IN THIS ISSUE: Better Safe Than Sorry How Well Do You Know …flightcomment.ca/wp-content/uploads/2003/03/2003-3-eng.pdf · Flight Comment, no 3, 2003 1 It was another gray day in

IN THIS ISSUE:How Well Do You Know Your Crew?

Try Not to Fry

Better Safe Than Sorry▼▼

▼SUMMER 2003

TABLE OF CONTENTS

Directorate of Flight SafetyDirector of Flight SafetyCol R.E.K. Harder

EditorCapt T.C. Newman

Art DirectionDGPA–Creative Services

TranslationCoordinatorOfficial Languages

Printer Beauregard PrintersOttawa, Ontario

The Canadian Forces Flight Safety MagazineFlight Comment is produced 4 times ayear by the Directorate of Flight Safety.The contents do not necessarily reflectofficial policy and unless otherwise stated should not be construed as regulations, orders or directives.

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“To contact DFS personnel on an URGENT Flight Safety issue, aninvestigator is available 24 hours a day by dialing 1-888 WARN DFS (927-6337). The DFS web page atwww.airforce.dnd.ca/dfs offers other points of contact in the DFS organization or write [email protected].”

ISSN 0015–3702A–JS–000–006/JP–000

1 ........................................................................................For the Birds?

2....................................................How Well Do You Know Your Crew?

4 ............................................................................A Long Day of Flying

6........................................................................................Try Not to Fry

8..................................................................................Eject! Eject! Eject!

10............................................................Air Force Flight Safety Training

11 .............................................What Would You Do?…ever been there?

12 ..............................................................................Maintainer’s Corner A Lesson NOT Learned:

A Disaster Waiting to Happen

14...................................Perishable Skill — Currency is Not Proficiency

16 ......................................A Simple Slap on the Tank Wasn’t Sufficient!

17 .............................................................When You Read…Do You See?

18 .................................................Did You Check All Those Cotter Pins?

20 ..........................................................................Better Safe Than Sorry

22 ........................................................................Discovering Electricity!!

24 ..............................................Did I Grow Wiser from the Experience?

26 .....................................................Won’t need ‘em — take two secs …

27 ..................................................................................A “Wake-Up” Call

28 .................................................................................................Épilogue

32 ............................................................................................Good Show

33 ...............................................................................For Professionalism

Flight Comment, no 3, 2003 1

It was another gray day in thespring on the west coast. — lower

mainland, Langley airport, specifi-cally. I flew L-19 tow aircraft for theRegional Cadet Air Operations —Lower Mainland Air Cadet GlidingProgram, and we were about toembark on another day of familiar-ization flying. The gliders wereuntied and the daily inspections(DI’s) were done. The gliders werepushed out to the field while I didthe DI’s on the Birddog, and taxiedout for the launch.

Away we went; the first series oflaunches went well and I began tosettle into the routine of towing,releasing, descending, approaching,and landing at nine to ten-minuteintervals. It was busy but there wasalways time to look out the window

for other traffic and for birds. It’s agood idea to note where the birdsare; our little planes don’t take tookindly to bird strikes.

About midway through the morning,I was at about 500 feet and begin-ning a climbing right turn with aglider in tow, when I noticed twoherons slightly above and crossingin front of me about a quarter of amile away. I continued the climbingturn and thought that they’d seeour two airplanes and move away.After all, our airplanes were biggerthan they were, and one of themwas very noisy, too. I was also usingall the lights on the airplane as perStandard Operating Procedures(SOP’s). My navigation lights, pulselights, strobe lights, and beacon

were all on, and I remember think-ing that the herons couldn’t missseeing us.

Call it complacency, or expectancy,but these two birds just kept fillingup the windscreen. Now I wascaught. There was no longer anytime to maneuver. I couldn’t makeany aggressive moves with a gliderin tow without seriously compro-mising the glider pilot and passen-ger’s safety. Fortunately, the heronsdid see our little formation at thelast second, and they did what birdsnormally do when they see troublein the air — they dove for theground. The rest of the flight wasuneventful, and the day’s operationcarried on.

I didn’t even report the incident;nothing happened, so there wasnothing to report, right? Hindsightbeing what it is, I now know that Ishould have said something to theflight commander, or whoever wasthe flight safety officer that day.Someone could learn from myexperience…or would they just saythat it was “for the birds?” ◆

Lieutenant Kerry

For the

Birds?Birds?

2 Flight Comment, no 3, 2003

The highlight of my career wasthe time I spent as a Tactical

Helicopter (Tac Hel) FlightCommander. The flying was excel-lent and the people I worked withwere very professional, althoughsome required prodding now andthen. However, I soon discoveredthat it is not necessarily the peoplethat you think require attention that will eventually surprise you.

When I introduced myself to mynew flight, I laid out the groundrules for performance. I had highexpectations and was particularlyattentive for the need to abide byregulations and flight discipline.Some, I’m sure, felt I was ratherpedantic, as I had little tolerance for pilots that did not strive to fly to the best of their abilities or wereignorant of orders governing airoperations. If I noted deficiencies,I personally took an interest in theindividual, ensuring that the mostqualified member of the flight

provided proper remedial training.In order to periodically verify thestandard within the flight, I preferredto fly with all members, however, ashortage of experienced pilots oftenforced me to concentrate on theweaker first officers, depending on the more competent aircrew to cultivate their own abilities without my immediate supervision.Occasionally, one would have diffi-culty with an Instrument RatingTest (IRT) or a check-ride, but theseproblems were usually quickly recti-fied and the embarrassment wassufficient to provide the impetus to seek a higher personal standard.

After some time, I developed con-siderable confidence in my subordi-nates. I had seen many maturewhile they progressed from secondpilot to aircraft captain. I had cometo know many of them quite wellover time, having served togetheron various deployments under very

arduous conditions; and I thoughtthey knew me. This particularlyapplied to one person that hadarrived in my flight at the sametime I did. Over two years, he hadbecome an excellent pilot and aresponsible, professional officer.Indeed, he was one of the manymembers of my unit that I dependedon to carry out his tasks with mini-mal supervision and guaranteedgood results. Indeed, he did not dis-appoint me for the entire month wehad been deployed to CFB Gagetownto support both 438 and 430Squadrons on a field exercise.I was proud of how we had performed during the exercise.

How Well Do You

KNOW YOUR

?


It had been a very long four weeksand we were all tired of living in thefield. Everyone continued to performwell, but it was evident that it wastime to leave and all were anxious.

Assuming that there was no wayanyone would ever dream of break-ing the rule prohibiting an overflightof the camp, I directed departurepreparations with the normal brief-ings and flight planning, concen-trating on salient details. We were to leave in sections in order to avoidcongesting some of the smaller airports where we would have tostop for fuel. As the first sectiondeparted and the second began tostart their aircraft, it seemed to beturning out to be a beautiful day for flying. The wind was calm andthe sun was shining. It was almosttranquil until I heard the thunder-ing blades of a Twin Huey. Withouteven seeing it, I could tell unmistak-ably from the sound that the aircraft

was approaching fast and low. Iturned just in time to see it fly overthe camp and turn sharply on thedeparture path. I knew who it was.How could he do this potentiallydangerous and very unsafe act,knowing how I felt about flying by the rules?

At first you could have knocked myeyes off with a stick, however, myshock soon turned to anger. Yet,my anger was easily subordinatedby the rage of the 430 SquadronCommanding Officer (CO). He wasabsolutely livid and was certain thatthis undisciplined act was a directresult of my supervisory skills, orlack thereof. I soon departed, stillaffected by the incident. I was dis-appointed in the pilot’s behaviourand the CO’s opinion of me. WhenI caught up to the individual at thenext stop, the individual was some-what surprised at my irritation.He assumed it was okay to do the

flypast since the exercise was nowover, not thinking that it was a serious breach of flight discipline.Needless to say, my discipline wasswift and effective.

The individual in question neverdid get a last flight before taking his release as part of the CanadianForces reduction plan (FRP). It hadbeen his farewell flight, albeit some-what premature. It just goes to showthat some things may be worthrepeating, even if you don’t thinkthem necessary. Maybe your peopledon’t know you as well as you thinkthey do and it is likely you don’tknow them any better. They justmight surprise you! ◆

Major Vogan

CREW


On November 1987, while basedout of 413 Rescue Squadron in

Summerside, Prince Edward Island,our Buffalo crew was tasked torespond to an air medical evacua-tion (med-evac) to Bathurst, NewBrunswick. We were to transfer apregnant woman who was havingextreme difficulty giving birth. Theweather at the time was rainy andcool and it was dusk. The transferwas to Halifax, Nova Scotia and wehad an air med-evac team on board.It was our third tasking of the day,and we had already flown approxi-mately seven hours. Although wewere tired from the day of taskings,we felt because of the short transittime to Bathurst, Halifax, and thenback home (approximately twohours), that the task would be quick

and the woman saved. As a crew,we had decided to accept the taskbecause of the nature of the emer-gency and also because it would taketoo long to call in the back-up crew.

After landing in Summerside, werefueled and, with the air med-evacteam on board, we proceeded toBathurst to complete our mission.It was raining at the airport whenwe started our approach to landingand the runway lights were on.The landing was smooth due to thewet runway and the taxi to the main terminal seemed as normal as any

other time. Usually during an air med-evac, while taxiing to the terminal, I would be helping theteam set up their equipment for thearrival of the patient. This particularday I felt tired and, as there were lotsof people to help with the set-up, Idecided to sit on the right-hand-sidespotter seat.

As we were taxiing and only about100 feet from the turn off to the terminal, I noticed the right-hand,landing-gear wheels were right onthe edge of the taxiway. When theaircraft just started its turn into the terminal, the pilot had turned

A LONG


of FlyingDAYa little early and the right-handwheels rolled off the taxiway andwere lined up to hit the blue taxiwaylights that indicate the turn-off tothe terminal.

Immediately, on the intercom, I gavethe command “stop, stop, stop”and the pilot jumped on the brakes,sending whoever was standing up to the floor of the aircraft. With “not happy voices” coming acrossthe intercom, they soon calmeddown after realizing that the aircraftcame to stop only inches away fromrunning over the light stand, which

would have caused not only thedelay of the med-evac, but alsomajor damage to the landing gear.

