ASN Wikibase Occurrence # 343523
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| Date: | Wednesday 11 March 2020 |
| Time: | 20:26 |
| Type: |  Lockheed C-130J Super Hercules |
| Owner/operator: | Royal Norwegian Air Force |
| Registration: | |
| MSN: | |
| Fatalities: | Fatalities: 0 / Occupants: 8 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Mosken, Værøy, Lofoten -
 Norway
|
| Phase: | En route |
| Nature: | Military |
| Departure airport: | Bodø Air Base |
| Bodø Air Base | |
| Investigating agency: | NSIA |
| Confidence Rating: |  Accident investigation report completed and information captured |
In connection with exercise Cold Response, a C-130J Hercules transport aircraft with eight people on board nearly crashed into the rocky island Mosken in Værøy municipality in Lofoten. A last-minute avoidance manoeuvre prevented a collision, and the aircraft cleared the terrain by 144 ft (44 metres). The aircraft was the first in a formation of two C-130J aircraft practising low-level flying with night optics under night visual conditions.
Main conclusion
It was largely coincidence and the last-minute actions of the aircraft commander that prevented the loss of another RNoAF C-130J aircraft and crew. Had the first aircraft in the formation initiated the manoeuvre less than one second later, the outcome would have been a catastrophic collision with Mosken.
The NSIA understands the incident to have been caused by a combination of local conditions, active failures and latent weaknesses. The local conditions can be related to a combination of demanding weather and light conditions, low-level flying with night optics and commander check-out. The active failures were that the formation deviated from the planned route and weaknesses in the crew resource management (CRM). In addition, the authorised mission entailed too high a risk and was not in accordance with the regulatory framework for C-130J operations. The authorisation process thus failed to function as a safety barrier. The latent weaknesses in particular can be linked to the RNoAF’s safety management, a pressure to deliver combined with under-staffing and a high-performance culture, and inadequate supervision and follow-up. The RNoAF’s management had not identified safety-related weaknesses in the 335 squadron. Also, the RNoAF did not adequately dimension missions in relation to the available resources.
The NSIA supports the recommendations made in the RNoAF investigation report and the guidelines issued by the Chief of the RNoAF. At the same time, the NSIA is of the opinion that the RNoAF should intensify its safety management work, including risk control, competence building and safety culture. The NSIA also questions whether the RNoAF is capable of identifying and remedying its own systemic safety issues, and believes that the investigation has identified a need for an external supervisory body.
Accident investigation:
 |
|
Sources:
https://www.nsia.no/Defence/Published-reports/2021-02?pid=SHT-Report-ReportFile&attach=1
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 14-Aug-2023 08:05 | harro | Added |
| 14-Aug-2023 08:05 | harro | Updated |
Corrections or additions? ... Edit this accident description
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