CANADIAN FORCES FLIGHT SAFETY INVESTIGATION REPORT (FSIR)

FINAL REPORT

FILE NUMBER: 1010-CF188925 (DFS 2-2-3) DATE OF REPORT: 26 August 2011 AIRCRAFT TYPE: CF188925 DATE/TIME: 01:34 Z 18 November 2009

(Local time 19:34 17 November 2009) LOCATION: Smoky Hill Range, near Salina, KS

N38 41.3 W 097 51.4 CATEGORY: "E" Category Incident

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

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 sole purpose of

accident prevention. This report is released to the public under the authority of the Director of Flight Safety (DFS), National Defence Headquarters, pursuant to powers delegated to him by the

MND as the Airworthiness Investigative Authority (AIA) of the Canadian Forces.

SYNOPSIS The incident occurred at night on the Smoky Hill Air National Guard Range (SHANGR), near Salina Kansas. Canadian military personnel conducting a Forward Air Controller (FAC) course were using a Ground Laser Target Designator (GLTD) to guide a laser guided training round (LGTR) from aircraft CF188925 to a range target located approximately 790 metres (m) to their south. Using standard procedures and following pilot / FAC mutual confirmation of the correct target using infra-red markers, the pilot was cleared for his attack run; however, instead of guiding on the intended target, the LGTR impacted approximately 50 feet southwest of the ground personnel and the laser designator. There were no injuries and further training using the GLTD was terminated. The investigation determined that the Observation Post (OP) was established within the LGTR seeker Field of View (FOV) when lasing was commenced and the FAC team had positioned the Portable Lightweight Designator and Range Finder (PLDR) so that the laser beam passed through tall grass immediately in front of the PLDR. This created a second laser spot that was disregarded by the seeker while the target area laser spot was still visible. At some point during the LGTR fly-out, the seeker lost sight of the target area laser spot and switched to the laser spot in the grass and guided to that location. Contributing to the occurrence was insufficient guidance and information available to allow the FAC team to ensure they were positioned outside of the LGTR’s FOV.

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TABLE OF CONTENTS

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

1.1 History of the Flight ............................................................................................ 1 1.2 Injuries to Personnel........................................................................................... 3 1.3 Damage to Aircraft .............................................................................................. 3 1.4 Collateral Damage............................................................................................... 3 1.5 Personnel Information ........................................................................................ 4 1.6 Aircraft Information............................................................................................. 4 1.7 Meteorological Information ................................................................................ 6 1.8 Aids to Navigation............................................................................................... 6 1.9 Communications ................................................................................................. 6 1.10 Aerodrome Information ...................................................................................... 7 1.11 Flight Recorders.................................................................................................. 7 1.12 Wreckage and Impact Information .................................................................... 7 1.13 Medical ................................................................................................................. 7 1.14 Fire, Explosives Devices, and Munitions.......................................................... 7 1.15 Survival Aspects ................................................................................................. 8 1.16 Test and Research Activities ............................................................................. 9 1.17 Organizational and Management Information. ............................................... 12 1.18 Additional Information...................................................................................... 13 1.19 Useful or Effective Investigation Techniques ................................................ 18

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

2.1 General............................................................................................................... 19 2.2 Placement of the OP ......................................................................................... 19 2.3 Target details..................................................................................................... 19 2.4 The effect of grass on the laser beam............................................................. 19 2.5 LGTR release conditions.................................................................................. 20 2.6 LGTR trajectory ................................................................................................. 20

3 CONCLUSIONS...................................................................................... 22

3.1 Findings ............................................................................................................. 22 3.2 Cause ................................................................................................................. 24

4 PREVENTIVE MEASURES..................................................................... 25

4.1 Preventive Measures Taken ............................................................................. 25 4.2 Preventive Measures Recommended.............................................................. 25 4.3 Other Safety Recommendations...................................................................... 26 4.4 DFS Remarks..................................................................................................... 26

Annex A Abbreviations and Acronyms used in the Report........................A-1 Annex B Figures.............................................................................................B-1 Annex C LGTR Safety Footprint....................................................................C-1 Annex D Weapon Danger Zone Safety Template.........................................D-1 Annex E Example of Safety Zone and Optimal Attack Zones ....................E-1

1 FACTUAL INFORMATION

1.1 History of the Flight

1.1.1 The incident occurred during FAC training at the SHANGR, located southwest of the Salina, Kansas airport (KSLN). Aircraft and personnel from a Canadian CF188 Squadron were deployed to nearby Salina, Kansas in support of the planned FAC training. The intent was to provide training and instruction to a group of student FACs and to allow the CF188 pilots to exercise their air-to-ground weapons skills. The occurrence CF188 was a dual-seat aircraft and both pilots were equipped with and wearing Night Vision Goggles (NVG).

1.1.2 The ground team, 11 personnel in total, comprising three qualified FAC instructors, a Senior Instructor, another qualified FAC there for currency and six FAC students, arrived at the range at approximately 18:20 Central Standard Time (CST) and checked in with the range operations staff at the operations building. They were advised that they were cleared for the planned Laser Guided Training Round1 (LGTR) activities against the desired target group and decided to set up their OP at a location known as “Coiner Dome”, N38 41.253 W097 51.391 at an elevation of approximately 1,500 feet (ft) Above Mean Sea Level (MSL). “Coiner Dome” had been used for other FAC course serials without any issues. “Coiner Dome” was a rounded hill covered with tall thin grass. This was noted by the FAC team during an earlier trip to the OP during daylight hours but it was felt that this would not impact the evening exercise because when the IR pointer was aimed at the target the grass did not appear to affect the laser beam (See Annex B Figure 1). The group then departed for the OP, accompanied by the Range Control Officer (RCO), who was a member of the Range operations staff. It was a low illumination moonless night under clear skies. To make the target easier to see for the students, one of the closer targets was selected for the exercise. The target area was located at position N38 40.854 W097 51.307 at an elevation 1,388 ft MSL and consisted of four vehicle mock-ups, each in its own revetment. The specific target was target 307B, the most north-easterly vehicle, located approximately 790 m from the OP on a bearing of 160 degrees Magnetic (M) (see Annex B - Figures 2, 3, 4, 5 and 6). Because this was the first night LGTR exercise of the course, the Senior Instructor decided that the first drop would be a demonstration for the students, with staff instructors manning the key positions of FAC and Laser Designator Operator (LDO). The FAC and other personnel were equipped with NVGs.

1.1.3 Upon arrival at the OP the FAC students began to assemble the PLDR (Annex B - Figures 7 and 8) (see Section 1.18.2 for a detailed description). The LDO lowered the tripod so that the PLDR was as close to the ground as possible (approximately 0.6 m from the ground to the laser exit aperture), because this provided a much more stable base and is more tactically sound. The LDO collimated the laser to the Maxi-Kite night scope2 and the PEQ-4 Infrared (IR) pointer, which were mounted on

1 A relatively low cost, non-explosive, training ordnance which simulates the performance of an actual GBU-12 laser guided bomb. See Section 1.14 for a detailed description. 2 The Maxi-Kite is a rifle scope.

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top of the PLDR. A light source on a distant tower, which could be seen through the PLDR optics, was used to match the PLDR crosshairs with the Maxi-Kite crosshairs. The accuracy of the boresighting was then confirmed by the instructor FAC. The LDO then aimed the PLDR, using the Maxi-Kite night scope, to point at the target and adjusted the PEQ-4 IR pointer so that the IR spot matched the Maxi-Kite cross hair position. This was then re-confirmed independently by the FAC and the Senior Instructor. Because of the low ambient light level the target appeared against the background as a dark square through the Maxi-Kite night scope and the LDO aimed the Maxi-Kite at the center of the dark square. A laser spot detector, used to verify the exact placement of the spot on the target, was not available to the FAC team on the night of the occurrence.

1.1.4 As the PLDR was being assembled and bore-sighted the FAC communicated via radio with the airborne CF188 to pass the target coordinates and other standard information required to conduct the exercise. The RCO asked the FAC if they could use an attack heading of between 150 and 160 degrees M, as recommended in the Smoky Hill Range Guide for an LGTR against this particular target set. The FAC advised they could not because those headings were within the 20 degree safety zone (See Annex E) centered on the Laser Target Line (LTL) of 160 degrees M. Instead, the FAC suggested a 170 to 190 degree M cone for the attack heading. The RCO called back to Range Operations to check on the suitability of these headings. Range operations ran the Weapons Danger Zone (WDZ) software (see Section 1.18.4.4 and Annex D) to ensure the OP was safe to use with the planned attack headings, selected target and ordnance.

