RCAF Snowbirds Fatal Mishap May 17, 2020 AIB Report Review

on may 17 2020 a canadian forces ct-114 tudor aircraft flown by the snowbirds aerial demonstration team crashed in british columbia the unsuccessful ejection attempt injured the pilot and killed public affairs officer captain jennifer casey that mishap report has been released to the public and today we're going to take a look at the cause of the crash and why that ejection attempt was unsuccessful [Music] oh the mishap was tragic captain casey was well known through social media and her work with the snowbirds demonstration team and the snowbirds team has an awesome team known worldwide for their outstanding performance and flying abilities it happened at the beginning of some of the lockdowns and trying to inspire people through their aerial demonstrations very tragic loss of such an outstanding officer and person in a mishap that probably could have been avoided and we'll talk about the causes and kind of the recommendations and stuff like that that came out of the report as always we'll just look at the facts and analyze i'll try to explain as best i can and kind of translate some of the uh pilot speak and safety speak into something digestible we're only going to look at the actual facts we're not going to speculate or anything like that out of respect for captain casey and the pilot and those involved i want to thank the canadian national defense media relations that sent me this full report i know it's been last week i think a lot of news outlets have picked it up and there's a summary on the internet but i wanted the actual report so we could go through it and analyze it as we've done with other mishaps in the past so the synopsis on 17th of may the snowbirds air demonstration team was operating in kamloops british columbia to reposition the kamaks british columbia as part of operation inspiration a task undertaken by the 431st aerial demonstration squadron to travel across canada and support a frontline workers in the battle against coven remember this was right at the beginning of the lockdowns and we were doing this in the united states we had blue angel flyovers we had thunderbird flyovers were trying to inspire uh and thank the healthcare workers for all they were doing it was number two of a formation of the tudor aircraft the two occupants consists of the pilot and passenger who was the team's public affairs officer that's captain casey following take off a loud impact like sound was heard by both occupants and the aircraft then experienced a loss of thrust the pilot initiated a climb straight ahead and then elected to carry left hand turn back towards the airport maneuver resulted in an aerodynamic stall halfway through the turn before the pilot gave the order to abandon the aircraft both occupants subsequently ejected and the aircraft was destroyed upon impact in the residential area passengers succumbed to injuries sustained during ejection sequence and the pilot received serious injuries evidence gathered during the investigation revealed that both occupants ejection sequences were outside of the ejection envelope the passenger ejected after the pilot and their ejection seat was observed to fly backwards temporarily after leaving the aircraft the passenger did not achieve the requisite amount of separation from the seat during the ejection sequence the most probable cause of the passenger's reverse direction of travel and delayed separation during the ejection sequence was due to the passenger's limb extending into the airstream which imparted a rotational moment to the ejection seat the reverse direction of the seat prevented the arrow rigid arm drogue arad shoot from catching the wind and pulling the seat away from the occupant the chute did eventually release however not without causing the seat to rotate backwards its original trajectory thereby potentially causing collision with the passenger as well as temporary entanglement further preventing normal distance dna evidence collected from the engine's internal components confirmed the ingestion of a bird as witnessed from the video evidence however the damage it caused was insufficient to cause a catastrophic failure rather it results in a compressor stall that was never cleared the investigation recommends a director be published which outlines the cruise priority where an injection emergency during takeoff or landing phase occurs and has potential to result in ejection near or over a populated area investigation also recommends further training on engine related emergencies in the takeoff low level environment it is also recommended the practice of storing items between the ejection seat and airframe wall cease immediately finally further researchers recommended into potential option that would stabilize the ct-114 ejection sheet from any tendency to pitch rule or yaw immediately following its departure from the ejection seat rails so that's the synopsis um it's a you have what's called they'll talk about it an ejection envelope so it's basically the limitations with which the seat can work a lot of modern seats have a very wide envelope zero zero up to 600 knots older seats like the tudor and the t-38a that i fly and l-39s that you see in civilian use have a smaller envelope that you can easily find yourself out of at low altitude low airspeed high bank angles or even high air speeds so we'll talk about that in a second but that's really what happened here is it was an unsuccessful ejection uh after the aerodynamic stall so when he turned back to the airport he stalled and they were immediately outside of that envelope all right so the factual information uh we talked about it was the two flame formation they took off at approximately 11 40 