ch146434-fsir-06jul09

“Non-Controlled Goods / Marchandises Non-Contrôlées”
CANADIAN FORCES
FLIGHT SAFETY INVESTIGATION REPORT (FSIR)
FINAL REPORT
FILE NUMBER: 1010-CH146434 (DFS 2-4)

FSOMS: 139123
DATE OF REPORT: 29 October 2012
AIRCRAFT TYPE: CH146 Griffon Helicopter
DATE/TIME: 06 0908Z July 2009
LOCATION: Forward Operating Base, Afghanistan
CATEGORY: "A" Category Accident
This report was produced under authority of the Minister of National Defence pursuant to
section 4.2 of the Aeronautics Act, and in accordance with the A-GA-135-001/AA-001,
Flight Safety for the Canadian Forces.
With the exception of Part 1, the contents of this report shall only be used for the
purpose of accident prevention. This report was released to the public under the
authority of the Director of Flight Safety, National Defence Headquarters, pursuant to
powers delegated to him by the Minister of National Defence as the Airworthiness
Investigative Authority for the Canadian Forces.
SYNOPSIS
Aircraft CH146434 was the formation lead of a two-helicopter formation tasked

with transferring passengers to and from a Forward Operating Base (FOB) in
Afghanistan. The passengers were delivered to the FOB in the morning without
incident. At 0841Z (1311 local) the formation departed to retrieve the
passengers. Due to wind direction and obstacles, the pilots elected to land in the
northern corner of the FOB instead of the designated landing site to optimize
takeoff distance available for the subsequent departure. The number two (#2)
aircraft landed first to collect its passengers, completed the takeoff and cleared
the HESCO Bastion Concertainer ®, a seven to eight foot-high wire mesh wall
filled with earth and stone referred to as the barrier in this report, by an estimated
10 feet. The accident aircraft landed next and collected its passengers. As
power was increased for takeoff, a very large dustball developed. Immediately
after takeoff, the aircraft began to drift forward and right, and shortly thereafter
struck the barrier, rotated 90 degrees left, rolled onto its right side and
immediately caught fire. Two pilots and one passenger exited the wreckage.
One pilot was unharmed, one sustained minor injuries and the passenger
suffered serious injuries. The remaining three personnel did not escape the
aircraft and perished in the crash. The aircraft was destroyed.
i “Non-Controlled Goods / Marchandises Non-Contrôlées”

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 ............................................................................................... 3
1.5 Personnel Information ........................................................................................ 4
1.6 Aircraft Information............................................................................................. 6
1.7 Meteorological Information .............................................................................. 14
1.8 Aids to Navigation............................................................................................. 15
1.9 Communications ............................................................................................... 15
1.10 Aerodrome Information .................................................................................... 15
1.11 Flight Recorders................................................................................................ 16
1.12 Wreckage and Impact Information................................................................... 17
1.13 Medical ............................................................................................................... 17
1.14 Fire, Explosives Devices, and Munitions ........................................................ 18
1.15 Survival Aspects ............................................................................................... 19
1.16 Test and Research Activities ........................................................................... 21
1.17 Organizational and Management Information ................................................ 23
1.18 Additional Information ...................................................................................... 25
1.19 Useful or Effective Investigation Techniques................................................. 30
2 ANALYSIS ................................................................................................31
2.1 Environmental Operating Conditions in Afghanistan.................................... 31
2.2 CH146 Day-HUD................................................................................................. 34
2.3 Human Factors .................................................................................................. 36
2.4 Post-Crash Fire.................................................................................................. 38
2.5 Cabin Survivability ............................................................................................ 39
2.6 Accident Takeoff Procedure............................................................................. 41
2.7 CVFDR and HUMS Analysis ............................................................................. 44
2.8 CH146 Performance Charts.............................................................................. 47
2.9 Inter-Turbine Temperature Exceedences........................................................ 54
2.10 Post-accident Performance Calculations ....................................................... 57
2.11 Organizational Issues ....................................................................................... 60
3 CONCLUSIONS ........................................................................................67
3.1 Findings ............................................................................................................. 67
3.2 Cause Factors.................................................................................................... 73
4 PREVENTIVE MEASURES ......................................................................76
4.1 Preventive Measures Taken ............................................................................. 76
4.2 Preventive Measures Recommended.............................................................. 80
4.3 Other Safety Concerns ..................................................................................... 82
4.4 DFS Comments.................................................................................................. 83
ii “Non-Controlled Goods / Marchandises Non-Contrôlées”

ANNEXES
Annex A: Photographs .................................................................................... A1

Annex B: Aircraft Performance Definitions ................................................... B1
Annex C: Weight, Altitude, Temperature (WAT) and Hover Ceiling Charts C1
Annex D: Cruise Performance Charts............................................................ D1
Annex E: Hover Torque Required Charts ...................................................... E1
Annex F: Comparative Analysis of Flight Data ..............................................F1
Annex G: DTAES Technical Note 75-00-15 .................................................... G1
Annex H: ROTO 6 Performance Chart............................................................ H1
Annex I: DAY-HUD and NVG-HUD Hover Page Symbology ...........................I1
Annex J: CH146 Emergency Procedures........................................................J1
Annex K: CH146 Power Performance Software Output................................ K1
Annex L: Abbreviations....................................................................................L1
iii “Non-Controlled Goods / Marchandises Non-Contrôlées”

1 FACTUAL INFORMATION
1.1 History of the Flight
1.1.1 The aircrew were tasked with the mission of inserting four passengers
into a Forward Operating Base (FOB) in Afghanistan and to extract them a few
hours (hrs) later. The accident aircraft, CH146434 was the formation lead of a
two helicopter formation assigned to this mission. The number two (#2) aircraft
was CH146414. Throughout the report, the two aircraft will be referred to as the
accident aircraft and the #2 aircraft. With four passengers in total, the plan was
for each aircraft to carry two passengers. The accident aircraft had a total of six
people on board: the aircraft captain (AC), the first officer (FO), a Flight Engineer
(FE), a Door Gunner (DG), one Canadian soldier and one Coalition soldier. The
passengers were picked up in the morning by their respective aircraft and were
flown to the FOB. The landing was carried out in sequence, with one aircraft
landing while the other circled overhead. The insertion was conducted at the
designated landing zone and was uneventful.
1.1.2 After the insertion both aircraft returned to Kandahar Airfield (KAF) to
wait for the afternoon extraction mission. Once the passengers were ready for
pick-up the aircraft departed KAF for the FOB. On arrival, as directed by the
accident AC, the #2 aircraft was the first to land. Due to a wind shift from the
morning insertion the approach was conducted in the opposite direction from that
used previously, on a heading of approximately 210 degrees (º) magnetic (M).
The #2 aircraft landed past the midway point within the FOB, picked up its two
passengers and departed, only clearing the top of the barrier by approximately
10 feet (ft). The crew of the #2 aircraft informed the crew of the accident aircraft
via radio that there was a large dustball 1 and that the takeoff required “a lot of
power.” In order to provide maximum room for obstacle clearance on departure,
the accident aircraft then landed in the first third of the length of the FOB. After
landing the accident crew retarded both throttles to flight idle in order to reduce
the dustball enough to enable them to see the passengers approaching the
aircraft.
1.1.3 Once the two passengers were on board, the crew of the accident
aircraft developed their takeoff plan taking into consideration the #2 aircraft’s
departure, information provided by the #2 aircraft and the configuration of the
FOB. The first officer (FO) intended to conduct an Instrument Takeoff (ITO) but
in order to maximize vertical obstacle clearance the aircraft captain (AC)
suggested to the FO to use more power than normal. The pilots decided to
initiate a Maximum Performance Takeoff (MPTO) and then transition to an ITO
1
A dustball is the common term used to describe the dust cloud produced by the helicopter main
rotor downwash on takeoff or landing. Brownout is the common term used to describe the
degraded visual environment / conditions / phenomena caused by a dustball. The NATO
description of Brownout, Whiteout, Dustball and a Degraded Visual Environment (DVE) is
provided in Annex B.
1 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

once visual ground references were lost. A departure heading of 210ºM was
briefed to maintain lateral separation from obstacles on either side.
1.1.4 The first officer, who was seated in the right seat and was the flying
pilot (FP), rolled the throttles up to 100 percent (%) rotor revolutions per minute
(RRPM) and a severe dustball started to develop. The FP increased power and
initiated the MPTO sequence while maintaining control of the aircraft using visual
ground references. As is standard procedure, the non-flying pilot (NFP) called
mast torque (Qm) from 80% to 95% in increments of 5%. When the NFP called
95% Qm the FP quickly cross-checked the inter-turbine temperature (ITT) gauge
and noticed that it was reading approximately 840o - 850o Celsius (C). At that
moment, the NFP in the left seat, also using visual ground references noticed
right drift and advised the crew they were drifting right, as per standard
procedures. At the exact same time the FE, who was located on the right side
rear cabin, stated that he was losing visual ground references. The FP
acknowledged the drift call by the NFP and looked outside but he no longer had
visual ground references due to the intensity of the dustball. The FP immediately
referred back to the cockpit instruments for the transition to an ITO, as previously
briefed. He did not inform the crew that he had lost visual ground references nor
did he inform them that he was flying solely referencing cockpit flight instruments.
Once the FP transitioned to instruments he noticed the aircraft heading was now
220ºM and immediately introduced a correction to bring the heading back to the
pre-briefed 210ºM. The NFP could still see right drift so a second “drifting right”
call was made. Within two seconds after the word “right” the aircraft impacted
the barrier next to the FOB entrance. The FP saw the barrier just prior to impact
but did not have sufficient time to manoeuvre the aircraft to avoid it. The aircraft
collided with the barrier at the helicopter’s one to two o’clock position, between
the aircraft nose and forward of the right pilot door hinge. Upon impact the
aircraft rotated approximately 90º counter-clockwise, rolled on its right side and
immediately caught fire.
1.1.5 One pilot was unharmed and one sustained minor injuries during the
crash sequence. The FP noticed that the fire handles were lit and pulled both.
However, the fire extinguishing activation switches that discharge the fire
suppression bottles were not activated. Both pilots noticed the fire starting,
unstrapped, and exited the aircraft through the broken windshield. Outside the
aircraft, the pilots ran around the wreckage to assist possible survivors. As the
fire quickly developed, they noticed movement in the cabin and saw one
passenger attempting to exit the aircraft through the pilot’s windscreen. The
pilots assisted the passenger in exiting the aircraft and all three moved to the
HESCO barrier located in the middle of the FOB where the passenger advised
the pilots that he had fractured his upper arm and required first aid. As the fire
grew in intensity, the onboard ammunition began to cook-off 2 preventing any
2
Cook-off: The premature ignition of an energetic material due to external heat (Defence
Terminology Bank). In this case, cook-off refers to the explosion of the onboard ammunition.

further rescue attempts. The FE, the DG and the Coalition soldier were unable to
exit the aircraft and perished.
1.2 Injury to Personnel
Injuries Crew Passengers Others Total

Fatal 2 1 0 3
Serious 0 1 0 1
Minor 1 0 0 1
No injury 1 0 0 1
Total 4 2 0 6
Table 1: Injuries to Personnel
1.3 Damage to Aircraft
1.3.1 The aircraft sustained A category damage and was destroyed by the
collision with the barrier, the impact with the ground and the resultant post-crash
fire. The aircraft sustained catastrophic fire damage from the nose of the aircraft
to approximately station line 129 of the tail section. The fire intensity was such
that very few recognizable aircraft parts remained (Annex A: Photo 1). The tail
section suffered less fire damage but was significantly damaged as a result of the
impact with the ground.
1.3.2 The transmission, main rotor head, main rotor blades and engines also
sustained considerable fire damage. To facilitate the fire fighting process, these
components were dragged out of the accident site by FOB personnel using a
ground vehicle.
1.4 Collateral Damage
1.4.1 Collateral damage was limited to the barrier surrounding the accident
site. There is a gap in the barrier that serves as an entrance to the FOB. This
gap is protected by another barrier outboard of the FOB to protect the FOB
entrance. This protective wall also sustained damage.
1.4.2 The aircraft fuselage struck and damaged the barrier’s metal wire
mesh structure (Annex A: Photo 2). All other damage to the barrier’s retaining
membrane (inner fabric) was caused by either fire or contact with flying aircraft
debris. There were two main rotor blade strike marks at approximately a 45º
angle on the right side of the impact point on the barrier (Annex A: Photo 3).

North
#2’s - Departure heading of
o
220 M and approximate
takeoff location
Crash site and Impact Point
Obstacle / barrier
Protective Wall / barrier
CH146434 - Intended departure FOB Entrance

heading of 210oM and
approximate takeoff location
Figure 1: FOB Diagram – Not to Scale
1.5 Personnel Information
1.5.1 The crew was qualified, current and was properly authorized to fly the
mission. They did not report any issues with fatigue, nutrition or hydration. The
currency and duty information are summarized in Table 2 and Table 3.
AC FO FE DG
Proficiency Check 9 Mar 09 27 Oct 08 13 Feb 09
Medical VALID VALID VALID VALID
Total Flying Time 998.3 904.5 1081.2 127.6
Hrs on Type 769.5 663.3 1081.2 127.6
Hrs Last 30 Days 48.7 68.9 30.2 14.9
Hrs Last 48 Hrs 8.0 8.0 8.0 8.0
Duty Time - Day of Accident 5.0 5.0 5.0 5.0
Duty Time - Last 48 Hrs 13.5 13.5 13.5 13.5
Table 2: Summary of Crew Personnel Currency and Duty Information.
AC FO FE DG
Theatre Check-Out 3
10 Apr 09 29 Apr 09 25 Apr 09 Completed 4
5
Egress training 10 Apr 09 30 Apr 09 22 Apr 09 27 Apr 09
Dustball 6 24 Jun 09 2 Jul 09
Table 3: Summary of Currency Requirements for Theatre Qualifications.
3
The Theatre Check-Out flight includes FOB and dustball landings. No comments were made on
the trip report card for either pilot.
4
The DG theatre check-out form had been filled out but no date was entered.
5
Egress training is a 12-month recurrent training requirement. All crew members were current at
the time of the accident.
6
Dustball training is a 30-day recurrent training requirement for Afghanistan operations and both
pilots were current at the time of the accident.

1.5.2 Aircrew Experience - The AC had approximately 1,000 total flying hrs,
with over 760 hrs on the CH146. This level of experience is considered normal
for an AC in the Tactical Aviation community. At the time of the accident, the AC
had approximately three months of theatre experience. The FO, with over 660
flying hrs on the CH146, was considered an experienced FO. Other pilots
described the FO’s flying skills as excellent. The FO had over two months of
theatre experience before the accident. The crew of the #2 aircraft was more
experienced; that AC had 3,000 flying hrs and his FO had 700 flying hrs.
1.5.3 Aircrew Training – Helicopter training is Phase III of the Canadian

Forces (CF) Undergraduate Pilot Training System, which is conducted at 3 CF
Flight Training School (3 CFFTS). Upon graduation, pilots proceed to the
specific aircraft operational training units (OTU) for type conversion. There is no
formal or dedicated training for helicopter operations in a Degraded Visual
Environment (DVE), either in whiteout/snowball or brownout/dustball, in the
Royal Canadian Air Force (RCAF) either at 3 CFFTS or at the CH146 Griffon
OTU. Exposure to snowballs or dustballs is infrequent and often only provided
for those students attending the course during the winter months where the
chance of entering snowballs is greater. Also, formal briefings on DVE or
Obscuring Phenomena at 3 CFFTS are limited. In the Canadian environment,
crew exposure to snowballs is relatively common while exposure to dustballs is
rare; intense snowballs are more predominant than intense dustballs. To
prepare aircrew to deploy to Afghanistan additional training was conducted at
Fort Bliss, Texas, where environmental conditions are similar to Afghanistan.
Training normally included a total of six flights, including at least two dedicated
flights for dustball training. Both pilots conducted this pre-deployment training in
2008 and 2009; however, the FP did not complete the training in 2009, due to
aircraft serviceability issues, and only observed a demonstration of the landing
technique rather than practiced dustball landings himself. Additionally, the FP
did not observe or complete any dustball takeoff techniques. The NFP did
practice the dustball landing technique but the serviceability issues also reduced
the number of times it was practiced.
1.5.4 Once in Afghanistan, a theatre check-out for all aircrew arriving in

theatre was conducted with a seasoned AC. This training comprised of four
flights and was recorded on a form that specified the completed manoeuvres and
the necessary comments to improve performance. The dustball landing
technique was a specific item on the theatre check-out; however, dustball takeoff
techniques or takeoffs, requiring an MPTO or ITO, were not. Both pilots had
completed their respective theatre check-outs with no comments made on the
reporting form, indicating that their performance of a dustball landing was
satisfactory and met the standard. The FP had flown only two flights, one day
and one night, on his theatre check-out. For the day flight, he flew two to three
dustball approaches and departures in light to moderate conditions. For the night
flight, the FP was shown two approaches in heavy dustball conditions but these
did not terminate with a landing on the ground and resulted with the aircraft
overshooting and aborting the approach and landing. The night dustball landings

were not conducted. The FP did not conduct any night dustball takeoffs or
departures.
1.5.5 Dustball landings were a 30-day currency requirement in theatre and a

pilot had to complete at least one dustball landing while at the controls for his
aircrew category to remain valid. A pilot not fulfilling this requirement was
considered not current and was precluded from any flying until successfully
demonstrating a dustball landing to a current and qualified aircraft captain. In the
course of normal operations, one dustball landing every 30 days was not difficult
to achieve. However, there was no currency or proficiency requirement in
theatre for dustball takeoff techniques, including the ITO or the MPTO.
1.6 Aircraft Information
1.6.1 The CH146 Griffon is the Canadian Forces (CF) version of the Bell 412
light utility helicopter and is used mainly for carrying passengers and cargo. In
Afghanistan, the CH146 with a standard crew complement of two pilots, one FE
and one DG also provided fire support for other aviation assets and troops on the
ground.
1.6.2 The accident aircraft was flying with both main cargo doors removed,
which is a typical Afghanistan configuration for weight saving considerations.
The only cabin seats installed were the transmission side-facing seats, which
were occupied by the FE and the DG to operate their respective door guns. The
aircraft was equipped with flares, an Infrared Suppression System and two
M134D Dillon door guns. The M134D Dillon ammunition container was located
in the centre of the cabin, in front of the transmission housing.
1.6.3 The aircraft had accumulated 3,657.5 hrs (based on the last CF335
entry). Engine number one, serial number (S/N) 140239, was installed at 2017.9
airframe hrs (AF hrs) on 25 February 2007 and had accumulated 1946.9 hrs.
Engine number two, S/N 140214, was installed at 2017.9 AF hrs on 25 February
2007 and had accumulated 1231.8 hrs. The reduction gear box, S/N TJ0061,
was installed at 3041.1 AF hrs and had accumulated 2,440.4 engine hrs. A
review of the Servicing Set and Log Set found no overdue inspections, Out of
Sequence Inspections (OSI), time expired components, overhauls, modifications
or Special Inspections (SI).
1.6.4 Aircraft Certification
1.6.4.1 The Griffon was brought into service in the early-mid 1990's. At the
time the Directorate of Technical Airworthiness (DTA) and the Directorate of
Technical Airworthiness and Engineering Support (DTAES) did not exist and the
CF did not have an airworthiness program that was as developed as it is
currently. As a result, virtually all certification approvals were managed and
controlled by the Griffon project management office. Since this was
predominately an off-the-shelf acquisition, the Aerospace Engineering Test

Establishment (AETE) role was very limited. The CH146 certification was based
on the Bell Model 412, which was originally certified under the United States
Federal Aviation Administration (FAA) Airworthiness Regulations (FAR) for
transport-category helicopters, or FAR Part 29 Airworthiness Standards. 7 The
Basis of Certification for the CH146 was the civil FARs but these do not cover
employment of the system. The aircraft was transferred to a Canadian Military
Airworthiness Type Certificate (CMATC) immediately and prior to operating
under military control. The intent was, and always has been, that the aircraft
would be operated in accordance with the flight manual including all limitations
contained therein.
1.6.4.2 FAR Part 29 prescribes specific airworthiness standards for the issue
of type certificates for transport-category rotorcraft (helicopters) defined as
Category A or Category B. FARs also lists specific aircraft and rotorcraft
equipment, performance and flight characteristics for operations in Visual Flight
Conditions 8 (VFC) and Instrument Flight Conditions 9 (IFC). For safe instrument
flight, FAR Part 29 establishes a parameter that is unique to helicopters, the
Minimum Speed for Instrument Flight 10 (VMINI). The certified Aircraft Flight
Manual (AFM) is publication C-12-146-000/MB-002 and is commonly referred to
as the “MB” within the CH146 community. The AFM (or the MB) for the Bell
Model 412/CH146 states VMINI is 60 knots. This parameter is essential for safe
flight as helicopters inherently lack the adequate stability and control
characteristics, flight instruments, and situational awareness cues for pilots, to
permit safe flight in Instrument Meteorological Conditions 11 (IFC/IMC) below this
airspeed.
1.6.4.3 Inadvertent flight into IMC or flight in a DVE such as flight into cloud or
flight near the ground where rotor downwash may kick up dust, snow, or spray, is
a high risk evolution or flight condition that can be considered an emergency.
The severity of these flight conditions can vary depending on several
circumstances such as the type of helicopter flown, ambient lighting, duration of
flight in, and density of, the obscuring phenomena to name a few. Moving
7
FAR Category definitions are available on the FAA website at: http://www.faa.gov/. Rotorcraft
with a maximum weight greater than 20,000 pounds and 10 or more passenger seats must be
type certificated as Category A rotorcraft. Rotorcraft with a maximum weight of 20,000 pounds or
less and nine or less passenger seats may be type certificated as Category B rotorcraft.
8
Visual Flight Conditions (VFC): Flight conditions in which control of an aircraft may be
accomplished solely by visual outside references. B-GA-100-001/AA-000, National Defence
Flying Orders, Book 1 of 2, Flight Rules. pg. GL-20/20.
9
Instrument Flight Conditions (IFC): Flight conditions in which control of an aircraft is required to
be maintained solely by reference to aircraft flight instruments (e.g. flight in cloud or night VFR
with no discernible horizon).B-GA-100-001/AA-000, National Defence Flying Orders, Book 1 of 2,
Flight Rules. pg. GL-12/20.
10
VMINI: minimum speed for instrument flight. VMAX: maximum velocity.
11
Instrument Meteorological Conditions (IMC): meteorological conditions expressed in terms of
visibility, distance from cloud and ceiling less than the minima specified for visual meteorological
conditions. B-GA-100-001/AA-000, National Defence Flying Orders, Book 1 of 2, Flight Rules.
pg. GL-12/20.

quickly through the obscuring phenomena requires a generous power margin

(power available over power required, as discussed in Annex B); advanced
stability-augmentation or autopilot systems or finally; “see through” or “dust-
penetrating” systems. However, the effectiveness of these mitigating procedures
or systems can be reduced by the specific aircraft model (i.e. an under-powered
helicopter with basic flight control, stability or autopilot systems), the lack of
adequate systems and the nature of the operating environment (i.e. operating in
high, hot and heavy flight regimes). 12
1.6.4.4 As described in the NATO Research and Technology (RTO) Technical

Report TR-HFM-162, Rotary-Wing Brownout Mitigation: Technologies and
Training, published in January 2012, there are potential risk mitigating strategies
for rotary-wing brownout take-offs and landings and these fall into two broad
categories:
a) Technology development to overcome the environmental limitation

described above under DVE conditions, for example, “see through” or
“dust-penetrating” technology, and
b) Technology development to overcome the physiological limitation

under DVE conditions, for example, provide pertinent information, in an
intuitive manner (better landing symbology systems or other sensory
displays) to the pilot in order to compensate for the lack of external visual
cues. 13
1.6.4.5 There is currently no helicopter designed to safely and effectively

operates in DVE conditions; some types, both military and civilian, are simply
better equipped to do so. Therefore, in keeping with both operating regulations
and good airmanship, pilots are responsible to remain vigilant in conditions that
may readily deteriorate from Visual Meteorological Conditions 14 (VMC) to IMC
where they could inadvertently lose their visual references due to a DVE. When
a civil helicopter is operating in conditions below VMC, and where instrument
flight is required, it may not be flown at a speed slower than VMINI. According to
civil aviation regulations, operations in IMC require that aircraft have been
certified (by FAR 29 Airworthiness Standards in this case), that aircrew have
been adequately trained, and that certain operating rules are adhered to (FAR 91
General Operations and Flight Rules and others). It is important to stress that
neither procedural nor technological mitigations have been adequate to achieve
an acceptable level of safety required by civil airworthiness and operating
12
High, hot and heavy flight regimes is referred to as high altitudes or high density altitudes (HD),
hot referring to high OATs and heavy referring to high AUWs.
13
North Atlantic Treaty Organisation, Research and Technology Organisation, (January 2012),
RTO Technical Report TR-HFM-162, Rotary-Wing Brownout Mitigation: Technologies and
Training.
14
Visual Meteorological Conditions (VMC): Meteorological conditions expressed in terms of
visibility, distance from cloud and ceiling, equal to or better than specified minima. B-GA-100-
001/AA-000, National Defence Flying Orders, Book 1 of 2, Flight Rules. pg. GL-20/20.

regulations. As such, the total set of airworthiness and operating regulations for
civil helicopters such as the Bell Model 412 prohibit flight slower than VMINI when
taking off, or landing in conditions below VMC or in DVE/IMC.
1.6.4.6 Many military missions would not be possible if these same restrictions
were imposed on military helicopters. For the CF, military helicopter operations
are often exposed to DVE conditions or where VMC may readily deteriorate to
IMC and many of these are at low speed, i.e., below VMINI, as was the case with
the accident aircraft. The CF has implemented training and flight procedures to
help mitigate the risks and to focus on minimizing the duration in which a
helicopter is exposed to these high-risk conditions. Mitigating measures are
based on specific procedures described in the CH146 Standard Manoeuvre
Manual (SMM) and techniques which are taught during pilot training. These
procedures reduce the time in which the helicopter is flown in instrument
conditions below VMINI by effecting as quick a transition through the DVE
conditions as possible. By minimizing the time spent within the obscuring
phenomena, the time in which the aircraft may wander off course and/or the pilot
becomes disoriented is reduced, thereby reducing the likelihood of a rollover or a
collision with either the ground or an object.
1.6.4.7 On the technological side, some stability-augmentation and autopilot

systems have provided mitigation for select helicopter models and these
measures have continued to help reduce the risk for military operations.
However, research and development of adequate systems, as proposed in the
NATO paper, have not yet matured to a level for operational use. Therefore,
none of the CF helicopters, including the CH146, have such see-through or dust-
penetrating technology systems or systems using landing symbology or sensory
displays for safe flight in a DVE below VMINI. While the CH146 is equipped with
some stability-augmentation and autopilot systems, neither of the current CH146
systems, handling qualities or flight instruments are designed, certified,
approved, intended, nor precise enough to allow aircrew to allow safe flight in a
DVE below VMINI. Also, the helicopter’s inherent hover instability, combined with
this lack of advanced instrumentation and awareness cues, do not allow for safe
flight in a DVE below VMINI.
1.6.5 Aircraft Flight Manual (AFM)
1.6.5.1 The definitions and differences between an AFM and an Aircraft

Operating Instructions (AOI) are not listed in the current version of the C-05-005-
001/AG-001, Technical Airworthiness Manual (TAM). The Technical
Airworthiness Authority (TAA) has identified this discrepancy and is drafting a
proposal to the next amendment of the TAM that will provide definitions and
descriptions of an AFM, an AOI and SMM as provided in the footnote below. 15
15
The following are definitions that are proposed for the next amendment of the CF Technical
Airworthiness Manual:

The CH146 had a civil AFM for the Bell Model 412 approved by the FAA. By
adding additional information, the Canadian Forces Technical Order (CFTO) for
the CH146 was developed from the civil AFM. While for other CF fleets this type
of document is often called the AOI, the CH146 CFTO was titled "Flight Manual"
and no CH146 AOI was created. This CFTO is specifically referenced on the
civil Type Certificate Data Sheet for the Bell Model 412CF, the CH146, as the
approved AFM. The difference between an AFM and an AOI is that while
Technical Airworthiness Data (TAWD) or performance charts are included in both
documents, the AFM provides the charts with only minor explanations on their
use. Specific details on how to use the charts for mission-oriented purposes are
normally contained in the AOIs.
1.6.5.2 The AFM is an integral part of the aircraft airworthiness certification

process and details pertinent information under Limitations, Normal Procedures,
Performance and Operating Information for use by the aircrew. The version of
the AFM in use at the time of the accident was Change (Ch) 2 dated 2009-02-20.
The AFM contains charts depicting limitations in Section 1 - Limitations. These
are limits imposed by the manufacturer and/or regulator to ensure safe operation
and they shall not be exceeded. Section 4 - Performance includes charts that
determine aircraft performance guaranteed by Minimum Specification 16 (Min
TECHNICAL AIRWORTHINESS DATA (TAWD) – That portion of the information and data
contained in the Type Record that is required to safely operate the aircraft throughout its
approved envelope, which comprises the TAWD for an aircraft type. An applicant for an aircraft
Type Certificate must submit to the TAA for approval a Flight Manual that contains this TAWD.
AIRCRAFT FLIGHT MANUAL (AFM) – The AFM is an operational document that contains the
TAWD along with additional non-TAA-Approved data and information. The AFM TAWD shall be
identified, clearly distinguished, and preferably segregated from the non-approved data.
AIRCRAFT OPERATING INSTRUCTIONS (AOI) – The AOI is the operating manual provided by
the aircraft operator to aircrews. It is normally issued and approved by the operating authority. In
general, the AOI expands upon the AFM by including supplementary and mission-oriented
information that is not included in the basic AFM. TAWD reproduced in the AOI shall be
consistent with that appearing in the AFM. In some cases, the AFM contains sufficient
supplementary and mission-oriented information to serve as the AOI directly. For many legacy
aircraft, the AOI is the sole document and it includes all the TAWD. When the AOI is the sole
document, the TAWD should be clearly identified as TAA-approved information and preferably
segregated. In this case, the TAWD within the AOI constitutes the AFM.
The STANDARD MANOEUVRE MANUAL (SMM) is a document produced by the aircraft

operator under the authority of the OAA to provide aircrews with guidance regarding the manner
in which the aircraft is to be flown to accomplish its intended missions. A SMM is produced for
each aircraft operated by the CF. The TAA provides no oversight of the SMM. A statement in the
foreword of each SMM states that, in case of any disagreement between the SMM and the TAA
approved AFM (or AOI), the TAA-approved document has precedence. TAWD appearing in any
SMM, aircraft operating manual or checklist must be consistent with the TAWD appearing in the
AFM.
16
See also Annex B, paragraph b. Aircraft engines performing at Min Spec or above meet the
certification requirements and are considered serviceable. The engine may exceed this

Spec) performance. The performance levels found in Section 4 are not

limitations as specified in Section 1 and there are no directions within Section 4
restricting aircrew from exceeding these parameters. Section 8 - Operational
Information includes additional information for operational flight planning and may
at times depict aircraft performance beyond the limitations set in Section 1.
Terms and definitions pertaining to aircraft performance are listed in Annex B.
The AFM Ch 2 Section 1 limitations that are pertinent to this accident for twin-
engine operations are copied below:
Figure 2: ITT limits (left column), Mast Torque limits (right column). 17
1.6.5.3 The FARs in place at the time the CH146 was certified only required
IGE hover limitations be identified in Section 1. OGE charts (Weight-Altitude-
Temperature (WAT) or Hover Ceiling) were not a FAR requirement at the time
the CH146 was certified but were added as requirements in later amendments to
the FARs.
1.6.5.4 Section 1 - Weight-Altitude-Temperature (WAT) Charts: The AFM

contains WAT charts for operations In Ground Effect (IGE). IGE WAT charts are
required by certification and are contained in Section 1. The IGE WAT chart
Figure 1-1 (Weight-Altitude-Temperature limitations for takeoff, landing and
in-ground-effect maneuvers, all wind azimuths, 10 passengers or more),
(Annex C: pg. 1/6) is used to determine the aircraft maximum allowable weight
limit and maximum Density Altitude (HD) for takeoff, landing and IGE hover
performance, but is not considered serviceable if it is producing less than the minimum specified
performance.
17
C-12-146-000/MB-002, Ch 2 dated 2009-02-20, pg 1-7 and 1-8.

operations. It is also referenced when using the Height - Velocity diagram. A

very critical note on Figure 1-1 states:
Figure 3: WAT chart Figure 1-1 note.
1.6.5.5 IGE WAT chart Figure 1-1A (Weight-Altitude-Temperature

limitations for takeoff, landing and in-ground-effect maneuvers, wind from
-45o to +45o azimuths, 9 passengers or less) (Annex C: pg. 2/6) was also
available but it did not include the note directing the reader to the Hover Ceiling
charts in Section 4. There is no direction provided in Section 1 on how to use
this chart. This chart does not fully meet the FAR requirements (as defined in
para 1.6.5.3.) for limitations since it only represented ITT limited performance
and did not include maximum AUW limitations or maximum density altitude limits.
1.6.5.6 Section 4 - Hover Ceiling IGE/OGE Charts: The various Hover Ceiling
IGE/OGE charts found in Section 4 (of which two examples are at Annex C: pg.
5/6) depict the maximum allowable aircraft gross weight (GW) for hovering IGE
or OGE at all pressure altitudes (HP) and outside air temperature (OAT)
conditions. Conversely, the hover ceiling altitude can be determined for any
given GW. While the OGE Hover Ceiling charts were not a FAR requirement at
the time of CH146 certification, they were provided by the OEM for flight planning
purposes. The Hover Ceiling charts in combination with the Figure 4-3 Critical
Relative Wind Azimuths chart determine, among other factors, a maximum GW
for which satisfactory cyclic and directional control (flight control authority) is
available while not exceeding other engine parameters. Exceeding WAT or
Hover Ceiling weights (i.e. too heavy for a given altitude or temperature) means
that there is a potential risk of reaching a variety of limits. These various limits,
dependant on aircraft type and environmental conditions, could include rotor
aerodynamic performance, flight control authority (where inputs are limited by a
physical control stop or effective aircraft control is hampered), height-velocity
limitations, transmission limits and, engine limits (ITT or N1). Weight limits
derived from the WAT or Hover Ceiling charts do not determine or calculate
maximum aircraft performance, since these are based on Min Spec engine
performance. When the aircraft is operated with engines that perform better than
Min Spec, the power available will be increased while the presence of a positive
or negative wind vector will reduce or increase power required respectively.
1.6.5.7 Section 8 - OGE WAT Charts: At the time of certification for Bell Model
412 these performance charts were required for FAR Part 29 Category A
performance certification. 18 As the Bell Model 412 was certified under FAR Part
18
FAR Category definitions are available on the FAA website at: http://www.faa.gov/. Rotorcraft
with a maximum weight greater than 20,000 pounds and 10 or more passenger seats must be
type certificated as Category A rotorcraft. Rotorcraft with a maximum weight of 20,000 pounds or
less and nine or less passenger seats may be type certificated as Category B rotorcraft.