1.1.5 The FAC passed the initial attack heading restriction of 170 to 190 degrees M to the CF188 pilot but the CF188 pilot advised the FAC this would probably not work because it would likely require him to overfly the Range Operations building (a prohibited manoeuvre) during his run-in to the target. Nevertheless, they continued the set up and the CF188 repositioned to the north of the OP. At this time, the position of the OP was confirmed with the CF188 pilot using IR techniques. The CF188 then attempted to track the laser spot from the PLDR using its onboard equipment, but was unable to. To ensure the PLDR was in fact transmitting, three FAC staff then independently confirmed the laser cover door was fully open and also re-confirmed that the aircraft and the PLDR were using the same laser Pulse Repetition Frequency (PRF). The FAC and CF188 pilot then reverted to standard IR techniques to confirm the correct target had been selected by the CF188.

1.1.6 Once the target was mutually confirmed the FAC approved the CF188 to attack. The CF188 confirmed that the planned attack headings would not work because of the proximity of the Range Operations buildings to the run-in headings. The FAC changed the attack heading restriction to between 130 and 150 degrees M, basically a mirror image of the previous headings around the laser-to-target heading of 160 degrees M. The RCO again phoned Range Operations to have them run the WDZ program for the new attack headings. The WDZ software calculated a safety footprint which indicated the OP was located just within the danger zone but at the edge of the safety footprint with a calculated risk estimate of zero (see Annex D) if the aircraft was

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restricted to 10,000 ft MSL or below. Based on this information the exercise was continued and the CF188 pilot was limited to a maximum altitude of 10,000 ft MSL for the drop. The aircraft acknowledged the change, repositioned to approximately 10 nm northwest of the target, descended to approximately 9,600 ft MSL and commenced the run-in on a heading of 129 degrees M (ground track 132 degrees M). The aircraft’s approach was visible to the FAC who noted that the aircraft was heading towards the target and coming in over his right shoulder (as he faced the target), as expected.

1.1.7 Eight seconds prior to the Head Up Display (HUD) indicated LGTR release point the pilot radioed "10 seconds" to the FAC. The pilot released the LGTR at the designated release point, approximately 2.8 nm back from the target, as the CF188 was flying level at 418 Knots Calibrated Airspeed (KCAS), 472 Knots True Airspeed (KTAS), (499 knots ground speed) on a heading 128 degrees M from an altitude of 9,660 ft MSL (8,272 ft above the target) with the Time to Impact (TTI) indicating 23 seconds. The pilot in the rear seat of the CF188 observed the LGTR release and reported it looked normal and did not contact the aircraft after release. At 13 seconds TTI the pilot radioed "laser on" to the FAC. The LDO and FAC, who had been counting down from 10 to 0 as well, switched on the laser immediately after the aircraft’s laser on call using the PLDR laser firing remote switch. The LDO heard the usual noise that is made when the laser is transmitting and the LDO and the FAC started to count down again from 10 to 0. As both the LDO and FAC reached zero, they heard the sound of the approaching LGTR and immediately thereafter the noise of the LGTR as it impacted the ground in a 45 degrees nose down attitude on a heading of approximately 080 degrees M approximately 15 meters to the south of their position (See Annex B Figure 9). There were no injuries and the exercise was terminated. The CF188 returned to Salina and landed without further incident.

1.2 Injuries to Personnel

Injuries Crew Passengers Others Total Fatal 0 0 0 0

Serious 0 0 0 0 Minor 0 0 0 0 Total 0 0 0 0

Table 1: Injuries to Personnel

1.3 Damage to Aircraft

1.3.1 There was no damage to the aircraft. The LGTR, however, was destroyed on impact.

1.4 Collateral Damage

1.4.1 Other than a small hole in the ground at the impact point, no other collateral damage was reported.

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1.5 Personnel Information

CF188 Pilot (front seat)

FAC LDO

Currency / Category Valid Current Fighter Weapons

Instructor

Current and Qualified

Current and Qualified

Medical Category Valid Yes N/A N/A Total flying time (hrs) 2500 N/A N/A Flying hours on type 1000 N/A N/A Flying hours on day of occurrence

1 N/A N/A

Duty hours on day of Occurrence

8 N/A N/A

Table 2: Personnel Information

1.5.1 CF188 Pilots

1.5.1.1 The front-seat pilot was the Aircraft Captain. He was a graduate of the Canadian Air Force’s Fighter Weapons Instructor Course and employed as the Squadron Air-to-Ground Weapons Standards Pilot. The rear-seat pilot was a newly qualified combat ready wingman. The mission was flown by the front-seat pilot.

1.5.2 Forward Air Controllers

1.5.2.1 The occurrence FAC was considered very experienced in this role and had been a qualified FAC since 2004. He qualified as a FAC Instructor in 2006 and had instructed on every Canadian Forces (CF) FAC course since 2006. He has also trained and worked with the US military as a FAC. The FAC had operated on this range several times before and had personally controlled approximately 25 to 30 LGTR drops and estimated he had observed well over 200 LGTR drops, although the FAC was not able to identify how many of those drops were guided using the GLTD and how many were guided by the aircraft’s onboard laser target designator.

1.5.2.2 The FAC performing the LDO duties had been a FAC since 2006 and had participated in approximately 12 LGTR drops as either the FAC or the LDO, although the LDO was not able to identify how many of those drops were guided using the GLTD.

1.6 Aircraft Information

1.6.1 The occurrence aircraft was a CF188B (dual seat) model R2 aircraft. The aircraft external store configuration is presented at Table 3. The BRU 5002/A LGTR Rack is authorised for stations 2, 3, 7, and 8 on the CF188. The LGTR is connected to the rack by a single suspension lug and an ejector rod that utilises a 300 ft-pound (lb) spring to eject the weapon.

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Occurrence Aircraft External Store Configuration

Station 1

Station 2

Station 3

Station 4

Station 5

Station 6

Station 7

Station 8

Station 9

NIL BRU-5002 LGTR

NIL Sniper Pod

Center-line Fuel Tank

NIL Nil SUU-5003

6xMPB LD

NIL

Table 3: CF188 External stores configuration 1.6.2 HUD

1.6.2.1 The HUD provides the pilot with an NVG compatible display of primary flight, navigation and weapon aiming. For the delivery of precision guided weapons, the HUD displays lateral flight path guidance in the form of an Azimuth Steering Line (ASL), an indication of the time remaining prior to the release point is reached, or Time To Release (TTR), and a release cue that is displayed on the ASL towards the top of the display five seconds prior to when the release point is reached. As the release point is approached, the release cue moves down the ASL. Provided the Master Arm switch is set to ARM and the “pickle” button on the control column pressed and held, when the release cue intersects the Velocity Vector the LGTR will be released. After release, the TTR indication switches to display TTI.

1.6.3 Navigation Systems

1.6.3.1 Navigation information for the CF188 is generated by a self-contained, fully combined Inertial Navigation System (INS) and Global Positioning System (GPS). Provided there is sufficient GPS coverage, the INS automatically switches to Assisted INS (AINS) mode to include the GPS information to enhance the navigational accuracy. At the time of the occurrence, the CF188 was operating in the pure INS mode, resulting in some degradation in positional accuracy.

1.6.4 Sniper Targeting Pod

1.6.4.1 The Sniper Advanced Targeting Pod or simply “Sniper” pod is carried on the left hip station of the CF188 Hornet. The Sniper pod includes a high-resolution, mid-wave forward looking infrared (FLIR), dual-mode laser, HD-TV, laser spot tracker, laser marker, video data link, and digital data recorder3. In the presence of multiple laser sources, caused when the laser passes through airborne obscurants such as dust or smoke or when the laser passes through foliage such as grass, a Last Pulse Logic (LPL) algorithm ensures that the LST aims at the laser source furthest from the laser designator. The Sniper pod provides automatic tracking and laser designation of tactical size targets via real-time imagery presented on cockpit displays for target detection/identification.

3 Information taken from the Lockheed Martin website: http://www.lockheedmartin.com/data/assets/mfc/pc/MFC_Sniper_pc.pdf

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1.6.4.2 On the occurrence flight, the pilot entered the coordinates of the target into the onboard navigation system. When commanded by the pilot, the Sniper pod attempted to look at the ground location of the coordinates entered by the pilot. However, because of the degraded positional accuracy (see Section 1.6.3) and the narrow field of view of the laser spot tracker, the actual target was outside the field of view and was not picked up by the laser spot tracker; however, the FAC and the pilot used visual techniques to positively identify the correct target. Once the correct target had been visually identified, the pilot used the Sniper pod’s FLIR sensor and slewed the system derived target designation back onto the correct target, thus compensating for the INS position error. For the remainder of the attack, the INS positional information was precise and the CF188’s mission computer calculated the proper release parameters for the weapon to be dropped.

