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1010-CP140-165804 (DFS 2-3-2)

20 February 2017

CP140103

Flight Safety Investigation Report

INTENTIONALLY LEFT BLANK

Flight Safety Investigation Report – CP140103 – 27 Aug 2015

CANADIAN ARMED FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FINAL REPORT

FILE NUMBER: 1010-CP140-165804 (DFS 2-3-2)

FSIMS IDENTIFICATION NUMBER: 165804

DATE OF REPORT: 20 February 2017

OCCURRENCE CATEGORY: "B"

AIRCRAFT TYPE: CP140 Aurora

AIRCRAFT REGISTRATION NUMBER CP140103

DATE OF OCCURRENCE: 27 August 2015

TIME OF OCCURRENCE (L): 1115

LOCATION: 14 Wing Greenwood

OPERATOR: 405 (Long Range Patrol) Squadron

This report was produced under authority of the Minister of National Defence (MND) pursuant to section 4.2 (1)(n) and 4.2 (2) of the Aeronautics Act, and in

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

The contents of this report shall only be used for the sole purpose of accident prevention. This report was released 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) for the Canadian Armed Forces under Part II, section 12 of the Aeronautics Act.


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SYNOPSIS

The CP140 was taking off from 14 Wing Greenwood, Nova Scotia, on a transit mission to Iqaluit, Nunavut, in support of Operation (Op) QIMMIQ. Thunderstorms had recently passed over the airfield and the runway surfaces were wet.

During the takeoff roll, the crew observed a flock of birds flying towards the runway. Perceiving a conflict and concerned about the risk of collision, the aircraft commander called “Malfunction” and the pilot flying aborted the takeoff. During the abort procedure, the pilot flying the aircraft rapidly selected full reverse on all four propellers. Both propellers on the left side of the aircraft went into full reverse; however, both propellers on the right side of the aircraft continued to produce forward thrust, resulting in asymmetric thrust pushing the aircraft left of the runway centreline.

The crew was not successful at keeping the aircraft on the runway and it departed off the left side of the runway, approximately 1000 feet before the departure end. The propellers contacted a runway distance marker and a precision approach path indicator (PAPI) light.

The aircraft plowed through the soft earth and the nose gear collapsed, causing the inside propeller on the right side of the aircraft to strike the ground and break away from the engine. After the aircraft came to a stop, all personnel on board exited the aircraft safely; only minor injuries were incurred.

The investigation examined human factors, the takeoff abort procedure, and the technical serviceability of the aircraft. No aircraft technical faults were discovered. The investigation recommended changes to procedures for the CP140 takeoff abort procedure, safeguarding CVR data, and the cockpit shoulder harness inertial reels. The investigation also recommended making improvements to the runways at 14 Wing in order to minimize the chance of hydroplaning.


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TABLE OF CONTENTS

1 FACTUAL INFORMATION .................................................................... 1

1.1 HISTORY OF THE FLIGHT ........................................................................... 1

1.2 INJURY TO PERSONNEL ............................................................................. 3

1.3 DAMAGE TO AIRCRAFT .............................................................................. 3

1.4 COLLATERAL DAMAGE ............................................................................... 4

1.5 PERSONNEL INFORMATION ........................................................................ 4

1.6 AIRCRAFT INFORMATION ........................................................................... 5

1.7 METEOROLOGICAL INFORMATION ............................................................... 7

1.8 AIDS TO NAVIGATION ................................................................................ 7

1.9 COMMUNICATIONS .................................................................................... 8

1.10 AERODROME INFORMATION ....................................................................... 8

1.11 FLIGHT RECORDERS ................................................................................. 8

1.12 WRECKAGE AND IMPACT INFORMATION ...................................................... 9

1.13 MEDICAL .................................................................................................. 9

1.14 FIRE, EXPLOSIVES DEVICES, AND MUNITIONS ........................................... 10

1.15 SURVIVAL ASPECTS ................................................................................ 10

1.16 TEST AND RESEARCH ACTIVITIES ............................................................. 10

1.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION .................................. 11

1.18 ADDITIONAL INFORMATION ...................................................................... 12

1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES ................................. 18

2 ANALYSIS ........................................................................................... 19

2.1 GENERAL ............................................................................................... 19

2.2 PILOT ACTIONS ....................................................................................... 19

2.3 ABORT PROCEDURES ............................................................................. 20

2.4 COCKPIT SHOULDER RESTRAINT HARNESS INERTIAL REELS ...................... 21

2.5 CVR DATA RETENTION ........................................................................... 21

2.6 14 WING RUNWAY WATER POOLING ........................................................ 22

2.7 FATIGUE ................................................................................................ 22

3 CONCLUSIONS .................................................................................. 23

3.1 FINDINGS ............................................................................................... 23

3.2 CAUSE FACTORS .................................................................................... 25

ACTIVE CAUSE FACTORS ........................................................................................ 25

LATENT CAUSE FACTORS ........................................................................................ 25


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4 PREVENTIVE MEASURES ................................................................. 26

4.1 PREVENTIVE MEASURES TAKEN .............................................................. 26

4.2 PREVENTIVE MEASURES RECOMMENDED ................................................. 26

4.3 OTHER SAFETY MEASURES RECOMMENDED ............................................. 26

4.4 DFS REMARKS ...................................................................................... 27

ANNEX A – AIRFRAME, ENGINE, AND PROPELLER HOURS ...................... A-1

ANNEX B – SYSTEMS DESCRIPTION FROM C-12-140-013/MB-001 ............ B-1

ANNEX C – CP140 TAKEOFF ABORT PROCEDURE ..................................... C-1

ANNEX D – CP140 NORMAL LANDING PROCEDURE .................................. D-1

ANNEX E – SELECTED CYZX METARS ......................................................... E-1

ANNEX F – CB DIAGRAM FOR THE FLIGHT ESSENTIAL DC BUS ............... F-1

ANNEX G – ABBREVIATIONS......................................................................... G-1

ANNEX H – LIST OF TABLES AND FIGURES ................................................. H-1


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1 FACTUAL INFORMATION

1.1 HISTORY OF THE FLIGHT

1.1.1 The CP140 was operating out of 14 Wing Greenwood with a crew from 405 (Long Range Patrol) Squadron (405 (LRP) Sqn). The mission was to transit to Iqaluit, Nunavut on Thursday, 27 August 2015, in support of Op QIMMIQ.

1.1.2 The four crewmembers in the cockpit consisted of a Long Range Patrol Captain (LRPC) who was the Pilot Not Flying (PNF), a Long Range Patrol First Officer (LRPFO) who was the Pilot Flying (PF), a B Category Flight Engineer (FE1) under training and performing FE duties, and an A Category Flight Engineer (FE2) who was instructing FE1. The LRPFO occupied the left seat, while the LRPC occupied the right seat. FE1 was sitting in the designated FE seat slightly aft and between the pilots. FE2 was sitting on the radar cabinet, aft of the left-hand pilot seat. There were a further 13 personnel on board in the aft cabin.

1.1.3 The pilots scheduled for this mission had completed a flight functional1 on the same aircraft at 19452 the night before. The next morning, the FEs arrived at 0700 to begin their pre-flight checks and the pilots arrived just before the mission brief scheduled for 0800. It rained during the aircraft pre-flight checks and the mission was delayed by one hour due to a thunderstorm producing heavy rain over the airfield.

1.1.4 After the line of thunderstorms had passed, the crew started the aircraft and taxied for takeoff on Runway 26. The takeoff commenced at 1114. FE1 set takeoff power and confirmed that the engines were producing rated horsepower at 80 knots indicated air speed (KIAS). After the 80 knot call, the LRPFO concentrated on judicious application of rudder input in order to maintain runway centerline alignment. The LRPFO last checked the airspeed at 105 KIAS as the aircraft accelerated down the runway. At 110 KIAS, the LRPC observed a flock of birds, which he assessed as a hazard due to collision potential with the aircraft. Using the takeoff and landing distance (TOLD) chart, rotate/refusal speed on this takeoff was 117 KIAS, but was not called by either pilot. The LRPC called “Malfunction” at approximately 133 KIAS and the LRPFO initiated the takeoff abort procedure. The “Malfunction” call was not followed by a brief description of the fault. FE2 scanned the cockpit for obvious faults, but could not determine the reason for the “Malfunction” call.