local time runway 9 east towards the city of kamloops at approximately 180 feet fairly low altitude the landing gear was retracted and a loud impact sound was heard by both occupants the passenger which is captain casey verbalized bird and the aircraft then experienced a loss of thrust so she saw it she saw the bird go down the you know basically coming at them and end up going down the intake following a climb straight ahead the pilot elected to continue the climb with a left-hand turn towards the general direction of the airport so he was climbing out and then decided okay i'm going to turn back towards the airport this will require the airplane to complete a 180 degree turn towards the west starting from approximately 200 feet agl i don't know uh what the flame out landing pattern uh procedures are for the tudor uh in the f-16 uh we did flame out patterns because we're single engines so we had the ability to come back and land if we lost an engine i'm sure they practiced this i don't know what their min altitude was uh if you remember when we talked with stormy they could do it very low altitude because they had that big straight wing on the u2 uh and they didn't need a whole lot of room to do it but in the f-16 for example if you were 200 feet you wouldn't try to turn back around because you just didn't have enough altitude you just zoom straight ahead and eject uh you wouldn't try to make a turn unless you were trying to avoid populated areas through approximately 70 degrees of left turn the aircraft increased its bank angle to almost 90 degrees after a slight pause the aircraft then rolled rapidly down in the same direction through 270 degrees ending upright but with a 45 degrees nose low so as it turns it over banks because that's when he gets in that buffett aerodynamic stall ran out of airspeed but then recovered but now he's lit nose low um following the roll the ejection sequence commenced with the right seat departing first followed thereafter by the left seat pilot who was in the right seat landed atop a residential roof the passenger who was in the left seat landed in the residence backyard aircraft continued in the nose down uncontrolled descent crashing into an adjacent property injury the pilot received serious injuries while the passenger was fatally injured aircraft was destroyed collateral damage you can see it hit a neighborhood ejection debris was spread over two blocks um in a straight line landed on neighboring properties house where the aircraft crash suffered extensive damage from the ensuing post crash fire that enveloped the northwest section of the house most of the fuel uh and other pol burn when the aircraft impacted the ground rupturing fuel cells and bursting the flame personnel information he was an experienced pilot 2 500 hours in the military he was fatigued was not a factor he was qualified for the planned mission aircraft information so the ct-114 tudor is canadian-built low-wing monoplane jet that was used by the royal canadian air force as a basic pilot training aircraft from 1963 until 2000 so that jet is almost 60 years old which is a lot like the t-38as that i'm flying now they are old they have old instruments they are the seats you have to wear a parachute out unlike a normal newer fighter where parachutes in the head box so to speak and all the stuff is contained you just hook the harness into the seat and it kind of handles everything the old seats like jets that were made in the 60s like the t-38 t-37 which the t37 is a lot like the tudor except it's twin engine the older jets you wear the parachute and then strap into the seat and it basically is a catapult that throws you out of the airplane and then you it separates you from the seat and pulls the chute for you um as if you're skydiving if you will so it's not all in the seat itself which is why it's not zero zero it's a side-by-side design it's a single ge j85 can 40 axial turbo flow so it's one of the t-38 engines essentially 2 700 pounds of thrust no afterburner they have been modified to let them use a single pilot airshow aircraft records indicate that the maintained accordance with existing regulations and approved procedures serviceable at the time of the occurrence it had 10 591.5 hours on it at the time of the mishap so here's the thing the ejection system we talked about the rocket assisted catapult tally ejection seat so it's just rocketing you out of the aircraft as a means of emergency egress from 60 to 350 knots so that's your envelope it's not a zero zero seat uh because you need some air speed to get that shoot to to inflate and deploy uh indicated air speed in the aircraft altitude is 150 feet or greater from ground level these are the absolute minimum ejection seat system limits it does not talk about the angle of bank but i'm sure there's some bank limits as well uh with that ejection seats are operating independently of one another by the seat occupant same thing like i said aircraft i i keep i'm gonna keep bringing up the t-38as because one of them flying now but they're very very similar uh so i'm a little familiar with it uh having done that now each city is equipped with ejection controls which consists of loop type hand grips on both sides so it's hand grips raise that's all it is you pull the hand grips and that's what sends you out pulling one does not pull the other there is no inter-seat sequencing system it takes a half-second time delay after the hand grips are raised to allow for automatic jettison of the canopy there is no electro-mechanical connection between the seats each seat will individually apply this half second delay before rejection regardless if the canopy is already departed or not so if they both simultaneously go and one goes before