The day was saved and the med-evac was carried out successfully.Enroute to Summerside, the crewdiscussed the importance of team-work and the importance of beingalert after a long day of flying. Imade it a point from that time onto always be aware, both in the airand on the ground, for any possibleincidents that could happen. ◆

RESCUEP.H. Fleming

Fry


Those of you who have been inthe Air Force for a while will

know that, every so often, aviatorsexperience a metamorphosis,which I call “The Changing of theFlight Suit.” Since the halcyon daysof the 50,000-strong air force (yes Martha, we really were thatbig once!) we have slipped thesurly bonds of earth clad in flyingtogs that morphed from dull grayto dark blue to dark green, to tan,and to blue-gray. Finally, afterspending time in such interestingneighborhoods as Rwanda, Iraq,Aviano, and the Balkans, many ofus realized what the tactical heli-copter folks had known all along;pretty blue suits with flashy goldaccoutrements just don’t cut it outthere. Toned down flight suits,while less than totally cool at airshows and at the bar, are just theticket on operations. Now, we’reshedding our skins again, toemerge from the hangar, anew,clad in toned down sage green.This time, however, more than thecolour has changed; our new suitsare made of flame resistant (FR)Aramid. We’ve gained significantoperational capability, but at quitea cost; the price of our flight suitshas risen by 130 percent!

We received our first shipment of approximately 9700 summerflight suits (one-piece) last spring,with more on the way. This was

followed by 2700 tactical heli-copter two-piece flight suits and12,000 interim flight jackets lastsummer. The FR winter flightsuits (two-piece) were tested inCold Lake before Christmas andwe expect to receive 9000 sets inNovember 2003. Until we havesufficient quantities of the newgarments to equip all aircrew,they are being issued under thecontrol of 1 Canadian Air DivisionHeadquarters. Thereafter, theywill be available for general issue.

Many of us have never wornAramid, so this may be an oppor-tune time to replace the inevitablerumours and flight line legendswith some facts about the capa-bilities and limitations of thesecool (and costly) new duds.Aramid is the generic name for atype of FR fiber known to manyof us by the DuPont trademark“Nomex.®” Aramid does notmelt or drip and forms a toughchar when exposed to flame or high temperatures. Beinginherently flame resistant, its FRcapabilities are not affected bylaundering. The flight suits canbe machine-washed using house-hold detergents, but fabric soft-eners should be avoided. Fabric

softeners contain paraffin, a flam-mable substance that adheres tothe material. There’s not muchsense in wearing a FR suit coatedwith a flammable substance!

Now you know that our new suits won’t burn. That’s the goodnews, but there’s a catch. Yourtender little body, clad only in a FR flight suit, can still sustainsubstantial second and thirddegree burns in a flash fire. Why?In a word, insulation. Canadiansunderstand insulation when itcomes to houses, parkas, andother means of preventing heattransference. The same principlesapply to protecting ourselvesfrom the extremely high tempera-tures of a flash fire. While it maynot burn, the flight suit will stilltransfer lots of heat through thematerial to the body. Insulation,in the form of a second layer, isthus essential to the minimizationof burn injuries. This has beenproven conclusively in burn trials conducted both by DND at the University of Alberta and by DuPont, using their fully instrumented mannequin(Thermo-Man®) to measure heattransferrance. In the illustrationsbelow, kindly provided by DuPont,the mannequin was clad in thestandard USAF 4.3 ounce Nomexflight suit (model 27/P) and sub-jected to a three-second flash fire.In the first test, the mannequinwas clad only in the FR flight suit.In the second test, the mannequinwas wearing a second layer, consisting of short-sleeve T-shirtand briefs. Note the burns on the lower arms and legs. In thethird test, a second layer of long underwear was used.

FryTry Not

to to Try Not


head (helmet, visor, oxygen mask)will add protection and increase the chances of survival, but thenumbers are still significant.

Depending on what we fly andwhat the temperature is, manyof us may already be partially orfully covered by a second layer inthe form of flights jacket, anti-Gtrousers, or survival vests, not tomention the standard issue cot-ton long underwear. But when itgets hot and dusty, we tend toshed layers; indeed, our flyingorders direct local commandersto “promulgate an order on thewearing of dual clothing layers,with due consideration for heatstress.” This way we can mitigatethe risk of heat stress when itoutweighs the risk of burn injury.

Aircrew are trained to use initia-tive and, those of us who use itwisely, tend to go far. Chancesare then, that some of us makepersonal decisions to chuck thelong johns sooner than autho-rized, when the mercury starts to rise. Hopefully, this article willsensitize all aircrew to the riskswe take when we make thesepersonal choices. Fly safe!

DuPont Thermo-Man® thermalprotection system is based onASTM Standard F 1930-99 whichapplies to flame resistant cloth-ing. These conditions may not bytypical of the conditions encoun-tered in actual situations. Theresults of these tests are only predictions of body burn injuryunder these specific laboratoryconditions. These results do notduplicate or represent garment orfabric performance under actualflash fire conditions. The user issolely responsible for any inter-pretations of the test data pro-vided by DuPont, and included inthis material, and for all conclu-sions and implications made con-cerning the relationship betweenmannequin test data and real lifeburn injury protection. SINCECONDITIONS OF USE ARE OUTSIDE DUPONT’S CONTROL,DUPONT MAKES NO WAR-RANTIES OF MERCHANTABILITYOF FITNESS FOR A PARTICULARUSE AND ASSUMES NO LIABILITYIN CONNECTION WITH ANY USEOF THIS INFORMATION. This datais not intended for use in adver-tising, promotion, publication orany other commercial use. ◆

Because the mannequin is bareheaded, test results always includeburns to the head. The followingtable shows that a person clad inthe new summer flight suit andlightweight long underwear willsustain burns on 18 percent of thebody, including the head, andwill have an estimated chance ofsurvival of 97%. Depriving the legsand arms of second layer protection(photo 2 above) will lower thechances of survival to 80%. Of course, anything worn on the

Photo 1

Photo 2

Burn table

Photo 3

THERMO-MAN® TEST RESULTS FORCANADIAN AF PROTOTYPE SYSTEMS

SYSTEM PRED. BURN INJURY ESTIMATEDWeights in oz/yd2 2ND D 3RD D TOTAL % SURVIVAL

4.3 Nomex® + Lt. Wt. Long Und. 18% 11% 29% 94

5.5 Nomex®IIIA + Lt. Wt. Long Und. 9% 9% 18% 97

5.5 Nomex®IIIA + Hv. Wt. Long Und. 1% 7% 8% 99

Nomex® Rainwear + Lt. Wt. Long Und. 1% 7% 8% 99

Nomex®IIIA Fleece + Lt. Wt. Long Und. 1% 7% 8% 99

Nomex® Rainwear + Fleece + Sht. Und. 0% 7% 7% 99

* Thermo-Man® Single Test results, 1X HML, 2 cal/cm2s, 4 second ExposureSource of Estimated Survival: American Burn Association 1991-1993 Study

PERFORM WHEN THE HEAT’S ON


When a pilot utters thesewords and pulls the

handle on the ejection seat, the escape systems better workproperly. These systems are thelast resort life-saving measurefor aircrew and must be reliable.As the flight test authority forthe Canadian Forces, AerospaceEngineering Test Establishment(AETE) was tasked to addressdeficiencies associated with theCT-114 Tutor and CT-133 Silver

Eject!

Eject!

Star seat ejection systems. An escape systems specialistteam was formed, headed bythe project officer, CaptainCharles Matthewson.

In June 1999, AETE was assignedto clear the 28-foot circularparachute on the CT-114 Tutorand the CT-133 Silver Star. TheCT-114 passed all tests; the CT-133 did not. The team at AETEdiscovered a potential hazard —major seat/person separation

Eject!problems. In some instances, onejection, the combination ofcertain “all-up weights” (AUWs)and low centres of gravity(CofG), pitched the seat slightlyforward, inhibiting seat/personseparation. The last thing apilot wants when ejecting froman aircraft is the added worrythat the seat might collide withthe parachute or worse, withhim or her. What was neededwas for the seat to “aft tumble,”


as the slight rotation spins theseat away from the pilot, likewhat happens when snow fliesoff the treads of a car tire.

The team tried to modify thevariables of the test (AUW andCofG) but after two failures,they were faced with the factthat the plane ejection systemon the CT-133 was unsafe,which led to the grounding ofthe fleet on 8 Oct 99. To find asolution, the team went to theAerospace Equipment ResearchOrganization (AERO) to test the AERO rigid arm drogue

(ARAD) — a telescopingaluminium

arm with a drogue chuteattached to it. During an ejection sequence, the ARADextends and the drogue chutedeploys, increasing the drag on the seat, which allows forseat/person separation. Thisequipment now had to gothrough various stages of quali-fication testing on the groundand in the air.

ejection envelope. In order totest the ARAD from ground levelto simulate the low-altitude, low-speed ejection, a test vehicle wasneeded. And what a vehicle itwas — a jet black standard 1998Dodge 3500 Series Chassis CabModel truck powered by an 8L,10 cylinder gas engine capable of speeds of up to 175 kph, aptlynamed “Black Thunder.” It has aprotective cage enclosing the cabin case of direct hit from the ejec-tion seat after firing. The rear ofthe cage also serves as protectionfor the passengers in case of arollover. All of the test equipment(generators, cameras, strobes,radio, fire extinguishers andother test components) includingthe ejection seat and the “dummy”were mounted on an 8-by-10 footflat deck located behind the cab.

An even bigger challenge was to create a test bed for in-flightejection seat testing. The teammodified a CT-133 aircraft. Theyremoved the rear seat and allrear cockpit controls from the 2-seater, low-wing monoplaneand installed a test ejection seat.Among many of the changesmade to the aircraft, a stainlesssteel blast shield was put in to

protect the rear cock-pit from heat

and reducethe chancesof gases andsmoke waft-ing to theforward

cockpit. Theyalso removed

the rear cockpitplexiglas so therewould be an unob-structed path forthe ejection seat to clear the aircraft.Extensive testing on the ARAD beganin Dec 99 and wasdone in a phasedapproach.

• Technology demonstration andrisk reduction testing:

A prototype ARAD wasinstalled on the ejection seatand was fired one time from“Black Thunder” and fourtimes from the air in the modified CT-133.

• Basic certification:

During this next phase, the team needed to have aminimum of eight consecutivesuccessful tests. This includedtwo ground-based ejectionsfrom “Black Thunder” for the low-speed testing and sixairborne shots at various AUWand CofG offsets. Both the 24-ft and 28-ft flat circularparachutes were used at thistest stage. An additional twotest points were conducted to address CofG concerns as directed by Director ofAirworthiness.

