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CANADIAN FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FINAL REPORT

FILE NUMBER: 1010-CT114120 (DFS 2-4-2) DATE OF REPORT: 24 November 2006 AIRCRAFT TYPE: CT114120 Tutor DATE/TIME: 242122Z (1722L) August 2005 LOCATION: Thunder Bay, ON CATEGORY: "A" Category Accident

This report was produced under authority of the Minister of National Defence (MND) pursuant to section 4.2 of the Aeronautics Act, and in accordance with

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

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

Director of Flight Safety (DFS), National Defence Headquarters, pursuant to powers delegated to him by the MND as the Airworthiness Investigative Authority (AIA) of the

Canadian Forces.

SYNOPSIS

The accident aircraft was flying the “opposing solo” position in 431 Air Demonstration (AD) Squadron and was the number 8 aircraft. Prior to the preliminary warm up for an air show at the Thunder Bay waterfront, the “solos” conducted a show line recce and then went inland to conduct the pre-show “shakeout”. During this sequence the aircraft rolls inverted and is pushed to negative 2 “Gs”. Immediately after achieving the inverted flight position, number 8 heard a loud bang and felt immediate loss of thrust. After conducting emergency procedures and returning to upright flight, the engine RPM was noted at between 2 and 3 percent. A “procedure one” relight was initiated and only 5 to 6 percent was noted on the RPM gauge. The pilot confirmed the path ahead of the aircraft was suitable for ejection and after calling his lead, he ejected. The aircraft impacted the ground 10 seconds later, near some derelict vehicles in a field, about nine kilometres north of the Thunder Bay airport. The aircraft was destroyed on ground impact.

The pilot landed one half kilometre north east of the aircraft. He was recovered about 20 minutes later with minor injuries associated with the ejection sequence. He made his way through a swamp to the rescue vehicles and civilian personnel who were searching the woods for him.

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TABLE OF CONTENTS 1. FACTUAL INFORMATION..........................................................................................1

1.1 History of the Flight ...........................................................................................1 1.2 Injuries to Personnel..........................................................................................2 1.3 Damage to Aircraft ............................................................................................2 1.4 Collateral Damage.............................................................................................2 1.6 Aircraft Information ............................................................................................3 1.7 Meteorological Information ................................................................................4 1.8 Aids to Navigation .............................................................................................4 1.9 Communications................................................................................................5 1.10 Aerodrome/Alighting Area Information ............................................................6 1.11 Flight Recorders ..............................................................................................7 1.12 Wreckage and Impact Information...................................................................7 1.13 Medical ............................................................................................................9 1.14 Fire, Explosives Devices, and Munitions.........................................................9 1.15 Survival Aspects............................................................................................10 1.16 Test and Research Activities.........................................................................12 1.17 Organisational and Management Information ...............................................13 1.18 Additional Information Nil ..............................................................................13 1.19 Useful or Effective Investigation Techniques Nil ...........................................13

2. ANALYSIS.................................................................................................................14 2.1 The Aircraft Engine..........................................................................................14 2.2 Aviation Life Support Equipment (ALSE) ........................................................18

3. CONCLUSIONS........................................................................................................22 3.1 Findings...........................................................................................................22 3.2 Cause Factors .................................................................................................23 3.3 Contributing Factors ........................................................................................23

4. PREVENTIVE MEASURES ......................................................................................24 4.1 Preventive Measures Taken............................................................................24 4.2 Further Preventive Measures Recommended.................................................24 4.3 Other Safety Concerns Nil..............................................................................25 4.4 DFS Remarks..................................................................................................25

ANNEX A: Abbreviations........................................................................................... A-1 ANNEX B: Photographs............................................................................................. B-1

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1. FACTUAL INFORMATION

The CT114 Tutor aircraft is flown by 431 (AD) Sqn for air display and public relations purposes. The CT114 was designed as a trainer aircraft and has side-by-side seating. The aircraft is not utilized in the instructional role at this time but 431 (AD) Sqn has continued to use the aircraft to conduct its mission.

The CT114 has undergone modifications to make it suitable as a single-pilot air show aircraft. This includes re-location of some vital controls so they can be reached from either seat. Also, the Snowbird aircraft have a smoke generation system to enhance visibility and aesthetics of the air display. This system consists of belly tanks for diesel fuel and a piping system to the exhaust pipe where the diesel fuel is aspirated for smoke generation.

The 431 (AD) Sqn display team normally consists of nine aircraft, seven of which form the “main” formation. The remaining two aircraft are the “solos”, with #9 the lead solo flying in the right seat and #8 flying in the left seat positions. However, for the Thunder Bay airshow, the show was going to be an eight-plane (6+2) display vice the normal nine-plane (7+2) show.

1.1 History of the Flight

The accident aircraft was flying the “opposing solo” position and was the number 8 aircraft of the planned eight-plane demonstration that was to take place at the Thunder Bay waterfront. Number eight took off as the wingman of number nine and was in the third element of the take off sequence. The “solos” were broken off from the main formation after take off to conduct a show line recce at the Thunder Bay harbour breakwater. Once the recce was completed the solos went inland to conduct the pre-show “shakeout”, a series of preliminary aerobatic manoeuvres designed to ensure the aircraft is set up properly before the formal start of the demonstration. One part of this sequence is for the aircraft to roll inverted and push negative 2 G. Immediately after achieving the inverted flight position, number 8 heard a loud bang and felt immediate loss of thrust. The pilot depressed the air start button and the aircraft was returned to upright flight with the engine RPM quickly decaying to between 2 and 3 percent. After transmitting “8’s Off Engine”, a “procedure one” relight was initiated and the RPM did not increase. The pilot confirmed the area ahead of the aircraft was suitable for ejection, and after calling his lead, he ejected. The aircraft was destroyed when it impacted the ground 10 seconds later near some derelict vehicles in a field about nine kilometres north of the Thunder Bay airport.

The pilot landed one half kilometre north east of the aircraft. He was recovered about 20 minutes later. He made his way through a swamp to the rescue vehicles and some civilian personnel who were searching the woods for him. He received minor injuries associated with the ejection sequence.

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1.2 Injuries to Personnel

Table 1: Injuries to Personnel

Injuries Crew Passengers Others

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

1.3 Damage to Aircraft

The aircraft, CT114120, sustained A category damage due to ground impact and post crash fire. The aircraft wreckage trail was spread over an area of about 60 metres wide and 100 meters long with the main site being approximately 20 by 40 meters. There were three large pieces in the main site consisting of the front wing spar with part of the wing section, the engine section and the tailpipe and a portion of the tail plane. The fuselage and cockpit areas were fragmented and nearly entirely consumed in the post crash fire. Damage to the aircraft was extensive and very little was salvaged. Preliminary examination of the engine indicated massive compressor damage with every stage that was exposed showing consistent patterns of eroded material and reverse airflow bends in both stator and rotor blades. One first stage compressor blade was not attached to the first stage compressor rotor. The compressor damage observed was consistent with a compressor stall as the result of hard Foreign Object Damage (FOD).

