The long-delayed final report has been released today.
In Swedish here:
http://www.havkom.se/virtupload/repo...%202013_02.pdf
In Norwegian here:
http://www.havkom.se/virtupload/repo...2013_02_no.pdf
English version hopefully to follow.
Conclusion in the Norwegian report (via Google Translate)
Accidents in complex systems are rarely the result of a single cause . Generally there are a number coinciding circumstances that come into play such accidents occur . This case is no exception in this respect. Of the report's analysis as it is clear that there has existed circumstances within the airline operations and Air Traffic Service area that together have made possible accident.
A key event for the Board's opinion is that the drivers and air traffic controllers do not fully understand the other's intentions and thus be able to put these into the surrounding ground and air space perspective. It is therefore important to note that both drivers and controllers together have an overall responsibility to enable a safe aviation , this regardless of the formal responsibility lies for the respective functions can . Both driver and controller should be prepared and understand that mistakes can occur and ready to handle them.
To the greatest extent possible to prevent the occurrence of incidents that required different types of barriers that can stop such a development . Such a barrier can for example consist of rules and methods ( organizational barriers ) , warning symbols and signs ( symbolic barrier) , physical obstacles such as fences instance (physical barrier) as well as passwords ( functional barrier). Barriers widely shared in two main groups , administrative and technical barriers , where administrative barriers is an organizational protection from improper action and a technical barrier is a physical barrier. Barriers requires people to regularly maintain them. When
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terms of the barriers that rarely used as it is experienced difficult and unattractive to verify functionality before the barrier is exposed to powerful test through the necessary bruk41 . In this case , the various barriers that were thought to prevent an accident occurred not worked . Current barriers in this case are discussed below .
Deadline Flight planning is an essential element to ensure a safe flight and thus constitutes a significant barrier when it comes to avoid a hazard . Planning material AIBN has had access to it is delivered by Mission Support and corresponds to the material that would have been applicable if the contract had been completed as a tactical lavflygnings assignment of visual character. To ensure that this flight was conducted in a safe set so it would be necessary to plan your trip thoroughly . Due to lack of information about besetting preparations it is not possible to determine in how planning actually happening.
To determine the lowest safe flight level at every stages of flight are an important part of planning for all IFR flight , this is regardless of whether it concerns military or civilian operations . An incident involving the crew must conduct a quick descent from cruising altitude to a much lower flight level , for example when the cabin pressure drops or smoke on board , so it is necessary that you have previously planned and has a clear understanding of the lowest safe flight level. This safe flight level shall provide a minimum hurdle freedom underlying terrain or obstacle at 1000 feet or 2000 feet depending on the height of the terrain . Here into account the appropriate correction of pressure, temperature and wind speed .
The thus calculated lowest safe flight level is acting as a barrier to prevent the crew leading aircraft at unsafe levels. In the Board's judgment then there are two occasions that the barrier is shattered ; whether they have visual conditions have been such that the crew during the flight ' last part has been given a clear perception of the underlying terrain did not constitute a hazard to flight or so have confidence in air traffic cladding service been such that they have found no reason to question the trust. This has then led to that one has not examined the information available or consulted Accompanying planning material. It is clear that also a combination of these two possibilities may constitute an explanatory model . This assumption is strengthened by the fact that the drivers are not in any way appear to discuss the content in the received clearances .
As regards flytrafikkstjenesten as presented here above all administrative barriers in the form of rules and methods which are intended to ensure that accidents do not occur. But there are also technical aids such as radar warning system monitors , etc. , to facilitate and ensure that work is carried out in the right way. It is required that air traffic controllers have sufficient training and practical exercise in applying these rules and methods and that they have access to technical hjelpemiddlr . Also, there should be systems for monitoring how these are applied and how the work carried out to identify discrepancies. It has emerged that the systematic follow-up has not worked in practice. As can be seen in the analysis section 2.2 as there have been differences in current regulations and used phraseology . Nor has there been access to technical aids in the form of radar or Equivalent technical solution that could follow and guide the traffic at the
41 Hollnagel , E. (2004 ) . Barriers and accident prevention . Hampshire : Ashgate .
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height HAZE 01 was. The above information implies that there is a considerable development potential for strengthening these barriers.
GCAS / TAWS is the final barrier in the incident. Normally, this barrier does not apply , since a signal from GCAS / TAWS information implies that a former barrier has already burst . GCAS / TAWS shall give such notice to the collision with terrain or obstacles to be avoided. The study has shown that with the terrain profile and preferences so does not meet the criteria for a warning. It is the Board's opinion that this barrier can be developed to achieve a safer business.
Finally, as the report gives the impression that for the Norwegian Air Force and LFV has existed latent weaknesses. AIBN considers that it is these weaknesses and not the mistakes that individuals have committed that evil root cause .