1.7 Meteorological Information

1.7.1 The ground personnel described the local conditions as night, clear skies, no moon, with relatively low illumination levels with some cultural lighting, primarily generated by the city of Salina, approximately 20 km to the northeast. There was no visible fog or dust in the air.

1.7.2 The nearest official weather recording station was located at Salina, KS airport (KSLN), approximately 20 km to the northeast. The weather observed there 20 minutes after the occurrence was calm winds, clear skies, 10 statute miles visibility, temperature 2 degrees Celsius (C), dew point -2 degrees C and a sea level pressure of 1019.3 millibar (mb). The temperature/dew point spread equate to a relative humidity of 75 percent.

1.7.3 The forecast upper winds/temperatures were as follows:

Altitude

(ft Above Sea Level) Direction

(degrees True) Speed (knots)

Temperature (degrees C)

3,000 070 13 Not reported

6,000 010 19 +3

9,000 000 28 0

12,000 010 32 -5

1.8 Aids to Navigation

1.8.1 Ground based aids were not used. The aircraft was navigating using the internal INS and ground based visual cues visible through the pilot’s NVG.

1.9 Communications

1.9.1 The FAC and the CF188 pilot were in direct communication via Ultra High Frequency (UHF) radio. In addition, the RCO was in contact with Range Operations via cell phone.

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1.10 Aerodrome Information

1.10.1 The CF188 was operating out of the Salina, KS airport (KSLN), located approximately 10 nm northeast of the Smoky Hill Range area.

1.11 Flight Recorders

1.11.1 The CF188 is not equipped with either a Flight Data Recorder (FDR) or a Cockpit Voice Recorder (CVR). However, certain flight data can be recorded via other means, such as the Advanced Memory Unit (AMU) and the Cockpit Video Recording System (CVRS).

1.11.2 The AMU has two receptacles; one for a Mission specific card and one for a Maintenance specific card. The Mission card allows the pilot to pre-program mission related data for upload to the aircraft during the start sequence. The Mission card also records certain mission specific data that can be viewed by the pilot post flight. The Maintenance card records a variety of flight data such as aircraft position, altitude and airspeed. This information was used by investigators to cross-check and confirm some of the information recorded by the video system.

1.11.3 The CVRS provides audio and color video recording on magnetic tape for viewing after flight. The system consists of video cameras, an airborne video tape recorder, and a video control panel. The Airborne Video Tape Recording (AVTR) system records the various pilot cockpit internal displays as well as the HUD. On the occurrence aircraft, the HUD, FLIR and horizontal situation display were recorded. These videos were used to reconstruct and better understand the flight path and weapon release parameters at the time of the occurrence.

1.12 Wreckage and Impact Information

1.12.1 The LGTR impacted the ground approximately 15 metres away from and on a bearing of 205 degrees M from the PLDR. It impacted the ground heading approximately 080 degrees M at a dive angle of approximately 45 degrees.

1.13 Medical

1.13.1 As the occurrence was not classified as an aircraft accident or aero-medical incident, neither a medical examination nor a toxicological screening were completed.

1.14 Fire, Explosives Devices, and Munitions

1.14.1 Fire

1.14.1.1 Not applicable.

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1.14.2 Munitions

1.14.3 The CF188 was carrying a single BDU-59 B/B Enhanced-LGTR. The LGTR was designed to approximately replicate the employment and flight characteristics of the GBU-12 Laser Guided Bomb (LGB). It performs as a low-cost GBU-12 simulator that can be employed on laser targets without the constraints imposed by the use of a high explosive. The LGTR weighs 89 lbs, is 75 inches in length and 4 inches in diameter and has four steerable front canards and four fixed rear wings (Annex B Figure 10). All cockpit indications during weapons delivery are identical to those used for the GBU-12 LGB.

1.14.4 The LGTR has an aero-stabilized seeker to align the seeker to the LGTR velocity vector. The seeker can detect reflected or pulsed laser energy on a number of discrete laser PRF that are pre-set on the LGTR by a rotary dial set on the ground prior to flight. The seeker focuses reflected laser energy onto a four quadrant detector, which sends an error signal to the guidance electronics. According to Canadian publications, the seeker has a gimbal limit of 18 degrees and a FOV of + or – 18 degrees; however, according to discussions with the Original Equipment Manufacturer4 (OEM), the seeker actually has a FOV of + or – 24 to 28 degrees, depending on the received signal strength. The LGTR seeker incorporates an LPL algorithm similar to the Sniper pod’s LST.

1.14.5 The guidance and control system uses pure pursuit navigation logic to null out the line of sight errors observed by the detector. Using “bang-bang”5 logic, non-proportional steering commands are provided to a pneumatic actuator driven by stored, compressed gas to deflect the canards. There is no lost acquisition logic and a loss of signal nulls the guidance commands and the LGTR will follow a ballistic trajectory from that point until it either detects a new laser source and commences guiding or it strikes the ground/target. Software controls preclude canard deflections for three seconds after release to ensure safe separation from the aircraft.

1.14.6 The LGTR also contained a C2 cartridge that produces a smoke blossom after impact for score marking purposes. The smoke from the cartridge contains Titanium tetrachloride (TiCl4) and accidental exposure to liquid TiCl4 can result in skin burns and can cause damage to the eyes, if they are not protected. After short-term or lower level exposure, less serious respiratory system effects can include coughing and tightness in the chest. None of the ground personnel at the OP reported any symptoms of exposure.

1.15 Survival Aspects

1.15.1 There were no injuries but had the LGTR actually struck an individual on the ground the injuries would likely have been fatal. If this had been a laser guided weapon containing high explosives, all ground personnel at the OP would likely have been killed.

4 Lockheed-Martin is the OEM 5 This means the bomb's fins deflect fully, rather than proportionally when it is attempting to guide to the laser spot.

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1.16 Test and Research Activities

1.16.1 The PLDR, serial number 207, was sent to the Quality Engineering and Test Establishment (QETE) to determine whether or not it was functioning correctly. The PLDR was found to be operating correctly within manufacturer’s specifications and laser safety limits.

1.16.2 LGTR Seeker FOV Across the Ground Determination

1.16.2.1 Currently there is no tool available to allow a FAC to calculate the LGB seeker FOV across the ground in order to facilitate safe placement of the OP. To further this investigation, a seeker FOV calculator was developed in-house as a proof of concept tool and to aid in determining where the OP should have been positioned in order for it to remain outside the seeker FOV when lasing was commenced. The FOV calculator employed basic kinematic drag-free ballistic formulae of a non-specific free fall weapon type operating in a zero wind, level terrain scenario. It only calculates an approximate solution to any given release scenario and has not been formally peer reviewed (it is not to be used operationally); however, results were compared with the occurrence LGTR release point data and a FOV template produced by Defence Research and Development Canada (DRDC) for the GBU-12 and were found to agree closely in both cases giving support to the tool’s validity. As an investigative tool, it helped to build an understanding of the dynamics of the seeker FOV across the ground as the weapon progressed from the release point to the point where lasing commenced (ie: unguided fly-out). Using this tool and programming the occurrence LGTR release conditions (8,272 ft above the target, 472 KTAS and 13 seconds delayed lasing, refer to paragraph 1.1.7), it was determined that the OP needed to be positioned approximately 1400 m away from the target to remain outside the LGTR seeker FOV. Therefore, in this occurrence the OP was approximately 600 m inside the LGTR seeker FOV when ground lasing was Initiated.

1.16.2.2 The Directorate of Technical Airworthiness and Engineering Support (DTAES) recommended LGTR template (Annex C) is valid from 0 to 30,000 ft AGL and from 400 KIAS to 0.98 Mach. Calculating the seeker FOV across the ground under the extreme release and delayed lasing conditions (30,000 ft AGL, 0.98 Mach and 20 seconds of delayed lasing (refer to paragraph 1.18.5.4.1)), indicates that the OP needs to be positioned approximately 3,200 m away from the target to ensure that it remains outside the LGTR seeker FOV.