1.4 Collateral Damage

The aircraft crashed on privately owned land near some derelict vehicles and dormant farm machinery. The aircraft did not directly strike these objects during the initial impact but many pieces of the aircraft were scattered throughout the debris field after they rebounded off the ground. Some of these pieces did contact the vehicles. The impact started a post crash fire that was contained within an area of about 20 by 40 metres by the prompt and successful response of the local fire department. The fire was intense enough to melt many pieces of the aircraft’s aluminium and burned several derelict vehicles and some farm machinery. As well, about 15 trees within the impact area were burned in this fire. It is likely the fire consumed most of the aircraft fuel, smoke tank diesel and other flammable fluids that were on the aircraft.

The 17 Wing Environmental Officer (EnvO) was present throughout the recovery process. A plan for establishing a baseline from surrounding soil and testing the level of contamination in affected areas was initiated. Environment Ontario was notified of the crash and it was reported to that organization as a “spill”.

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1.5 Personnel Information

The pilot has been with 431 (AD) Sqn for four years. Initially he flew in the Snowbird 6 position for two years, and then he changed to the Snowbird 8 position. He was then the Snowbird Standards Pilot for 3 months prior to returning to the Snowbird 8 position. In November 2004, the pilot obtained a maintenance test flight qualification for all 431 (AD) Sqn aircraft. The pilot holds a valid instrument rating, which was completed 01 Feb 05. His annual proficiency check was completed on 10 Feb 05, it was noted that all sequences were flown to a very high standard. His night proficiency check (22 Feb 05) and formation check (5 Apr 05) were also up to date. The pilot’s last ejection seat trainer was completed 07 Dec 04.

Table 2: Personnel Information

Pilot

Rank CAPT

Aircrew Category valid YES

Currency requirements YES

Medical Category valid YES

Total flying time 5022

Hours on type 2462

Hours last 30 days 19.7

Duty time - Day of accident 2.8

Flying hours on day of Occurrence 0.3

1.6 Aircraft Information

The aircraft had 11560.9 airframe hours and the engine 8418.8 hours.

The engine serial number 8058 and the aircraft’s tail portion (with exhaust pipe) were sent to the Quality Engineering Test Establishment (QETE) for further investigation. The ejection seat, parachute and various Aviation Life Support Equipment (ALSE) used by the pilot were impounded and shipped to the Aerospace Engineering Test Establishment (AETE) for further analysis by the Escape System specialists. Items of clothing including the pilot’s Universal Carrier Life Preserver (LP/UC) and helmet were shipped to the Defence

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Research and Development Centre (DRDC) in Toronto for further study. The helmet and LP/UC were shipped to QETE after DRDC examination for further tests.

1.7 Meteorological Information

The Snowbird team departed the Thunder Bay airport at 2115Z to commence their pre-show shakeout and air display over the Thunder Bay waterfront. The Snowbirds have three separate display routines: a high show, a low show, and a flat show. Because the cloud ceiling and visibility were not an issue, the high show routine was planned. Weather is not considered a factor in this occurrence. METAR CYQT 241900Z 17009KT 20SM FEW036 BKN250 23/12 A3019 RMK CU1CI2 SLP227 242000Z 15010KT 20SM FEW040 SCT180 BKN250 21/11 A3018 RMK CU1CI2 SLP225 242100Z 16009KT 20SM FEW042 FEW180 22/12 A3018 RMK CU1AC1CI2 SLP224 TAF CYQT 241339Z 241402 VRB03KT P6SM SKC BECMG 1618 15010KT RMK NXT FCST BY 20Z Winds Surface 170 09kts 3000ft 160 12kts 6000ft 200 28kts YQT FSS Observation after occurrence:

242130Z 15010KT FEW042 FEW160 22/12 A3018 RMK CU1AC1CI2

1.8 Aids to Navigation

All Aids to Navigation at the Thunder Bay airport were serviceable on the day of the occurrence. The Thunder Bay airport issued a NOTAM to all aircraft restricting airspace within five nautical miles of the airport from the surface to 8500ft MSL, except for air show participants, scheduled airlines, emergency medical/rescue and firefighting aircraft. This NOTAM was in effect from 2030Z to 2330Z.

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1.9 Communications

1.9.1 General

The CT114 Snowbird aircraft are equipped with both UHF and VHF communications. The UHF radios have pre-programmed frequencies with a rotating channel selector. Using the UHF channel selectors significantly reduces the workload for the pilots during the air display.

1.9.2 Thunder Bay Air Show Communications Setup

During the air display in Thunder Bay, the two Snowbird co-ordinators, (Snowbird 10 and Snowbird 11), were positioned at show centre located at the downtown marina, approximately 6 miles to the east of the airport. Snowbird 10 was the show’s narrator, and Snowbird 11’s duties included safety pilot and communications. Snowbird 11 had a radio with both UHF and VHF communications enabling him to communicate with both the display team and the Thunder Bay tower.

As the Snowbirds prepared for their departure for the evening air display, the Snowbird Team Lead (Snowbird 1) handled the communications on behalf of the formation for taxi and take off clearance on the VHF radio from the Thunder Bay air traffic controllers. Once the formation was clear of the airfield, the display team transferred to their discreet UHF frequencies, preset UHF CH 11 for the main display team and preset UHF CH 13 for the solo’s (Snowbird 8 and Snowbird 9). The two solo aircraft were given a separate frequency from the remainder of the display team because they were conducting a show line recce and their own “shakeout” manoeuvres prior to the commencement of the show. The solos were to switch to UHF CH11 once they were ready to return to the main formation. The Snowbird co-ordinator on the ground was monitoring both the VHF tower frequency 118.1 and UHF CH 11; he was responsible for the communications between the main display team and the tower. Snowbird 5 was the designated aircraft to monitor the Guard frequency, (243.0 Mhz UHF). Thus, if there were an emergency, Snowbird 5 would be the only aircraft in the formation to hear the distress calls or bail out tones from an ejection seat on the UHF frequency.

1.9.3 Emergency Communications

At 1722L, Snowbird 8 communicated to Snowbird 9 on Channel 13 that he had engine problems and that he was ejecting. Snowbird 9 then quickly switched to Channel 11 to give the “knock it off” call to Snowbird Lead. Snowbird 9 was ordered by Lead to maintain “top cover”. Snowbird 5 later stated that he heard the bail out tone on the Guard frequency; and post accident review of the tower tape revealed a bailout tone was broadcast on Guard at 1722 (L) lasting 10 seconds.