The CT-133 testing occurred without incident resulting in theapproval of the ARAD installationon all T-Bird ejection seats by theDirector of Technical Airworthiness.Aerospace and TelecommunicationsEngineering Support Squadron(ATESS) in Trenton made installa-tion kits, under contract withAERO, with the ARAD installationon all the ejection seats performedat the Squadrons operating theaircraft. The grounding of thefleet was lifted on 26 Jul 2000.

AETE is currently involved in aprogram to test the installation ofthe ARAD on the CT114 Tutor andimprove the seat/person separa-tion to make the escape systemssafer. This world-class facility, intesting the operation of the ejec-tion seat and making significantimprovements on safety and relia-bility standards, has improved theseat-person separation and greatlyreduced the risk of serious injuryfollowing an ejection. ◆

Ray Carter Project Escape Systems Specialist

The CT-133 seat had a 0/60 (0 altitude and 60 knots of speed)


Many members have heardof the flight safety (FS)

course, which is conducted bythe 1 CAD FS Team. The courseis a seven-day, interactive ses-sion that is designed to developessential skill sets to form andrun a unit safety managementprogram. This article will pro-vide you a brief overview of theBasic Flight Safety Course (BFSC),which arguably is one of themost effective safety manage-ment courses available, be itmilitary or civilian.

The flight safety system as we know it today, was createdin the mid-60s by GroupCommander “Dutch” Schultz.The BFSC was in response to therapidly increasing aircraft acci-dent rate of the time and waspart of many initiatives thatnow form the core of our flightsafety program. For many yearsthe course was only for aircrewofficers; however, as we haveevolved the ‘team concept,’today’s course is 50% NCMs and 50% officers, which is idealfrom our perspective.

The FS system has evolved quitea bit since its early days in the60’s; however there remainsonce constant, that being toprovide specialist advice toenhance operational effective-ness. Over the past few years,

the BFSC has made human factors in decision making theheart of the program. Humanfactors and their consequencesform an essential part in under-standing “why” a course ofaction was chosen in a particu-lar situation; moreover it is oneof the more dynamic and inter-esting portions of the syllabus.These tools provide the unitflight safety professional theability to conduct effectiveflight safety incident investiga-tions, make the assignment of meaningful cause factorsthereby improving our ability to introduce more effective preventative measures.

The BFSC is offered five times ayear with one advanced serial(AFSC) in September. BFSC can-didates are selected by theirCommanding Officers (CO’s) to fill the FS NCM or FS Officerpositions on their unit. The can-didates must be operationallycapable and have supervisoryexperience, for it is their skillsets that enhance the effective-ness of executing the CO’s flightsafety program. The course isseven days in length and is heldat CFSSAT, 17 Wing Winnipeg.The schedule is ‘packed’ andprovides the candidates a hostof topics essential for a safetymanagement program. This was best typified in a recent comment of the course critique“Okay I am not thirsty now, you can turn off the fire hose!”In addition to human factorstraining, risk management, incident investigation and report-ing, cause factor assignment,

promotion and education tech-niques, and program develop-ment are some of the topicstaught; additionally, skill sets for effective utilization of thecomputer based FS InformationSystem (FSIS) are developed. The main cadre of instructorsare from the 1 CAD FS team,however, numerous subject matter experts are brought in from across the country toinstruct on a variety of topics.

For those selected for Wing FSHQ staff flight safety positions,the AFSC is offered eachSeptember. If the candidate has not had the BFSC within the past three years, the entirecourse must be taken with theAFSC modules as the contentand scope has changed signifi-cantly. The advanced coursereinforces many of the topics on the BFSC as well as coveringadditional topics such as medical,media and accident investigation.There are also a series of casestudies and emergency responseanalysis.

For those interested in takingthe BFSC, contact your unit FSrepresentative and indicate you are interested in joining theFlight Safety Team. If selectedby your unit CO, names are forwarded to the WFSO whowill in turn prioritize candi-dates. The flight safety role is a tremendous leadershipopportunity and allows individ-uals to directly enhance missionaccomplishment. ◆

Captain Green1CAD FS TRG

AIR FORCE FLIGHTSAFETY TRAININGwww.airforce.dnd.ca/orgdocs/hq_fs_e.htm


It was supposed to be one of thosereally great trips we get only once

every blue moon. I was a junior co-pilot on an air show trip fromShearwater, Nova Scotia to LangleyAir Force Base in Virginia. Theweather in Shearwater was lovely,but we were heading into a develop-ing low on the eastern seaboardwith, as usual, several associatedfronts. We stopped in Hartford-Brainerd, Connecticut for fuel beforecontinuing our flight over JFK,LaGuardia, Newark, and variousother busy international airports.

Hartford was reporting ceilings lessthan 1000-feet with visibility threemiles in heavy rain showers. Wewaited for the “1000/3” call from the tower before we pulled into thehover in our Sea King. About fiveminutes southwest of the airport,we encountered 400-500-foot ceilingsin climbing terrain, poor visibility,and rain. The decision was made by our Aircraft Commander (AC) to climb into the cloud to ensureground clearance. We consideredturning around, flying out to thecoast where we could descend, orsimply flying the contours, but, notwanting to be late for the Air ShowParty, we elected to press on.

When we entered cloud, I beganpreparations for contacting NewYork Approach Control to file anairborne IFR flight plan. To myprotest, I was told by the AC not to file IFR, as we would simply rely on VFR flight-following fromNew York Radar to maintain aircraftseparation. The AC’s reasoning was

that New YorkApproach certainlywouldn’t appreciate alittle old Canadianhelicopter requestingan airborne IFR flightplan, right while they werebusy vectoring no less than thirtyairliners through the cloud. Atabout 3000-feet, while in cloud,radar contacted us and queried ourcurrent meteorological conditions.“We’re VFR,” responded the AC.Again, radar queried, “Talon XX,confirm you’re VFR?” to which thereply came again, “that’s affirmative,we’re VFR.” To my protests, we con-tinued to fly VFR, in IMC conditions,over the busiest airspace on the east-ern seaboard of North America,relying only on the premise thatNew York Radar would vector usaround all the IFR traffic in the area!

Nearing 6300 feet, New York Radarcalled us with traffic information,“Talon XX, you’ve got a Mooneyheading your way at 6300 feet, oppo-site direction, three miles. Confirmvisual?” “Looking,” came the reply.“Looking at what?” I thought,“All I can see is white!” At 6500 feet,45 minutes after entering IMC con-ditions, we broke out of cloud, onlyto see, seconds later, a bright red,single-engine Mooney roar belowthe cockpit. The crew figured that we were less than 1/2 mile from theMooney, with vertical clearance of less than 200 feet.

That trip has taught me manythings, and thankfully, I’ve lived to

tell the tale. Even as a new crewmem-ber who is unfamiliar with localoperating procedures, we all knowthe CFP-100, and there are noSquadron standard operating proce-dures (SOP’s) which permit us tobreak its rules! If you feel your air-craft is in jeopardy, or you or yourcrewmembers’ lives are being put inharms way without due cause, thereare many options available to you.I tried several, but to my regret Ididn’t try all of them. You should:

• Speak up, voice your concerns!

• Turn the aircraft around, and flyback into a safe flight regime!

• Tell your AC why you’re not com-fortable with what is happening,and why you don’t want to be apart of it!

• If all else fails, report the incidentto a higher authority!

• Regardless of the outcome,write a Flight Safety — shareyour lessons learned so that allmay benefit!

What would you do? ◆

Captain Leonard

WHAT WOULD YOU DO?…ever been

there?WE’RE

VFR !!!


What incited me to writethis article was an incident

that happened in February2003. As the story goes, it was a dark night, and a van was proceeding along a taxiway. The van driver saw a tow vehicleapproaching and moved to theright. Unfortunately, the towvehicle appeared to be movingin the same direction. The driverof the van sensed somethingwas wrong, swerved to the leftto avoid the vehicle, passed thetow vehicle and saw that an aircraft was being towed. Thedriver of the van did not knowuntil that moment that therewas an aircraft behind the towvehicle. The incident report didnot say but I bet that the vandriver’s heart must have skippeda beat or two when he or sherealized how close to the aircraft the van had came.

When I read this incident, myown heart skipped a few beats,and I was taken back 14 years: itwas October 1989, and a frienddied that night. That was a terrible accident, one we allwish will never repeat itself.However, the incident of lastFebruary (2003) was almostidentical to the accident of ’89,except nobody died. So, when Isaw this latest incident I was

shocked and I could not helpwondering HOW THE HECKCOULD THIS HAPPEN? Haven’twe learned anything from thattowing accident — a fatal acci-dent? I know that preventivemeasures had been implementedfollowing the mishap; I clearlyremember that when we towedat night we had to have strobelights attached to the wingtipsand the tail hook of the aircraft.That way, vehicles coming fromany directions could see thatsomething was being towedbehind the mule. So, what happened to those measures?To tell you the truth, I have noanswers. They may have beenonly local operating procedures.Nevertheless, I looked in theCFTOs to find out what theproper towing procedures are,and what I found was prettyinteresting.

The basic reference for towingof aircraft is in the C-05-005-P06/AM-001. A caution afterparagraph 7.g in Part 2 says: “… the aircraft extremities shallbe made visible from the frontand rear.” This can be accom-plished by using “… floodlightsfrom the towing and followingvehicles, or may be indicated byflashlights of safety personnel.”

CORNERMAINTAINER’SA LESSON NOT LEARNED:

A DISASTER WAITING TO HAPPEN

The work of maintainers has many inherent dangers. Tasks such as starting or parkingaircraft, refuelling operations and towing can be dangerous if we do not follow basicsafety procedures. Towing at night can be particularly deadly, if we are not careful.

The message in the caution is that the aircraft under tow has to be visible, no matter fromwhich directionanother vehicle may approach it.

On a well-lit ramp, this step maynot be necessary because theaircraft will be visible. But whenthe aircraft has to be moved topoorly lit or dark parts of theairfield, precautions have to betaken to protect other drivers.Of course, this demands somekind of preparations before thetow job is started, such as thelighting conditions of the routeto be taken and serviceability ofthe floodlights on the towingvehicle and of the flashlightscarried by personnel.

As mentioned above, the air-craft has to be visible at night,and that responsibility falls onthe tow crew chief. However,other drivers have their share of responsibilities when drivingaround an airfield.