1.16.3 PLDR System and Boresight Technique Evaluation

1.16.3.1 General

1.16.3.1.1 DFS deployed personnel to Salina Kansas, 5-8 December 2010, to conduct a two day field evaluation of the PLDR system and the standard system boresighting technique. This evaluation was performed concurrently with an ongoing FAC training session with locally deployed CF188 aircraft. The evaluation was conducted during the day and at night using equipment similar to that used on the night of the occurrence.

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The night-time evaluation was conducted with very similar meteorological conditions and illumination levels as on the night of the occurrence. A handheld CORAL LS laser spot detector (a recently acquired device that was not available on the night of the occurrence) was used to view the laser spot location on the target. The evaluation was conducted on “Coiner Dome” on the same spot as the incident set-up and against the same target (307B). The grass was found to be much shorter than on the night of the occurrence and during the evaluation against target 307B it did not penetrate the laser beam.

1.16.3.2 Tripod and angulation head

1.16.3.2.1 The investigation noted a number of unsatisfactory aspects of the tripod and angulation head that is used with the PLDR. The tripod consisted of three three-segmented carbon fibre tubular legs that bowed under the weight of the PLDR, particularly when the tripod was adjusted to its lowest, most stable, position, and would bend when force was applied to the tripod handle in any axis with the tripod gimbals locked, when tightening the gimbal locks or when pressing the PLDR mounted laser firing button. When the tripod was adjusted to its lowest height, adjusting and aiming the PLDR was difficult because the operator was required to either crouch or sit with his legs nested around/over the tripod legs and then hunch to peer through the PLDR/Maxi Kite optics. The tripod would also bend, thereby shifting the aim point, when the operator pressed his eye into the rubber eyepiece of the Maxi Kite night scope to confirm the target aim point as well as when viewing the laser spot through the CORAL LS when it was installed on the combined PLDR/CORAL LS mounting bracket.

1.16.3.2.2 The tripod gimbals exhibited an undesirable degree of friction when the gimbals were unlocked and the friction set to minimum. When the operator attempted to aim the PLDR the friction caused the tripod legs to twist or bend slightly. When pressure on the tripod handle was released the legs would untwist/unbend and negate some of the aiming input made by the operator. This required the operator to “over-aim” to compensate for this unwanted twisting/untwisting action making it quite difficult to precisely aim the tripod as repeated over/under-shoots occurred. It needs to be emphasized that based on the geometry of the setup, very small movements of the PLDR resulted in large displacements at the target. For instance, a 1 millimetre (mm) movement at the back end of the tripod handle results in 3 m movement of the aim point on the target.

1.16.3.3 PLDR mounting bracket

1.16.3.3.1 There was excessive freeplay in the PLDR mounting bracket; so much that the aim point would move from off the target to the right to off the target to the left when the PLDR was grabbed and gently twisted to the left and right. This was over and above the inherent twisting of the tripod described earlier. It was discovered that the locking tongue of the tripod mounting plate attached to the PLDR needed adjustment. The operators in the field did not know about this adjustment nor did they have the requisite Allen key needed to adjust the locking tongue. Inserting a folded piece of paper between the locking tongue and the locking handle was sufficient to force the

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PLDR mounting plate into the tripod receptacle thereby eliminating the freeplay. Following that adjustment, there was no further freeplay observed.

1.16.3.4 Boresighting technique

1.16.3.4.1 To boresight the Maxi Kite with the PLDR at night, both the PLDR and the Maxi Kite needed to be precisely aimed at the same distant light source. Previously discussed issues of tripod flexibility and gimbal friction made it difficult to precisely align the PLDR optical cross hairs on a distant light source. Once the PLDR crosshairs had been aligned with the distant light source, the operator then needed to adjust the Maxi Kite to align with the same distant light. Using a small screw driver, the operator turned the two small adjustment screws (left-right and up-down) that are located on the rear left side of the scope. Each screw could be turned through discrete steps, which were felt/heard as clicks, where each “click” represented 50 mm of sight movement (left-right or up-down) for every 100 m of distance from the target. These numbers are relevant when the Maxi Kite is used on a rifle (what it was originally designed for) but have no relevance when used on the PLDR. To adjust the aim point of the Maxi Kite the operator looked through the Maxi Kite, while trying not to press the rubber eyepiece and shifting the aim point, and then decided which screw needed to be turned and approximately by how much (an initial guess of the number of clicks was made as a starting point). After an adjustment screw was turned through the guessed number of “clicks”, the operator looked back through the PLDR to ensure that the PLDR cross hairs were still on the target, and if they weren’t the operator re-aimed the PLDR, and then looked through the Maxi Kite to see the effect of the previous adjustment. The operator then decided how much more, or less, adjustment of that axis was required. This process was repeated over and over until that axis was properly aligned and then the process was carried out on the other axis. This was a long and arduous process and was fraught with potential for misalignment between the PLDR and the Maxi Kite. This was particularly problematic since the adjustment was carried out in the dark on a cold night where the adjustment screws were not visible without illumination and where the operator needed to use a glove free hand to have the finger dexterity to align the screwdriver and turn it. In spite of these deficiencies, it was shown during this evaluation that with sufficient patience, time and effort, it was possible to satisfactorily collimate the Maxi Kite with the PLDR.

1.16.3.5 Stability of laser spot

1.16.3.5.1 Once the Maxi Kite was boresighted with the PLDR, the PLDR was aimed at the target using the Maxi Kite and the laser was activated using the remote laser firing button. The CORAL LS was used to identify spot location. It was found that the spot jittered in an elliptical pattern (up and down approximately 0.6 m and left and right approximately 0.3 m) around a centroid aim point on the target. The frequency of the jitter appeared to match the PRF of the laser firing. Pressing the PLDR mounted laser firing button, located on the right aft face of the PLDR, moved the elliptical laser spot pattern to the left approximately 0.3 m. Lightly rapping the PLDR on various surfaces, particularly in the sides, caused the aim point to oscillate, although the oscillation would die down and the aim point would return to the original location (like an oscillating

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spring). Rapping the PLDR more sharply or bumping a tripod leg or the tripod handle moved the aim point permanently off the original aim point and was frequently large enough to cause the aim point to move off the target.

1.16.3.6 Effects of foliage

1.16.3.6.1 On day two of the evaluation the PLDR was deliberately aimed at various targets through grass and other foliage while a deployed CF188 with a Sniper pod installed was used to conduct runs against the targets using its LST in order to evaluate the effects of foliage projecting into the laser beam as the laser was pointed at a target. No weapons were released for this evaluation.

1.16.3.6.2 On one run with the laser passing through grass immediately in front of the PLDR, the LST initially locked onto the correct target some 500 m away but then it tracked up the laser beam and finally locked onto the area immediately in front of the PLDR.

1.16.3.6.3 PLDR laser ranging carried out prior to the target designation indicated the correct range to the target. The range to the intervening grass was not detected so there was no obvious indication to the operator that the laser was illuminating the grass immediately in front of the PLDR. Standing to the side and viewing the area immediately in front of the PLDR through the CORAL LS did reveal that the grass in front of the PLDR was penetrating the laser beam.

1.17 Organizational and Management Information.

1.17.1 The Joint Army and Air Force FAC course is conducted by the Land Force Doctrine and Training System’s Royal Regiment of the Canadian Artillery School, based at Canadian Forces Base (CFB) Gagetown, New Brunswick. The aim of the FAC Course is to produce officers and non-commissioned members capable of performing the duties of a FAC to the level of Certified/Qualified. This training includes all aspects of planning and coordinating Close Air Support (CAS), conducting all types of CAS missions and learning to use FAC equipment, such as communications equipment, laser target markers and designators, GPS and night observation devices. It comprises twenty days of academic lectures followed by six weeks of simulated and live CAS training in Fort Sill, Oklahoma and surrounding areas until the necessary number of successful controls have been achieved to qualify as a FAC to North Atlantic Treaty Organization (NATO) standards.

1.17.2 The CF organization responsible for FAC and CAS doctrine, tactics and procedures is the CF Air Land Integration Cell (ALIC), based at CFB Kingston, Ontario. ALIC, which was formed in September 2009 and is not yet fully manned, belongs to the Directorate of Army Training and is also responsive to A3 Fighters at 1 Canadian Air Division. Among other duties, ALIC conducts standards and evaluation checks of FACs and is the CF point of contact for CAS, FAC and other air-land integration topics.

