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Final Report RM 2013:02E

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Final Report RM 2013:02E Mil: ISSN 1400-5727 Final report RM 2013:02e Accident involving a Royal Norwegian Air Force aircraft of type C-130 with call sign HAZE 01, on 15 March 2012 at Kebnekaise, Norrbotten County, Sweden. Ref no M-04/12 22/10/2013 SHK investigates accidents and incidents from a safety perspective. Its investigations are aimed at preventing a similar event from occurring again, or limiting the effects of such an event. The investigations do not deal with issues of guilt, blame or liability for damages. As far as SHK is concerned, the material in this report may be reproduced free of charge, provided due acknowledgement is made. The report is also available on our web site: www.havkom.se This document is a translation of the original Swedish report. In case of discrepancies between this translation and the Swedish original text, the Swedish text shall prevail in the interpretation of the report. Postadress/postal address Besöksadress/Visitors Telefon/Phone Fax/Facsimile E-post/E-mail Internet P.O. Box 12538 Sveavägen 151 +46 8 508 862 00 +46 8 508 862 90 [email protected] www.havkom.se SE-102 29 Stockholm Stockholm Sweden Final report RL 2013:02e The Swedish Accident Investigation Authority (Statens haverikommission, SHK) has investigated an accident that occurred on 15 March 2012 at Kebnekaise, Norrbotten County, involving an aircraft from the Royal Nor- wegian Air Force with call sign HAZE 01. In accordance with Section 14 of the Ordinance on the Investigation of Ac- cidents (1990:717), the SHK investigation team herewith submits a final report on the results of the investigation. The Swedish Accident Investigation Authority respectfully requests to re- ceive, by 10 February 2014 at the latest, information regarding measures taken in response to the recommendations included in this report. On behalf of the Swedish Accident Investigation Authority, Mikael Karanikas Agne Widholm Chairperson Investigator in Charge 2 Table of contents ABBREVIATIONS AND EXPLANATIONS ............................................. 8 1 FACTUAL INFORMATION ...................................................... 17 1.1 History of the flight ............................................................................... 17 1.1.1 Overview history of the flight ................................................................. 17 1.1.2 Circumstances of the flight ...................................................................... 17 1.1.3 Planning of the flight ............................................................................... 18 1.1.4 Detailed history of the flight .................................................................... 22 1.2 Interviews conducted ............................................................................ 29 1.2.1 Interviews with personnel in the Norwegian Air Force .......................... 30 1.2.2 Interviews with the crew on TORCH 03 ................................................. 32 1.2.3 Interviews with ANS personnel (Sweden control) .................................. 32 1.3 Injuries to persons ................................................................................. 36 1.4 Damage to the aircraft .......................................................................... 36 1.5 Other damage ........................................................................................ 36 1.6 Flight crew and air traffic controllers ................................................. 37 1.6.1 Commander ............................................................................................. 37 1.6.2 Co-pilot .................................................................................................... 37 1.6.3 Loadmaster 1 ........................................................................................... 38 1.6.4 Loadmaster 2 ........................................................................................... 38 1.6.5 The passenger .......................................................................................... 38 1.6.6 The crew members' duty schedule during the period in question ............ 38 1.6.7 The air traffic controller (E- executive) Stockholm ACC ....................... 38 1.6.8 The air traffic controller (P- planner) Stockholm ACC ........................... 38 1.6.9 The air traffic controller in Kiruna .......................................................... 39 1.6.10 The air traffic controllers' duty schedule during the period in question .. 39 1.7 Aircraft information .............................................................................. 39 1.7.1 General .................................................................................................... 39 1.7.2 Technical data .......................................................................................... 40 1.7.3 Airworthiness and maintenance .............................................................. 41 1.7.4 Aircraft manual ........................................................................................ 41 1.7.5 Outstanding remarks ................................................................................ 41 1.7.6 External dimensions of the aircraft .......................................................... 42 1.7.7 Avionics................................................................................................... 42 1.7.8 Aircraft systems for Ground Collision Avoidance and Terrain Avoidance ................................................................................................ 43 1.7.9 Other ........................................................................................................ 50 1.8 Meteorological information .................................................................. 50 1.8.1 General .................................................................................................... 50 1.8.2 Swedish Meteorological and Hydrological Institute (SMHI) .................. 51 1.8.3 Weather on the route between Evenes and Kiruna .................................. 53 1.8.4 Expert opinion on current weather conditions ......................................... 53 1.8.5 Space weather .......................................................................................... 54 1.9 Aids to navigation .................................................................................. 54 1.10 LFV and the Norwegian Air Force ...................................................... 55 1.10.1 LFV's organisation .................................................................................. 55 1.10.2 Changes to Air Navigation Services ........................................................ 56 1.10.3 Air traffic controller training ................................................................... 56 1.10.4 Stockholm ATCC .................................................................................... 58 1.10.5 The control tower in Kiruna .................................................................... 61 1.10.6 LFV's incident investigation .................................................................... 65 1.10.7 The Swedish Transport Agency's control of LFV's operations ............... 66 1.10.8 The Royal Norwegian Air Force ............................................................. 69 1.11 Regulations ............................................................................................. 69 3 1.11.1 Provisions on traffic rules for civil aviation etc. ..................................... 69 1.11.2 Regulations for foreign state aviation under the Admission Ordinance .. 72 1.11.3 Regulations and manuals for Air Traffic Services .................................. 72 1.11.4 Regulations for flight operational duty .................................................... 81 1.12 Flight recorders ..................................................................................... 84 1.12.1 Data from the Digital Flight Data Recorder (DFDR) .............................. 85 1.12.2 Data from the Cockpit Voice Recorder (CVR) ....................................... 85 1.12.3 Non crash protected recorders ................................................................. 86 1.12.4 Evaluation of recorded data ..................................................................... 86 1.13 Accident site and aircraft wreckage .................................................... 87 1.13.1 Accident site ............................................................................................ 87 1.13.2 Salvage of the aircraft wreckage ............................................................. 89 1.14 Medical information .............................................................................. 91 1.14.1 The crew .................................................................................................. 91 1.14.2 Air traffic controllers ............................................................................... 91 1.15 Chance of survival ................................................................................. 91 1.15.1 Fire .......................................................................................................... 91 1.15.2 Physical impact on the human body ........................................................ 91 1.15.3 Emergency Location Transmitter ............................................................ 92 1.16 The rescue operation ............................................................................. 93 1.17 Tests and research ................................................................................
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