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One of Snowbird 9’s duties as “top cover” was to switch to Guard frequency to listen for possible radio transmissions from the accident pilot on the emergency radio that could be recovered from the seat pack. Snowbird 9 did not switch to Guard frequency, as he was very occupied with other duties as he circled the location attempting to sight the pilot on the ground. This had no consequence to the occurrence because the seat pack and its contents were disconnected from the pilot during his descent, resulting in the loss of his emergency radio.

Of note, the Air Traffic Controllers switched the “top cover” aircraft to a discreet frequency so that he could communicate with the ground emergency service vehicles. The aircraft was able to help the ground vehicles locate the accident site, and Snowbird 9 put out a smoke signal to confirm the location with the emergency vehicles. At the same time the accident pilot on the ground was waving to the top cover aircraft to indicate that he was OK, and when he saw the smoke signal, he believed that the aircraft had seen him. When the accident pilot exited the wooded area, ground emergency vehicles communicated to Snowbird 9 that the pilot was safe.

The Snowbird co-ordinators first became aware of the problem when Snowbird 9 called “knock it off” on CH 11. The co-ordinators then made several attempts before they were able to successfully contact the airport control tower on VHF to relay the information. The co-ordinators were able to communicate to the air show crowd that the air display would be cancelled due to an occurrence. Because of the remote location from the airport and the accident site, and the fact that there were other events and entertainment at the waterfront, there was no need for the crowd to exit the show site. Crowd control and crowd safety was not an issue during this occurrence.

1.10 Aerodrome/Alighting Area Information

The Snowbird team arrived in Thunder Bay on 23 August, and the aircraft were parked on the Confederation Flying College ramp. The aircraft remained on the ramp until the departure for the air display on 24 August. The ramp was cleaned with the ramp vacuum sweeper and a FOD walk was completed prior to the Snowbird Team’s arrival. The ramp was visually inspected by the FSI team and was observed to be in excellent condition.

Thunder Bay airport has two main runways, R 07/25 (6200 x 200ft) and R 12/30 (5300 x 200ft). The airfield is equipped with a VORTAC, ILS, and an NDB. All NavAids were operational during the occurrence. The air display was considered a remote display, because the show centre was six miles to the east of the Thunder Bay airport. The Naval reserve unit HMCS GRIFFON was tasked to coordinate water borne support for the Snowbird performance.

Prior to commencing their “shakeout”, the solo aircraft completed a recce of the show line to look for obstacles and to inspect for birds. The recce revealed that birds did not appear to be a problem over the show line.

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1.11 Flight Recorders

This aircraft is not equipped with a crashworthy CVR/FDR, however it does have an operational load-monitoring (OLM) device. While not designed as a data recorder for accident investigation, the OLM can monitor parameters such as aircraft speed, altitude, Gs, instantaneous roll rates and weight-on-wheels. Of note, the OLM does not record any engine data and it is not designed to be crashworthy.

The OLM equipment was not located amongst the aircraft wreckage, and was presumed destroyed by impact and post fire damage. The availability of an FDR may have provided information regarding the cause of the engine power loss.

1.12 Wreckage and Impact Information 1.12.1 Impact and Debris Trail

See photo no. 01. An impact scar, extending about 3 meters by 4 meters and up to ½ meter deep, was noted at the point of impact. Extending to each side and just up track of this scar was an impact mark from the leading edge of the wing, which indicated the aircraft impacted the ground roughly wings level but about 70 degrees nose down. The main impact scar contained some debris and was spanned by the remains of the main wing spar and small pieces of wing structure. Most of the aircraft debris was expelled from the initial impact point in a very fragmented condition and at steep upward angles that resulted in a relatively small debris field. Several large trees within a few metres of the impact point were damaged by flying debris and post crash fire, but the trees were not cut down by the aircraft during the destruction sequence. This fact is a good indicator of the extent of fragmentation and steep debris trajectories.

The extent of the full wreckage trail, without the ejection seat, ALSE and canopy fragments, was about 60 by 100 meters with the majority of debris in an area of 20 by 40 metres. There were three main pieces in the trail, the front wing spar with part of the wing section, the engine section and tailpipe and a portion of the tail plane. The fuselage and cockpit areas were fragmented and nearly entirely consumed in the post crash fire. Local fire department resources extinguished the post crash fire, thereby containing the fire damage to the immediate impact area.

1.12.2 Hazardous Materials Disposition

Some of the equipment fitted to the CT114 posed hazardous materials concerns from a wreckage and salvage perspective. The 17 Wing Recovery and Salvage Officer (RASO) and EnvO were made aware of these concerns and the site was approached throughout the salvage operation with these hazards in mind. The hazardous materials and aircraft equipment of concern included:

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Depleted Uranium Rudder Counter Weight - Hazard - Radioactive, if uncontained pose contamination danger. Disposition – Weight was located in the main wreckage site and appeared undamaged. Detection equipment was utilized to read radioactive levels (twice) and these were within predicted ranges. The weight was appropriately packaged and marked before shipment to 15 Wing for disposal.

O2 Bottles -Hazard – Fragmentation through failure of bottle (pressurized vessel) or feeding explosive or fire situation during recovery operations through adding pure O2 to the situation. – Disposition - confirmed depleted by escape system specialists – 27 Aug.

Inflated Tires - Hazard – Potential catastrophic explosive failure during recovery operations. Disposition – all three tires deflated during impact sequence and fire, confirmed by RAS personnel - 27 Aug.

Inflated Oleos - Hazard – Potential catastrophic failure of inflated vessel. Disposition – nose oleo destroyed on impact and main oleos appear intact. Main oleos are in containers of gathered debris being shipped to 17 Wing – 29 Aug. The main oleos were deflated in 17 Wing.

Batteries - Hazard – Corrosive materials. Disposition – both batteries destroyed within the battery compartment area of aircraft wreckage and found dry. Pieces recovered by salvage team and packaged in containers for shipment to 17 Wing – 29 Aug.

Seat and canopy charges - Hazard – Explosive charges. Disposition - All charges made safe by AETE Escape Systems team on seat utilized by pilot and the canopy jettison system – 26 Aug. Charges and other explosive devices on unused seat were spread throughout wreckage trail. All charges were located, collected and destroyed in a remote site by EOD team on 27 Aug except for one M27 cartridge that was located on 28 Aug. This last cartridge was given to the OPP for disposal.

Possible Radioactive Luminous Paint - Hazard – Contamination. In the past some of the very old aircraft instruments in the CT114 utilized this type of paint for its radiance qualities. This form of paint was to be phased out of the fleet inventory and throughout the salvage, personnel were aware of this hazard. No gauges of this type were located on the accident site and QETE was informed about this hazard and the possibility that the parts being transported to their location may be painted with this material.

