind landing at approximately 51 kts. Had he conducted a normal turn into wind as per his training at 300 to 500 ft above the surface he could have ended up to 1800 ft short of the target. These factors contributed to him landing upwind of the target, likely much farther away from the raft than he intended.

2.3 TL’s Post-Landing Activities

2.3.1 The TL was found without his parachute harness. Given the complexity and robustness of the harness and his lack of fall-related injuries from early harness release, the investigation determined that the TL landed in the water under his main parachute and that he did not drown at initial immersion shock. Instead, he remained conscious to complete post landing activities that included the removal of his parachute harness and the donning of his dive hood.

2.3.2 The investigation considered three possible main theories concerning the TL’s post landing activities; these involved entanglement with his equipment and parachute harness at removal leading to drowning, early drowning and towing by the raft, and travel in the one person raft until drowning.

2.3.3 Entanglement at Parachute Removal

2.3.3.1 TM1 and TM2 landed in the water and became tangled in their numerous lines and gear tethers. This occurred even though they landed into wind because the movement of the waves mixed them with their lines. SAR Techs are trained to expect this possibility and to methodically extricate themselves from the lines while being careful to abandon only their parachute harness. The TL likely experienced this same entanglement; however, his may have been made worse by his loose left LSRK

31 TL Flight & Travel Time Calculation: The 2,100 ft exit altitude minus 500 ft for opening provides 1,600 ft for descent under canopy; using the parachute’s maximum specified descent of 16 fps, a descent time of 100 seconds is determined. Considering a parachute forward speed of 16 to 25 kts (27 - 42 fps) and an average wind speed of 35 kts (59 fps), the SAR Techs’ ground speed while facing into wind could have been 10 to 19 kts (16 - 32 fps) to the rear; while facing downwind it could have been 51 kts to 60 kts (86 - 101 fps). These are conservative estimates. 32 Training Wind Limits: Maximum surface wind for water jumps is 20 kts and for land jumps is 25 kts.

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attachment strap. It is possible the loose strap caused the LRSK, tether, or one person raft to become caught in the parachute harness and during doffing of the harness, the one person raft was lost. Further, the weight of his sinking parachute harness, fouled in his LRSK tether to the LPY33, could have placed sufficient tension on the LRSK to LPY cloth attachment tab to rip it from his LPY. This scenario is more plausible if the TL was distracted from the entanglement issue by the sensation of water entering his suit through an incompletely closed neck seal or dry suit zipper. For this scenario to be realistic, the harness would have been required to sink or drift away quickly and the TL would have to have been unable to swim after it, once he addressed the leak.

2.3.3.2 If the TL had lost his one person raft early on, he would likely have been able to swim for a period, particularly without the added drag of additional gear. Nearing exhaustion and floating to await rescue without his equipment, it is assessed he should have activated his SLB to indicate his location for immediate recovery as the others had done. However, this scenario was assessed as unlikely by the investigation because the TL did not activate his SLB and it does not explain how he travelled over 23,100 ft in the water that evening.

2.3.4 Towed by the Raft

2.3.4.1 After 5.2 hrs in the water, the TL had travelled over 23,100 ft from his landing short of the original target location and he was within 6º of TM2’s course. It is unlikely that he swam this distance because swimming conditions were poor even without the increased drag of equipment. Also, to swim in a straight line at night he would have needed to have had nearly continuous lighting of a large target, which was not the case. Both the six person raft and TM2 were lighted and could have been targets; however, these were likely only intermittently visible because the TL’s line of sight from the water’s surface to these targets would have been obscured by wave crests and spray. Therefore, the investigation concluded that in order for the TL to travel over 23,100 ft within 6º of TM2’s course, he required the use of his one person raft for at least part of the journey.

2.3.4.2 The autopsy concluded that the TL’s cause of death was drowning, though the time of death was undetermined. Drowning occurs by aspirating very little water and then, consequently due to an involuntary reflex, breathing-in even more water. The TL’s drowning shortly after water entry was considered to be less likely than later once darkness fell; the TL was trained in water survival skills, was a competent scuba

33 There are two known occurrences where LRSK tethers have been tangled in the parachute harness. They involve one at CFSSAR where the parachute harness right leg strap caught the LRSK tether while the occupant was dragged behind a simulated inflated reserve parachute. This is unlikely to have been the TL’s scenario because he landed under his main parachute and activation of his main parachute cut away handle would have released the parachute, preventing tension on the LRSK tether caused by dragging. The other occurrence happened during prototype testing of the modification to the LRSK. On this instance the LRSK tether was routed under the right parachute leg strap and at removal it wound around the LRSK tether, fouling it such that when the parachute harness was removed, the weight of the harness and the LRSK was born by the LRSK to LPY tab. This malfunction was addressed by routing the LRSK tether over the right parachute leg strap. On this jump the TL had the routing of his LRSK tether confirmed as correct by TM2.

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diver, wore fins for increased manoeuvrability, was positively buoyant, and had daylight available for on-water orientation.

2.3.4.3 SAR Techs do not typically fully inflate their LPY due to the inherent buoyancy of their dry suits and if required, they prefer to add air to the LPY manually to ensure they add just enough. This protocol allows them to save the inflation bottles for an urgent situation. The TL’s LPY inflation bottles were both expended and his LPY was fully inflated, indicative of an urgent requirement for increased buoyancy. This is consistent with an unexpected aspiration of water and a consequential critical requirement to get above the water’s surface; however, this activity does not help determine the time of death.

2.3.4.4 All items floating in water are subject to equal movement over a distance by the total water current34. Additionally, any item with freeboard, such as a raft, is subject to leeway, a separate movement force from the wind35. Notably, a body low in the water is subject to movement only by the total water current and it is not subject to leeway.

2.3.4.5 The TL drowned sometime after he released from his parachute harness. Had he fallen out of the raft and drowned but remain tethered to it, the wind would have propelled the raft and dragged the TL until the tether failed. Comparatively speaking, the wind would have propelled the TL’s possibly-swamped raft to a lesser degree than TM2’s because TM2’s raft would have had increased sail area due to his bailing actions and upright body position36. Compounding this scenario, the TL’s body would have acted as a large sea anchor, reducing his raft’s leeway effect when compared to TM2. The presence of the tethered raft would have provided leeway, for an unknown amount of time, until the LRSK-to-LPY cloth attachment tab failed. This scenario may explain the TL’s movement over such a distance37. This would have required an average wind speed of 35 kts and produced a travel distance of 12,500 ft due to leeway, leaving a balance of 10,600 ft of travel due to total water current, or an average current of 0.34 kts.

2.3.5 Travel in the Raft

2.3.5.1 The investigation determined that the TL made a radio call to R-323 after his parachute jump but before R-323 left the SAR Area. The stored location of the TL’s radio was unknown; however, if it was in his SARPELS, he would not likely have retrieved it for use until he was established in his own raft. Like TM2, the TL would likely not have made a radio call until he had news to report. This news may have been

34 Total Water Current: is the resultant sum of the wind generated water current, the local sea current and the tide current. It is the vectorial sum of all applicable current in a particular drift plot. National SAR Manual, Chapter 7 article 7.42. 35 Leeway: is the movement of an object through water caused by the action of the wind on the exposed surfaces of the object. National SAR Manual, Chapter 7 article 7.31. 36 It is believed the TL would have configured his raft similar to TM2. 37 Propulsion by Leeway on Swamped Raft: {(30 kts/hr X 0.013 coefficient) -0.06/hr correction} X (6,076 ft/nm) = 2,005 ft/hr; or, at 35 kts = 2,400 ft/hr. National SAR Manual, Chapter 7 figure 7.2.

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that he could no longer swim to or see the target, that he was established in his raft, or that he wanted to know the status of others. Further radio transmissions may have been impossible if the radio was accidently lost in the sea or if the radio failed like TM2’s.

2.3.5.2 Being in the raft above the water’s surface would have more easily allowed the TL to remove his helmet, activate the strobe light and don his dive hood. The helmet could have been replaced on his head, although testing indicates that this would have been uncomfortable unless portions of the liner or ear cups were removed38. The helmet was spotted but not recovered and, therefore, could not be examined. Marks on the TL’s face indicated that he had trouble releasing the buckle on his helmet’s chin strap, as had occurred to TM2. Reinstalling the helmet would have provided additional warmth and been a convenient way of utilizing the lights attached to it. The helmet chin strap buckles would not likely have been re-fastened due to their fine features and the TL’s reduced finger dexterity given the cold penetrating his five finger gloves. His helmet, with portions of the interior removed, would have fit imprecisely and it would come off when he drowned, explaining why it was spotted 3,400 ft downwind from his position. Also, the flashing light on the helmet would have been significant enough for an arriving helicopter to spot for recovery, thus further avoiding the need to activate his SLB.

2.3.5.3 The TL travelled over 23,100 ft on the water’s surface prior to his pick-up by R-915. Since his equipment configuration in the raft would have been identical to TM2, a comparison of distance travelled between the TL and TM2 was conducted with considerations from the National SAR Manual, regarding the effects of total water current and leeway. The distance TM2 travelled in 4.5 hrs was proportionally increased to project his probable location at 5.2 hrs in order to match the TL’s time on the water. In this comparison, the total water current would have affected all floating objects to the same degree and therefore movement produced by this effect is cancelled out. The distance travelled by each raft would then solely have been as a result of leeway, where the TL’s travel due to leeway would stop when he was no longer attached to the raft. Comparing the distance the TL travelled with the theoretical distance TM2 would have travelled in 5.2 hrs yields the time the TL was in his raft. This time was calculated as 3.2 hrs. From this analysis the investigation concluded that floating in the one person raft is the most probable way to account for the distance the TL travelled and that he likely was separated from his raft about 3.2 hours after water entry.

2.3.6 Drowning

2.3.6.1 How could TM2 survive and not the TL? TM2 was still functional39 when he was recovered 4.5 hrs after water entry, although he was on the water for 0.7 hrs (13%) less time than the TL. TM2 was wearing his dive hood prior to entering the

38 Helmet Liner: The ear cups for communication and the liner provide a close fit to the head. They are held in place with a hook and pile fastener system. They can be ripped from the helmet with one hand. 39 Functional: TM2’s was likely cold but his core temperature was well above 34ºC, a known reference below which a person lives but is unable to perform tasks (not lucid). Note: Normal core body temperature is 37.5ºC.

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water, whereas the TL’s head and neck were cooled when he bared them to install his dive hood. Notwithstanding the loss of the one person raft, the investigation looked for additional reasons for this tragic outcome.

2.3.6.2 A direct comparison of the thermal performance40 of their dry suits and undergarments was not possible because these items were not tested at procurement; however, certain trends can be identified.

2.3.6.3 The garments TM2 wore that provided thermal protection included a set of two piece polypropylene long underwear (covered wrist to wrist and to his ankles), a cotton T shirt and a Whites Glacier Mark 2 John with sleeves (fleece from wrist to wrist and to his ankles). The TL’s garments that provided thermal protection included a Whites Glacier Mark 1 micro fleece undergarment (covered wrist to wrist and to his ankles), a Whites Glacier Mark 2 John with sleeves (fleece from wrist to wrist and to his ankles) and cotton long underwear (legs). Given the thermal protection accorded each individual, the TL should have had similar or even better insulation than TM2. Although they each wore a different style of dry suit, neither suit is assessed to have provided any insulating protection by itself.

2.3.6.4 DRDC Toronto’s Cold Exposure Survival Model indicated that on the night of the occurrence, an individual with dry undergarments in a sealed dry-suit immersed to the neck in sea water could have remained functional for up to 19 hrs. Conversely, an individual with soaked undergarments, would have remained functional for only 1.7 hrs. This emphasizes the importance of dry insulating undergarments to preserve functional time in a marine environment.