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1.18 Additional Information

1.18.1 Target description

1.18.1.1 Target 307B was a sheet steel structure, painted with flat olive drab paint, and positioned in a shallow U-shaped revetment with 1.2 m berms open towards the OP. The target was manufactured to look like a tracked mobile missile launcher with a simulated radar dish mounted to the top. The target was approximately 2.4 m wide and 3.1 m high when viewed from the front (See Annex B Figure 4). The vehicle was positioned slightly towards the west side of the revetment (See Annex B Figure 5). The revetment and berms were covered with tall grass and large weeds. Inside the revetment just to the east side of the target were dried weeds approximately 1.8 m high (See Annex B Figure 6).

1.18.2 Portable Lightweight Designator / Rangefinder II (PLDR)

1.18.2.1 The PLDR is a portable lightweight designator rangefinder system that incorporates daylight optics for aiming. The system enables a ground operator to guide laser guided weapons and airborne LSTs through the emission of a high-power narrow laser beam, not visible to the naked eye, aimed at the target. It includes a built-in GPS receiver, electronic compass, tactical computer and a daylight video camera that incorporates a laser spot detector. The camera provides continuous viewing of the target and the laser spot to allow the operator to check the accuracy of the aim point; however, this is only useable during daylight when the target can also be seen in the video display. The desired laser PRF can be modified by the operator to match that used by the intended weapon.

1.18.2.2 The laser is fired when the LDO activates the “FIRE” button mounted on the unit or via a remote laser firing button and the laser will transmit continuously at the selected PRF until the button is released. While the laser is firing, a green Light Emitting Diode (LED) indication is displayed to the operator in the eyepiece and there is an audible rapid clicking noise. If the “FIRE” button is depressed for less than half a second a single pulse will be sent to measure target coordinates and range to the target.

1.18.2.3 To overcome the daylight limitations of the PLDR, two accessory devices were attached to the top of the PLDR. The first was the “Maxi-Kite” military standard night vision rifle sight designed specifically for medium-to-long range surveillance and target engagement. This was used to visually site the target in low ambient light conditions. The second was the AN/PEQ-4 IR illuminator/pointer which provided a highly collimated beam of IR energy, visible with NVG, to mark the target. Prior to night use, the AN/PEQ-4 IR pointer is collimated with the PLDR. The AN/PEQ-4’s IR laser is visible with night vision devices, such as the Maxi-Kite and the NVG that the FAC and the CF188 pilots were wearing and is one method for identifying both the target and the FAC’s position to the aircraft.

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1.18.3 PLDR Tripod and Angulation Head

1.18.3.1 The PLDR Tripod is a lightweight carbon fibre and magnesium alloy stand for mounting and stabilizing the PLDR. Each three segment leg is adjustable in length and spread. The operating height can be adjusted between 0.41 m and 0.86 m. Maximum stability is achieved when the legs are spread fully; however, this results in the PLDR laser aperture being lowered to approximately 0.6 m above the ground. Attached to the top of the tripod is the gimballed angulation head upon which the PLDR is installed and allows for PLDR aiming. The angulation head can be panned 360 degrees and tilted from 90 degrees up to 75 degrees down. Each axis incorporates a friction adjust mechanism and an axis lock to anchor the desired orientation.

1.18.4 Templates

1.18.4.1 Two known safety footprints or templates are pertinent to this occurrence. One is the LGTR OEM developed generic LGTR safety template and the other is the WDZ software template, in this case calculated in real time specifically for the circumstances of the Coiner Dome LGTR exercise.

1.18.4.2 The OEM developed safety template is a kinematic footprint, general in design, and covers the widest possible range of weapons delivery conditions. It was generated based on a simulated 1 x 106 drops. The area encompassed in the footprint captures the area in which all 1 x 106 simulated drops landed, and includes scenarios such as canard or guidance failures. It encompasses a very large area, approximately 14,000 feet (4,270 m) long and 8,000 feet (2,439 m) wide (see Annex C). The footprint does not consider the seeker’s FOV and the location of a ground laser designator.

1.18.4.3 In April 1999, based on information provided by the LGTR OEM, DTAES sent a letter to 1 Canadian Air Division (11500-200, (DTA 3-4-6), dated 9 April 1999) recommending the use of the Annex C LGTR safety template for incorporation into the C-07-010-011/TP-000 Canadian Forces Air Weapons Ranges publication. There is no record of further activity until following the Shilo LGTR incident in August 2007 (Flight Safety Occurrence Management System (FSOMS) No.131837). Following the incident in 2007, 1 Canadian Air Division was queried about the status of the LGTR safety template. At the time of that occurrence, it had not yet been incorporated into the Canadian Forces Air Weapons Ranges publication and the occurrence FAC team had not seen nor were they aware of this particular safety template. The LGTR safety template has still not been incorporated into the approved CF Air Weapons Range publication. Taking into consideration the location of the OP from the target, the LTL and the release point of the LGTR, the minimum safe distance prescribed by the OEM produced LGTR safety template was approximately 1200 m (the OP was positioned approximately 400 m inside this safety template).

1.18.4.4 CF personnel conducting operations with air weapons systems are governed by the B-GA-297-001/TS-000, Safety Orders for Canadian Forces Air Weapons Systems, 1 Canadian Air Division Orders, Vol 3, 3-202, Air Weapon Range Procedures and 1 Canadian Air Division Orders, Vol 3, 3-209, Air Weapons Range Licensing

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Procedures. Of note, B-GA-297-001/TS-000 states “When operating outside Canada, safety distances shall meet the minimum criteria of the host country if these are more stringent than those required by CF regulations.” The Canadian approved safety templates are documented in C-07-010-011/TP-000, Canadian Forces Air Weapons Ranges; however, as described in paragraph 1.18.4.3, this publication did not include a safety template for the LGTR. 1 Canadian Air Division Orders, Vol 3, 3-202 notes that “there are an additional five weapons templates yet to be incorporated in C-07-010-011/TP-000 (AGM-65, GBU-16, GBU-12, GBU-24B, and LGTR)” and also indicates how to get copies of these templates; however, the FAC team did not know this and therefore relied on the host nation to provide the safety template for the LGTR. The WDZ safety template that was produced by the RCO (Annex D) indicated the planned Coiner Dome OP location was just at the edge of the danger area with a calculated risk of injury from the LGTR of zero. This template was produced by the WDZ software used at the SHANGR operations office and was produced at the request of the RCO based on the planned ordnance, the location of the target and the location of the designator. The altitude of the CF188 was limited to 10,000 ft MSL or below to reduce the size of the danger zone until the OP was deemed to be in a safe location (ie: Risk = 0). The investigation attempted to gather further information from the software company to better understand the algorithms used by this software to calculate its danger footprint; however, the information was not provided. Although in widespread use by the US Department of Defence (DoD), the WDZ software is not currently used on Canadian ranges or by CF range template designers.

1.18.5 FAC Publications and Procedures

1.18.5.1 General

1.18.5.1.1 Canadian FAC procedures are governed by three main unclassified Tactics, Techniques and Procedures (TTP) publications. The first is the DoD Joint Publication (JP) 3-09.3 Close Air Support dated 8 July 2009. This publication provides joint doctrine for planning and executing CAS. The second publication is the DoD JFIRE Multi-Service Tactics, Techniques and Procedures manual for the Joint Application of Firepower, dated 17 December 2007. JFIRE is a pocket-size, quick-reference guide for requesting fire support in accordance with approved joint TTP. The CF has not formally approved the use of JP 3-09.3 and JFIRE; however they represent the state of the art and are often used by the CF FAC community. The third publication is the NATO Allied Tactical Publication (ATP) 3.3.2.1(A) Tactics, Techniques and Procedures for Close Air Support, dated August 2005, which covers general doctrine and fundamental considerations regarding air interdiction and close air support and essentially covers the same material as JP 3-09.3.

1.18.5.1.2 Two other documents are available that provide detailed information not contained in the other manuals, namely, JP 3-09.1 “Joint Tactics, Techniques, and Procedures for Laser Designation Operations (Rescinded)” and MIL-HDBK 828A “Laser Safety on Ranges and Outdoor Areas”.

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1.18.5.2 JFIRE Multi-Service Tactics, Techniques, and Procedures for the Joint Application of Firepower

1.18.5.2.1 JFIRE is a pocket-size, quick-reference guide for requesting fire support in accordance with approved joint TTP. JFIRE contains calls for fire, joint air attack team techniques, a format for joint air strike requests, close air support coordination and planning procedures, communications architecture, and weapons data. Use of the document assumes that all detailed information about ground laser designations is already understood by the user.