the other it's a half second for the canopy and another half second the other seat weights as well for the canopy it doesn't matter if the canopy is gone or not it waits a half second before it actually fires belt opening is automatic as part of the ejection sequence and requires no additional assistance from the occupant as the seat travels up the rails during ejection a mechanical tripper located near the top of the rails activates the m32a1 one second delay gas initiator which opens the lap belts because remember we're lap belted in to the seat with the harness and you're also wearing a parachute so you have to separate from the seat and then the chute has to open an aero rigid arm drogue assembly arad is fitted in order to improve the seat document separation during ejection a-rad assembly which is fitted on the right side of the seat frame consists of a telescoping a-rad arm assembly and lock down assembly the deployment bag which contains the assist shoot and drogue chute is housed within a drogue container above the a-rad arm the plumbing of the drug shoot stabilizes the ejection seat also slows the ejection seat in relation to the occupant thereby allowing for good seed separation for the occupants parachutes deployed primary shoot worn by the air crew and passengers is 28 foot diameter flat circular parachute that's standard as the occupant is separated from the seat the parachute opening device our main cable is pulled so there's a cable uh called the silver key that you disconnect from your chute and it hooks into the lap belt and that is what actually times your shoot from firing that's what oh not firing but opening that's what opens your shoe known as the mark 10 automatic open device activates the lay mechanism in the parachute pack and at a preset time interval at one second unlocks the android type release which delays the parachute at pre-sales altitude to 16 000 feet if it's below it'll open after the interval so it just goes on a timer and as soon as that timer expires it will open the chute because it has to give you time to separate from that seat total time required for the and this is what drives the limitations of the seat right so in a normal like f-16 f-18 seat it's 0-0 because everything's contained in in the seat itself and it can open quickly and fully open to get you enough swings in the chute if you will to land safely the reason this is 60 knots and lower out or higher altitude up to 350 knots is because it has to give you time to get the canopy open get the seat to fire get the yourself separated from the seat and then open the chute that is wedged between you and the back of the seat so you have to get that separation so it takes a while for that seat to work total time is five seconds ejection sequence is that time beginning with the raising of the hand grips until the parachute is provided a survivable rate of descent that's usually one or two swings if the aircraft is in a dive in a sink rate condition or an attitude inverted wings level banking or turning that would cause ground impact in less than five seconds suggest successful ejection cannot be expected so that so that's when they talk about the bank angle you know so you know like we talk about the t38 if you're in a final turn a lot of that time you're low altitude you're out of the ejection seat envelope even though you have the air speed you don't have the altitude and you have too much of a sink rate sink rake being in feet per minute how fast you're descending both ejection seats were in their service inspection schedule and all explosive devices when they're service life both ejection seats were serviceable at the time of ejection i believe that i don't believe that this was a malfunction of the system as designed back in the 50s and 60s i just believe this was an outdated system that they're using uh for the weather it was vmc a few clouds had a thousand uh no significant ceiling no significant winds the first ejection was commenced at an altitude of 441 feet 113 feet per second at 45 degree nose down angle and that is expressed as the vertical component of the aircraft speed in feet per second video evidence shows the ejection seat briefly rotated about its vertical axis before reversing back to its original flight path as the a-rad shoot deployed video further illustrates the pilot having a partially inflated shoot as they pass a tree line at 4.2 seconds after canopy jettison in accordance with test and ct 114 operating instructions it takes five seconds for it to reach a steady state which means the parachute is descending with the occupant correct rate of descent for the weight of the occupant it's unlikely that the pilot ever reached that state as the tree line that they pass by is viewed by the videos approximately 40 feet tall and they landed on a roof of a house was 15 feet above the ground roof structure materials absorb the pilot's energy during their landing thereby reducing the effects of rapid deceleration subsequent trauma on the human body that is probably the only reason he's alive is because he hit that roof uh sloped and it is enough to absorb the impact they classified it as unsuccessful survivable it occurred inside the airspeed and altitude window it remained outside the envelope time wise for the ct-114 injection due to the nose low attitude and sink rate when it was initiated so that's why they say it's a zoom climb to get you climbing up because that gives you more time if you're descending you have to add your descent rate which can quickly put you outside that envelope the second ejection occurred at 0.4 seconds after the pilot at an estimated altitude of 394 feet and an air speed or speed of 133 feet per second at 50 degree nose down so it was slightly