1 A flight functional is a flight performed to confirm serviceability of a particular aircraft component. 2 The time used in this report is referenced to local Atlantic Time Zone which is UTC/GMT -3 hours (daylight savings time).


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1.1.5 The LRPFO rapidly retarded the power levers into full reverse. At that time, the airspeed was 133 KIAS and reached a maximum of 137 KIAS due to aircraft momentum. The aircraft began drifting to the left side of the runway. The LRPFO attempted to use full right rudder and nose wheel steering to keep the aircraft from drifting. The LRPFO did not use differential power to help in directional control. FE1 called “No BETA 3 and 4”3 and FE2 called “E-Handle.”4 The LRPC tried to assist with directional control by pushing No. 1 and 2 power levers forward, but did not take control of the aircraft. Differential braking was applied, but the starboard main landing gear tires locked up and began reverted rubber hydroplaning. The aircraft departed the left side of the runway at about 80 KIAS.

1.1.6 The propellers on the left side of the aircraft struck the 1000-foot runway distance marker as the aircraft slid across the grass infield and then struck the first of a series of PAPI lights. A few seconds later, the nose gear collapsed and No. 3 propeller broke away from its engine. FE1 injured his head on the centre console during rapid deceleration as the aircraft dug into terrain. The aircraft came to a complete stop left of the runway in the saturated infield. The LRPC directed that all four engines be E-Handled, but No. 3 E-Handle would not move. The No. 3 engine was shutdown using the fuel and ignition switch and the aircraft immediately lost all electrical power.

1.1.7 The LRPC pressed the command bell to start the evacuation. All personnel on board evacuated through the starboard overwing hatch. A one bell emergency was sounded by air traffic control (ATC) personnel in the control tower. The firefighters were on the scene within two minutes. They accounted for all on-board personnel, made sure the area was safe, and began triage of injured personnel. FE2 was then escorted back onto the aircraft by a firefighter to ensure power was removed from the aircraft. In doing so the CB for the standby attitude indicator (AI) was pulled.

3 “No BETA” means that the propeller blade angle was not in the ground/reverse range. 4 “E-Handle” means the Emergency Handle. The E-Handle shuts down the engine and feathers the propeller in case of an emergency.


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1.2 INJURY TO PERSONNEL

1.2.1 All injuries to personnel on board are outlined below in Table 1.

Injuries Crew Passengers Total in the Aircraft

Fatal 0 0 0

Serious 0 0 0

Minor 7 1 8

None 6 3 9

TOTAL 13 4 17 Table 1. Injuries to Personnel

1.3 DAMAGE TO AIRCRAFT

1.3.1 The final resting position of the aircraft is shown below in Figure 1.

Figure 1. Photo of final resting position of CP140103

1.3.2 The aircraft sustained very serious damage (Category B). The nose gear collapsed and was bent backwards underneath the fuselage. Significant structural buckling was observed on the left hand (LH) side of the fuselage forward of the LH wing, the vicinity of the nose wheel, and the No. 1 and 3 engine nacelles. Propeller blades from all engines were damaged due to the blades


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striking either ground, flying debris and/or obstacles after the aircraft departed the runway. The No. 3 propeller and a portion of the No. 3 engine reduction gear box (RGB) separated from the aircraft.

1.4 COLLATERAL DAMAGE

1.4.1 One PAPI light and one runway distance marker were damaged when they were struck by blades from the No. 1 propeller. A quantity of engine oil and hydraulic fluid leaked onto the ground underneath the No. 3 engine after the propeller separated from the engine.

1.5 PERSONNEL INFORMATION

1.5.1 Pertinent flying hours and duty hours, as well as flying currency and medical category for the crew in the cockpit are shown below in Table 2.

LRPC LRPFO FE 1 FE 2

Total flying time hours (military)

1678.4 4346.7 372.0 4760.8

Flying hours on type 1449.0 48.5 372.0 2491.0

Flying hours - last 30 days 5.2 15.7 9.3 13.1

Flying hours - last 90 days 128.9 48.5 26.1 13.1

Duty hours - last 48 hours 27.5 21.25 19.5 14.5

Duty hours - day of occurrence

3.25 3.25 4.25 4.25

Flying currency Valid Valid Valid Valid

Medical category Valid Valid Valid Valid

Table 2. Personnel information

1.5.2 The LRPFO was an experienced ex-Royal Air Force (RAF) pilot with 4,346 military flying hours, including experience as an instructor. He had accumulated 2,815 hours on the Nimrod jet, which is a RAF aircraft and performs a similar role to the CP140. He joined the RCAF in April 2015, and his first posting was to 405 (LRP) Sqn. He completed a shortened CP140 Maritime Operational Aircrew Training (MOAT) course due to his previous experience and above average flying performance during the MOAT course. He was awarded an LRPFO category on 17 July 2015. The accident flight was his fifth flight on Sqn after the MOAT.

1.5.3 The LRPC completed pilot training in February 2011, after which he was posted to 405 (LRP) Sqn. His MOAT course was completed in February


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2012. The PNF upgraded to a Long Range Patrol Aircraft Commander (LRPAC) in January 2014, and was upgraded to an LRPC in November 2014. He was progressing well and the Sqn lacked qualified LRPCs so soon after his return from the Op IMPACT deployment, he was pushed to re-qualify as an LRPC four days prior to the accident flight. He was the only 14 Wing LRPC available to do the flight functional the day prior to the accident. He felt compelled to complete the flight functional, despite delays, in order not to impede the Iqaluit deployment. His preparation for the deployment was cut short due to the flight functional.

1.6 AIRCRAFT INFORMATION

Technical Information

1.6.1 The CP140 is a multi-mission reconnaissance and anti-submarine warfare aircraft. The CP140 is powered by four Allison T56-A-14 LFE turboprop engines with Hamilton Standard 54H60-77 hydromatic propellers. (See Annex A for engine and propeller details)

1.6.2 The aircraft maintenance record set was reviewed and no overdue inspections were noted.

1.6.3 The most pertinent aircraft systems to this occurrence are the electrical system, landing gear, nose wheel steering, normal brakes, ground-air sensing (weight on wheels (WOW)) system, propulsion and associated control systems, BETA lights and rudder. See Annex B for full systems descriptions from the Aircraft Operating Instructions (AOI).5

Anti-Skid Brakes

1.6.4 Anti-skid brakes provide improved steering capability and stopping distances on slippery surfaces. The CP140 does not have anti-skid brakes. Therefore, the wheels are more prone to locking up and once skidding begins, the aircraft may lose directional control and may experience hydroplaning, or reverted rubber hydroplaning, if the conditions are suitable.

Operational Information

1.6.5 In the CP140, refusal speed (VR) is the maximum speed from which the aircraft can abort a takeoff and stop within the runway length remaining. Rotate speed (VRO) is the airspeed at which the transition from ground run attitude to climb-out attitude is begun. Normally, a takeoff abort can be safely initiated up to VR. In the case where VR is computed to exceed VRO, the takeoff may be aborted

5 C-12-140-013/MB-001, Book 1 of 2, AIMP Block 3 – CP140 Aurora, Basic Aircraft Systems, 20 October 2014


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at any speed up to VRO. For the takeoff in this occurrence, refusal speed was calculated to be greater than rotate speed. As a result, refusal speed was adjusted to be equal to rotate speed. The distance to accelerate and stop based on the refusal speed chart is based on ground idle thrust on three operating engines and maximum braking. However, CP140 pilots are very cautious of using brakes in the high speed regime due to the lack of anti-skid brakes. Therefore, CP140 pilots tend to rely more on reverse thrust when initially decelerating the aircraft.