2.3.6.5 The TL’s CWFS contained water and his undergarments were frozen and wet. Possible sources for this could have been urine, perspiration or sea water. The amount of water found in the TL’s suit was greater than an amount representing urine alone and it is unlikely the TL would have perspired more than TM2, because the TL dressed later and did not perform as much heavy lifting in the aircraft. Therefore, the TL’s suit contained some seawater. Besides the known water leakage rates around the neck and wrist seals on this style of suit, other sources for water may have been the open zipper observed prior to his jump or his neck seal, if it was not sufficiently tensioned prior to the jump. The exact status of the zipper and the neck seal before the jump were unknown. Both of these could have been closed after the TL entered the water and felt water enter his suit. Although testing showed the TL’s suit had microscopic holes in the black sock fabric that, under minimal hydrostatic pressure, would have allowed water into his suit, these socks were inside his boots and unlikely to have been the sole cause of any water ingress to the suit.

2.3.6.6 It is likely that water in the TL’s CWFS reduced the insulating properties of his undergarments such that over the evening his core temperature cooled, causing increased functional impairment. As the TL became lethargic, he would have been 40 Thermal Performance of Clothing: Insulating efficiency of clothing is measured in “Clo.” A Clo is the amount of insulation required to keep a sedentary individual thermally comfortable in a room whose temperature is at 21ºC.

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prone to unanticipated ejection from his raft by high waves or pieces of ice from the approaching ice field. Functional impairment would have reduced his ability to swim back to the raft (tethered or not) or to hoist himself aboard it. Functional impairment would also have hindered his ability to activate his SLB. Once ejected from the raft, without the ability to re-enter it, his only recourse would have been to inflate his LPY. His core temperature would then have continued to cool until he unintentionally aspirated water and drowned.

2.3.7 LRSK-to-LPY Attachment Tab Failure

2.3.7.1 When the TL was unable to re-enter his raft, the LRSK-to-LPY cloth attachment tab was likely subject to multiple tension applications as the tether was pulled taunt between the TL’s body, acting as a sea anchor, and the wind and waves tugging on the possibly swamped raft41. Repetitive cyclic loading below the catastrophic single pull failure force may have over time failed individual weakened threads42 in succession until the attachment fitting departed, allowing the raft to float away. As long as the TL was functional, he would have been able to swim after his even if not tethered to it, as TM1 had performed on two occasions. Once functionally impaired, the TL would not have been able to swi

raft

m to his raft.

2.3.8 Comment on Analysis of TL’s Post-Landing Activities

2.3.8.1 Many of the exact details of the TL’s post-landing activities will never be known, they will remain theoretical or probable based upon limited factual information and interpretation. The discussion in the above section is a way to explain those facts where the loss of function, time of drowning, and the mode of drowning remain unknown.

2.4 SAR Tech Equipment

2.4.1 TL’s Use of the CWFS

2.4.1.1 The TL had both a serviceable Whites dry suit43 and the CWFS onboard the aircraft in his kit bag. Why the TL chose to wear the CWFS remains undetermined; however, the TL had previously obtained specific authorization to use the CWFS on a water jump while trialing the new SARPELS in the spring of 2011. His positive experience with it and the CWFS’ reported comfort made it easier to swim in, possibly motivating him to select it.

2.4.1.2 The CWFS was only authorized for wear for operations from the CH146 helicopter (per the OAC message and the AIF, which the TL had signed as having read). Authorizations in CF regulations are permissive by nature and there was no

41 During testing, a one person raft without the floor inflated, held enough water to weigh 308 lbs. 42 LPY Weakened Threads: This mode of tab failure is theoretical; however, an examination of the TL’s LPY suggests the stitching failed versus a catastrophic single overload event. See the results of QETE LPY analysis at paragraph 2.4.4. 43 This suit was tested and found free of leaks and defects following the occurrence.

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need to issue an exhaustive list of excluded activities44 concerning the use of the CWFS.

2.4.1.3 The TL’s CWFS was examined at QETE where it was determined the suit was generally in very good condition. The wrist seals were unmodified and undamaged. The neck seal and zippers were in good condition but cut by rescue staff during removal of the suit. Reconstruction of the neck seal did not demonstrate its position when the TL entered the water. The water barrier layer of the black sock material had been compromised at some locations where, under testing, water would pass through the material at hydrostatic pressures at as little as 1.2 lbs psi. This pressure occurs at approximately three ft below the water’s surface45. The black sock material may have been compromised by repeated stretching required for foot insertion. Of note the socks would have been mostly contained inside the TL’s boots46 except for an estimated four inch high portion, circumscribing the calf above the top of the boot.

2.4.1.4 Though the TL was found soaked inside his CWFS, the exact source for water entry could not be positively identified. Given the quantity of water, this was unlikely to be entirely from urine or perspiration. Possible sources of water entry included the black sock material, the wrist seals, the neck seal, and an unintentionally open neck seal or zipper. Had the neck seal or zipper been open, the TL would have closed them once he felt water enter. Similarly, had he worn the Whites dry suit and left the zipper open, the same event sequence would likely have happened as the closure method was similar. The only difference was that the Whites dry suit did not leak and it did not have the complexities of the drawstring neck collar to attend to.

2.4.1.5 The investigation determined that the SAR Tech CWFS was maintained in a manner that was consistent with other SAR Tech dry suits, that is to say in a manner not consistent with the maintenance of CF aircrew immersion suits. Had CF aircrew immersion suit maintenance protocols been applied to SAR Tech suits then the leak in the TL’s CWFS may have been discovered.

2.4.2 Jump Master Safety Check – Static Line Checklist

2.4.2.1 The Jump Master Safety Check – Static Line, reprinted at Annex A, is a comprehensive checklist of items to be worn or actions to be completed prior to executing the jump. However, there is no reference to the proper wearing of a dry suit and the importance of ensuring all dry suit zippers are closed. The investigation concluded that inclusion of this information would serve to emphasize the importance of this step.

2.4.2.2 The TL jumped with the left attachment strap of his LRSK so loose that the LRSK hung at a near 45º angle. Line d. of the checklist says “flotation equipment is to be properly worn.” The investigation concluded that the addition of routing instructions

44 Identifying what not to do would have required unspecified foresight and made regulations prohibitively long, resulting in many amendments. 45 Salt water pressure increases at approximately 0.44 psi per ft below the surface. 46 Boots: note, they were not designed to be waterproof.

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for the LRSK-to-LPY tether and direction to ensure the tight cinching of the LRSK attachment straps would improve this checklist.

2.4.3 Radio Failure

2.4.3.1 QETE conducted the performance analysis and environmental testing of TM2’s XTS 5000R radio47, described as the accident radio, because it had failed to function during the rescue mission. The XTS 5000R radio used by the TL was never recovered but is suspected to have either failed also or been lost overboard.

2.4.3.2 Phase 1 performance testing concluded that the issued antenna was not optimized for use with any of the nine pre-set frequencies. This antenna mismatch was found to create a 40% decrease in the radio operating range.

2.4.3.3 The XTS 5000R radio is reported to be waterproof; however, analysis of TM2’s radio indicated that salt water was allowed to enter the case, causing it to fail. Due to the complete failure of the accident radio during the Phase 2 environmental tests, a separate XTS 5000R radio not involved in this accident was subjected to Phase 2 testing. Testing of this second radio was halted due to water ingress as well. It was further found that once submerged in salt water, the exposed electrical contacts created an un-commanded radio transmission that disabled the receive mode and forced a rapid depletion of battery power48. A September 2012 report of other XTS 5000R radio failures indicated cracked cases were a known failure mode under wet conditions. Finally, testing that created ice-build up due to salt water spray or salt water dipping also reduced operating ranges up to 50% and 16%, respectively. Given these test findings, the level of damage to TM2’s radio, and a sample of nine other failed radios, the investigation concluded that the radios were insufficiently robust for the SAR environment and that a means of periodic testing of waterproof SAR radios needs to be developed. The procurement of an alternate radio is also recommended.

2.4.3.4 Even if the radios had worked, TM2 was still unable to swim with his gear to the six person raft due to his landing location, his lack of on-water mobility, the wave conditions, reduced visibility, and the speed at which the target raft was drifting downwind. R-323 may have provided directional assistance from overhead except this would have been difficult as there was no way to differentiate the similar looking white lights of the SAR Techs and the raft’s white light, if in fact it was visible considering the collapsed roof. Therefore, the investigation concluded that the success of this mission required more than functional radios.

2.4.4 Life Preserver Yoke (LPY)

2.4.4.1 15 in-service LPYs and 15 new LPYs were examined or tested to determine the cloth attachment tab thread failure mode. The exact way in which the TL’s LPY tab had failed could not be positively determined but the results of this examination suggested that there was likely pre-existing, undetected thread damage

47 QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013. 48 QETE’s theoretical calculations for battery drain were measured to be from 16.8 hrs, under optimum conditions, to 0.85 hrs, when immersed in salt water.

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that resulted in thread failure that released the tab from the LPY.

2.4.4.2 There was no stated design strength specified for the cloth attachment tab. Also, at the time of the occurrence and contrary to regulations, it was common practice to use the same LPY for both training and operations. Therefore, the tab stitches could have been subject to considerable strain that remained undetected until the stitches failed during operations. Also, the use of black thread to secure the black cloth attachment tab to the LPY makes it very difficult for the user to detect failed stitches. Mountaineering equipment, deck safety harnesses49 and fall arrest gear typically use contrasting thread against the backing to make stitch failures easier to spot. While the sample size of LPYs examined was small, numerous examples of irregular and balloon type stitches used to hold the cloth tab to the new LPYs were observed. In addition, a variance in the box X stitch pattern used on the tab and an inconsistent stitch pattern below the male Fastex buckle on the quick release coupling were observed. These variances demonstrate a quality control issue with the LPY stitching. Testing of the cloth attachment tab for security in the samples obtained indicated that the tab could separate from the LPY backing at a force as low as 135 pounds.

2.4.5 Life Raft Survival Kits (LRSK)

2.4.5.1 Both TM1 and TM2 wanted to keep their one person rafts in the valise even though the LRSK was designed to deploy the raft as they shed their parachute harnesses. TM1 had the least amount of gear to propel through the water with only his SARPELS and the one person raft still in its valise. This reduced his swimming effort when compared to the TL and TM2, both of whom had this gear and an extender bag. The investigation concluded that a redesign of the LRSK should be considered so that a SAR Tech may choose to deploy the one person raft only when needed.

2.4.5.2 TM2 wanted to keep his fins on for urgent use while in the one person raft; however, the space under the apron flaps had insufficient room causing him to remove them. A redesign of the raft should be considered to allow SAR Techs to keep their fins on their feet. Keeping their fins on, better prepares them to return to the raft should they be inadvertently ejected from the raft due to wind or wave action.

2.4.5.3 TM2’s raft was not recovered; however, he reported that the stitches securing the hook and pile fastener failed when the aprons were separated after closure. This was believed to have occurred after the fastener became frozen together. The stitches that attached the fastener material to the raft apron likely failed in overload, given the freezing conditions.

2.4.5.4 TM2 reported the supplied tan coloured 1.3 litre bailing bucket had insufficient capacity to keep water out of the one person raft. An improved means for evacuating water from the raft should be considered. This may be a larger bailing

49 International Organisation for Standards (ISO) 12401 requires manufacturers to use contrasting stitching in the construction of small craft safety deck harnesses for ease of visual inspection. The ISO is a worldwide federation of national standards bodies.

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bucket or another manual device that could expel water while the apron flaps are closed.

2.4.6 Survivor Locator Beacon (SLB)

2.4.6.1 The ProFIND SLB 1000-200 used on the night of the occurrence is activated by raising a protective cover and pressing a button for two seconds. A similar device is the ProFIND SLB 1000-200RD; which is activated by pulling a lanyard. While not considered causal in this occurrence, an SLB with easier activation features under diverse environmental and illumination conditions should be considered for use.