29, Category B performance certification, the OGE hover performance

information was not required. Neither of these charts met the FAR requirements
for Section 1 limitations nor did the data contained therein match the data in the
Section 4 hover ceiling charts for IGE or OGE. The inclusion of these charts in
the AFM was optional for the Original Equipment Manufacturer (OEM) and DND.
Figure 1-1A was originally included in Section 8 (Figure 8-13) as operational
information, but was moved to Section 1 as part of a Temporary Revision and
then fully incorporated as part of CH2. In Dec 07, 1 Canadian Air Division (1 Cdn
Air Div) message UNCLAS APT RDNS 146, SUBJ: CH146 ALL-UP WEIGHT
LIMITS CLARIFICATION approved the move of Figure 8-13 from Section 8
Operational Information to become a limit in Section 1 Limitations. This
expanded the CH146 operating envelope and allowed improved performance
planning.
1.6.5.8 Section 8 - Cruise Performance Charts: The AFM cruise performance

charts found in Section 8, specifically Figure 8-1 (sheets 1 through 24), present
“engine torque available, fuel flow, indicated airspeed, true airspeed, and
standard drag configuration, for operational GW hover torque required, maximum
endurance torque required and best range, engine and mechanical limit
speeds” 19 (Annex D). These Section 8 charts consider the HP, ambient
temperature and aircraft weight and can be used to derive a torque value
achievable or available without exceeding any engine parameters (ITT or N1).
The 24 sheets of Figure 8-1 are provided from Sea Level to 14,000 ft in 2,000 ft
altitude increments and interpolation is required for altitudes that are not charted.
These were the charts that made reference to power available and mast torque
values at zero airspeed. A review of these charts found that in addition to being
complex, confusing and difficult to use, the sheer number and amount of charts
to be carried and referred to in-flight made it very difficult to calculate aircraft
performance values while conducting operations.
1.6.5.9 Section 8 - Hover Torque Required charts: The torque required to

hover (power required) is obtained from the respective IGE and OGE Hover
Torque Required charts (Annex E) also found in Section 8.
1.6.6 Aircraft Weight Information
1.6.6.1 Between the morning and afternoon missions both aircraft had
refuelled at the Forward Arming and Refuelling Point (FARP). The accident
aircraft refuelled with 2,050 lbs of jet fuel while the #2 aircraft refuelled with 1,840
lbs of jet fuel. At the time of the afternoon takeoff from KAF, the accident aircraft
weighed approximately 11,500 lbs, which included 1,810 lbs of fuel. On takeoff
out of the FOB the reduced fuel quantity was noted to be approximately 1,300
lbs. However, with the two passengers then onboard, the aircraft GW was
19
C-12-146-000/MB, Ch 2 dated 2009-02-20, pg 8-3, paragraph 8-6.

estimated to be 11,520 lbs. 20 The #2 aircraft weighed approximately 11,000 to

11,200 lbs at the time of the afternoon takeoff from KAF. Similarly, for the takeoff
from the FOB, with consideration for the reduced fuel quantity and added
passengers, the #2 aircraft weight was estimated to be near 11,200 lbs. Given
comparable fuel consumption rates for both aircraft for the flight time from the
refuelling point to the ramp, the start, the transit from KAF to the FOB and the
similar passenger weights, it is estimated that the accident aircraft weighed 300
to 500 lbs more than the #2 aircraft.
CH146434 Fuel Added AUW

KAF 2,050 lbs 11,500 lbs
FOB 0 11,520 lbs
CH146414 (#2)
KAF 1,840 lbs 11,200 lbs
FOB 0 11,200 lbs
Table 4: Aircraft fuel and weight information.
1.6.7 Engine Fire Warning System
1.6.7.1 In the event of an engine compartment fire, heat causes the thermistor
material in the fire detector elements to decrease in resistance value, which
allows an electrical current to then flow and illuminate the associated FIRE PULL
warning light. There are two separate engine fire-extinguishing systems, main
and reserve. The system components include the main and reserve fire
extinguisher agent bottles, a FIRE EXT activation switch with MAIN, OFF, and
RESERVE positions located between the engine FIRE PULL handles and
separate electrical power systems for each bottle. The FIRE PULL handle
contains the warning lights that are illuminated by the detection system. Pulling a
FIRE PULL handle arms both fire extinguisher bottles and selects the engine into
which the agent is released. It also closes the selected engine's fuel valve, the
particle separator door, and the bleed air ports on both engines. Selecting the
FIRE EXT to MAIN or RESERVE will then fire the respective bottle to the
selected engine (right, left or both). The FP pulled both fire handles, however,
the fire extinguishing activation switches were not activated, the throttles were
left open, and the battery bus switches were left in the ON position.
1.7 Meteorological Information
1.7.1 There was no meteorological station at the FOB. METARs (aviation

meteorological reports) were issued from Qalat Airfield and KAF. The weather
forecast consisted of a Graphical Area Forecast (GFA). There were very few
clouds. Although the winds at the FOB were noted to be light and variable as
assessed by the crew, they were strong enough to warrant a change of the
20
The CH146 community has predetermined estimates for passenger weights depending on an
individual soldier’s role and equipment being carried. In this case 250 lbs for each passenger was
assessed, which included personal weapons, ammunition and personal protective equipment.

intended approach path into the landing zone. Table 5 presents the relevant
OAT, HP and HD for the morning and afternoon flights.
Location / Time of flight OAT HP HD 21

KAF - elevation 3,310 ft
Morning flight 37ºC 3,470 ft 7,000 ft
Afternoon Flight 42ºC 3,520 ft 7,500 ft
Location / Time of flight OAT HP HD

FOB - elevation 4,595 ft
Morning flight 35ºC 4,625 ft 7,900 ft
Afternoon Flight 39ºC 4,675 ft 8,500 ft
Table 5: OAT, HP and HD for the morning and afternoon flights.
1.8 Aids to Navigation
Not applicable.
1.9 Communications
1.9.1 Air-ground communications between the accident AC and the #2

aircraft circling above were made using a Combat Search and Rescue Radio.
The request for medical evacuation was sent to KAF by the #2 aircraft who
provided relay communications from the FOB to Canadian Helicopter Force
(Afghanistan) [CHF(A)] during the initial emergency response activities. A
section of two CH146s later relieved the #2 aircraft on station so that #2 could
return to KAF for fuel.
1.10 Aerodrome Information
1.10.1 There were a great number of FOBs in Afghanistan. In the conduct of

their assigned missions, Canadian aircrew were required to fly to several FOBs,
many of which were not, as in this case, under Canadian control. This foreign
controlled FOB measured approximately 450 ft wide by 420 ft long. The FOB
entrance was located approximately in the middle of the northern wall. In the
middle of the FOB was an obstacle surrounded by a HESCO barrier. A
helicopter landing site was marked by rocks placed in a circle on the west side of
the FOB. There were no other markings for the helicopter landing site. (See
Figure 1, paragraph 1.4)
1.10.2 The day of the accident was the first time Canadian helicopter aircrew
had ever flown into that specific FOB. The crew prepared for their mission using
an aerial picture of the FOB in conjunction with a written description of the
landing site. For the morning insertion, the helicopters landed in the designated
21
The density altitude was calculated using the chart found in the CH146 AFM, Figure 4-2
Density Altitude (HD), at page 4-7. Accessed and reconfirmed via the IETM 12 Sep 12.

landing site. During the afternoon extraction mission, due to wind and obstacle
considerations, the aircrew landed in the FOB but at an alternate landing site.
1.10.3 Dust suppression methodologies varied greatly from FOB to FOB and
were based on available resources, costs, the individual nations responsible for
the FOB and logistical challenges. There were no standards published for dust
suppression within the Afghanistan theatre of operations. The FOBs under
Canadian control had gravel laid on the helicopter landing site to limit the amount
of dust that would be disturbed by the helicopter downwash on takeoff and
landing. This FOB was considered austere and dust suppression methods were
not available or employed.
1.10.4 Fire suppression capabilities also varied from FOB to FOB. The
accident FOB had only hand-held fire extinguishers available, all of which were
used in the attempt to extinguish the post-crash fire. For the same reasons
affecting dust suppression methodologies, there were no standards published
regarding fire suppression within the Afghanistan theatre of operations.
1.11 Flight Recorders
1.11.1 Cockpit Voice and Flight Data Recorder
1.11.1.1 The CH146 is equipped with a Penny and Giles solid state, Type 2000,
combined Cockpit Voice and Flight Data Recorder (CVFDR) encapsulated within
the same protective case. The CVFDR was retrieved from the debris after the
post-crash fire was extinguished.
1.11.1.2 Preliminary inspection of the CVFDR revealed a breach of the unit’s

integrity and severe localized heat damage. The recorder was sent to the
National Research Council (NRC) Flight Data Recorder Replay Center in Ottawa
where it was confirmed that the unit sustained fire and heat damage (Annex A:
Photo 4) that significantly exceeded its design limits. However, NRC, in
conjunction with the CVFDR manufacturer, was able to recover the majority of
the stored data by placing the accident CVFDR memory chips into a serviceable
CVFDR.
1.11.1.3 Since the CVFDR does not record Qm, NRC and AETE each
developed mathematical methods to estimate Qm from the combined engine
torques. In the 2009 to 2011 timeframe, and based on the available data from
the CH146 Weapon System Manager (WSM), AETE and the NRC, the maximum
Qm used by the accident aircraft and the #2 aircraft was estimated to be 91%
and 92% respectively. Since then, the WSM and AETE have worked together
and conducted additional flight tests to further refine CH146 aircraft performance.
This data and other selected FDR data is explained in Section 2 and presented in
graphical format in Annex F.

1.11.2 Health and Usage Monitoring System
1.11.2.1 The CH146 is equipped with a Health and Usage Monitoring System
(HUMS). The HUMS recorder is not crashworthy and was destroyed in the post-
crash fire however the HUMS data file from the previous download and the
HUMS data from the #2 aircraft were examined for comparative analysis. HUMS
data from the #2 aircraft recorded a ITT exceedences greater than 810ºC for
longer than 5 seconds on both engines at values up to 850ºC (40 degrees in
excess of the maximum continuous limit) during the morning and afternoon
takeoffs from the FOB. Actual recorded values are depicted in Section 2,
paragraph 2.7.11, Table 6.
1.11.2.2 HUMS data is regularly downloaded and analysed by the CH146

Technical Authority for maintenance purposes. From December 2008 to
November 2009, collected HUMS data recorded a total of 1,322 exceedences in
Afghanistan. These included main rotor (Nr), gas generator (Ng), and power
turbine (Nf) overspeeds, exceedences with mast torque and 1,120 ITT
exceedences in which the ITT was between 810ºC and 940ºC for more than five
seconds.
1.12 Wreckage and Impact Information
1.12.1 The barrier where the aircraft impacted was located approximately 95
ft away from the takeoff point and located at the one to two o’clock position
relative to the nose of the aircraft. The impact point was approximately four to
five ft high on the inside wall of the barrier (Annex A: Photo 2). Two distinct main
rotor blade strikes were found on the outside wall of the barrier, cutting at
approximately a 45º angle from the horizontal (Annex A: Photo 3). One of the
main rotor blades was severed just inside the blade attachment point and lodged
itself into the barrier opposite the FOB entrance. One of the oil cooler inlet
cowlings was thrown over the barrier opposite the FOB entrance when it was
struck by a main rotor blade. The right pilot windscreen shattered on impact with
either the barrier or the ground. Otherwise, the aircraft was relatively intact when
it came to rest on its right side (Annex A: Photo 5).
1.12.2 The post-crash fire destroyed much of the physical evidence (Annex A:
Photo 6). The wreckage was further disturbed during the fire fighting effort and
subsequent recovery of the bodies.
1.13 Medical
1.13.1 The aircrew medicals were valid at the time of the accident.
1.13.2 The survivors were medically evacuated from the FOB to the Role 3
medical facility 22 at KAF for assessment and treatment. The Canadian
22
Role 3 is the specialized medical facility that treats all critically injured personnel at KAF.

passenger was transferred to Landstuhl Regional Medical Centre in Germany

and medically repatriated to Canada.
1.13.3 As required by flying orders, blood and urine samples were taken from
the two pilots and sent to the Armed Forces Institute of Pathology (AFIP) in
Washington, DC for analysis. The toxicology results were negative.
1.13.4 The remains of the deceased were recovered from the wreckage by
FOB personnel prior to the arrival of Flight Safety personnel. Their location in the
wreckage was not documented prior to their removal. The remains were
transported by helicopter to KAF mortuary affairs for positive identification.
1.13.5 Causes of Death
1.13.5.1 The forces of impact were likely survivable and the causes of death
were directly related to the post-crash fire. As reported by the official
pathologists and coroners’ reports, the cause of death for the FE was inhalation
of smoke and fire gases. The cause of death for the DG was inhalation of fire
gases with thoraco-abdominal trauma as a contributing factor. The cause of
death for the coalition soldier was multiple injuries and inhalation of fire fumes.
1.14 Fire, Explosives Devices, and Munitions
1.14.1 Fire
1.14.1.1 The aircraft caught fire immediately after coming to rest on its side.
The FDR data indicated that the number Two Engine Fire Warning light
illuminated, followed immediately by the number One Engine Fire Warning light.
The pilots recalled seeing the illumination of these lights and having pulled the
FIRE PULL handles. The fire was first observed in the rear cabin in the vicinity of
the number two hydraulic pump near the ceiling of the cabin in front of the
transmission housing. Both hydraulic and fuel lines are routed through the
transmission housing. Hydraulic fluid (MIL-PRF-5606 type) is extremely
flammable, as is aviation turbine fuel (JP-8 or F-34 type). Aviation turbine fuel
vapours are heavier than air and may travel a considerable distance to sources
of ignition and then flash back. The precise cause of the fire or the source of
ignition could not be determined. The fire intensity was such that it prevented the
pilots from assisting personnel in the rear cabin area and melted or reduced to
ash nearly all parts of the aircraft forward of the tail section (Annex A: Photo 6).
1.14.1.2 Once the personnel from the FOB realized that an accident had
occurred and that the aircraft had caught fire, many of them started bringing
portable fire extinguishers from the FOB stocks. All of the available fire
extinguishers were portable types and every fire extinguisher was discharged in
an attempt to put out the fire. The #2 aircraft radioed back to KAF and requested
a high capacity deployable fire extinguisher; however, the aircraft burned for over
an hour before the unit arrived at the FOB.

1.14.2 Explosive Devices
1.14.2.1 Two Cartridge Actuated Devices for the engine fire bottles were
installed on the aircraft. These were not found and likely were destroyed in the
post-crash fire.
1.14.3 Munitions
1.14.3.1 M134D Dillon Gun: There were two M134D machine guns installed on
the aircraft. The aircraft servicing set, form CF338 - Aircraft Armament State,
indicated there were 8300 rounds of 7.62 mm on board. Most of the M134D
Dillon ammunition detonated in the post-crash fire.
1.14.3.2 ALE 29A Dispenser: The form CF338 indicated there were 30
ASD3627 flares installed in the left-hand flare dispenser and 27 installed in the
right-hand dispenser prior to the mission. The post-crash fire detonated all but
one flare.
1.14.3.3 Personal Weapons: Each pilot carried a 9mm pistol and a C7 rifle. The
FE and the DG each carried a C7 rifle. The total ammunition count was not
recorded in the aircraft servicing set. Most of the personal weapon ammunition
carried in the aircraft detonated in the post-crash fire.
1.14.3.4 Miscellaneous Armament: According to the CF338, there were four

smoke grenades on board. These were not found and likely detonated in the
post-crash fire.
1.15 Survival Aspects
1.15.1 Cabin seating configuration
1.15.1.1 The CH146 AFM establishes the standard and approved seating
configurations. At the time of the accident, there were 14 approved configuration
changes listed that were deemed most typically encountered to satisfy the
majority of training and operational requirements. These included the standard
configuration and configuration changes for operations with the door guns, litter,
parachute or rappel operations, and transport of Very Important Persons. At the
unit level, deviations to the standard configuration or the approved configuration
changes were authorized by opening form CF349 in the aircraft servicing set. A
review of the aircraft servicing set found no anomalies however a review of the
AFM, the SMM and CHF(A) flying orders found that no specific direction or
authorization for the use of seats or lap belts existed. The investigation found no
documentation provided by higher headquarters approving or rejecting the proper
selection of a specific configuration or the specific use of seats or lap belts.
There were four personnel in the rear cabin: the FE, the DG, and two
passengers. The FE and DG were seated on their respective transmission side-
facing seat and manning their door gun with the FE on the right side and the DG
on the left side. The passengers were not securely seated in approved seats

with approved lap belts. The Canadian passenger was seated on the floor of the
left side of the cabin with both legs hanging over the side. His seatbelt was
attached and secured to the floor mounted cargo tie-down fittings. The Coalition
soldier was similarly seated on the floor, but on the right side of the cabin.
During the morning flight into the FOB he had been seated at the door with his
legs crossed and inside the cabin. Conversation between the two passengers
between flights focussed on the uncomfortable seating arrangements and
possible alternatives. It was pointed out to the Coalition soldier that one
alternative was to sit with his legs over the side.
1.15.2 Crash Survivability
1.15.2.1 The deceleration forces were a combination of forces along the G(x)
(fore/aft) axis and G(y) (lateral) axis. The initial impact with the barrier was at low
velocity and was survivable. The liveable space of the aircraft remained mostly
unchanged (Annex A: Photo 5). The right door gun and pintle mount may have
protruded into the cabin space at the FE station as the aircraft came to rest on its
right side. Due to the extent of fire damage, the post-impact position of the door
gun and pintle mount could not be determined.
1.15.3 Aviation Life Support Equipment
1.15.3.1 The Aviation Life Support Equipment (ALSE) of all four aircrew was
recorded as serviceable at the time of the accident.
1.15.3.2 There were two types of aircrew helmets in service use for CH146
aircrew: the SPH-5 and the HGU56P. The HGU56P helmet could be fitted with
a Maxillo Facial Shield (MFS) while the SPH-5 could not. The MFS was a
protective shield worn below the helmet visor and extended just below the chin
level. Its intent was to protect the eyes and face of the cabin crew from flying
dust and debris. There were dust protective goggles approved for use as well.
Both the MFS and the dust protective goggles were approved for use in February
2009. 23
1.15.3.3 The HGU56P helmets and the MSV98HC survival vests of the two
pilots were undamaged in the accident. The remaining crew members’ ALSE
was destroyed in the post-crash fire.
1.15.3.4 CHF(A) FEs and DGs were using a prototype tactical aviation quick
release harness in Afghanistan. The 30 Mk 1 Crewman Restraint Harnesses
(CRH) delivered to theatre were under Operational Test and Evaluation (OT&E)
following a recommendation made after the 13 July 2006 Cormorant CH149914
accident. The CRH incorporates the Crewman Restraint Release (CRR) system
with the Crewman Restraint Tether (CRT). One end of the CRT (often referred to
as a Monkey Tail) is attached to a strong point on the aircraft and the other end is
23
UNCLAS COMD 571, COMD auth for MFS, CEP, and aircrew eye protection goggles, 231818Z
Feb 09.

attached to the CRR tail on the back of the harness. The CRT can be adjusted
from 16 inches to nine ft. The SMM states that the Monkey Tail should be
adjusted in such a way as to prevent no more than one third of a person’s body
from projecting beyond the door opening. The CRR design includes an
emergency release mechanism located in front of the left shoulder which can be
activated using a single hand. When the emergency release process has been
completed the CRR tail is released from the harness freeing the wearer from the
CRT still attached to the aircraft. The two attachment hooks (one at each end of
the CRT) have also been redesigned to allow single-hand release.
1.15.4 Search and Rescue
1.15.4.1 Before evacuating the aircraft, the two pilots looked back in the rear
cabin area to assess the situation. The post-crash fire had already started and
the cabin was reported as very dark, possibly due to smoke and/or dust from the
rotor wash and/or impact with the ground. The pilots could not see anybody in
the rear cabin but were able to exit the aircraft through the right shattered
windscreen. The Canadian passenger, despite serious injuries, followed the
pilots through the same exit. Immediately after egress, the pilots attempted to
provide assistance to the personnel still inside the helicopter, but were precluded
from doing so by the intensity of the post-crash fire. FOB personnel could not
assist in rescue activities due to the explosive cook-off of ammunition and
intensity of the post-crash fire.
1.16 Test and Research Activities
1.16.1 Fluid Sampling
1.16.1.1 The post-crash fire consumed all possible sources of fluid samples
from the accident aircraft. A fuel sample was taken from the #2 aircraft as it
refuelled from the same facility at approximately the same time as the accident
aircraft. Engine oil, transmission oil, and hydraulic fluid samples were taken from
the pump carts that last serviced the accident aircraft. All samples were sent to
the Quality Engineering and Test Establishment (QETE) on 15 July 2009 and
were determined to be authorized for the CH146 and of good quality.
1.16.2 Publications Review
1.16.2.1 DTAES conducted a review of the CH146 AFM, C-12-146-000/MB-002

on behalf of the TAA. DTAES’ post-accident findings regarding the AFM and the
performance charts detailed in the DTAES technical note 75-09-15 indicated
several discrepancies and errors including the validity of various hover OGE
(HOGE) and hover IGE (HIGE) charts. DTAES consulted with the OEM who
supported these findings but this was testimonial in nature as no formal
documentation such as certification reports were provided for review. The
technical note was completed in October 2009. The technical note is included as
Annex G.

1.16.2.2 As a result of this review, 1 Cdn Air Div released UNCLAS COMD 628,
PUBLICATION AMENDMENT: CH146 FLIGHT MANUAL dated 051658Z NOV
09 and authorized the removal or correction of several charts. Specifically;
a. On Figure 1-1, the indication of 10 passengers or more was deleted

allowing for the use of this chart regardless of passenger configuration;
b. As WAT charts were no longer to be used as the basis for performance

planning, Figures 1-1A, 8-11, 8-12 and 8-13 were removed entirely; and
c. Figure 4-4 (sheets 4, 5, 9, and 10) were removed entirely as these

charts referred to the standard Bell heater. (Again, this heater was not
installed on the CH146 which has the upgraded winterization heater
instead. In this case Figure 4-4 sheets 6 and 11 apply.)
1.16.2.3 It is important to note that the title change of Figure 1-1 and the
removal of Figure 1-1A from the AFM reversed the changes that were
introduced by AFM Ch 2. Further, Figures 8-11 to 8-13 were removed because
they were viewed as incomplete, potentially misleading and of questionable
validity.
1.16.2.4 The DTAES technical note indicated that Ch 2 did not receive TAA
approval. The Operational Airworthiness message approving Ch 2 was a joint
Operational Airworthiness Authority (OAA) and Senior Design Engineer (SDE)
message. What could not be determined was the level of review that was
undertaken by the SDE or TAA staff prior to the release of this message. TAA
staff was not involved in the approval that was provided for the Ch 2 amendment
to the AFM. Questions arose concerning the approval authority provided to the
SDE. The investigation found issues that caused a lack of clarity on the
requirement for TAA review and approval of flight manual amendments, and led
the SDE to believe that approval was within the SDE’s scope of delegated
airworthiness authority. It is not to suggest that an SDE operated beyond their
scope, but rather the investigation identified factors that confused the boundaries
of that scope and the roles and responsibilities of the WSM, DTAES, and Air
Force staffs in regards to flight manual amendments. A review of TAA and
Director General Aerospace Equipment Program Management (DGAEPM)
processes has indicated that no formal review and approval processes were in
place at the time of the accident. At the time of the Ch 2 approval, the CH146
WSM utilized the Aircraft Modification Approval Form (AMAF) process to manage
changes to the AFM. No AMAF could be found for this Ch 2. Since the accident,
TAA/DGAEPM processes for amendments, review and approval of publications
of CF aircraft have been published. This is intended to prevent any further
changes to the CH146 AFM, or any other CF aircraft AFM, without appropriate
review by both TAA and OAA staff.