Seat Pack Survival Kit -Hazard – Contents include some hazardous materials, in particular, “Gyro Jet” mini flares (seven flares, based on a 410 shot gun shell design, and a launcher that is installed as an unloaded signalling device), a CO2 cylinder on the one-man life raft (inflation device) and the Emergency Radio AN/PRQ 501 lithium battery (power source). These items are contained in the

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seat pack that separated from the pilot’s Life Preserver/Universal Carrier (LP/UC) during the parachute descent. A concerted search from both the ground and the air could not locate this equipment. More than 50 airborne passes over the area of probability failed to spot the seat pack and life raft due to the difficult terrain (dense bush and swamp bog). This equipment is yet to be located. 1.12.3 Field Examination of Wreckage

Initial engine examination on the scene revealed that there appeared to be hard FOD damage and compressor stall damage throughout all stages of the compressor and stator blades. All of the blades on the first stage compressor were bent at relatively the same angle and pushed together, with damage on the blades intermeshed. This style of compressor damage is consistent with impact damage at low or zero rotational speed. One entire compressor blade was missing from the first stage. See photo no. 03 and no. 04. Since the remainder of the blades on the first stage remained intact, this evidence was of very high interest. The pin from the missing blade remained attached and both the shaft of the pin and the larger diameter-retaining casing had marks that required further laboratory examination.

1.13 Medical

The pilot sustained minor injuries during the ejection sequence directly related to the sequence.

After walking out of the swamp and bush where he landed, the pilot met emergency response vehicles and was transported to the local hospital by a vehicle driven by the local Fire Chief. He was examined by the emergency room attending physician and a Canadian Forces Flight Surgeon that happened to be attending the air show. After toxicology, x-rays and other medical procedures were completed, the pilot was released from the hospital a couple of hours after the accident. Complete recovery from his minor injuries took about 14 days but the pilot returned to flying status on 01 September 2005.

Toxicology samples of the pilot were gathered as per CFMO 42-04 by the responding Flight Surgeon at the local hospital and no anomalies were detected.

1.14 Fire, Explosives Devices, and Munitions 1.14.1 Fire

There was a post impact fire in the field where the aircraft impacted the ground but it was contained within a relatively small area due to the efforts by the local fire department. See photo no. 02. The burn area was about 10 by 25 metres but several derelict cars and farm machinery were in the burn area and were consequently damaged. Also, there were several trees set afire but the containment efforts prevented the spread of the fire to the adjoining forest. The

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fire likely consumed all of the aircraft fuel, smoke tank distillate, and other flammable liquids. Due to the great fragmentation of much of the aircraft, the fire was intense enough to consume or melt much of the small debris, which destroyed nearly all of the cockpit area and much of the aluminium pieces of the aircraft. 1.14.2 Explosive Devices (Ejection Seats and Components)

All explosive devices in this aircraft are associated with the Ejection System except for the flares carried in the Seat Pack Survival Kit.

During the post occurrence activities, 431 (AD) Sqn personnel walked through the main wreckage site and several explosive components from the unused ejection seat were located and marked.

Post accident examination of the ejection components revealed that the canopy functioned as designed in the sequence with all related ballistics and charges expended. These items were therefore safe.

The left (used) ejection seat was within it's service inspection schedule and all explosive devices were within their service life. The ejection seat was serviceable at the time of ejection and all charges and ballistics appear to have functioned as designed during the sequence and were therefore safe. The seat and its components were sent to AETE for further investigation.

The right seat was “tied down” at the time of the accident for solo flight. It was never ejected because the CT114 does not utilize a command ejection system. The right seat was completely destroyed on impact and all the seat explosive devices were accounted for and destroyed by either 17 Wing Explosive Ordnance Disposal (EOD) or the local Ontario Provincial Police (OPP) EOD teams. No indications of any discrepancies with the right seat were observed. 1.14.3 Munitions

No munitions were carried on this aircraft; however, the emergency flares from the Seat Pack Survival Kit (“Gyro jet” brand) were not located due to the swamp and thick bush where they fell. Search attempts were unsuccessful and due to the terrain further efforts will not occur. The local OPP were notified of this fact.

1.15 Survival Aspects

1.15.1 Ejection Sequence

After attempting to correct the engine problem, the pilot realized that he would have to eject. After calling his lead, he assumed an upright posture, and utilized both seat handles to initiate ejection. He did not place his legs back against the calf guards before the ejection. Aircraft parameters were, wings level, between

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200-250 knots indicated airspeed (KIAS), and at an altitude between 1000 and 1500 feet above ground level (AGL).

After the pilot left the aircraft he noted that the seat was not tumbling but flying with a slight side drift. He felt the seat aggressively depart from him followed by a moderate parachute opening shock. Initially the pilot was unable to view his parachute but after he raised his single dark visor and tilted his helmet back, he successfully observed a good parachute.

The pilot then pulled the seat pack release handle to release his seat pack, but he noticed that the seat pack remained hanging from the left side. He then pushed the release button on the airlock fastener, which caused the seat pack to fall away. He saw the life raft starting to inflate, then he looked a second time and there was no survival equipment attached to him. After landing in a swamp uninjured, the pilot realised that he no longer had his seat pack with the survival equipment which includes a PRQ 501 emergency radio. He used his cellular telephone and left a message on Snowbird 10’s cellular phone at 1730L. As well, he had a cellular telephone conversation with Snowbird 1A, the crew chief.

After assessing his environment and having situational awareness on his whereabouts gained through observations made during the parachute descent, the pilot decided to leave his landing position and walk in a southerly direction towards a built up area. About 20 minutes later, after making his way through the swamp towards the noise of the rescue vehicles, he encountered some civilian personnel who were searching for him in the woods.

Based on the injuries sustained during the ejection and the pilot’s ability to walk out of the swamp and heavy bush after landing, the ejection was classified as successful.

1.15.2 Civilian Response

The immediate emergency response to the site consisted of local fire fighters, civilians and police. At 1722L Snowbird 8 ejected, as determined from the bail out tone on the ATC tapes. Three fire/rescue trucks were dispatched to the scene at 1724, which involved 35 personnel with the first truck arriving on scene at 1733. Two water hoses were laid to extinguish all flames and smouldering debris at the scene. The quick response by the fire fighters undoubtedly reduced the impact of the post crash fire upon the private property where the aircraft crashed and it also reduced some of the fire’s effects on aircraft wreckage. In addition to extinguishing the fires from the aircraft, firefighters extinguished fires from six vehicles located on the property. The firefighters efforts minimized damage to the vehicles and the aircraft.