2.4.7 Rafts

2.4.7.1 The investigation determined that personnel were surprised the one person and six person rafts were not fully inflated by the supplied CO2 cartridges. An examination of the raft inflation systems indicated this was an expected outcome in order to prevent the rafts from overinflating and to prevent their failure in warmer climatic conditions. Both the technical orders describing the rafts and the user manual, The Manual of Aviation Life Support Equipment and Techniques, CFTO B-22-050-278/FP-000, were reviewed where a description of this phenomena for the operator’s consideration was found absent. The investigation concluded that the distribution of this information in CFTO B-22-050-278/FP-000 would re-assure users that an automatically inflated raft would often be underinflated, particularly when employed in cooler climates; that this is normal and that the manual addition of air to an automatically inflated raft is to be expected.

2.5 Inter-Personnel Crew Gradient

2.5.1.1 Crew gradient is an aircrew management term typically used to label the relationship and management style between the aircrew member in charge and his subordinates. In this case, there was a working relationship between the most junior SAR Tech, TM1, and the TL, who was in charge. In general, a shallow gradient between the in-charge and a subordinate may indicate an inexperienced leader and deferral of important decisions to a lesser qualified individual. A steep gradient could represent an authoritarian style of leadership where absolute subordination is expected. Although there is a place for all styles, modern crew resource management programs predominantly promote a balanced gradient where suggestions and ideas from subordinates are welcomed, analyzed and accepted if appropriate.

2.5.1.2 On this occurrence, TM1 advised the TL that his zipper was open and his LRSK straps were loose yet the TL did not appear to take appropriate action. This represented a crew communication error. 1 CAD Order 2-007 paragraph 14 describes a pilot incapacitation regulation where in the event the pilot flying does not respond intelligently to two verbal communications, the pilot not flying is to assume control in order to correct the deviation. While no such regulation applies to SAR Techs, the concept holds some merit. TM1 was very junior and the TL was seen as quite senior, especially given the TL’s actions as a mentor during the instructional portion of the

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sortie. This steep interpersonal authority gradient or relationship likely dissuaded TM1 from further action concerning the observed loose LRSK strap or the open zipper after he had mentioned each to the TL.

2.5.1.3 There was no evidence to indicate that the TL was an autocratic leader, however, the resulting communication failure may have occurred due to the TL’s reflection on the challenges of the mission or an intercom discussion in progress; the exact reason remains unknown. Nonetheless, the TL’s lack of immediate corrective action in response to TM1’s verbal observations may have resulted in the TL jumping with an open zipper and definitely resulted in the TL jumping with a loose LRSK strap. Each omission may have contributed to the outcome of the occurrence.

2.6 Safety Person Activities

2.6.1.1 The LM (SP1) occupied his time observing the target, preparing and dropping MLMs and assisting the SAR Techs to dress and remain upright under the weight of their gear in the manoeuvring aircraft. Despite his years of experience, prior to this jump he had never seen a SAR Tech attach the LRSK to his harness like he specifically recalls the TL doing. He believed the SAR Techs completed checks on one another’s equipment and does not recall noticing other anomalies about their equipment.

2.6.1.2 SP2 was aware of his role as a safety person and mainly supported SP1, TM1 and the TL. He believed the individual safety checks were completed by the SAR Techs with one another; therefore, after they were dressed, he focused on assisting TM2 with his fin reinstallation and his SARPELS re-connection issue. He also focused on ensuring the static lines were positioned correctly. He did not observe the TL’s loose LRSK attachment strap.

2.6.1.3 While the SMM SP Duties and Responsibilities section (repeated at Annex B) indicates that SPs should observe each parachutist for equipment connection anomalies, in this case SP1 and SP2 focussed on the arrangement of the parachute static lines and deferred the security of the SAR Techs dress to the SAR Techs themselves. It is difficult to determine the effect the loose TL’s LRSK attachment strap had on the outcome of the occurrence. Straps are typically made snug to reduce the likelihood of entanglement. The video of the jump exit clearly showed a state of dress omission that escaped the oversight of all involved.

2.7 Pre-Jump Planning

2.7.1 Planning Considerations - General

2.7.1.1 The TL was primarily responsible to address all obstacles to the rescue in order for it to be successful. This included getting to the target, casualty support, survival in situ and pick-up. There is no way to completely understand the TL’s thoughts and considerations as he prepared for the jump; however, the following topics represent planning issues that needed to be properly addressed in order to successfully conduct this rescue.

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2.7.1.2 Floating Object Drift Calculation

2.7.1.2.1 There was no evidence to indicate that the crew of R-323 calculated the drift rate and drift direction of the target and there was no instruction requiring them to do so for personnel drops50. Post-occurrence examination of the target’s location over time showed that it was moving at approximately two fps in the direction of the wind. Calculating this drift was well within the capability of the crew given the availability of the latitude and longitude readout features of the aircraft FMS. The National SAR Manual indicates that total water current affects different sized objects in the water equally and that the wind affects obstacles with freeboard and not floating persons due to the absence of freeboard or sail area. Given this information, the TL should have planned their water landing with the expectation that the six person raft would drift onto their location once they were in the water. On this jump, the TL planned to land upwind of the six person raft; however, more prudent planning would have been to use a landing zone downwind from the raft. The plan to land upwind required the SAR Techs to swim faster than the 2 fps that the raft was drifting, a likely impossible task given the need to swim in the dark in very rough, cold, ice-laden waters with a significant amount of survival equipment in tow. In the end, this was a task that only TM1 could accomplish because he was closest to the target at water entry and he had the least amount of gear to tow. Landing downwind from the six person raft would have reduced the need for the SAR Techs to chase the raft over the swells, allowing them to conserve energy by remaining largely stationary in the water while the raft came upon them. The investigation concluded that a procedure change is required in order to determine a proper open water landing zone by assessing the surface winds, sail area, target’s drift rate and drift direction.

2.7.1.2.2 The difference in speed or leeway between TM1 in the six-man raft and TM2 and possibly TL in their one-man rafts is also cause for concern. TM2 reported that he was continuously bailing his raft and that he had overlooked his option to manually inflate the floor. TM1 also bailed the six-man raft but he inflated the floor and the arches. The assumption is that these actions increased the six-man raft’s freeboard, increasing leeway over the one-man rafts. This potentially increased the distance between TM1 in the six-man raft and both TM2 and TL; the National SAR Manual does not provide this level of granularity in leeway or drift calculations and this assumption could not be accurately assessed. However, the investigation concluded that this factor should be included for consideration in pre-jump planning and when discussing rendezvous points and recovery plans.

2.7.1.3 Jumper Exit Point Determination

2.7.1.3.1 While both a C8 and WDI were dropped together from the aircraft to determine a suitable release point, it is likely that only the C8 orange coloured smoke was visible on the sea from the exit altitude when the aircraft captain calculated the 50 Drift Calculation: See paragraph 1.18.2.1 and SMM CH 2: 11 January 2011, Chapter 2, Section 3 Paragraph 13 (Notes) Paragraph 4. The SMM reference states to conduct a drift calculation when dropping an SRK. The same benefit of this methodology applies to personnel drops but it is not stated in the SMM.

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displacement timing of 45 seconds. This was because the WDI paper likely became awash and quickly blended-in with the sea.

2.7.1.3.2 The low pressure weather system approaching the area and the strong gusting surface winds at Igloolik were indicative of high winds of greatly varying speeds in the target’s vicinity. The FMS in CC130323 displayed winds of up to 55 kts that afternoon and analysis of the FDR showed the winds at 2,000 ft ASL to be from the south-southwest at 40 kts in the minute preceding the jump. Notably, 24 minutes prior to the jump and coincidentally during the JEP calculation, the investigation determined the wind speed to be 60 kts.

2.7.1.3.3 The accurate calculation of a suitable JEP using a dropped object, vice a computer program, is contingent upon the aircraft speed and winds remaining consistent for the duration of the drift indicator drop, for the timing correction of the drift indicator to the target and for the actual jump. If the JEP is determined in higher winds and the drop takes place under lighter winds, the aircraft will be further upwind of the ideal exit location when the jump commences, which increases the distance to the target. A variance of 20 kts, as appears to be the case for this jump, would displace the jumpers 1,530 ft further from their target51 and this is believed to have contributed to TM1 sensing he was a long way from the target and to TM2 and the TL landing short of the target.

2.7.1.3.4 Direction in the SMM (Chapter 2 Section 1 paragraph 6. a.) implies the TL can drop an additional drift indicator over the JEP and observe its movement. If it drifts back to the target, then the JEP is determined to be appropriate for the wind conditions at the time of release. This is called a check drift indicator procedure. If the drift indicator does not return to the target then the TL would interpret the winds as variable or the initial JEP selection as inaccurate. The completion of a check drift indicator procedure to confirm the JEP on the day of the occurrence was likely not an appealing option because it would have delayed the rescue, consumed fuel reserves and reduced daylight available for the parachute descent and swim to the raft.

2.7.1.3.5 There was an estimated 20 minute delay between the drift indicator drop and the SAR Techs’ deployment. This was due to three stop drop calls and the aircraft’s descent and climb back to altitude for the MLM drop. This delay contributed to the jumpers being dispatched both in conditions that were not the same as those present when the drift indicator timings were determined and too far upwind of the target. The SMM already states the parachute jump should closely follow the JEP timing determination to prevent this from happening; however, to allow for contingency planning or postponement of the jump, the investigation highly recommends the completion of the check drift indicator procedure when the surface winds are estimated to be above 20 kts or are gusting and an accurate landing is required.

51 WDI/SSDI Drop: if the SSDI was released at 2,000 ft ASL and it falls for 100 seconds at 20 ft per second, and the average wind during its descent was 45 kts (76 ft per second), then the SSDI would land 7,600 ft from the target. The CC130 would determine the timing by flying into wind from the SSDI to the target, covering 7,600 ft in 45 seconds. This would translate to a ground speed of 100 kts.

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2.7.1.4 Parachute Landing Accuracy

2.7.1.4.1 The exact surface winds at the target were unknown; however, winds displayed on the FMS together with surface wind observations from Igloolik and the openness of the sea should have caused the aircraft captain and the TL to expect winds at the target to be in excess of 25 kts.

2.7.1.4.2 When the winds are stronger than 24 kts the parachute has no penetration ability and the likelihood of accurately reaching the target is diminished. A parachutist will often experience a lack of penetration ability under the influence of higher winds aloft, but this is regained as the he descends to an altitude where the winds are lighter. Typically, surface winds for training are well below the 25 kt land jump limit; training under this limitation allows the parachutist to fly in any direction to reach his target and it biases SAR Techs to expect to be able to make their target.

2.7.1.4.3 On the day of the occurrence, high winds prevented the SAR Techs from penetrating air at all altitudes; therefore, they would not have been able to fly their parachutes over the water in all directions, denying them the ability to circle their target and to achieve a precise landing. The SAR Techs would never have previously performed this kind of manoeuvre because the training wind limits prohibit practice for such high wind conditions. The TL impressed upon the aircraft captain, TM1 and TM2 that they would land together and swim a short distance to the raft, when in fact the possibility of accurately attaining the landing zone was extremely remote given the high winds and lack of parachute penetration ability. The investigation concluded that when parachute landing accuracy is paramount due to the lack of mobility once on the water, as it was for this rescue, regulations should prohibit water jumps when the surface winds are estimated to be above parachute penetration ability.

2.7.1.5 Exit Altitude Selection

2.7.1.5.1 An exit altitude of 2,000 ft was chosen to remain below all clouds and to limit time lost climbing to altitude following low altitude observations of the target. The actual exit altitude of 2,100 ft was considered to be within acceptable parameters. While the exit altitude was above the 1,200 ft minimum dispatch altitude, 2,000 ft was considered to be acceptable but low, reducing the time available for the SAR Techs to complete their under canopy checks and to assess and react to the winds affecting their descent to the target.

2.7.1.6 Stick of Three

2.7.1.6.1 A CC130 SAR aircraft typically carries only two SAR Techs. The SAR Techs are usually parachuted sequentially in a stick of two so they can attend quickly to multiple casualties. In this sense they can gain experience in a supervised setting when one SAR Tech is less qualified and also they may support one-another in the event that they encounter difficulties.