CP140 Co-Pilot Takeoff Procedures

1.6.6 The following excerpt is from the CP140 Co-Pilot Takeoff Procedures:

Advise the Pilot upon reaching VR by stating "REFUSAL" and VRO by stating "ROTATE". If VR is calculated to equal or exceed VRO, then state "ROTATE".

CP140 Takeoff Abort Procedure

1.6.7 The CP140 Takeoff Procedure includes the following direction:

If any malfunction occurs prior to refusal speed, carry out the abort procedure.

1.6.8 The following statements are excerpts from the CP140 Takeoff Abort Procedure (see Annex C):

If a fault is observed by any Flight Deck crewmember prior to VR, it shall be reported by stating "MALFUNCTION" followed by a brief description of the fault or if propeller-related, by stating "MALFUNCTION PROP No.______." If a fault is observed by any other crewmember, it shall be reported by stating "PILOT" followed by a brief description of the fault. An abort shall be initiated by the Pilot calling "ABORTING". He or she then carries out the ABORT PROCEDURE while the Flight Engineer monitors the engine instruments and responds to the Pilot’s direction.

NOTE: If power levers are retarded from maximum power to flight idle in less than 1 second, significant RPM undershoot may result and generators may drop off line momentarily.

WARNING: If aborting because of a propeller malfunction, E-handle the associated engine prior to retarding the power levers into the ground range.

WARNING: Do not pull the power levers over the ramp into the ground (BETA) range until below 135 KIAS or propeller pitchlock or decouple may result.


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CP140 Normal Landing Procedure

1.6.9 The following direction is included in the CP140 Normal Landing Procedure (see Annex D):

As the nose wheel touches the runway, lift the power levers over the ramp into the ground range. The Flight Engineer checks that each engine BETA light illuminates as the Pilot retards the power levers into reverse.

NOTE: If a BETA light does not illuminate, the Flight Engineer will call "NO BETA LIGHT #_____". Continue to slowly retard the power levers anticipating a swerve. If a swerve does occur, order the Flight Engineer to "E-HANDLE #_____". If no swerve occurs, continue to reverse normally.

1.7 METEOROLOGICAL INFORMATION

1.7.1 The following METARs (aerodrome routine weather report) show the actual weather at CYZX (Greenwood Aerodrome) at the time of the accident:

METAR CYZX 271400Z 00000KT 3SM SHRA BR 0VC014 20/20 A2988 RMKSC8

SPECI CYZX 271411Z 00000KT 5SM –SHRA BR SCT010 OVC030 21/20 A2988 RMK SF4SC4

1.7.2 See Annex E for a full listing of METARs leading up the accident.

1.7.3 The following amended TAF (terminal aerodrome forecast) was valid at the time of the accident:

TAF AMD CYZX 271249Z 2712/2812 16005KT P6SM -SHRA SCT 006 BKN040 TEMPO 2712/2714 VRB15G25KT 1SM TSRA BR OVC006CB FM271400 18008KT P6SM -SHRA SCT008 BKN040 TEMPO 2714/2717 3SM -SHRA -DZ BR OVC008 FM271700 28005KT P6SM SCT008 BKN015 BECMG 2718/2720 SCT012 BKN050 FM280700 27005KTP6SM SCT008 BKN050 PROB30 2807/2811 2SM BR OVC008

1.7.4 In the period between 0900 and 1100, the meteorological office recorded a total rainfall of 13mm. This is considered to be heavy rainfall and is equivalent to slightly more than ½ inch of rainfall (3mm = 1/8 inch). ATC reported the runway surface condition as bare and wet due to its apparent reflective state.

1.8 AIDS TO NAVIGATION

Not applicable.


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1.9 COMMUNICATIONS

Not applicable.

1.10 AERODROME INFORMATION

1.10.1 Greenwood aerodrome, CYZX, is located at N44°59’04” W064°55’01” at an elevation of 92 feet above sea level. Runway 08/26 and 12/30 are both 8,000 feet long and 200 feet wide. The runways are asphalt and not grooved. All runways are lighted and have associated PAPI lights.

1.10.2 There is an active wildlife control program at 14 Wing. The number of bird strikes reported in the previous 15 years followed a decreasing trend.

1.10.3 The CYZX airfield diagram showing the direction of take-off and the accident location is shown in Figure 2 below.

Figure 2. CYZX airfield diagram and accident location

1.11 FLIGHT RECORDERS

1.11.1 The crash position indicator (CPI)/flight data recorder (FDR) AN/USH-502(V)6 system provides a recording of selected aircraft parameters, audio information and a battery-powered emergency locator transmitter (ELT). Power for the system is provided through the flight recorder system (FLT RCDR SYS) circuit breaker (CB) from the flight essential DC bus (see Annex F). The FLT RCDR SYS CB is powered by the battery after a loss of normal electrical power.

1.11.2 The recorder records in a continuous loop, with the oldest data being overwritten by new data after one hour for the cockpit voice recorder (CVR)


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channels, and 25 hours for FDR channels. The CPI/FDR records three channels of voice data from the pilot and co-pilot headsets and from a flight station microphone. The FDR system records digital data acquired from sensors monitoring parameters such as aircraft attitude, flight control positions and engine performance.

1.11.3 Circuit Breakers on the flight essential DC bus, including the FLT RCDR SYS circuit breaker, are pulled by maintenance personnel as part of the After-Flight (A) Check and are reset by the FE as part of the Pre-Flight Check.

1.11.4 The recorder will begin to record whenever any of the following conditions are met:

• Any engine is running with rpm greater than 10 per cent;

• CVR TEST switch depressed;

• Weight on wheels switch open (in air - this is the default position); or

• Bypass switch selected to TEST.

1.11.5 The recorder will cease to record 10 minutes after the above start condition no longer exists.

1.11.6 In this accident, the CVR kept recording after the engines were shut down due to a known issue with the recording system start conditions. Once power is removed from the aircraft, the WOW system defaults to sense an ‘airborne’ condition. This fact, coupled with the battery being connected, allows the CVR to keep recording until the battery is depleted (usually about 6 hours). CVR data was overwritten because the FLT RCDR SYS CB was not pulled in a timely manner.

1.12 WRECKAGE AND IMPACT INFORMATION

Not applicable.

1.13 MEDICAL

1.13.1 Toxicology sample testing did not reveal the presence of any substances hazardous to aviation.

1.13.2 Sleep duty logs were taken from the LRPFO, LRPC and FE1 in order to determine whether fatigue was a factor. The LRPC self-reported mental fatigue at the time of the accident.

1.13.3 The accident caused eight minor injuries including one possible psychological injury. The injury that is pertinent to this investigation is the head injury to FE1.


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1.14 FIRE, EXPLOSIVES DEVICES, AND MUNITIONS

1.14.1 Witnesses reported a brief flash of fire and smoke from the No. 3 nacelle area when the aircraft came to a rest. The fire self-extinguished and there was evidence of charred wires.

1.14.2 All explosive devices on board, sonobuoys and flares, were confirmed safe by the Explosives Ordnance Disposal (EOD) team within two hours of the occurrence, except for the Survival Kit Air Droppable (SKAD) which was inaccessible due to the collapse of the nose gear. The SKAD was made safe once the aircraft had been moved to a hangar for engineering inspection.

1.15 SURVIVAL ASPECTS

1.15.1 The following crew seats incorporate an inertia reel on the shoulder harness: pilot, co-pilot, flight engineer and seven tactical compartment seats. Each of these crew seats is equipped with a shoulder harness designed to be connected and released by the buckle on the safety belt. The inertia reel permits forward body movement without loosening the shoulder harness. The locking control is located on the left side of the seats. The inertia reel is designed to automatically lock when a forward force of 2 g to 3 g is applied.

1.15.2 An updated version of the inertial reel is being fitted to the CP140 as a result of HAZREP #98815. However, this newer version has a tendency to lock up with minimal movement of the seat occupant. As a result, FEs on the CP140 routinely loosen the shoulder restraint harness in order set the takeoff power setting with the power levers. In this accident, FE1 received an injury to his head during the takeoff abort sequence as a result of his shoulder harness being loosened.