1.17 Organizational and Management Information
1.17.1 Deployment of the CH146 into Afghanistan
1.17.1.1 The idea of deploying the CH146 into Afghanistan was first conceived
in 2003. In 2004-2005, the Chief of the Air Staff (CAS), now called Commander
of the Royal Canadian Air Force (Comd RCAF) and Chief of the Air Force (C Air
Force), tasked several staff checks to 1 Cdn Air Div to review and compare
CH124 Sea King and CH146 Griffon performance capabilities. In 2007, the Air
Force renewed its efforts to convince the chain of command to approve the
CH146 for deployment to Afghanistan. The role of the CH146 was to gather
intelligence, conduct surveillance, reconnaissance and limited tactical airlift
missions. The main issues were the aircraft performance limitations in the high,
hot and heavy flight regimes and the limited on board self-defence/survivability
equipment that elevated the risk for certain missions in Afghanistan.
1.17.1.2 In January 2008, the Independent Panel on Canada’s Future Role in

Afghanistan, commonly referred to as the Manley Report, was made public and
recommended that Canada should continue with its responsibility for security,
including its combat role in Afghanistan. One key aspect was the
recommendation to secure medium helicopter lift capacity before February 2009.
The RCAF proceeded with the acquisition of six CH147D Chinook helicopters
and by mid-2008, the CH146 deployment to Afghanistan was revisited and now
included the Chinook escort role to the CH146’s list of potential roles in
Afghanistan. While deployment preparations and training for the Chinook
deployment started shortly after the release of the Manley Report, the request
and decision to deploy the CH146 to Afghanistan was not approved until later in
2008. In approving the deployment of the CH146, the chain of command had the
full expectation that the aircraft would be operated within its known limitations.
1.17.2 CH146 Statement of Operating Intent 24 (SOI)
1.17.2.1 The accident mission type was included within the Tactical Helicopter
Missions listed in the CH146 Griffon SOI version 1.0, 19 September 2008.
Section 2 SYSTEM OPERATION, paragraph 2.3 Environment, states that the
“CH146 will be expected to conduct mission throughout broad and complex
physical, meteorological, electromagnetic and threat environments.” In 2.3.1 it
goes on to state that the “CH146 shall be expected to operate at altitudes from
24
As defined in the C-05-005-001/AG-001, TECHNICAL AIRWORTHINESS MANUAL (TAM),
Ch/Mod 5 - 2007-07-28: The SOI is developed by the intended operators of the aircraft and
approved by the OAA prior to submission to the TAA. In general, the SOI identifies the intended
roles, missions, tasks and usage of an aircraft type in sufficient detail to permit the engineering
analysis and assessment of the proposed type design and allow selection of appropriate
airworthiness standards. It should be noted that the operating environment and specific usage of
an aircraft are fundamental to establishing and maintaining airworthiness. To assure continuing
airworthiness, the SOI must be maintained and revised as necessary throughout the service life
of the aircraft to reflect any changes to the roles, missions, tasks, operational usage and/or
environment.

sea level up to 10,000 feet above sea level (ASL)…. the CH146 shall complete
missions from austere and unprepared locations and under conditions of blowing
and/or re-circulating dust, sand, snow water and debris.” In paragraph 2.3.2.1 it
also indicates “the climates in which CH146 operates range from the snow and
intense cold of the arctic, to turbulent, high density altitude conditions
encountered in mountain ranges, to the rain and fog of the littoral environment.”
Table 4: Aircraft Meteorological Design Limitations of the SOI lists the maximum
HDs of 14,000 ft for takeoff, landing and all in-ground effect manoeuvres. In the
same table, the maximum HD for the maximum Gross Weight of 11,900 lbs is
4000 ft. In paragraph 2.3.2.3 these limits are reiterated: “In order to counter the
high density altitude effects that dominate many of the potential theatres of
operations for the CH146, it is necessary to examine solutions to improve CH146
performance. The current density altitude limitation for maximum gross weight
operations is approximately 4000 ft HD. The current limiting factor is tail rotor
authority. Given the increase of CH146 operations in high and hot environments,
it is anticipated that future CH146 operations will be conducted at maximum
gross weight at 4,000 ft HP and an OAT of 35ºC, which equates to an HD of
7,000 ft.” In paragraph 2.3.2.3 the SOI offered short- and long-term solutions.
The short-term solution was to adapt a “combat configuration” that “would see
the removal of mission kits that are not relevant for the specific operational
theatre, as determined by mission analysis, thus optimizing the CH146 available
payload to support Land Force Operations.” The SOI offered that “engineering
solutions will be examined to increase the density altitude envelope for all-up
weight operations” as the long-term solution.
1.17.3 In-theatre Turnover
1.17.3.1 The Joint Task Force Afghanistan [JTF(A)] Air Wing comprised all CF
air assets deployed in the southwest Asia theatre of operations. On 6 December
2008, the JTF(A) Air Wing stood up and consisted of a headquarters, the Tactical
Airlift Unit and the Theatre Support Element for a total of approximately 200
personnel. The initial deployment of the CH146 as part of the CHF(A) and the
JTF(A) Air Wing was the sixth personnel rotation (Roto 6). 25 Roto 6 was mainly
comprised of RCAF personnel from 408 Tactical Helicopter Squadron (THS).
After their six month tour Roto 6 was replaced in May 2009 by Roto 7, manned
mainly from 430 Escadron tactique d’hélicoptères (ETAH).
1.17.3.2 During the Roto 6 and Roto 7 in-theatre turnover, Roto 6 personnel
presented Roto 7 personnel with a Desert Operations performance presentation
that detailed the performance planning required using the AFM charts in use at
the time. This presentation made reference to the various WAT, Hover Ceiling
IGE/OGE, Cruise Performance and Hover Torque Required IGE/OGE charts.
Roto 6 had also created a performance matrix chart entitled Desert Performance
Chart that could be used as a quick reference guide for pre-flight performance
planning. This chart depicted several IGE/OGE takeoff weights and torque
25
Roto is used to define the personnel or time period of a specific deployment.

values for various HP and OAT ranges (from 2000’ to 6000’ HP in 500’
increments and 20ºC to 50ºC in 5ºC increments) (Annex H). This unofficial chart
was neither validated nor approved by the OAA or the TAA; however, it provided
Roto 6 crews with an aircraft performance planning guide that enabled a rough
prediction regarding mission acceptability for various atmospheric and aircraft
parameters present in theatre. The promulgation of non-airworthiness approved
performance charts is unacceptable and not authorized. Condoning of such
unofficial matrices encourages the production of other types of uncertified and
potentially dangerous “cheat-sheets” by operational aircrew and can significantly
elevate the level of risk when conducting flight operations.
1.17.4 Mission Acceptance and Launch Authorization (MALA)
1.17.4.1 The Air Wing had implemented a risk management tool to review the
scheduling of missions and to designate the appropriate authority needed to
approve the actual launch of the aircraft. This tool, included in the Wing Orders,
was called the Mission Acceptance and Launch Authority (MA-LA) process which
was a two-part authorization process to manage risk, satisfy operational
requirements and assist in decision making. The process asked detailed
questions to highlight potential areas of risk. Mission Acceptance and Launch
Authority were two different processes. The first part of the MA process was the
mission assessment conducted by the CHF(A) staff to consider various criteria
such as the type of mission, mission profile, landing zones, threats, etc.; it was
usually undertaken 24 hrs in advance for routine operations and 48 - 86 hrs in
advance for large scale operations. In the second step of this process the results
of the mission assessment were approved, rejected or referred to a higher
authority by the applicable mission acceptance authority which was either the CO
CHF(A), the Air Wing Commander (WComd) or the Comd JTF (A). The LA
process was the second part of the MA-LA process. This was a flying supervisory
function used to authorize flights after reviewing conditions that could affect the
specific mission such as crew rest, qualifications, time in theatre, weather, and
other risk factors at the time of launch. These results were forwarded to the
proper launch authority, the CO CHF(A) or the Air WComd. At the time of the
accident, the MA-LA matrix had been applied in accordance with the procedures
in place for operations in Afghanistan. However further review indicated that
when considering landing zones the MA process only differentiated between
landing in MOBs, FOBs or at unprepared surfaces; there was no specific criteria
for examining the actual conditions of the landing site which could have included
size, obstacles, dust suppression, crash-fire-rescue capabilities or the potential of
DVE. Within the LA process weather was included as criteria but only examined
day or night operations, cloud ceilings and visibility. It did not include specific
environmental conditions such as density altitude or elevated OAT.
1.18 Additional Information
1.18.1 Operating Conditions in Afghanistan

1.18.1.1 With a mix of desert regions and rugged mountainous terrain with
altitudes up to 24,500 ft and temperatures from -25°C to +53°C, the Afghan
theatre provided extremely challenging flying conditions. In particular, the often
high HD, which resulted from decreased air density at altitude that was combined
with high ambient temperature, negatively affected aircraft performance. These
conditions placed the CH146 near or at several of the aircraft’s maximum
operating limits, such as the combining gearbox oil temperature, Qm, ITT, battery
temperature (primarily on engine start) and the maximum operating OAT. The
maximum OAT for the CH146 is +51.7ºC but it is reduced by 2 degrees per 1000
ft of elevation. For operations at Kandahar, Afghanistan the calculated maximum
OAT was +45 ºC.
1.18.2 Degraded Visual Environment (DVE)
1.18.2.1 Afghan soil consists mainly of sand and rock. The sand is extremely
fine and light and is often compared to talcum powder. In dry conditions
helicopters generate a donut-shaped dust cloud, commonly referred to as a
dustball, during initial lift-off and the approach/landing that contributes to the DVE
known as brown-out. In the most severe dustball/brown-out conditions the entire
aircraft becomes engulfed in the dust cloud and, in Afghanistan, these can reach
a height of a few hundred ft (Annex A: Photo 7). Helicopter operations in such a
DVE are very challenging, reducing visibility for the crew sometimes to the point
where the crew loses all visual ground references (Annex A: Photo 8). These
dustball/brown-out conditions have been recognized and continue to be a
significant risk and threat to operations by many civil and military helicopter
operators.
1.18.2.2 In order to maintain position during hovering flight, helicopter pilots

select near and far points, both in front and to the side of the aircraft as normal
hover references. A dustball will preclude aircrew from using the far points as
ground references, limiting them to only the near references which can be just a
few feet from the aircraft. Aircrew will also use relative motion in comparison with
their selected normal hover references as an indication of aircraft movement or
drift. This technique is used to assess drift in both the vertical and horizontal
planes, however, vertical movement is more difficult to assess because it relies
mainly on depth perception. When encountering a DVE, the motion of the
particles within the obscuring phenomena can severely hamper depth perception
and also create visual illusions for the crew, like inducing a false sense of relative
motion. These illusions can be seen and interpreted in two distinct ways: the
aircraft appears to be drifting when in fact it is stationary or the aircraft appears
stationary when in fact it is drifting. The most severe dustballs can also obscure
all ground references.
1.18.2.3 As previously mentioned, the CH146 does not have see-through

technology systems or systems using landing symbology or sensory displays for
safe flight in a DVE below VMINI. Additionally, neither of the CH146 systems,
handling qualities or flight instruments are designed, certified, approved,

intended, nor precise enough to allow aircrew to allow safe flight in a DVE below
VMINI. Therefore, aircrew must have the ability to maintain or regain visual
ground references quickly or apply a flying procedure that will ensure an effective
visual or instrument transition to a point where references can be acquired and
maintained allowing for safe flight. Aircrew must rely on cockpit flight instruments
or other systems such as a Helmet Mounted Display (HMD) to detect changes in
motion/position.
1.18.3 Helmet Mounted Display (HMD)
1.18.3.1 The pilot’s helmet can be fitted with a day or a night HMD. The two
HMDs are often referred to as the Head-Up-Display 26 (HUD) and are called the
Day-HUD and the Night Vision Goggle HUD (NVG-HUD). The two HUDs are
different in design, the Day-HUD can only be mounted over the right eye while
the NVG-HUD can be mounted over either eye. Both systems display the same
symbology and include a drift vector. The Day-HUD hover page displays a drift
vector which provides the pilot with drift information. The drift vector is depicted
as a simple line with the length representing the rate of drift and the orientation
representing the direction of drift (Annex I). This information is only relative to
the aircraft movement, only indicates the direction and rate of movement and is
not locked on a specific point over the ground like a GPS point, for example.
Once drift has occurred and been stopped, there is no way for aircrew to
accurately fly back to the point of origin. Unit Flying Orders mandated that the
HUD, day or night, be worn at all times in theatre.
1.18.4 Standard Manoeuvre Manual Procedures
1.18.4.1 The SMM details the techniques and procedures used to fly the
CH146. The version of the SMM valid at the time of the accident was Ch 3 dated
15 May 2009.
1.18.4.2 Crew Duties - The crew duties specific to each crew position are
described in the SMM Table 1-1 - Standard Crew Duties. In Table 1-1, both the
FP and the NFP are assigned the duty to “crosscheck systems and instruments.”
The table includes a note that specifies that the FP should resist the temptation
to perform NFP duties. The table assigns the NFP the duty of advising the FP of
the power setting. Specifically, it states that the NFP must advise the FP when
the power setting is at 80% Qm and above in increments of 5%, and approaching
100%. It should be noted that CH146 aircrew have historically operated
predominately in colder or temperate climates where they were accustomed to
being Qm limited before reaching an engine limitation, such as ITT or N1. The
SMM did not indicate how the NFP was to advise the crew about power settings
when the Qm was not the power limiting factor.
26
Head-Up-Display or Heads-Up-Display

1.18.4.3 In addition to the standard crew duties mentioned above, each flying
task described in the SMM has a section for crew management which specifies
additional crew duties specific to the task described. Table 1-1 stipulated that the
FE was responsible at times for conning the aircraft and providing advisory calls
to the FP on drift motion by providing verbal drift information derived from his
visual ground references. For the task VMC Approach and Landing, the crew
management information specifically directs that the FP and the FE shall inform
the crew when they lose visual ground references. This direction was not
provided for the task VMC Takeoff/Level Off.
1.18.4.4 CH146 Takeoff Procedures - There are two types of takeoff

procedures: the no-hover takeoff and the vertical takeoff. The vertical takeoff is
further subdivided into the four ft hover takeoff, the MPTO, and the ITO.
1.18.4.5 In accordance with SMM Ch 3, both the MPTO and ITO procedures
required a minimum power margin of 20% Qm over and above the required IGE
hover torque. There was no minimum power margin specified for a four ft hover
vertical takeoff and transition into forward flight using ground effect. There was
also a note following the description of the MPTO and prior to the ITO description
that stated “Any hesitation in power application will cause a loss in climb
momentum and will require additional power to re-establish the initial rate of
climb.”
1.18.4.6 The SMM Ch 3 stated that the ITO is a composite visual/instrument

procedure used to depart an area where obscuring phenomena are expected.
Desert operations procedures were published in the SMM during Ch 3 in
preparation for the operations in Afghanistan and clearly stated “The ITO
procedure shall be used. Pilots should not attempt the max performance take off
procedure when a vertical rejection of the take off is likely. Taking off in brown
out conditions should only be attempted when the aircraft weight is within the
limit specified by the HOGE chart and appropriate wind azimuth chart.” Due to
the dust conditions in Afghanistan, a rejection of a takeoff is often likely. The
reason for mandating an ITO under these conditions is to maximize crew
efficiency at flying the aircraft accurately with reference to flight instruments. On
takeoff, the FP controls the aircraft using flight instruments until suitable visual
references can be acquired and maintained. The NFP can continue cross-
checking visual ground references until they are lost and, at the same time,
monitor the FP’s performance and instrument indications. In the case of an
MPTO, both pilots look outside at visual ground references. If visual ground
references are lost partway through the takeoff, the FP has no choice but to
transition to flying on instruments. The transition from flying on visual references
to flying on instruments takes a few seconds because the FP has to assimilate
and process flight instrument information. Once assimilated, the information is
used to build an air picture of the aircraft’s attitude and motion. This transition
from flying using visual ground references to flying on instruments is recognized
as a critical period, thus the stipulation that the FP be on instruments throughout
the entire ITO procedure. The direction in the SMM Ch 3 Desert Operations to

confirm that the aircraft weight is within the limits of the HOGE and wind azimuth
charts is based on the anticipated increased OGE power requirements of the ITO
during the takeoff. This is consistent with the intent of having 20% Qm over and
above the required IGE hover torque for the MPTO and ITO. Although not exact,
it was assessed that the 20% provided a margin of safety for performance during
these manoeuvres.
1.18.4.7 Additionally, the SMM Ch 3 stated that the NFP should stand by the
controls, as required. The CVR and testimony indicated that the NFP was
standing by the controls for the takeoff.
1.18.5 Spatial Disorientation
1.18.5.1 Spatial disorientation is defined in the CF Manual of Instrument Flying,

Annex B - SPATIAL DISORIENTATION as “the failure to achieve accurate
orientation with respect to the earth’s surface. The attitude of an aircraft is
generally determined by reference to the natural horizon or other visual
references to the earth’s surface. …If neither horizon nor surface references
exist, the aircraft attitude must be determined by artificial means from flight
instruments.” Spatial disorientation is generally classified as either unrecognized
(Type I), recognized (Type II), or incapacitating (Type III). 27 Defence Research
and Development Canada (DRDC) human factors specialists also define spatial
disorientation as the failure to sense or sense incorrectly the position, motion and
attitude (orientation) of the aircraft with respect to the earth’s surface and the
gravitational vertical. The fixed frame of reference that is used for spatial
orientation is both the earth’s surface and the gravitation vertical.
1.18.5.2 Situation Awareness (SA) is defined as keeping track of prioritized

events and conditions in one’s environment. It is a mental process that a pilot
uses to guide his movements, to anticipate events and to build a mental picture
of reality. His ability to accomplish this accurately is based on his experience,
knowledge, and proficiency as well as how rapidly he can analyze and prioritize
changing events correctly during the mission. 28 Operationally, SA in the aviation
environment is used to refer to the awareness of the large group of factors that
are important to keep the aircraft safe from hazardous situations or potentially
dangerous flight paths (including tactical SA and spatial orientation (SO)). The
hierarchical structure dictates that SO is part of SA. Analysis of spatial
orientation accidents demonstrates that common attention anomalies such as
channelized attention, distraction or task saturation 29 could contribute to spatial
27
A-OA-148-001/AG-000, Manual of Instrument Flying Annex B - SPATIAL DISORIENTATION.
28
Ibid.
29
Channelized attention is the focusing of conscious attention on a limited number of
environmental cues to the exclusion of others of higher or more immediate priority. Distraction is
the interruption of conscious attention to a task by non-task related cues. Task saturation occurs
when an individual has too much to attend to at one time; thus missing possibly important cues.

disorientation and loss of SA. 30 Distraction is further defined in The Concise

Oxford English Dictionary as “a thing that diverts someone’s attention, a thing
offering recreation or entertainment, an agitated mental state.”
1.18.5.3 For the purposes of this investigation, the term loss of SA refers to the
channelized attention, distraction and task saturation suffered by the FP when
referring to and crosschecking the ITT gauge during the takeoff procedure. It is
not intended to indicate that the FP was engaged or focussed on non-task
related activities, events or factors from the takeoff procedure.
1.19 Useful or Effective Investigation Techniques
1.19.1 Mast Torque (Qm) calculations
1.19.1.1 Early in the investigation process, as the CH146 CVFDR or HUMS did
not capture Qm, NRC and AETE each developed mathematical methods or used
rules of thumb to estimate Qm from the combined engine torques. Both methods
were very similar and provided a calculated Qm of approximately 91% Qm
(results were within 1% of each other). NRC results are presented in graphical
format at Annex F, Graph 4. As a result of additional testing conducted under the
auspices of AETE project 2011-023, the AETE final report found that Mast power
ratio varies not only with power, but also with HD. Engine to Mast Torque Ratio
(QR) was also calculated from the hover performance data and was included in
the same report. The QR function found from flight test converts engine power to
mast torque as a function of total engine power, HD and OAT. The accident
aircraft performance calculations were recalculated using these factors and are
presented in Section 2. (See also Annex F, Graph 5).
1.19.2 Performance Calculator Software
1.19.2.1 Measuring actual power available on a production aircraft in real-time

is not feasible. Following the accident the Directorate of Aerospace Equipment
Program Management (Transport & Helicopter) [DAEPM (TH)] developed
software that estimated aircraft power available under given environmental
conditions to assist aircrew with aircraft performance planning. The software
provided an estimate only and calculations were based on Power Assurance
Check (PAC) 31 data for each aircraft and specific ambient environmental
conditions.
30
Cheung, B. (2004) Spatial Orientation – Nonvisual Spatial Orientation Mechanisms. In: F.
Previc, W. Ercoline (Eds.) Spatial Disorientation in Aviation. Progress in Astronautics and
Aeronautics Volume 203. pp 37-94. American Institute of Aeronautics and Astronautics, Inc.
Restoin, Virginia.
31
Power Assurance Check – see Annex B.

2 ANALYSIS
General
This was an elaborate and lengthy investigation that focussed mainly on

environmental operating conditions, takeoff procedures and CH146 performance.
Organizational issues within the RCAF and the CH146 community also surfaced.
Three DFS investigators conducted numerous independent interviews with
multiple agencies and personnel, including civilian and military representatives
from the OEM, NRC, AETE, and QETE; the CH146 WSM; the chain of
command; as well as qualified CH146 aircrew at the tactical level and formerly
qualified CH146 aircrew at the operational and strategic levels.
The post-crash fire consumed the majority of the aircraft and left little usable
material evidence. Both pilots survived the accident and had a good recollection
of the events as they unfolded. The CVR/FDR data and historical HUMS data
were used in comparison with CH146 baseline performance and other deployed
aircraft. These data indicated that the accident aircraft was performing according
to the OEM’s specifications for the ambient conditions at the time of the accident.
The analysis examined the environmental operating conditions in Afghanistan,
the use of the CH146 Day-HUD, Human Factors affecting aircrew performance,
the post-crash fire and cabin survivability. The investigation team also reviewed
the accident takeoff procedure, CH146 performance charts, ITT exceedences
and conducted post-accident performance calculations. Finally, some
organizational issues with the CH146 Deployment to Afghanistan were also
examined.
2.1 Environmental Operating Conditions in Afghanistan
2.1.1 The crew prepared for the afternoon flight using information gained
during the morning mission. During that mission the helicopters landed in the
FOB in the designated landing site. The ensuing takeoff from the FOB was less
challenging from a performance perspective; after dropping off passengers,
which reduced weight, and with a lower OAT, aircraft performance permitted a
successful takeoff from the FOB. (However, the investigation revealed that
similar DVE conditions existed, and it is confirmed, as described in paragraph
2.7.11, that the #2 aircraft exceeded ITT limits during that morning takeoff as
well.) The conditions during the afternoon’s mission were quite different. The
landing was not conducted at the designated landing site due to the wind shift
and takeoff distance considerations. The OAT was 4ºC higher, creating a higher
HD, and the aircraft AUW was heavier, after refuelling at KAF and boarding two
passengers. These differences meant that the crew faced a different situation for
the accident takeoff; as the combination of these factors would have reduced
aircraft performance, this should have warranted more detailed pre-flight
performance calculations.

2.1.2 Dust and Fire Suppression
2.1.2.1 The investigation found that there were no standards for dust
suppression or fire suppression methodologies in the Afghanistan theatre of
operations. While the larger bases in Afghanistan had hard-surfaced operating
areas or other systems in place such as spray-applied solutions, fabric or rigid
mats or gravel and grid systems, few of these solutions were available to control
dust at remote helicopter landing sites or in FOBs. Fire suppression was also not
standardized. While the larger bases could provide Crash Fire Rescue services
with adequate fire extinguishing agent or fire suppression systems, implementing
similar solutions at remote locations and in FOBs in such a hostile military
environment was impractical. Interviews with International Security Assistance
Force (ISAF) Flight Safety personnel in KAF revealed that the establishment of
theatre-wide standards were seen as impossible to implement at the time. The
various reasons included the number of FOBs, cost, resource availability, the
number of disparate countries responsible for maintaining FOBs and logistical
issues. The accident FOB was considered austere, not Canadian-controlled and,
did not employ any dust or fire suppression measures. While the FOB had
handheld fire extinguishers, these were not effective facing this size of post-crash
fire.
2.1.2.2 Attempts to control dust were often beyond Canadian control or

influence, and operations in dustballs were recognized as an inherent risk of
operating in the Afghan theatre. Some nations implemented mitigating measures
for dust landings and takeoffs in FOBs or unprepared landing zones such as the
identification and assessment of various criteria to determine the suitability,
selection or rejection of a FOB or unprepared landing zones for helicopter
operations. If certain dust or fire suppression criteria were not met, then
operations would not take place. For CF operations, a review of CHF(A)
documents indicated that training and flying orders were in place for dust landing
procedures, however, these did not contain criteria to determine the suitability,
selection or rejection of a FOB or unprepared landing zones considering
dustballs or potential helicopter operations in DVE. Standard Operating
Procedures (SOPs) for deployed operations should include accurate descriptions
and evaluations of FOBs and landing zones for flight planning purposes and
these should be updated regularly. (Of note, measures were taken in
subsequent Rotos to ensure FOBs were sprayed with water for operations to
occur.)
2.1.3 Degraded Visual Environment
2.1.3.1 In deciding to land at an alternate location inside the FOB, the crew’s
reasoning was sound in that this allowed for a landing into wind and also
provided maximum distance available for the takeoff and departure. Landing into
wind maximizes aircraft performance and keeps the dustball behind the aircraft
longer, thereby allowing the crew to maintain visual ground references for a

longer time. The distance available for the takeoff was important due to
obstacles in and around the FOB.
2.1.3.2 Assessing dust conditions in a landing zone prior to landing is very

difficult. Both crews were unable to accurately assess the dust conditions in the
FOB prior to the landing. The accident crew reported that the dustball created
during the accident takeoff was one of the worst that they had ever experienced.
In their opinion, the obscuring phenomena played a major role in this accident in
that it severely impeded the FP’s and FE’s ability to detect drift and ultimately the
FP’s ability to correct the unintended drift, to see and to avoid the barrier. Photos
and videos of multiple landings and takeoffs into the FOB by both CF and
coalition helicopters taken the day of the accident revealed the creation of
intense dustballs on all occasions. Deciding to land at the designated site or an
alternate site within the FOB would not have eliminated or reduced the creation
or intensity of the dustball. With the sand conditions present and lack of dust
suppression, the creation of an intense dustball contributed to a DVE for the
accident crew.
2.1.3.3 Both the FE and the FP, who were seated on the right side in the
helicopter, lost visual ground references while the NFP, who was seated on the
left side, maintained his references. In a dustball, the density of the obscuring
phenomena is greater near the main rotor blade tips, (in the donut-shaped outer
area of reduced visibility created by the rotor downwash) than it is in the centre.
Once in the hover, as the aircraft drifted to the right, it moved towards the outer
area of reduced visibility. This explains why both the FP and FE lost visual
ground references while the NFP, who was able to see references towards the
centre of the dustball, did not.
2.1.3.4 Contributing to the loss of the FE’s references was the type of ALSE
equipment used. As the cargo doors were removed, which was the standard
configuration for operations in Afghanistan, the FE was fully exposed to the
effects of the dust, more so than the pilots in the front cabin. However, even had
the doors been installed and closed, the intensity of the DVE was such that
visibility through the cargo door window or through goggles would likely have
been equally poor. In this dustball, the FE’s ability to see his visual references
and, therefore, communicate information concerning drift and obstacles would
have been significantly degraded.
2.1.3.5 As previously explained, within the MA-LA process there was no

specific criteria for dust suppression, crash-fire-rescue capabilities or the
potential of DVE or environmental conditions such as density altitude or elevated
OAT. At the time the MA-LA process was seen as a rigorous tool supporting
mission planning, risk identification and mitigation and final launch authorization.
The investigation found that the MA-LA process did not support or lead to a
proper assessment of the climatic conditions, and hence aircraft performance for
that specific mission at the FOB that day.

2.1.4 To summarize, due to different OAT, HD and AUW, the crew was
faced with degraded aircraft performance when compared to the morning takeoff.
While the selection of an alternate landing site did not play a role in the creation
or intensity of the dustball, the lack of dust suppression methodologies and the
poor sand conditions did. Additionally, the FP lost all visual hover references
while the FE’s ability to provide the FP with drift information was significantly
degraded. Together, these factors combined to create a DVE that completely
removed the crew’s visual references, which was a main contributor and causal
factor in this accident.
2.2 CH146 Day-HUD
2.2.1 Roto 7 deployed with the intent to use both the Day-HUD and NVG-
HUD at all times. At night, both the NVGs and the NVG-HUD performed well.
The main reason for operating with the Day-HUD was to allow for continuity
between day and night flying. However, some limitations of the Day-HUD did not
surface until actual operations and use of the Day-HUD in Afghanistan forced a
reconsideration of this approach. Aircrew reported various problems or
inconsistencies such as a pink tint, a blind spot, and difficulties reading the Day-
HUD during certain daytime illumination conditions. Furthermore, due to the
weight and location of the HUD on the helmet, some aircrew experienced neck
pain which led to fatigue. Apart from the issues of neck pain, the issues with the
Day-HUD were not present with the NVG-HUD. Some aircrew were concerned
that the pink tint and blind spot would hinder the field of view and limit their ability
to detect enemy presence and/or actions while flying certain missions.
Additionally, it was discovered that under certain conditions, the intensity of the
illumination from the sun reflecting on the sand was such that aircrew could not
read the Day-HUD even with the symbology display at full intensity. These
issues were known within the CHF(A) chain of command and with these
limitations, continued reliance on and use of the Day-HUD during certain flying
conditions was seen as a higher risk than not using it at all.
2.2.2 To mitigate this risk, following the identification of these issues, the CO
ensured that aircrew were aware of the limitations, directed that aircrew use the
cockpit instruments as a primary reference if the Day-HUD did not perform to
expectations and left individual aircrew to decide, depending on the flight
conditions, whether or not to wear the Day-HUD. The CO’s intent and risk
mitigation, provided via verbal orders, was clear and reasonable; the modification
of his unit’s flying orders was seen as an administrative issue that would follow in
time and so at the time of accident, Unit Flying Orders had not been updated.
The reason why the Unit Flying Orders did not reflect the CO’s most recent
direction on the use of the Day HUD when the accident occurred was because
the unit leadership faced a barrage of issues in May and June, almost all of them
related to increasing temperature and the associated limitations experienced on
the Griffon, aircraft OAT limitations, never exceed speed (VNE) limitations, ITT

and Ng limitations, to name a few.32 In the span of three weeks, CHF(A) went
from a situation where they could fly as per the SMM to one where a number of
manoeuvres could no longer be flown as per the SMM. The implications were
quite significant. The CO directed his Operations Officer; he was double hatted
as the Unit Standards Officer and tasked to communicate these challenges to 1
Wing and 1 Cdn Air Div since they needed to transition rapidly from flying off the
Qm to flying off the ITT and Ng limitations. This was a comprehensive task and
saturated the Operations cell for the better part of two months (mid-May to mid-
July). Having lost some capacity in the Operations Centre, the CO elected to use
alternate methods (verbal orders, Aircrew Information Files) to communicate his
intent and directions, during that period. The amendments to the use of the Day-
HUD were communicated through verbal orders and this verbal direction allowed
aircrew to decide on the use of the Day-HUD and accept the operational risk at
their level. As such, the decision to not wear the Day-HUD was common practice
with aircrew for certain missions under certain flight conditions.
2.2.3 While the use of the Day-HUD could be seen as a significant brownout
risk mitigation tool, it should be emphasized that the CH146 HUD and its internal
symbology is not certified as a primary flight instrument. As noted in the AETE
Project Directive 2000-004, CH146 NVG HUD, Draft Report, undated (project
closure by AFTEC / A/A3 APT, 12 Aug 2011), “The use of the AN/AVS-503
ANVIS HUD during the performance of hovering and low speed flight
manoeuvring [at night under NVG] modestly increased aircrew situational
awareness and was satisfactory. The flying pilot should minimize the use of the
AN/AVS-503 ANVIS HUD and continue to rely on external visual cues during
hovering and low speed flight operations. The Hover and Transition vectors
should be used only as a secondary cue by the flying pilot during hovering and
low speed flight manoeuvring in degraded visual cueing environments.” The
AETE Project Directive 2005-012, CH146 Day Helmet Mounted Display, Final
Report, 29 Jan 2007, includes a CAUTION statement indicating: “The use of the
HUD attitude reference line may assist in maintaining SA, but when conditions
dictate inadvertent instrument meteorological conditions (IIMC) procedures, the
aircraft's primary flight instruments must be referenced.” The CAUTION
statement above is reiterated in the SMM under the Task 114 Perform IIMC
32
It is important to understand that, at the time, CHF(A) were also trying to assess the second
and third order effects that higher than normal temperatures would have on operations. This
example speaks of a real time situation that occurred in June where the SAMEO and one of the
CH146 test pilots requested guidance after maintenance was completed on a helicopter. The
maintenance procedure required a test flight to be completed (after the maintenance action) so
that autorotation parameters could be confirmed within limits. Upon reviewing the autorotation
charts, the test pilot realized that the rotor speed to be achieved for the altitude and temperature
at Kandahar was outside the allowed aircraft limits. Technically, they could therefore not confirm
the aircraft serviceable for flight after routine maintenance. Following consultation with the WSM
and the OEM, clear direction regarding the applicable aircraft limits (to declare the aircraft
serviceable) was provided. For a period of two months, as they entered the warmer months of
the year in Afghanistan, they continued to try and identify those second and third order effects
that were not necessarily obvious but that could have arisen to impact to CH146 maintenance
and operations in Afghanistan.