• Always assume that anincoming mule is towing an aircraft.

• Slow down so you have timeto get out of the way beforethe tow vehicle reaches you.

• Drive on the far right of thepaved surface.

I just hope that by reading thisarticle, people will be remindedof the danger of towing atnight and will take the neces-sary precautions to avoid colli-sions. Look at the pictures of

the accident of October 1989,the night a friend died. We were supposed to havelearned from that. ◆

Sergeant Anne GaleDFS 2-5-2-2

The aviators involved in thisaccident were NVG current.They met the ATM standardsrequired to conduct the mission.However, neither crewmemberhad flown more than threehours of NVG flight in a singlemonth for over seven months.We have all seen this in ourunits at one time or another.Other mission requirements,administrative obstacles, orflight time restrictions have putnearly everyone in this positionat some time. Most often, wemanage to get the missionaccomplished when called on.The problems arise when an aviator who is just maintainingcurrency is placed in conditionswith which he is unfamiliar andthat require real proficiencyrather than currency.

In this case, we put these aviatorsin a dusty, windy environment,with low illumination, with littlerecent experience under NVGs,and all these things added up to


Perishable Skills.” We have allheard the phrase, “That’s a

perishable skill,” but what doesit really mean? I have heard itfor almost twenty years andalways thought of my golfswing as my most “perishableskill.” But a recent accidentinvestigated by the SafetyCenter brought the phrase back to mind in a much moreappropriate way.

This UH-60L accident serves as a prime example of how perish-able some skills really are. Itinvolved a crew that no oneever expected to have an acci-dent. The instructor pilot hadover 8000 hours of rotary-wingexperience; the pilot was youngbut highly thought of, and allthe crew members had flowntogether many times in thepast. Both aviators were quali-fied and current for the nightvision goggle (NVG) environ-mental training mission. Theproblem? Neither crewmember

had significant recent experi-ence in NVG flight. The hostileconditions overcame their skills.They became disoriented duringa takeoff and crashed, destroy-ing the aircraft. Fortunately,everyone on board will fullyrecover from their injuries.

We are all aware of “NVG cur-rency” requirements as stated in the Aircrew Training Manual(ATM) for each aircraft. Instructorpilots and unit commandersconstantly monitor aviators toensure that everyone remainscurrent by flying at least onehour every forty-five days undergoggles. As long as we maintainthat standard, we can reportcombat-ready goggle crews tothe chain of command everymonth. However, in the back ofour minds, we all know that oneflight every forty-five days doesnot maintain the proficiencynecessary to execute the toughmissions we may be called uponto complete. This mission is aperfect example.

“Perishable”

— Currency is Not ProficiencySkill

“


a situation primed for an acci-dent. The cumulative effect ofthe risks associated with thismission exceeded the capabilityof the crew, and a major accident was the result.

If any one of the conditions —low recent experience, dust,winds, or low illumination —had not been present, perhapsthe accident would not haveoccurred. If the aircrew hadmore recent experience, theywould have been better able to deal with the harsh environ-ment. If the illumination hadbeen better, their low recentexperience might not have beena factor. If the conditions hadnot been as dusty, perhaps thecrew would not have becomedisoriented. If, if, if...

The key lesson to be learned isthat there are perishable skills.Night vision goggle flight is oneof the most perishable skills inour business. When circumstances

force us to maintain NVG cur-rency rather than proficiency,we must be aware that thoseaviators are not ready to proceeddirectly into harsh environments.Commanders must transitionthrough the crawl, walk, runscenario. NVG currency is thecrawl. NVGs in adverse condi-tions, such as the desert orother severe environments, are Olympic events. We can’texpect aircrews to go straightfrom one to the other. ◆

LTC W.R. McInnis, Chief,Aviation Systems and AccidentInvestigation Division, U.S. Army Safety Center, DSN 558-9552 (334-255-9552),[email protected]

Reprinted with kind permission of“Flightfax” magazine, editionFebruary 2003.

DFS Note:We include this recent article from the US Armynot because of the NVGproficiency lesson, butbecause that lesson appliesto almost any kind of pro-ficiency. I’ve been using the words: “currency is not equal to proficiency”(because I heard them fromyou, the people of our Air Force whom I admire so much) in the annual DFSbriefings for some timenow, but understandingthe concept doesn’t makeit eliminate the problem.What can you do to ensureinsufficient proficiencydoes not turn into an acci-dent in your part of the Air Force? You can identifythose tasks or sequencesfor which, in your profes-sional and valuable opin-ion, proficiency is not whatit should be to conductthem safely. You can thinkand brainstorm ways youcould improve that profi-ciency or reduce the risksassociated with the tasks,and you could ensure yourleaders know about yourconcern and collaboratewith them in reducing therisk. To get you thinking,read the article…

Colonel HarderDirector of Flight Safety

Is your NVG proficiency morefunctional than thisoutdated helmet??


Iwas an air weapons system (AWS)technician, fresh from my training

in Borden, and I had been at ColdLake for just two weeks. Naturally,I was very excited about starting my new career in the Air Force and I was especially excited aboutworking on fighter aircraft. At 419Squadron, passionately known asthe “Moose” Squadron, I was work-ing on the night shift, carrying out reconfiguration changes.Reconfigurations were very com-mon on the CF-5 as the studentpilots transitioned through variousphases of their training.

Most of the work had been com-pleted, but we had one more job to do. It involved the removal of acentreline fuel tank, followed by the

installation of a rocket launcher.The job was to be completed by twovery experienced corporals and me.I was directed to take up my posi-tion, as I had on other occasions,at the tail of the fuel tank with mybutt on the floor and my kneespropped up underneath the stabi-lizer fin. One of the corporals tookup position at the front and theother prepared to remove the safetypin and unlock the rack, allowingus to lower the tank. When the rackwas unlocked, the front of the tankcrashed to the hangar floor and Iwas left supporting the weight of afull centre-line fuel tank. I wasquickly helped from under the fueltank and, luckily, everybody escapedwithout injury.

The procedure required us to physically open the fuel tank anduse a flashlight to confirm the tankwas empty, prior to removing it.Obviously, this very important stepwas omitted. Instead of using theproper method, we used a simpleslap on the tank to determine itscontents. This incorrect practicewas used to save a little time.Hindsight being what it is, the mistakes are easy to identify. We leta hectic pace and poor judgementallow us to omit a very importantstep in the process. Unfortunately,this created a very dangerous situa-tion. The fuel tank sustained dam-age at the front end, but we werefortunate to escape without injuryto personnel. ◆

Sergeant Coombs

Wasn’t Sufficient!A Simple Slap on the Tank


Prior to autumn 1999, I wasemployed as an Avionics

Technician on a First Line RepairCrew at 8AMS Trenton. I havealways taken pride in the attention I paid every job I was given, but the following incident causes me to question how observant I have been.

During AUP update, an aircrafttechnician employed by the con-tractor created two entries into the CF336 Aircraft Minor DefectRecord on aircraft #334. The firstentry stated that wires to a cannonplug had broken strands andrequired resoldering. The secondentry stated that the pilots forwardcircuit breaker panel had damagedwires. The type of damage was notstated. The repairs were deferredand this unit carried out the aircraftacceptance check. The aircraft flewclose to 180 hours without rectifica-tion. A supplementary check wascarried out and again these snagswere not rectified. A further 421 flying hours were accumulated untila technician examining the log setbefore Periodic Inspection noticedthe defect.

Inspection of the cannon plugfound six wires with brokenstrands. One wire was so badlydamaged that attempts to read thelabeling on the wire caused it tobreak completely. A second wirealso broke during the inspection.Wires affected were part of the NLGPosition Indication System, GroundCollision Avoidance System, IFFTransponder, and Emergency BrakePressure circuits. Wires behind the

CB panel had damaged insulationand exposed conductors, however,no strands were broken. The poten-tial for dire consequences hadexisted for over 600 flying hours.

During my Integral Systems TQ3, Iwas taught that broken strands arenot permissible on wire gauges #12to #22 installed on CF aircraft. TheAircraft Wiring Procedures in C-17-010-002/ME-001 further articulatesthis. Furthermore, the importanceof examining the log set beforedoing a job was stressed repeatedlyduring all aspects of my tradestraining. With that in mind, it isinconceivable to me that an aircraftcould accumulate that many flyinghours without anyone questioningthese entries. How could anyone,myself included, continue to read

these entries beforeand after every flight,and not “see” them?

I feel that the answer to that questionlies in one word — Discipline.Checking the log set had become soroutine for me (and I am guessingeveryone else as well) that I failed tothoroughly pay attention to what Iwas reading. These entries were notworded ambiguously. In fact, theywere very explicit. The statement ofbroken strands should have cluedme in, and would have, if my checkswere more than cursory. Personaldiscipline should be applied to allaspects of the job, not just thehands-on. This incident drovehome this point to me. I can guar-antee my checks of the log set willbe more than perfunctory fromnow on. ◆

THE LOG BOOKS LOOK OK

TO ME…

When You Read

Do You See?

Check All

Did You


It was a Monday morning in lateJune, the day after a three-day

air show weekend, and all of the visiting aircraft were preparing todepart. There was one lone Boeing707 in the circuit doing some training…as if things weren’t busyenough! Looking up at the greatwhite sacred cow, it seemed thatsomething just wasn’t right. As itflew past the tower, I saw that onlythe nose-wheel gear and the leftmain-gear were down. Shortly afterreporting the news back to the sec-tion, a two-bell emergency soundedand things just got busier.

The Boeing went to dump fuel andto try to shake loose the hung-upgear in the air. Departure timeswere rapidly moved up in anattempt to get all the visiting aircraft airborne before the Boeingwould possibly tie up the runwayfor hours. After all the departures,the pilot made several failedattempts to shake the gear looseusing the runway, and finallybrought the Boeing in on thesmoothest landing I had ever seen.First, the left main-gear touched the concrete, followed by the nose-wheel and then the #3 and #4

nacelle. The pilot brought theBoeing right down the middle of the runway to a halt.