1.16 TEST AND RESEARCH ACTIVITIES

Quality Engineering Test Establishment (QETE) Report6

1.16.1 The analysis of the propeller mechanisms by Standard Aero Limited (SAL), and included in the QETE report, concluded that propellers No. 1 and 2 went into ground (BETA) range and propellers No. 3 and 4 showed evidence of pitchlock at approximately 18 degrees.

CP140 Simulator Scenarios

1.16.2 The CP140 simulator was used to qualitatively assess the occurrence takeoff abort and to explore different abort techniques. The simulator was first

6 Project Report, D038015 CP140103 Runway Excursion, 29 July 2016


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evaluated to assess its representativeness of the actual aircraft. The stopping capability of the aircraft in the simulator was determined to be not representative of the real aircraft.

1.16.3 Takeoff abort scenarios were conducted to explore the aircraft’s response to various propeller failure conditions, aircrew communication and handling, and outcomes from different abort techniques. All takeoff aborts were initiated by the pilot in the left seat by making a rapid power lever reduction of all four engines, either to full reverse within 1 second, or to flight idle position to evaluate the TOLD data.

1.16.4 In the symmetric thrust scenarios to full reverse or flight idle, the aircraft remained laterally on the runway, with or without the use of brakes.

1.16.5 The simulator could not accurately simulate a pitchlocked propeller scenario; therefore a low pitch stop failure was used to simulate an asymmetric thrust situation. The asymmetric thrust scenarios on No. 3 and 4 engines included a low pitch stop failure (13 degree propeller blade angle), as well as propeller decouplings. The low pitch stop failure scenario appeared very representative of the occurrence takeoff abort, whereas the decouple scenario caused little difficulty to the pilot who was easily able to maintain the aircraft on the runway. An additional low pitch stop failure scenario was carried out, but this time the pilot commanded E-handle No. 3 and 4 as part of the abort procedure and the handles were pulled by the FE. The PF had little difficulty maintaining the aircraft on the runway when the E-handles were pulled.

1.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION

1.17.1 405 (LRP) Sqn was experiencing a high operational tempo since the start of Op IMPACT. Scheduling of crews and aircraft kept senior supervisors very busy due to several challenges. The Block 3 upgrade process was reducing the number of aircraft available for missions. Deployments to Op IMPACT reduced available personnel and aircraft for domestic missions. 19 Wing crews were not yet qualified on the Block 3 aircraft and therefore could not relieve the deployment pressure on 14 Wing crews. The lack of qualified, experienced personnel put the burden of test flights and domestic missions on a small cadre of experienced personnel, including the occurrence LRPC.


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1.18 ADDITIONAL INFORMATION

Reverted Rubber (Steam) Hydroplaning7

1.18.1 Reverted rubber (steam) hydroplaning occurs during heavy braking that results in a prolonged locked-wheel skid. Only a thin film of water on the runway is required to facilitate this type of hydroplaning. The tire skidding generates enough heat to cause the water to change to steam which then causes the rubber to revert to its original uncured state. The reverted rubber acts as a seal between the tire and the runway, and delays water exit from the tire footprint area. The water heats and is converted to steam which supports the tire off the runway. Reverted rubber hydroplaning frequently follows an encounter with dynamic hydroplaning, during which time the pilot may have the brakes locked in an attempt to slow the airplane. Eventually the airplane slows enough to where the tires make contact with the runway surface and the airplane begins to skid. The remedy for this type of hydroplaning is for the pilot to release the brakes and allow the wheels to spin up and apply moderate braking. Reverted rubber hydroplaning is insidious in that the pilot may not know when it begins, and it can persist to very slow groundspeeds (20 knots or less).

7 http://aviationglossary.com


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1.18.2 Reverted rubber hydroplaning produces a distinctive mark on the tire tread in the form of a burn, a patch of reverted rubber.8 In this accident, the right hand (RH) main landing gear (MLG) inboard tire showed evidence of reverted rubber as shown below in Figure 3.

Figure 3. RH MLG inboard tire reverted rubber

8 http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11h0003/a11h0003.asp


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1.18.3 The RH MLG outboard tire also showed evidence of reverted rubber as shown below in Figure 4.

Figure 4. RH MLG outboard tire reverted rubber


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1.18.4 Hydroplaning is also known to produce steam-cleaned marks on the runway when sufficient heat is generated between the tire and the runway to change the water into steam, producing a steam cleaned effect.9 In this accident, the RH MLG tires began reverted rubber hydroplaning just before the departure-end arrestor gear cable position (2739 feet from threshold of Runway 08) and continued for 1800 feet, until the aircraft left the hard surface. A sample of the steam-cleaning is shown in Figure 5 below, as the RH MLG tires crossed the 1000-foot marker for Runway 08.

Figure 5. Steam-cleaning of the 1000-foot marker for runway 08

9 http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/a11h0003/a11h0003.asp


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1.18.5 The path of the RH MLG tires on the runway while reverted rubber hydroplaning is highlighted by the orange cones below in Figure 6. The steam-cleaning began just before the Runway 26 departure-end arrestor gear cable position and continued until where the aircraft left the hard surface.

Figure 6. Path of the RH MLG tires

Nimrod and/or Jet Engine Throttle Handling

1.18.6 Engine handling on the Nimrod aircraft (jet engine) is such that the throttles can be rapidly retarded to idle without any adverse effects on the engine. As described in para 1.6.7, if the power levers are pulled directly over the ramp into the ground (BETA) range at or above 135 KIAS on the CP140, propeller pitchlock or decouple may result.


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Takeoff Abort Decision Making

1.18.7 In 1989, in reaction to a number of takeoff accidents resulting from improper rejected takeoff decisions and procedures, a joint Federal Aviation Administration/industry taskforce studied what actions might be taken to increase takeoff safety10. Boeing led an industry wide effort to develop a training aid. The result was a publication entitled Takeoff Safety Training Aid11, released in 1993, which included the Pilot Guide to Takeoff Safety (Section 2, updated in 2004). The Pilot Guide to Takeoff Safety states the following:

Available data indicates that over 75% of all RTOs [Rejected Take Offs] are initiated at speeds of 80 knots or less. These RTOs almost never result in an accident. Inherently, low speed RTOs are safer and less demanding than high speed RTOs. At the other extreme, about 2% of the RTOs are initiated at speeds above 120 knots. Overrun accidents and incidents that occur principally stem from these high speed events.

In order to eliminate unnecessary RTOs, the crew must differentiate between situations that are detrimental to a safe takeoff, and those that are not.

As speed approaches V1, the successful completion of an RTO becomes increasingly more difficult.

1.18.8 One example from an RCAF aircraft in which the industry best practices are captured in the direction provided to its pilots is with the CC144 Challenger. The CC144 Standard Manoeuver Manual12 states the following:

Minor faults are not normally considered cause for a takeoff abort. In all such cases, the decision to continue (or abort) the takeoff should be made solely by the AC. The decision to abort above 80 KIAS should not be considered unless the AC is convinced that a take-off and immediate recovery places the aircraft and crew in more jeopardy than that associated with a high-speed reject.

10 http://www.skybrary.aero/index.php/FAA_Takeoff_Safety_Training_Aid 11 http://flightsafety.org/files/RERR/TakeoffTrainingSafetyAid.pdf 12 SMM 60-CC144-1000, Change 2, 31 January 2001


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Aircraft Commander Actions in an Emergency

1.18.9 The National Defence Flying Orders13 state the following:

Notwithstanding anything contained in these or any other orders, in an emergency, the aircraft commander shall take action to preserve the safety of the aircraft, crew and passengers.