Procedures, Night Considerations, paragraph 7. A NOTE is also included which

indicates: The information displayed on the HUD is NOT certified for use in
instrument flight conditions. However a contradictory statement is provided
under Task 106, Perform VMC Approach/Landing, Desert Operations, paragraph
37, where it is stated: Once references are lost, the landing can be accomplished
by flying on HUD/HMD using a scan between the ATT-G/S-ATT-Rad Alt
symbology.
2.2.4 During the accident flight the crew did not use the Day-HUD.
Approximately five seconds after lift off right drift was identified by the NFP and
verbalized to the crew. The FP acknowledged the first drifting right call and thus
was aware of the aircraft drift. Three seconds later, the NFP again called drifting
right two seconds prior to barrier impact. It is impossible to determine if the use
of the Day-HUD would have assisted the FP in eliminating the right drift or if it
could have prevented the accident, but it certainly could not have assisted in
returning the aircraft to the original takeoff position. While a drift indicator is seen
as a desirable brownout risk mitigation instrument, as previously explained,
AETE determined that pilots should minimize the use of the Day-HUD, rely on
external visual cues and only use the drift vector as a secondary cue during
hovering and low speed flight manoeuvring in DVE.
2.2.5 Aircraft groundspeed was estimated using the accident timeline and
the distance from the takeoff point to the barrier. Due to the unknown position of
the helicopter after takeoff and unknown start time of the right drift, calculations
varied depending on the time estimated to travel the 95 ft from the takeoff spot to
the impact point. Without an accurate time start, physical start point and aircraft
acceleration, these calculations could not be used conclusively. However it is
possible that the aircraft could have accelerated to greater than 10 kts
groundspeed which would have eliminated the drift vector. The investigation
concluded that the Day-HUD drift vector would have only provided the FP with an
additional source of drift information, re-confirming the direction and rate of drift
to the FP. It is unknown if the use of the Day-HUD would have assisted the FP
to recognize, reduce or eliminate the drift more quickly.
2.3 Human Factors
2.3.1 Loss of Situation Awareness
2.3.1.1 The total flight duration from skids clear of the ground to impact with
the barrier was under 10 seconds. Crew testimony and CVR analysis indicated
that that time was very busy for the crew. The FP commenced the takeoff
looking at his normal hover references but upon hearing the NFP’s call of 95%
Qm, coupled with his concern for the ITT limit, the FP quickly cross-checked the
ITT gauge inside the cockpit. 33 At that specific moment the NFP realized the
33
The value of 95% Qm was reached due to the combination of the ITT exceedence, the time
spent in ground effect and the droop in the main rotor RPM.

aircraft was drifting to right at an approximate walking pace and called “drifting
right,” as per the SMM. The FP’s attention was drawn back outside in an attempt
to control the drift using visual ground references but they were no longer
available. With no visual ground references, the FP transitioned to the ITO,
relying on flight instruments as per the briefed takeoff plan. The CH146 has no
single aircraft instrument that can provide drift information and assist the pilot in
maintaining control of the A/C in the hover. In addition, the rapid and numerous
transitions of attention and focus from scanning visual references outside the
cockpit to monitoring the flight and engine instruments inside the cockpit did not
allow sufficient time for the FP to detect, interpret, and understand the flight
information; build an appropriate air picture; and then respond with proper flight
control inputs. FDR data at Annex F confirms that the FP did not immediately
action the information received. However, DRDC Human Factors specialists
have determined that the normal delay or reaction time required from detection
until proper flight control input could be as long as five seconds. 34 While there
was a delay in reaction time, which is normal or routine behaviour, it is assessed
that the NFP calls may not have improved the FP’s SA.
2.3.1.2 Without an appropriate air picture the FP could not know which control
inputs were necessary to control the aircraft in the desired manner. With the FP
unable to effectively stop the drift and/or gain altitude, the helicopter continued to
drift towards the unseen barrier within the dustball. This analysis led the
investigation to conclude that due to the rapid and numerous transitions of
shifting focus, the FP was distracted and task-saturated which led to a loss of SA
during the takeoff sequence.
2.3.2 Crew Training, Coordination and Communication
2.3.2.1 As indicated in section 1.5, a review of the RCAF helicopter

dustball/snowball training, exposure to DVE and aircrew training files revealed a
discrepancy in and lack of initial and advance training for operations in obscuring
phenomena for the FP. Notwithstanding the apparent training shortfall,
discussions with some CHF(A) aircrew indicated that the FP’s time in theatre
(over two months) afforded the opportunity to be familiar with dustball operations.
The investigation determined that the training provided to the FP for operations in
dustball/snowball and DVE was insufficient for dealing with the DVE encountered
during the accident flight. Upon further review, the investigation determined that
the training for operations in obscuring phenomena provided to CF helicopter
34
DRDC human factors specialists have determined that the process of identifying an object can
take 1.05 seconds. If a decision must be made on what to do, this can take an additional 2.00
seconds. Reaction time can also be affected by the time interval required to shift vision from
outside the aircraft to inside the aircraft which, can increase response times by an additional 2.39
seconds due to the physiological time that is spent with eye movements to an instrument panel,
recognize the instrument reading, then move back to outside the cockpit and perceive the outside
environment. Studies have shown that there is also an inherent delay (seconds) in regaining
orientation information when transition from VMC to IMC (especially from head out to head
down). This latency would be lengthened if the pilot was disoriented even when it is recognized
SD.

pilots, and CH146 aircrew in particular, should be improved. The use of

advanced simulators and training exercises in actual conditions could provide
potential mitigating training solutions.
2.3.2.2 Crew actions and coordination was analysed via a detailed review of
the CVR recording and crew testimony. This revealed that although they were
extremely busy, the crew had been working well as a team and that
communication among the crew was generally effective and in accordance with
the SMM. Two factors surfaced that could have altered the outcome of the flight:
overlapping communications and informing the rest of the crew that visual ground
references were lost.
2.3.2.3 CVR analysis revealed that there were several internal calls made by
the crew and in some instances these communications overlapped. Aircraft radio
limitations in transmit and receive functions do not allow for continuous
transmissions to be sent and heard by all stations at the same time. In this case,
drifting calls made by the FE were not heard by the FP. The investigation
concluded that the FP was aware of the drifting condition and even if these calls
had been heard they would only have reconfirmed what he already knew.
2.3.2.4 CVR analysis and interviews also revealed that the FP did not inform
the crew that he had lost visual ground references or that he was flying on
instruments. Had either call been made, the NFP could have taken control of the
aircraft since he still had visual ground references. However, it cannot be
determined with any degree of confidence that had the NFP taken control, the
right drift would have been corrected in sufficient time to avoid colliding with the
barrier or that the NFP would not have also eventually lost visual references.
2.3.3 In the most critical case where the entire crew loses visual references,
the appropriate actions would be to advise the rest of the crew, stabilize the
aircraft as much as possible using flight instruments and establish a climb profile
through the obscuring phenomena. While the FE had time to advise the crew
that he had lost visual references, the investigation concluded that the FP was
distracted and task saturated during the takeoff due to the numerous changes in
his focus during the 10 seconds prior to impact during his attempt to stabilize the
aircraft and climb away. This can explain why the FP never informed the crew
that he had lost visual ground references or that he was flying on instruments.
2.4 Post-Crash Fire
2.4.1 Before exiting the aircraft, the FP pulled both Fire Handles, which is
the second of four steps in the Engine Fire checklist response. The first step,
closing the throttles, and the third step, activating the fire extinguisher switch to
main and then reserve, were not actioned. The investigation could not conclude
if the engine fire bottles were discharged. In any event, these steps are for the
engine compartment and would not have aided in extinguishing the post-accident

cabin fire. The fourth step, Emergency Ground Egress was also only partially
completed.
2.4.2 The first and second steps of the Emergency Ground Egress
procedure were not carried out, leaving the throttles open and the Battery Bus
switches ON. The third step, Rotor Brake, was not required but completed. The
steps that were completed are steps that have an associated cueing: visual
cueing for both Fire Handles and auditory cueing for the Rotor Brake (engine
noise). All omitted steps (bold steps in Annex J) were steps that are required to
be committed to memory and do not have specific associated cueing. The pilots
had the steps committed to memory but it is likely that the actions were simply
omitted in the stress and confusion of the situation.
2.4.3 The post-crash fire started very rapidly in the upper area of the rear
cabin and was visible to the survivors before they exited the aircraft. While the
ignition source could not be specifically identified, the rapidity at which the fire
developed indicates that the fire had a readily available source of fuel. Both
hydraulic fluid and fuel supply lines are located in the upper rear cabin area and
may have been compromised during impact. When the main rotor blades struck
the barrier, the rotational moment forces of the main rotor transferred to the main
transmission and caused it to come free from its mounts, thereby possibly
severing these lines.
2.5 Cabin Survivability
2.5.1 The initial impact forces were survivable yet only one person was able
to successfully egress from the aircraft cabin. The three remaining people were
not able to egress due to incapacitation, impact injury, post-crash fire,
disorientation, physical restraint, or blocked exits.
2.5.2 The prototype CRH was under OT&E and only a limited number of
harness sizes were produced, delivered and available (five medium, 10 large and
15 extra large). The investigation was unable to retrieve official supply
documentation pertaining to the sizes and distribution of the prototype CRHs and
CRTs, however, an unofficial survey taken in theatre indicated that most FEs and
DGs were using a prototype CRH which was too large and did not fit properly. A
properly fitted and adjusted CRH and CRT, when connected to a correct
attachment point, will provide proper restraint and allow, as indicated in the SMM,
no more than one third of a person’s body to project beyond the aircraft door
opening. Due to the limited size availability and the loose play that some CRHs
allowed, some length combinations of the prototype CRH/CRTs could not be
adjusted or shortened to prevent the entire body from being projected beyond the
door opening.
2.5.3 The locations in the aircraft where the CRTs can be attached are also
a safety concern. A properly fitted and adjusted CRH and CRT may restrict
aircrew from effectively performing their duties in the cabin or allow more than

one third of the body to project out of the aircraft, depending on which attachment
point is used. Post-accident discussions with 1 Wing FEs indicated that there
was no 1 Wing or CHF(A) policy or procedure directing which attachment points
FEs and DGs should use during various phases of flight. The issue was that with
the two M134D Dillon guns mounted in the CH146 the front transmission anchor
points were no longer accessible due to the presence of the ammunition cans
and therefore the transmission side wall anchor points had to be used instead.
Due to the ad hoc distribution, lack of official supply documentation on the
prototype CRH/CRTs and fire damage, the investigation could neither determine
if the harnesses were fitted and adjusted properly nor which attachment points
were used.
2.5.4 The investigation’s DRDC human factors specialist indicated that, in

combination with equipment, the Fragmentation Protective Vest (FPV) worn by
the FE and the DG provided limited flexion, extension, abduction and rotation at
the shoulder, restrictions known by CF Land Forces. These movement
restrictions limited the effective reach envelope of the wearer. For FEs and DGs,
two other pieces of ALSE strapped over top of the FPV exacerbated the problem.
Therefore, to extricate themselves, the FE and DG would likely have had to twist
their bodies with extreme difficulty to free themselves from the debris generated
by the crash sequence.
2.5.5 The FE was seated on the right transmission side-facing seat in the
rear cabin area and when the aircraft came to rest, he would have been facing
the ground if still in his seat. In order to egress, the FE would have had to have
been physically able to follow a relatively unimpeded path towards the cockpit
area before it was consumed by the post-crash fire, which appeared to originate
also in the rear cabin area. The Coroner’s medical examination identified that
the FE was not fatally injured on impact; however, the investigation could not
conclude the reason for the FEs inability to egress the aircraft. It is possible that
the FE may have been disoriented or injured following the impact and
subsequent crash. No calls for assistance from the FE were heard by other crew
members, possibly indicating he may have been somehow rendered
unconscious during the crash sequence. Alternatively, there is very little cabin
space on the side of the transmission (Annex A: Photo 9) and the combination of
ALSE and personal protective equipment with the proximity of the M134D door
gun further limited his freedom of movement. Considering the aircraft’s initial
impact, subsequent rotation, and final position resting on its right side, the FE
may have been injured by the violent rotation and contact with the door gun. The
door gun would likely have collapsed towards the inside of the cabin, further
impeding his egress. The evidence suggests the FE was precluded from
successful egress because he was either unconscious, injured, disoriented, did
not have time to undo his restraints or was impeded by the door gun or
surrounding aircraft structure.
2.5.6 The DG was seated on the left transmission side-facing seat in the rear
cabin area and when the aircraft came to rest, he would have been facing

skyward if still in his seat. The Coroner’s examination indicated that the
significance of the impact and the DG’s possible contact with the aircraft or his
door gun would certainly have incapacitated the DG and may even have
rendered him unconscious. The inability to undo his restraints, impeded by the
door gun or surrounding aircraft structures and the bulk of the equipment he was
wearing, could have also contributed to the DG’s inability to egress. The most
likely scenario is that the DG was hit by the handgrip of the M134D door gun
during the violent rotational moment when the aircraft first struck the barrier,
sufficiently injuring and incapacitating him such that egress was not possible.
2.5.7 The Coalition soldier was seated on the floor on the right side of the
cabin, behind the right seat pilot and forward of the FE. While attempting to
render assistance to the three people still trapped in the aircraft, the pilots
noticed that at least one leg was protruding from underneath the aircraft,
approximately where the Coalition soldier was seated. The uniform was
identified to be camouflage pattern similar to what the Coalition soldier was
wearing. Although the investigation could not determine with certainty his exact
seating position at the cabin door, analysis of the injury pattern indicates that the
Coalition soldier was facing the right side of the helicopter with both legs hanging
outside at the time of impact. His legs became pinned underneath the helicopter
as it rolled onto its right side, precluding him from exiting the aircraft before the
post-crash fire reached that area. The multiple injuries specified in the Coroner’s
report are consistent with the Coalition soldier being violently thrown towards the
ground, likely due to the violent rotational moment of the aircraft. The
investigation could neither conclude what would have been the Coalition soldier’s
final resting place had he been seated in an approved seat wearing an approved
lap belt - though it is possible that it could have prevented him from being pinned
underneath the aircraft - nor what impact it could have had on his egress.
2.6 Accident Takeoff Procedure
2.6.1 Based on their perception of aircraft performance and the anticipated

degraded visual conditions from their self-generated dustball, the accident crew
developed a takeoff plan while emplaning the two passengers. As they circled
overhead, the accident crew watched the #2 aircraft takeoff and narrowly clear
the barrier. Although difficult to measure accurately due to their elevated position
and distance they estimated that the #2 aircraft had cleared the barrier by only 10
ft (The investigation found that the #2 aircraft did not clear the barrier by the 15 ft
requirement stipulated in the SMM). Based on this and the radio transmission
from #2, they were aware that their own takeoff would demand maximum
performance. However, neither of these factors cued any member of the crew to
reconsider performance calculations or the takeoff attempt. These factors only
reinforced their plan to land within the first third of the FOB in order to maximize
their takeoff distance available from the barrier. During the pre-takeoff
discussion, the FO intended to conduct an ITO but in order to maximize vertical
obstacle clearance the AC, who realized that the takeoff would require maximum
power, suggested to the FO to use more power than required for an ITO. The

AC knew the takeoff would be challenging and that the aircraft would be at the
limit of its performance capabilities. However, even during the takeoff attempt,
the intensity of the dustball, the loss of references, drift as well as height and
proximity of the barriers weighed in as more critical factors than the expected
aircraft performance.
2.6.2 The plan was to combine two separate takeoff techniques: the MPTO
to use all available power to clear the barrier while visual references were still
available and the ITO once visual references were lost in the DVE. Specifically,
the MPTO technique was to be used to generate the maximum vertical
separation from the ground and surrounding obstacles and to clear the barrier by
at least 15 ft as specified in the SMM. Once all visual references disappeared,
the ITO procedure was to provide both forward and vertical speed to eventually
exit forward of the dustball. This combination of the two takeoff procedures is
contrary to the takeoff procedure detailed in the DESERT OPS section of Task
106 within the SMM Ch 3. Paragraph 43 indicates that when conducting a
takeoff in brownout conditions, “The ITO procedure shall be used. Pilots should
not attempt the max performance take off procedure when a vertical rejection of
the take off is likely. Taking off in brown out conditions should only be attempted
when the aircraft weight is within the limit specified by the HOGE chart and
appropriate wind azimuth chart.” However, the SMM was not clear in
recommending the use of either an ITO or an MPTO when conducting takeoffs in
a confined area where the possibility of a DVE exists. In addition, if performed as
described (in paragraph 9. a. of Task 105), an MPTO would create problems with
dustball generation due to the requirement to first takeoff to a four ft hover and
confirm power, descend to one ft and then commence the MPTO. The crew did
not attempt this initial power check as it would have initiated the dustball and the
subsequent transition to an ITO from an aborted MPTO, once airborne and
drifting, would not have been an acceptable solution. Instead they planned to
takeoff from the ground and proceed directly with the MPTO and ITO. The
investigation found that the intent to conduct the combination of a modified
MPTO and transition to an ITO was a logical plan for the crew at the time facing
the conditions they faced that day. However, it raises several issues. This was
not an approved procedure and this combination of both techniques would have
increased pilot workload during the takeoff, which is conducive to an increased
likelihood for a loss of SA. Additionally, the crew had to clear the 8 ft barrier by
15 ft and therefore had to be able to hover at 23 feet AGL. Finally, had they
performed pre-flight performance planning and calculations, or considered the
directions provided in the SMM to consult HOGE and wind azimuth charts, they
would have discovered the overweight situation and the flawed plan from its
inception; an MPTO takeoff had to consider OGE parameters. The subsequent
takeoff revealed problems with the ITO procedure that had not been considered
either by the accident crew, those in theatre or others within the CH146
community.
2.6.3 Interviews with both current and former CH146 pilots at the tactical,
operational, and strategic levels revealed two major issues. First, the ITO

procedure was not developed or intended to be flown from confined areas or

without obstacle clearance considerations. The ITO was not designed to be
flown from restricted areas, such as FOBs, for the simple reason that
manoeuvring for obstacle clearance and avoidance always requires good visual
references. Second, the ITO procedure did not account for the aerodynamic
phenomenon known as tail rotor couple 35 , or in other words right drift induced by
the tail rotor. Helicopters normally do not hover in a level attitude. The CH146
hovers slightly nose high to compensate for a forward tilt of the main
transmission that improves its forward flight characteristics. Additionally, when in
a wings-level hover tail rotor thrust causes the CH146 to drift right. To counter
this, flight controls are rigged such that a left cyclic bias is incorporated and, as a
result, a slight left wing low attitude is introduced to keep the helicopter
stationary. Therefore, when a pilot slightly changes the hover attitude from left
wing low and nose-high to wings level and on the horizon, neither tail rotor thrust
nor main transmission tilt are compensated for and the helicopter will drift right
and forward, respectively.
2.6.4 The helicopter’s inherent hover instability is also responsible for drift.
The helicopter is only stabilized in the hover by the pilot’s active control inputs,
and that can only be accomplished with adequate references. Any of a number
of variations in localized wind or turbulence around the aircraft will cause the
aircraft to drift. The fidelity of a traditional attitude indicator is inadequate to
provide the degree of references that the pilot requires to control position,
attitude, and movement.
2.6.5 The crew described the ITO technique using the terminology “bar-on-
bar.” The bar-on-bar technique was explained by the accident and other CHF(A)
aircrew as superimposing the attitude indicator’s artificial aircraft symbol over the
horizon line. The SMM Ch 3 did not utilize or refer to bar-on-bar terminology,
however, it did direct aircrew to “maintain the aircraft in a flat pitch attitude 36 on
35
The following definition for tail rotor couple is taken from the A-12-050-001/PT-001, Manual of
Aerodynamics: “Hovering flight requires that a position be maintained over the ground. But, the
tail rotor anti-torque force (operating at right angles to the aircraft heading), produces sidewards
drift (to the right) proportional to the tail rotor thrust. The drift must be overcome by flapping the
main rotor so that a lateral main rotor force balances the tail rotor anti-torque force. As the
helicopter point of suspension from the main rotor is above the point where the tail rotor thrust
acts, a main-tail rotor couple is set up, which will roll the machine to the left. This rolling couple in
turn produces a couple between the main rotor lift force operating through the point of suspension
and the aircraft centre-of-gravity. The helicopters will hover, left side low, balanced by the two
couples.”
36
Pitch angle is the angular difference between the chord line of a rotor blade and a reference
datum (Manual of Aerodynamics, A-12-050-001/PT-001). With helicopters, flat pitch would refer
to a neutral, or zero, pitch angle of the main rotor blades regardless of aircraft attitude and this
usually refers to the pitch angle of the rotor blades being flat which is associated with a lower
collective position. There is some confusion created when adding the word “attitude”. A flat pitch
attitude is thought to be referring to the overall attitude of the helicopter and is not a standard
term due to the conflict with the definition associated with rotor blade angle. In this case, a flat

the ADI” (attitude director indicator), which is interpreted by aircrew to mean

wings level and on the horizon. Therefore, when properly flown by aircrew, a
lower than hover attitude pitch and a wings-level roll combine to accelerate the
helicopter forward with right drift. The forward acceleration is required in the ITO
in order for the helicopter to attain VMINI, however, the right drift is a hazardous
and unwanted effect, especially in a confined area where DVE may exist.
2.6.6 During the field investigation, the lead investigator selected a few
CHF(A) CH146 aircrew to fly the ITO in visual conditions. Results of three flown
ITO procedures revealed that the aircraft drifted forward and to the right on every
occasion. The SMM Ch 3 only mentioned a flat pitch attitude for the ITO
technique and provided no direction on the desired roll attitude, leaving it up to
the aircrew to determine. While the inherent hover instability and the lack of
adequate instrumentation and awareness cues in this flight regime (low speed
and poor visibility) must be considered, the direction provided in the ITO section
of the SMM, and the crew’s bar-on-bar interpretation and application of this
technique, also contributed to the forward and right drift of the helicopter. The
ITO, as described in the SMM and as interpreted by some aircrew, created
intentional forward drift but also unwanted and unintentional right drift.
2.7 CVFDR and HUMS Analysis
2.7.1 A comparison of FDR data from both aircraft was completed and the
results are depicted in Annex F. Aircraft orientation and pilot inputs were
analyzed by reviewing pilot interviews and CVFDR data. Cyclic movement in the
longitudinal (fore and aft) and lateral (left and right) planes as well as roll attitude
were examined. Heading data, tail rotor pedal inputs and corresponding heading
changes were reviewed. Finally collective position and estimated Qm values
were also studied. The FDR data indicated that there were no engine N1 limit
exceedences.
2.7.2 The comparison of cyclic position – longitudinal (Annex F: Graph 1)

shows some minor variation between the two aircraft but nothing that was
deemed out of the norm for an aircraft on a departure flight profile. The
comparison of the cyclic position – lateral (Annex F: Graph 2) shows a right cyclic
input between the five and 10 second mark for the accident aircraft. This right
cyclic input is also reflected in the aircraft roll attitude data (Annex F: Graph 7)
which shows a steady increase in right bank angle to a maximum value of
approximately 6º right bank. Both the cyclic position – lateral and the roll attitude
show that corrective actions were introduced by the FP at the 10 second mark.
2.7.3 The heading data taken from the FDR, Annex F: Graph 6, shows a
heading change from 221º to 199º (a 22º left turn). This is initially a slow and
gradual heading change that increases considerably between the five and 10
pitch attitude is non-standard and is intended to refer to the helicopter’s attitude, or pitch, in level
or hovering flight.

second mark. Changes in heading data reveal that the FP made positive inputs
to correct the aircraft heading back to 207º indicating that the FP had at least
partial SA on the aircraft situation.
2.7.4 For the vertical climb, two sources of data were analysed: estimated
Qm and collective position. While Qm is not very telling, the collective position
shows a difference in collective increase between accident aircraft and the #2
aircraft.
2.7.5 The #2 aircraft’s collective position increases gradually and steadily to

a maximum position of 70% of travel. The collective position for the accident
aircraft shows a staged application of collective. It is increased in stages twice to
a maximum position of 72% of travel and then decreased to 69% of travel at the
five second mark before settling at approximately 71% of travel for the remainder
of the flight.
2.7.6 From the accident timeline derived from both the CVR and witness
testimony it was identified that the FP was distracted by cross-checking the ITT
gauge as he looked inside the cockpit upon hearing the NFP’s call of 95% Qm.
The FP’s attention was then refocused outside to visual references when the
drifting right call was first made by the NFP. These head movements from the
FP occur near the five second mark, which coincide with the flight control inputs
that translated into right bank and left yaw. The five second mark is also the
point at which the FP lost visual ground references. Distracted by cross-
checking the ITT gauge and now having lost visual ground references, the FP
focussed his attention for the final five seconds of the flight back inside the
cockpit to control the helicopter and transition to the ITO procedure using flight
instruments.
2.7.7 Several factors at play included the inadvertent initial drift and yaw; the
possible drift and yaw due to DVE, illusion and motion; the transition to the ITO
procedure; and the staged application of collective in the climb. Considering
CVFDR review and pilot interviews, it is assessed that the initial drift and yaw
deviations on takeoff from the planned departure profile were inadvertent and
unwanted. FDR data may indicate the amount of aircraft motion and how much
of that was due to pilot inputs and what the inputs were intended to correct.
However, in such a dynamic situation considering the helicopter’s inherent
instability and with variables affecting the aircraft attitude such as wind and
weight combined with visibility, perception and acceleration cues affecting pilots
in a DVE, it is difficult to conclude why certain pilot inputs were made in this
situation. Without visual references, pilots may be inclined to respond to
perceived acceleration cues or “seat of the pants” feel. For example, with the
forward position of the cockpit relative to the aircraft centre of gravity or mast, a
left yaw could have been perceived as a left roll. Conversely, a right roll could
have been perceived as a right yaw, perhaps influencing pilot to input left pedal.
This could have contributed to the FP pedal or right cyclic inputs beyond what

was required. Only adequate visual references or advanced aircraft auto-hover

systems could have prevented the inadvertent and unwanted drift.
2.7.8 As previously explained, the ITO procedure called for a flat pitch, wings
level or bar on bar aircraft attitude. The cyclic movement required from a normal
hover position to adopt and transition to the ITO forced the pilot to move the
cyclic forward (dot on the horizon) and to the right (wings level). This right cyclic
input eliminated the aerodynamic forces required to counter tail rotor drift and
contributed to the forward and right drift.
2.7.9 For the climb profile, the more consistent the collective increase, the
more efficient the main rotor becomes at generating vertical lift. The SMM states
with regard to collective increase that, “Any hesitation in power application will
cause a loss in climb momentum and will require additional power to re-establish
the initial rate of climb.” Due to the plan to execute a MTPO before transitioning
into an ITO, which requires the crew to operate the aircraft at or near maximum
power and to be conscious of the aircraft limits, the FP attempted to conduct the
takeoff while trying to respect and stay within these limits. Upon hearing the
NFP’s call of 95% Qm and then noticing the ITT, the FP reduced collective to
85% Qm which also reduced or eliminated climb momentum. However, given
the environmental conditions present at the FOB, the FP would have had to
exceed normal aircraft limits (ITT, Qm and/or N1) in order to execute the takeoff
and clear the barrier.
2.7.10 Forward acceleration also aids in generating vertical lift as the main
rotor accelerates through its downwash or turbulent air and flies into clean air.
This aircraft movement is referred as translational lift. 37 The accident aircraft,
due to the right drift towards the one to two o’clock position, did not have
sufficient time or distance available between the takeoff point and the impact
point to go through translational lift. The #2 aircraft, following its intended
departure path (refer to Figure 1: FOB diagram), also had little time and distance
available to fly through translational lift before having to cross the barrier.
However, as #2 crossed the barrier sooner, this meant much less time spent in
the dustball.
2.7.11 The #2 crew attempted and completed the same takeoff as the
accident crew, combining an ITO takeoff with an MPTO with no hesitation at four
ft. They also lost all references around four ft but regained them as they were
37
The efficiency of the main rotor blades of an aircraft in the hover is improved with each knot of
incoming wind gained through translation (aircraft moving horizontally across the ground or an
increase in surface wind). Because of this movement of the aircraft through the air, turbulence
and vortices are left behind and the flow of air becomes more horizontal which improves the
efficiency of the rotor system. Improved rotor efficiency resulting from directional flight is called
translational lift. At about 16-24 knots (depending on the size, area, and RPM of the rotor
system) the rotor completely outruns the recirculation of old vortices and begins to work in
relatively clean air. (CF Manual of Aerodynamics)

crossing the barrier. The difference is that their application of power was more
gradual and steady and they did not pause or limit their application during the
takeoff. However, as they only cleared the barrier by an estimated maximum of
10 ft, and with recorded ITT exceedences above 810 to 850ºC, they were also in
an overweight and power deficit condition. The HUMS from the #2 aircraft
recorded ITT exceedences greater than 810ºC for longer than five seconds on
both engines during both the morning and afternoon takeoffs from the FOB as
depicted in Table 6. While not conclusive, this analysis assumes that the
similarly configured accident aircraft also recorded ITT exceedences in the
morning takeoff.
Above 810ºC Above 830ºC Above 850ºC

Morning takeoff Left engine 10 secs 5 secs
Right engine 16 secs 9 secs 4 secs
Afternoon takeoff
Left engine 17 secs 15 secs 1 secs
Right engine 15 secs 3 secs 1 secs
Table 6: CH146414 Engine ITT Exceedences for the morning and afternoon FOB takeoffs.
2.7.12 In summary, a review of interviews, CVFDR and HUMS data indicated

that there were initial inadvertent inputs which initiated left yaw and right drift. A
right cyclic input was made approximately six seconds before impact, the
collective position was raised in three distinct stages and lowered once, as the
aircraft’s heading transitioned from 221ºM to 199ºM before coming back to
207ºM at the time of impact. The staged application and slight decrease of
collective were not efficient at generating vertical lift and are believed to have
contributed, in addition to the overweight condition and lack of translational lift, to
the accident aircraft’s loss of climb momentum. The right cyclic movement
during the transition to the ITO procedure contributed to the right bank which
resulted in an accelerating aircraft attitude towards the barrier. The fact that the
#2 aircraft cleared the barrier is attributed to their smooth and constant
application of collective, the additional power gained when they exceeded the ITT
limits and the reduced AUW due to the 200-300 lbs difference in fuel load. It is
assessed that neither aircraft could have successfully completed its takeoff and
cleared the barrier without exceeding ITT limits.
2.8 CH146 Performance Charts
2.8.1 Certification
2.8.1.1 As indicated in section 1.6, virtually all certification approvals were

managed and controlled by the CH146 Project Management Office as AETE's
role was very limited. Research of AETE project files was limited to focus on
performance testing and found a summary of the limited Cat I Experimental Test
& Evaluation test results for the CH146 conducted from 1994 to 1996. The AETE