I was part of the crew that assistedin the investigation and recovery ofthe Boeing off the runway. Sincethere was a heavy training schedulefor the next day, removal of theplane became a priority. It was hotand humid and the work was gruel-ing, and every attempt to raise theright wing initially failed. The hugecable on the crane snapped; we atechalk as the airbags burst like bal-loons; we stumbled chasing their

CheckAll

Did You

Those Cotter Pins?


compressors as they vibrated acrossthe runway. Finally, with persever-ance and a combination of theremaining airbags, the crane, and acouple of strategically placed jacks(which required field-level modifi-cations as pieces fell off) we man-aged to raise the wing high enoughto lower the gear. The following listis the ingredients required to lowerone hung-up Boeing main gear:

• one temporary, well-placed jack;

• cargo straps (various lengths);

• one 6 x 6 piece of lumber,wedged under main wheel;

• one nice big sledgehammer (for above-mentioned 6 x 6);

• a couple of chains; and,

• the assistance of one firefighterwith the Jaws of Life.

How, you ask? I’ll leave that to yourimagination and, all I’ll say is, itseemed like a good idea at thetime!?! It worked and the gear wasdown and locked quickly. Therewere probably a series of events thatled up to what happened, but whatstuck in my mind the most was thatit was a small cotter pin, or lack

thereof, on a 3/16 bolt on the up-lock link that caused the up-lock tofail that day, hanging up the right-hand main gear. The bolt and thecastellated nut were found withouta mark on one of the gear doors,while gaining access to lower thegear. It’s surprising how that smallcotter pin could bear such hugeconsequences. Since that day,I always ask myself (and everyone I work with!) “did you check allthose cotter pins?” ◆

Master Corporal Rosche

Those Cotter Pins?

SorrySafeSorrySafe


About ten years ago, I was workingas a new air weapons controller

(AWC) on my first tour in theNorth Bay underground complex.We were known as “Sidecar control.”It was a midnight shift and most of the CF-18 flying operations hadended for the day. It looked likeanother night destined for simula-tor training when, from the radioconsole, we heard “Sidecar, Sidecar,this is XPLR; request a mode-4check.” It only took a simple switchaction to perform the electronicidentification test that revealed that the transponder system on theoutbound Aurora was functioningproperly. I replied “XPLR, mode-4sweet; have a good flight.” Theirflight plan indicated that theywould be conducting an over-watersovereignty patrol for the next sevenhours. Tracking them by radarwould be futile as they fly low-levelwith their transponders turned offduring tactical operations.

The Air Defence community recentlyhad a renewed interest in the capa-bilities of the Aurora as this aircraftwas ideally suited to track and monitor drug smuggling aircraft.Such aircraft are typically classifiedas small, slow-moving, single ortwin-engine models that try to pen-etrate North American Air Defence(NORAD) airspace. The drugsmuggler’s flight profiles make them a difficult target for high

performance fighter aircraft to trackwithout being detected, whereas theslower speed, high manoeuvrability,and extended endurance of theAurora make it a platform of choicefor such air operations. Althoughnot officially tasked in this capacity,the Aurora can lend assistance ifcalled upon.

That night, nothing out of the ordinary transpired. When earlymorning came, the eastboundtransatlantic airline traffic was begin-ning to trickle into Canadian airspace.Not long after, a westbound trackwithout any apparent transpondercode appeared just outside the AirDefence Identification Zone (ADIZ),east of Nova Scotia. Once anunidentified track enters the ADIZ,the air defence control facility(ADCF) has two minutes to identifythe intruder, otherwise fighter inter-ceptors would be launched to dothe job. Luckily, a positive mode-4interrogation reply confirmed thatit was an inbound, friendly, militaryaircraft. In fact, this was XPLRreturning from its sovereigntypatrol at 15,000 feet. Being starvedfor some live action, instead ofsome simulated traffic, I radioed the crew to ask if they would be

Than

Better


interested in performing a fewintercepts on targets of opportunity.Being motivated in their new role,they accepted.

In Canada, “scramble, intercept,and recovery” (SIR) control regula-tions are quite liberal and apply to practically all types of airspace,provided that a minimum of tenmiles horizontal or 5,000 feet vertical separation is maintained

course and turn at the precise timeinto the target’s rear quarter toadopt a shadow/monitor position.To my surprise, XPLR took an inordinate amount of time todescend to the directed altitude of11,000 feet. Being determined tokeep things safe, I quickly repeatedthe instructions and asked the pilotto expedite the descent. Both aircraftwere now converging towards eachother with less than 5,000 feet ofvertical separation and only fifteenmiles of lateral separation betweenthem. Not taking any chances onbreaking our SIR agreement, I gavethe Aurora a hard turn (snap) to the southwest in a last ditch attemptto maintain separation. The two aircraft came within eleven miles ofeach other with 5,000 feet of verti-cal separation and no violation ofairspace occurred. I was technicallysafe on both accounts but my heartwas racing like I was running the100-metre race. Needless to say, thefinal roll-out to complete the inter-cept was less than textbook geome-try. After this run was complete, theAurora aircrew humbly requested toreturn to their base, citing that theyhad had a long night. I cordiallycomplied and thanked them for thetraining opportunity they had givenme, hoping that I hadn’t muddiedthe waters for the future.

Since then, I have figured out how to make the experience morerewarding for both the controllerand the aircrew. I no longer expectfighter performance from a non-fighter aircraft and crew. I alsoallow for more lead and set-up timeprior to an intercept, particularlyunder last minute circumstances.After all, it is better to be safe and to not break the SIR agreement thanto be sorry. ◆

Captain Riffou

between the designated flight andthe other aircraft. Additionally, acontinuous mode-C read-out,which confirms altitude, is required.Looking for a suitable target, I tookcontrol of the Aurora and turned ittowards a civilian commuter aircrafttracking northeast at 16,000 feet,according to his mode-C. The directedmission was a “stern intercept”where the Aurora would offset its

Discovering


The Aurora had been sitting onthe ramp, awaiting departure

for over an hour. To continue themission, Operations (Ops) wouldhave to issue new orders to the aircraft. Little did I know how thisnight shift would prove to shapeitself into something memorable.

The first problem to overcome wasto figure out how to get the paper-work into the aircraft without creat-ing any undue delays. The weatherwas cold and windy so I deducedthat approaching the aircraft fromthe 6 o’clock position would not bean issue as I was heavily dressed

and, if anything, the exhaust wouldgive a warming effect. The nextissue would be how to get the envelope onboard without havingto shut down the engines. Easy, Ithought, just hang a plastic bag on a cord down the general-purposechute. I would simply place theenvelope in the bag and thecrewmember would pull it back upinto the aircraft. After all, we did itthat way on the Argus for years. So,we passed our brilliant plan on tothe aircrew and briefed how theevolution would be handled fromstart to finish. Everything was set,or so we thought!

The orders from Ops arrived asexpected, so I left for the aircraftwith my rigger buddy to get thisairplane on its way. As briefed, Iwent to the port wingtip and sig-nalled the pilot that I was ready toapproach, as planned. I received thethumbs up signal, and off I went.What a genius I was!!! So, as I waspassing under the stinger, I notedhow comfy it was in the exhaustand how much I adored the smell ofburning JP4 fuel, but I didn’t noticethe bag I was supposed to put theorders in. It must be there, I wasthinking, so when I got a bit closer,I spotted it just on the edge of the

Discovering

ElectricityElectricity


chute. OK, they don’t want it flap-ping in the prop wash; that was asmart idea. Too bad I wasn’t assmart!! I removed one mitten andreached for the bag. BAAAM!! Sixinches from the chute, I got hit witha jolt at the left hand. OK! I was fineand I just wanted to get the jobdone. I stuffed the orders in the bag,making sure I stayed at least a foot

away from the chute. As planned, Ipulled the bag far enough away so Icould safely pull the cord, signallingits retrieval. Unfortunately, thecrewmember was waiting on theother end so, the millisecond itmoved, they yanked it up. Youguessed, it, BAAAM! Again!

In disgust, I headed back away fromthe Aurora and returned inside.What happened? In short, the Auroralikes to keep the grounding straps off the ground when the inboardengines are running, leaving the aircraft looking for somewhere toground. The Argus didn’t exhibit thistrait. So…what did I learn on that

cold and windy night? Well, the Aurora was a brand new plane backthen and I elected to carry out a procedure, which I assumed wouldwork. That was a Big Mistake! Sincethen, I never approach a strange aircraft unless certain that, whateverthe task, I’m content that what I’mdoing doesn’t hold any surprises in store.

While some might say that Ben Franklincouldn’t have been thinking too clearlywhen he flew his kite into that thunder-storm, he was by no means the only one to discover electricity in the mostunexpected of places. ◆

J. Samson

!!!!


They say that when you lookback, you remember only the

good times. This is a story about atime that I clearly recall being reallymiserable. During the mid 80’s,whilst serving in the Royal Air Force(RAF), I was stationed at a godfor-saken place on the tip of the westcoast of Wales called RAF Brawdy.The place was pretty remote by UKstandards. The nearest town wassixteen kilometers away and popu-lated by relatively unfriendly peo-ple. As another measure of isola-tion, there were no single servicewomen permitted to serve there andthe nearest McDonald’s was 176 kmaway and didn’t even have a drivethru! The airfield was on top of acliff, overlooking the Irish Sea.If you stood at the end of the run-way and projected a line, the nextlandmass that you hit was in theCaribbean. Consequently theweather, and especially the wind,used to roll in with nothing to stopit. The place was renowned for horizontal rain pushed by extremewinds. Wind speeds of over onehundred kilometers per hour werenot unusual and I have seen sea fogroll in at almost fifty kilometers per hour. To work outside, even on a relatively normal day, requireda jacket, bobble hat (toque),and gloves.

This particular day had started outbadly; the temperature was -1°Cwith a mixture of rain and sleet thatwas coming in at a forty-five degree

angle and gusting to seventy kilome-ters per hour. My day got slightlyworse when a snap security alert(Northern Ireland, etc) had me get-ting soaking wet on my way to workwhen my vehicle was inspected forbombs, both under the bonnet(hood) and in the boot (trunk).When I arrived at work, it was stilldark but the message was to get theaircraft airborne. A break in theweather was expected, which wouldallow at least one wave of planes tobe launched. After towing, I wasdetailed by the line controller to topup the hydraulics on an aircraft outon the line. I gathered my tools —torch (flashlight), snips (side cut-ters), spanners (wrenches), lockingwire pliers (wire locking pliers), ris-bridger gun (version of a PON) andother items I needed and went outto the aircraft. The weather by thistime seemed to have gotten worsebut, bundled up in the RAF versionof foul weather clothing, I reasonedthat the simple task I was about toundertake should not take morethan twenty to thirty minutes.