2.7.1.6.2 On the day of the occurrence, TM1 could have been directed to remain onboard the aircraft; however, he was unqualified to perform any duties there without TL

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supervision. Since he was qualified to perform duties clear of the aircraft it is likely that the TL believed this was an excellent opportunity for TM1 to gain valuable experience, particularly since SAR Techs may go their whole career without conducting a rescue of this nature.

2.7.1.6.3 Alternatively, two SAR Techs could have satisfactorily conducted the rescue leaving either TM1 or TM2 onboard the aircraft. This would have reduced their individual exposure to risk but was counter intuitive to their role where acceptance of risk is expected and experience gained invaluable.

2.7.1.6.4 Aircraft flight paths for crosswind jumps, lower training wind limits and the expected performance of the parachute in a training environment are all factors that have normally allowed SAR Techs to expect to reach their targets. In this case, the upwind flight path away from the target, the reduction in wind speed between the calculated JEP and the actual jump, and the time interval between the JEP and the individual jumps resulted in considerable distance between the jumpers’ individual landings and the target. The disadvantage of all three SAR Techs jumping together, sequentially in the same stick, involved the latter jumpers being further from the target due to the distance the aircraft flies between the first and last jumper’s exit. This practice, while permitted under the present SAR protocols, increased the likelihood of undesirable distance between the landings particularly when the exit altitude was lower and the high winds did not permit parachute penetration ability. The investigation concluded that the jump procedure for three or more jumpers should be reviewed to reemphasize crosswind jumps or bracket the JEP with jumpers exiting before, at and after the JEP. A similar incident occurred on 7 Jul 09 in Greenwood when a SAR Tech exited the aircraft as the number 4 of a stick of 4 from 1,500 ft above water level. He was unable to make the intended landing zone and sustained serious injury on landing52.

2.7.1.7 Mobility on the Water

2.7.1.7.1 All three SAR Techs were fit and capable swimmers and they jumped wearing swim fins; however, the ability of TM1 and TM2 to swim any distance with equipment in the water conditions that they encountered was very limited. The investigation determined that the SAR Techs had not discussed or trained how to swim in the large swells or how to swim with such a large amount of equipment. The SMM (Chapter 4 Section 3 Paragraph 1d.) required the SAR Techs to carry a penetration kit and, as part of the rescue plan, each wanted to bring personal equipment in their 52The DFS investigation revealed that the jumpers/divers were slow in advancing to the edge of the rear exit ramp due to restrictions in their walking ability wearing flippers. This resulted in a delay of approximately 20 seconds before the fourth member (J4) was in a position to exit. Under optimum deployment conditions, J4 needed to exit the aircraft within 12 secs of the planned exit point to safely make the DZ. The loss of altitude during recovery from line twists coupled with the extended jump sequence placed J4 in a position where it was not possible to make the intended DZ. Preventive measures were aimed at the Safe Training Practices of local unit orders and improvements to the Team Leader qualification training. These preventive measures were closed 30 Sep 09 when TRSET reviewed 413 Sqn SAR Tech Orders and forwarded them to the other SAR Sqns with the recommendation to incorporate in local orders.

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SARPELS in order to survive unassisted for up to 48 hrs. The LRSK they each carried was configured to deploy the one person raft with removal of the parachute harness, further increasing their cross-sectional area in the water (although TM1 was able to keep his in the valise). The investigation found that there was no recurring training requirement for SAR Techs to perform a water jump with a full SARPELS and LRSK and no requirement to swim a distance with this equipment in high waves or even swim in a wave pool. Also, there was no description in the SMM of how to swim in high waves with or without this equipment.

2.7.1.7.2 Mobility on the water with a sea state is an issue for all water jumps where a supporting boat cannot pick-up the SAR Techs. Large seas make swimming with additional equipment to a drifting target impractical, as was the case in this occurrence. During rescues without a supporting boat, the SAR Techs should jump with minimal additional gear to reduce their cross-sectional area in the water, thereby reducing drag and increasing their ability to swim to the target. Furthermore, a means for enhancing their mobility on the water should be carried during such jumps. A number of small portable battery-operated devices, like a “sea scooter,” should be examined to fulfill this requirement. A portable self-inflating kayak may also fulfill this role. Once aided or mechanical propulsion on the water is established, additional rescue kit could be air dropped near the target where it could be retrieved using the propulsion device. The investigation concluded that having a means of on-water aided or mechanical propulsion as an equipment requirement for rescues conducted in any sea state greater than calm conditions should be considered by appropriate SAR operations authorities.

2.7.1.7.3 The TL had no recorded swimming experience or training on the open ocean or in high waves or guidance reference material to consult; consequently, the TL was unable to foresee the problem that the lack of water mobility in these conditions presented, which, had he recognized, may have precluded or modified the jump.

2.7.1.8 Swimmer’s Limited Visual Range

2.7.1.8.1 The six person raft is designed to under-inflate to prevent catastrophic failure of the chambers when it is deployed in locations with higher air and sea temperatures. Consequently in the Arctic, the roof was collapsed, reducing its height and, at times, obscuring the low powered roof-mounted light from the view of the SAR Techs in the water.

2.7.1.8.2 The ability of a swimmer to see an object on the sea is dependent upon limitations to visibility from weather and spray, selection of the correct viewing direction, suitable object contrast and illumination, ambient lighting conditions and line of sight limitations due to the height of the viewer, the object and the surrounding seas. In this case, the low lying raft, MLM and the heads of the swimming SAR Techs would often be obscured from one another by the surrounding 10-15 ft high waves. A swimmer could spend most of his time in a wave trough and only momentarily have the advantage of height on a wave crest. On a crest, he would have to quickly determine the direction to look and the object would have to be simultaneously un-obscured by a rising wave. The investigation determined it was unlikely that the SAR Techs could have seen one

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another in the water due to their separation from one another upon landing, their dark helmets blending with the sea, the reduced visibility in twilight, the presence of spray and their reduction in line of sight viewing range because of the wave heights. The above factors would have made it so they could not have seen one another even had they been separated by a single wave. Similarly, each swimmer’s view of the MLM and target would only have been momentary when they were not obscured by the sea conditions. Therefore, the visual acquisition of low lying targets by a swimmer in the open sea and in a high sea state is an unreliable technique for the orientation and tracking of an object, such as a six person raft, even in full daylight.

2.7.1.8.3 From their vantage point overhead, the aircraft crew had no way of discriminating the surface lights from one another as they were all the same colour. Without radio communications to the SAR Techs and with a limited fuel supply, the aircraft could not loiter overhead sufficiently to provide directional assistance to enable the SAR Techs to move to their target. The requirement for the aircraft to remain overhead in order to provide the swimmers with vectors to their target might have been effective had the swimmers been visually differentiated from the air and had they had mobility, operating radios, and a means of establishing direction. For redundancy, individually-worn, waterproof, portable GPS devices with an updated target position may have provided individual directions to the target in the event of radio failure.

2.7.1.8.4 The use of aircraft-mounted optical, infrared or thermal imaging equipment would have been beneficial for observing the target and it could also have been used to differentiate swimmers in the water in order to direct them to the target. However, the purchase and employment of this equipment may be a long way off. Alternatively, the unique radio tagging of swimming SAR Techs with miniature vessel tracking equipment known as the Automatic Identification System (AIS) and the fitment of a suitable aircraft receiver would be another way to identify SAR Techs and their status at sea regardless of illumination levels or weather conditions. The fitment of rafts with radio tracking devices or rescue laser flares may also artificially increase their profile and visibility. On this occurrence, the water mobility of each SAR Tech was a significant obstacle; this was followed closely by their inability to determine in which direction to swim. Correction of these deficiencies will require evaluation, testing and the employment of additional technology. The investigation concluded that a redundant capability to enable SAR Techs to locate their target on the water should be investigated.

2.7.1.9 Freezing Sea Spray

2.7.1.9.1 The investigation determined that the SAR Techs did not consider the effects of freezing spray on their rescue although the likelihood of its existence was identified in the marine forecast. Freezing spray becomes heavy after repeatedly adhering and freezing on an object. Furthermore, once frozen, it prevents fasteners and other mechanical devices, such as clasps or the hook and pile fasteners on the raft aprons, from operating as designed. Freezing spray can clog the pile and prevent it from closing or, once fastened, the pile can hold spray that then freezes and prevents the hook and pile from separating when desired. An application of force on frozen, closed hook and pile fasteners may cause stitching to separate from the fabric rendering

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further closure impossible. Sufficient accumulation of freezing spray can result in floating objects becoming unstable and, eventually, to capsizing. The accumulation of ice on exposed but clothed body parts also restricts mobility. As discussed in paragraph 2.4.3, the radios were also susceptible to sea spray and this significantly reduced radio operating range. The investigation concluded that SAR equipment used during freezing spray conditions must be able to function in this condition or the exposure time must be curtailed or eliminated.

2.7.1.10 Drifting Ice Hazard

2.7.1.10.1 Ice pieces and slush in a seaway are heavy and unstable. Larger pieces of ice propelled by the actions of the wind and waves may damage a raft, capsize it or eject the occupants. Once ejected from the raft, successive pieces of ice may trap the occupant under water or result in crush injuries. There was no physical evidence to suggest the TL was struck unconscious by a piece of ice; however, he was found in an ice field. Even relatively small pieces of ice moving in a large sea have sufficient momentum and mass to injure an individual or eject him from a raft. There was no evidence to suggest this hazard was addressed prior to the jump; however, the presence of ice in a sea state where one must remain for some time should be considered during pre-jump planning and within a jump decision matrix, particularly where its presence may preclude the jump.

2.7.1.11 Arrival on a Lee Shore

2.7.1.11.1 The TL believed the rescue team would be able to survive for up to 48 hrs while waiting for pick-up by helicopter. He expected to drift in the six person raft onto land or an ice-pan; this was why the group carried rifles. Analysis of the drift pattern and pick-up location of TM1 and TM2 indicated that they were approximately one hour from shore had they continued to drift in the same direction and at the same rate. There was no evidence to indicate that the TL considered their arrival on shore in the darkness and in 10-15 ft waves let alone the larger waves the SAR Techs experienced at the time of pick-up, nor were there any written instructions in the SMM on this issue. Large waves tend to break in the shallow depths of a lee shore, causing raft occupants to be ejected and pinned underwater by the rolling waves to drown or to be fatally injured when they are forced against subsurface obstructions like rocks. Freezing spray accumulating on a rocky shore could also make rocks very slippery and hazardous or impossible to transit while trying to get ashore.

2.7.1.11.2 SAR Techs are required to have a recovery plan (SMM Chapter 4 Section 2 paragraph 4) but part of the TL’s plan centered upon arrival on an ice pan or shore landing in high waves, possibly under darkness. At the time of the jump, there was no ETA for the helicopter (R-915) available and the helicopter had to overcome serviceability problems prior to departing on its final leg to the SAR area. Had it not arrived when it did, the outcome of this rescue could have been considerably worse. The investigation concluded that while reaching the target is often the prime focus of a rescue mission, the prospect of being blown ashore in high waves should be addressed prior to the jump and a reasonable recovery plan with an ETA for pick-up must be

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established. This should also form part of the jump decision matrix as a standard protocol for such jumps.

2.7.1.12 Immediate Activation of Tracking Device on Exit

2.7.1.12.1 The crew of R-915 accurately estimated the position of the TL in the water to enable recovery; however, this was not an expeditious and reliable location method. To increase the chances of finding SAR Techs, especially if injured and unable to activate an SLB, a personal radio tracking or position enhancing device should be activated prior to parachuting from the aircraft.

2.7.1.13 Mutual Support

2.7.1.13.1 The investigation determined the SAR Techs had no specific contingency plan concerning mutual support for their parachute descent or water activities, nor was there expanded guidance53 for them to do so. Typically, rescue workers, firefighters and even soldiers make every effort to rescue one another prior to attending to the task because without a suitable number of functional personnel, the mission will fail or be unachievable. As an example, firefighters work in pairs in view of one-another and they are not permitted to enter a burning structure until water coverage has been established.