The firefighters were notified by the Snowbird crew chief of the possible hazards associated with the depleted uranium located in the tail section. A safety zone perimeter of 1000ft around the scene was established, and a Ludlum radiation

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detector was used to measure the background radiation. The background radiation was determined to be minimal; consultation with a scientist from the Canadian Nuclear Safety commission confirmed this fact.

There were approximately 70-80 persons at the crash scene when the fire trucks arrived, and police assistance was requested for crowd control. The scene was turned over to the Thunder Bay Police at 2041.

About ½ kilometre north east of the main wreckage site, the pilot’s ejection seat and aircraft canopy were identified and cordoned off in two separate, but nearby, locations by the local Emergency Measures Organization (EMO) personnel. This not only preserved evidence for the investigation team, but also isolated possible dangerous materials in the ejection seat or canopy. The efforts by civilians searching the forest helped the pilot find the rescue vehicles and sped his journey to the hospital.

1.15.3 Military Emergency Response

The first military personnel on the scene were members of 431 (AD) Sqn maintenance team who informed the fire personnel of the possible radiation hazard. After the scene was declared safe, they started to mark the crash site for any unexploded cartridges from the ejection seat that was destroyed during the aircraft impact.

Later, personnel from local Reserve Units secured the three separate sites and established a very effective security zone as observed by the investigation team.

1.16 Test and Research Activities

The engine was removed from the crash site for shipment to QETE for further examination on 27 Aug. The engine arrived on 30 Aug and preliminary examination began on 31 Aug. During disassembly of the engine at QETE, a first stage compressor blade was found lodged against the diffuser section. The part was quite worn from machining indicating it had likely travelled through all 8 stages of the compressor, thereby causing considerable damage. The tangs, which are lugs at the bottom of the part that are utilized to pin the blade to the mounting location, were observed as incomplete.

After the immediate response to the emergency, fuel and fluid samples were gathered from equipment in Thunder Bay and shipped to QETE labs for analysis.

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1.17 Organisational and Management Information

17 Wing Winnipeg, the closest geographical Air Force support location, was designated as the main support base for the investigation team and follow on remediation efforts vice the unit of ownership of the aircraft, 15 Wing Moose Jaw. Therefore, the Recovery and Salvage Officer (RASO), the EOD team and the Environmental Officer (EnvO) were provided by 17 Wing. Similarly, transportation, administration and legal advice requirements were provided by 17 Wing.

Thunder Bay Reserve Units provided additional support such as site security and secure storage locations for aircraft, parachute and ejection seat components. The Thunder Bay Armoury was utilized for storage and examination of certain components while transport to various laboratories was arranged.

Personnel from the Canadian Forces Recruiting Centre (CFRC) Thunder Bay provided invaluable contact points within the local community and with civilian authorities as well as arranging outstanding administrative and logistic support for the full breadth of the investigation teams’ and RAS requirements.

1.18 Additional Information Nil

1.19 Useful or Effective Investigation Techniques Nil

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2. ANALYSIS

2.1 The Aircraft Engine 2.1.1 General

The primary focus during the technical investigation was to determine the cause of the engine failure. It was quickly determined at the accident site that a probable cause of the engine failure was due to the failure of one of the first stage compressor blades resulting in massive damage to the remainder of the engine. The engine was sent to the QETE laboratory for an in depth technical examination and analysis. As well, the maintenance history of the particular engine was examined and is discussed below. 2.1.2 Fuel

Fuel samples were taken from the Thunder Bay refuelling tender and the storage tank. These Jet A-1 fuel samples were sent to QETE for examination. Both samples were individually tested and found to be satisfactory. In addition, gas chromatography was performed and compared to a reference sample and these tests confirmed that the samples had no presence of chemical contamination. QETE’s Engine Analysis

2.1.3 QETE’s Engine Analysis The QETE investigation team made the following observations.

See photo no. 05. The engine had very heavy rotational damage to all of the compressor blades and stator vanes, and none of the blades had failed at the root. The blades and vanes all showed a very ragged appearance, which is characteristic of ingestion of solid metallic foreign objects. There was also very heavy impact damage whose characteristics were consistent with impact at zero engine rotation speed. The impact damage had peeled away the front frame of the engine as well as one of the compressor casing halves. The other half of the casing was still partially attached. The first stage compressor had one blade missing, but the missing blade's retaining pin was still attached. A neighbouring compressor blade had been folded over and into this gap. In order to examine the pin of the missing blade, several blades to either side were cut away.

The missing first stage compressor blade was subsequently found wedged in the diffuser section of the engine. This blade was removed for examination. See photo no. 06. The outer tip of the compressor blade was missing, (it broke off or was ground off), and all three lugs were each missing the lower lobe section (the end opposite the blade tip). The remaining portions of the lugs were heavily deformed and abraded to the extent where some metal melting had started to occur. Low power microscopic examination indicated that the fracture faces of all

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three lugs were obliterated or at least severely damaged. The degree of abrasion and melting on the lugs of the separated first stage blade seemed to be consistent with the blade passing through an engine operating at high RPM. This type of damage could not have occurred if the blade had been knocked off at impact.

The damaged lug was examined under the Scanning Electron Microscope, and under high magnification, fatigue features were discovered.

Once removed from the disk, the missing blade’s retaining pin was examined under high power magnification. QETE found wear marks on the pin caused by the missing first stage blade where the rear lug contacts the pin. The impression of the crack opening, seen as a horizontal wear mark, could clearly be detected on both sides of the pin caused when the front lug broke off. This wear area is indicative of a progressive failure in that the front lug must have been cracked or broken for some time before the accident. A similar but lesser wear mark, showing indications of a cracked lug could also be seen on the area where the central lug would have been positioned.

Further inspection of the outer compressor case halves in the area of the first stage, showed an area of rubbing consistent with trailing edge corner rub. In one section the rub indentation grows drastically deeper, as though the blade suddenly caught and dug in. This area was most probably where the blade finally failed and continued downstream into the engine. See photo no. 07.

The overall appearance of the engine is indicative of massive rotational damage due to the ingestion of a solid metallic object, such as the first stage compressor blade. The severe impact damage is distinctly different from the rotational damage. The impact damage occurred after the rotational damage as indicated by ragged edged blades folded over each other. The random directions of the impact damage indicate that there was essentially no rotation at the time of impact. The fact that a neighbouring blade was found folded into the gap left by the missing first stage blade is an indication that the missing blade had separated prior to impact.

