Directorate of Flight Safety -- History of DFS

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The first known formal recognition of the need for a dedicated Flight Safety (FS) Organization occurred in mid 1942 when the RCAF Aircraft Accident Investigation Board (AIB) was formed under a Chief Inspector of Aircraft Accidents. This small cell of 16 people headed by a RAF Group Captain (later transferred to the RCAF) was expected to examine past aircraft accidents and to investigate new ones with a view to reducing non-operational losses. It was a very tall order and the war ended before much progress in accident prevention could be made. During the unsettled period of demobilization, the record of their efforts along with most of the staff, appears to have been lost. The designation AIB and a small staff of 6 survived, until the early 1950's when the Directorate of Flight Safety (DFS) was established and the strength increased.

With the establishment of DFS, the "AIB" still remained by far the major responsibility, but some long overdue recognition was intended to be given to education and prevention. Regrettably, this first slight shift of emphasis to learning from our mistakes was set back by the rapid RCAF expansion during the Korean conflict. How dearly this set back cost us is indicated by the 1953-57 losses of 476 aircraft and 405 people.

Regardless of the circumstances, such a destruction rate could not continue and in 1957-58, the then Chief of the Air Staff directed in no uncertain terms that the development of a positive and effective flight safety program had the highest priority. This declaration is considered by many to have been the first real break with the traditional air force syndrome of "press onward regardless".

The need for thoroughness in AIB investigations was if anything increased during the next 6 to 7 years. The very carefully selected and trained pilots and engineers were now expected to assist the President of the B of I in every way possible, particularly in finding the true cause(s) for aircraft accident so that corrective action could be taken: "In other words, treat the disease not the symptoms." How effective this FS program was is indicated by the fact that in 1958 we lost only 42 aircraft compared with 81 in 1957.

Over the next ten years, the overall trend was a gradual reduction in losses with the years 1963 and 1965 being slight aberrations (like 1982). It was during this period that a definite shift developed away from the long standing legal requirement for a Board of Inquiry convened under QR&O 21.56 to assign blame, except in the strong case (CFAO 24-6 para 2a) and recommend punishment. More important was the fact that none of the information given to an aircraft accident investigation could be used in disciplinary proceedings (A-GA-135 Chap 15). With such a positive approach, the evolution of our "before the fact" aircraft accident prevention system was fairly rapid until 1965 when unification took place. At that time, the RCAF/DFS establishment was 31 but the combined strength of 34 was immediately cut to 24. This set back in manpower had no immediate degrading effect because those remaining in DFS had the opportunity to change priorities. More important, drastic philosophical changes that had not been possible under traditional sea, land and air concepts were introduced. The more significant developments during this period were:

publications of CFP-135, Manual of Flight Safety for the Canadian Forces which for the first time laid out a comprehensive FS program plus the direction on how best to do it;
acceptance and approval of the philosophy that information given to an investigation into an aircraft occurrence whether formal or otherwise be classed as "privileged" (QR&O See 8-CFP 135 Chap 15);
expansion of the Flight Safety reporting system to include anything that might hazard aviation resources or the people involved; with specific emphasis on the importance of the so called incident;
development of definitions which are realistic, understood and accepted over the longer term by most of the people involved. (This made comparisons meaningful.);
re-establishment of to the need of FS staff officers to report the most senior individual at each level of command ( i.e. DFS reports to the office of the CDS); and
probably the most important single step of all was elimination of the distasteful, derogatory word ERROR when assigning human cause factors.

These and other factors brought about a degree of stability in the total Flight Safety program that never existed before. People learned to trust the system more than in the past and expected it to help them do the job better (and safer). They in turn were willing to come forward and report candidly even when they were deeply involved. No other Air Force has such a philosophy or privilege of information which established a spirit of trust, the benefits of which are still being realized in the CF. The principle of this philosophy has been recognized in the recent Canadian Aviation Safety Board Act (Bill C163 paras 26 & 30).

The formation of Air Command in 1975 while obviously necessary to consolidate and concentrate aviation efforts and resources did not improve the operation of the Flight Safety system: at least not initially. It added another level of command which compounded some of the command and control problems that already existed and it made it difficult to delineate responsibilities between NDHQ, AIRCOM and CFE. Flying units outside Air Command, such as 1 CAG and 444 Sqn in CFE and AETE an ADM(Mat) unit, posed particular problems which were eventually solved through assignment of responsibility for matters of Air Policy, Air Doctrine, Air Standards and Flight Safety to Commander Air Command for all flying units within the Canadian Forces. Of equal concern, during the early days of Air Command, was the heated controversy over the division of responsibility between Air Command Flight Safety staffs and DFS. While the dividing lines are still not absolute, there has developed a basic understanding and good working relationship. The Commander Air Command, who exercises control over the vast majority of air resources is the convening authority for all aircraft accident Boards of Inquiry, while NDHQ, through VCDS/DFS prepares the Closing Action Report and assigns the final cause factors. Air Command Senior Staff Officer Flight Safety and his staff oversee the day-to-day Flight Safety programs as administered by the Air Groups while DFS staff are responsible for accident investigation, Flight Safety prevention programs, specialist education, and statistical reporting, collection and analysis. The most recent development in the evolution of the CF Flight Safety system has been the expansion of the DFS mandate to include air weapons safety. This responsibility involves monitoring air weapons activities from weapon breakout, through the convoy process, the loading and the air delivery of the weapons. It also includes downloading, if necessary, and the return of the weapons to the storage area.

There have been a number positive steps taken over the years which influenced the program and helped to improve accident/incident statistics. The one significant, negative factor has been our inability to retain, as far result of the Access to Information Act the "privilege" status for Flight Safety Board of Inquiry which did so much to foster trust in the system. The Boards are now provided the limited protection offered in the Access to information Act and the Privacy Act, but they, as an entity, can no longer be withheld. We have yet to feel the full impact of this policy; however, it has forced a rewrite of our manual and a restructuring of our accident-reporting format.

As the new millennium begins, it is fair to say that Flight Safety has come a long way since the disasters of the mid 50's. That there remains room for improvement is a given however, as the gap narrows between performance and expectation, every gain demands greater and greater effort. Flying is not risk-free and military flying even less so. Managing this risk in an ever changing environment is the task facing airmen of the future. A dynamic and responsive Flight Safety program supported by all levels of command will assist in meeting this challenge.