less she had a little less altitude a little more sink rate and more nose down angle so the jet was doing this because it eventually impacted near vertical video evidence provided the seat rotating 180 degrees about his vertical axis to the right then temporarily flying backwards then i think that's because one of her limbs ended up in the wind stream which caused that rotation seed separation also appeared to be delayed video evidence showed the passenger past the tree line 3.6 seconds after canopy jettison along with the seat in close proximity passenger ejection did not reach a steady state as the tree line that they pass is at approximately 40 feet in height and there's no indication of shoot inflation a combined combination of deceleration through obstructions and impact with the ground result injuries passengers which is not survivable therefore it's classified as unsuccessful unsurvivable passengers ejection occurred inside the airspeed altitude envelope it was outside the time envelope for the ejection seat to perform properly severe nose down altitude or attitude and sink rate so there's a lot of factors that play into a successful ejection here so they did some testing uh and then they looked at the video evidence and they found bird congestion engine having occurred led to extensive visual search biological material which they found uh and that's the bird engine damage there was no damage to the trailing edge of the inlet guide veins from the contact from the first stage compressor rotor blades evidence of contact damage between the first stage compressor and the inlet guide vein suggests the inlet guide vagues were closed prior to impact the first stage compressor rotor blades exhibited both minor hard fod damage and soft fod damage the soft fly damage consisted with low rotational compressor speed and ingested of soft fiberglass airframe intake so yeah bird went down the intake damage the blade which causes a compressor stall the airflow is now disrupted through those blades because they're airfoils and it can't it can't spend the blades get enough air flow through that and you'll get that pop bang buzz um happened to me with a t-38c uh when i took a bird down the right intake uh and you're not going to recover that once the blades are bent it's fodded out it's there's no way to get that motor uh going again nunciator panel inspection results suggest the engine was producing power at the time of impact as only the canopy unlocked bulbs exhibited signs were eliminated seven of the turbine nozzle partitions were cracked and blistered in the center of the leading edge damage observed to the partition suggests an overheating event which is consistent in sustained compressor stall this reversal and airflow with no reduction in fuel flow can result in overheat damage to the turbine section due to a reduction in cool air flowing through the compressor stages they looked at the engine fuel oil cooler no evidence suggests that it was contributory [Music] mechanical damage was observed within the fuel inlet and outlet porch was consistent with damage previously observed on other engines within the aircraft fleet but there was no evidence to suggest this is what happened o-ring material tested extensively is found the o-rings were brittle excessively compression set with excessive compression set that would likely have made the fitting susceptible to leakage ongoing study is currently being performed so there's some o-ring stuff but they said it was not contributed to the accident itself so this is what it looks like uh you can't see the mouse so uh in the seat though looking at the picture you have parachute shoulder straps and the arm and key that's the little silver key that i was telling you about t38 has the same thing so you wear the parachute and then you strap into the seat which is different from again normal uh newer ejection seats so they looked at training records uh the passenger seat call because she has to have seat training so she actually was not current is on paper but they looked and said yep she did have seat training investigation discovered that our current aircrew had placed items between the seat side of the seat and the airframe wall for both of the ejection seats these included a laptop and a loose leaf binder this is a common practice within the 431st emergency takeoff briefing they must consider aircraft ejection system operating limits personal comfort surface conditions and environmental factors for emergency response the standard maneuver manual says time is of the essence during takeoff phase so you must do your thinking on the ground in order to react quickly in the air a pre-takeoff briefing is essential for a pilot's ability to react instinctively and possibly during the takeoff phase a typical takeoff brief in the tudor which includes three or more distinct phases in which specific set of actions would be performed by the pilot should an emergency occur first phase consists of the moment the brakes are released up until the moment the aircraft is rolling down the runway and about to lift off if a major malfunction emerges the pilot could potentially reduce the throttle apply brakes and stop the aircraft before going airborne so this is standard stuff we talked about um we have bold faced we have take off the landing data go no go decisions is stuff we brief every time we know the bowl face we memorize the bold phase we know what happens if we lose an engine at different points uh in the flight we had critical action procedures in the f-16 both facing the f-18 both facing the t-38 that you just have to know because there's no time to get off the checklist in a critical phase like this second phase is when it's airborne however the gear is