It is concluded that the CT114120 engine failed as a result of the separation of one of the first stage compressor blades. The blade failed at the lug from fatigue cracks most likely starting with the rear lug as evidenced by the position of the blade tip rub on the compressor case. After separation, the first stage compressor blade moved rearwards through the engine, causing massive and sudden damage to the rest of the compressor. The degree of damage was such that the engine could not run or restart, and could possibly not even rotate. 2.1.4 Blade Tip Rub Inspection The Canadian Forces Technical Orders (CFTOs) include a J85-CAN-40 engine inspection process to look for blade tip rubbing. One occasion when blade tip

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rubbing can occur is when the lugs elongate causing the blade tip to contact the outer casing during rotation. The initial indications of blade tip rubbing will be a visible burning/discoloration on the outer compressor blade tip. If evidence of blade tip rubbing is observed, this may be an indication of an impending lug failure that would have catastrophic results for the engine.

Following this occurrence a Risk Assessment Procedure and Record of Airworthiness Risk Management (RARM) was conducted by DAEPM(FT) to analyze the risks of first stage compressor blade tang attachment failures. In order to confirm the continuing serviceability of the J85-CAN-40 engine, the RARM made the following recommendations:

a) a caution was added in the CFTOs to highlight the importance of blade tip rubbing;

b) a fleet SI was ordered to inspect first stage compressor blades for tip rub; and

c) a Maintenance Alert was issued to increase technician awareness of early indication of blade fatigue.

The SI was conducted on all of the CT114 engines and all were found to be within limits. It was discovered by the engineers that some discrepancies remain with the blade tip rub inspection. A difficulty for the technicians is that there is no clear definition of blade tip rub in the CFTOs. Rubbing of the blade tip against the compressor casing causes erosion of the blade metal. It is only the friction from that erosion that causes the burning/discoloration of the blade and its coating. It is the metal erosion that is specifically considered as ‘tip rub’. Because the dimension of metal erosion is difficult to measure unless the compressor casing is removed, the burn/discoloration is used for measurement. This area may be larger than the area of the metal erosion due to thermal propagation properties, resulting in more stringent limits.

Another important difficulty with the blade tip rub inspection is that there are weaknesses with the current first stage compressor blade tracking process. If the blade tip discoloration is within certain dimensions, the blade tip burn marks can be sanded down and painted with yellow Dykem. The Dykem paint allows technicians to notice any further indication of subsequent damage to the affected blade. The J85-CAN-40 compressor blades are not serialized and there is no reference point that can be used to identify or number each blade individually. It would not be practical to serialize each compressor blade as this could damage the blades protective coating and impact their corrosion resistance. This carefully placed paint is the only method of identifying blades that have had previous blade tip rubbing work carried out. In the case of this accident, the post crash fire left no indication of Dykem paint marks on any of the compressor blades. The FSI team recommends that when blade tip rubbing has been

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identified, strict adherence to CFTO procedures and limits is required by technicians in order to prevent a recurrence of blade lug failure.

2.1.5 Accident Engine S/N 8058 Maintenance History

An investigation into the maintenance history of the accident engine revealed that the engine had undergone maintenance for blade tip rubbing within the year prior to the accident.

The accident engine was removed from aircraft CT114159 in December 2003 and was subsequently sent to the Original Equipment Manager (OEM) for periodic inspection in May 2004. When the engine was returned to the unit, technicians discovered evidence of blade tip burn/discoloration on one of the first stage compressor blades following an engine run up on the engine test stand. This engine test run was part of the Build Up test prior to returning the engine to service. The technician who identified the burnt discoloration on the blade tip in November 2004, sent an email including photographs to the Life Cycle Maintenance Manager (LCMM) requesting advice.

The LCMM responded in an email to the technician to carry out the following list of recommended maintenance procedures: remove compressor top half, inspect the rest of the compressor for heavy rub and remove burrs as required, remove burrs from first stage blades, clean and use Dykem to identify rub area, remove high metal on compressor casing (spot), re-install top half and carry out full engine test, re-check first stage blades for tip rub, and advise LCMM of the results. Ideally, the LCMM should have referred the technician to the appropriate CFTO to complete this maintenance action.

The technician completed the list of recommended maintenance actions, except the compressor top half casing was not removed prior to completing the remainder of the work. Removing the compressor top half casing is a time consuming task, and the technician felt he could satisfactorily complete the inspection without removing the casing. It was noted that the CFTOs were not clear in providing direction on the requirement to remove the compressor top half casing when inspecting for evidence of blade tip rub. After the engine was run in the test cell, the technician stated that the blade tip rubbing was within CFTO limits and the engine was declared serviceable. Note, that this conclusion was made without removing the top half casing. There was no evidence of Dykem on any first stage compressor blades following the accident. Thus it is unknown if the blade that had evidence of blade tip rubbing in 2004 was the same blade that separated from the engine during this accident. However, the fact remains that this engine had a history of blade tip rubbing, and extra attention should have been made during engine inspections to monitor the compressor blades for evidence of blade tip rubbing.

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The maintenance action carried out at the unit was not recorded in the CF349 paperwork. As well, the LCMM did not receive any feedback from the unit concerning the outcome of the recommended maintenance actions.

2.2 Aviation Life Support Equipment (ALSE)

2.2.1 Life Preserver / Universal Carrier (LP/UC)

Following the ejection sequence, the pilot realised that his Seat Pack Survival Kit, including the contents, were no longer attached to his LP/UC. The Seat Pack Survival Kit is attached to the LP/UC by the maritime lanyard. The pilot did observe the Survival Kit deploy and saw the inflated life raft during the parachute descent. The FSI team investigated the reason why the Survival Kit had separated from the LP/UC. The Seat Pack Survival Kit was not located at the accident site.

During the analysis of the stitching on the LP/UC where the maritime lanyard is attached, the investigation team discovered that the stitching used was not in accordance with applicable orders. See photo no. 09. In 1997, a modification leaflet was issued directing the number of stitches and the size of the patch to be used on the LP/UC for the attachment of the maritime lanyard. The modification leaflet directed that there be between 8 and 10 stitches per inch, and nearly double that number were found in some locations on the pilots LP/UC. This increase in the number of stitches would greatly reduce the strength of the sewn materiel. The leaflet directed that the attachment point include patches of materiel to be 2 inches by 2 inches in size. The patch found on the pilots LP/UC was only 1 inch by 1-½ inches. This smaller patch meant that the forces would be distributed over a smaller area and would therefore increase the chance of failure.

Following the accident, an “Advanced Notification Special Information to Universal Carrier Maritime Lanyard Connector” was issued to the CT114 fleet. This notification called for a visual inspection of all LP/UCs to ensure the proper embodiment of the original leaflet. If the stitching was found to be incorrect, the full modification was to be carried out including the replacement of the attachment. Out of the 35 ready-to-use LP/UCs at 431 (AD) Sqn, 25 were found to have either deficiencies in original design implementation or had suffered wear and tear that caused the integrity of the attachment to be in question. The defective LP/UCs were modified and returned to service by 31 August 2005.