Now, it must be said that the foulweather clothing issued at that timewas not the best and the generalissue of Gore-Tex was still twelvemonths away. The nylon stuff wehad was optimistically termed asweatherproof, not waterproof,and was designed for the temperate

climate of Northwest Europe.Unfortunately, the conditions at thetime were bordering, in UK terms,on the Arctic. At a temperature ofminus one with gusts of seventykilometers per hour, the wind-chillfactor was minus Omygoodnessitscold!! So, there I was, using myshoulder to clamp the torch tightlyin the crook of my neck, trying toshelter from the rain and carry outthe task at the same time. Needlessto say, I got very cold; my handsand feet were numb and, on thebasis that they couldn’t really getany colder, I carried on.

About an hour later, I was relievedfrom the task and the work I hadmanaged to complete was rechecked.I’m not even sure how far I had gotten with the task. When I wentback inside and reported to the linecontroller, he immediately recognizedthat I was in the early to middlestages of hypothermia. After achange of clothing, a warm-up asclose to a radiator as I could get, agood brew (cup of tea), and a quickcheck by the medics, I was told thatI was going to be alright and to bemore careful in the future. Thewind-chill had got me, but whatreally caught me out was the factthat I had been wet in the firstplace. My clothes had already

Grow WiserDid I


started out wet from the securitycheck, the weatherproof clothing letthe rain in like a floodgate, and mybody heat was just taken away by the wind. I have never been thatcold, either before or since, and it isdefinitely not an experience that I would care to repeat.

However, did I grow wiser from the experience? In the words ofsongwriter Shel Silverstien, “Yes,my dear, I grew wiser in many ways,but the thing I learned most was…”Well, I learned several things thatday. I learned that it doesn’t matterwhere you are in the world, you canbe caught out by the weather. We’veall been briefed about being “winterwise” or, for that matter, “sun wise”,but how much notice do we actuallytake. The expected weather windownever did materialize so, now, Inever implicitly trust a weatherman.Another thing I learned was that Ididn’t have to do the job on my own.

I could have asked for help. I knewwhat I was doing, or thought I didand, in the final analysis, how good a job did I do?

Nevertheless, the lesson I learned the most was taken from the atti-tude of the line controller and it is an approach that I have tried tolive up to ever since. Even thoughhis job was extremely busy thatmorning, (forty guys and a flyingschedule to look after), he still tookthe time to look after his men.Somehow, in the hubbub, he hadnoticed that I hadn’t returned ataround the expected time, so hesent someone to find me because he suspected something was wrong.He knew my capabilities and mewell enough for that “sixth sense”to kick in and give him the message

that something was not quite right.What I have since realized, andwhat he already knew, was that thepeople we work with are our mostimportant asset and, without themand without looking after them, itdoesn’t matter how simple or com-plex the task is, it won’t get done.

As for being really miserable? Theexperience of getting really cold wasbad enough but the really, really mis-erable part was when I was thawingout. Good grief, never again! ◆

Greg Hallsworth

from the Experience?

HEY YOU,COME

WITH ME!!!


Attending the recent annual DFSbriefing inspired me to relate

an event here that happened to memore than a decade ago, on my firstoperational posting. Why am Imaking noises now, and not tenyears ago? It could be because, as anapprentice technician, not only did Inot know what was going on aroundme, but also I failed to grasp eventhe scope of that unfamiliarity.Today — given a greater familiaritywith the nature of Flight Safety —the time just seems right.

I was at the unit basically since cof-fee-break — the only thing wetterthan the space behind my ears wasthe ink on my TQ3 (apprenticeship)qualifications, and everyone knewit, most of all me.

Assigned (“Hey you, come withme!”) to a Corporal Airframe Techto help with some gear retractionson a jacked Tutor, my place — asresident Instrument Electrical Tech

— was in the cockpit,working the gear

handle. Everythingseemed right,

except I thought it oddthat we would not bemaking use of the niftyheadsets that were sittingon the shelf for just thispurpose. (“Won’t need‘em — take two secs …”)Headset communica-tions seemed reason-

able, what with one of twotechs being buried inside a wheelwell for the job, but I was as greenas a wet clump of broccoli, and gotabout as much respect.

It was business as usual in thehangar that day — in other words,it was noisy. A few spots down,another crew was scrambling allover their jet, doing some sort ofcheck. Just outside, another Tutorwas being run through a start.

The Corporal got himself set upquickly, and disappeared into theport wheel well. He hadn’t briefedme on very much, but the gist ofthe job was that he would make anadjustment deep in the wheel well,climb out, have me cycle the gear,and then make another adjustment.We devised a clever method fordetermining when he wanted me to cycle the gear — if he shouted“Up!” that was my cue.

If you don’t know where this isheading by now, you weren’t paying

attention back in paragraph three.Sure enough the whole thingworked as advertised for severalcycles. I figured we wouldn’t have to do too many more …

I heard “Up,” and reached for thehandle, as I had done half a dozentimes already. But this time some-thing in the Corporal’s tone soundedodd; so I craned my head aroundand down to take a look. He wasstill deep in the wheel well, makinghis adjustment. He hadn’t shouted“Up!” or even shouted anything atall. What I had heard was the crew afew spots down shouting instruc-tions to each other. The noise fromthe running jet about a hundredfeet away had completely destroyedmy ability to localize sounds.

I almost killed that guy! I told himthis afterward — being shocked andstunned that only chance hesitationhad kept me from crushing this tech— and he shrugged. The incidentdidn’t mean a thing to him. Lifegoes on.

In hindsight we pretty muchengaged in every violation we’ve gota rule against. That incident hasstayed close to my scalp since then,fuelling a better-than-average inter-est in Flight Safety. Nowadays, forbetter or for worse, I refuse to berushed, and insist on being informed.It’s the least someone in my positioncan do. ◆

Cpl Marcel Gassner

Won’t need ‘em — take secs …2


My years as an airframe techni-cian, a term now replaced by

“aviation technician with a strongrigger background,” saw me workingon everything from Hornets to T-Birds to Hercules to Challengers.Somehow, as I moved from place to place, I managed to retain a reputation as a “good” technician.Normally, having your peers envisionyou as an accomplished technician isa badge of honour. However, as theyears went by, and the aircraft fleetshave become a blur of unidentifiableairplane parts, this moniker becamedifficult to maintain.

It seemed as if every time I wasintroduced to a different fleet, myrate of qualification and authoriza-tion became quicker. Knowing this,in the back of my mind, I elected notto say anything and, if my peers andsupervisors thought that I was capa-ble of performing the required tasks,then I must have been. Don’t get mewrong; every time I received a newqualification I was asked “are youcomfortable with doing this?”Normally, I was. Occasionally, how-ever, my little voice tried to intervenebut would be obscured by another,not so little voice, yelling “shut up…-he’s done lots of stuff like this onother jets.”

I accepted 99% of what was thrownmy way and, as personnel shortagesbecame more and more evident,what choice did I have? “More withless,” after all! I continued to workand I’m sure that I made the oddtechnical mistake and the occasional

error in judgement. Luckily, itwas never anything poten-tially life-threatening or neveranything that could possiblycause injury. It was certainlynothing that would warrant aflight safety incident report.Nonetheless, I was makingmistakes that I wouldn’t havepreviously. Was I getting lazy?Was it a case of too much work and too little time?

Finally, IT happened!! An aircrafthad a flight safety occurrencereport against it and my name wasall over it. I distinctly remember thesickening feeling that swept overme as I realized what might havebeen. I lost a lot of sleep. I tried torecount the job in my head innu-merable times and to this day, forthe life of me, I cannot figure outwhat went wrong. Fortunately, themistake was found before anythingof consequence had happened.

This became my “wake-up” call.Shortly after the incident, I satdown and did some soul-searchingand tried to identify how all of thiscame about and what I could havedone to prevent it. This is my list.

• If you receive the label “goodtechnician,” don’t let it go to your head. Wear it well by alwaysbeing aware of just how easilyand quickly it can turn to “terrible technician.”

• When Hornet parts and Herculesparts start to look the same,step back and take some time to get perspective on what youare doing.

• If qualifications and authoriza-tions (Q&A) are coming fast andfurious, ensure that your compe-tence level for each and every jobis worthy of the Q&A.

• When asked “are you comfortablewith doing this?,” let pride take a back seat. It is a question thatseems hard to answer in the negative, but if you are not comfortable, just say “NO!”

• When hearing “little voices in the back of your mind,” just payattention to them. You are notnuts for listening!

• If you find the frequency of littlemistakes on the rise, step backand take stock. Be wary, as littleones can become big ones very quickly.

Whether you are in your first year,your last year or somewhere inbetween, technicians are chargedwith ensuring our fleets remain as incident free as possible. We allmake mistakes but, if the little mis-judgements and errors are writtenoff to pride in ones work or justbeing a “good technician” eventu-ally, IT will happen to you. ◆

Master Corporal Spencer

A

Call“Wake-Up”


ÉPILOGUEAircraft Accident Summary

The instructor and student were conducting aNight 1 Lesson Plan. Following some initial circuit

work in Area North they proceeded to ‘GrabberGreen’ autorotation landing area. The instructorwas demonstrating a ‘500 foot’ straight aheadautorotation to touchdown. The aircraft struck the ground firmly during the termination of theflare. The crew received minor back strain injuries. The aircraft sustained “B” category damage.

This was the instructor's first night auto to touch-down during the mission. Wind conditions wereideal with a southerly flow of 10 knots. The groundelevation at Southport is 885 feet, but due to tem-perature and humidity, the density altitude (DA)was high (2300 feet). The flare entry progressednormally but the instructor elected to terminate theflare with a more aggressive collective check due tothe high DA. Either the collective check was tooaggressive for the conditions or the timing was too early because the aircraft ended up being highfor the level-off and cushion stage (10 feet). From10 feet it becomes more difficult to safely land theaircraft. The instructor recognized his error andattempted to overshoot by adding throttle. Throttleapplication was tentative as the instructor was concerned about causing a loss of tail rotor effec-tiveness. If the RRPM gets low (70% range) the tailrotor speed and effectiveness become proportion-ally lower as well. If throttle is applied too quickly

TYPE: Jet Ranger CH139314

LOCATION: Southport, MB

DATE: 27 June 2002

you can reach high torque levels prior to the tailrotor reaching sufficient effectiveness to counterthe main rotor torque. This can cause a loss of tailrotor effectiveness and result in an uncontrolledswing of the aircraft tail. If this were to happen as the aircraft was touching down it could causethe helicopter to roll over.

