# Snowbird Flight Safety Report - "a somewhat complacent attitude"



## dapaterson (7 Jul 2009)

The flight safety report on the 18 May 2007 crash of a CT-114 has been released.  A news article is online at http://www.ottawacitizen.com/Life/Somnia/1764177/story.html  The Flight safety report is at http://www.airforce.forces.gc.ca/dfs/reports-rapports/I/pdf/fsir/CT114159-eng.pdf

Of interest to me was the observation "Pilots at 431 (AD) Squadron had developed a somewhat complacent attitude towards the performance of the lap belt funcitonal checks".  Earlier flight safety reports on other Tutor crashes had reported "The mission involved unbriefed and unapproved aerobatic manoeuvring", "Both survivors wore the UCLP which did not have all of the mandatory survival contents.", "The level of training and preparedness given to Snowbird passengers was inadequate to assure their safety.", "The life support equipment fitting of passengers flying with 431 (AD) Squadron was inadequate to assure their safety." (http://www.airforce.forces.gc.ca/dfs/reports-rapports/I/pdf/fsir/ct114006.pdf).  A 2005 catastrophic engine failure lead to numerous observations about ALSE equipment being out of spec (http://www.airforce.forces.gc.ca/dfs/reports-rapports/I/ct/CT114120-eng.asp).

So my question:  Is there a problem with 431 (AD) Sqn (The Snowbirds) and complacent attitudes towards flight safety?  To me, the 2001 mid-air collision, the 2005 and 2007 incidents taken together are suggestive of a unit culture where flight safety is less of a priority than perhaps it should be.


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## SupersonicMax (7 Jul 2009)

Strapping in becomes, after a while, something you get pretty proficient at, doing it flight, after flight, after flight. People get comfortable doing something they believe they are proficient at, ommiting/modifying some checks.  It saves time on the 100+ checks you have to do before you even take off, and time is perceived to be important.  We don't want to be the last one ready.  We all do it to a certain extent, regardless of the trade.  I'm not saying it's okay, especially on tasks that will save your life, however, it's human nature.

Also, it seems SB2 and his Ground Crew had the habbit of the ground crew checking the lap belt before the flight.  On that day, that didn't happen.

One thing I learned in my training is to try as much as possible to stay in your routine, especially for critical stuff like strapping in.  You may ommit something that is quite important.  

It happenned to me on a X-Country flight.  I strapped in, but I was at a foreign airport.  It was a bit different than usual.  I usually put my helmet as I am walking to the plane, however that day, I didn't because we spent quite a bit of time around the airplane.  I strapped in and forgot to secure shoulder straps.  I caught it on the pre-take off checks, thank god. 

It's not that people are complacent towards flight safety in general.  People get complacent with some tasks.  The fact that they are flight safety related is irrevelant to what people are complacent with, while it probably should!

Just my 2 cents


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## Occam (8 Jul 2009)

After reading the report on the 2007 crash, I didn't get the impression that there was a huge problem.  Like Max said, is there room for improvement...yes, always.  That's what the Flight Safety program is all about.

Do we all do circle checks on our vehicles before starting up and driving off?  No.  

999,999 times out of a million, we'll drive off just fine.  It'll be that one in a million occurrence that causes catastrophe.  Recognized risk?  Definitely.  Preventable?  You betcha.  But just about all of us can say "Wow, that could've easily been me that ran over the toddler that was playing behind the car".


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## dapaterson (8 Jul 2009)

So is it less that 431 (AD) is complacent, and more that they accumulate more flight hours, so there are more incidents?


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## Occam (8 Jul 2009)

I'll defer to someone who knows more about that subject, but I'd be curious to know the answer to that question as well.  Do Snowbirds pilots rack up the hours faster than other pilots?


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## Loachman (8 Jul 2009)

It's not the amount of flying time, but what goes on during it.

Manoeuvring a large formation aerobatically as close as they do leaves very little room for error.

Flying at a hundred knots a few feet above the ground has its hazards, too.

A small error under some circumstances can be trivial, or not even noticed, but can be catastrophic under others - like when inverted at less than 1 G.


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## SupersonicMax (8 Jul 2009)

34 hours in 30 days is definately a lot on a single pilot aircraft, especially doing what they do (Formation Aerobatics, transits, etc). That would mean roughly 410 hours a year.  Granted I was a student, I flew 350 hours in the last 2 years.


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## Sf2 (8 Jul 2009)

Flight safety calls it the swiss cheese model.  Each slice is a factor that could potentially lead to an accident.  Put two slices together, and once in that blue moon, all the holes line up and the chain of factors causes something.

In this case, from what I've read in the FSIR, the combination of design flaw, complacency, presence of media, personal mental/physical state , all lined up to cause an unfortunate, catastrophic event.

This could have happened to a student on ALP1, or a Snowbird with 1700 hrs.  Flying time has nothing to do with it.

On a side note, good friend of mine flew his entire BIT with the shoulder straps undone.  Instructor in the front seat saw the glaring orange strips in his mirrors.  He still passed


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## Strike (8 Jul 2009)

SF2 said:
			
		

> On a side note, good friend of mine flew his entire BIT with the shoulder straps undone.  Instructor in the front seat saw the glaring orange strips in his mirrors.  He still passed



For those not of the pilot persuasion:
BIT = Basic Instrument Test


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## Journeyman (9 Jul 2009)

Strike said:
			
		

> For those not of the pilot persuasion:



Nahhh, if you want to _really_ fly....you have to get out of the plane.  :nod:







Edit:   ff topic:    Apologies


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## observor 69 (9 Jul 2009)

Occam said:
			
		

> After reading the report on the 2007 crash, I didn't get the impression that there was a huge problem.  Like Max said, is there room for improvement...yes, always.  That's what the Flight Safety program is all about.
> 
> Do we all do circle checks on our vehicles before starting up and driving off?  No.
> 
> 999,999 times out of a million, we'll drive off just fine.  It'll be that one in a million occurrence that causes catastrophe.  Recognized risk?  Definitely.  Preventable?  You betcha.  But just about all of us can say "Wow, that could've easily been me that ran over the toddler that was playing behind the car".



Murphy's Law " What can go wrong will go wrong."

Starfighter 104749 served with 439 Squadron at CFB Baden Soellingen, West Germany which is where this photograph was taken. Unfortunately '749 fell victim to a hangar fire on 2 March, 1984 and was subsequently struck off strength on 29 August of the same year, just two years prior to the majority of the remainder of the fleet being retired and transferred to Turkey. 
http://www.airforce.forces.gc.ca/site/equip/historical/starfighterlst_e.asp

A hurried mistake compounded by another mistake caused a hanger fire and the loss of a couple of 104.


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