The original LP/UC modification was issued in 1997. At that time, 15 Air Maintenance Squadron (AMS) carried out the maintenance for 431 (AD) Sqn. As well, it was in 1997 when the amalgamation of the MOC 500 series trade took place. The inspection of the units LP/UCs following this accident revealed that there were significant deficiencies with the manner in which the modification was implemented. During the 8 year time span from the time of the original

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modification to the accident, the LP/UC’s would have undergone many 180 day inspections and audit inspections. The fact that the deficiencies were not detected suggests an issue with the training and experience levels of both the technicians and supervisors involved with the LP/UCs.

2.2.2 Aero Rigid Arm Drogue (ARAD)

The Aero Rigid Arm Drogue (ARAD) was fitted to the CT114 ejection seat to add to its flight stability during the ejection sequence and to ensure positive seat man separation during that phase of the ejection. Post crash ARAD examination indicated that the device worked as designed, but two areas of dis-similar metal corrosion were noted on components of the ARAD. One was on the lock down arm locking bar and the other was on the lock down arm washer. The corrosion was a result of untreated 1020 steel with poor anti-corrosion characteristics. This corrosion on the ARAD had been seen on earlier CT114 seat inspections and a Modification leaflet was implemented to change the material to stainless steel. The identified corrosion had no impact on the proper function of the ARAD, and is not considered an airworthiness issue. In March 2006, the CT114 units received the required parts to rectify the corroded components. As of the date of this report, 20 out of the 26 CT114’s at 15 Wing and AETE have received the modification.

2.2.3 Parachute

The parachute canopy was recovered in excellent condition and showed very minor signs of opening shock damage. A more detailed examination of the parachute pack tray revealed that it had been previously repaired to have the parachute cone plate re-attached. The repair was not done IAW the CFTOs as the thread was not stitched in all the top cone holes and this resulted in a partial separation of the plate during this accident. See photo no.10. A cable housing which houses the cable that activates the parachute automatic opening device at a certain barometric pressure altitude is attached to the cone plate. Had the cone plate completely separated from the parachute, the pilot would have had to manually pull his rip-cord to activate the parachute. 431 (AD) Sqn conducted a local survey of all their parachutes to ensure the proper stitching of the top cone plates. Out of the 59 parachutes inspected, all of the top cone plates were found to have the correct stitching; however, 3 of the parachutes cone plate stitching were found to be slightly frayed and they were subsequently replaced. Because the remainder of the parachutes had the correct stitching on the top cone plates, this is considered to be an isolated incident with the accident pilot’s parachute.

The accident pilot was wearing a modified parachute undergoing Operational Test and Evaluation under Air Training Test and Evaluation Flight, (ATTEF). His parachute had a modified lanyard arming key attachement. The arming key was attached to the lap belt and it functioned as designed.

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Additionally, the inspection cycle for the parachute was mis-calculated by two days, which would have made the parachute overdue by two days when next inspected. It is important that repairs be done as per the CFTOs and that inspection due dates are correctly calculated to ensure that the equipment will operate as specified when required.

2.2.4 Helmet, Visor, and Oxygen Mask

Investigation of the pilots’ helmet revealed that the dark visor did not match the oxygen mask. 431 (AD) Sqn carries two types of oxygen masks, two types of visors, and one type of helmet. Each type of oxygen mask correctly fits with only one type of visor. If an oxygen mask is matched with the incorrect visor then a small gap will occur between the mask and the visor, which may result in injuries during an ejection. Following the accident, 431 (AD) Sqn carried out a local survey of all of the helmet/visor and mask assemblies. Out of the 26 assemblies, none were found to have a wrong match.

There is currently no direction in the CFTOs to remind the technicians about the correct mask/visor match when fitting the helmet assemblies. It is recommended that a note/caution be added to the CFTOs to ensure that the technicians verify the proper match of helmet and visor during the helmet assembly process. The CFTOs state that the acceptable limits for fitting is ‘little to no gap’. This definition requires further clarification, as the term ‘little’ is open to interpretation.

Initial observation of the pilots’ helmet showed a crack on the outer surface. See photo no.11. The helmet was sent to QETE for further examination. Through microscopic inspection, it was revealed that the deformation was a result of a separation within the outer paint layers and the integrity of the helmet was not compromised. The separation occurred because several paint layers were applied on top of a vinyl decal. This is not standard practice, as vinyl is an unstable medium that is susceptible to expansion and contraction.

Prior to the accident, 431 (AD) Sqn sent all of their helmets to a contractor to have them painted with the Snowbird colour scheme. A standard Snowbird helmet has 5 layers including the grey paint, primer, red paint, vinyl decal, and a clear coat. The accident helmet was found to have 12 layers. The CFTOs do not have any direction regarding the maximum layers of paint allowed on a flying helmet, and no direction was provided to the contractor regarding this issue.

The helmet-painting contract was terminated in January 2006, and 431 (AD) Sqn currently conducts all of the helmet painting locally within the unit. The Sqn policy is to sand the outer paint layer slightly to allow for better adhesion prior to applying the next coat. Stripping the helmet with a solvent is not an option due to the layers of epoxy, fibre, and Kevlar. Another important issue is the extra weight of the helmet associated with the additional paint layers. The Snowbird pilots conduct frequent high ‘G’ manoeuvres where an increase in the weight of the helmet could contribute to neck injuries. The FSI team recommends that the

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TAA develop refinishing procedures directing the maximum layers of paint allowed on a flying helmet.

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3. CONCLUSIONS

3.1 Findings

3.1.1 The CT114120 engine failed due to separation of one of the first stage compressor blades that moved rearwards through the engine, causing massive and sudden damage to the rest of the compressor.

3.1.2 The compressor first stage blade failed at the lugs due to progressive fatigue cracking.

3.1.3 The engine impact damage indicates that the engine was not rotating upon impact.

3.1.4 The accident engine had been diagnosed with first stage compressor blade tip rubbing in November 2004.

3.1.5 The engine was returned to service after a portion of the LCMM maintenance advice/direction was completed.

3.1.6 The maintenance actions carried out on the engine were not properly documented.

3.1.7 The maritime lanyard carrying the Seat Pack Survival Kit separated from the pilots LP/UC during the parachute descent due to the poor workmanship that was carried out during a LP/UC modification in 1997.

3.1.8 A survey of the unit's ALSE revealed that the maritime lanyard stitching problem was also evident in 25 of 35 ready use LP/UCs indicating an issue with the training and experience levels of both the technicians and supervisors involved with the unit’s LP/UCs.

3.1.9 The ARAD device fitted to the pilot’s ejection seat worked as designed. Metal corrosion caused by dissimilar metals was observed on two areas of the ARAD.