still down and locked should there be an issue they could actually land so they take off and oh lost an engine i can put it right back down however the phase is short in duration as the landing gear is raised relatively quickly after takeoff as they produce drag and delays third is the most challenging which is where they were in this phase the aircraft's landing gear stowed and is at a position space without runway beneath that they can land airspeed altitude is increasing however they are still relatively low so it's that phase where hey runways behind us can't land again this is kind of an important part when an aircraft has experienced a loss of thrust it does not necessarily signify the aircraft can no longer sustain flight in fact an aircraft can maintain level flight by continuously raising the nose and reducing its speed to the point of achieving a stall with a complete engine failure or partial loss of thrust that the aircraft has an excess of speed it can trade the excess speed for altitude by performing what is known as zoom so you're just climbing out you're zooming you're trading your altitude you're training your airspeed for altitude it's a sharp pull in the control column which these changes the altitude of the aircraft and begins to decelerate the amount of climb is proportional amount of speed when an emergency arises during takeoff especially one where the issue involves the engine on a single engine aircraft priority is to obtain as much vertical separation from the ground without delay zoom zoom stores jet eject that was one of the things on the f-16 and i still remember it to this day because we had stores we'd punch off which gives you less drag and less weight time is of the essence as its kinetic and potential energies are still relatively low and will rapidly decay regardless of the amount of climb achieved once established at a higher altitude the pilot has afforded more time to analyze the situation that's when they can decide if they can turn back or if the engine's still running they can apply any other secondary actions at any time an engine a malfunction is suspected tudor pilots are susp expected to carry out the suspected engine malfunction checklist zoom if possible wings level maintain current throttle position turn on the air start ignition and take the time to properly analyze the situation concentration concentrating on the engine instruments and your condition of flight holy crap that's a lot of words consider the possibility of ejection as you may well be in a position where cover the engine is to a usable condition may not be possible the above response is used when the nature of the malfunction is not readily apparent the intent is to prioritize the climb away from the ground so their initial action is just climb climb trade airspeed for altitude get away from the ground give yourself time to figure out if you're going to do a flame out landing or eject so loss of dust compressor stall zoom if possible place the throttle to idle turn on the air start ignition this is standard every jet i've flown is pretty much like this um if you have the ability to do that if it's not a fadec or something if but you can go to afterburner in some jets and that actually hits the igniters going if there is no immediate relight of the engine eject or force land if time permits continue procedure one or two of the relight emergency response if time does not permit uh if you don't have a relight by 2500 feet agl use procedure one and re-light engine light up times from the point of relight is 25 to 45 seconds immediate response so now we get into kind of what the pilot did at the time of the bird strike he was 190 feet above the ground and knots the pilot had briefed before takeoff should an engine failure arise during this phase a separation from lead because he was in a formation so he was number two followed by a zoom climb straight ahead would be carried out once airborne after a momentary zoom on a straight ahead course the decision was made to continue with a climbing left hand turn back towards the general direction of the airport this would require the aircraft to complete 180 returns towards the west starting from 200 feet agl once the turn was commenced the aircraft bank was progressively increased to the point where the aircraft's lift factor was essentially directly horizontal by the time the aircraft had rolled through 90 degrees of heading change at this point the aircraft was heading north and the maximum altitude it achieved was 800 feet so we got the zoom climb but not so much without thrust his air speed decayed it and it had an aerodynamic stall to the left and rotated 270 degrees about its longitudinal axis before leveling upright approximately 440 he had 113 feet per second towards the ground and three seconds to impact so not within that four to five seconds that they needed attempts by ct-114 aircrew to turn back towards the airport with a confirmed loss of injury power have been previously documented in flight safety in these incidents all of which occurred at the same stage of flight as this occurrence the pilots had convinced the zoom turn towards the airport and attempt to land on a prepared surface all occurrences resulted in insufficient energy to perform maneuver and at all occurrences the aircrew ejected at low out level unfortunately two occurrences resulted in a total of three fatalities so this is a known thing they've done it before they know it doesn't work and that's what he did he did something that you know in the past they've known doesn't really work following the completion of those investigations director of flight safety stressed the importance of maintaining aircraft control analyze situation timely decision to