It is difficult to determine if a more positive application of throttle would have prevented the accident or simply aggravated the situation.Regardless, there was insufficient rotor RPM left at the cushion stage to safely land the aircraft.

The investigation revealed that instructor profi-ciency in night flying was not being re-evaluatedfollowing completion of the Flight InstructorCourse. This meant that instructor ability to safelyexecute a night autorotation, conduct circuit train-ing and basic aircraft handling at night was not re-visited unless a lapse in currency took place. This was not a factor in this accident as the instruc-tor had recently regained currency in night autoro-tations during a standards check ride. DFS has recommended that night proficiency be includedin the annual category check for instructors.

At the time of the accident, students were stillbeing assessed for their ability to execute nightautos despite the removal of night solo flightsfrom the training syllabus. In order to reduce therisk exposure incurred during night autos, theschool has removed the night auto as an assessedmanoeuvre for students. Instructors continue to execute this manoeuvre for demonstration purposes. The school has added two night missions to the Flight Instructors Course in order to allow further proficiency training in night autorotations. ◆



Approximately 25 minutes after launching fromHMSC PROCTEUR, a hot Main Transmission

Gearbox (MGB) was noted. As the crew returned to land, cockpit indications were assessed as severeenough to require a controlled ditching. After thecrew successfully egressed uninjured, the aircraftsank, suffering “A” category damage.

The investigation eliminated all possible MGB malfunctions as causal to this accident with theexception of an over-temperature condition similarto previous 21000 Series MGB overtemps. Only thisinherent overtemp condition, that previously hadneither been satisfactorily explained nor caused anyknown damage, offered a plausible explanation ofthe indications experienced by the crew.

The CF Sea King fleet has, since 1994, documented a phenomenon of inherent overtemp in all regimesof operation in which MGB temperature rapidlyincreases above the normal operating range up to and exceeding the maximum operating limit.Through informal trial, the “#1 SSL Procedure” wasdeveloped in which the #1 Speed Select Lever wasretarded to the ground idle position. This actionwas known to work with not only CF Sea Kings, butalso with USN Sea Kings despite the lack of the orig-inal equipment manufacturer’s engineering data tosupport the theoretical cause of internal overtempconditions. CF flight safety data showed that in all27 overtemp occurrences when the #1 SSL proce-dure was employed, it was 100% effective in notonly arresting further MGB temperature, but also inreducing that temperature regardless of maximumvalue reached. Furthermore, a significant number of these occurrences indicated that MGB pressurefluctuations were evident with the overtemp indica-tions. Despite this data, the procedure remained adiscretionary one in the Sea King AOI; it was notincluded for reference in the Pilot Checklist.

Analysis concluded that had the #1 SSL procedurebeen mandated for use in instances of MGBovertemp, it is highly probable that the high tem-perature condition and all its associated indicationswould have been reduced or eliminated, thus

TYPE: CH12422

LOCATION: 150 NM South of Honolulu, Hawaii, USA

DATE: 23 Jun 2000

reducing the severity of indications from Land AsSoon As Possible to Land As Soon As Practicable.

Given lack of guidance and resulting non-use of the #1 SSL procedure, the crew decided to enter the hover with only Land As Soon As Possible criteria in evidence. Once in the hover, significantpressure fluctuations, strong welding-like metallicodours and radiant heat from the MGB developed.These new indications led the crew to conclude thatMGB failure was imminent. Had the aircraft contin-ued (as suggested by the Land As Soon As Possiblecriteria in the AOI and checklist) instead of comingto the hover, the aircraft may have successfullyreturned to land on the nearest flight deck.

As a result of this accident, the AOI and Checklistwere updated to accurately reflect the mandateduse of the #1 SSL procedure in instances of inherentMGB overtemp. The requirement for this procedurehas subsequently been overcome by events with theintroduction of the new 24000 Series MGB. It wasfurther recommended that emergency proceduresbe reviewed to give aircrew specific direction withrespect to the notion of coming to the hover forMGB emergencies.

Other preventative measures included staff work to address both the experience levels and trainingoffered to HELAIRDET senior NCMs. 12 Wing alsoinitiated a training program to ensure that linemaintenance personnel are aware of torquing procedures in accordance with the CFTO and thatthe techniques are uniformly applied.

Finally, due to some confusion over ditching andegress SOPs, it was recommended that the AOI and Pilot Checklist be amended to give aircrew alogically flowing sequence of reactions to wateroperations emergencies. It was also recommendedthat current aircraft egress training be reviewed to ensure that correct procedures are adequatelyemphasized and that the hazards posed by non-standard actions are understood by all aircrew. ◆

Crewmember in life-raft, immediately after ditching.



The Standards Officer was conducting a profi-ciency check ride on one of the instructors

from the Basic Helicopter School in Southport. The focus of the flight was to assess the instructor’sproficiency in autorotations. The crew successfullycompleted a number of straight-ahead and 500-foot turning autorotations, but the aircraft struckthe ground during the landing portion of a 250-foot turning auto. Both crew members receivedserious back injuries. The aircraft sustained “A”category damage.

The winds at the time of the accident were variablein strength and direction but within the limitsindicated in School Orders. Crews operating in thearea reported having to add throttle to cushionsome landings and to adjust the entry point ondownwind due to strong winds aloft. The crew ofthe accident aircraft experienced problems withairspeed control on some of their autorotations,overshooting on several (both pilots’ first attempt

TYPE: Jet Ranger CH139308

LOCATION: Southport, MB

DATE: 2 July 2002

at the 250-foot turningauto). These facts point tothe likelihood of a decreas-ing performance wind shearas the aircraft descendedfrom circuit altitude to theground. Unfortunately thereis no wind recording equip-ment at the autorotationtraining area.

The accident manoeuvre was the Instructor’s secondattempt at the 250-footturning auto. The Instructorwas sitting in the right seatand flying right hand circuits.The entry was normal, butduring the turn to final theinstructor used considerable

bank and backpressure to expedite the turn. Thisbled off the airspeed to below the ‘60 knot’ ideal.Although the requirements of the ‘100 foot’ checkwere met, the aircraft was on the low end of para-meter acceptance (low and slow). The Instructorcommenced the flare at 50-60 feet AGL. As thenose of the aircraft was pulled up for the flareboth pilots stated that the airspeed dropped offquickly and an excessive descent rate developed.The Instructor was somewhat startled by the air-craft reaction and did not immediately initiate theovershoot. The Standards Officer took control at30-40 feet and applied throttle and then collective(“low level save”). This did not seem to have anyeffect and therefore he concentrated on gettingthe aircraft level prior to impact.

It is possible that the transition out of the turn(low and slow) and into forward autorotation may not have been “clean enough". This wouldhave left less time to develop a steady forward


autorotative glide prior to flaring. With low airspeed, the descent rate would be higher thandesired. At the commencement of the flare, therate of descent notably increased coincident with amarked decrease in airspeed. It is perhaps at thispoint that the aircraft entered a zone of decreas-ing performance shear. It is possible that these twofactors (glide and shear), in combination, createdconditions where the flare would be unable toeffectively reduce the rate of descent.

The investigation also examined the possibilitythat Vortex Ring State (VRS) may have been a contributory factor during the landing phase. Forthis accident, the steep descent and/or the suddenincrease in rotor thrust during the power recoveryattempt may have combined to create conditionsfor VRS to occur. However, the rotor must be gen-erating significant lift for VRS to develop fully, andthat would have occurred only after collective andthrottle application. These occurred too close tothe ground for VRS to develop sufficiently to havehad material effect. It is unlikely that fully devel-oped VRS was a factor in the accident however; it is possible that the application of power duringthe ‘low level save’ put the aircraft into the incipient stage of VRS, thereby reducing the effectiveness of the overshoot attempt.

As an interim measure, the entry altitude for thelow level turning autorotation was raised from 250 feet above ground to 350 feet above groundto allow more time for the set-up of the sequence.DFS further recommended that:

a. a formal review of the policy for autorotationtraining be conducted. The resulting policy mustensure that pilots have the skills and knowledgeto preserve life and limb during helicopteremergencies requiring autorotation. It shouldalso maximize the potential for saving the aircraft in such an emergency, but only to theextent that it does not unnecessarily jeopardizeaircraft or crew in training.

b as a part of the above review, the possibility ofestablishing wind variability limitations forautorotation training be investigated.

c. the feasibility of employing wind and videorecording equipment at ‘Grabber Green’ beinvestigated.

d. more emphasis be placed during Supervisoryand Proficiency Checks on low level save tech-niques and recognizing the parameters when alow level save/overshoot is required. ◆

We have included, by exception,

an insert in this issue of “Flight

Comment.” These articles reflect

several perspectives on a 1 Wing

incident, which has taught us some

lessons about some of our vulnerabili-

ties as “can do” aviators. While out of

the normal “Flight Comment” format,

we thought these articles excellent for

stimulating thought, discussion, and

self-examination. My hat is off to

1 Wing for being willing to look hard

at what happened and to share the

results of that introspection with the

rest of us. This positive and active

approach to promoting flight safety

at all levels is a good example

for everyone. ◆

Colonel Ron HarderDFS

1 Wing

Flight Safety Newsletter

GOOD SHOW

PAR approach if the pilot was willing. The pilotaccepted and Mr. Blizzard proceeded to the termi-nal building to open the unit and align the PAR.

While on Gander frequency, N45NP advised he was “fuel critical.” Nine minutes (record time fromtower cab to terminal, let alone opening up andaligning the PAR) after devising the plan, Mr.Blizzard coordinated transfer of control withGander. The pilot advised that it was not his firstPAR, but it had been awhile and he said, “We’lltake all the help you can give us.” One minutelater, the pilot said “Be advised there is no ‘go-around’ on this one” and then declared a fuel emergency. Thirty-eight minutes after initial contact, N45NP landed safely in Goose Bay.

Mr. Hutcherson and Mr. Blizzard went beyond thescope of their normal duties and as a result oftheir professionalism, quick plan and control skills,they were able to safely recover an aircraft andtwo people. ◆

MR. ROBERT BLIZZARDMR. BRUCE (HUTCH) HUTCHERSON

On Sunday, 22 Dec 2002, a civilian Lear jet, call signN45NP, was conducting an instrument landing system (ILS) approach to runway 08 in Goose Bay,when he lost glide slope indications. As the terminal unit is closed on Sundays and precisionapproach radar (PAR) services are only availablewith two hours prior notification, control of theaircraft was handed off to Goose Bay towerdirectly from Gander Centre. The visibility at thetime was _ mile in blowing snow, with a verticalvisibility of 300 feet.