1.18.5.2.2 On the night of the occurrence the JFIRE publication was used to identify a suitable location for the OP in relation to the target. According to JFIRE Table 37 “Minimum Safe Distances for Ground Parties” for an LGTR drop, personnel needed to be located a minimum of 500 m away from the target. Ground parties are defined in JP 3-09.3 as being the FAC party. The information used to calculate this number is based on classified data and was not available to the flight safety investigation. The table’s notes indicate that the hazard area (distance) is highly dependent upon launch conditions and in some cases coordinate accuracies. It also states that weapon malfunctions, such as fin failures, are not included, with the assumption that malfunctioning weapons have the same probability of impacting any point within the hazard area. The table data also assumes that the environmental conditions are conducive to seeker / weapon acquisition, and reflected laser energy is sufficient to guide the weapon to the target. JFIRE Table 37 minimum safety distances of ground parties does not differentiate between ground parties that are not conducting ground laser designations and ground parties that are conducting ground laser designations. The FAC believed that this safety distance was valid for ground parties performing ground laser designations and that it ensured they would be outside the seeker FOV when lasing was initiated at 10 seconds TTI. On the night of the occurrence, the FAC had consulted this table, and because Coiner Dome was located at 790 m from the target, well beyond the prescribed 500 m, it was assumed this meant they were at a safe distance for the purposes of the exercise.

1.18.5.2.3 JFIRE Figure 17 (Annex E) presents the 2-dimensional laser safety and optimal attack zones diagram but it does not specify what Laser Guided Weapons (LGW) the diagram was designed for. JFIRE Figure 17’s origins, technical validity and applicability to any particular LGW are uncertain. The United States Marine Corps (USMC) Marine Aviation Weapons and Tactics Squadron (MAWTS) One was queried and following their own internal investigation they were unable to offer any insight about these questions. The figure is identified as a sample Safety Exclusion Zone for Ground Laser Designator, which implies that each weapon should have a specific diagram to accommodate all of the unique aspects of that particular weapon. For instance, JFIRE Figure 18 presents the Hellfire designator exclusion zone, which was designed to accommodate specific Hellfire aspects. Even though it is documented that Figure 17 is a sample plan view of a Safety Exclusion Zone for Ground Laser Designator, Figure 17 is being used by American and Canadian FAC personnel specifically for Paveway-type LGBs. JFIRE Figure 17 also provides a note that specifically states that the “seeker FOV must not encompass the area of the laser designator”. It was found in discussion

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with a number of FAC personnel in the Canadian Army as well as a number of USMC and US Army FAC personnel that this note was already taken into account in the Table 37 minimum safety distances (see paragraph 1.18.5.2.2).

1.18.5.2.4 The figure also provides a qualitative measure of the relative risk of releasing laser guided ordnance, as a function of angle off the LTL and is marked as Low, Moderate and High. No further description of what these values represent is provided in any of the approved documentation. A considerable effort was made to gather information about the background and reasons for the specific aspects of this figure by contacting the managers of the JFIRE publication but it was determined that these aspects were not even understood by them.

1.18.5.3 JP 3-09.1 Joint Tactics, Techniques, and Procedures for Laser Designation Operations

1.18.5.3.1 JP 3-09.1 provides joint tactics, techniques, and procedures for employing light amplification by stimulated emission of radiation (laser) target designators, laser acquisition devices, and laser-guided munitions. It describes joint laser planning, coordination procedures, capabilities, and limitations.

1.18.5.3.2 The JP 3-09.1 publication was rescinded in Nov 2008 after a vote by the Joint Doctrine Planning Conference (JDPC) and was removed from the Joint Doctrine, Education and Training Electronic Information System when JP 3-09 was revised. While later chapters of this document contain considerable redundancy with other approved publications, such as JP 3-09.3, the first two chapters present basic laser designator theory and planning considerations not included in any other approved document. In particular, JP 3-09.1 discusses seeker false lock-on issues due to atmospheric scatter where the ground laser designator could become the target and it recommends that the designator should be masked from the seeker FOV, although it does provide a warning that states this is no guarantee to prevent the seeker from locking onto the ground designator. JP 3-09.1 makes reference to MIL-HDBK 828A “Laser Safety on Ranges and Other Outdoor Areas” which provides additional important information not contained in any other approved publication. MIL HDBK 828A is not referenced in any of the other approved publications. JP 3-09.1 also states that during delayed-lasing ground laser designations, the laser needs to be activated for at least eight seconds prior to ground impact to ensure there is sufficient time for the weapon to guide. By rescinding JP 3-09.1 and not incorporating the unique information in any other publication, this critical information is unavailable to the FAC community.

1.18.5.4 JP 3-09.3 Close Air Support

1.18.5.4.1 This publication provides joint doctrine for planning and executing close air support. It is a high level document that specifically discusses CAS and there is very little material discussing particular aspects of ground based laser designations; however it does explain that during delayed-lasing if communications between the pilot and the FAC are unreliable, delayed lasing should commence 20 seconds prior to impact. Use

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of this document assumes that the user already understands the basics of ground laser use.

1.18.5.5 NATO ATP-3.3.2.1(A) Tactics, Techniques and Procedures for Close Air Support Operations

1.18.5.5.1 NATO ATP-3.3.2.1(A) introduces principal TTP to be used during CAS operations. It is very similar to JP 3-09.3 CAS in that it is a high level document that specifically discusses CAS and spends very little time discussing particular aspects of ground based laser designations. Use of this document assumes that the user already understands the basics of ground laser use.

1.18.5.5.2 It lists five basic considerations for using laser guided weapons. All of these conditions were met on the occurrence weapon delivery.

1.18.5.6 MIL HDBK 828A Laser Safety on Ranges and in Other Outdoors Areas

1.18.5.6.1 MIL HDBK 828A provides uniform evaluation guidance for the safe use of military lasers and laser systems on DoD military reservations or military controlled areas worldwide. This document was unknown to the FAC team until it was identified during the course of this investigation. In particular, chapter 4.14 discusses ground laser designators and provides information not found in other documents regarding issues when using ground designators to guide laser guided weapons or LSTs.

1.18.5.6.2 Paragraph 4.14.1b states,” Due to the possibility of false target indications from atmospheric scatter of the laser beam close to the laser exit port, attack headings should avoid target-to-laser designator safety cones unless the tactical situation safely dictates otherwise. The safety cone is usually a 20-degree cone whose apex is at the target and extends 10 degrees either side of the target-to-laser designator line.”

1.18.5.6.3 Paragraph 4.14.1e states,” To reduce the potential for seeker lock-on to the designator position, the designator should mask themselves from the seeker field of view. Terrain, vegetation or other obstruction can sometimes mask the designator.”

1.19 Useful or Effective Investigation Techniques

1.19.1 Not applicable

2 ANALYSIS

2.1 General

2.1.1 The following analysis will discuss OP placement decisions, target details, the effects of foliage on the laser beam, the LGTR release conditions and the LGTR’s trajectory until ground impact.

2.2 Placement of the OP

2.2.1 The FAC situated the OP in the location that he did because the commonly accepted documentation, JFIRE, indicated that the OP was within safe parameters to do so and the location provided a desirable position from which to spot the target. While JFIRE Table 37 specified the minimum distance of personnel from the target, it did not distinguish between personnel who were conducting ground laser designations and personnel who weren’t. Although JFIRE Figure 17 states that the seeker FOV must not encompass the laser designator, in the absence of clear direction the FAC assumed that the safe distance prescribed at Table 37 already accounted for the seeker FOV and was valid for either case.

2.2.2 The investigation determined that none of the safety templates (DTAES recommended LGTR template, WDZ and JFIRE) account for the seeker FOV, therefore, JFIRE Table 37 minimum safety distances of ground parties only applies to ground parties that are not performing ground laser designations. The FOV is an additional constraint that must be considered when conducting ground laser designations; however, there is no tool available to allow the FAC to make this calculation even if he had understood the requirement to do so.

2.2.3 The location chosen for the OP was incorrect and unsafe because it was within the LGTR seeker FOV when ground lasing was initiated and could become the target if the target was not properly designated.

2.3 Target Details

2.3.1 The target was located in a U-shaped revetment open to the OP and the LDO aimed the PLDR, via the Maxi Kite, at the center of the vehicle’s front face. From the heading that the aircraft flew on the attack run, the flat front face of the vehicle was exposed to both the OP and to the LGTR and would have been visible to the LGTR seeker throughout its entire flight. The painted target would have ensured a good diffuse laser spot.