FSIMS #165629, CC130H Tail Strike in Red Lake, Ontario

1.18.10 On 5 August 2015, an approach into Red Lake was flown by the FO in the left seat being supervised by the AC in the right seat. Initially, the final approach was fast and the AC stated that to the FO several times. The AC was guarding the power levers with a hand below the FO’s hand in preparation for the touch and go checklist. The FO was not correcting and the AC felt the need to reduce the power and did so. The FO simultaneously reduced power not knowing the AC was going to at the same time. The aircraft then slowed to 3-5 KIAS below landing reference speed above the runway threshold. At 20 feet above ground level, the FO, concerned about runway length and float, abruptly pulled off all the power creating a high sink rate. The FO then initiated a nose high flare to arrest the sink rate. Given the slightly low energy state of the aircraft, the excessive flare did nothing to arrest the sink rate and the aircraft landed hard. The AC was unable to react to correct the FO’s unexpected actions before the aircraft landed.

1.18.11 The aircraft landed with a decent rate of 720 feet per minute. The maximum descent rate for a 115,000 pound aircraft is 540 feet per minute. The high decent rate, combined with the high nose attitude and tire/shock compression, created a geometric condition that allowed the fuselage to contact the ground. The double power reduction created a low energy state. The low energy state combined with the abrupt power reduction by the FO caused the hard landing. The double power reduction was a result of the breakdown in crew coordination.

1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES

Not applicable.

13 B-GA-100-001/AA-000, Book 1 of 2, Flight Rules, 1 October 2013


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2 ANALYSIS

2.1 GENERAL

2.1.1 The investigation determined that the aircrew was current and qualified, the aircraft was serviceable at the time of the accident, and the mission was properly planned and authorized IAW orders and procedures. The following analysis addresses the takeoff abort procedure, the cockpit shoulder harness inertial reels, CVR data retention, 14 Wing runway water pooling, and fatigue.

2.2 PILOT ACTIONS

2.2.1 The CP140 Takeoff Procedure requires the PF to monitor and acknowledge an airspeed check/call by the PNF at 80 KIAS, but the PF is not mandated to monitor nor call Refusal Speed (VR) or Rotate Speed (VRO). There is always a possibility of the PNF missing or not calling VR or VRO, thereby having a critical speed-call missed all together. VR or VRO are critical speeds where the AC (in this case the PNF) must decide whether to continue or abort the takeoff. Aborting above VR or VRO is not recommended due to the risks of runway overrun. In the specific case of the CP140, brake pressure sensitivity and the lack of anti-skid brakes increases the likelihood of locking a main wheel. VR or VRO speeds are critical and need to be monitored by both pilots, and if necessary, called by the PF in such cases as the PNF misses the call. This is a standard technique used on other RCAF multi-engine fleets.

2.2.2 The investigation sought to determine why the LRPC did not call “Rotate” and later on called “Malfunction” after VRO. A Canadian Forces Environmental Medicine Establishment (CFEME) Human Factors Specialist determined that the LRPC “Malfunction” call was delayed due to the influence of “episodic memory.” Episodic memory is the process of remembering a past event. In this case, the LRPC experienced episodic memory of a prior CP140 bird strike incident, and used this event to help formulate a decision to abort the takeoff. However, this process requires cognitive effort which competes with working memory, the capacity to manipulate information in the present, resulting in a delay calling “Malfunction.” The LRPC took too long to formulate a decision whether to take off or abort, and lost situational awareness of the aircraft’s airspeed. As a result, the LRPC did not call “Rotate” at the calculated rotate speed (VRO) of 117KIAS as required by the AOI. Subsequently, a late “Malfunction” call was made by the LRPC, with the takeoff abort procedure commencing at approximately 133KIAS. The investigation determined that if the abort procedure had commenced at or before VR/VRO, the aircraft should have been able to stop in the runway remaining.

2.2.3 The Canadian Forces Environmental Medicine Establishment (CFEME) Human Factors Specialist also determined that negative transfer affected the LRPFO during the takeoff abort. Negative transfer can be triggered by elevated cognitive requirements when a person returns to previously learned behavior


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when stressed, instead of attempting to modify his or her reaction based on the circumstances. Engine handling on the Nimrod aircraft (jet engine) is such that the throttles can be rapidly retarded from maximum power to idle, whereas on the CP140 it is recommended that the power levers not be retarded from maximum power to flight idle in less than 1 second (see Annex C). Furthermore, the CP140 AOI warns not to pull the power levers over the throttle quadrant ramp into the ground (BETA) range until below 135 KIAS, or propeller pitchlock or decouple may result. In this case, when the LRPC called “Malfunction,” the LRPFO perceived a lack of runway remaining and likely reverted to the Nimrod throttle handling technique. At approximately 133 KIAS, the LRPFO rapidly retarded the power levers from a high power setting straight into the ground (BETA) range without checking the status of the BETA lights during the movement of the power levers farther aft towards ground range/reverse.

2.2.4 A technical analysis of the propeller mechanisms concluded that propellers No. 1 and 2 went into ground (BETA) range and propellers No. 3 and 4 showed evidence of pitchlock at approximately 18 degrees. The difference in blade angles between the propellers on the left side and the right side of the aircraft caused an asymmetric thrust situation. The asymmetric thrust, combined with the reverted rubber hydroplaning, did not allow the crew to keep the aircraft laterally on the runway. The simulator trials demonstrated that if the PF had directed FE1 to E-Handle No. 3 and 4 engines once “No BETA 3 and 4” and “E-Handle” were called by the FEs, the asymmetric thrust would have reduced and the aircraft would have most likely stayed laterally on the runway.

2.2.5 Similar to the CC130H tail strike in Red Lake, the LRPC attempted to assist the LRPFO with the asymmetric thrust situation by adjusting throttles No. 1 and 2 forward. However, at no point during the takeoff abort procedure did the LRPC attempt to take control of the aircraft or take action to shut down the engines with BETA lights which did not illuminate. Compared to LRPFOs, LRPCs are typically more experienced, should have better handling skills and most importantly, have the overall responsibility for the safe operation of the aircraft. Given the LRPC’s responsibilities, it would be expected that once the situation deviated from the norm and it was clear the LRPFO was having trouble controlling the aircraft, that the LRPC would exercise his command authority and take action to preserve the safety of the aircraft, crew and passengers. In this case it appears that the LRPC was suffering from mental fatigue and was cognitively overloaded. These factors led to his inability to take control of the aircraft in this abnormal situation.

2.3 ABORT PROCEDURES

2.3.1 The CP140 Takeoff Abort Procedure does not include direction as to what to do when the power levers are moved into the BETA range, and the associated BETA light does not illuminate. However, there is specific direction of what to do in the case of an abort with no BETA light in the Normal Landing Procedure (see Annex D). The FE is to call “NO BETA LIGHT # __.” If there is a


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swerve, the pilot is to order the FE to “E-HANDLE No __.” This is to shut down the associated engine to prevent asymmetric control problems and possible loss of directional control.

2.3.2 The takeoff is a critical regime of flight, where aircraft speed and weight (kinetic energy) is constrained by a finite amount of runway remaining, and the ability to safely abort is dictated by dissipating takeoff energy as soon as possible. A takeoff abort is, in essence, a critical emergency where a clear, concise, executive command is absolutely necessary. In the preamble to the CP140 Takeoff Abort Procedure, if a fault is observed by any flight deck crewmember prior to VR, the term “Malfunction” is used, followed by a brief description of the fault, to indicate to the “pilot” that there is a fault. If the pilot determines that the fault dictates an abort, then the pilot is to call “Aborting” and carries out the Abort Procedure. However, the preamble does not differentiate between LRPC/AC and LRPFO roles or provide direction as to what to do if the AC decides that the fault is not serious enough to require an abort.

2.3.3 In Section 22 of the CP140 AOI, Takeoff Procedures – Pilot Procedures, it states that if any malfunction occurs prior to refusal speed, carry out the abort procedure. It is recognized as a best practice in aviation, particularly in larger multi-crew aircraft, to consider the severity of the malfunction as well as the speed regime at which the malfunction is noticed before deciding on the best course of action. It is also recognized in the aviation industry that takeoff aborts at high speed significantly increase the risk of an accident. The current CP140 practices do not follow these recognized best practices.