2.7.1.13.2 On this rescue, because the target was more distant and difficult to achieve, TM1 and TM2 focused on flying to the target versus landing short but together with the TL. Had one of the SAR Techs shown signs of an airborne malfunction, a designated SAR Tech should have altered his descent to attend to him. There was no evidence to indicate this was pre-briefed. For effective mutual support after a parachute descent, SAR Techs should ascertain their collective safety prior to rescuing others. This requires the capability to communicate with each other. In this case, TM1 was authorized to jump without a radio. Without a radio or a suitably briefed back-up signalling plan, there was no way for the SAR Techs to determine the status of their colleagues and therefore no way for them to initiate mutual assistance. If all the SAR Techs had dispatched with a radio and a back-up means to locate one-another and with mobility on the water, TM1 or TM2 or the aircraft captain could have directed assistance to the TL when he encountered difficulty on the water. If he had been located by the other SAR Techs after encountering difficulty, he may have survived just as the casualties survived with their soaked clothing and lack of footwear.

2.7.1.14 Motivation, Recognizing the Difficulties

2.7.1.14.1 Once overhead the SAR scene, the TL consumed a significant portion of his pre-jump time observing the target and discussing the rescue with the aircraft captain. Likely, the TL wanted to see activity in the raft that would change his decision on the requirement to provide immediate assistance. He received unanimous support from TM1 and TM2 in his decision to jump but he did not communicate to them the 53 Mutual Assistance: See SMM Chapter 4, Section 4, paragraph 3 “…a goal of landing in close proximity to each other for ease of assembly and mutual assistance.”

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complexities, contingency plans and considerations necessary to ensure arrival at the raft likely because TL did not foresee these issues and he did not have the training or appropriate protocols to aid him in solving and discussing them.

2.7.1.14.2 The condition of the men in the boat motivated the TL to provide timely assistance, especially considering the perceived lack of timely alternative rescue resources. The planning and decision-making time available was constrained by the aircraft’s fuel reserves, the distraction of the search for the community rescue boat and the need to reach the target before full darkness. Following the TL’s request to jump, the time available to plan and prepare for the rescue was 53 minutes, though it was interrupted by the boat search.

2.7.1.14.3 To review, the planning items that the investigation is concerned about and that should be addressed include a lack of target drift calculation and correct selection of landing zone, the single JEP calculation and the over 20 minute time delay between determination and jumper dispatch, the wind speed above training limits and parachute penetration ability, exit altitude selection, the dispatch in a stick of three, the lack of radio for TM1, mobility on the water and selection of gear, the sea state’s effect on visible range, the effect of freezing spray, the hazards of encountering an ice field and an arrival on a lee shore in the darkness with high waves and rocks, and the signalling and plans for mutual support. Undoubtedly, these items have been analysed by the investigation with the considerable benefit of hindsight bias and time available. However, the investigation believes that the large number of unmitigated items and the inappropriateness with which they were considered indicates the TL neither had the training nor the full understanding of the difficulties he would encounter getting to the target. The TL was confident with his plan even though he and the crew had no experience conducting this style of rescue. Had a detailed planning checklist concerning an open-sea, cold water, parachute rescue been available, the TL and the aircraft captain could have better assessed the risks and accurately determined if they could be suitably mitigated. Additionally, a checklist could have helped prepare the rescue team for the challenges associated with the jump or perhaps even have resulted in the refusal or postponement of the jump.

2.7.1.15 Decision-Making Under Time Pressure

2.7.1.15.1 Due to the dynamic nature of aviation, aviators are forced to make high-risk decisions to achieve shifting goals under time pressure. Aviators often unknowingly use a decision-making model based upon Naturalistic Decision-Making54 (NDM) theory instead of more classical methods better suited to engineers in a laboratory setting. NDM theory is characterized by personnel that believe they are an expert and they use their experience to make decisions in operational settings. These settings are characterized by high levels of uncertainty, missing data, competing goals, multiple players, time pressure, high stakes and changing conditions. Once committed to a functional course of action there is a tendency for the decision-maker to stay their

54 Naturalistic Decision Making Model: new decision making theory first described in 1989 at a United States Army Research Institute conference (Lipshitz, Klein, Orasanu, Salas, 2001).

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course unless a radical new variable occurs that restarts the decision process. In contrast to a laboratory setting, aviators do not usually have enough time to identify all possible courses of action, to identify evaluation criteria, to assign weights to the criteria, to rate each course of action on the criteria and to compare scores to determine the best option.

2.7.1.15.2 Aviators using the NDM model for decision-making usually obtain a suitable solution, although not necessarily the best solution. To solve problems, the decision-maker would rely on their significant experience as typically their solutions are recognition-based. Experts using the NDM model rely on learned biases, rules of thumb, detailed checklists, regulatory instructions that provide pre-determined restrictions and solutions, and pattern recognition of past experiences in order to assess situations and build mental models against which potential solutions can be evaluated. In the absence of these resources, a person using the NDM model would be unable to anticipate mission complications or to provide suitable solutions.

2.7.1.15.3 During this rescue, the TL was the expert although he had neither previously performed a water rescue jump of this nature nor did he have a suitable mission-specific checklist to consider. Both of his SAR Tech colleagues had just five months experience and the aircraft captain was junior, on his first flying tour. In general, over their career, SAR Techs complete only a few actual land rescue jumps and may never jump into a hostile environment like the Arctic Ocean. Therefore, the TL using NDM theory, without suitable experience, suitable regulatory guidance or a suitable checklist could not recognize his own limitations, the risks to the other SAR Techs and the unforeseen issues involved in conducting a rescue of this nature.

2.7.1.16 Regulatory Direction

2.7.1.16.1 Good regulations produce outcomes that might not otherwise occur. They indicate a commander’s intent and they represent the considered and collective judgments of the whole community’s experience vice the limited experience of the individual. At the time of the occurrence, there were no 1 CAD Orders or directions in the SMM regulating the environmental limits, degree of risk and the operating conditions under which the SAR Techs were expected to conduct this type of rescue and there was no airborne checklist guidance for the conduct of an open sea, cold water, parachute rescue. Also, direction from outside the aircraft,55 such as a situation based approval process56 was not employed by the SAR community.

2.7.1.16.2 The acceptance of the parachute mission portion of risk at the lowest level, in this case the TL, empowered him to take charge of his team’s own fate and it

55 Jump approval from the JRCC air controller does not condone or accept the risk to the SAR Techs. This approval endorses their dispatch as an effective means to solving the SAR situation (see paragraph 1.17.4). 56 The activity or risks encountered on some military missions requires the aircraft captain to obtain further approval from a home agency before conducting those activities. A significant obstacle to this method of operation is the need for the approver to be fully aware of the situation at hand and suitable connectivity to provide for dialogue and approval.

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gave him significant freedom about how to conduct this rescue. It also meant he undertook the decision without the benefit of limiting regulations designed to reduce the SAR Techs’ exposure to unacceptable levels of risk.

2.7.1.16.3 The lack of regulatory restrictions will at times cause autonomous SAR crews to make incorrect decisions due to unforeseen shortfalls in their training and reliance on their own limited experiences. In contrast, decisions made under defining regulations would be based upon the collective wisdom of decades of SAR community experience. Appropriate regulations would serve to restrict operations when the risk is pre-determined to be too high. They would override excessive self-reliance and would serve to temper the SAR motto “that others may live” because the motto was not intended to promote a rescue in the face of unreasonable risks.

2.7.1.17 Pre-Jump Planning Summary

2.7.1.17.1 The issues examined in this section only highlight some of the numerous factors and considerations that SAR crews face in an operational setting. It is clear that SAR operations present unique obstacles on each and every call out. The challenge for these crews is to identify the hazards, assess the risks and establish a plan that will ensure mission success while attempting to mitigate the hazards and risks previously identified. Often crews will accept those risks and make the proper decisions. At times, where the risk to too high, crews may elect to delay, refuse the mission or seek guidance and acceptance of risk from a higher authority. Alternatively, crews may also push, accept risks at their level and make decisions which may be proper or possibly improper. However, as explained in this report, decisions are based on regulatory directions, training and experience levels available within the crew. This investigation has revealed that crew training, progression and experience levels combined with the myriad of considerations and factors during SAR operations present a significant safety concern. The acceptance of risk at the lowest level may also not be the most prudent approach. The investigation concluded that the factors identified in this section should be considered during pre-jump planning, and while this list is not exhaustive, a pre-jump planning checklist should be created and available to SAR crews and JRCC SAR mission coordinators. Equally important is the requirement for a risk assessment procedure to ensure that hazards, risks, mitigation plans and final decisions are identified and accepted at the appropriate level. A jump decision matrix should be available to SAR crews, JRCC SAR mission coordinators and their commanders to help with risk identification, risk acceptance and decision-making.

2.7.1.17.2 Cognizant of the speed, time, distance and communication pressures that are present during SAR operations, this proposed jump decision matrix could not be recommended without timely and reliable communications established between all stakeholders which are required for an effective decision loop. This is not the case with the CC130 Hercules during certain operations in Canada’s far north. Therefore, the investigation concludes that the SAR communications capabilities for CC130 Hercules SAR operations should be upgraded to ensure effective and timely communications. Possible options could include systems such as satellite phones.

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2.8 Aircraft Captain’s SAR Tech Dispatch Decision

2.8.1 The aircraft captain received training concerning the dispatch of SAR Techs throughout his upgrade process. The training was often situation-dependant and, therefore, a rescue of this nature was not necessarily discussed. The investigation learned that he had participated in only one operational water jump mission that was considerably less challenging than this one. In broad terms, the aircraft captain was taught to evaluate a TL’s jump request for obvious risks and the expected outcome but he was not taught about the intricacies upon which a jump rescue is based. The aircraft captain was knowledgeable of the SMM contents, but there were no cautions or a checklist of actions to consider for open sea, cold water, parachute rescues. Ultimately, the aircraft captain was taught to rely upon and to trust the judgments of experienced subject matter experts, such as SAR Techs with credentials like the TL.

2.8.2 The investigation determined that the aircraft captain was cautious in his consideration of the TL’s request to jump. The aircraft captain reviewed his concern for the environmental conditions with the TL where the TL consistently re-iterated his belief that he could make it and that the casualties’ condition could not wait several hours for assistance from the inbound helicopter.

2.8.3 The SMM clearly states that the SAR Techs shall be dispatched unless it can be confirmed that no assistance is required or that the lives of the SAR Techs will be placed in undue jeopardy. The investigation determined the aircraft captain did not foresee the jeopardy into which the SAR Techs were to be placed and that information explaining the issues of this type of rescue was not published to help him assess this problem. In this circumstance and without extensive experience the aircraft captain had to rely on those around him. Although the aircraft captain always bears responsibility for the conduct of the mission, with his first tour experience as his reference, his ability for a complete and rigorous assessment of the rescue jump was limited and dependent on the strengths of the experts that flew with him. The investigation concluded that the availability of a pre-jump planning checklist and a jump decision matrix could have assisted with him in this situation.

