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Old 22nd Oct 2013, 08:56
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roaldp
 
Join Date: Jun 2009
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Different Swedish and Norwegian reports

The Swedish accident report differs from the Norwegian.

Swedish conclusion (via Google Translate):

Findings
a) The crew was qualified to perform the flight .
b) The aircraft was airworthy and maintained in accordance with the approved maintenance program
and other agreed relevant maintenance data.
c) any technical malfunction, the aircraft has not caused or contributed to
the accident.
d ) All on board were killed instantly in the collision with the rock.
e ) The Swedish air navigation service lacked radar coverage in that part of the
Swedish airspace where the flight was conducted.
f) The crew has not checked the air traffic service clearances
the minimum safe flight level or the highest terrain in the area.
g ) All controllers were relatively newly trained and inexperienced in their respective
roles.
h) The crew has in no way been aware of the impending
the danger of the underlying terrain .
i) Accident Investigation Commission has found no consistent routine at Norwegian Air Forsvaret
which means that the flight is planned under current regulations .
j ) 'clearance from ACC Stockholm meant that the aircraft was cleared unconsciously
out of controlled airspace and relevant flight information was thus
not .
k) 'clearance from Kiruna meant that the aircraft is assigned a height not
acknowledged clearance to underlying terrain on its route to Kiruna
Airport.
l) planning document that was delivered to the crew showed deficiencies in
map material and concerned also another kind of assignment .
m) Whether the air traffic controllers at the ACC Stockholm or tower in Kiruna at degivna
clearances able to geographically position the aircraft where the
reality was.
n ) Accident Investigation Board's investigation revealed several conditions that may indicate
weaknesses in the LFV security.
o) GCAS / TAWS has not warned of collision with the terrain.
p) The combination of the actual terrain profile and the current settings
not meet the criteria for a warning of GCAS / TAWS.
q ) GCAS / TAWS has acted in conformity with the description
collectively revealed by studies of the system description , checklist
and supplements to the flight manual.
r ) Inadequate procedures at Norwegian Air Forsvaret and ambiguity in the system documentation
and training could have led to shortages of crew
knowledge and use of the system for GCAS / TAWS.
s ) the decision to give the master a dispensation to undergo flight medical examination
was not taken by a competent person.
t) No alarm was conducted from Stockholm ACC due to the information
if non-response to radio for HAZE 01.
u ) The alarm on the missing aircraft was triggered from Kiruna TWR 20 minutes
later than that stipulated in applicable regulations.
v) Police in Norrbotten ordered the operation in four mountain rescuers
about 3.5 hours after the incident became known at the agency.
131 (134)
w ) The management of air rescue at JRCC was conducted without application
of a clear and effective leadership model that took charge of system management
and operational command including how management at the site of the feared
breakdown area would be implemented and coordinated .
x ) The JRCC was no training plan, which was approved by the Transport Agency ,
for initial and recurrent training of flight incident commander.
y) The JRCC was no specific connection procedures for whereabouts of missing
aircraft in mountainous terrain.
z) Maritime Administration did not have any program or equivalent training
and exercise at the individual level of helicopter crew capability for operations
in the mountains.
å) The Swedish SAR helicopter had about two and a half hours from the alarm ,
with two stopovers for refueling, before it came to the search area .
ä ) The Norwegian Armed Forces and the Armed Forces put units available
with the skills to operate in alpine terrain for research on the ground.
ö) ELT showed such damage that it could not send any distress signal.
3.2 Causes
The accident was caused by the crew at HAZE 01 not noted
shortcomings of the clearances which air traffic left and risks to follow
these , which meant that the aircraft came to leave controlled airspace and
be operated at an altitude that was lower than the surrounding terrain .
The accident occurred due to the following organizational security flaws :
 Norwegian Air Forsvaret has failed to ensure that crews have had enough
safe practices to prevent the aircraft is being operated under
the minimum safe flight level of stretch.
 LFV has not had enough secure approach to ensure , first, that
clearances granted only within controlled airspace when flying IFR operations
no driver specifically requests otherwise , and to relevant flight information is provided .


Last edited by roaldp; 22nd Oct 2013 at 09:53.
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