The Weekly Reflektion Week 05 / 2020

During multi-national NATO exercises, communication between nations is one of the main issues being tested. Sometimes these communication weaknesses become fatal. 

Are the assumptions made in roles and responsibilities in your operation clear? When you change the organisation, do you use management of change procedures to manage risk? When you remove a position do you really understand what role that position actually had?

In March 2012, the multi-national NATO exercise ‘Cold Response’ was carried out in Northern Scandinavia and was led by the Norwegian Military. These exercises are vital to ensure the interfaces between the different nations are functioning well, and, if not, identify weaknesses and make improvements. A Hercules C130J left Evenes airport in Harstad, Norway en-route to Kiruna airport in Sweden, to ‘evacuate’ personnel and equipment in connection with the exercise. The expected flight time was 50 minutes.The plane flew straight into the western wall of Mount Kebnekaise, Sweden’s highest mountain at 2106 m (6909 feet), with the loss of 5 lives, all the personnel on board.

The charts used for planning the route had terrain information from Norway, but none on the Swedish side of the border. Due to the scale of the charts, information boxes giving terrain information in Norway were positioned on the charts on the Swedish side of the border. This may have confused the pilots, giving the impression that the charts covered the Swedish peaks as well. To ensure safe passage over mountain terrain, pilots use an emergency safe altitude (ESA) system to plan the flight path. The ESA requires flying at 2000 feet above the highest obstacle within 22 nautical miles of the track. The pilots did have access to European charts which gave a ‘minimum safe altitude’, which is 500 feet above the highest obstruction, which gave a safe altitude of 9300 feet (2834 m).

After take-off, the plan was to climb to Flight level 130 and fly towards Kiruna. Flight level 130 is, in principle, 13,000 feet (3962 m), but referenced to a standard atmospheric pressure of 1013,25 hPa to ensure that planes know where they are with respect to each other. As atmospheric pressure at sea level changes, the actual height of the plane will be slightly different. The pilot put the plane into ‘tactical’ mode, which effectively inhibited the aircraft’s ‘terrain warning system’, meaning that the pilot’s were not alerted to the risk of collision with the terrain. The reason for this is unclear, as the application of the ‘tactical’ mode is for low flying operations with good visibility, which was not planned for this flight. In low level operations, the continual audible warnings would be distracting to the pilot, therefore they are disabled. This was found to be a contributory factor to the accident.

The Norwegian air traffic control handed the plane over to the Swedish air traffic control (ATC) as it crossed the border, but the aircraft could not be seen by the Kiruna radar, putting it in outside controlled air space. It appears that the pilots were not aware that they were outside controlled air space. Swedish ATC instructed the pilot to descend to FL100 (10,000 feet, 3048 m) “when ready”, but being off radar, they did not know exactly where the plane was. The “when ready” means ‘at the pilot’s discretion’. The Swedish ATC had little experience of planes approaching from the west since most flights into Sweden approach from the south. Closer to Kiruna, they were instructed by ATC to descend to FL 70 (7,000 feet, 2134 m), again “when ready”, with the plane still being outside controlled air space. The collision with the mountain occurred at 2014m (6608 feet) shortly after reaching FL 70, and correcting for actual atmospheric pressure, the plane was at the height requested.

During the investigation, the ATC in Kiruna explained it was not their task to prevent collision of an aircraft with the terrain, it is the pilot’s responsibility. The pilot probably did not realise they were outside controlled air space, and assumed that the ATC considered terrain when giving instructions.

The investigation found that the Norwegian Air Force flight planning process was ‘unclear’, with no uniform procedure for planning, and in this case the planning was found to be deficient. The pilots did not have detailed knowledge of the terrain, and the charts they used did not have sufficient information on the Swedish side of the border. Other charts were available, but apparently not used. Lack of clarity in communications from the Kiruna ATC was found to be a contributory factor.

The Hercules C130J is an upgraded version of the C130H, with more automatic systems resulting in the navigator position being no longer required  in the crew. The navigator was pivotal in planning the flight path, and monitoring progress. A question was raised as to whether the management of this crew change was handled optimally. Were the navigators tasks distributed, and was the distribution of responsibility understood?

Are communications in your operation clear and concise? Are roles and responsibilities clear? When you are making changes to your organisation do you carry out a management of change process? Do you really understand all the roles of any position that is being considered for phasing out.

Reflekt AS