CH146 Cat 1 Testing Final Report 38 concluded that “Within the scope of BHTC’s
Category I testing, the CH-146 showed excellent potential as a civil transport
category helicopter. However, BHTC testing did not include any testing germane
to the specific requirements of its intended military missions, therefore, the
suitability of the CH-146 as a utility tactical transport helicopter in support of land
forces or as a combat support helicopter in support of air forces could not be
assessed.” The AETE report went on to recommend an additional 14 issues for
further testing with the relevant five copied here:
a. mission specific testing to identify and define technical and human

factor limitation of the CH-146 with respect to its intended military roles
(para 4.01);
b. an evaluation of the visibility and accessibility of the CH-146’s

instruments, panels, displays and caution, advisory and warning
annunciators for its intended military roles and crewing (para 4.15);
c. flying and handling qualities testing to the criteria of MIL-H-8051A 39 and

ADS 33D 40 (para 4.18);
d. independent validation of the performance criteria of the Detailed

Specification 41 (Ref 1-1) (para 4.19); and
e. a safety of flight crew workload assessment under mission

representative conditions (para 4.22).
2.8.1.2 There was a variety of test plans covering various aspects of CH146
Cat II testing that were completed by AETE such as FLIR and NVG testing,
among many others. It was the Project Directive for Cat II testing, Test Plan C,
which could have captured the recommendations from the Cat 1 Final Report
that originally tasked AETE with “Validation of flight manual performance charts
found in Section 8 of the flight manual which are not associated with the FAA civil
certification.” Test Plan C was only one of many CH146 Cat II test plans carried
out by AETE but this was the particular one that included performance testing
and it was eventually cancelled due to personnel limitations, time constraints and
conflicting project priorities. That decision was made by the flight test working
group which included representation from the 1 Cdn Air Div, 1 Wing, WSM and
AETE. No final report was produced and therefore performance charts unique to
the CH146 were never independently validated by AETE. With limited testing
and no validation completed, the CF accepted the civil Bell Model 412 charts as
38
AETE 10081-S40-9401 (Plans 3), PROJECT S40-9401 CH-146 CATEGORY I TESTING –
FINAL REPORT, 2 May 1997.
39
MIL-H-8051A: Helicopter Flying and Ground Handling Qualities.
40
ADS 33D: Aeronautical Design Standard, Handling Qualities Requirements for Military
Rotorcraft.
41
Detailed Specification: BHTC Report 412-947-044A Detailed Specification for Canadian Forces
Utility Tactical Helicopter (CFUTTH) Post CDR Edition.

the CH146 Griffon performance charts. The main point was that the CF did not
conduct an independent check of performance data upon which certification was
based. Investigators could not determine what processes or requirements were
in place at that time to verify and validate aircraft performance data. Currently,
the TAA/DGAEPM certification defines the level of flight testing required.
2.8.1.3 Interviews with key people from within the TAA, the OAA and the
CH146 community also identified that the differences between an AFM and an
AOI and the impact on military operational performance planning were not well
known within these organizations. The aim of the AFM is to provide TAWD to
safely operate the aircraft. There is no requirement to provide explanations on
the performance charts or to direct aircrew to specific mission-oriented
performance calculations for given environmental conditions. This information is
normally included in an AOI, an SMM or provided during aircrew training.
However, without such clear information for CH146 operations, the investigation
revealed that there was no clear understanding of, or clear process for,
calculating mission-oriented performance data from the AFM, other CH146
operation manuals or within the training provided to aircrew at the time before the
accident. Ideal performance planning would have involved a review of the Hover
Ceiling charts and the Critical Wind Azimuth charts in the AFM Section 4 to
determine the allowable or maximum takeoff weight. This would then be followed
by a review of the Cruise Performance and Hover Torque Required charts found
in Section 8 of the AFM to determine the expected performance for their specific
aircraft. While the Cruise Performance charts were not intended to provide hover
performance data (power available or AUW in the hover) these were the charts
available that could offer a close estimate. The fact that the AFM was not
validated by the CF and that no AOI was created meant that there was little
guidance on how to use these charts for mission-oriented performance planning.
As previously explained, (refer to paragraph 1.6.5.8 dealing with the cruise
performance charts), the sheer number and amount of charts to be carried and
referred to in-flight also made it very difficult to calculate aircraft performance
values while conducting operations. Eventually the development of the notebook
with performance software easily enabled re-calculations in-flight for Afghanistan.
However, at the time of the accident, performance planning could only be
extrapolated from information within the AFM; with no clear directives on how to
properly use the charts and with the high number of charts to actually use, there
was a high risk for confusion, lack of understanding, misinterpretation and
improper calculations.
2.8.2 AFM Charts: Confusion and Lack of Understanding
2.8.2.1 During post-accident interviews and the review of CH146 performance

charts, the investigation found both confusion and a lack of understanding of the
various charts found in the CH146 AFM by the technical and operational
communities. Initial indications were evident during the post-accident CH146
AFM performance chart review that included the personnel from the OEM, the
TAA and the OAA with representatives from DGAEPM (TH), DTAES, AETE, 1

Cdn Air Div and C Air Force Staff. During these meetings it became increasingly
clear that, in addition to the errors and discrepancies found within the
performance charts, the required knowledge for using the CH146 AFM
performance charts was low and posed a high risk for improper and inadequate
performance calculations. As indicated in the DTAES technical note in section
1.16, these issues included the origins and validity of the charts, incorrect charts
and the placement of the charts within inappropriate sections of the AFM.
2.8.2.2 Discussions with TAA stakeholders revealed some confusion when

dealing with the AFM charts. From the TAA viewpoint, as not all charts are
developed using TAWD exclusively, it is the OAA staff, via the operational
community, that should be able to identify issues with the flight manual. The
technical staff is typically not trained in using the charts for flight planning and
does not control how aircrew are trained or when and how aircrew use them.
Should the operational community find issues, errors or discrepancies, it is
incumbent upon them to report these to the TAA for resolution. It is understood
that the technical staff within the TAA (WSM/DTAES) have the requisite
knowledge and expertise to deal with technical airworthiness data, to answer or
find answers to technical questions and to quickly learn and understand the
issues if and when they arise. It is not expected or feasible for them to have in-
depth knowledge of all performance charts when no issues have been raised by
the operational community to focus attention on the subject. However, the
investigation noted considerable confusion with the AFM charts during
discussions between WSM and OEM specialists. This was further confirmed
during additional post-accident meetings, exchange of email, telephone and in-
person interviews.
2.8.2.3 This was equally apparent within the operational community; while
some pilots and flight engineers were very knowledgeable and educated on the
proper use of the AFM and the charts, a surprising number of aircrew showed
difficulty in explaining the use of the appropriate charts, selecting the proper
charts or conducting proper calculations. Several aircrew interviewed showed an
inconsistent level of knowledge and understanding on using the AFM charts.
Personnel interviewed from both the technical and operational communities
confided that this confusion and knowledge gap existed and that it could have
developed over many years, potentially beginning as far back as the CH146’s
introduction to service.
2.8.3 AFM Charts: Section 1 and Section 4
2.8.3.1 The investigation found that the differences between Sections 1 and 4
of the CH146 AFM were not clearly understood by the 1 Wing aircrew
interviewed. Section 1 includes limitations set by the OEM and/or regulator that
shall not be exceeded. However, for the charts depicting performance levels in
Section 4, sound airmanship and risk management principles suggest that going
beyond these certified minimum-assured performance levels should only be done
in carefully controlled circumstances. In situations where conditions are

favourable (such as good visibility and weather) and other operational risks are
controlled or minimized, operating beyond the depicted performance levels can
be an effective use of the aircraft's maximum capability. Doing so in less than
optimum conditions, such as at high HD and/or in the presence of obscuring
phenomena, does place the aircrew and aircraft in an operating region with
minimal or no safety or performance margins and this can significantly elevate
the risk level. At times the military operational imperative may justify operations
in this region, though this should be accepted and directed by the chain of
command.
2.8.4 AFM Charts: Lack of Confidence
2.8.4.1 The investigation found a lack of confidence in the accuracy of the

AFM performance charts within the CH146 aircrew community. In the span of
the CH146 service life, in-flight aircraft performance was often much better and
outperformed the values that had been calculated using the cruise performance
charts, which are based on Min Spec engines. Over time, this led to gradual
erosion in the confidence of the accuracy of the charts’ information and this
influenced the way crews were conducting power and performance calculations
in preparation for their respective missions. This also led CH146 aircrew to
question the validity of the charts and downplay the importance of completing
detailed performance calculations. Several senior and experienced aircrew from
within 1 Wing confirmed that this degradation of confidence existed but admitted
that the issue had never been officially addressed or raised to the technical
authorities. As explained, the TAA would have been unable to address these
concerns when they had not been formally reported. This lack of confidence in
the accuracy of the AFM charts resulted in their limited, and at times, inadequate
and improper use during flight planning. With the mindset that the performance
charts were incorrect or overly conservative, many crews reverted to using only
the Weight-Altitude-Temperature (WAT) charts for mission planning.
2.8.5 AFM Charts: Performance Calculation Training and Improper

Calculation Methods
2.8.5.1 Investigators also found deficiencies in the aircrew performance

calculation training. A review of the training, details and methodology on using
AFM charts for CH146 mission planning could not be found in the AFM or the
SMM; additionally, an AOI did not exist to provide such details. Initial
discussions and interviews with SMEs in 1 Wing headquarters revealed
discrepancies and errors in calculation methods. Follow-on interviews with
personnel from 1 Cdn Air Div and the CH146 training unit, 403 Helicopter
Operational Training Squadron (HOTS) indicated that with pre-flight calculation
duties primarily conducted by the FEs, their training was typically more detailed
and comprehensive than that provided to pilots. Investigators discussed the
AFM charts and performance calculations with several current and formerly
qualified pilots and FEs. As these calculations were part of their typical pre-flight
duties, the investigation found that the FE’s were typically more proficient with

the AFM charts. However the investigation found a wide range of experience
and knowledge, from excellent to quite poor. Pilots received similar performance
calculation training and, as this task was typically conducted by FEs, their
knowledge and proficiency with the AFM charts was generally lower than that of
the FEs. The range of experience and knowledge also varied. Overall, the
investigation found that skill or knowledge in conducting proper calculations was
lacking. This is not to suggest that all aircrew within 1 Wing could not conduct
proper calculations. However, multiple interviews with former and current CH146
pilots and FEs from within the CH146 community found a surprising number of
aircrew whose knowledge of conducting proper calculations had degraded and
was either incomplete or erroneous.
2.8.5.2 As revealed in DFS interviews, some aircrew often used improper

calculation methods as they incorrectly applied the WAT chart as the primary
reference for mission planning. Many were not in the habit of consulting the IGE
or OGE Hover Ceiling charts, Cruise Performance or Hover Torque Required
charts to calculate aircraft performance and determine if they would have a
sufficient power margin to conduct a mission. The investigation found that many
CHF(A) crews based their aircraft performance planning, solely and erroneously
on Figure 1-1A (WAT limitations for takeoff and landings and IGE
manoeuvres, winds from -45 deg to 45 deg, 9 passengers of less) of the
AFM or the similar WAT chart Figure 8-13.
2.8.5.3 For the Hover Ceiling IGE/OGE charts, neither power available nor
power required calculations could be derived using these charts. For power
required calculations, calculations assume that the aircraft is operated with Min
Spec engines, with zero wind, at a weight within the limit of the charts and,
provided the charts depict a limit line. For the CH146 fleet and aircraft in general,
it is very common for engines to perform well above Min Spec. With the CH146,
for a given flight condition and ITT value where the engine is able to produce
more power than Min Spec, the resultant aircraft power available will normally be
higher; therefore, if an aircraft is operated with engines that perform better than
Min Spec, power available will be increased. While an engine may operate
better than Min Spec, the resultant increase in power available can be hampered
and reduced by exceeding weight, temperature and altitude limits. As previously
indicated, the presence of a positive or negative wind vector will reduce or
increase power required. Combined, (the increase in power available with the
reduction in power required) these factors will increase the power margin; this
actual amount could not be calculated for the accident aircraft or for any CH146.
Although not required by certification standards, neither the AFM nor the SMM
contained a methodology for aircrew to determine the actual margin of power
available above Min Spec power. Also, certain WAT charts in use at the time of
the accident, such as Figures 1-1A, 8-11, 8-12 and 8-13 did not include a limit
line as depicted on the WAT chart Figure 1-1 or on the IGE Hover Ceiling chart
Figure 4-4. In this scenario, the proper OGE Hover Ceiling chart should have
been Figure 4-4 (sheet 3 of 11).

2.8.5.4 In addition, the SMM did not specify any minimum power margin to
conduct a takeoff from a four ft hover IGE. There was no information to
determine what percentage of additional power was required to go through
translational lift. Only in the case of an MPTO was there guidance that directed a
minimum power margin of 20% to be available above hover torque IGE. With the
assumption that power available was always 100%, some CHF(A) CH146
aircrew interviewed in the conduct of this investigation also erroneously assumed
that any hover torque value below 80% was acceptable to conduct the MPTO.
2.8.5.5 As performance calculations are normally conducted by the FE, and

since the accident FE perished in the accident, investigators could not locate pre-
flight calculations or determine with certainty which WAT chart was used by the
accident FE. The #2 aircraft FE used the least restrictive WAT chart, Figure 1-
1A. Again, it is important to understand that the Figure 1-1A chart did not
contain the note referring the reader to the Hover Ceiling charts, nor did it contain
a limit line that guaranteed aircraft performance with Min Spec engines as
depicted on Figure 1-1. In addition, use of only the WAT chart Figure 1-1A was
facilitated by the fact that the WAT chart Figure 1-1 indicated all wind azimuths
and for 10 passengers or more while WAT chart Figure 1-1A indicated -45o to
+45o wind azimuths and 9 passengers or less. The indication of the number of
passengers (10 or more or 9 or less) is a certification criteria but this was
misunderstood by CH146 aircrew and erroneously led them to use Figure 1-1A.
Generally, performance planning stopped there and the IGE or OGE Hover
Ceiling charts, Cruise Performance or Hover Torque Required charts were
seldom used.
2.8.6 The investigation concluded that aircrew from both the accident and #2
aircraft referred to the AFM WAT charts (specifically Figure 1-1A) to determine
whether they would be able to safely takeoff from KAF as was common practice;
and this was the extent of their performance planning. The WAT limit derived for
the IGE takeoff out of KAF was 11,900 lbs, the aircraft’s certified maximum GW.
The estimated aircraft weight for the takeoff out of KAF was 11,520 lbs, close to
400 lbs less than the WAT limit. This led the accident crew to believe,
erroneously, that they had sufficient power available. For the takeoff out of the
FOB, the density-altitude (see paragraph 1.7) had increased, requiring higher
performance from the aircraft. Due to obstacles that were present, the takeoff
required OGE performance and therefore reference to the applicable WAT chart
for OGE operations. The WAT limit was 11,060 lbs. The estimated aircraft
weight on takeoff from the FOB was 11,520 lbs, or 460 lbs overweight. Evidence
indicates that both the accident and #2 helicopter crews assumed that, if they
could depart from KAF (according to the WAT charts) and as long as they
expended a sufficient amount of fuel to reduce weight, they would have sufficient
performance to takeoff from intermediate stops. In this case, since their
calculations for KAF gave them a 400 lb margin, they expected that the additional
weight savings from the fuel burn en route would allow them to safely takeoff
from the FOB. As previously indicated, interviews revealed that CHF(A) crews
commonly used the WAT charts only and there was little use of or no reference

to the Section 4 Hover Ceiling charts, which in most cases are more restrictive.
The relevant OGE chart that should have been used was the OGE Hover Ceiling
Chart, Figure 4 - 4 (Sheet 3 of 11), which showed a guaranteed Min Spec
weight of only 10,000 lbs thus providing an estimate that the accident aircraft
was close to 1,500 lbs over the Min Spec weight. With such an apparent and
drastic overweight condition, the investigation concluded that the accident crew
did not consult the appropriate charts, power margins were not determined,
performance calculations were conducted for the takeoff from KAF only and none
were completed for intermediate stops or the accident FOB.
2.8.7 These deficiencies in training, the improper calculation methods, the

lack of confidence in the accuracy of the charts and the overall lack of knowledge
with respect to the expected engine performance paved the way for this accident
as well as ITT and/or other exceedences to occur in Afghanistan’s high density
altitude environment.
2.9 Inter-Turbine Temperature Exceedences
2.9.1 Over the span of the CH146 service life on both domestic and
deployed operations abroad, the aircraft was rarely operated at the extreme end
of its performance limits as it was in Afghanistan. Interviews with various current
and former CH146 qualified aircrew indicated that during most operations, the
CH146 was historically and generally flown within the Qm band of limits and
aircrew rarely encountered situations where ITT became the limiting factor. The
normal ITT operating limitation for CH146 twin-engine operations is 810ºC with a
five second transient limit to 940ºC; the AFM also prohibits intentional operations
above these limits. After the accident and as part of the regular HUMS data
analysis supporting routine maintenance, the WSM identified that the ITT limit of
810º-940ºC for more than five seconds was exceeded over 1,120 times in
Afghanistan between Dec 08 and Nov 09. When the CH146 first entered theatre
in Dec 08 the aircraft would likely have been Qm or AUW limited. With the onset
of the hot summer season and with elevated OATs, the aircraft would have
become temperature limited or ITT limited. As a result, the rate of exceedences
significantly increased. However, with the historical expectation that the aircraft
was Qm limited and with minimal use of the OGE charts for flight planning, it
would have been difficult for aircrew to anticipate that ITT would become the
limiting factor. Although these exceedences were reported to maintenance
personnel and recorded, they were not reported to Flight Safety personnel or
entered into the Flight Safety Occurrence Reporting System.
2.9.2 Maintenance Actions
2.9.2.1 Interviews with WSM staff as well as with CHF(A) aircrew and
personnel revealed a difference between operator and technical manuals. As is
the case for all aircraft, technical limitations identified in maintenance
documentation are not necessarily identical to operating limits. However,
common practice should be to report exceedences of published operating limits

to the maintenance and/or operational authority. Apart from the stated ITT limits,
there was no direction in the AFM or the SMM concerning ITT exceedences and
the required aircrew or maintenance actions. The maintenance personnel
referred to the CH146 maintenance manual C-14-108-000/MF-001, page 619,
Figure 604 for guidance. Some aircrew reported that after initially identifying to
maintenance personnel that they had exceeded ITT limits, no maintenance
activity was carried out. For the vast majority of these exceedences, the
maintenance manual directed “no maintenance actions required” and/or
“maintenance recording required” meaning the only actions taken were to record
the event in the aircraft record set. Based on the assumption that no
maintenance actions were required some aircrew believed that the exceedences
did not constitute reportable Flight Safety occurrences. Testimony indicated that
reporting ITT exceedences directly to maintenance vice Flight Safety became the
informal SOP; this reporting procedure gradually diminished to the point where
no ITT exceedences were reported. This and the lack of information within the
AFM concerning ITT exceedences contributed to the lack of reporting by aircrew,
which allowed the exceedences to continue to occur without any maintenance,
operational or flight safety authorities to have knowledge, oversight or be in a
position to deal with this issue.
2.9.3 Interpretation of Limits
2.9.3.1 The number of ITT exceedences was exacerbated by several CHF(A)

and 1 Wing aircrews’ interpretation of the ITT limitations found in the AFM. The
ITT limit is 810ºC with a five second transient limit to 940ºC, but the AFM
CAUTION states that “intentional” use of ITT above 810ºC is prohibited during
normal operations except during start. This raised two issues. First, Notes,
Cautions, or Warnings tends to be advisory in nature, whereas limitations are
mandatory. The proper terminology for warnings, cautions and notes is defined
in the Foreword page i of the AFM and are used to emphasize important and
critical instructions. 42 This is not uncommon in CF AFM/AOIs. This specific
limitation was embedded in the Caution depicted after all ITT limits and may have
been perceived by aircrew as advisory information only. Second, the
investigation found that CHF(A) aircrew did not hesitate to regularly use and
exceed the transient ITT limits. When questioned on their interpretation of ITT
limits and intentional operations above 810ºC, several aircrew stated they never
“intended” to operate beyond 810ºC but operational pressures and climatic
conditions often required the exceedences. Since there was no initial intent to
exceed limits, several aircrew did not consider these exceedences as reportable
Flight Safety occurrences. Aircraft limits are often set to consider the negative
effects of use, fatigue, and service life on aircraft components and exceeding
established limits thus has a direct impact on these factors. Understanding this,
42
The AFM definitions are copied as follows: WARNING: An operating procedure, practice, etc.,
which, if not correctly followed, could result in personal injury or loss of life. CAUTION: An
operating procedure, practice, etc., which, if not strictly observed, could result in damage to or
destruction of equipment. NOTE: An operating procedure, condition, etc., which is essential to
highlight.

aircrew will normally avoid exceeding aircraft limits in power-limited conditions

unless facing rare and extreme conditions requiring the maximum performance
available. The large number of ITT exceedences clearly indicates that the
aircraft was power-limited in Afghanistan. However this number also indicates
that aircrew did not hesitate to regularly use and exceed the transient ITT limits.
Given witness testimony and statements from aircrew in CHF(A), the
investigation revealed that several aircrew were not aware of the negative effects
on component service life and regularly turned a blind eye to the 810º-940ºC five
second transient limit. In this case, their justifications were based on the stated
extremely high importance of the mission in Afghanistan, their own perception of
operational necessity, their lack of awareness concerning the negative effects on
component service life, and the perception of a lack of maintenance impact.
2.9.3.2 As previously discussed, the CH146 was often Qm limited and aircrew
were seldom dealing with ITT as the limiting factor. In order to mitigate the risk of
over-torque and to avoid exceeding a Qm limit, the SMM included directions to
call out Qm during takeoff procedures. Standard crew duties detailed in Table 1-
1 indicated that the NFP “was to advise when power setting is 80% Qm (mast
torque) and above in increments of 5% and approaching 100%; and to start
timing so as not to exceed the 5 min limit above 81% Qm.” Such detailed calls
were not included for ITT limits. A review of the SMM only found a general
statement indicating that the NFP should crosscheck systems and instruments.
There was no specific reference to calling ITT limits on takeoff. The CH146
community continues to apply torque margin however, through a somewhat
complicated method of trying to equate engine ITT limits to torque values, and
using those for go/no-go decisions. This approach is not recommended and a
method should be developed for flight planning that can account for either
environment, without requiring the conversion of actual limits into surrogate
values, such ITT into torque margin. Normally this could be simplified greatly if
the aircraft had an integrated power display in the cockpit showing a “first limit”
indication, and also providing situational awareness of the margin remaining to
the first limit. However, the CH146 does not have this capability.
2.9.4 In summary, while ITT exceedences were initially often reported to

maintenance personnel, follow-on maintenance action was not always required.
After the accident, the CH146 WSM staff investigated these exceedences and
discussed them with the OEM and, although the frequency of the exceedences
was concerning, no additional maintenance action was required outside of the
maintenance practices already existing. The required operational action was that
the exceedences had to stop and that proper planning needed to be carried out.
Routinely exceeding the ITT limits should have been a clear indication to the
aircrew that they were repeatedly going beyond the engine power limited AUW
capabilities of the aircraft. DFS interviews confirmed that CH146 aircrew had
rarely operated in conditions where ITT was a limiting factor or been exposed to
operating near ITT limits. A review of the SMM found little guidance for
monitoring ITT limits during takeoffs. However, the large number of ITT
exceedences demonstrated the aircrew’s acceptance to regularly exceed

published limitations. Further investigation revealed confusion among the

aircrew and maintenance communities’ understanding of the differences between
operational limitations, maintenance limitations and the potential negative effects
on an aircraft component’s service life when these are exceeded.
2.10 Post-accident Performance Calculations
2.10.1 The review of performance calculations indicate that both aircraft were
operating in an area of power deficit within the power curve as depicted in Figure
3 of Annex B: Aircraft Performance Definitions. A significant factor that must be
taken into consideration is the method used to calculate the aircraft’s
performance capability for each mission. Aircraft performance can be
determined for either torque or engine temperature limitations. The CH146
community, having customarily operated in torque-limited environments, typically
used a performance planning approach based on torque margins. On the day of
the event, given the environmental conditions at the FOB, a different planning
approach was required as the aircraft was limited by engine temperature and not
by the torque margins.
2.10.2 Performance Calculator Software
2.10.2.1 As described in section 1.19, the Performance Calculator planning

software was developed to provide an estimate of aircraft power available under
given environmental conditions. The software provided an estimate only.
Screen captures of the Performance Calculator software output for both aircraft
are depicted in Annex K. Using the applicable environmental conditions and
aircraft data for the FOB takeoff, Table 7 presents the software estimated power
available, maximum takeoff weight and shows the difference with the AUW. 43
Aircraft Estimated Maximum Estimated

Power available Takeoff Weight AUW
CH146434 IGE 89.6% Qm 11,683 lbs FOB required OGE takeoff
OGE 89.6% Qm 10,776 lbs 11,520 lbs
CH146414 IGE 88.9% Qm 11,683 lbs FOB required OGE takeoff
OGE 88.9% Qm 10,951 lbs 11,200 lbs
Table 7: Software performance - Estimates Only.
2.10.2.2 Analysis of historical daily PACs revealed that both engines from the
accident aircraft were performing better than Min Spec and that they had a
slightly higher margin of performance than the #2 aircraft engines. Based on
HUMS and FDR data, the accident aircraft reached an ITT of 840º-850ºC on
takeoff, 30º-40ºC above the allowable maximum continuous twin-engine limit of
43
The software is not based on all of the AFM charts that were in effect at the time of the
accident. Some of those charts have since been replaced and newer ones (based on FAR 29
Cat B performance) were added which may permit an increase in performance. Therefore, the
weights and Qm values quoted here from the software are estimates only for comparison with
the #2 and accident aircraft. These indicate what was authorized with the software, and not what
the aircrew could have or should have derived at the time of the accident.

810ºC. As depicted in Table 6, the #2 aircraft recorded ITT exceedences above

810ºC for more than five seconds during its takeoff out of the FOB proving that it
too was in an overweight condition.
2.10.3 Annex C depicts the WAT and Hover Ceiling charts that were available
and the calculations (estimates) 44 pertinent to the environmental conditions
present on the day of the accident for the takeoff out of KAF and for the takeoff
out of the FOB. Annex D depicts the Cruise Performance chart calculations
(estimates) and Annex E depicts the Torque Required to Hover calculations
(estimates). The Qm values derived from the AFM WAT and Cruise
Performance charts are representative of an aircraft with Min Spec engines.
2.10.4 KAF Takeoff
2.10.4.1 Performance data for the afternoon takeoff out of KAF resulted in the
values in Table 8. (Using and interpolating between the 2,000 and 4,000 HP
cruise performance charts - see Annexes C, D, and E.)
KAF Takeoff
(HP 3,520 ft; OAT 42ºC; AUW 11,520 lbs)
WAT IGE limit 11,900 lbs

WAT OGE limit 11,300 lbs
IGE Hover Ceiling limit 10,600 lbs
OGE Hover Ceiling limit 10,200 lbs
Hover torque required OGE 92% Qm
Hover torque required IGE 78% Qm
Power available 77% Qm (-1%)
Table 8: Performance data for the KAF takeoff (IGE values could be used) 45
2.10.4.2 Given the ambient conditions for the takeoff at KAF and using the
Cruise Performance charts, the power available for an aircraft with Min Spec
engines would have been 77% Qm. Using the Hover Torque Required charts,
the Qm required for an aircraft with Min Spec engines would have shown 78%
Qm for hover IGE. This 1% deficit indicated that the aircraft was limited by
engine power (and therefore ITT) and not limited by Qm. The fact that Qm
required was greater than Qm available indicates the aircraft was in an
overweight condition. Max AUW at KAF (for 3,520 ft and 42°C) was 11,415 lbs
for IGE; the actual aircraft weight was 11,520 lbs, 105 lbs overweight. Although
overweight for the takeoff out of KAF, it would only have required a slight ITT
exceedence to get airborne. The reason for which they were able to get airborne
out of KAF without exceeding the ITT limit could be explained by several factors
44
The calculated values in paragraphs 2.10.4.and 2.10.5.were derived using the charts of the
AFM Ch 2 dated 2009-02-20. The values depicted within the Annexes may not be exact due to
software limitations or the width of the lines in trying to align exact values.
45
The importance of this table is to show the weight differences between the AUW of 11,520 lbs
and the calculated limits in bold. The -1% is the difference between the Hover Torque Required
IGE and the Power Available.

such as engines operating at better than Min Spec (which could not be
determined), wind effects, lower hover altitude used in the transition to forward
flight or smoother aircraft handling.
2.10.5 FOB Takeoff
2.10.5.1 Performance data for the afternoon takeoff out of the FOB resulted in
the values in Table 9. (Using and interpolating between the 4,000 and 6,000 HP
cruise performance charts - see Annexes C, D, and E.)
FOB Takeoff
(HP 4,675 ft, OAT 39ºC, AUW 11,520 lbs)
WAT IGE limit 11,750 lbs

WAT OGE limit 11,060 lbs (-460 lbs)
IGE Hover Ceiling limit 10,300 lbs
OGE Hover Ceiling limit 10,000 lbs (-1,520 lbs)
OGE AUW 9,600 lbs
OGE AUW @ 23 ft 9,800 lbs (-1,720 lbs)
Hover torque required IGE 78% Qm
Hover torque required OGE 93% Qm
Power available 76% Qm (-17%)
Table 9: Performance data for the FOB takeoff (OGE values should have been used) 46
2.10.5.2 Using the Cruise Performance charts, the power available with Min
Spec engines was a maximum of 76% Qm. The Hover Torque Required charts
identified 93% Qm as the power required to hover OGE at the FOB. This
represents a performance deficiency of 17% below what was required for hover
OGE which, had these calculations been made, would have necessitated a
further review of environmental conditions, aircraft performance and the mission.
A review of the CH146 operating manuals found little guidance on how to use
performance calculations to support mission acceptance or substantiate mission
rejection. However, RCAF flying regulations stipulate that the aircraft must be
flown according to its published operating limits (as per AFM or AOIs), thus
providing ACs the required authority to accept or reject missions that can
accomplished within these limits.
2.10.5.3 The takeoff from the FOB was much more challenging on a
performance perspective from both the KAF takeoffs and those conducted that
morning. Given that the barrier was eight ft high and the SMM required a 15 ft
clearance over the obstacle, the ITO procedure (applicable in situations involving
a DVE, such as brown-out) required a 23 ft hover capability. The CH146 WSM
and AETE sanctioned a Hover Performance Project where an assessment of the
accident was performed. Based on the AETE flight test results, it was
46
The importance of this table is to show the weight differences between the AUW of 11,520 lbs
and the calculated limits in bold. The -17% is the difference between the Hover Torque Required
IGE and the Power Available.