2.4 The Effect of Grass on the Laser Beam

2.4.1 The FAC team positioned the PLDR in such a manner that the laser beam passed through the tall grass immediately in front of the PLDR when aiming at target 307B. As a result, when the laser beam was turned on, the grass was illuminated by the laser and therefore it was visible to the LGTR seeker throughout most of its flight. Coiner Dome was a rounded hill and from the position of the OP, the terrain rolled away

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giving a clear look-down view to the target and the grass on the hill only penetrated the laser beam at the point immediately in front of the PLDR. Therefore, there would have only been two distinct laser sources for the LGTR seeker to detect; the target and the grass immediately in front of the PLDR.

2.5 LGTR Release Conditions

2.5.1 Airborne coordination between the FAC and the CF188 pilot was good. In spite of the navigation issues that caused the Sniper pod LST to fail to detect the laser spot during the FAC’s target marking attempt with the PLDR, visual techniques between the FAC and the pilot were effectively carried out and the correct target was visually identified and selected by the CF188 pilot using the Sniper pod. The Sniper pod track of the correct target ensured that the positional errors were eliminated so that the aircraft’s weapon aiming calculations were correct. The LGTR was released at the proper point in space and ground lasing was initiated by the LDO at the correct time using the PLDR remote firing button. PLDR lasing was activated for the entire time of flight of the LGTR.

2.6 LGTR Trajectory

2.6.1 Analysis of the LGTR trajectory indicates that when ground lasing was initiated, the LGTR initially guided towards the target, vice the grass in front of the PLDR; however, approximately six seconds prior to impacting the target the LGTR commenced a hard left diving turn towards the OP indicating that the LGTR seeker switched from guiding on the target to guiding on the grass in front of the PLDR. Even though the target and grass in front of the PLDR were both visible to the seeker, the LGTR LPL algorithm should have ensured that the LGTR guided on the target. Since the LGTR guided to the spot in front of the PLDR, it is clear that the LGTR seeker no longer detected the target at that point but was still in a position to detect the laser spot in the grass.

2.6.2 There are a number of possible reasons why the LGTR switched from guiding towards the target to guiding towards the point in front of the PLDR. The three most plausible reasons are as follows:

2.6.2.1 Boresight errors between the Maxi Kite and the PLDR could have resulted in the laser spot being off to the left side of the target (east), even though the Maxi Kite reticle was positioned on the front face of the target. In this case, the laser would have illuminated the berm or the tall weeds within the revetment. Based on the geometry of the target and the LGTR at release, the LGTR seeker would have initially seen the misplaced spot on the opposite side of the vehicle structure and guided accordingly; however, as the LGTR guided the vertical line of sight between the seeker and the laser spot would have decreased. At approximately six seconds TTI, the line of sight between the seeker and the laser spot would have become obstructed by the target

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(podium effect)6 and at that point, the only laser source still visible to the seeker would have been the grass immediately in front of the PLDR; or

2.6.2.2 The boresight between the PLDR and the Maxi Kite and the original aim point could have been good; however, the LDO could have inadvertently bumped the PLDR and/or the tripod in the latter stages of the LGTR’s flight and moved the laser spot off to the left (east) side of the target illuminating the berm or the tall weeds within the revetment and creating the same scenario described in paragraph 2.6.2.1; or

2.6.2.3 Some combination of the circumstances described in the previous two paragraphs occurred.

6 The podium effect is when the laser designator is aimed at a target in such a way that the horizontal or vertical dimension of the target obscures the line of sight between the laser spot and the weapon’s seeker.

3 CONCLUSIONS

3.1 Findings

3.1.1 JFIRE is a quick reference guide, commonly accepted by CF personnel, for requesting fire support. (1.18.5.1.1)

3.1.2 JFIRE Table 37 states that the minimum safety distance of ground parties from the target for LGTR usage during training is 500 m. (1.18.5.2.2)

3.1.3 The FAC assumed the JFIRE Table 37 prescribed minimum safety distances of ground parties took into account the requirement to keep the GLTD outside the seeker FOV when ground lasing was initiated. (1.18.5.2.2, 2.2.1)

3.1.4 Other Canadian FAC personnel in addition to a number of USMC and US Army FAC personnel assume that the note in JFIRE Figure 17 requiring the GLTD to be outside the seeker FOV is already accounted for in the Table 37 minimum safety distances of ground parties. (1.18.5.2.3)

3.1.5 Coiner Dome was 790 m from the target and the FAC believed the OP position was compliant with JFIRE Table 37. (1.18.5.2.2, 2.2.1)

3.1.6 JFIRE Table 37 minimum safety distances of ground parties does not differentiate between ground parties that are not conducting ground laser designations and ground parties that are conducting ground laser designations. (1.18.5.2.2, 2.2.1)

3.1.7 JFIRE Table 37 minimum safety distances of ground parties only applies to ground parties that are not performing ground laser designations. (2.2.2)

3.1.8 When planning to conduct ground laser designations, the FOV is an additional constraint that must be considered when conducting ground laser designations. (2.2.2)

3.1.9 JFIRE Figure 17 presents the 2-dimensional laser safety and optimal attack zone diagram to be used when employing LGBs. (1.18.5.2.3)

3.1.10 JFIRE does not specify to which LGWs Figure 17 specifically applies to. (1.18.5.2.3)

3.1.11 JFIRE Figure 17 includes a note that states “seeker FOV must not encompass the area of the laser designator”. (1.18.5.2.3)

3.1.12 There is currently no tool available to allow FAC teams to calculate the seeker FOV of various LGBs as a function of release parameters. (1.16.2)

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3.1.13 Specific aspects of JFIRE Figure 17 were not understood by the JFIRE Publication managers. (1.18.5.2.4)

3.1.14 The dimension of the LGTR seeker FOV documented in Canadian publications is +/- 18 degrees, whereas according to the OEM, the FOV is actually +/-24 to 28 degrees. (1.14.4)

3.1.15 The OP was approximately 600 m inside the LGTR seeker FOV when ground lasing was initiated. (1.16.2.1)

3.1.16 In accordance with Canadian Orders, CF personnel operating on foreign ranges must meet minimum criteria of the host country if they are more stringent than those required by CF regulations. (1.18.4.4)

3.1.17 The DTAES approved LGTR safety template has not yet been incorporated into the approved CF Air Weapons Range publication. (1.18.4.3)

3.1.18 The OP was located approximately 400 m inside the DTAES approved LGTR safety template. (1.18.4.3)

3.1.19 In the absence of a DTAES approved LGTR safety template, the FAC elected to use the SHANGR produced WDZ template for the LGTR. (1.18.4.4)

3.1.20 Although in widespread use by DoD, the WDZ software is not currently used on Canadian ranges or by CF range template designers. (1.18.4.4)

3.1.21 The altitude of the CF188 was limited to 10,000 ft MSL or below to reduce the size of the danger zone until the OP was deemed to be in a safe location (ie: Risk = 0). (1.18.4.4, ANNEX D)

3.1.22 Coiner Dome was covered with tall thin grass that penetrated the laser beam in the vicinity of the PLDR when the PLDR was aimed at the target. (1.1.2)

3.1.23 JP 3-09.1 presented basic laser designator theory and planning considerations not included in any other approved document. (1.18.5.3.2)

3.1.24 JP 3-09.1 recommended that the designator should be masked from the seeker FOV although it does state that this is no guarantee to prevent the seeker from locking onto the ground designator. (1.18.5.3.2)

3.1.25 JP 3-09.1 was rescinded in November 2008. (1.18.5.3.2)

3.1.26 MIL HDBK 828A stated that to reduce the potential for seeker lock-on to the designator position, the designator should mask themselves from the seeker FOV. (1.18.5.6.3)

3.1.27 The FAC team considered the presence of the grass as not being a factor when guiding an LGTR to the target. (1.1.2)

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3.1.28 The mission was conducted on a low illumination cold, clear night with light winds in the presence of very little airborne obscurants. (1.1.2, 1.7)

3.1.29 The PLDR only has daytime optics for aiming. It must be aimed at night using a Maxi Kite night scope mounted to the top of the PLDR. (1.18.2.1)

3.1.30 The Maxi Kite must be manually boresighted to the PLDR. (1.18.2.3)

3.1.31 Insufficient tripod rigidity and deficiencies with the tripod mount make boresighting of the Maxi Kite to the PLDR difficult. (1.16.3.1)

3.1.32 Tripod deficiencies make the aim of the PLDR susceptible to being inadvertently knocked off target. (1.16.3.1)

3.1.33 The correct target was selected by the pilot and designated by the FAC, the LGTR was released at the correct point in space and ground lasing was initiated at the correct time. (1.1, 1.6.4.2, 2.5.1)

3.1.34 The LGTR seeker employs a Last Pulse Logic algorithm that causes the LGTR to guide to the target furthest from the laser designator when there are multiple laser targets present. (1.6.4.1, 1.14.4)

3.1.35 The LGTR initially guided on the target but approximately six seconds prior to impact, the LGTR switched guidance to the grass that was illuminated in front of the PLDR. (2.6.1)

3.2 Cause

3.2.1 The OP was established within the LGTR seeker FOV when lasing was commenced. Although the FAC team had positioned the PLDR so that the laser beam passed through tall grass immediately in front of the PLDR, they believed the grass would not be a factor; however, this created a second laser spot that was disregarded by the LGTR seeker while the target area laser spot was still visible to the seeker. Approximately six seconds prior to impact, the seeker lost sight of the target area laser spot, switched to the laser spot in the grass and guided to that location. Contributing to the occurrence was insufficient guidance and information available to allow the FAC team to ensure they were positioned outside of the LGTR’s FOV.

