Norwegian media reporting RNoAF Hercules missing
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Accident report not published until December
The accident report will not be published until December, according to a spokesman for the Swedish Accident Investigation Commission. He refuses to comment on the contents found in the "black boxes" to avoid speculation.
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Last edited by roaldp; 24th Aug 2012 at 06:35.
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No warning before crash
Contents of the black boxes show that the plane's warning systems gave no alarms before the crash; probably because the systems already were set for the landing in Kiruna.
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Last edited by roaldp; 13th Dec 2012 at 18:21.
SkyGod
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The final report is out: Human Error, but the full report is classified..
Link to Norwegian newspaper:
Svensk avis: Menneskelig svikt årsak til Hercules-ulykken - Aftenposten
Link to Norwegian newspaper:
Svensk avis: Menneskelig svikt årsak til Hercules-ulykken - Aftenposten
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Report not out, has been leaked
The much-delayed final report is not out; it has been classified. But parts of it have been leaked to the small Swedish newspaper, Norrbottens Kuriren. According to this, the investigation does not assign blame to any single person(s) or circumstance, although it states that the flight control could have been more helpful.
The GPWS was turned off, and the newspaper tries to speculate why. Previous speculations have claimed that this GPWS will not work at that latitude. A proper explanation will hopefully be given when the whole report is published.
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The GPWS was turned off, and the newspaper tries to speculate why. Previous speculations have claimed that this GPWS will not work at that latitude. A proper explanation will hopefully be given when the whole report is published.
Google Translate
Last edited by roaldp; 27th Aug 2013 at 10:33.
SkyGod
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investigation does not assign blame to any single person(s)
If not, who is then? The Load Master?
The Air Traffic Controller?
How does that work then? A committee is responsible for the safety of the flight, but not the pilot..?
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Two different goals...
The safety investigation attempts to discover the cause of the crash.
The regulatory authorities may attempt to assign blame.
So, you can have a safety investigation that simply tells why an aircraft did a CFIT. Have a look at the report on that Sukhoi 100 Superjet crash in Indonesia, for instance, for an example of the "why."
Say you manage to survive a CFIT, as sometimes happens. Then you may find yourself, as the PIC, having that proverbial "chat without coffee" with whoever gives you permission to fly, if they find that you are to blame.
One quirk of these two systems is that CVR information may only be used, in the USA, for a safety investigation, not for an enforcement investigation. It will be interesting to see what happens with cockpit video recording, if that technology comes into common use.
The regulatory authorities may attempt to assign blame.
So, you can have a safety investigation that simply tells why an aircraft did a CFIT. Have a look at the report on that Sukhoi 100 Superjet crash in Indonesia, for instance, for an example of the "why."
Say you manage to survive a CFIT, as sometimes happens. Then you may find yourself, as the PIC, having that proverbial "chat without coffee" with whoever gives you permission to fly, if they find that you are to blame.
One quirk of these two systems is that CVR information may only be used, in the USA, for a safety investigation, not for an enforcement investigation. It will be interesting to see what happens with cockpit video recording, if that technology comes into common use.
Permit an old fart for a mo....
.....if you google nrk.tv and put in the search window "tragedeiren in kebnekaise" there is a shortish video doco about the accident. It's in Norwegian but oddly has subtitles which help a bit with comprehension. There is a particularly interesting explanation by the met man about 2/3 way through which gives a strong clue. You might consider modifying your judgement towerdog.
Best of luck.
The Ancient Mariner
Best of luck.
The Ancient Mariner
SkyGod
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You might consider modifying your judgement towerdog.
Best of luck.
Best of luck.
Fluent in Norwegian and Swedish and have 35 years of flying under the belt.
The question still is: Who is responsible for terrain clearance?
ATC or PIC?
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Could the GPWS be turned off or just ignored because it gives so many nuisance false warnings.
There is a recent video of C-130 from USANG firebombing in Californiw, and crew said they did the video largely to show Boeing the nuisance of the warnings, and how the crew now just tune out the terain warnings from their mind.
There is a recent video of C-130 from USANG firebombing in Californiw, and crew said they did the video largely to show Boeing the nuisance of the warnings, and how the crew now just tune out the terain warnings from their mind.
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Final report released today
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
134 ( 140 )
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 .
135 ( 140 )
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 .
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
134 ( 140 )
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 .
135 ( 140 )
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 .
Last edited by roaldp; 22nd Oct 2013 at 08:52.
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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 .
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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English report released
The report in English is now finally released.
http://www.havkom.se/virtupload/repo...02013_02_e.pdf
http://www.havkom.se/virtupload/repo...02013_02_e.pdf