determined that the aircraft was in fact capable of hovering IGE in the FOB
conditions at 11,520 lbs (Min Spec with no margin), however for the same
conditions the OGE hover capability would have been 9,600 lbs. The OGE
Hover Ceiling chart indicated a max OGE weight of 10,000 lbs. Using the effects
of the skid height chart for a 23 ft departure shows a max AUW of 9,800 lbs,
indicating that the aircraft was 1720 lbs overweight for the intended departure.
2.10.6 The evidence of the overweight condition due to fuel and passengers,
the review of performance calculations, and the ITT exceedences recorded on
both aircraft indicate that both the accident aircrew and the #2 aircrew were
operating the aircraft/engines well beyond their normal operating limits. Although
new charts were used in the development of the software which provides
increased performance over the charts that were available at the time of the
accident, both the new charts and the software reveal that neither the accident
aircraft nor the #2 aircraft would have been able to takeoff without exceeding ITT
limits and that neither aircraft had power available to attempt an OGE takeoff
given their estimated AUW.
2.11 Organizational Issues
2.11.1 CH146 Deployment to Afghanistan
2.11.1.1 It is important to note that the CF was not the only nation to operate
helicopters in Afghanistan. A wide spectrum of helicopter types from other
nations, including variants of the Bell 412, operated in the Afghan theatre. All
were subject to the hostile military and meteorological environment including
operations in DVE and in high, hot and heavy flight regimes. Several staff
checks had been completed to assess the various options in deploying the
CH149 Cormorant, the CH124 Sea King or the CH146. With the CH146 already
fulfilling the role of being the CF’s tactical aviation helicopter, selecting the
CH146 was the logical solution. This facilitated the transition into combat
operations and the integration with the Canadian Army and Allied land forces in
theatre. In addition, the selection of the CH146 offered the CF the ability to
effectively support the newly acquired Chinook and its missions in theatre.
Essentially, the CF was tasked with a mission to deploy tactical aviation assets
into a combat theatre; the CH147D Chinook and the CH146 Griffon were the best
capabilities that the CF had available to support this mission. With that, the
RCAF chain of command, including operational and technical authorities, had the
full expectation that the helicopters would be flown within stated limitations
detailed in the aircraft’s respective flight manuals.
2.11.1.2 A review of the various pre-deployment decision briefings conducted

prior to the deployment into Afghanistan revealed that the CH146 capabilities and
limitations were presented by experienced aircrew but focussed mainly on its
range and payload capacities. The limited CH146 performance data that was
presented was based solely on Figure 8-11 WAT chart, all azimuths (Annex C
pg 4/6) of the AFM. As previously indicated in paragraph 1.6.5, the WAT Charts

only determine the maximum allowable weight and maximum HD for takeoff,
landing and IGE/OGE hover operations. The Hover Ceiling, Cruise Performance
or Hover Torque Required charts were not referenced and, therefore, critical
aircraft performance information was not presented. Given the high HD
operating environment, the overall expectation was that the aircraft would be
power-limited and that performance would be limited by parameters such as Qm.
However, the brief presented little information concerning power performance
including Qm or ITT. With the briefed aircraft capabilities and limitations based
solely on the Figure 8-11 WAT chart, and while CH146 power performance may
not have been presented, the chain of command could have been left with the
impression that the CH146 performance would be significantly better than it
actually was. On one hand, despite the challenges of operating at high OATs
and HDs, the Griffon was suitable and very effectively employed within
operational limits for operations in Afghanistan for certain specific missions (e.g.
passenger transport in winter months when OAT was lower, Intelligence
Surveillance and Reconnaissance (ISR) missions, Escort, and Fire Support roles
when properly managed.) On the other hand, passenger transport or other utility
flights in such extreme environmental conditions, with OATs and HDs, combined
with flights conducted to very austere unprepared surfaces, at high elevations or
with the potential for DVE, could prove challenging and extremely difficult to
accomplish. Nonetheless, the chain of command had the full expectation that the
aircraft would be operated within its performance limitations.
2.11.1.3 1 Cdn Air Div uses the Record of Airworthiness Risk Management
process to identify and mitigate risk. RARM - CH146 2008-001 Combat
Configuration for Afghanistan was released on 03 March 2008, well before the
CH146 deployment and the accident, to assess the impact of conducting flying
operations without certain aircraft components. With an understanding of
Afghanistan’s challenging environmental conditions, the aim of the RARM was to
reduce the basic aircraft weight and tailor its configuration to afford greater
flexibility, enhance mission accomplishment and mitigate the inherent adverse
HD impacts. This initial RARM proposed the removal of the basic survival kit,
IFR equipment, the paper copy of the AFM, and daytime anti-collider lights;
subsequent versions of the RARM eventually led to the removal of the cargo
doors. Included in the RARM were mitigation strategies such as flight operations
to be conducted using the principle of section integrity (flying as a pair of
helicopters), under VMC, under the cover of darkness to the maximum extent
possible and above the small arms threat. The RARM did not initially address an
expansion to operating limits.
2.11.1.4 At the tactical level as early as October 2008, initial RARMs for CH146
operations in Afghanistan had been drafted to identify and mitigate the risk of
helicopter employment, mission flight profiles and weapon employment in a high
threat environment. These had been drafted as some unit-level officers saw a
need to identify these risk factors and to ensure that these were in line not only
with the CF’s Airworthiness Authority’s (AA), OAA and TAA acceptable levels of
risk, but also with other allied tactical aviation forces in theatre. These proposed

RARMs included operational issues such as operations in low illumination,

countering rocket-propelled grenade/indirect fire/small arms fire, operations at
high HD, mountainous terrain, operations in mixed formations, and operations in
small/dusty FOBs. Discussion with 1 Cdn Air Div Operational Airworthiness staff
in addition to a review of their website and RARM database revealed that these
RARMs had not been staffed to 1 Cdn Air Div. Despite the intent behind these
proposed RARMs and the mitigating actions identified, this accident occurred at
a very high HD, mid-day in July and with an increased passenger and fuel load;
high, hot and heavy.
2.11.1.5 The investigation revealed that Roto 6 had stopped flying passengers
as early as February. However with the arrival of Roto 7 at the beginning of the
summer season, as the temperature rose steadily during the month of May and
as they were trying to deal with the associated issues with the Griffon, CHF(A)
made an attempt to shift the majority of its operations at night and succeeded
partially. In that month, CHF(A) led several multinational deliberate operations in
the Canadian Area of Responsibility (AOR), thereby allowing the bulk of the flying
activities to be conducted at night and mitigating the effect of increasing
temperatures. This was also made possible because CHF(A) could obtain
support from an allied nation for the delivery of specialized capabilities needed at
the point of insertion and because this also aligned with the Commander JTF-A’s
priorities for that period of time. However in June, the allied nation reassigned
their support elements and the Campaign Plan entered a new phase that
required predominantly daytime support. Consequently, CHF(A) had to transfer
the bulk of its flying back to daytime missions.
2.11.1.6 CHF(A) adapted and contributed significantly to the change in the

Campaign Plan and the shift to daytime operations. However this shift and the
accident, as it occurred in the high, hot and heavy regime, revealed a breakdown
in communication between the commander’s strategic level intent to mitigate the
CH146 performance in the high, hot and heavy regimes and the day to day
operations at the tactical level. To mitigate the CH146 performance in the high,
hot and heavy regimes and the limited on board self-defence/survivability
equipment issues, specific operational parameters were identified during the pre-
deployment briefings regarding where, when and how the aircraft was to be
operated. Considerations included operating with reduced fuel loads, operating
at night using NVGs and avoiding conditions that would require the aircraft to
operate at high AUWs and high HDs. Although these mitigating measures were
presented during the pre-deployment briefs, the investigation could not identify
any strategic level documentation, including the OP ATHENA CHF(A) Concept of
Operations (CONOPS), that directed implementation of these detailed measures
at the tactical level.
2.11.2 Lack of Operational and Strategic Level Support
2.11.2.1 At the start of the deployment, operational and strategic level direction
and support for certain issues was often incomplete or not available. Tactical

level solutions and decisions were required often with extremely short notice and
with short timelines. One example of this was the identification of the OAT limits
affecting CH146 operations. Due to increases in the OAT above the CH146
operating limit of 45oC (51.7 minus 2 degrees per 1000 ft elevation) that were
forecasted to occur within a week, the unit CO approached the WComd and
advised of a potential impact to CH146 operations. CHF(A) was compelled to
request short-notice support from the WSM to resolve this issue. Two 1 Cdn Air
Div messages (UNCLAS COMD 077 and UNCLAS COMD 559) as well as the
associated RARM (RARM-CH146-2009-12) were signed on 19 June 2009 by the
Commander 1 Cdn Air Div authorizing CH146 operations up to 5ºC above the
normal maximum OAT limit under specific risk-mitigating conditions. 47 A second
example surfaced when it was discovered that the CH146 had exceeded its VNE
on several occasions while conducting Chinook escort missions. With technical
support from the WSM, 1 Cdn Air Div released two messages (UNCLAS COMD
556 and UNCLAS COMD 565) authorizing an increase to the VNE envelope. 48
From the technical and operational staff’s perspective, significant effort and
resources were expended to resolve these issues once they were identified. For
those in theatre, these issues should have been resolved prior to deployment.
2.11.2.2 Interviews with WSM staff and aircrew in theatre revealed that while
some performance limitations were identified prior to the deployment, details of
associated challenges such as mission planning, operating speeds and operating
temperature limits as well as potential and specific solutions to these challenges,
were not addressed. It is not expected that higher headquarters technical or
operational level staff would be cognizant of, or could have anticipated, tactical
requirements that were never raised by the operational community prior to
deployment. It was only anticipated that operations would be conducted by
trained military professionals within aircraft limits that would be adhered to.
However, personnel and resources at the tactical level in theatre faced an
increasingly demanding operational tempo in a challenging and hostile
environment. Operational and environmental issues surfaced, such as the
expectation to fly faster than the VNE to escort the Chinook or the necessity to
operate above certified OAT values. The lack of resolution on certain issues left
operators in an unfavourable situation where they were expected to react to
issues in theatre as they arose.
2.11.2.3 Under normal circumstances (i.e. domestic operations, non–combat

environments), there are CF and RCAF technical, operational and strategic level
headquarters responsible for airworthiness and administrative procedures that
are called upon to address and resolve issues related to aircraft limitations and
47
UNCLAS COMD 077, COMD AUTH CH146 DEPLOYED OPS ABOVE OAT LIMIT dated 19
Jun 09, UNCLAS COMD 559, POAC: CH146 DEPLOYED OPS ABOVE PUBLISHED AOI OAT
LIMITS dated 06 Aug 09, and RARM-CH146-2009-12 - Deployed Operations Beyond CH146
outside Air Temperature Limitations.
48
UNCLAS COMD 556, CH146 POAC: OP ATHENA INCREASED VNE LIMITS dated 14 Jul 09,
and UNCLAS COMD 565, CH146 POAC: OP ATHENA INCREASED VNE LIMITS dated 05 Aug
09.

operational challenges. At the operational level headquarters, A3 Maintenance

Maritime and Tactical (A3 Maint Mar Tac), comprised of only five personnel, is
responsible for technical and maintenance issues for the CH146 as well as the
CP140 Aurora, CH124 Sea King, and the new CH148 Cyclone. The A3 Tactical
Aviation (A3 Tac Avn) cell within 1 Cdn Air Div is comprised of only six personnel
and they are the subject matter experts for CF Tac Avn matters responsible to
the Commander 1 Cdn Air Div for Tac Avn Force Generation (FG). Their core
activities include the coordination of standards, training, personnel and resource
management as well as operational airworthiness efforts. In addition, they
provide extensive input by coordinating emerging issues such as acquisition
projects like the CF Medium-Heavy Lift Helicopter (MHLH). (Of note, there were
only three personnel in the A3 Tac Avn cell at the time of OP ATHENA and one
Major was deployed. The increase to six personnel occurred in 2011 when
MHLH positions were established.) The Combined Air Operations Centre
(CAOC) is responsible for Force Employment (FE) issues but again, there are
limited personnel within the CAOC with CH146 experience available; they often
rely on A3 Tac Avn and A3 Maint Mar Tac for FE support.
2.11.2.4 On the technical side at the strategic level, the CH146 WSM Section,
DAEPM(TH) 6, comprised of approximately 30 personnel, is responsible for the
maintenance policy, in-service support, engineering support, and technical
airworthiness of the CH146 Griffon Helicopter fleet. For FE support at the
strategic level, there were limited personnel within the offices of the CDS, C Air
Force Staff, the Strategic Joint Staff or within the Canadian Expeditionary Force
Command (CEFCOM) with specific aircraft experience and knowledge to provide
continued support for individual aircraft fleet issues or deployments; they also
often rely on the specific aircraft WSM or 1 Cdn Air Div A3 cells for support.
2.11.2.5 The technical, operational and strategic level staffs strive in all
operations to provide the best support possible within their sphere of influence
and abilities. To ensure effective oversight and planning support for operations,
it is essential that an adequate amount of subject matter experts (SMEs) are
available, involved, and empowered to make appropriate decisions regarding the
platform and mission in question. With the reality of manning shortages and
reductions in headquarters at all levels, it was and will be, essential that the
RCAF ensure that more time is taken to consult the right SMEs or that an extra
level of approval be instated where ambiguity exists in dealing with emerging
issues such as aircraft performance capabilities prior to deployments. These
SMEs must be available and in sufficient numbers to help resolve issues as they
arise during deployments.
2.11.2.6 The Afghanistan mission proved to be the largest international

deployment that the RCAF has had to face in several decades. In this case, the
operational tempo and the continuous requirement to have aviation assets
available to support and protect ground forces placed tremendous pressure on
the Air Wing to keep the CH146 serviceable and flying. Investigators could only
conclude that while the technical, operational and strategic level staffs were

knowledgeable, professional and committed in supporting operations, several

factors contributed to hamper the amount of support that they provided. This
included the pressure to deploy, the short timelines faced by the CH146
community from initial notification to deployment onward to reaching operational
capability, the operational pressures faced in theatre and most importantly, the
limited number of specific personnel in key technical, operational and strategic
level headquarters, such as in CEFCOM, C Air Force Staff, A3 Tac Avn, A3
Maint Mar Tac and CH146 WSM cells, to effectively support CF and RCAF FE
activities.
2.11.3 CH146 Statement of Operating Intent
2.11.3.1 The SOI is normally a high level planning document typically used in
the acquisition phase for a major project or capability. In this case, the CH146
SOI describes how the CF intends to use the CH146 Griffon and is used as the
basis for continued analysis and development. It is considered a living document
and will undergo amendments during the service life of the CH146. The SOI
version 1.0 was dated 19 Sept 2008 indicated that it had been created well after
the acquisition of the CH146. The CH146 SOI stated that the maximum HD
limitation for the maximum gross weight of 11,900 lbs was 4000 ft HD and that
operating at HD up to 14,000 ft, which it can, was possible at weights less than
11,900 lbs. The short-term solution for reducing the CH146 AUW and adapting a
“combat configuration” was addressed with the creation of RARM - CH146 2008-
001 Combat Configuration for Afghanistan. The long-term solution “to increase
the density altitude envelope for all-up weight operations” required a review of
the environmental limits stipulated in the SOI and the anticipated operating areas
for the CH146; historical environmental and meteorological data from
Afghanistan should have been considered prior to the CH146 deployment. The
Canadian Army had been operating in Afghanistan for some time and a
considerable amount of environmental and meteorological data was available to
properly assess CH146 performance in that environment. However, despite this
data and the efforts made to improve CH146 performance and expand the
operating envelope in the multiple RARMs and POACs produced by the OAA or
TAA, nothing specifically addressed expanding the CH146 performance in the
high HD environment. Neither the long-term engineering solution to increase the
HD envelope for AUW operations nor the environmental limitations offered in the
SOI were addressed, amended or increased. The fact that possible future
requirements were highlighted in very broad detail did not represent a tasking to
any organization to take action to expand the performance envelope nor did it
define the conditions specific for Afghanistan. Had this document been used and
developed into a formal tasking it would still have had required more detail on
exact mission roles and profiles. 49 Additionally, had this requirement been
formally staffed to the CH146 WSM, the WSM and the OEM could have been
engaged to resolve the issue. Regardless, the investigation found that the long-
49
Note that the requirement for operating at Max GW up to 4,000 ft Hp at 35°C (7,000 ft Hd) was
met by the MB-Z60 supplement for IGE that was created after the accident.

term solution to increase the HD envelope for AUW operations had not been
resolved.
2.11.4 Issues such as OAT limits, VNE and ITT exceedences, were identified
by personnel in theatre, raised by WSM staff or as a result of this flight safety
investigation and ultimately resolved with support from the technical and
operational staffs within the CF. Investigators could not identify why
environmental and operational issues such as the expansion to OAT operating
limits and VNE to conduct the Chinook escort missions had not been addressed
prior to deployment. While the amendment of the SOI could have been an
oversight, such issues affecting or limiting the CH146 performance and
operations should have been addressed and resolved prior to their deployment to
Afghanistan. Investigators found that the limited number of personnel in key
technical, operational and strategic level headquarters contributed to a lack of
oversight and planning support from higher headquarters during the preparation
and planning phases of the CH146 deployment to Afghanistan.

3 CONCLUSIONS
3.1 Findings
Note: All findings include references to the applicable paragraphs in Section 1,

Section 2 or the Annexes of this report.
Findings concerning the accident flight:
3.1.1 The crew was medically fit, qualified, current, and properly authorized
to fly the mission. (1.5.1, 1.13.1)
3.1.2 Anticipating a dustball and high power requirement, the accident crew
agreed to conduct an MPTO followed by an ITO. (1.1.3, 2.6.1, 2.6.2)
3.1.3 During the takeoff, the creation of an intense dustball contributed to a

DVE that severely impeded the FP’s and FE’s ability to detect drift and ultimately
the FP’s ability to correct the unintended drift, to see and to avoid the barrier.
(1.1.4, 2.1.3.2, 2.1.4)
3.1.4 The FP suffered a loss of situational awareness during the takeoff due
to the rapid and numerous changes in his focus during the 10 seconds prior to
impact as he attempted to stabilize the aircraft and climb away. (2.3.1.1, 2.3.1.2,
2.3.3, 2.7.6)
3.1.5 During the takeoff, while cross-checking the ITT gauge, the FP lost
visual references in the dustball. (1.1.4, 2.3.1.1, 2.3.2.4)
3.1.6 During the takeoff, while cross-checking the ITT gauge, the FP
reduced power which reduced the helicopter’s climb momentum and
inadvertently made a right cyclic input that exacerbated the right drift. (2.3.1.1,
2.7.2, 2.7.5, 2.7.7, 2.7.8, 2.7.9)
3.1.7 The FP employed the SMM recommended procedure of setting a flat

pitch attitude on the ADI, which exacerbated both forward and unintentional right
movement, causing the helicopter to drift forward and to the right. (2.6.5, 2.7.2,
2.7.8)
3.1.8 The aircraft collided with the barrier at the helicopter’s one to two
o’clock position, yawed left, quickly rolled onto its right side, and immediately
caught fire. (1.1.4, 1.3.1, 1.12.1, 1.14.1.1, 2.4.3)
3.1.9 The total flight duration from skids clear of the ground to impact with
the barrier was under 10 seconds. (2.3.1.1)
3.1.10 The fire developed very rapidly, precluding the pilots from rendering
assistance to the personnel trapped in the rear cabin area. (1.1.5, 1.14.1.1,
1.15.4.1, 2.4.3)

3.1.11 The Engine Fire checklist and Emergency Ground Egress procedures
were committed to memory but it is likely that the actions were simply omitted in
the stress and confusion of the situation. (1.6.7.1, 2.4.2)
3.1.12 The fatally-injured crew members’ egress was likely impeded by a

combination of impact injuries, physical obstructions or restrictions to egress and
smoke, fumes, and gases from the intense post-crash fire. (1.13.5.1, 2.5.1, 2.5.5,
2.5.6, 2.5.7)
3.1.13 The forces of impact were likely survivable. The causes of death were
directly related to the post-crash fire. (1.13.5.1)
3.1.14 The aircraft sustained A category damage and was destroyed. (1.3.1)
Findings concerning the accident FOB:
3.1.15 There were no standards published for dust or fire suppression within
the Afghanistan theatre of operations. The accident FOB was considered
austere, not Canadian-controlled, and did not employ any dust or fire
suppression measures. (1.10.3, 1.10.4, 2.1.2.1)
3.1.16 While some nations implemented mitigating measures for helicopter

operations in FOBs considering dust and fire suppression criteria, CHF(A)
training and flying orders did not. (2.1.2.2)
3.1.17 The selection of an alternate landing site within the FOB was
inconsequential to the creation or intensity of the dustball; however, the lack of
dust suppression methodologies and the poor sand conditions combined to
create a DVE that eliminated the crew’s visual references. (2.1.3.2, 2.1.4)
Findings concerning crew training:
3.1.18 There is no formal or dedicated training for helicopter operations in a

Degraded Visual Environment (DVE), either in whiteout/snowball or
brownout/dustball, at 3 CFFTS or in the RCAF. (1.5.3)
3.1.19 In-theatre there was a 30 day currency requirement for dustball

landings; however, there was no such requirement for dustball takeoffs or
takeoffs requiring either an MPTO or ITO. (1.5.4, 1.5.5)
3.1.20 The investigation determined that the training provided to the FP for
operations in dustball/snowball and DVE was insufficient for dealing with the DVE
encountered during the accident flight. (1.5.3, 1.5.4, 1.5.5, 2.3.2.1)
3.1.21 The investigation determined that the training for operations in

obscuring phenomena provided to CF helicopter pilots, and CH146 aircrew in
particular, should be improved. (2.3.2.1)

Findings concerning the Day-HUD, Restraints and ALSE:
3.1.22 The accident crew was not using the Day-HUD; this had been
approved by the CO and had become common practice in theatre. (2.2.2, 2.2.4)
3.1.23 The CH146 HUD is not certified as a primary flight instrument. (2.2.3)
3.1.24 The Day-HUD drift vector would have only provided the FP with an
additional source of drift information, re-confirming the direction and rate of drift.
It is unknown if this would have assisted the FP to recognize, reduce or eliminate
the drift. (2.2.4, 2.2.5)
3.1.25 FEs and DGs were using the prototype tactical aviation Crewman
Restraint Harness Mk I and some, due to limited availability, did not fit properly or
could not be adjusted to a length that would prevent the entire body from
projecting beyond the door opening. (1.15.3.4, 2.5.2)
3.1.26 Due to fire damage and the ad hoc distribution and lack of official
supply documentation on the prototype CRH/CRTs, the investigation could
neither determine if the harnesses were fitted and adjusted properly nor which
attachment points were used. (2.5.3)
3.1.27 There was no policy or procedure directing which CRT attachment

points FEs and DGs should use during flight. (2.5.3)
3.1.28 The passengers were not securely seated in approved seats with
approved lapbelts. (1.15.1.1, 2.5.7)
3.1.29 In this dustball, the FE’s ability to see his visual references and,
therefore, communicate information concerning drift and obstacles would have
been significantly degraded. (2.1.3.4)
Findings concerning the CH146 flight instruments and systems:
3.1.30 As see-through or dust-penetrating technology systems or systems

using landing symbology or sensory displays have not yet matured to a level for
operational use, none of the CF helicopters, including the CH146, have such
systems to conduct safe flight in a DVE below VMINI. (1.6.4.7)
3.1.31 The CH146 helicopter’s inherent hover instability, combined with the
lack of adequate instrumentation and awareness cues do not allow for safe flight
in a DVE below VMINI. (1.6.4.7, 1.18.2.3, 2.6.4)
3.1.32 The CH146 does not have an integrated power display in the cockpit
showing a first limit indication or providing situational awareness of the margin
remaining to that first limit. (2.9.3.2)

Findings concerning the SMM:
3.1.33 The SMM directed that the FP and the FE inform the crew when they
lose visual ground references on approach and landing, however, this direction
was not provided for the task VMC Takeoff/Level Off. (1.18.4.3)
3.1.34 The SMM Ch 3 Desert Operations stated that the ITO procedure shall
be used during takeoff in obscuring phenomena and that pilots should not
attempt the MPTO when a rejection of the take off is likely. Additionally, the
SMM suggested that such takeoffs should only be attempted when the aircraft
weight is within the limit specified by the HOGE and appropriate wind azimuth
charts. (1.18.4.6, 2.6.2)
3.1.35 The investigation found that the intent to conduct the combination of a
modified MPTO and transition to an ITO was a logical plan for the crew at the
time facing the conditions they faced that day. However, this was not an
approved procedure and it would have increased pilot workload conducive to an
increased likelihood for a loss of SA. (2.6.2)
3.1.36 The SMM Ch 3 only mentioned a flat pitch attitude for the ITO
technique and provided no direction on the desired roll attitude. The direction
provided in the ITO section of the SMM, and the crew’s “bar-on-bar”
interpretation and application of this technique, created intentional forward drift
but also unwanted and unintentional right drift. (2.6.3, 2.6.5, 2.6.6, 2.7.8)
3.1.37 The SMM contained specific details for advising on Qm power setting
on takeoff; such detailed calls were not included for ITT limits. (1.18.4.2, 2.9.3.2)
3.1.38 The SMM contains contradictory information concerning the use of the
HUD between Task 114 Perform IIMC Procedures, Night Considerations,
paragraph 7 and Task 106, Perform VMC Approach/Landing, Desert Operations,
paragraph 37. (2.2.3)
Findings concerning the AFM:
3.1.39 The AFM contained discrepancies and errors in the limitations and
performance charts that resulted in confusing and inaccurate information
regarding aircraft operations and flight planning. (1.16.2.1, Annex G)
3.1.40 The aircraft performance calculation training provided to aircrew

contained discrepancies and errors in using AFM charts that resulted in
erroneous and inaccurate performance calculations during flight planning.
(2.8.5.1)
3.1.41 The investigation revealed that there was no clear understanding of, or
clear process for, calculating mission performance data from the AFM or other
CH146 operation manuals. (2.8.1.3, 2.8.2.1, 2.8.5.1)

3.1.42 Investigators found confusion within the technical community and a

lack of understanding within the operational community concerning the CH146
AFM charts; the requisite knowledge for using the CH146 AFM performance
charts was low and posed a high risk for improper and inadequate performance
calculations. (2.8.2.1, 2.8.2.2, 2.8.2.3, 2.8.5.1)
3.1.43 Several CH146 aircrew sampled during the investigation used and
incorrectly applied the AFM WAT chart Figure 1-1A (or the similar WAT chart
Figure 8-13) as the primary reference for mission planning to determine aircraft
performance limitations. Many aircrew were not in the habit of consulting the
appropriate charts to calculate aircraft performance and determine if they would
have a sufficient power margin to conduct a mission. (2.8.2.3, 2.8.4.1, 2.8.5.2,
2.8.5.5, 2.8.6)
3.1.44 A lack of confidence in the accuracy of the AFM charts within the
CH146 aircrew community existed. This led crews to question the validity of the
charts, downplay the importance of completing detailed performance calculations
and resulted in limited, and at times, inadequate or improper use during flight
planning. (2.8.4.1)
Findings concerning ITT:
3.1.45 In Afghanistan from December 2008 to November 2009, CH146 HUMS

data recorded 1,120 ITT exceedences in which the ITT was between 810ºC and
940ºC for more than five seconds. (1.11.2.2, 2.9.1)
3.1.46 Aircrew regularly disregarded the 810º-940ºC 5 second transient limit

and accepted to regularly exceed published limitations. (2.9.3.1)
3.1.47 HUMS data from the #2 aircraft recorded ITT exceedences greater
than 810ºC for longer than 5 seconds on both engines during both the morning
and afternoon takeoffs from the FOB. (1.11.2.1, 2.7.11)
3.1.48 ITT exceedences continued to occur without any maintenance,

operational or flight safety authorities’ knowledge or oversight. (2.9.2.1)
3.1.49 Investigators found confusion among the aircrew and maintenance

communities’ understanding of the differences between operational limitations,
maintenance limitations and the potential negative effects on an aircraft
component’s service life when these are exceeded. (2.9.2.1, 2.9.3.1, 2.9.4)
Findings concerning performance calculations:
3.1.50 Roto 6 crews had created a performance matrix chart; however, it was
neither validated nor approved by the operational or the technical airworthiness
authorities. This chart was not used by Roto 7. (1.17.3.2)

3.1.51 It is estimated that the accident aircraft weighed 300 to 500 lbs more
than the #2 aircraft. (1.6.6.1)
3.1.52 The ITO procedure required a 23 ft hover capability and therefore OGE
performance calculations. The accident aircraft was 460 lbs overweight
according to the WAT charts, 1,520 lbs overweight according to the OGE Hover
Ceiling Chart available at the time of the accident, and 1,720 lbs overweight
according to revised charts provided by AETE. (1.6.6.1, 2.8.6, 2.10.5.1)
3.1.53 The #2 crew attempted and completed the same takeoff as the
accident crew; they also lost all references but their application of power was
more gradual and they did not pause or limit their application during the takeoff.
(2.7.1, 2.7.12)
3.1.54 Both helicopter crews attempted their takeoffs without having checked
the appropriate performance charts or verified power margins and they were
unaware that insufficient power was available to conduct an OGE takeoff without
exceeding ITT limits. (2.8.5.5, 2.8.6, 2.10.6)
3.1.55 Both the accident aircraft and the #2 aircraft were operating in an area
of power deficit within the power curve and exceeded ITT limits during their
takeoff out of the FOB; they were both in an overweight condition. Neither had
power available to attempt an OGE takeoff given their estimated AUW. (2.10.2.2,
2.10.4.2, 2.10.5.2, 2.10.6)
3.1.56 A review of the CH146 operating manuals found little guidance or

criteria on how to use performance calculations to support mission acceptance or
substantiate mission rejection but RCAF flying regulations provide ACs the
required authority to accept or reject missions that can accomplished. (2.10.5.2)
3.1.57 A review of the CH146 SOI found that given the environmental
conditions of the day, the accident aircraft was capable of IGE hover but not
capable of OGE hover. The investigation also found that the long-term solution
to increase the HD envelope for AUW operations found in the CH146 SOI had
not been resolved. (1.17.2.1, 2.11.3.1)
Findings concerning the CF and RCAF:
3.1.58 AETE reports concluded that BHTC testing did not include any testing
germane to the specific requirements of its intended military missions, therefore,
the suitability of the CH146 as a utility tactical transport helicopter in support of
land forces or as a combat support helicopter could not be assessed. (2.8.1.1)
3.1.59 Performance charts unique to the CH146 were never independently

validated by AETE; the CF accepted the civil Bell Model 412 charts as the
CH146 Griffon performance charts. (2.8.1.2)

3.1.60 The CH146 deployment decision briefings focussed mainly on the

range and payload capacity; the limited CH146 performance data that was
presented was based solely on the Figure 8-11 WAT chart. (2.11.1.2)
3.1.61 Despite the challenges of operating at high OAT and density altitudes,
the Griffon was suitable and very effectively employed within operational limits for
operations in Afghanistan for certain specific missions. (2.11.1.2)
3.1.62 The RCAF chain of command, including operational and technical

authorities, had the full expectation that the helicopters would be flown within
limitations detailed in the aircraft flight manuals. (1.17.1.2, 2.11.1.1)
3.1.63 To mitigate the CH146 performance in the high, hot and heavy regimes
and the limited on board self-defence/survivability equipment issues, specific
operational parameters were offered. However no strategic level documents
were found directing the tactical level in Afghanistan to implement these
measures; the investigation revealed a breakdown in communication between
the commander’s strategic level intent to mitigate the CH146 performance in the
high, hot and heavy regimes and the day to day operations at the tactical level.
(2.11.1.6)
3.1.64 Investigators found several factors that contributed to hamper the

amount of support provided from higher headquarters. Specifically the limited
number of personnel in key technical, operational and strategic level
headquarters contributed to inadequate oversight and planning support from
higher headquarters during the preparation and planning phases of the CH146
deployment to Afghanistan. (2.11.2.1, 2.11.2.2, 2.11.2.6, 2.11.4)
3.1.65 The investigation found that the MA-LA process did not support or lead
to a proper assessment of the climatic conditions and, hence, aircraft
performance for that specific mission at the FOB that day. (2.1.3.5)
3.2 Cause Factors
Active Cause Factors
3.2.1 The intense dustball contributed to a DVE that removed the crew’s
visual ground references and the FP’s ability to see and avoid the barrier.
3.2.2 The CH146 inherent hover instability and lack of adequate

instrumentation and awareness cues when operating in instrument conditions or
in a DVE below VMINI contributed to forward and unintentional right drift.
3.2.3 During the takeoff, while by cross-checking the ITT gauge, the FP lost
visual references.
3.2.4 The FP suffered a loss of situation awareness due to the rapid and
numerous changes in his focus during the takeoff.