eject ensuring the optimum ejection parameters are met in addition they further highlighted that the immediate response to a loss of thrust at low level in a single engine jet should be speed permitting climb straight ahead to maximize time and therefore options this is further reflected in the current aois which are the operating instructions state a loss of thrust in flight may be caused by an engine flame out or compressor stall however the immediate action the immediate reaction to either one is the same if operating at low altitude is imperative the wings level zoom be carried out to optimize the ejection parameters so they stress don't turn the pilot's decision to zoom and turn towards the airport vice zoom straight ahead was based on the perception that should an ejection be required while maintaining their current heading and result in the airframe crashing into a populating area so he knew that this was not against this was not what procedure dictated but his assessment was if i keep going this aircraft's going to kill a lot of people so i need to turn back and at least try it to get it into a place where it's not going to hurt people on the ground in doing so however the potential energy gained by turning and zooming may have been lower than what would have been gained by zooming straight ahead not only did the maneuver potentially produce the altitude to be gained it also channels the pilot's attention resulting in the loss of positive control of the aircraft and subsequent stalls so that first step of maintaining aircraft control he was unable to do that because he was worried about the people on the ground commander the jack this was another thing that that came up immediately following the level off from the aerodynamic stall so once he finally recovered and now they're 45 degrees low and those low the pilot ejected pasture ejected 4.4 seconds after the pile this resulted in the passengers ejection occurring uh 50 feet lower and 50 degrees nose down attitude this is five degrees more evidence suggests that the pastor was aware of the emergency situation that a bird strike had occurred and the pilot was attempting to maneuver clear of the lead however the sudden roll as a result of the aerodynamic stall halfway through the turn may have come as a surprise right because it's probably kind of violent the sudden change in trajectory was likely outside the passengers expectations that moment in time and could have interrupted their situational wear following the aerodynamic stall the order to eject was called out by the pilot using the phrase pull the handle the word or phrase commonly rebriefed and used among ejection c qualified aircrew is the word eject and is called out in rapid succession and the clear and loud voice i.e eject eject eject the format of this command is designed so the pastor initiates ejection upon hearing the first eject of the command followed by the pilot on the third eject who initiates their own ejection the difference in wording may have contributed the overall confusion and certainty which resulted in the passenger ejected sect this is a thing that happens all the time when we take fam riders uh flying in the t-38 one of the briefings that i give is we don't use the word eject actually as a command so when we talk about ejection so we're going to discuss hey we think we might eject for us eject is not a command we have the same seats we are not sequenced so what we have to do is ensure that the passenger the backseater goes first and then we go second to give time for that sequence separation so for us what i brief and what most other t38a pilots brief is that we will use the command bailout as a command so bailout bailout bailout on the second bailout i want you to pull the handle and i'm going to go on the third bailout so that gives us time to sequence now granted we're not side by side we're tandem but it's the same thing as applies we give clear commands so they know exactly what it is pull the handle may not be i mean what handle the landing gear handle uh you know the canopy hand what handle are you talking about so that could definitely delay her ability to eject and she was obviously uh second out when she should have been first now granted there's not a lot of time right they're a couple seconds from impact we're monday morning quarterbacking something that you know the first thing that comes out but when you're talking about what could be causal and what could contribute pull the handle versus the very clear in their case eject eject eject is definitely a difference it is possible the pilot may have also experienced a component of situational surprise following the stall and the expectation was to successfully complete the turning maneuver that's i agree with that you know he just that's all he could get out because he was busy flying the aircraft temporary impairment resilience coupled with the time compression may have impacted their choice of verbal command to eject yeah he might have just been hey just get out you know i mean at that point reverse travel of the seat upon further analysis of the video evidence became apparent that the passenger's ejection did not proceed as would normally be expected video presented the investigation with evidence of the passenger seat flying backwards briefly almost 180 degrees with no distance of the passenger from the seat potentially due to the interference the investigation could not conclusively determine how the [Music] [Music] there's no available of scarring on the seat supports in this scenario and it was a very common practice but not recommended scenario two the seat is essentially connected to the aircraft only moment movement possible up these rails adjusted before the bottom