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3 CONCLUSIONS

3.1 Findings

Findings concerning the occurrence jump

3.1.1 The TL did not remove the boom microphone from his helmet prior to the jump. (1.1.14)

3.1.2 After being notified by TM1 that his LRSK attachment strap was loose, the TL did not take action to correct it. (1.1.11), (2.5.1.2)

3.1.3 TM1 checked the TL’s parachute harness connections and pointed out that the main zipper of his dry suit was open a few inches. No immediate corrective action on the TL’s part regarding this anomaly was detected by the other SAR Techs or SP1 and SP2. (1.1.11), (2.5.1.3), (2.6)

3.1.4 The jump occurred at 1734 hrs, 40 minutes after sunset. (1.1.14)

3.1.5 At the calculated JEP, the aircraft was at 2,100 ft MSL, 136 kts IAS and the winds at this altitude at 41 kts. (2.2.1)

3.1.6 TM1 jumped four seconds and TM2 jumped six seconds after the JEP. The TL exited the aircraft 10 seconds after the JEP, which placed him 9,400 ft upwind of the target. (1.1.17.1), (1.1.18.1), (2.1.1)

3.1.7 At 1810 hrs, 36 minutes after the jump, R-323’s on-station fuel was depleted and they proceed to Iqaluit. They could not return due to insufficient time remaining in their crew day. (1.1.16)

3.1.8 TM1 was recovered at 2144 hrs and had been on the water for 4.2 hrs. (1.1.17.9)

3.1.9 TM2 was recovered at 2206 hrs and had been on the water for 4.5 hrs. (1.1.18.6)

3.1.10 The TL was conscious and functional on the water’s surface after the parachute descent. (2.2.2), (2.3.1)

3.1.11 The Coroner's report and the Pathologist's report list the cause of death as drowning. (1.13.2) (2.3.4.2)

3.1.12 The TL’s post-landing activities, time of drowning, loss of function and drowning mode remain unknown. (2.3.8.1)

3.1.13 After 5.2 hrs in the water, the TL was recovered in an ice field of 45% slush with ice pieces up to five ft in diameter. (1.1.19.2), (1.7.3.2), (2.3.4.1)

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3.1.14 The most probable way to account for the over 23,100 ft distance the TL moved on the water was that he travelled in his raft for 3.2 hrs. (2.3.5.3)

Findings concerning the environment

3.1.15 DRDC Toronto’s Cold Exposure Survival Model indicated that on the night of the occurrence, an individual with dry undergarments in a sealed dry-suit immersed to the neck in sea water could have remained functional for up to 19 hrs while an individual with soaked undergarments, would have remained functional for only 1.7 hrs. (2.3.6.4)

3.1.16 Maximum training wind limits are 20 kts for water jumps and 25 kts for land jumps. (1.18.4.3), (2.2.3)

3.1.17 When the winds are stronger than 24 kts the parachute has no penetration ability and the likelihood of accurately reaching the target is diminished. (2.7.1.4.2)

3.1.18 The local TAF issued at 1534 hrs reported winds of 25 kts gusting to 35 kts with the aviation weather observations reporting 30 kts gusting to 35 kts at 1600 hrs and 25 kts gusting to 30 kts at 1700 hrs. (1.7.1.1), (1.7.1.2)

3.1.19 At the time of the jump, 1734 hrs, wave swells were approximately 10-15 ft in height and 20-30 ft when the SAR Techs were hoisted from the water. (1.1.19.2), (1.7.3.1), (1.7.3.2)

3.1.20 24 minutes prior to the jump and during the JEP calculation, the wind speed was 60 kts. While the exact surface winds at the target were unknown, FDR analysis showed the winds at 2,000 ft ASL to be at 40 kts in the minute preceding the jump. (2.7.1.3.2), (2.7.1.3.3), (2.7.1.3.5), (2.7.1.4.1)

3.1.21 A variance of 20 kts would displace the jumpers 1,530 ft further from their target. (2.7.1.3.3)

Findings concerning the CWFS

3.1.22 Even though it was onboard the aircraft the TL did not wear his Whites dry suit, the proper dry suit for this environment, but instead chose to wear the CWFS for undetermined reasons. (1.15.6.1), (2.4.1.1)

3.1.23 The CWFS was only approved for use on the CH146 helicopter when conducting operations other than diving. (1.15.7.1)

3.1.24 The CWFS manufacturer designed specific insulating undergarments for this suit to maximize thermal protection; however, the CF did not procure these items. (1.15.7.1)

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3.1.25 A direct comparison of the thermal performance of the dry suits and undergarments was not possible because these items were not tested at procurement; however, certain trends were identified. (2.3.6.2)

3.1.26 There is no CF-prescribed inspection cycle or periodic leak testing requirement for SAR Tech dry suits and there are no maintenance records kept concerning when inspections are completed or if rectifications are undertaken. (1.15.6.3), (1.15.7.3), (2.4.1.5)

3.1.27 The TL had similar or better insulation under his CWFS than TM2. (2.3.6.3)

3.1.28 The TL’s undergarments were frozen, wet, and his CWFS contained some seawater. (1.15.7.3), (2.3.6.5)

3.1.29 The exact source for water entry into the CWFS could not be positively identified. (2.4.1.4)

3.1.30 The black sock material of the CWFS was compromised such that water pressure at 1.2 psi could penetrate the sock. (2.4.1.3)

3.1.31 There is no reference to the proper wearing of a dry suit and the Jump Master Safety Check - Static Line does not include a checklist item to close all dry suit zippers. (2.4.2.1)

Findings concerning the LRSK and the LPY

3.1.32 The Jump Master Safety Check – Static Line does not describe LRSK tether routing instructions and cinching of the LRSK attachment straps. (2.4.2.2)

3.1.33 The one person raft’s bailing bucket was too small to keep up with the water ingress from the wind and waves. (1.1.18.5), (2.4.5.4)

3.1.34 The TL’s LPY was found with the LRSK-to-LPY quick release coupling and the black cloth attachment tab missing. The backing cloth where the cloth tab was attached was undamaged. (1.15.2.4)

3.1.35 There is no stated design strength specification for the LRSK-to-LPY cloth attachment tab. (1.15.2.2), (2.4.4.2)

3.1.36 The exact way in which the TL’s LPY tab failed could not be duplicated but there was possibly pre-existing, undetected thread damage that resulted in thread failure, releasing the tab from the LPY. (2.4.4.1)

3.1.37 The use of black thread to secure the black cloth attachment tab to the LPY makes it difficult for the user to detect failed stitches. (2.4.4.2)

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3.1.38 The variances in LPY sewing demonstrated a quality control issue with the LPY stitching. (2.4.4.2)

3.1.39 Despite the LRSK’s design to inflate the one person raft as the parachute harness is removed in the water, both SAR Techs wanted to keep the LRSK in its valise in order to reduce their bulk when swimming. (1.15.3.1), (2.4.5.1)

3.1.40 The warning concerning one person raft stability and over-inflation of the floor may not be well known among users. (1.18.4.7)

3.1.41 An informal survey of SAR Tech users indicates the LPY inflation by the CO2 cartridges would be undertaken only in a state of urgency. (1.15.2.3)

3.1.42 The TL’s LPY inflation bottles were both expended and his LPY was fully inflated, indicative of an urgent requirement for increased buoyancy. (2.3.4.3)

Findings concerning communications

3.1.43 TM1 jumped without a radio. (1.9.1.3)

3.1.44 The Motorola XTS 5000R radio antenna was not optimized for use with any of the nine pre-set frequencies. This antenna mismatch created a 40% decrease in the radio operating range. (2.4.3.2)

3.1.45 The XTS 5000R radio is insufficiently robust for SAR operations. This is due to salt water ingress; uncommanded radio transmissions when submerged, resulting in rapid battery depletion; and up to 50% reduction in operating range when covered in ice-build up due to sea spray. (2.4.3.3)

3.1.46 Even if the radios had worked, TM2 would still have been unable to swim to the six-person raft due to a lack of water mobility, wave conditions, six person raft drift and parachute landing locations. (2.4.3.4)

3.1.47 An overhead aircraft could provide swimming SAR Techs with vectors to the target if they were visually differentiated from the air, were equipped with radios and had a means of establishing direction. (2.7.1.8.3)

3.1.48 The CC130 aircraft does not have a satellite phone capability and therefore, R-323 was not in direct communications with R-915. (1.1.8), (1.9.1.2)

Findings concerning activities on the water

3.1.49 Inflating the floor and the arches of the six-man raft likely increased its freeboard and leeway over the one-man rafts, increasing the distance between TM1 in the six-man raft and both TM2 and TL. (2.7.1.2.2)

3.1.50 Large seas make un-assisted swimming with additional equipment to a drifting target an ineffective means of mobility on the water. (2.7.1.7.2)

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3.1.51 The visual acquisition of low-lying targets by a swimmer in anything but a calm sea state is an unreliable technique for the orientation and tracking of a low lying-object, such as a six person raft, even in full daylight. (2.7.1.8.2)

3.1.52 SAR Techs should have a redundant capability to provide SAR Tech individual identification, navigation to and location of their target on the water. (2.7.1.8.4)

3.1.53 The accumulation of freezing spray on the six person raft’s hook and pile fasteners prevented them from operating as designed. (2.7.1.9.1)

3.1.54 The motion of ice and slush in the water created a hazard to the SAR Techs that was unmitigated and not addressed in the SMM. (2.7.1.10.1)

3.1.55 High wind and waves arriving on a lee shore created a hazard to the SAR Techs that was unmitigated and not addressed in the SMM. (2.7.1.11.1)

3.1.56 Individually-worn radio tracking devices increase the chances of finding an injured SAR Tech on the ground or water. (2.7.1.12.1)

Findings concerning jump planning and execution

3.1.57 The TL relied upon the aircraft captain to calculate the JEP, which was determined to be 45 seconds upwind of the target. (1.1.12)

3.1.58 The parachute jump should take place within a few minutes of the release of the last drift indicator. (1.18.1.3)

3.1.59 A review of the SMM for water jump planning considerations shows instructions for SRK drops but no guidance for parachutists when considering the need to land upwind or downwind of the target. (1.18.4.8)

3.1.60 A SAR Tech’s ability to reach the target is maximized when he exits at a judicious altitude to judge the gliding performance of his canopy, has an accurately calculated JEP and the jump is conducted under zero wind conditions that provide him with the maximum penetration ability. (1.15.1.3)

3.1.61 The crew of R-323 did not calculate the drift rate and drift direction of the target and there was no instruction requiring them to do so. (2.7.1.2.1)

3.1.62 The TL’s plan was to land upwind of the raft and to rendezvous with the other SAR Techs in the raft. (1.1.10), (1.1.17.1), (2.2.3), (2.7.1.4.3)

3.1.63 The SAR Techs should have planned to land downwind of the target. (2.7.1.2.1)

3.1.64 The TL relied upon a single wind drift assessment to determine the JEP in varying wind speeds. (1.1.12), (2.7.1.3.4)

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3.1.65 The TL was estimated to have landed at least 800 to 1800 ft short of the target, further upwind than he intended. (2.2.3)

3.1.66 The SAR Techs had neither a specific contingency plan concerning mutual support for their parachute descent or water activities nor suitable written guidance for them to coordinate one. (2.7.1.13.1)

3.1.67 The SAR Techs jumped one after another in a stick of three. This practice increased the TL’s distance to cover to the target, particularly when the exit altitude was lower and the winds did not permit parachute penetration. (1.1.14), (2.7.1.6.4)

3.1.68 There was neither a recurring training requirement for SAR Techs to perform a water jump with a full SARPELS and LRSK nor a requirement to swim with them in high waves, whether in open ocean or in a wave pool. There was also no SMM description of how to swim in high wave, in large seas or arctic conditions. (1.18.4.6), (2.7.1.7.1)

3.1.69 The TL did not foresee the lack of mobility on the water as an issue to overcome in order to complete the rescue. (2.7.1.7.3)

3.1.70 The TL did not communicate sufficient planning details about the rescue to TM1 and TM2 because he did not understand or foresee many of the issues. (2.7.1.14.1)

3.1.71 A suitable open sea, cold water parachute rescue planning checklist would have assisted the TL and aircraft captain to assess the rescue’s difficulties and to mitigate them, to prepare the rescue team for the challenges associated with the jump, or to refuse or postpone the jump. (2.7.1.14.3)

3.1.72 Good regulations produce outcomes that might not otherwise occur and they represent the wisdom of knowledgeable leaders and SAR Techs that come before them. (2.7.1.16.1)

3.1.73 There were no 1 CAD Orders or directions in the SMM regulating the environmental limits, risks and the operating conditions under which the SAR Techs were expected to conduct this type of parachute rescue. (1.18.4.5), (2.7.1.16.1)

3.1.74 The JRCC air controller does not assess the risk of the jump. Once the jump receives JRCC approval, risk mitigation concerning the jump and subsequent rescue is the responsibility of the aircraft captain and the TL. (1.17.4)

3.1.75 During this rescue, the TL was the expert although he had neither previously performed a water rescue jump of this nature nor did he have a suitable mission-specific checklist to consider. (2.7.1.15.3)

3.1.76 The TL, without suitable experience, suitable regulatory guidance or a suitable checklist could not recognize his own limitations, the risks to the other SAR

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Techs and the unforeseen issues involved in conducting a rescue of this nature. (2.7.1.15.3)

3.1.77 The aircraft captain did not foresee the jeopardy into which the SAR Techs would be placed on this rescue because he had no comparative experience and no information explaining the issues was published. (2.8.3)

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3.2 Cause

3.2.1 Active

3.2.1.1 The TL drowned for undetermined reasons where it is probable that following water entry into his CWFS, he became non-functional and was unable to re-enter his raft.