3.2.5 During the takeoff, while cross-checking the ITT gauge, the FP
reduced power, which reduced the helicopter’s climb momentum, and
inadvertently made a right cyclic input which exacerbated the right drift.
3.2.6 The bar-on-bar or flat pitch attitude technique described in the SMM
ITO exacerbated forward and unintentional right drift.
3.2.7 The accident aircraft AUW exceeded aircraft limits given the
environmental conditions.
Latent Cause Factors
3.2.8 The crew used a non-standard procedure by combining an MPTO and

ITO. Although a logical plan for them at the time, it was contrary to the
procedures in the SMM, increased pilot workload and the chances for loss of
situation awareness.
3.2.9 The training received by the FP for operations in DVE or obscuring

phenomena was inadequate.
3.2.10 The crew attempted to conduct a takeoff not knowing that the aircraft
had an insufficient power margin to remain within engine ITT limitations.
3.2.11 Power and performance calculations were not completed for the FOB
takeoff; the crew did not realize the substantial performance limitations and did
not expect or anticipate having to complete performance calculations for this
particular takeoff given the AUW and environmental conditions.
3.2.12 Several aircrew within the CH146 community incorrectly applied the
WAT charts as the primary reference for mission planning.
3.2.13 A lack understanding and lack of confidence in the accuracy of the

AFM performance charts led CH146 aircrew to question the validity of the charts
and downplay the importance of completing detailed performance calculations.
3.2.14 Errors and omissions in critical operational and technical reference

material precluded the crew from accurately conducting essential pre-flight
calculations had they attempted to do so. Insufficient information was available
to CH146 aircrew to properly explain or describe the use of the performance
charts or how to determine actual power margins.
3.2.15 The CH146 was approved for use in Op ATHENA for a variety of
missions without the direction, development and implementation of proper
mitigation strategies for certain missions.
3.2.16 There was a breakdown in communication between the commander’s

strategic level intent to mitigate the CH146 performance in the high, hot and
heavy regimes and the day to day operations at the tactical level.

3.2.17 The limited number of personnel in key technical, operational and

strategic level headquarters contributed to inadequate oversight and planning
support from higher headquarters during the preparation and planning phases of
the CH146 deployment to Afghanistan.

4 PREVENTIVE MEASURES
4.1 Preventive Measures Taken
4.1.1 The TAA and OAA conducted risk identification and management
activities through the RARM process on several CH146 performance issues,
including OAT limitations, performance chart discrepancies, AUW adjustment
factors and OGE Hover GW. The applicable CH146 RARMs are listed in the
footnote below. 50
4.1.2 The TAA conducted a review of the CH146 AFM. Many of the AFM
performance charts have been, or are in the process of being replaced with new
charts that accurately depict aircraft performance and limitations. The FLIGHT
MANUAL SUPPLEMENT, CH146 GRIFFON, OPERATION WITH NINE
PASSENGERS OR LESS (ENGLISH) was released on 13 Oct 09. The current
version was released on 18 Nov 09 and was then transferred into the Integrated
Electronic Technical Manual (IETM) 51 on 09 Jul 10. The long-term goal is to
review the entire AFM for accuracy, applicability and ease of use. With respect
to Hover Ceiling charts, the CH146 WSM is working to finalize new Min Spec
charts for both IGE and OGE.
4.1.3 The TAA processes have been changed since the release of AFM Ch
2, which will prevent any change to the AFM without appropriate review by TAA
and OAA staff. This should prevent both the introduction of unauthorized charts
and their use to predict performance and limitations.
4.1.4 The DAEPM(TH) staff developed software and procedures capable of

accurately predicting power required and available for takeoff. These were in
use in Afghanistan until the end of the mission. Due to certification,
implementation and increased maintenance challenges in supporting the PPI
software, a variation of this software for domestic operations will not be pursued.
4.1.5 The Crewman Restraint Harness MK II with the Crewman Restraint

Release has been fully fielded and is now available in all sizes and sufficient
50
The applicable RARMs listed by serial number and title include:
a) CH146-2010-010: CH146 Flight Manual Hover Performance Chart Discrepancies
b) CH146-2009-020: CH146 AUW Adjustment Factors Based on Actual Engine Performance
c) CH146-2009-019: CH146 Enhanced Maximum OGE Hover Gross Weight with Effect of Skid
Height Above Ground
d) CH146-2009-016: CH146 Roll Limit Exceedences – Deployed Operations
e) CH146-2009-015: CH146 Flight Manual WAT/Performance Chart Discrepancies
f) CH146-2009-014: CH146 Expansion of VNE Limitations – Deployed Operations
g) CH146-2009-012: Deployed Operations Beyond CH146 Outside Air Temperature Limitations
h) CH146-2009-008: CH146 Cumulative Effect of VNE Exceedences – Deployed Operations
i) CH146-2009-003: CH146 Fatigue Life Calculations for Deployed Operations – OP Athena
j) CH146-2008-003: CH146 Operations with Doors Opened and Pinned
k) CH146-2008-001: CH146 Combat Configuration for Afghanistan
51
Integrated Electronic Technical Manual (IETM) is the electronic database storing all CH146
technical publications.

quantities. The CRH Mk 1 is no longer in service. The OEM for the CRH MK II
CRR has been tasked to develop of a shorter version of the CRR for use on the
specific CH146 Gun configuration with the CRH MK II.
4.1.6 1 Cdn Air Div released several messages concerning CH146

publication amendments, performance planning calculations and mitigation
plans. They are listed in the footnote below. 52
4.1.7 Additional post-accident activities included publishing SMM Change 4

and Change 5 as well as an entire re-issue of the SMM on 31 May 2011.
Amendments directly related to this accident include changes to the following
Chapters and Tasks:
a. Chapter 1 CREW COORDINATION:
i. The paragraph HEADS-UP DISPLAY (HUD) SYSTEMS was added

providing guidance on the use of the Day and NVG HUD/HMD for use
in various operating environments.
ii. The paragraph ADI SETTINGS was added providing guidance on

the use of the ADI.
52
1 Cdn Air Div messages include:
a) UNCLAS A3 APT 057, Mitigation Plan - CH146 OGE Charts - Amendment 1
b) UNCLAS A3 APT 047, Immediate Mitigation Plan - CH146 OGE Charts
c) UNCLAS COMD 1157, POAC CH146 – OP Athena Performance Planning – Rev 1
d) UNCLAS COMD 1124, CH146 POAC – OP Athena Performance Planning
e) UNCLAS COMD 625, CH146 POAC – OP Athena Performance Planning
f) UNCLAS COMD 1203, OA Appr - B-GA-002-146/FP-001 Change 0 CH146 SMM
g) UNCLAS COMD 594, OA Appr: C-12-146-000/MB-Z60 CH146 AOI Supplement
h) UNCLAS COMD 628, Publication Amendment: CH146 Flight Manual
i) UNCLAS COMD 621, OA Approval B-GA-002-146/FP-001 Change 5 CH146 SMM
j) UNCLAS COMD 620, OA Approval C-12-146-000/MB-Z60 CH146 AOI Supplement
k) UNCLAS COMD 1334, CH146 POAC: Rotor Track and Balance Regime – Hot and High
l) UNCLAS COMD 1024, POAC CH146B Deployed Operations Configuration Rev 1
m) UNCLAS COMD 565, CH146 POAC: Op Athena Increased VNE Limits
n) UNCLAS COMD 556, CH146 POAC: Op Athena Increased VNE Limits
o) UNCLAS COMD 559, POAC: CH146 Deployed Ops Above Published AOI OAT Limits
p) UNCLAS COMD 077, Comd Auth CH146 Deployed Ops Above OAT Limit
q) UNCLAS APT RDNS 034, CH146 VNE Exceedences
r) UNCLAS APT RDNS 044, CH146 Doors Open Operational Restriction
s) UNCLAS COMD 1061, POAC CH146B Deployed Operations Configuration
t) UNCLAS COMD 616, POAC CH146B Deployed Operations Configuration
u) UNCLAS COMD 652, POAC CH146B Deployed Operations Configuration
v) UNCLAS COMD 154, Commander’s Authorization for Use – CH146 Combat Configuration
w) UNCLAS COMD 524, Use of IR Anticolliders on CH146

iii. Chapter 2 AIRCREW TASKS, Task 100 CALCULATE AIRCRAFT

WEIGHT AND BALANCE: The paragraph Environmental
Considerations was amended to introduce considerations for operations
at higher altitudes and warmer temperatures. This includes discussion
on performance limitations (weight, Qm, ITT or N1), power available,
power required, go/no-go criteria and the requirement to monitor aircraft
operation and performance throughout the flight.
b. Chapter 2, Task 101 PREPARE A PERFORMANCE PLANNING

CARD: This task saw multiple changes to improve pre-flight calculations
including:
i. The mission planning procedure for calculating power and

performance numbers for both IGE and OGE (power available and
power required);
ii. The calculation of maximum aircraft weight allowable at all planned

landing locations for the mission;
iii. A flow chart to identify the charts to be followed to calculate

maximum AUW from the various performance charts contained in the
CH146 Flight Manual;
iv. Sample performance calculations; and
v. Modifications to the CH146 Performance Planning Card to include

power available and power required IGE and OGE as well as
performance information for intermediate landings during the mission.
c. Chapter 2, Task 105 PERFORM VMC TAKE-OFF / LEVEL-OFF, was

amended with several procedural changes to improve the MPTO and the
ITO:
i. The MPTO procedure was amended with changes to pre-flight

preparations, the requirement or feasibility of the hover check, power
and performance considerations (i.e. Qm, N1 and ITT limitations),
operations in DVE considering obstacle clearance and confined areas,
abort procedures and specific crew duties;
ii. The ITO procedure clarified the technique, the use of the ADI, the
use of the drift vector from the HUD/HMD and included a Caution on
the use of the ITO in confined areas or near obstacles. The Caution
also highlighted the presence of right drift in a wings-level attitude; and
iii. A 5% power margin was incorporated into the SMM to account for
additional power required for transition to forward flight. This was also

built into the performance calculator software developed by the WSM

staff.
d. Chapter 2, Task 106 PERFORM VMC APPROACH / LANDING was

modified and consolidated information for operations in DVE under
sections entitled OBSCURING PHENOMENA and DESERT
OPERATIONS.
e. Chapter 2, Task 109 PERFORM CONFINED AREA (CA)

OPERATIONS was amended to include crew management duties for
Tactical Aviation aircrew.
4.1.8 1 Cdn Air Div Orders, Volume 2, 2-007, was amended to mandate that
all passengers be seated in an approved seat and secured with an approved lap
belt for all takeoffs and landings.
4.1.9 1 Wing Tactical Aviation Standards and Evaluation Team (TASET)

included a 10-part question in the CH146 Pilot Annual Category Open Book
Examination to address AFM performance planning and chart utilization.
Standards personnel correct the examinations to 100%.
4.1.10 Directorate Air Requirements (DAR) 9 has been tracking DVE

solutions before OP ATHENA and after two Flight Safety Investigations which
had issues with DVE. DAR 9 assesses that the solution (as explained in
paragraphs 1.6.4) for DVE operations encompasses three elements: improved
handling qualities, see-through sensors, and symbology. The improved handling
quality requirements call for a 4-5 axis stabilization systems mostly available on
advanced helicopter platforms only. With the CH146 Griffon as a 2.5 axis
platform, improvements to handling qualities would require significant
modifications to the flight control and navigation systems to the extent of a full
mid-life upgrade. It is highly likely that such an extensive modification program
would not be entertained as a replacement by a modern platform would most
likely be a more fiscally and prudent course of action. The area of see-through
sensors is still considered at the developmental and experimental stages.
Developmental work is being carried out by DRDC on symbology and the results
could be considered for implementation on existing rotary wing fleets within five
yrs.
4.1.11 Under the Degraded Visual Environment Solution for TacHel (DVEST)
technology demonstration program, DRDC funded a trial on a number of HMD
brown-out symbology systems to enhance crew efficiency in DVE. Two leading-
edge symbology systems for takeoffs, landings, approaches and hovering flight
under DVEST will be assessed; the evaluation also concentrates on the human
factor elements inherent in these symbology systems. DRDC is in the process of
setting a contract through Public Works and Government Services Canada
(PWGSC) once a specific symbology system is chosen. It is expected the
contract will be awarded in 2012 with a simulator evaluation, a flight test and

recommendations to DAR 9 before end-2013. Finally, DRDC is concurrently

working on a form of dust penetration laser radar so that it might be combined
with the symbology system.
4.2 Preventive Measures Recommended
4.2.1 The OAA/1 Cdn Air Div/A3 Tac Avn, with support from TASET and the
TAA/DAEPM(TH), should amend the CH146 AFM with validated and accurate
CH146 performance charts.
TAA/DAEPM(TH), should amend the CH146 AFM, and the SMM if required, with
clear direction on the correct use of the CH146 performance charts.
TAA/DAEPM(TH), should amend the CH146 AFM to develop clear unambiguous
wording for AFM ITT limits.
4.2.4 The OAA/1 Cdn Air Div/A3 Tac Avn/TASET should address the CH146
aircrew training and knowledge concerning performance calculations provided at
403 HOTS. Training should provide clear direction on the use of performance
charts for proper and accurate calculations in various operating and
environmental conditions, including scenarios for high altitudes, OATs and
AUWs.
4.2.5 The OAA/1 Cdn Air Div/A3 Tac Avn/TASET should address the CH146
training and knowledge concerning tail rotor couple and right drift during the ITO
procedure. The procedure should be reviewed to consider a vertical departure
based on a hover attitude that would not induce drift.
4.2.6 The OAA/1 Cdn Air Div/A3 Tac Avn/TASET should improve the
training for operations in obscuring phenomena provided to CF helicopter pilots,
and 1 Wing aircrew in particular.
4.2.7 The OAA/1 Cdn Air Div/A3 Tac Avn/TASET should further amend the
SMM to include:
a. Monitoring and calling ITT limits during takeoffs;
b. Providing an Abort procedure for an ITO;
c. Providing direction on specific safety distances required for obstacle

clearance and during confined area operations when considering an ITO;
d. Providing direction on crew advisory calls when losing references

during critical phases of flight; and

e. Correcting the contradictory statements in the SMM concerning use of

the HUD between Task 114 Perform IIMC Procedures, Night
Considerations, paragraph 7 and Task 106, Perform VMC
Approach/Landing, Desert Operations, paragraph 37.
4.2.8 The OAA/1 Cdn Air Div/A3 Tac Avn/TASET should include dustball
takeoff techniques, including an MPTO and ITO, in CH146 initial training and as
ongoing currency requirements during exercises or operations (domestic or
deployed abroad) where the potential for DVE exists.
4.2.9 The TAA/DAEPM(TH) should continue the development of

performance software planning tools or quick reference performance matrix
charts for the CH146 operations in high HD, high OAT and high AUW conditions
for both domestic and deployed operations abroad.
4.2.10 The TAA/DAEPM(TH) should modify the Day-HUD symbology display

illumination levels to ensure effective use of the Day-HUD in various operating
environments.
4.2.11 The AA/DAR should continue its research into current technologies
regarding brownout or dustball symbology systems to improve operations in the
DVE and provide the C Air Force with recommended systems for acquisition and
use by CF helicopters.
4.2.12 The AA/DAR 9 should consider an upgrade to the symbology of the

CH146 HUD from the current 2 Dimensional (2-D) set to an advanced 3-D
symbology set.
4.2.13 The AA/DAR 9 should include improved handling qualities to allow for
auto-hover capability and see-through sensors as requirements for the Griffon
replacement.
4.2.14 The AA/DAR 9 should consider an upgrade to the cockpit for an

integrated power display showing a first limit indication of torque and ITT. This
could provide situational awareness of the power margin remaining to the first
limit.
4.2.15 Canadian Joint Operations Command (CJOC) [formerly known as

CEFCOM]/1 Cdn Air Div should implement criteria and minimum standards for
Crash Fire Rescue response and dust suppression for Main Operating Bases,
FOBs and landing zones during internationally deployed operations. These
criteria should be clearly communicated to Canadian and Allied Forces at the
onset of future missions and should be added to future MA-LA risk factors so that
the Chain of Command could have visibility of the risk in advance of accepting
particular missions.

4.2.16 DRDC should consider and evaluate other potential options for
displays, sensors, and flight controls for helicopter operations in DVE by various
groups in the broader international aviation industry.
4.2.17 The AA should consider the creation of capability planning teams for
major deployments. These would include technical, tactical, operational, and
strategic level SMEs to conduct comprehensive expert assessments of RCAF
capabilities to identify and address issues when deploying forces. The intent is
also to ensure the commander’s strategic level intent is effectively communicated
down to the tactical level.
4.3 Other Safety Concerns
4.3.1 This and other occurrences have highlighted to DFS and TAA staff that
CF rotorcraft are often not operated according to certification assumptions, i.e.,
different takeoff or landing procedures and flight profiles are used. The
performance data in the AFM is valid only for specific procedures; if other
procedures are used, the AFM data can be inaccurate or misleading and data
that would be applicable is not available. Flight profiles used for the AFM data
often provide safety margins for specific events; altering these profiles can
eliminate these safety margins which lead to an elevated risk that must be
weighed against the operational context. The intent of the following safety
recommendations is twofold: first, to review aircraft performance data to ensure it
is applicable to CF operations and second, to avoid new certification programs
where AFMs could be developed with data that would not be used in the CF
operational context and/or without the data that should be. If such gaps exist the
OAA and the TAA should obtain and provide the applicable data to ensure safe
and effective operations can be conducted.
4.3.2 Given that the CT146 Outlaw is a civil registered aircraft and not
managed by DGAEPM, the TAA should engage PWGSC/Transport Canada to
approach BHTCL to review the validity of the applicable performance charts for
the CT146 Outlaw.
4.3.3 The AA should ensure that performance deficiencies associated with

adapting civilian aircraft models for CF use, such as differences between
certification assumptions/standards and CF operational procedures, are
considered and rectified for the CH146 Griffon. This should also be completed
for future CF aircraft acquisitions, such as the CH148 Cyclone, the CH147F
Chinook and other replacement projects.

4.4 DFS Comments
First and foremost, I would like to acknowledge the individuals who made the
ultimate sacrifice for their country while struggling to bring peace and stability to
Afghanistan. Two Canadians and one coalition military member from the United
Kingdom perished in this tragic accident.
The decision to deploy the CH146 to Afghanistan was not taken lightly as the
capabilities and risks were evaluated, assessed, and ultimately accepted by the
Chain of Command. Back in the 2006-08 timeframe, the number of Canadian
casualties in Afghanistan was increasing at a rate that Canada had not seen
since the Korean conflict. The deployment of the Air Wing, including the CH146,
provided crucial support for our ground forces and the missions flown by our
crews ultimately saved lives; however, that is not to say that we, as an
organization, deployed the CH146 without error.
CH146434’s accident highlighted some weaknesses and gaps in our operating

procedures and with our capabilities, such as aircraft and aircrew equipment,
flight training, and procedures for helicopter operations in obscuring phenomena.
Significantly, both the technical and operational authorities had an incomplete
understanding of aircraft performance charts that were somewhat confusing and
not operator friendly. The result was that CH146 crews conducted missions in
the Afghan theatre using wrong charts while dismissing correct ones.
Of even more concern was the lack of feedback from those operational
experiences interfacing with the Airworthiness Process. During operations,
personnel are empowered to make decisions in order to carry out their assigned
missions to the best of their abilities given their training, the equipment with
which they deploy, and the situations they face. However, when problems are
encountered during mission execution, operators must interface with
Airworthiness Authorities so that assessments of the problems can occur. In this
case, the constant over-temps and over-torques over many months should have
been reported to the appropriate Airworthiness Authorities. Because this
feedback into the Airworthiness Process did not occur, the Airworthiness
Authorities could not validate the mission planning and execution, offer mitigation
strategies, direct alternate mission profiles or understand and plan for the
consequences of accelerated equipment wear. As the Airworthiness
Investigative Authority I find this worrisome and a problem that must be
addressed so that our Airworthiness Processes emerge stronger and better
prepared to operate in conflict operations.

To conclude, my comments are not meant to diminish the outstanding

professionalism, devotion and heroism of our personnel who conducted essential
missions under the most demanding circumstances. Rather, they are intended to
submit that as a planning and risk assessment tool, the operational staffs need to
work closely with the Flight Safety Team to ensure effective mission
accomplishment within a combat environment.

Annex A “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex A: Photographs
Impact Point
Protective Wall
Tail Section
N
Photo 1: Accident site from impact point
Photo 2: Damaged barrier showing side of aircraft impact
A-1/5 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
N
Photo 3: Damaged barrier showing main rotor blade strike
Photo 4: CVFDR as received at NRC

1010-CH146434 (DFS 2-4)
Photo 5: Accident site after the evacuation of survivors
Tail Section
N
Photo 6: Accident site looking from the protective wall

1010-CH146434 (DFS 2-4)
N
Dustball photographed at the
accident site during morning
insertion
Photo 7: A dustball at the accident site as viewed from the air
Photo 8: A dustball at the accident site as viewed from the ground

1010-CH146434 (DFS 2-4)
Photo 9: Transmission side-facing seat, FE side (investigator seated, photo used

with permission)

Annex B “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex B: Aircraft Performance Definitions
To facilitate the understanding of aircraft performance, definitions relevant to this

accident are listed here:
a. Brownout: A condition during taking off or landing in an arid climate where

there is little or no out-the-cockpit window visibility caused by dirt and dust being
stirred up by the rotor downwash and then re-circulated by the rotor blades of a
helicopter. Similar conditions can be created by landing or taking off in snow
(whiteout) or over water. It should be noted that whiteout in snowy conditions is
also commonly referred to as “snowball” by aircrew to distinguish this particular
condition from atmospheric whiteout caused by omnidirectional cirrus cloud
formation, fog, or overcast sky over continuous snow surface or intermittent cloud
blend in with snow-covered terrain. In general, DVE cause pilots to rely on
inadequate cockpit instrumentation, callouts by on-board aircrew, and innate
piloting skill to successfully execute a brownout landing. Flying in DVE has
always been a challenge for rotary-wing pilots. Since NATO has been operating
in the arid climates (e.g., Africa and Afghanistan), Rotary-Wing Brownout (RWB)
is responsible for approximately 75% of coalition helicopter mishaps. 53
b. In Ground Effect (IGE)/Out of Ground Effect (OGE): When a helicopter is

hovering in close proximity to the ground (one rotor diameter or less), it is said to
be hovering IGE. Because of the close proximity to the ground, the downward
and outward airflow pattern tends to restrict vortex generation. This makes the
outboard portion of the rotor blade more efficient and reduces overall system
turbulence caused by ingestion and recirculation of the vortex swirls. Therefore,
for the same collective (power) setting, more weight can be lifted IGE than
OGE. 54
c. Minimum Specification (Min Spec): Aircraft performance information in the

AFM is predicated on Min Spec engines. Aircraft engines performing at Min
Spec or above meet the certification requirements and are considered
serviceable. Engines performing below Min Spec are considered unserviceable
and require maintenance action before returning to service.
d. Power Assurance Check (PAC): The PAC is used to determine if the

installed engines can produce Min Spec power. CH146 aircrew were to conduct
a PAC on the first flight of each flying day to determine if the engines were
serviceable. The PAC compares an ITT value on a checked engine to the
calculated value of a Min Spec engine. For a given Qm, pressure altitude (HP)
and outside air temperature (OAT), a serviceable engine will have an ITT value
at or below the calculated or chart derived ITT value. The PAC, however, does
53
North Atlantic Treaty Organisation, Research and Technology Organisation, (January 2012),
RTO Technical Report TR-HFM-162, Rotary-Wing Brownout Mitigation: Technologies and
Training.
54
As defined in Manual of Aerodynamics, A-12-050-001/PT-001.
B-1/3 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
not indicate, determine or calculate the actual power margin available. The
majority of CH146 aircraft perform better than Min Spec.
e. Power Required 55 : In the calculation of power required, one must

understand the importance of total drag curves. On a drag/velocity diagram, the
total drag curve represents the combination of induced, parasite and profile
drag 56 , as in Figure 1. At low velocities, the drag curve starts at a relatively high
point, decreases as speed increases to reach the optimum lift over drag ratio (the
low point in the curve) and then increases as speed increases. The power
required to maintain steady un-accelerated, level flight is equal to the total drag.
As such, the total drag curve may also be referred to as the power required
curve. Power required at low speed, or in the hover is relatively high. It will
decrease as speed reaches the optimum lift over drag speed and then increase
as speed increases in forward flight.
Total Power Required Power Avail - Sea Level
Power Avail - High HD

SHP SHP
Parasite
Induced
Profile
Power Required
KIAS KIAS
57
Figure 1 – Power Required Curve Figure 2 - Power Available Curve 58
f. Power Available: To determine aircraft performance characteristics, power

available must also be considered. Helicopters demonstrate roughly the same
power available in a hover as they do at their maximum airspeed, it is the power
required that varies in the different flight conditions between the hover and
forward flight. Therefore on a drag/velocity diagram Figure 2, the maximum
power available is depicted as a relatively flat curve that rises slightly as airspeed
increases above the lift/drag/power required curve. Power available is the
maximum power that can be produced by the aircraft (combining total engine
55
Major David P. Lobik, Power Available vs Power Required - the saga continues…, With
permission from the School of Aviation Safety, Pensacola Fl, Rotary Wing Aerodynamics
Instructor.
56
R.W. Prouty, Helicopter Aerodynamics Volume 1, 2009 Eagle Eye Solutions, LLC. Induced
power is that associated with producing rotor thrust. Profile power is used to overcome friction
drag on the blades. Parasite power is that needed to overcome the drag of all the aircraft
components except rotor blades.
57
The diagrams in Figures 1, 2 and 3 are consolidated graphs taken from Lobnik, Power
Available vs Power Required - the saga continues….and modified with information taken from
Prouty, Helicopter Aerodynamics Volume 1.
58
Ibid.

1010-CH146434 (DFS 2-4)
power with other demands from systems such as rotor systems, main and tail
rotor drive gearbox losses, hydraulic pumps, generators, etc) and is affected by
factors such as temperature, HD and GW. As temperatures, altitudes, HD and
GW increases, most engines cannot provide all of the horsepower demanded by
the transmission and other aircraft components; therefore, the aircraft power
available line will shift downward. 59
g. Power Margin: A power margin is that differential between the power

available and the power required.
h. Power Deficit: The deficiency or lack of power that is depicted by that area
where the power required curve is above the power available curve. In Figure 3,
it is depicted at those speeds below VMINI and above VMAX (shaded area), as
would be the case in a high (high altitudes or high HD), hot (high OAT) and
heavy (high GW) flight regime.
Power Avail - Sea Level VMAX
VMINI Power Avail – Medium HD
Power Avail
– High HD
SHP
Power Required
KIAS
Figure 3 - Power Deficit (At speeds in the shaded areas slower than VMINI and
faster than VMAX. The Sea Level, Medium and High HD lines are provided as
examples.)
i. Power/Mast Torque Limited: In addition to Qm, CH146 performance can

be limited by, among other parameters, ITT and gas producer RPM (N1). When
an aircraft is described as power-limited, sufficient Qm is available but ITT or N1
limits would be reached first. Conversely, an aircraft is Qm limited when Qm
would be met prior to reaching ITT or N1 limits.
59
D.P. Lobik. As jet engines need to balance a proper fuel-to-air ratio to ensure maximum
efficiency at all torque settings, when the air gets thinner as it will with an increase in DA, then the
fuel introduced by the fuel management systems becomes less thus limiting the power available.
This is because jet engines operate most efficiently when the fuel-to-air ratio is held constant for
combustion.