susceptible changes direction of forces including those acting on the very tip an airflow so the fact that the aircraft was uh a slight rolling movement to the left just as both occupants ejected which theoretically could have influenced because remember they're side by side the seats movement uh but the resolution is just not clear enough then they can't really tell scenario three um the aircraft applying a force to the seat once it left the rails i.e arm or leg extended the airstream caused the yaw moment uh the phenomenon of lymph flail and the subsequent moment it created was recorded back in 1999 ejection c to commence the severe yaw to the mannequin arm extending out in the airstream this results in the seat flying backwards so uh and that's the mannequin and that's what it looks like there's not really high visibility on that but it's the same most probable cause is that limb flying into the air stream the ejection seat is prone to respond unpredictably once it leaves the ejection seat rails up to the point where the a-rad chute successfully deploys in the airstream does not contain stabilizers it's old i mean 1960s you know early late 50s the conclusion weather and fuel and fatigue were not a factor air crew were currently qualified certain discrepancies were noted maintenance promulgation of progress reports and crew training mechanical damage was observed in the fuel inlet and outlet ports which was consistent with previous damage on other engines they didn't have a flight data recorder pilot received serious injuries passenger was fatally injured evidence suggests that the bird ingestion is what caused it pilot briefs to take off should an engine malfunction arise separation from lead zoom straight ahead would be carried out however they started the left-hand bank towards the general direction the airport they stalled at 440 feet the pilot's decision to zoom turns toward the airport via straight ahead was based on a perception that an ejection would put the aircraft in a populated area but by doing so they lost their energy and put themselves in an unsurvivable ejection envelope attempts to turn back toward the airport with confirmed loss of indian power have been well documented and they were unsuccessful following the completion of the investigations they stress maintain aircraft control we talked about that stall condition the engine would have been displayed by cockpit instruments it's uncertain whether he was able to process that though investigation discovered the air crew are known to place items between the side of the seat and airframe however there's no there's no evidence that says that uh it interfered but there's no evidence that it not it didn't we talked about pull the handle versus eject eject that's a confusing thing immediately following level off the pilot was the first to eject video evidence shows the ejection seat briefly rotated pilot had an inflated chute and never reached steady state however the roof broke his fall passenger had no such luck and the investigation could not conclusively identify the cause of the ejection seat rotation but they think it's because her one of her limbs ended up in the airstream and they still couldn't figure out why the arming cable was uh around the arad lanyard cause factors ingestion of the bird pilot decision to zoom and turn vice straight ahead potential energy lost execution turn back channelize attention and pilot losing control into a stall not be determined whether the final steps of the engine malfunction checklist was completed and saying eject eject eject latent cause factor so i guess this is the primary and the secondary following an engine malfunction after takeoff this exists predeficient for aircrew execute turn back towards the airport and attempt to land on a prepared surface such attempts have proven unsuccessful as documented preventative measures they issued an operational pause which are usually worthless and they have consolidated appropriate word for command to eject across all publications preventative measures recommended uh directive to be published which outlines aircrew priority where an emergency during takeoff has a potential resultant ejection near overpopulated area so actually they have now they're addressing that part or they should that's what they've recommended and then additional guidance on low altitude engine failure equal emphasis placed on emergencies while away from their base and within metropolitan areas recommend research and implement a potential option to stabilize the seat provide directive operators for placing items between the seat and then acquire of fdr cvr airworthine investigation authority remarks tragic incident highlights the importance of continuous situation specific training minimize a reaction time and the importance of a timely decision snowbird one one's loss of power because of a bird strike occurred during takeoff which like the landing phase is one of the most critical phases of flight for fixed-wing aircraft on takeoff the aircraft is a low interstate very close to the ground the combination of these factors means the pilot has very little time to react in flight it's a vital well thought out plan that reflects the flight path environment thus in the event of a critical emergency it would be easy to fall victim to behind-side bias and second-guess the action of the pilot pilot had moments to the side zoom carry out the emergency checklist the ejection sequence initiated this accident was well outside the safe ejection envelope is recommended research development of potential options to stabilize and that's the end of that report okay my thoughts first of all i'm not going to second guess what he did it he used his best pilot judgment at the time