2.4 COCKPIT SHOULDER RESTRAINT HARNESS INERTIAL REELS

2.4.1 FE’s on the CP140 routinely loosen their shoulder restraint harness in order to set takeoff power. This has been identified as a CP140 fleet-wide systemic problem. The issue has caused aborts due to FE’s not being able to set the power levers to the required power setting for takeoffs and touch-and-go’s. If the situation is not resolved, more CP140 crew members could experience injuries in the future. To facilitate operations and reduce risk to CP140 crews, a solution needs to be found to the overly-sensitive locking of the inertial reels.

2.5 CVR DATA RETENTION

2.5.1 In this accident, the CVR data was overwritten because the FLT RCDR SYS CB was not pulled in a timely manner. CVR data is a critical source of evidence for investigators to properly assess crew interaction and performance. Relying on interviews alone can lead to errors in establishing facts, analysis of data, and the resulting preventive measures. If the CP140 CVR had a longer recording capability, the chances of saving critical CVR data would increase.


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2.6 14 WING RUNWAY WATER POOLING

2.6.1 There was compelling evidence that there was standing water on the airfield surfaces, including Runway 08/26, at the time of the accident. The METARs indicated thunderstorms and moderate rain for the 90 minutes prior to takeoff. The meteorological office indicated that 13mm of rain fell that morning. There were photos and video showing rain showers and puddles during the takeoff and immediately after the accident. The investigators noted a saturated infield upon arrival on scene and were also informed that water pooling at the intersection of the runways was a common problem, as supported by HAZREP #166951.

2.6.2 One of the requirements for reverted rubber (steam) hydroplaning to occur is to have water on the runway. The loss of directional control due to the asymmetric thrust situation, combined with reverted rubber hydroplaning, caused the aircraft to leave the runway. Therefore, the standing water on the runway was a contributing factor to the aircraft leaving the hard surface.

2.7 FATIGUE

2.7.1 Sleep and duty logs for the LRPFO, LRPC, and FE1 were analyzed. Fatigue modelling using the Fatigue Avoidance Scheduling Tool (FAST) suggested that aircrew performance at the time of the incident should not have been impaired by fatigue. However, fatigue is complex, and no fatigue prediction model can account for all of the factors that will affect an individual’s susceptibility to fatigue.

2.7.2 In this case, despite favourable fatigue prediction modelling, the LRPC self-reported mental fatigue at the time of the accident. FAST can only give the best case scenario based on a limited number of factors, and has limitations when identifying mental fatigue. Therefore, self-reported fatigue supersedes FAST modelling and the LRPC was likely mentally fatigued at the time of the accident, which may have adversely affected decision making during the takeoff.


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3 CONCLUSIONS

3.1 FINDINGS

3.1.1 The mission was properly planned and authorized IAW orders and procedures, the aircrew were current and qualified, and the aircraft was serviceable at the time of the accident. (2.1.1)

3.1.2 The LRPC was likely mentally fatigued at the time of the accident, which may have adversely affected his decision making during the takeoff. (2.7.2)

3.1.3 The PF is not required to monitor or check critical airspeeds above 80 KIAS. (1.6.6, 2.2.1)

3.1.4 The LRPC delayed calling “Rotate,” and called “Malfunction” after VRO. (2.2.2)

3.1.5 At approximately 133 KIAS, the LRPFO rapidly retarded the power levers from a high power setting straight into the ground (BETA) range without checking the status of the BETA lights during the movement of the power levers further aft towards ground range/reverse. (2.2.3)

3.1.6 Propellers No. 1 and 2 went into ground (BETA) range and propellers No. 3 and 4 most likely pitchlocked at approximately 18 degrees. The difference in blade angles between the propellers on the left side and the right side of the aircraft caused an asymmetric thrust situation. (2.2.4)

3.1.7 The aircraft departed the runway surface due to loss of directional control caused by the asymmetric thrust situation, the lack of E-Handle activation with engines 3 and 4, and combined with reverted rubber hydroplaning. (2.2.4)

3.1.8 Simulator trials indicated that if the No. 3 and 4 engines were secured using the E-Handles this would have lessened the asymmetric thrust situation and the aircraft would have most likely stayed laterally on the runway (2.2.4)

3.1.9 The LRPC should have taken action once it was clear that the LRPFO was not able to control the asymmetric thrust situation. (2.2.5)

3.1.10 The CP140 Takeoff Abort Procedure does not include direction as to what to do when the power levers are moved into the BETA range and the associated BETA light does not illuminate. (2.3.1)

3.1.11 The CP140 Takeoff Abort Procedure does not provide direction as to what to do if the AC decides that the fault does not require an abort. (2.3.2)


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3.1.12 The CP140 Takeoff Procedure dictates the initiation of the Takeoff Abort Procedure for any malfunction prior to refusal speed, regardless of the severity, and with no consideration to the speed regime. (2.3.3)

3.1.13 FEs on the CP140 routinely loosen their shoulder restraint harness to allow them to set the takeoff power setting with the power levers. (2.4.1)

3.1.14 CVR data was overwritten because the FLT RCDR SYS CB was not pulled in a timely manner. (2.5.1)


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3.2 CAUSE FACTORS

ACTIVE CAUSE FACTORS

3.2.1 The LRPC delayed calling “Rotate,” and called “Malfunction” after VRO. (3.1.4)

3.2.2 At approximately 133 KIAS, the LRPFO rapidly retarded the throttles from a high power setting straight into the ground (BETA) range without checking the status of the BETA lights during the movement of the power levers further aft towards ground range/reverse. (3.1.5)

3.2.3 No. 3 and 4 engines and propellers were not secured using the E-Handles when the asymmetric thrust situation occurred. (3.1.7)

LATENT CAUSE FACTORS

3.2.4 The PF is not required to monitor or check critical airspeeds above 80 KIAS. (3.1.3)

3.2.5 The CP140 Takeoff Abort Procedure does not include direction as to what to do when the power levers are moved into the BETA range, and the associated BETA light does not illuminate. (3.1.10)

3.2.6 The CP140 Takeoff Abort Procedure does not provide direction as to what to do if the AC decides that the fault does not dictate an abort. (3.1.11)

3.2.7 The CP140 Takeoff Procedure dictates the initiation of the Takeoff Abort Procedure for any malfunction prior to refusal speed, regardless of the severity, and with no consideration to the speed regime. (3.1.12)

3.2.8 The standing water on the runway caused reverted rubber hydroplaning and was a contributing factor to the aircraft leaving the hard surface. (3.1.7)

3.2.9 The LRPC was likely mentally fatigued at the time of the accident, which may have adversely affected his decision making during the takeoff. (3.1.2)


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4 PREVENTIVE MEASURES

4.1 PREVENTIVE MEASURES TAKEN

4.1.1 1 Canadian Air Division (CAD) Head Quarters (HQ)/Director Fleet Readiness (Dir Flt Rdns) directed all 1 CAD fleets to include a consideration for pulling CVR/FDR circuit breakers, or equivalent, as part of the normal shut down procedure on all aircraft in order to safeguard data. (3.1.14)

4.1.2 1 CAD HQ/Long Range Patrol Standards Evaluation Team (LRPSET) issued “Aircrew Information File (AIF) 011/16 Abort Procedure” to all flight deck personnel, adding direction to the CP140 Takeoff Abort Procedure regarding what to do when a BETA light does not illuminate when entering the ground range. AIF remains in effect until revised AOI CP140 Takeoff Abort Procedure is promulgated in upcoming AOI Change. (3.2.5)

4.2 PREVENTIVE MEASURES RECOMMENDED

4.2.1 1 CAD HQ/LRPSET to amend the CP140 Takeoff Abort Procedure to direct both PF and PNF to monitor the indicated airspeed for 80 KIAS, VR and VRO, and the PF must call VR or VRO if this call is missed by the PNF. (3.2.4)

4.2.2 1 CAD HQ/LRPSET to include information in the CP140 Takeoff Abort Procedure regarding what to do when a BETA light does not illuminate. (3.2.3, 3.2.5)

4.2.3 1 CAD HQ/LRPSET to specify that an executive command be used if the AC determines that a fault does not dictate an abort. (3.2.6)