Annex C “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex C: Weight, Altitude, Temperature (WAT) and Hover Ceiling Charts
Figure 1-1: WAT Chart – IGE

Note: Notice the note referring to the Hover Ceiling charts and the Limit Line to
guarantee Min Spec performance.
Limit Line
Source: C-12-146-000/MB-002
C-1/6 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
Figure 1-1A: WAT Chart – IGE

Note: KAF takeoff in red, FOB takeoff FOB in blue. Notice the lack of a note to
refer to Hover Ceiling charts and lack of a Limit Line to guarantee Min Spec
performance. This chart has since been removed.
Takeoff FOB in blue
Takeoff KAF in red
Source: C-12-146-000/MB-002

1010-CH146434 (DFS 2-4)
Figure 8-12: WAT Chart – OGE
Takeoff FOB in blue

Takeoff KAF in red
Source: C-12-146-000/MB-002

1010-CH146434 (DFS 2-4)
Figure 8-11: WAT Chart – OGE

Note: This chart was used for CH146 deployment decision briefings.
Source: C-12-146-000/MB-002

1010-CH146434 (DFS 2-4)
Figure 4-4: Hover Ceiling Chart IGE

Note: This is the same chart as Figure 1-1: WAT Chart – IGE.
.
Takeoff FOB
in blue
Takeoff KAF
in red
Source: C-12-146-000/MB-00
Source: C-12-146-000/MB-002

1010-CH146434 (DFS 2-4)
Figure 4-4: Hover Ceiling Chart OGE
Takeoff FOB in blue
Takeoff KAF in red
Source: C-12-146-000/MB-002
Source: C-12-146-000/MB-002

Annex D “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex D: Cruise Performance Charts
Figure 8-1: Cruise Chart 2000 ft
Source: C-12-146-000/MB-002
D-1/3 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
Figure 8-1: Cruise Chart 4000 ft
Takeoff KAF in red Takeoff FOB in blue
Source: C-12-146-000/MB-002

1010-CH146434 (DFS 2-4)
Figure 8-1: Cruise Chart 6000 ft - Afternoon Takeoff FOB
Source: C-12-146-000/MB-002

Annex E “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex E: Hover Torque Required Charts
Figure 8-7: Hover Torque Required IGE
Takeoff FOB
in blue
Takeoff KAF
in red
Source: C-12-146-000/MB-002
E-1/2 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex E “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Figure 8-8: Hover Torque Required OGE
Takeoff FOB
in blue
Takeoff KAF
in red
Source: C-12-146-000/MB-002
E-2/23 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex F “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex F: Comparative Analysis of Flight Data
1. A comparative analysis of the #2 and the accident aircrafts’ flight was

conducted using FDR data. The data of interest to the investigation were:
a) Cyclic Position – Longitudinal, Graph 1;
b) Cyclic Position – Lateral, Graph 2;
c) Collective Position 60 , Graph 3;
d) Calculated Mast Torque (NRC Method), Graph 4;
e) Revised Calculations (WSM), Graph 5;
f) Aircraft Heading, Graph 6; and
g) Roll Attitude, Graph 7.
2. A graphical depiction of the data can be found on pages two to seven of

this annex.
60
Collective position is represented as a percentage of travel and, while directly related to, is
different than Qm.
F-1/8 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
GRAPHS FROM FDR DATA
Cyclic Position - Longitudinal
30,0
20,0
Cyclic Position (%)
10,0
Accident Aircraft
0,0
No. 2 Aircraft
0 1 2 3 4 5 6 7 8 9 10 11
-10,0
-20,0
-30,0
Seconds
Graph 1 – Cyclic Longitudinal Position
Note: Cyclic position is expressed in percentage of travel. Positive values

indicate aft cyclic and negative values indicate forward cyclic.

1010-CH146434 (DFS 2-4)
Cyclic Position - Lateral
15,0
10,0
5,0
Cyclic Position (%)
0,0
0 1 2 3 4 5 6 7 8 9 10 11 Accident Aircraft
-5,0
No. 2 Aircraft
-10,0
-15,0
-20,0
-25,0
Seconds
Graph 2 – Cyclic Lateral Position
Note: Cyclic position is expressed in percentage of travel. Positive values

indicate right cyclic and negative values indicate left cyclic.

1010-CH146434 (DFS 2-4)
Collective Position
100,0
90,0
80,0
Position (% of travel)
70,0
60,0
Accident Aircraft
50,0
No. 2 Aircraft
40,0
30,0
20,0
10,0
0,0
0 1 2 3 4 5 6 7 8 9 10 11
Seconds
Graph 3 – Collective Position
Note: Collective position is expressed in percentage of travel. While collective

position is generally proportional to mast torque, the collective position values are
slightly different. Collective position is a physical measurement of the collective
position while mast torque is a measure of the torque on the main rotor mast
itself. Mast torque may vary depending on wind conditions. (i.e. gusty winds may
vary mast torque values with a constant collective position)

1010-CH146434 (DFS 2-4)
Calculated Mast Torque (NRC Method)
100
90
80
Mast Torque (%)
70
60
Accident Aircraft
50
No. 2 Aircraft
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11
Seconds
Graph 4 – Calculated Mast Torque
Note: See note at bottom of graph 3. See paragraph 1.19.1

1010-CH146434 (DFS 2-4)
Graph 5 – Revised Calculations CH146434 – (WSM)

1010-CH146434 (DFS 2-4)
Aircraft Heading
225,0
220,0
215,0
Degrees Magnetic
210,0
205,0 Accident Aircraft
200,0
195,0
190,0
185,0
1 2 3 4 5 6 7 8 9 10 11 12
Seconds
Graph 6 – Aircraft Heading
Note: This is for the accident aircraft only.

1010-CH146434 (DFS 2-4)
Roll Attitude
8,0
6,0
Bank Angle (degrees)
4,0
Accident Aircraft
2,0
No. 2 Aircraft
0,0
0 1 2 3 4 5 6 7 8 9 10 11 12
-2,0
-4,0
Seconds
Graph 7 – Aircraft roll attitude
Note: Aircraft roll attitude is expressed in degrees of bank. Positive values

indicate right bank and negative values indicate left bank. The CH146 normally
hovers with slight left skid low.

Annex G “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex G: DTAES Technical Note 75-00-15
1. The cover page of the technical note is copied here with the entire
technical note included in the following pages of this annex.
G-1/9 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
1. AIM / OBJECTIVES
1.1 This technical note records the results of the review of the subject amendment
to the CH146 Aircraft Flight Manual (AFM), ref A, and to provide
recommendations to TAA staff (DTAES 5-3) for TAA approval of the amendment,
as well as to the CH146 SDE and the AFM OPI.
2. BACKGROUND
2.1 Following the accident of CH146434 in Afghanistan, it was discovered that

some of the hover performance charts in ref A that were being used by aircrew for
flight planning do not indicate the appropriate Weight-Altitude-Temperature (WAT)
limits for hot/high conditions. Specifically, some the charts do not show the lower
WAT limits due to engine temperature limits (ITT limits).
2.2 To address this situation, the AFM OPI, A3 Tac Avn Sys, requested that a
new supplement be added to ref A, which would include performance charts
suitable for these conditions. A draft supplement, ref B, was prepared by the
OEM, Bell Helicopter Textron Canada Limited (BHTCL).
2.3 Ref B is based upon the Category B supplement, ref C, used for the civilian
Bell Model 412 AFM, ref D. The ref B supplement is thus based upon the FAA
civil airworthiness regulations and standards contained in FAR Part 29 Transport
Category Rotorcraft, Ref E, and the associated advisory material in Ref F.
3. DISCUSSION
3.1 In order to review Ref B, the basis of the performance information contained
in Ref A needed to be understood. Various meetings and telecons were held with
BTHCL representatives to explain the origins of the performance information used
in refs C and D, and thus refs A and B. No formal documentation, such as
certification reports, were provided for review, so the information from the OEM is
testimonial in nature. The following are the key findings.
3.2 GENERAL
3.2.1 The performance limitations and charts in the basic civilian AFM, ref D, are
in accordance with FAR 29 Category A requirements. (Note: the actual Cat A
takeoff and landing profile information is not contained in the basic AFM, and is
instead provided in a Supplement for Cat A Operations.).
3.2.2 In accordance with the Model 412 basis of certification for Part 29 Category
A, given at Ref G, both the hover in ground effect (HIGE) WAT chart and the
Height-Velocity (H-V) diagram are considered as airworthiness limitations. In
Category B, the H-V diagram is no longer a limitation, and the HIGE WAT chart
requires less-restrictive constraints, thus permitting higher WAT limits.

1010-CH146434 (DFS 2-4)
3.2.3 For either Cat A or B, the hover out of ground effect (HOGE) charts were
not required by the Model 412CF basis of certification and are provided as
performance info only. (This requirement was not added to FAR 29, Ref E, until
2008, which is some 13 years after the certification date of the Model 412CF on
Ref G.)
3.3 CAT A (BASIC FLIGHT MANUAL)
3.3.1 CAT A HIGE
3.3.1.1 The HIGE WAT chart in the basic flight manual (Fig 1-1 of Ref A) has an
upper limit at high WAT combinations equivalent to a Referred Weight1 (Wref) of
13200 [lb]. This chart provides the limitations for maximum safe takeoff weight.
3.3.1.2 The chart is based upon flight testing at this Wref, in winds from all
azimuths, and with the effects of a control actuator failure (“hard-over”). The
testing revealed no control authority limitations in wind speeds up to the limits in
Fig 1-4 of Ref A. Fig 1-4 does highlight the relative wind azimuth angles in which
the least control authority is available.
3.3.1.3 The H-V diagram, Fig 1-5 of Ref A, is valid for the WAT limits in Fig 1-1.
3.3.2 CAT A HOGE
3.3.2.1 The HOGE charts contained in Ref A Fig 4-4 (multiple sheets) are
provided for performance information only.
3.3.2.2 Area A on these charts represents the area covered by the HIGE chart,
with Wref up to 13200 [lb]. Area B has Wref extending up to 14400 [lb], which
provides additional hover capability that may be used OGE. As the Wref in Area B
exceeds the max takeoff weight permitted by the HIGE chart, Area B can be
achieved only in external load operations.
3.3.2.3 Just as for the HIGE chart, Area A of the HOGE chart is valid for winds
from all azimuths at speeds up to the limits in Fig 1-4 of Ref A, and includes the
effects of a control actuator failure. Fig 1-4 also identifies the critical relative wind
azimuths where control margins are lowest.
3.3.2.4 Area B of the HOGE chart is valid only outside the critical wind azimuth
angles of Fig 1-4 of Ref A. Within the critical azimuth areas, control authority
issues may be encountered for left tail rotor pedal or aft cyclic, particularly in the
effect of a control actuator failure.

1010-CH146434 (DFS 2-4)
3.3.2.5 The Cat A HOGE charts feature reductions in maximum Wref based on
Outside Air Temperature (OAT), which are due to the engines reaching
temperature limits.
3.3.2.6 The H-V diagram, Fig 1-5 of Ref A, is not valid in Area B, as the flight
testing did not include demonstrations of landings following an engine failure at
these higher Wref.
1 Bell uses the term “referred weight” to represent W/σ, “weight-over-sigma”

(where σ is the atmospheric density ratio ρ/ρ0, and ρ0 is the standard sea level
air density), however other sources define referred weights differently. For this
technical note, Wref is based on the Bell definition.
3.4 CAT B (FLIGHT MANUAL SUPPLEMENT)
3.4.1 CAT B HIGE
3.4.1.1 The HIGE chart in the Model 412 Cat B supplement, Ref C, is based upon
flight testing at Wref up to 15000 [lb], compared with only 13200 [lb] that was
used for Cat A in the basic flight manual. This permits operations at higher takeoff
weights than are permitted by Cat A.
3.4.1.2 In addition, the Cat B certification raised the density altitude (DA) limit to
16000 [ft] from the 14000 [ft] that was used for Cat A. The Wref at 16000 [ft] is
reduced by a small percentage from that at 14000 [ft], which the FAA required to
be applied based on the flight test data that was available.
3.4.1.3 A fundamental difference from Cat A is that the Cat B certification did not
require controllability assessments to include the effects of a control actuator
failure.
3.4.1.4 Unlike the Cat A flight testing where HIGE controllability demonstration
included winds from all azimuths, the Cat B flight testing demonstrated relative
wind only at forward azimuth angles. Based on this, the FAA credited the Model
412CF with relative winds demonstrated only within +/- 45 degrees of the nose up
to 14000 [ft] DA, and within +/- 30 degrees up to 16000 [ft] DA. Outside of these
azimuths, control authority may be limited.
Note however that this applies only to the portion of the HIGE WAT envelope that
was added by the Cat B certification, i.e., at Wref above 13200 [lb]. Below 13200
[lb] Wref, the relative wind was demonstrated at all azimuths as per the Cat A
certification, explained above at 3.3.1.2. Also note that the wind speeds used for
the Cat B certification were higher at higher DA than was the case for Cat A.
3.4.2 CAT B HOGE

1010-CH146434 (DFS 2-4)
3.4.2.1 The Cat B HOGE charts are based on Wref up to 14150 [lb], or about 250
[lb] less than was the case for Cat A at 14400 [lb], despite Bell intending no
change for the Cat B certification. Bell reports this is due to an evolution in the
FAA’s willingness to accept flight test substantiation without witnessing it, and as
a consequence they gave “less credit” during the Cat B certification program than
they had in the original Cat A program, despite it being the same aircraft at the
same flight conditions.
3.4.2.2 Note that the HOGE Wref of 14150 [lb] is also significantly less than the
HIGE Wref of 15000 [lb]. This signifies that the additional takeoff weight permitted
by the Cat B certification in excess of 14150 [lb] is useable only with an IGE
takeoff, i.e., with transition through forward flight to climb profile while still IGE.
3.4.2.3 Just as for the Cat B HIGE chart, the FAA required that the Wref at 16000
[ft] DA was reduced from that at 14000 [ft] based on the available flight test data.
3.4.2.4 Just as for Cat A, the Cat B HOGE charts feature reductions in Wref
based on OAT, due to the engines reaching temperature limits.
3.4.2.5 Considering that Cat B HOGE limits were intended to be that same as Cat
A, and that they are nearly identical, the relative wind limits and azimuth
considerations are no different than as in Ref A for the Cat A HOGE charts.
3.4.2.6 The H-V diagram is valid to approximately 14500 [lb] Wref (close, but not
identical, to the Wref of the HOGE charts, which is 14150 [lb]).
3.5 OTHER FLIGHT MANUAL ISSUES
3.5.1 Ref A includes some hover performance charts in Section 8, at Figs 8-11,
12, and 13. These charts are not included in the Model 412 AFM, Ref D, and
were created specifically for the CH146 at DND/CF request. The technical basis
for these charts is not known at this time. Unfortunately these charts do not reflect
the WAT reductions due to engine temperature limits at higher air temperatures. If
used by aircrew for flight planning in conditions where engine temperature limits
could be encountered, the charts may suggest more performance capability then
is actually available. This could contribute to a flight safety situation.
3.5.2 Ref A includes a HIGE chart at Fig 1-1A, which is a copy of the Fig 8-13.
This is presented as the HIGE WAT limitation when operating with 9 passengers
or less, i.e., a Cat B limitation. However it is presented in a Cat A basic flight
manual. The chart was inserted here in a temporary revision of Ref A prior to
being fully incorporated in Change 2 or Ref A. At the same time the title of Fig 1-1
was changed to state it applies only to 10 passengers or more. These revisions
did not receive TAA review and approval.

1010-CH146434 (DFS 2-4)
3.5.3 Some of the hover charts include the basic heater in addition to the
winterization heater. The CH146 is equipped only with the latter, and charts for
the former, which apply to the Model 412, should be removed.
3.5.4 It was discovered that HIGE chart for Maximum Continuous Power
contained in Ref C and proposed for Ref B is in error, as it reflects the incorrect
performance limitations.
3.5.5 Regardless of the certification basis for Ref A being FAR 29 Cat A, it is well
known that the CH146 is not operated according to Cat A performance
information or operating regulations. Further, it is perhaps not operated according
to Cat B, either. CH146 operators appear to have no knowledge of the Cat A and
B technical limitations of their aircraft and the associated operating rules that
apply. Thus the significance to any references to Cat A or B in the flight manual
are not understood by aircrew. CH146 operations are generally conducted as
directed by the CH146 Standard Manoeuvres Manual.
3.5.6 The Ch 2 of Ref A did not receive TAA review and approval. Ch 2 included
the permanent incorporation of a number of temporary revisions, and an unknown
number of additional new revisions. Some of the content may have received TAA
review during the associated AMAF process, where applicable, however this does
not cover all of the revisions, nor constitute a proper TAA review and approval of
the AFM amendments.
3.6 SUPPLEMENT STRATEGY
3.6.1 Through several revisions of the Ref B supplement, the immediate strategy
developed as follows.
3.6.1.1 Ref B should be added to Ref A, while simultaneously removing Figs 1-

1A, 8-11, 12, and 13 entirely from Ref A, and restoring the title of Fig 1-1 in Ref A.
3.6.1.2 Ref B would be titled “Operations with Nine Passengers or Less” rather
than Ref C’s title “Category B Operations when Configured with Nine or Less
Passenger Seats”. This removes the reference to “Cat B” which is not understood
by CH146 aircrews. Further, for CF operations, the concern is with the
passengers on board rather than the seat configuration. These changes add
flexibility while maintaining the same level of safety intended by the FAR 29 Cat B
standards.
3.6.1.3 The Ref B supplement would have all HOGE charts removed, and instead
the HOGE charts in the basic flight manual Ref A would be used. This was
justified due to their similarity and Bell’s original intention that they be identical.
3.6.1.4 Ref B would have the incorrect HIGE chart for Maximum Continuous
Power removed.

1010-CH146434 (DFS 2-4)
3.6.1.5 The maximum DA in Ref B would be contained at 14000 [ft] versus the
16000 [ft] in the civil supplement Ref C. This is done only as a short-term
measure to ensure commonality with Ref A.
3.6.1.6 The wind charts would be harmonized to use the Cat A wind speed limits,
as contained at Fig 1-4 of Ref A. The critical azimuth angles for Cat B HOGE
would be the same as Cat A HOGE. Similarly, the critical azimuth angles for Cat
B HIGE at Wref below 13200 [lb] would be the same as for Cat A HIGE, however
at Wref above 13200 [lb], it would be as per the civil supplement, Ref C. These
changes were made to clarify the cautionary regions of the relative wind
envelope, as well as to simplify the presentation of this information.
3.6.1.7 As the hover charts currently available were based on the Model 412 150-
amp generator, whereas the CH146 has 200-amp generators, a limitation is
inserted into Section 1 of Ref B requiring max generator load not exceed 150
amps each. This is an interim measure until the Cat B charts based on the 200-
amp generator are provided.
3.6.1.8 A General Information section would be added to the front of Ref B,

indicating: the changes that the Cat B supplement brings over the Cat A
certification basis of the basic flight manual; any increase in risk of using Cat B
compared with Cat A; and the derivation basis for Ref B being Ref C, as
explained in this technical note.
3.6.2 The longer term strategy should include:
3.6.2.1 A full TAA review and approval of Ref A, Change 2.
3.6.2.2 An assessment of 1 Cdn Air Div of the risk inherent with adopting Cat B
operations (or a derivative) as the primary performance limitations in Ref A, rather
than Cat A. Should this be accepted, Ref A could be converted to a set of
performance limitations more suitable to CH146 operations, such as those
derived from Cat B. Where beneficial, such as for civilian and VIP operations, Cat
A performance provisions should be retained as a supplement to the flight
manual.
3.6.2.3 Inclusion of the 16000 [ft] DA limit in Ref A.
3.6.2.4 Harmonization of the confusing critical relative wind azimuth information

for the various hover charts. Where available, additional flight test information
could be used to expand this information beyond that provided during the civil
certification programs.
3.6.2.5 Update hover charts to be based on the correct equipment, for example,
200-amp generator and winterization heater.

1010-CH146434 (DFS 2-4)
3.6.2.6 Inclusion of the correct HIGE chart for Maximum Continuous Power.
4. CONCLUSIONS
4.1 The actions explained at 3.6.1 should be taken to secure TAA approval of Ref
B, and at 3.6.2 to obtain likewise for Ref A.
5. RECOMMENDATIONS
5.1 The actions at 3.6.1 should be incorporated into Ref B before its initial
release.
5.2 Upon completion of 3.6.1, TAA Approval should be given to Ref B.
5.3 The actions at 3.6.2 should be incorporated into Refs A and B as soon as
practicable.
5.4 Upon completion of 3.6.2, Ref A should be given TAA Approval.
Distribution List
Action
DAEPM(TH) 4-6
Info
DTAES 5-3
1 Cdn Air Div A3 Avn Tac Sys

Annex H “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex H: ROTO 6 Performance Chart

20 25 30 35 40 45 50
3500’ OGE WAT Takeoff WT / Q 11,400 / 89 11,300 / 88 11,100 / 86 10,900 / 84 10,700 / 83 10,500 / 81 10,300 / 79
Twin Engine 810 ITT OGE WT / Q 11,700 / 92 11,400 / 89 11,000 / 85 10,600 / 82 10,300 / 78 9,900 / 75 9,600 / 72
IGE WAT Takeoff WT / Q 11,400 / 76 11,300 / 76 11,100 / 74 10,900 / 72 10,700 / 71 10,500 / 69 10,300 / 68
Twin Engine 810 ITT 4’ WT / Q 11,900 / 92 11,900 / 89 11,900 / 85 11,800 / 82 11,500 / 78 11,200 / 75 10,800 / 72
Max 810 WT / Q for IGE T/O +5% 11,900 / 87 11,900 / 84 11,800 / 80 11,400 / 77 10,900 / 73 10,600 / 70 10,200 / 67
Max 810 WT / Q for IGE T/O +5% 11,900 / 85 11,900 / 82 11,600 / 79 11,100 / 75 10,800 / 72 10,500 / 69 9,900 / 65
Max 810 WT / Q for IGE T/O +5% 11,900 / 83 11,700 / 80 11,300 / 77 10,900 / 76 10,600 / 71 10,200 / 67 9,800 / 64
OGE WAT Takeoff WT / Q This is the most you can lift OGE based on the ability of the rotors to produce lift/thrust
Twin Engine 810 ITT OGE WT / Q This is the most you can lift OGE based on the ability of the engines to produce power
IGE WAT Takeoff WT / Q This is the most you can lift IGE based on the ability of the rotors to produce lift/thrust
Twin Engine 810 ITT 4’ WT / Q This is the most you can lift IGE based on the ability of the engines to produce power
Max 810 WT / Q for IGE T/O +5% This is the most you can lift IGE with 5% remaining for rotation based on the engines ability to produce power
Note: Although unofficial, this chart also indicated that the accident aircraft was overweight, even if only using 4500’ HD
and 40ºC OAT.
H-1/1 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex I “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex I: DAY-HUD and NVG-HUD Hover Page Symbology
Drift Vector
Notes:
1. The drift vector as currently displayed would indicate aircraft movement in a

direction of approximately 45º to the right and rear.
2. The hover velocity vector symbol is a single line with one end point centered
on the HUD display. The symbol depicts aircraft drift magnitude and direction
over a range from zero to 10 knots groundspeed and from 0ºM to 359ºM. As
speed increases the symbol elongates. The direction of the line from the centre
of the display indicates aircraft drift direction relative to aircraft heading. Above
10 knots the symbol blanks.
I-1/1 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex J “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex J: CH146 Emergency Procedures
(Source: CH146 Flight Crew checklist – C-12-146-000/MC-002)
ENGINE FIRE
Fault Condition: Engine Fire
On Ground:
Corrective Action: 1. Both Throttles CLOSE
2. FIRE PULL Handle PULL

(affected engine)
3. FIRE EXT Switch MAIN, then RESERVE
4. Emergency Ground Egress
EMERGENCY GROUND EGRESS
Corrective Action: 1. Throttles CLOSE
2. BATTERY BUS Switches OFF
3. Rotor Brake AS REQUIRED
4. Door OPEN/JETTISON
5. Exit Aircraft
J-1/1 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex K “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex K: CH146 Power Performance Software Output
Figure 1 - Software output for a generic CH146 performance for FOB conditions and 0ºC PPI.
K-1/1 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Figure 2 - The #2 aircraft for the afternoon FOB takeoff. This is the best case scenario for the #2 aircraft without
exceeding limits. Note baseline PPI of 25.4ºC and various AUWs for OGE and IGE hover heights.

Figure 3 - The #2 aircraft at a 20’ hover. Note 90.8 % Qm and 32ºC PPI. Since baseline PPI was 25.4ºC this indicates
that they would have seen and ITT exceedences of 6.6ºC to hover at 20’. (32 – 25.4 = 6.6)

Figure 4 - The accident aircraft for the afternoon FOB takeoff. This is the best case scenario for the accident aircraft
without exceeding limits. Note baseline PPI of 27.9ºC.

Figure 5 - The accident aircraft at a 20’ hover. Note 94.4 % Qm and 44ºC PPI required for an AUW of 11537lbs. 27.9ºC
PPI indicates that they would have seen an ITT exceedence of 16ºC to hover at 20’. (44-27.9=16.1)

Figure 6 – Shows PPI required to achieve transition assuming a 5% above hover Qm. ITT exceedences of 34.1ºC
required for transitions at 99.7% Qm. (62 – 27.9 = 34.1)

Annex L “Non-Controlled Goods / Marchandises Non-Contrôlées”
1010-CH146434 (DFS 2-4)
Annex L: Abbreviations
1 Cdn Air Div 1 Canadian Air Division
ADI Attitude Director Indicator

AETE Aerospace Engineering Test Establishment
AF Airframe
AFIP Armed Forces Institute of Pathology
AFM Aircraft Flight Manual
ALSE Aviation Life Support Equipment
AOI Aircraft Operating Instructions
BHS Basic Helicopter School

BHTCL Bell Helicopter Textron Canada Limited
C Celsius
C Air Force Chief of the Air Force
CAS Chief of Air Staff
CDS Chief of Defence Staff
CEFCOM Canadian Expeditionary Force Command
Ch Change
CO Commanding Officer
Comd RCAF Commander of the Royal Canadian Air Force
COO Concept of Operation
CF Canadian Forces
CHF(A) Canadian Helicopter Force (Afghanistan)
CJOC Canadian Joint Operations Command
CRH Crewman Restraint Harnesses
CRR Crewman Restraint Release
CRT Crewman Restraint Tether
CSAR Combat Search and Rescue
CVFDR Cockpit Voice and Flight Data Recorder
CVR Cockpit Voice Recorder
DAEPM(TH) Directorate of Aerospace Equipment Program Management

(Transport & Helicopter)
DG Door Gunner
DGAEPM Director General Aerospace Equipment Program Management
DRDC Defence Research and Development Canada
DTA Directorate of Technical Airworthiness
DTAES Directorate of Technical Airworthiness and Engineering Support
DVE Degraded Visual Environment
ETAH Escadron tactique d’hélicoptères
FAA Federal Aviation Administration

FAR FAA Airworthiness Regulations
FDR Flight Data Recorder
FE Flight Engineer
FOB Forward Operating Base
L-1/3 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1010-CH146434 (DFS 2-4)
FP Flying Pilot
ft Feet/Foot
GFA Graphical Area Forecast

GW Gross Weight
HD Density Altitude
hr(s) Hour(s)
HIGE Hover In Ground Effect
HP Pressure Altitude
HESCO Hercules Engineering Solutions Consortium
HMD Helmet Mounted Display
HOGE Hover Out of Ground Effect
HUD Heads-Up Display
HUMS Health and Usage Monitoring System
IETM Integrated Electronic Technical Manual

IFC Instrument Flight Condition
IGE In Ground Effect
IIMC Inadvertent Instrument Meteorological Condition
IMC Instrument Meteorological Condition
ITO Instrument Takeoff
ITT Inter-Turbine Temperature
JTF(A) Joint Task Force (Afghanistan)
KAF Kandahar Airfield

KIAS Knots Indicated Airspeed
lbs Pounds
M Magnetic
MALA Mission Acceptance, Launch Authorization
METAR Meteorological Aviation Report
MFS Maxillo-Facial Shield
Min Spec Minimum Specifications
MPTO Maxi Performance Takeoff
N1 Gas Producer RPM

NFP Non-Flying Pilot
NRC National Research Council
NVG Night Vision Goggle
OAA Operational Airworthiness Authority

OAT Outside Air Temperature
OEM Original Equipment Manufacturer
OGE Out of Ground Effect
OSI Out of Sequence Inspection
OT&E Operational Test and Evaluation

1010-CH146434 (DFS 2-4)
PAC Power Assurance Check

POAC Provisional Operational Airworthiness Clearances
PWGSC Public Works and Government Services Canada
Qm Mast Torque
QETE Quality Engineering and Test Establishment
RARM Record of Airworthiness Risk Management

RCAF Royal Canadian Air Force
ROTO Rotation
RPM Revolutions Per Minute
RRPM Rotor Revolutions Per Minute
SA Situational Awareness
SDE Senior Design Engineer
SI Special Inspection
SMM Standard Manoeuvre Manual
SOI Statement of Operating Intent
S/N Serial Number
TAA Technical Airworthiness Authority

TAM Technical Airworthiness Manual
TAWD Technical Airworthiness Data
TASET Tactical Aviation Standard and Evaluation Team
Temp Rev Temporary Revisions
THS Tactical Helicopter Squadron
TIC Troops in Contact
VCDS Vice Chief of Defence Staff

VFC Visual Flight Condition
VMC Visual Meteorological Condition
VMAX Maximum Velocity
VMINI Minimum Speed for Instrument Flight
VNE Never Exceed Speed
WAT Weight-Altitude-Temperature
WComd Wing Commander
WSM Weapon System Manager
% Percent
° Degree

ch146434-fsir-06jul09

Uploaded by

Copyright:

Available Formats

ch146434-fsir-06jul09

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ch146434-fsir-06jul09

Uploaded by

Copyright:

Available Formats

“Non-Controlled Goods / Marchandises Non-Contrôlées”

FILE NUMBER: 1010-CH146434 (DFS 2-4)

Aircraft CH146434 was the formation lead of a two-helicopter formation tasked

i “Non-Controlled Goods / Marchandises Non-Contrôlées”

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

ii “Non-Controlled Goods / Marchandises Non-Contrôlées”

Annex A: Photographs .................................................................................... A1

iii “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.1 History of the Flight

1 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

2 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.2 Injury to Personnel

Injuries Crew Passengers Others Total

1.3 Damage to Aircraft

1.4 Collateral Damage

3 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Protective Wall / barrier

CH146434 - Intended departure FOB Entrance

Figure 1: FOB Diagram – Not to Scale

1.5 Personnel Information

4 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.5.3 Aircrew Training – Helicopter training is Phase III of the Canadian

1.5.4 Once in Afghanistan, a theatre check-out for all aircrew arriving in

5 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.5.5 Dustball landings were a 30-day currency requirement in theatre and a

1.6 Aircraft Information

1.6.4 Aircraft Certification

6 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

7 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

quickly through the obscuring phenomena requires a generous power margin

1.6.4.4 As described in the NATO Research and Technology (RTO) Technical

a) Technology development to overcome the environmental limitation

b) Technology development to overcome the physiological limitation

1.6.4.5 There is currently no helicopter designed to safely and effectively

8 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.6.4.7 On the technological side, some stability-augmentation and autopilot

1.6.5 Aircraft Flight Manual (AFM)

1.6.5.1 The definitions and differences between an AFM and an Aircraft

9 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

1.6.5.2 The AFM is an integral part of the aircraft airworthiness certification

The STANDARD MANOEUVRE MANUAL (SMM) is a document produced by the aircraft

10 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

Spec) performance. The performance levels found in Section 4 are not

1.6.5.4 Section 1 - Weight-Altitude-Temperature (WAT) Charts: The AFM

11 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

operations. It is also referenced when using the Height - Velocity diagram. A

Figure 3: WAT chart Figure 1-1 note.

1.6.5.5 IGE WAT chart Figure 1-1A (Weight-Altitude-Temperature

12 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

29, Category B performance certification, the OGE hover performance

1.6.5.8 Section 8 - Cruise Performance Charts: The AFM cruise performance

1.6.5.9 Section 8 - Hover Torque Required charts: The torque required to

1.6.6 Aircraft Weight Information

13 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”

estimated to be 11,520 lbs. 20 The #2 aircraft weighed approximately 11,000 to

CH146434 Fuel Added AUW

1.6.7 Engine Fire Warning System

1.7 Meteorological Information

1.7.1 There was no meteorological station at the FOB. METARs (aviation

14 / 84 “Non-Controlled Goods / Marchandises Non-Contrôlées”