Flight Safety Investigation Report for CH147310 Chinook Accident

Pete Fisher
3 weeks ago
• Categories: National

The Royal Canadian Air Force’s (RCAF) Directorate of Flight Safety, which is the Canadian Armed Forces’ (CAF) Airworthiness Investigative Authority, has concluded its Flight Safety Investigation into the accident that occurred on June 20, 2023, in the Ottawa River near Garrison Petawawa involving a CH-147F Chinook helicopter that claimed the lives of two CAF members. The helicopter, known by its call-sign Hammer 31, was conducting a nighttime training flight over the river.

The training flight had a crew of four members. Tragically, the two pilots, Captain Marc Larouche and Captain David Domagala, were fatally injured. The two flight engineers egressed the helicopter with minor injuries.

The Flight Safety Investigation determined that as the crew initiated a turning manoeuvre over the river, the aircraft entered a constant but imperceptible descent. None of the crew realized the aircraft’s altitude and/or rate of descent until impact, resulting in a Controlled Flight into Terrain accident.

It concluded that unrecognized downward acceleration, along with environmental conditions that night, were significant contributors to the accident, causing spatial disorientation among the crew.

The complete findings of the investigation and recommendations are detailed in the CH147310 Flight Safety Investigation Report.

Quotes
“This accident was not caused by a single factor, instead, multiple elements contributed to the unrecognized spatial disorientation of all crew members of Hammer 31, leading to the continued descent until water impact. Over 16 months, we thoroughly analyzed a large amount of data and collaborated closely with partners to identify additional contributing factors. Several recommendations are provided to help prevent similar accidents in the future.”
Colonel Jean-François Gauvin, Director of Flight Safety, Royal Canadian Air Force

“We continue to grieve alongside all those affected, and our thoughts remain with the loved ones of Captain Marc Larouche and Captain David Domagala. The results of the Flight Safety investigation provide us details and recommendations surrounding this tragic accident. We are committed to learning from this heartbreaking loss, and providing safety for our aviators as we continue our mission in service of Canada.”
Lieutenant-General Eric Kenny, Commander, Royal Canadian Air Force

Quick Facts
Prior to being publicly released, the CH147310 Flight Safety Investigation Report was briefed to all designated next of kin of the fallen RCAF personnel.

On August 29, 2023, the preliminary From the Investigator report was released and confirmed the investigation was focusing on human, technical, and environmental factors.

Preventative measures are recommended at the base, squadron, wing, division and strategic levels.

These measures will enhance safety and mitigate the risks associated with over-water missions.

The CH-147F Chinook is an advanced, multi-mission helicopter used to transport equipment and personnel during domestic or deployed operations. The current fleet of 14 was acquired starting in 2013.