Investigation Reports

The RCAF / DFS has launched their newly restructured website, based on the Government of Canada’s Standard on Web Usability. We are striving to have the Investigation reports and other important Flight Safety information back online as soon as possible.  Until they are available, please contact DFS (dfs.dsv@forces.gc.ca) if you require any specific information.

Flight Safety reports are produced under the authority of the Minister of National Defence 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.

The FS reports are prepared solely for the purpose of accident prevention and shall not be used for legal, administrative, or disciplinary action. Although most investigations are performed at the wing level by the Wing or Unit Flight Safety Officer, more significant occurrences will be investigated by DFS, in accordance with regulations.

CT155211 Hawk

CT155211 Hawk - From the investigator

A near mid-air collision occurred between the CT155 and a Thrush aerial application aircraft returning to Moose Jaw Municipal Airport, following an aerial application in some fields located to the west of Moose Jaw.
August 21, 2018

Bellanca scout

Bellanca Scout - From the Investigator

The accident flight was part of the Air Cadet Gliding Program and in support of the summer glider pilot training.
July 17, 2018

CH146432 Griffon

CH146432 Griffon- Epilogue

The occurrence involved a Griffon helicopter from 424 Transport and Rescue Squadron (search and rescue configuration) with a six person crew operating out of the Opa-Locka airport, near Miami, Florida.
February 28, 2018

The glider sustained very serious damage.

Schweizer 2-33A Glider C-GCLE - From the Investigator

The accident took place during the summer Air Cadet Gliding Program at the Gimli Cadet Flying Training Center located at the Gimli Industrial Park Airport in Manitoba.
August 21, 2017

Cessna 172 (C-GAYE) accident site

Cessna 172 C-GAYE - From the Investigator

The accident flight was part of the Air Cadet Power Scholarship Program and flown under contract by a civilian flight training unit. The purpose of this flight was to conduct pilot training.
August 2, 2017

G-suit

CF188796 Hornet - Epilogue

Two CF188 pilots (call signs Mig-1 and Mig-6) completed individual Maple Flag missions uneventfully in the Cold Lake Air Weapons Range and returned to base together as a two-ship formation.
June 20, 2017

Search and Rescue training parachute jump. Stock photo not related to the accident.

CC130338 SAR Technician - Epilogue - Flight Safety Investigation Report

The accident occurred during a 435 (Transport and Rescue) Squadron CC130H Hercules search and rescue (SAR) training mission.
March 8, 2017

CT156 Harvard II accident site

CT156105 Harvard II - From the Investigator

A CT156 Harvard II was operating out of 15 Wing Moose Jaw SK, with a two pilot crew from 2CFFTS. The mission was an instructional flight to practice visual sequences including basic aerobatics.
January 27, 2017

Accident site

CF188747 Hornet - Epilogue - Flight Safety Investigation Report

The pilot of aircraft CF188747, using the call sign “Swift 32”, was part of a two-ship formation led by “Swift 31” for an air-to-ground training mission.
November 28, 2016

Glider impacted ground

Schweizer 2-33A Glider C-GFMB - Epilogue

On 15 August 2016, a cadet student pilot was conducting the eighth solo training flight under the Royal Canadian Air Cadet Gliding Program at Comox Airport.
August 15, 2016

Information: Investigation Report Types

At the wing level, following the notification of a FS occurrence, Supplementary Reports are produced for minor or non-complex incidents, once the investigation by the Wing or Unit Flight Safety Officer is completed. Those reports are not made public and, therefore, not published on the DFS website.

In the case of occurrences investigated by DFS, the investigation will usually be classified as a Class I, or Class II, investigation depending on the aircraft damage level, the personnel casualty level, and the safety of flight compromise level.

DFS will document their investigation results in one of the following reports, depending on the class level:

  • For Class I or Class II level investigations (investigations of aircraft accidents and serious incidents): From the Investigator (FTI), Flight Safety Investigation Report (FSIR) and Epilogue;
  • For selected Class II or Class III level investigations (occurrences that are sufficiently complex to warrant a more thorough investigation than a normal Supplementary Report produced at the wing level, but that do not require the same degree of scrutiny that is required for Class 1): Enhanced Supplementary Report (ESR) and Epilogue.

From the Investigator (FTI)

The FTI summarizes information contained in the preliminary report issued by the investigation team after it completes the first phase of its work. Subject to the requirements for operations security, this summary will describe factual information and immediate safety actions taken, and provide an indication of the direction in which the investigation is proceeding.

The FTI is usually made public and posted on the DFS website within five weeks of the incident.

Flight Safety Investigation Report (FSIR)

Once the investigation is complete, the final FSIR is prepared. This is a comprehensive report on a specific flight safety occurrence that includes recommendations for preventive measures.  The report will contain all conclusions and recommendations associated with the occurrence. It contains four sections - facts, analysis, conclusions and preventive measures - and is released to the public under the authority of the Director of the DFS.

The report closely parallels the internationally accepted International Civil Aviation Organization (ICAO) format.

The Report’s recommended preventive measures are provided to the chain of command and applicable action organizations for their consideration.  DFS has no executive authority to direct the implementation of the preventive measures.  If the investigation team uncovers information that the aviation community needs to be made aware of immediately, this information is communicated without delay.

The FSIR is usually posted on the DFS website within 12 to 18 months of the incident, depending on the complexity of the investigation.

Epilogue

The Epilogue summarizes the information contained in the FSIR. The Epilogue is made public and usually posted on the DFS website at the same time as the FSIR.

Enhanced Supplementary Report (ESR) and Epilogue

The ESR is to be used for Class II or selected Class III level investigations. The reporting requirements are the same as for the Supplementary Report (30 days) except that the investigation paragraph will be more detailed. This report will not be released to the public.

Once the Class II level investigation is closed, an Epilogue will be made public and posted on the DFS website, usually within six to 12 months from the incident.

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