it did not work out as he had hoped and it's very tragic i mean that sucks i can understand you know avoiding populated areas not wanting a ballistic aircraft to go crashing the neighborhood if you remember several years ago that happened at miramar where a hornet crashed into a neighborhood after ejection and killed a whole bunch of people it's not a good thing what i will say though i know the snowbirds are an awesome demonstration team i know that the they're the pride of the canadian air force or the canadian forces and they have done some awesome things i do not understand why they're still flying a 60 year old aircraft i say this as someone who currently flies a 60 year old aircraft and i don't understand why we're still flying a 60 year old aircraft in 2021 these aircraft probably should be in a museum or owned by um civilians who are you know have money in like l39s t-33s warbird collections i don't think they should be part of a premier demo team like i i just the fact that if you look at the instrument panel that aircraft my aircraft whatever i mean it's unsafe i mean it really is in with today's technology having an aircraft that old is a liability a single engine aircraft at that is a liability having a seat that old is a liability i mean we have the ability to upgrade them so they could probably put zero zero seats at a cost um they could do that i mean we don't do them with the t38a i have no idea why it's money i mean the t-38c got martin baker seats and that's a zero zero seat now um captain casey died because of flying in a 60 year old aircraft like i i that that's my opinion yes there was pilot error involved in that decision and they were outside of the envelope but the envelope was small from the get-go i don't know the politics behind it i don't profess to know uh what the canadians are doing as far as you know how they they view their demo team and what funding and stuff that they get to me the cf-18 would be a better uh candidate because two engines and it represents what they actually fly in combat they're not even flying these in training anymore even their old cf5 ds would be a better choice than than the tudor i mean i get it it's cheap and it's single engine and it's low maintenance and all that stuff but when you get an aircraft that gets into this life cycle and this age and you're putting it through these things that's that's you're not giving them a great chance when you've got a seat that requires you to wear a parachute on your back out to the aircraft and then doing these high demonstration high risk demonstration maneuvers i mean i'm sure half the routine they're out of their their envelope for ejection i mean there's a lot of points where it's like well if i eject that's it because you know some of their inverted stuff there's no way that shoot's going to open period dot i mean they're just going to go right into the ground so that to me i mean that's my soapbox on the thing is that i think these aircraft are too old for what they're doing and if their aircraft aren't too old then the very least they need to be upgraded they need to have new seats they need to have new avionics they need to have the voice recorders they need to have stuff that you would get in 2021 or 2020 at the time not stuff that you would have in 1958 when they were probably designed so to me that's a foul um i don't think any modern first world military should be talking about ejection seats failure and that includes the f-16 that we had at shaw that's a modern seed and it failed and that's a foul like that should we should never be talking about an ejection seat failure or a failure to sequence because we're out of the envelope the seats the technology exists with a aces or a martin baker assuming that the seat was working properly they'd have been in the envelope and they both would have survived i i just i i don't i i it hurts me to to be mourning the loss of someone like captain casey because of the last line of defense an ejection seat just like measures mishap at shaw with the f-16 or that seat failed it's unset but we just i don't know to me as a when you put yourself out there and you put yourself you're flying at the limit you have to know that that seat's going to save you and for what they're asking the snowbirds to do that level of flying and even though this was just a fairy flight this was a point a to point b it wasn't even a demo but for what they're asking they should have a seat that works 100 of the time and and doesn't have an envelope like that like even the fact that yep you know he didn't zoom straight ahead that's fine he tried to turn back to save civilians that's awesome seat should have worked they need to have better seats better aircraft or better seats pick one i don't i mean whatever you can fund but i just think it's irresponsible to have to ask people to go out with old uh 60 year old ejection seats i just i do anyway that'll do it for this one i am my thoughts are with captain casey's family uh canadian military uh you're all allies you know we we i've flown with the the canadians uh flown against the canadians they used to come down to homestead uh great group of uh fighter pilots great group of people i'm very sorry for your loss uh this is tragic and unfortunately like every other mishap we've done in 2020 highly avoidable you know we should not be talking about a fatality here i hope this was useful um i hope this brings up a good discussion uh thanks for watching we'll see you next time so [Music] you

Channel: C.W. Lemoine

Views: 201,511

Keywords: rcaf, snowbirds, snowbirds aerial demo team, airshow, crash, mishap, investigation, ccident, Jenn CAsey

Id: Wd-sJm9YO7Y

Length: 44min 9sec (2649 seconds)

Published: Wed Apr 07 2021