3.2.1.2 The aircraft captain’s and TL’s inability to recognize the difficulties the team was to have getting to the six person raft resulted in two of the SAR Techs being unable to make the raft.

3.2.2 Latent

3.2.2.1 The lack of established regulations and procedures concerning SAR Tech mobility and navigation on the water, SAR Tech identification and visibility in the waves and the TL’s selection of landing location were also causal.

3.2.2.2 Contributing factors affecting the outcome of this rescue included: the gusty winds that affected the correct calculation and selection of the JEP; the lack of adequate equipment and training concerning SAR Tech mobility, navigation, identification and communication once established on the water; and the TL’s parachute performance expectations.

3.2.2.3 1 CAD’s delegation of SAR risk management to the operator level without adequate regulation created the opportunity for an inappropriate jump decision. Insufficient directives, training and experience of a parachute rescue into open ocean arctic environmental conditions caused even an experienced SAR Tech to be unaware of the challenges he would face on this type of rescue.

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4 PREVENTIVE MEASURES

The aim of the DND/CF Airworthiness Program is to achieve and maintain an acceptable level of safety for military aviation. The aim of the Flight Safety Program is to prevent the accidental loss of aviation resources while accomplishing the mission at an acceptable level of risk. The goal of this investigation is to identify causes and determine effective preventive measures (PM).

This FSIR includes 57 PMs. DFS understands that all PMs are important and applauds the efforts put forth by the operational and technical communities with the PMs taken and in the pre-coordination of the PMs recommended. DFS proposes that some PMs may qualify as higher priority and should be addressed as such. Therefore, this FSIR recommends that the top eight PMs recommended in Group A are considered as high priority, expected to significantly reduce the levels of risk and are judged to have the most potential to prevent reoccurrence.

4.1 Preventive Measures Taken

4.1.1 The Comd 8 Wing and Commanding Officer (CO) 424 Sqn were advised to reiterate that the CWFS is to be used in accordance with its OAC, only on the CH146 aircraft.

4.1.2 The Comd 8 Wing and CO 424 Sqn were advised to instruct their SAR Techs, in accordance with the SMM, to remove the boom microphone from their 190C helmets prior to jumping.

4.1.3 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 c (In Water –Static Line) to instruct each parachutist to don the dive hood prior to cold water jumps. Approval to conduct operational water jumps with the full shell Pro-Tec helmet was also inserted.

4.1.4 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 c (In Water –Static Line) to instruct each parachutist to carry individual colour-coded illumination during night operations.

4.1.5 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 c (In Water –Static Line) to instruct each parachutist to wear three finger gloves for extreme cold water.

4.1.6 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 c (In Water –Static Line) to instruct each parachutist to perform a final check to ensure zippers are closed prior to exiting the aircraft.

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4.1.7 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 d (In Water –Static Line) to instruct each parachutist to place their PLB to the on position prior to the jump57.

4.1.8 1 CAD OC TRSET amended SMM Chapter 4 Section 3, paragraph 1 d (In Water –Static Line) to state that PLBs will not be used as a signalling device for jumper status.

4.1.9 1 CAD OC TRSET developed and distributed an education package on open sea, cold water parachute rescue hazards and techniques for success.

4.1.10 1 CAD OC TRSET amended the CFACM 60-St-00101 SAR Tech General Information and Abbreviated Checklist to include a cold water parachuting state of dress checklist.

4.1.11 DGAEPM / DAEPM (FT) 6 conducted 100% replacement of LPYs in service and issued an amendment to the LPY CFTO (C-22-100-003/MF-001) via message DAEPMFT6165 (171856Z May 12) expanding on the need to inspect the LPY for loose, broken, damaged, colour changed or missing stitches.

4.1.12 On 21 Jun 13, Comd 1 CAD / SSO SAR amended 1 CAD Order Volume 5, 5-503, Annex E, to include the annual requirement for fixed wing SAR Techs to conduct an open water live parachute jump with the LRSK, LPY and SARPELS. The currency requirement may be conducted during daylight or night conditions and includes an exit point calculation requirement, surface swimming with equipment, a navigation exercise using GPS or aircraft vectors, and sea survival practice that includes inflation of the one person raft.

4.2 Preventive Measures Recommended

Group A

4.2.1 Comd 1 CAD / SSO SAR, in conjunction with the JRCC OICs: create and implement an in-flight risk identification/acceptance decision matrix for the operational dispatch of SAR Techs to be used concurrently by SAR Tech TLs, Aircraft Captains, JRCC SAR Mission Coordinators and their respective commanders.

4.2.2 Comd 1 CAD / SSO SAR: provide all SAR aircraft with satellite phone capability integrated into onboard aircraft systems.

4.2.3 Comd 1 CAD / SSO SAR: procure a robust radio optimized for use in the SAR role. Issues to consider include the user’s ability to operate in a wet/icy environment, waterproof capabilities, transmit and receive operating ranges, and battery life.

57 While this practice achieves personnel tracking requirements it has since been determined to be incongruent with Canadian law concerning the use of distress signal devices. The procedure is under review at TRSET and alternate recommendations at 4.2.19, 4.2.20, 4.2.21 and 4.2.22 have been made.

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4.2.4 Comd 1 CAD / SSO SAR: provide SAR Tech swimmers with an on-water mobility capability. The intent is to provide a deployable capability within size and weight constraints suitable to be carried and/or deployed by SAR Techs and within SAR aircraft.

4.2.5 Comd 1 CAD / SSO SAR: provide SAR Tech swimmers with the capability to identify themselves and to locate their target on the water using devices such as GPS, AIS, radio signals, rescue laser flares, optical, infrared or thermal imaging equipment.

4.2.6 Comd 1 CAD / SSO SAR: amend the SMM to include a water parachute rescue mission planning checklist. The intent is to ensure crews consider operational and environmental impacts such as: of arriving on a lee shore, freezing spray, movement of local ice fields, restrictions to swimmer’s visibility in waves, swimmer’s drift in or on the water, target height, target illumination, target drift rate and direction, landing zone selection, stick size, top cover duration and vectors, mobility on the water, daylight available, unique swimmer identification, mutual support in the water, estimated surface winds, FMS winds at exit altitude, parachute penetration ability, estimated wave height, wave pattern and wave periodicity, water surface visibility in sea spray, water temperature, forecast weather until pick-up, method for pick-up or recovery, ETA and loiter time.

4.2.7 Comd 1 CAD / SSO SAR: amend the SMM to include the requirement for a realistic rescue plan, including a valid recovery platform ETA with sufficient loiter time, to be in place prior to the aircraft deployment of SAR Techs into water. The intent is to ensure that crews have a recovery plan and have considered environmental conditions given SAR Tech clothing worn, functional times in the environment and survivability rate tables.

4.2.8 JRCC OICs: amend unit orders to delay or prohibit the dispatch of SAR Techs into the water unless a realistic rescue plan, including a valid recovery platform ETA with sufficient loiter time, is in place prior to the aircraft deployment of SAR Techs into water. The intent is to ensure that the tasking authority has a recovery platform available considering transit and loiter times, environmental conditions given SAR Tech clothing worn, functional times and survivability rate tables.

Group B

4.2.9 Airworthiness Authority: consistent with current policies and processes for aircrew immersion suit maintenance, establish SAR Tech dry suit inspection intervals, leak check procedures, record keeping procedures and personnel qualifications to perform this maintenance.

4.2.10 Comd 1 CAD / SSO SAR: procure aircraft-mounted optical, infrared or thermal imaging equipment to locate, identify and observe deployed SAR Techs and their targets on land or water.

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4.2.11 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to implement a challenge and reply methodology for SAR Techs. The intent is to mirror the pilot challenge and reply procedure similar to that used by pilots where in the event a crew member does not respond intelligently to two verbal communications, the confirming crew member is to assume control in order to correct the deviation.

4.2.12 Comd 1 CAD / SSO SAR / OC TRSET: publish instructions on jump procedures for SAR Techs when jumping in sticks of three or more in order to bracket the SAR Techs closer to the JEP.

4.2.13 Comd 1 CAD / SSO SAR / OC TRSET: amend training for SAR Techs to swim with full SARPELS and LRSK in high waves or in a wave pool.

4.2.14 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM Jump Master Safety Check – Static Line to describe the LRSK tether routing instructions and cinching of the LRSK attachment strap.

4.2.15 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM Jump Master Safety Check – Static Line to check that all dry suit zippers are closed.

4.2.16 Comd 1 CAD / SSO SAR / OC TRSET: amend SMM to require SAR crews to determine the rate and direction of drift of water targets.

4.2.17 Comd 1 CAD / SSO SAR / OC TRSET: amend SMM to provide instructions concerning the selection of a landing zone by assessing the surface winds, sail area, target’s drift rate and drift direction when jumping to a drifting target.

4.2.18 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to state the completion of a check drift indicator procedure is highly recommended if the surface winds are estimated to be above 20 kts or are gusting and an accurate landing is critical to mission success.

4.2.19 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM Chapter 4 Section 3, paragraph 1.d. to add a note stipulating that all SAR Techs conducting an operational parachute jump should have a two-way radio on their person.

4.2.20 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM with instructions about how top-cover is to vector a SAR Tech swimmer to reach the target.

4.2.21 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM with instructions about how SAR Tech parachutists conducting water landings are to be uniquely identifiable to a loitering aircraft overhead.

4.2.22 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM with instruction for SAR Techs to discuss mutual support prior to each jump, including observing one another’s parachute descent, main and alternate methods for communication and signals, and rendezvous points short of the target. This should include SAR team members’ own drift rates in and on the water.

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4.2.23 Comd 1 CAD / SSO SAR / OC TRSET: publish instructions on how SAR Techs are to swim with bulky equipment in heavy sea states.

4.2.24 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM with a CAUTION to emphasize that inflating the floor and arches of the six-man raft will increase freeboard and leeway, which should be considered if mutual support or rendezvous with team members is required.

4.2.25 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to include a CAUTION stating: when surface winds are likely gusting or are estimated to be above parachute penetration speed, the jumper’s ability to land accurately at the target is significantly reduced.

4.2.26 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to include a CAUTION stating: when conducting a parachute water jump rescue to a low lying target, aircraft top cover will enhance target acquisition in the absence of a powered surface support vessel at the scene.

4.2.27 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to include a CAUTION stating: when conducting a parachute water jump rescue: a low lying target will often be obscured from a swimmer’s view due to the height of the swell or waves.

4.2.28 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to include a CAUTION stating: when conducting a parachute water jump rescue, swimmer mobility on the water in a sea state is significantly reduced without the support of a powered surface vessel or other mechanical propulsion device.

