SZ2-33 Glider C-GCLR
20 September 2003
Alexandria, Ontario
During the final flight of the day, the Air Cadet glider, piloted by a Cadet Instructor Cadre (CIC) pilot, crashed while manoeuvring to land at the Alexandria Gliding Site. The passenger, also a CIC pilot, suffered minor injuries to his lower back. The glider suffered "A" category damage.
The pilot took off from Runway 25 and, after some work at altitude, flew a standard circuit profile to Runway 25 until he was established on final at about 450' AGL. At this point, the pilot fully opened the spoilers and lowered the nose to begin a rapid descent. The aircraft was then levelled at approximately 50' AGL and 85 MPH before the pilot executed a 30 ° angle of climb pull-up, reaching approximately 100' AGL and 50 MPH. A 45 ° -60 ° angle of bank left turn was then initiated to line up on the Auxiliary Field, situated 90° to Runway 25 and adjacent the glider overnight parking area. The spoilers remained open throughout this manoeuvre. It was during this low level turn that the left wing first contacted the ground, sending the glider cartwheeling.
The investigation revealed numerous issues of concern. Although he departed from, and completed the initial part of the approach to Runway 25, the pilot chose to land on the Auxiliary Field in order to avoid the extra time it would take to push the glider from the end of runway 25 to the overnight parking area. To set himself up for landing, the pilot conducted the "very rapid pull up," an aerobatic manoeuvre; aerobatic manoeuvres are prohibited within the Air Cadet Gliding Program. This manoeuvre was initiated from a height of 50' AGL and resulted in a turn to final at about 100' AGL, both well below the 300' minimum altitude for being established on final approach in accordance with safe operating practices (and as specified in the Air Cadet Gliding Program Manual). While within wind limits on Runway 25 (260 11G18), the decision to land 90° from the take-off runway on the Auxiliary Field exceeded the crosswind limits by 3-10 knots. Finally, an underlying culture of non-compliance was present among the staff of the Quinte Gliding Centre. This led to instructors carrying out prohibited manoeuvres, specifically the Very Rapid Pull-up, while receiving accolades from their peers for their perceived flying ability.
Recommended safety actions included the establishment of an effective Standards Evaluation Team and the implementation of supervisory training for gliding site supervisors.
DFS Comments
For the past few years, the flight safety organization has emphasized the requirement for a strong safety culture. It is my firm belief that encompassing a just culture, a reporting culture, a flexible culture and a learning culture is a fundamental requirement for an effective safety program. Accordingly, the safety culture concept has been taught on our Basic and Advanced Flight Safety Courses and has been highlighted in a variety of our flight safety promotion mechanisms.
In reviewing this report, it is clear that the safety culture at the Alexandria Gliding Site was very poor. In particular, evidence of a just culture was lacking. The pilots at this site apparently understood the difference between what constituted acceptable behaviour and unacceptable behaviour in that they knew the rules and regulations as well as the aircraft operating limitations. However, by routinely allowing some personnel to operate outside of the acceptable limits, supervisors and CIC glider pilots effectively undermined the safety culture of this site. In addition, a number of impressionable young Air Cadets observed this behaviour. The conclusions that this latter group drew can only be postulated, but I suspect that they do not bode well for a strong safety culture.
So what can be learned from this accident? To me, this accident reinforces my belief that a good safety culture is critical to a safe flying operation. While a good safety culture will not prevent all accidents, it is highly likely that it would have prevented this one. Another point that needs to be emphasized is that a safety culture is not something that is practiced only by some members of the organization or only within sight of senior supervisors. By definition, a safety culture is a full time commitment by everyone.
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