4 PREVENTIVE MEASURES

4.1 Preventive Measures Taken

4.1.1 On 13 July 2010, the Commander of Land Forces Doctrine and Training suspended all terminal laser guidance by a ground FAC of all Laser Guided Bombs.

4.1.2 On 28 September 2010, ALIC held the first CF GLTD TTP Working Group (WG). The CF GLTD TTP WG was created as a joint forum with the purpose of understanding the issues related to ground based terminal guidance of LGWs, as highlighted by this occurrence, and to provide a steering mechanism to ensure the correct information and recommended procedures will be provided to the chain of command. The WG was attended by representatives from ALIC, the Royal Regiment of Canadian Artillery School, DFS, 1 Canadian Air Division and DTAES.

4.1.3 The Royal Regiment of Canadian Artillery School FAC Cell has forwarded the DFS PLDR/tripod field evaluation findings (paragraph 1.16.3) to the Directorate of Land Requirements (DLR) along with recommendations to conduct formal studies/trials on both the PLDR/tripod and the Maxi-kite, if required, to address these findings.

4.1.4 The Canadian Army continues to abide by NATO and US Joint publications; however, ALIC has incorporated the lessons learned from this investigation (presented by DFS at the 28-29 September 2010 GLTD TTP WG) into the FAC training package.

4.1.5 1 Canadian Air Division A4 Maint Arm has been tasked, as a top priority, to address air weapons range templating issues. One of the options is for the CF to adopt the WDZ software used by the US. Until a permanent solution can been implemented the Record of Operational Risk Management (RORM) operational airworthiness process is being applied on an as required basis to facilitate on-going FAC courses on US weapon ranges.

4.1.6 On 29 November 2010, ALIC circulated a Royal Regiment of Canadian Artillery School produced Supplementary Laser Training package which was approved by Land Force Laser Center of Excellence.

4.2 Preventive Measures Recommended

4.2.1 DTAES 8 develop a replacement to JFIRE Figure 17 for each laser guided weapon type that takes into account specific seeker characteristics and weapon performance.

4.2.2 DTAES 8 develop a laser seeker FOV calculation tool to aid the FAC when determining the appropriate location to situate the OP.

4.2.3 DTAES 8 obtain the correct LGB seeker FOV details from the OEM and distribute to the relevant stakeholders so they can update applicable CF publications.

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4.3 Other Safety Recommendations

4.3.1 Not applicable

4.4 DFS Remarks

This is the second such occurrence in two years. As this occurrence highlights, providing terminal guidance of LGBs using a GLTD can be an inherently risky operation for ground parties operating in the vicinity of a target. To mitigate these inherent risks, FAC personnel must thoroughly understand the mechanics of this type of operation, in addition to the limitations of the systems being employed, and position themselves appropriately. This will require that suitable CF approved technical and operational publications are made available to FAC personnel and that the appropriate weapon templates, planning tools and training are in place.

//Original Signed// J.C.Y. Choiniere Colonel Director of Flight Safety

Annex A 1010-CF188925 (DFS 2-2-3) 26 August 2011

ANNEX A

Abbreviations and Acronyms using in this Report

AINS Assisted Inertial Navigation System ALIC Air Land Integration Cell AMU Advanced Memory Unit ASL Azimuth Steering Line AVTR Airborne Video Tape Recording System C Celsius CAS Close Air Support CCD - TV Charge Coupled Device - Television CF Canadian Forces CFB Canadian Forces Base CST Central Standard Time CVR Cockpit Voice Recorder CVRS Cockpit Video Recording System DFS Directorate of Flight Safety DLR Directorate of Land Requirements DoD United States Department of Defence DRDC Defence Research and Development Canada DTAES Directorate of Technical Airworthiness and Engineering Support FAC Forward Air Controller FDR Flight Data Recorder FLIR Forward Looking Infrared FSOMS Flight Safety Occurrence Management System ft feet FOV Field of View GLTD Ground Laser Target Designator GPS Global Positioning System HUD Head Up Display INS Inertial Navigation System IR Infrared JDPC Joint Doctrine Planning Conference JP Joint Publication KCAS Knots Calibrated Airspeed KSLN Salina, Kansas airport identifier KTAS Knots True Airspeed lb pound LDO Laser Designator Operator LED Light Emitting Diode LFDTS Land Force Doctrine and Training System LGTR Laser Guided Training Round LGB Laser Guided Bomb

A-1/2

Annex A 1010-CF188925 (DFS 2-2-3) 26 August 2011

A-2/2

LGW Laser Guided Weapon LPL Last Pulse Logic LST Laser Spot Tracker LTL Laser Target Line m metres M Magnetic MAWTS Marine Aviation Weapons and Tactics Squadron mb millibar mm millimetre MSL Above Mean Sea Level NATO North Atlantic Treaty Organization NVG Night Vision Goggles OEM Original Equipment Manufacturer OP Observation Post PLDR Portable Lightweight Designator and Range Finder PRF Pulse Repetition Frequency QETE Quality Engineering and Test Establishment RCO Range Control Officer SHANGR Smoky Hill Air National Guard Range TTI Time to Impact TTP Tactics, Techniques and Procedures TTR Time To Release UHF Ultra High Frequency USMC United States Marine Corps WDZ Weapon Danger Zone WG Working Group

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011

ANNEX B

Figures Figure 1: View of the designator and target area taken the day after and is representative of the setup the night of the occurrence. The designator is a GLTD II vice the occurrence PLDR. The Maxi Kite and the AN/PEQ-4 are not installed.

B-1/6

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011 Figure 2: Overhead image of the OP and target area. Figure 2: Target area image taken from Google Earth

B-2/6

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011 Figure 3: Target area image taken from Google Earth. Figure 4: Intended target, looking southeast (there was no snow present at the time of the occurrence).

B-3/6

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011 Figure 5: Revetment dimensions Figure 6: Revetment Foliage southeast side of target facing northwest

B-4/6

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011 Figure 7: PLDR, view from operator side (back) of the equipment. Figure 8: PLDR, top view

B-5/6

Annex B 1010-CF188925 (DFS 2-2-3) 26 August 2011

B-6/6

Figure 9: LGTR impact point. Largest piece of debris is one of the LGTR tail fins, visible in the impact crater. Figure 10: Enhanced Laser Guided Training Round.

Annex C To 1010-CF188925 (DFS 2-2-3) 26 August 2011

C-1/1

ANNEX C

LGTR Safety Footprint

LGTR Safety Footprint, as approved by DTAES and forwarded to 1 Canadian Air Division as an attachment in letter 11500-200 (DTA 3-4-6) 09 April 1999. Relative location of OP / PLDR plotted for comparison (red dot).

Annex D To 1010-CF188925 (DFS 2-2-3) 26 August 2011

D-1/1

ANNEX D

Weapon Danger Zone Safety Template

Weapon Danger Zone (WDZ) Template as produced for the planned Coiner Dome LGTR drop on 17 November 2009. Note the Risk=0 calculation.

Target 307B

OP / PLDR

Annex E To 1010-CF188925 (DFS 2-2-3) 26 August 2011

E-1/1

ANNEX E

Example of Safety Zone and Optimal Attack Zones

Extracted from JFIRE 17 December 2007. Red box around the note and the two red arrows were not on the original but were added to highlight the FOV note to the reader.