4.2.29 Comd 1 CAD / SSO SAR / OC TRSET: amend the SMM to include a caution concerning use of the proper antenna, water ingress, battery depletion, and reduced operating ranges when using the Motorola XTS 5000R radio in wet, icy conditions. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.2.30 Comd 1 CAD / SSO SAR: replace the XTS 5000R radio antenna NAD6566 with Antenna NAD6567. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.2.31 Comd 1 CAD / SSO SAR: identify and reprogram the intended wattage (2W or 4W) for channel 9 of the XTS 5000R radio. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.2.32 Comd 1 CAD / SSO SAR: develop a means for SAR personnel to periodically test portable radios for waterproof qualities, operating ranges, and battery life. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.2.33 Comd 1 CAD / SSO SAR: ensure that operational LPY’s are not used for training. Refer to QETE Project Report D020011 SAR ALSE – FAILURE

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INVESTIGATION, 30 September 2013.

4.2.34 Comd 1 CAD / SSO SAR: incorporate a video recreation of this jump exit into the Safety Person Course syllabus in order to emphasize what to look for during the safety check of parachutists.

4.2.35 DGAEPM / DAEPM (FT) 6: determine if a one person raft (LRSK) may be modified to remove the need to clear the parachute leg straps from the LRSK container and to prevent inadvertent deployment by tugging on the tether.

4.3 Other Safety Concerns

4.3.1 DGAEPM/ DTAES 2: amend aviation design standards manual(s) to include provisions for use of contrast colour stitching in safety critical applications, to improve the efficacy of user visual inspections.

4.3.2 DGAEPM / DAEPM (FT) 6: to inform the manufacturer of the LPY of the quality assurance issues identified in this report and in the QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.3.3 DGAEPM / DAEPM (FT) 6: specify the requirement for contrasting colour stitching on load bearing seams, on future LPY procurements, in order to improve visual inspection processes. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.3.4 DGAEPM / DAEPM (FT) 6: investigate changes to the one and six person raft apron fastener systems for improved functionality, including use in freezing spray conditions.

4.3.5 DGAEPM / DAEPM (FT) 6: investigate changes to the one person raft apron to accommodate the wearing of swim fins.

4.3.6 DGAEPM / DAEPM (FT) 6: investigate the provision of a pump, special device or larger capacity bail bucket in the one person raft for more efficient bailing.

4.3.7 Comd 1 CAD / SSO SAR: determine a suitable design strength specification for the LRSK to LPY cloth attachment tab and apply it to the existing LPY stock. Refer to QETE Project Report D020011 SAR ALSE – FAILURE INVESTIGATION, 30 September 2013.

4.3.8 Comd 1 CAD / SSO SAR: determine if a lanyard activated SLB is a more suitable device and procure if deemed appropriate. The intent is to procure an SLB with easier activation features under diverse environmental and illumination conditions.

4.3.9 Comd 1 CAD / SSO SAR: procure the capability to identify and locate SAR Techs after a parachute jump when they are not capable of self-activating an SLB.

4.3.10 Comd 1 CAD / DIV ALSEO: Amend CFTO B-22-050-278/FP-00 to include

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a description of CO2 cartridge activation in cooler climates, raft under-inflation as an outcome and the likely need for manual inflation.

4.4 DFS Remarks

All CF members develop basic bush craft survival skills such that they are trained to survive on land with a knife, matches and a sheet of six millimetre plastic sheeting and where, with these limited resources, they should be capable of surviving at least 24 hours - in essence, survival on land is easy. On the other hand, just surviving, let alone operating, in a challenging open water environment requires a respectful and measured approach to its considerable dangers, much more so than on land.

This investigation identified gaps and deficiencies in training, equipment and operations. In the conduct of operations we strive to send our men and women on missions properly trained and equipped to do the job; this is a measured and planned approach where risks are identified, mitigated and accepted. This is not necessarily the case in a survival situation where we hope personnel will make use of what they have on hand to endure until rescued. In the case of SAR, our SAR Techs’ mission is to rescue those that are trying to survive. In that light, when we deploy SAR Techs across the full spectrum of the Canadian environment we should provide them with equipment that is optimized to operate there rather than just what is needed to survive.

Although R-323’s crew ultimately rescued the men in distress, the mission’s cost of one SAR Tech life was extreme. This tragic outcome emphasizes the need for dedicated training in open sea, cold water rescues and the need for highly specialized equipment, specific procedures and realistic contingency plans. On the sea, like in the air, the risks are high and the lack of experience with this sort of rescue must be tempered by a sound regulatory oversight that will ensure that the decisions and risks undertaken are appropriate and accepted at the proper level. // Original signed by // S. Charpentier Colonel Director of Flight Safety Airworthiness Investigative Authority

Annex A to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX A: JUMP MASTER SAFETY CHECK-STATIC LINE (Reference: SMM Chapter 4 Section 2 Paragraph 1 & 2)

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Annex A to 1010-CC130323 (DFS 2-2) 12 November 2013

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Annex B to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX B: SAFETY PERSON DUTIES AND RESPONSIBILITIES (Reference: SMM Chapter 1 Section 6, condensed)

7. A Safety Person is required for all personnel parachute and equipment drops from SAR aircraft. For CC-130 operations, the Loadmaster will be employed as the safety person. The Safety Person shall: a. assist in the preparation of the aircraft; b. assist the SAR Tech to dress;

c. complete safety checks of personnel involved in open door work wearing a restraining harness or parachuting equipment. This check is to be done systematically starting at the helmet and working down the front from head to toe and then down the back in the same manner:

(1) The safety checks for parachuting personnel shall include the following items: (a) helmet with visor/goggles down and intercom cord securely stowed; (b) gloves/knife; (c) parachute chest strap, leg straps and waistband; (d) proper attachment of SARPELS (if applicable); (e) proper attachment of snap fastener to anchor cable (if applicable); and (f) visual check of jumper and equipment for any abnormalities;

d. check static lines to ensure that the snap hook is properly secured to the anchor line cable with the button facing forward and that there is no slack between the pack and the anchor cable. This is done by having each jumper hold the static line of the jumper in front, while the Safety Person holds the static line of the last jumper. Ensure that the static line is held high and clear with a bight and on the exit of each jumper, the static line is pulled, positively, from the hand;

TL jumped with loose left LRSK attachment strap

NOTE

While conducting ramp jumps, Team Leader duties may prevent the Team Leader moving from the spotting position in the door to the ramp in time for him to hold his Team Members static line. In this case, the Safety Person should hold/control both static lines.

e. carry out SAR checklist items; and 8. Training in Safety Person duties is accomplished during the initial CC130 SAR conversion course. Both Loadmaster and ACSO personnel are trained in Safety and Assistant Safety Person duties respectively.

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Annex C to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX C: TARGET & RECOVERY LOCATION PLOT

Target, 22 nm northeast of Igloolik Airport

Igloolik Airport

Annex C Photo 1: Overview of Hecla Strait.

TM2

TM1 & Men Empty Raft

Distance from Target to TL=23,100 ft

Distance from Target to TM2 = 32,600 ft

Wind

TL

Annex C Photo 2: Plot of Target and SAR Tech Pick-up Locations.

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Annex D to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX D: PICTURES – EQUIPMENT

2. The yellow webbing and Fastex buckle connect to this serviceable LPY by the black LRSK to LPY cloth attachment tab.

1. The yellow webbing with the black Fastex buckle connects to a lanyard from the one person raft on this serviceable LPY.

3. The TL’s LPY shown as found with missing LRSK to LPY cloth attachment tab next to the white dot containing the number 1.

Annex D Photo 1: Serviceable LPY (inset) and close-up of TL’s LPY.

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Annex D to 1010-CC130323 (DFS 2-2) 12 November 2013

Annex D Photo 2: One Person Raft.

Annex D Photo 3: Motorola XTS 5000R Radio.

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Annex D to 1010-CC130323 (DFS 2-2) 12 November 2013

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Annex D Photo 4: Constant Wear Flight Suit (CWFS).

Constant Wear Flight Suit

Zipper

Socks

Neck Seal

Annex E to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX E: CWFS OPERATIONAL AIRWORTHINESS APPROVAL

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Annex E to 1010-CC130323 (DFS 2-2) 12 November 2013

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Annex E to 1010-CC130323 (DFS 2-2) 12 November 2013

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Annex F to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX F: AIRCREW INFORMATION FILE

This email and a copy of the OAC message represented AIF item number 62 (above). The OAC message text is as per Annex E.

TL’s Name

This segmented copy of the AIF “Initial as Having Read” document shows that the TL initialled for AIF 62.

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Annex G to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX G: EQUIPMENT FOUND on TL at RECOVERY ITEM 1 Whites “Titanium” model dive hood in place around head and face 2 LPY (inflated) with firefly 3 strobe light and whistle in front pocket, both cartridges

fired 3 100% cotton underwear briefs 4 100% cotton underwear undershirt 5 CF issue 100% cotton long john bottoms 6 Whites Glacier Mark 0 undergarment (covers wrist to wrist, crew neck to ankles) 7 Whites Glacier Mark 1 undergarment (covers wrist to wrist, crew neck to ankles)

(micro fleece) 8 Whites Glacier Mark 2 undergarment (covers wrist to wrist, crew neck to ankles)

(high loft fleece) but not associated jacket. 9 CWFS 10 5 Finger gloves Whites Titanium model 11 SLB 1000-200 in right pocket 12 Aqua Lung Dive knife 13 AP Day Night Flare 14 Wrist Altimeter, Galaxy 2 15 Wrist Watch 16 Petzel Light Tikka 2 17 McGreggor Socks 18 Whites Fleece Dive Booties 19 Whites EV03 Lace-up Boots 20 Force Fin Pro Swim Fins

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Annex H to 1010-CC130323 (DFS 2-2) 12 November 2013 ANNEX H: MANDATORY PERSONAL EQUIPMENT – In Water, Static Line (Reference: SMM Chapter 4 Section 3 Paragraph 1c.)

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Annex I to 1010-CC130323 (DFS 2-2) 12 November 2013

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ANNEX I: ABBREVIATIONS AA Airworthiness Authority ACSO Aircraft Combat Systems Officer AFMES Armed Forces Medical Examiner System AGL above ground level ALSE Aircraft Life Support Equipment AWL above water level C Celsius CAD Canadian Air Division CF Canadian Forces CMCC Canadian Mission Control Centre CO Commanding Officer Comd Commander CFTO Canadian Forces Technical Order CWFS Constant Wear Flight Suit CWIS Constant Wear Immersion Suit CVR Cockpit Voice Recorder DA Design Authority DND Department of National Defence DRDC Defence Research and Development Canada ETA estimated time of arrival f/s feet per second FDR Flight Data Recorder FMS Flight Management System FSIR Flight Safety Investigation Report ft Feet GPS Global Positioning Satellite System HOTEF Helicopter Operational Test and Evaluation Flight hrs hours IAS Indicated Air Speed JEP Jumper Exit Point JRCC Joint Rescue Coordination Center kts knots lbs pounds LM Load Master LPY Life Preserver Yoke LRSK Life Raft Survival Kit M magnetic m meters MHz Mega Hertz MLM Marine Locator Marker MND Minister of National Defence MSL mean sea level NDM Naturalistic Decision Making nm nautical mile

Annex I to 1010-CC130323 (DFS 2-2) 12 November 2013

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OAA Operational Airworthiness Authority OEM Original Equipment Manufacturer PLB Personal Locator Beacon POAC Provisional Operational Airworthiness Clearance QETE Quality Engineering and Test Establishment R Rescue RARM Record of Airworthiness and Risk Management SAR Search and Rescue SARPELS SAR - Parachute Equipment Lowering System SAR Tech Search and Rescue Technician SMM Standard Manoeuvre Manual 60-130-2605 Ch2 11 January 2011 SLB Survivor Locator Beacon SP Safety Person Sqn Squadron SRK Sea Rescue Kit SRR Search and Rescue Region SSDI Signal Smoke Drift Indicator SSO Senior Staff Officer TL SAR Team Lead TM1 SAR Team Member 1 TM2 SAR Team Member 2 T True north TOTEF Transport Operational Test and Evaluation Flight TAA Technical Airworthiness Authority TAM Technical Airworthiness Manual TRSET Transport and Rescue Standards and Evaluation Team VHF Very High Frequency USN United States Navy UTC Universal Time Coordinated WDI Wind Drift Indicator Wg Wing