3.1.10 An examination of the pilot’s parachute revealed that the cone plate had partially separated due to a previous repair that was not done IAW the technical orders. This was determined to be an isolated incident.

3.1.11 The pilot’s oxygen mask was not assembled with the correct matching visor.

3.1.12 CFTOs do not contain any direction with respect to how many layers of paint are authorized on flying helmets.

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3.1.13 QETE analysis of the pilot’s helmet revealed that a crack found in the helmet was the result of the separation of paint layers, and the integrity of the helmet was not compromised.

3.1.14 A crashworthy FDR may have provided additional information as to the cause of the engine power loss.

3.2 Cause Factors

3.2.1 The cause of the accident was the result of a catastrophic engine failure due to the separation of one of the first stage compressor blades, that moved rearward through the engine, causing massive and sudden damage to the rest of the compressor.

3.3 Contributing Factors

3.3.1 The engine had undergone maintenance action for blade tip rubbing within the year prior to the accident. This maintenance was not completed in accordance with CFTOs and was not properly documented.

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4. PREVENTIVE MEASURES

4.1 Preventive Measures Taken

4.1.1 Director General Aerospace Equipment Program Management “DGAEPM” issued a J85-CAN-40 Special Inspection (SI) on 30 August 2005. This SI detailed an inspection of the compressor rotor first stage blades for tip rub before the next flight. This was completed on 01 September 2005.

4.1.2 DGAEPM issued a maintenance alert to increase technician awareness when inspecting for first stage blade tip rub (burnt mark) and to emphasize the importance of following the CFTO limits associated with this phenomenon. (MA114-03, Aug 05, Doc# 492048).

4.1.3 DGAEPM issued a CFTO publication amendment on 31 August 2005. The following was inserted into the J85-CAN-40 ‘A’ check inspection: “special care and attention shall be observed when evidence of compressor first stage blade tip rub (burn) is witnessed. Blade tip rub (burn) is an indication of potential blade tang failure that may lead to catastrophic failure of the blade and subsequently lead to complete engine failure.”

4.1.4 A CFTO amendment was issued on 02 Nov 2005 to highlight the requirement of removing the Compressor Top Half Casing for better inspection of Blade Tip rub/burn.

4.1.5 All CT114 units have received the ARAD modification parts to replace the corroded locking bar and washer. As of the date of this report, 85% of the fleet’s ejection seats have had these modifications completed. The modifications are to be embodied on or before the next seat periodic.

4.2 Further Preventive Measures Recommended

It is recommended that:

4.2.1 The TAA/DTA conduct a formal audit of the 431 (AD) Sqn ALSE section.

4.2.2 The TAA add a note or caution to the CFTOs ensuring that the technicians verify the proper match of mask and visor during the helmet assembly process.

4.2.3 The TAA clarifies the following definition in the CFTOs describing the acceptable limits for mask/visor fitting of flying helmets: “the acceptable limits for fitting is little to no gap.”

4.2.4 The TAA develops refinishing procedures directing the maximum layers of paint allowed on a flying helmet.

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4.2.5 It is recommended that some form of a crashworthy CVR/FDR be obtained for the CT-114.

4.3 Other Safety Concerns Nil

4.4 DFS Remarks

4.4.1 This occurrence demonstrates the criticality of not delaying the decision to eject. Having rapidly assessed the situation, and realizing that the engine was unlikely to restart or generate any useful power, the pilot did not waste any more time and was able to eject well within the envelope of the seat. Establishing the parameters for a successful ejection must always be the first consideration in this type of emergency situation, particularly at low altitude.

4.4.2 Another important aspect of the occurrence is the conduct of maintenance. CFTOs appear not to have been followed when the maintenance actions for blade tip rubbing were carried out on this engine; worse, the work done was not documented. This is a recurring theme in occurrences, yet, it should be within our means to rectify this practice in our units. While we cannot draw a direct link between the specific maintenance action performed and the occurrence (due to the virtual destruction of the engine in the crash), the way in which the maintenance was carried out clearly raised the risk that an engine failure of this sort might happen. CFTOs specify certain procedures for good reason, and they need to be followed.

4.4.3 Finally, the ALSE issues that came to light in this occurrence are a cause of grave concern. Had this pilot ejected in an area where cell phone coverage was not available, the loss of his PLB and seat pack could have delayed his recovery and threatened his survival. ALSE is designed to protect aircrew in the performance of their duties, and must be properly maintained to function properly. Otherwise, it is useless, or in the worst case, deadly. The trend, in this and other occurrences, shows increasing failure or malfunction of ALSE equipment. DFS will be taking action on a broader front to determine the reasons for this trend and to address the overall ALSE situation with the Technical and Operational Airworthiness Authorities.

//ORIGINAL SIGNED BY// C.R. Shelley Colonel Director of Flight Safety

Annex A to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Annex A: Abbreviations

AD Air Demonstration AGL Above Ground Level AETE Aerospace Engineering Test Establishment ALSE Aviation Life Support Equipment AMS Air Maintenance Squadron ARAD Aero Rigid Arm Drogue ATTEF Air Training Test and Evaluation Flight CFRC Canadian Forces Recruiting Centre CFTO Canadian Forces Technical Orders DGAEPM Director General Aerospace Equipment Program Management DRDC Defence Research and Development Centre FDR Flight Data Recorder EMO Emergency Measures Organization FSI Flight Safety Investigation FOD Foreign Object Damage EOD Explosive Ordnance Disposal EnvO Environmental Officer KIAS Knots Indicated Airspeed LCMM Life Cycle Maintenance Manager LP/UC Life Preserver/Universal Carrier QETE Quality Engineering Test Establishment OAA Operational Airworthiness Authority OEM Original Equipment Manager OLM Operational Load-Monitoring Device OPP Ontario Provincial Police RAS Recovery and Salvage RASO Recovery and Salvage Officer RPM Revolutions per Minute RSSK Rigid Survival Seat Kit SI Special Inspection TAA Technical Airworthiness Authority

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Annex B: Photographs

Photo no. 01: Impact site (overhead view)

Photo no. 02: Impact Site

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Photo no. 03: Engine in the Field

Photo no. 04: Missing Compressor Blade

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Photo no. 05: Engine at QETE

Photograph no. 06: Blade at QETE

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Photograph no. 07: Scrape Mark on Compressor Casing from Blade

Photograph no. 08: Blade Comparison

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Photograph no. 09: UCLP Attachment point

Photograph no. 10: Parachute Top Cone Plate

Annex B to 1010-CT114120 (DFS 2-4-2) Dated: 24 November 2006

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Photograph no. 11: Pilot’s Cracked Helmet