As a result of the loss of glide slope, the pilot con-ducted a missed approach and control was handedback to Gander Centre for another ILS approach.Once again, on the second approach, the aircraftlost lock on the glide slope and opted to over-shoot. The tower controller, Mr. Hutcherson, inconjunction with the ground controller, Mr. Blizzard,(who happened to be PAR qualified) advisedGander that they might be able to conduct a



FOR PROFESSIONALISM

MASTER SEAMAN MARK VANDERHEYDEN

In April 2002, during a hot fuelling operation on HMCS Vancouver,the flight deck engineer, Master Seaman (MS) Vanderheyden,noticed that it was taking longer than usual to fuel the helicopter.After the hot fuel was completed, he took the initiative to inspectthe fuel hose in-line filter for any evidence of blockage. He founda severe delaminating of the inner hose lining, which was pluggingthe in-line hose filter.

Realizing that two helicopters (“Renegade 440” from HMCSOttawa and “Slapshot 429” from HMCS Vancouver) had recentlybeen fuelled using the defective hose, the HMCS Vancouver’s Air Chief recommended grounding both helicopters until the levelof contamination could be determined. “Renegade 440” was con-taminant free, but “Slapshot 429” had evidence of small rubberparticles in the fuselage fuel filters. A flight safety message wasinitiated and “Slapshot 429” had a complete fuel cell inspectioncarried out by the HMCS Vancouver maintenance crew. The fuelcell inspection revealed no contamination in the two fuel tanks.

MS Vanderheyden’s quick reaction to an abnormal fuelling rate and his fine eye to detail prevented a severe fuel contamination problem from occurring in “Slapshot 429.” Without his diligence, a catastrophic dual engine failure could have been the result. His prompt actions allowed two Sea Kings to be quickly returned to flight status during the OP APOLLO deployment. ◆

CORPORAL GREG ROGERS

On 28 May 2001, Corporal Rogers, an avionics technician, was performing a routine pre-flight check for bird nests on the search and rescue standby Hercules aircraft. While carrying out this custom-ary examination, he noticed what appeared to be a crack in the skinof the rudder. Although not part of a regular bird nest inspection,Corporal Rogers decided to further investigate. Upon inspection, he discovered a crack of 15 mm in length in the rudder, as well as a large dent in the skin of the aircraft. Immediately, he halted his inspection and informed the servicing desk sergeant. Aircraftstructures technicians investigated and concurred with the seriousnessof the damage and the aircraft was declared unserviceable.

Thankfully, because of the proficiency of Corporal Rogers, this did not result in a flight safety incident. Corporal Rogers demonstratedsuperior professionalism and observation. His quick, decisive actionsensured that a potentially disastrous flight safety hazarded wasaverted and corrected. ◆


FOR PROFESSIONALISM

MASTER CORPORAL DARRELL SHIELS

In August 2002, Master Corporal Shiels, while conducting a routine corrosion control inspection on Sea King #416, discovered that the electrical leads on the #1 engine fire bottle were connected in reverse. This mix-up rendered the emergency extinguishing system inoperative.

It is very difficult to see the labels on the cable assembly where they connect to the fire extinguisher system valve when the access panels are installed. The #2 corrosion control inspection requires the area to be accessed, however it does not call for inspection of the fire bottle.Had this discrepancy continued to go undetected, the potential for a serious accident was significant, as the capability to fight an in-flightengine fire was greatly impeded.

Master Corporal Shiels’ in-depth knowledge of aircraft systems, profession-alism, and initiative prevented the possible loss of a valuable aviation assetand the potential for serious or fatal injury to the crew. Master CorporalShiels is to be commended for his outstanding professionalism, alertnessand dedication. ◆

CORPORAL BOB MCDEVITT

Corporal McDevitt was the duty radar controllerand, after receiving a briefing from the terminalcontroller, made radio contact with the PA-32 pilot.While controlling, Corporal McDevitt noticed thatthe Piper aircraft had descended approximatelyfour hundred feet below the minimum safe alti-tude (MSA) and immediately initiated correctiveaction. As the PAR progressed, he recognized thatthe pilot was experiencing difficulty maintainingassigned headings. Corporal McDevitt suspectedthat the aircraft might have a defective compass,and briefed the Piper pilot on how to fly a “no-compass” approach. Although the pilotsounded quite shaken up and lacking in confi-dence, Corporal McDevitt initiated a “no-compass”approach to facilitate a safe transition to visualweather conditions and to help calm the pilot.

Corporal McDevitt was instrumental in alleviatingwhat could have easily resulted in a catastrophicaccident. After two unsuccessful ILS approaches at the Halifax airport, the pilot of the PA-32 wasnoticeably upset and very nervous. CorporalMcDevitt’s calm, professional demeanor through-out the whole situation influenced the pilot’s confidence resulting in a successful recovery at 12 Wing Shearwater. ◆

On 19 April 2002, Halifax Air Traffic Control (ATC)advised 12 Wing Shearwater ATC that they had aPiper Saratoga PA-32 who was experiencing diffi-culty with the instrument landing system (ILS)approach to Halifax International airport and hadlost the localizer on two occasions. Halifax ATCasked if Shearwater ATC could attempt to recoverthe PA-32 using their precision approach radar(PAR), since the weather at the Halifax airport was instrument flight rules (IFR) at the time.


FOR PROFESSIONALISM

SERGEANT RUSS MUIR

During Sergeant Muir’s pre-flight inspection on a Hercules aircraft, concernraised from a previous snag involving the electrical power distribution systemon another Hercules caused him to go beyond normal pre-flight checklistrequirements and inspect the electrical direct current (DC) transformer rectifier unit (TRU) more closely. When he pulled the #1 essential DC TRU,he noticed that the load on the #2 TRU dropped off line, and that whenthe # 2 essential DC TRU was pulled, the #1 TRU dropped off line. He suspected a wiring problem and alerted servicing personnel. This error was confirmed by servicing personnel and rectified.

Sergeant Muir demonstrated the utmost vigilance when he discovered two electrical TRUs that were incorrectly cross-wired. At the very least, this could have lead to a confusing emergency checklist response had oneof the TRUs failed and, quite possibly, could have resulted in more seriousconsequences. Sergeant Muir’s exemplary level of concern and vigilance

resulted in the discovery of a very serious hazard to flight safety that could have easily gone undetectedfor some time. His actions and attention to detail on this day exemplify an outstanding commitment ofthe Flight Safety program. ◆

MS. CHANTAL GAGNON

On 27 August 2002, Ms. Chantal Gagnon, aBombardier Aerospace journeyman technician atNATO Flying Training Centre (NFTC) Moose Jaw,was assigned to recover CT-155205, an arrivingNFTC Hawk aircraft. While performing the turn-around inspection, Ms. Gagnon noticed two centreline fuel tank (CLT) forward mounting bolts werestill in their forward holes, inside the wheel well

bays, although the CLT had been downloaded.The location is very difficult to see, as the mount-ing holes are located behind a maze of fuel andhydraulic lines and wire bundles. This is not achecklist item specifically identified in the turn-around inspection procedure and this conditionwas unobserved during previous inspections onthe aircraft. Ms. Gagnon immediately notifiedher supervisor and raised a flight safety initialoccurrence report.

During the subsequent investigation, it wasfound that only their last thread secured the six-inch bolts. The bolts could have readilybecome dislodged within the landing gear assembly, damaging fuel and/or hydraulic linesand electrical cables. They could also easily haveinterfered with the proper functioning of thelanding gear.

Ms. Gagnon’s diligent performance demonstratesher outstanding professionalism. Additionally,her professional expertise and attention to detail,combined with her superior flight safety workethic likely prevented a potentially hazardous in-flight emergency. ◆


FOR PROFESSIONALISM

CORPORAL RÉMI SIMARD

Corporal Simard is an aviation technician working in second line maintenance(snags) at 433 Tactical Fighter Squadron. As maintenance personnel werecarrying out an inspection on Hornet #917, they noted that hydraulic line # 74A6691068-1003 was rubbing against panel 113L. To access this line andcorrect the problem, personnel were required to take off both thehydraulic driving unit (HDU) and the remote valve.

Following the re-installation of the hydraulic line, Corporal Simard wasasked to reinstall both the previously removed HDU and the remote valve.Attentive to the safety details of the completed work and ensuring thatnothing was missed, he carried out a detailed foreign object damage (FOD)check and inspected the area for tidiness. Despite the fact that the work-space was quite restrained and dark, his inspection revealed a substantialcrack on the remote control bracket. Corporal Simard’s attention to detailled to a flight safety report.

Corporal Simard’s professionalism, alertness, and quick reaction revealedthis undetected problem, thus preventing a possible serious incident.Without his initiative, this damaged bracket could have failed in flight,which could have had disastrous consequences. ◆

SERGEANT STEVE TREMBLAY

Sergeant Tremblay was tasked to carry out an ordnance pre-flight inspection on Aurora #103, prior to a maritime patrol mission. During the inspection, the flight engineer questioned the weight limitations forthe rack and, subsequently, Sergeant Tremblay was asked to move thestores around to rectify the problem. While moving the stores, he noticedthat the weight distribution for the MK 58 smokes did not seem right.Upon opening the sonobuoy launch container, it was noticed that thesmokes were packed incorrectly; the smoke canister was packed next tothe explosive cartridge actuated device.

Upon further inspection by the technicians, it was found that twelve ofthe thirteen smokes on the aircraft were packed incorrectly. It is theresponsibility of the AESOP to verify the load on the aircraft, however,

they are not required to physically open the canisters to check the contents. Had this gone unnoticed, a potential existed for a fire in the pressurized sonobuoy launch tubes upon stores release.

Sergeant Tremblay’s alertness and commitment to his duties were instrumental in preventing a seriousaccident. He is to be commended for his professionalism and dedication that led to this discovery. ◆

Documents

IN THIS ISSUE: Better Safe Than Sorry How Well Do You Know …flightcomment.ca/wp-content/uploads/2003/03/2003-3-eng.pdf · Flight Comment, no 3, 2003 1 It was another gray day in