4.2.4 1 CAD HQ/LRPSET to determine a short list of critical emergencies that would normally necessitate an abort to assist the AC in determining whether a fault should dictate an abort in the high speed regime. (3.2.7)

4.2.5 Director General Aerospace Equipment Program Management (DGAEPM)/CP140 Weapon System Manager (WSM) to find a solution for the cockpit shoulder harness inertial reels which are overly sensitive to locking. (3.1.13)

4.3 OTHER SAFETY MEASURES RECOMMENDED

4.3.1 DGAEPM/CP140 WSM to increase the recording capability of the CP140 CVR. (3.1.14)

4.3.2 14 Wing/Officer Commanding (OC) Real Property Operations (RP Ops) to make improvements to the runways in order to minimize the chance of hydroplaning. (3.2.8)


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4.4 DFS REMARKS

4.4.1 This accident is a reminder once again of the inherent dangers involved with high speed takeoff aborts. Awareness was raised within the civil aviation community in the early 1990’s due to improper decision-making and procedures, but unfortunately these scenarios still do occur. Low speed takeoff aborts, initiated at speeds of 80 knots or less, are safer and less demanding than those initiated at high speed. Takeoff aborts initiated at speeds above 120 knots, like in this accident, are much more difficult to control. As speed approaches V1, the critical engine failure speed, the chances of a runway overrun are greatly increased. Aircraft commanders must be trained and given tools to be able to determine whether continuing the takeoff and dealing with a fault while airborne would be safer than aborting the takeoff.

4.4.2 If an emergency situation develops, the aircraft commander must be prepared to take control of the situation. The aircraft commander is typically the most experienced and knowledgeable on aircraft handling and systems, and is expected to be the most capable of managing and resolving the emergency situation. He or she is also ultimately responsible for the safety of the aircraft and his or her crew. // Original Signed By // S. Charpentier Colonel Airworthiness Investigative Authority


A-1/1

Annex A 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX A – AIRFRAME, ENGINE, AND PROPELLER HOURS

Component Serial # TSN TSO Aircraft CP140103 24644.3 148.3

RTLIR#5 No. 1 Engine

110766 23138.4 3166.2

No. 2 Engine

110785 16587.8 148.3

No. 3 Engine

110781 21022.8 1509.0

No. 4 Engine

110777 19696.5 821.0

No. 1 Propeller

N236763 16989.7 5665.0

No. 2 Propeller

N236840 17955.1 6042.9

No. 3 Propeller

N241076 9961.0 3381.3

No. 4 Propeller

N236958 16915.5 5074.3

Table 1: Airframe, Engine, and Propeller Hours Table


B-1/4

Annex B 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX B – SYSTEMS DESCRIPTION FROM C-12-140-013/MB-001

Electrical System

AC power is normally supplied by two engine-driven generators with generator No.4 and the APU generator provided as backup sources. AC power is distributed to two main AC buses identified as MAIN AC BUS A and MAIN AC BUS B and to the essential AC buses. Generator No.2 normally powers MAIN AC BUS A, the MONITORABLE ESSENTIAL AC BUS, the START ESSENTIAL AC BUS and the FLIGHT ESSENTIAL AC BUS. Generator No.3 normally powers MAIN AC BUS B.

DC power is supplied by three Transformer Rectifiers (TRs), which convert AC power to DC power whenever the AC buses are powered. TR No.1 is powered by MAIN AC BUS A, TR No.2 by MAIN AC BUS B and TR No.3 by the MONITORABLE ESSENTIAL AC BUS. DC power is distributed throughout the aircraft by the following busses: MAIN DC, EXTENSION MAIN DC, MONITORABLE ESSENTIAL DC, FLIGHT ESSENTIAL DC, GROUND OPERATION DC, START ESSENTIAL DC and the APU ESSENTIAL DC BUS. In addition, a 24 volt, 31 amp hour battery provides a limited amount of DC power to the FLIGHT ESSENTIAL DC BUS when all other DC sources have failed. The battery is automatically charged whenever the MONITORABLE ESSENTIAL DC BUS is powered.

Landing Gear

The Main Landing Gear (MLG) consists of a single oleo-pneumatic shock strut, drag strut, jury strut, automatic safety downlock, dual wheels, tires, and hydraulically operated multiple-disc brakes. MLG wheel braking is accomplished by toeing each rudder pedal. The brake system uses pressure supplied by the No.1 hydraulic system supplied to a dual cable operated brake controlled valve. The brake control valve is connected to the pilot’s rudder pedals by a cable system. The pilot’s and co-pilot’s rudder pedals are also interconnected by a cable system. Approximately 14.5 pounds of force is required at the pedal to initiate brake action. Pedal motion for full brake actuation is 18 degrees of rotation.

The Nose Landing Gear (NLG) is mounted in a well located in the forward fuselage. The NLG retracts forward and is stowed within the fuselage. The NLG consists of a single oleo-pneumatic shock strut, drag strut, jury strut, automatic safety downlock, dual wheels, tires, and hydraulically operated steering mechanism. The controllable nose wheel steering range is 67 degrees to the left or right of neutral.


B-2/4

Nose Wheel Steering

Nose wheel steering is controlled by a steering wheel located on the pilot side console. The nose wheel can be turned 67 degrees left or right of centre after the nose gear is extended. Travel of the steering wheel is approximately three turns from stop to stop. When the nose wheel is centred, an index arrow on the wheel points straight ahead. With the steering wheel index spoke pointing forward, the nose-wheels can be pointing straight ahead or 45 degrees to the left or right from centre.

The nose gear is designed to caster to align the wheels with the aircraft motion during all ground operations. The aircraft can be maneuvered without steering pressure by using thrust and brake combinations. When turning without nose wheel steering, the steering wheel will turn in response to nose wheel castoring and should not be held or all attempts to caster the wheels will be defeated.

Normal Brakes

Multiple disc brake assemblies installed on each main gear axle are provided to stop the aircraft. The brakes are applied by toe pressure on the pilot or co-pilot rudder pedals and are available only when the landing gear selector and brake shutoff valve is in the neutral or down position. Pressure is supplied from the hydraulic system and brake accumulator to a brake control valve which is connected to the rudder pedals by control cables. The brake control valve reduces hydraulic pressure to the brakes and provides feel to the pedals to gauge brake application.

Ground-Air Sensing System (Weight on Wheels System)

The ground-air sensing circuit restricts or inhibits various systems or equipment from operating on the ground or in-flight to protect the crewmembers from personal injury or the aircraft systems from equipment damage. The circuits are automatically energized by scissor switches located on each main landing gear when the struts are compressed. Two individual circuits, ground-air sensing electrical and electronic, are powered by the MAIN DC BUS. They energize or de-energize systems.

Propulsion - Engines

Each of the four powerplants (engines) consists of three major assemblies: the power section, the torquemeter assembly and the reduction gearbox (RGB) assembly. The engine is mounted in an engine nacelle along with accessories to comprise a Quick-Engine Change (QEC) assembly which is designed for quick removal and assembly.


B-3/4

Propulsion - Propellers

The Propeller assembly is a four blade, 13.5 foot diameter propeller. The propeller has a blade angle operating range of 101 degrees with a reverse-angle setting of -14.5 degrees, a low-pitch stop setting of +13 degrees, and a feather angle of +86.65 degrees. The blade-pitch change mechanism, in conjunction with the integral oil control, maintains a constant RPM of the engine at all power lever settings above flight idle (Alpha range). For ground idle and reverse (BETA range), the propeller blades can be positioned by the power levers to provide zero or negative thrust. Full feathering of the blades is provided to minimize drag of the propeller should engine shut down be required in-flight.

Pitchlock System

An RPM-sensitive mechanism is incorporated in the propeller to prevent excessive low pitch when control oil pressure is lost or RPM exceeds 103.5 per cent. Low blade angle is limited when the rotating pitchlock ratchet teeth, connected to the pitch control piston, engage the teeth on the fixed pitchlock ratchet attached to the propeller shaft. These ratchets are spring-loaded to mesh but are normally held apart by propeller governor control oil pressure.

An overspeed of greater than 103.5 per cent will result in oil being cut off by the pitch lock servo. Therefore, loss of control oil pressure or RPM greater than 103.5 per cent will both allow the springs to force the pitchlock ratchets to engage. Each tooth is equal to a blade angle change of approximately 2.5 degrees and is machined to only allow ratcheting toward high pitch. Once pitchlocked, published procedures shall be followed to ensure the pitchlock teeth are engaged and to prevent further blade angle decrease, hence avoiding high drag and extreme RPMs. Pitchlock is mechanically blocked out above 57 degrees of blade angle to allow for unfeathering and below 17 degrees of blade angle to prevent interference with the propeller-reversing process.

Safety Coupling

The safety coupling is an automatic, mechanical, safety back-up device for the NTS, installed at the rear face of the reduction gear-box, which will decouple the power unit from the reduction gear-box whenever the SHP reaches approximately (minus) -1700. The coupling consists of sections that are spring loaded together on helical splines. If the NTS system fails to function, the helical spline action will cause the sections to move apart and decouple the reduction gear-box from the power unit. When both the engine and propeller have stopped rotating, the decoupler automatically reconnects (if the decoupling unit is not damaged by prolonged operation before shutdown). Prolonged cycling of the safety coupling may cause the splined sections to be damaged.


B-4/4

BETA Lights – Centre Instrument Panel

These lights illuminate when a propeller blade angle is 10 degrees or less. During landing, if a BETA light fails to illuminate when power levers are moved into the ground (BETA) range and a swerve occurs, the E-handle on affected engine is to be pulled.

Figure 1: Engine Instruments with BETA Light location

Flight Controls - Rudder

The rudder is operated by a mechanical linkage and hydraulic boost package system by movement of either the pilot or co-pilot rudder pedals, which are interconnected by linkage. Both pairs of rudder pedals are adjustable forward and aft by an adjustment crank. Rudder movement is transmitted via cable assemblies, rods and a bellcrank to the rudder boost package located in the aft fuselage adjacent to the elevator boost package. The output of the boost package is transmitted to the rudder via a rod that connects with the horn on the rudder torque tube.


C-1/1

Annex C 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX C – CP140 TAKEOFF ABORT PROCEDURE

Figure 1: Takeoff Abort Procedure


D-1/1

Annex D 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX D – CP140 NORMAL LANDING PROCEDURE

Figure 1: Normal Landing Procedure


E-1/1

Annex E 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX E – SELECTED CYZX METARS

METAR CYZX 271200Z 19004KT 15SM –SHRA FEW006 BKN040 22/20 A2989 RMK SF2SC4 WNDY

SPECI CYZX 271234Z 18009KT 3SM –SHRA BR SCT006 OVC040 22/20 A2988 RMK SF4SC4 WNDY

SPECI CYZX 271245Z 26006KT 3SM TSRA OVC040CB 22/20 A2988 RMK CB8 WNDY

METAR CYZX 271300Z 23003KT 3SM TSRA SCT008 OVC020CB 21/20 A2988 RMK SF3CB5 WNDY

SPECI CYZX 271325Z 28010KT 3SM SHRA BR BKN011 OVC030CB 20/20 A2989 RMK SF6CB2 WNDY

METAR CYZX 271400Z 00000KT 3SM SHRA BR 0VC014 20/20 A2988 RMKSC8 WNDY

SPECI CYZX 271411Z 00000KT 5SM –SHRA BR SCT010 OVC030 21/20 A2988 RMK SF4SC4 WNDY

SPECI CYZX 271447Z 30005KT 4SM –SHRA BR SCT006 OVC026 21/20 A2988 RMKSF3SC5 WNDY

METAR CYZX 271500Z CCA 31005KT 5SM –SHRA BR SCT006 OVC026 21/20 A2987 RMK SF3SC5 WND


F-1/1

Annex F 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX F – CB DIAGRAM FOR THE FLIGHT ESSENTIAL DC BUS

Figure 1: Flight Essential DC Bus


G-1/2

Annex G 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX G – ABBREVIATIONS

ABBREVIATION MEANING

AC AI AIF AOI ATC AVS CAD CB CFEME CPI CVR DFS

Aircraft Commander Attitude Indicator Aircrew Information File Aircraft Operating Instructions Air Traffic Control Avionics (Technician) Canadian Air Division Circuit Breaker Canadian Forces Environmental Medicine Establishment Crash Position Indicator Cockpit Voice Recorder Director Flight Safety

DGAEPM Dir Flt Rdns ELT EOD FDR FE FO FAST FLT RCDR SYS GMT HFACS HQ IAW KIAS L LH LRP LRPAC LRPC LRPFO LRPSET METAR

Director General Aerospace Equipment Program Management Director Fleet Readiness Emergency Locator Transmitter Explosive Ordinance Disposal Flight Data Recorder Flight Engineer First Officer Fatigue Avoidance Scheduling Tool Flight Recorder System Greenwich Mean Time Human Factors Analysis Classification System Head Quarters In Accordance With Knots Indicated Air Speed Local Time Left Hand Long Range Patrol Long Range Patrol Aircraft Commander Long Range Patrol Captain Long Range Patrol First Officer Long Range Patrol Standards Evaluation Team Aerodrome Routine Weather Report


G-2/2

MLG MP MOAT NDHQ

Main Landing Gear Military Police Maritime Operational Aircrew Training National Defence Headquarters

NLG NORAD NTS NWS OC Op PAPI PF PNF QEC QETE RAF RCAF RGB RH RPM RP Ops SAL SHP SKAD TAF TOLD TR TSN TSO UTC VR VRO WFSO WOW WSM

Nose Landing Gear North American Aerospace Defence Negative Torque Signal Nose Wheel Steering Officer Commanding Operation Precision Approach Path Indicator Pilot Flying Pilot Not Flying Quick Engine Change Quality Engineering Test Establishment Royal Air Force Royal Canadian Air Force Reduction Gear Box Right Hand Revolutions Per Minute Real Property Operations Standard Aero Limited Shaft Horse Power Survival Kit Air Droppable Terminal Aerodrome Forecast Take Off and Landing Distance Transformer Rectifier Time Since New Time Since Overhaul Universal Time Coordinate Refusal Speed Rotate Speed Wing Flight Safety Officer Weight On Wheels Weapon System Manager


H-1/1

Annex H 1010-CP140-165804 (DFS 2-3-2) 20 Feb 2017

ANNEX H – LIST OF TABLES AND FIGURES

TABLES

TABLE 1. INJURIES TO PERSONNEL .................................................................... 3 TABLE 2. PERSONNEL INFORMATION .................................................................. 4 ANNEX A TABLE 1: AIRFRAME, ENGINE, AND PROPERLLER HOURS TABLE ................ A-1

FIGURES

FIGURE 1. PHOTO OF FINAL RESTING POSITION OF CP140103 ............................. 3 FIGURE 2. CYZX AIRFIELD DIAGRAM AND ACCIDENT LOCATION ............................ 8 FIGURE 3. RH MLG INBOARD TIRE REVERTED RUBBER ..................................... 13 FIGURE 4. RH MLG OUTBOARD TIRE REVERTED RUBBER .................................. 14 FIGURE 5. STEAM-CLEANING OF THE 1000-FOOT MARKER FOR RUNWAY 08 ........ 15 FIGURE 6. PATH OF THE RH MLG TIRES ........................................................... 16 ANNEX B, FIGURE 1: ENGINE INSTRUMENTS WITH BETA LIGHT LOCATION ............... B-4 ANNEX C, FIGURE 1: TAKEOFF ABORT PROCEDURE ............................................... C-1 ANNEX D, FIGURE 1: NORMAL LANDING PROCEDURE ............................................. D-1 ANNEX E, FIGURE 1: SELECTED CYZX METARS .................................................... E-1 ANNEX F, FIGURE 1: FLIGHT ESSENTIAL DC BUS ................................................... F-1 ANNEX G, FIGURE 1: ABBREVIATIONS ................................................................... G-1

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