Sweden

The intention of the flight was to drop eight parachutists from an altitude of 1,500 metres. It was the twelfth and planned to be the last flight of the day. The weather conditions were good. The parachutist bench to the right of the pilot had been replaced with a pilot's seat to distance the parachutists from the pilot as a Covid-19 precautionary measure. The pilot had no ability to perform a mass and balance calculation with the available information. After take-off, the aircraft climbed to an altitude of 400 to 500 feet above ground before changing course 180 degrees to the left. The aircraft turned around quickly in a descending turn with a high bank angle. During the final phase, the aircraft dived steeply and then slightly levelled off before impact. Upon impact, the landing gear was teared off, after which the aircraft skidded on its belly 48 metres straight ahead and caught fire. All nine persons on board sustained fatal injuries.

The purpose of the flight was to drop eight parachutists from flight level 130 (an altitude of 13,000 feet, approximately 4,000 metres). The load sheet that the pilot received did not contain any information about the individual weights of the parachutists or the total mass of the load. The pilot could thus not, with any help from the load sheet, check or make his own calculation of mass and balance before the flight. The aeroplane was approaching the airport and, at 14:05 hrs, the pilot requested permission to drop the parachutists slightly higher because of clouds. The airspeed was decreasing in conjunction with the aeroplane’s approach to the airport. Just over a kilometre from the airport where the jump point was located, the aeroplane suddenly changed direction to the left and began descending rapidly in almost the opposite direction. The aeroplane then travelled just under one kilometre at the same time as it descended 1,500 metres, which is a dive angle of over 45 degrees. The aeroplane broke up in the air as both the airspeed and the g-forces exceeded the permitted values for the aeroplane. From an altitude of 2,000 metres, the aeroplane fell almost vertically with a descent velocity of around 60 m/s. The fact that no one was able to get out and save themselves using their parachute was probably due to the g-forces and the rotations that occurred. All those on board remained in the aeroplane and died immediately upon impact.

The flight was uneventful until the start of the event, which occurred during the approach briefing in level flight at FL 330. The event started at 00:19:20 hrs during darkness without moonlight, clouds or turbulence. The lack of external visual references meant that the pilots were totally dependent on their instruments which, inter alia consisted of three independent attitude indicators. According to recorded data and simulations a very fast increase in pitch was displayed on the left attitude indicator. The pilot in command, who was the pilot flying and seated in the left seat exclaimed a strong expression. The displayed pitch change meant that the pilot in command was subjected to a surprise effect and a degradation of spatial orientation The autopilot was, most probably, disconnected automatically, a “cavalry charge” aural warning and a single chime was heard, the latter most likely as a result of miscompare between the left and right pilots’ flying displays (PFD). Both elevators moved towards nose down and nose down stabilizer trim was gradually activated from the left control wheel trim switch. The airplane started to descend, the angle of attack and G-loads became negative. Both pilots exclaimed strong expressions and the co-pilot said “come up”. About 13 seconds after the start of the event the crew were presented with two contradictory attitude indicators with red chevrons pointing in opposite directions. At the same time none of the instruments displayed any comparator caution due to the PFDs declutter function in unusual attitude. Bank angle warnings were heard and the maximum operating speed and Mach number were exceeded 17 seconds after the start of the event, which activated the overspeed warning. The speed continued to increase, a distress call was transmitted and acknowledged by the air traffic control and the engine thrust was reduced to flight idle. The crew was active during the entire event. The dialogue between the pilots consisted mainly of different perceptions regarding turn directions. They also expressed the need to climb. At this stage, the pilots were probably subjected to spatial disorientation. The aircraft collided with the ground one minute and twenty seconds after the initial height loss. The two pilots were fatally injured and the airplane was destroyed.

The aircraft, a Piper PA46-500TP Malibu Meridian, should carry out a private flight from Västeras airport to Prague. On board were a pilot and two passengers. Shortly after take-off an engine failure occurred and the pilot decided to make an emergency landing on Björnö Island, situated slightly to the right in the flight direction. The aircraft hit the ground with the left wing first and then rolled a number of times before it came to a final stop. During the accident both wings and parts of the tail separated from the aircraft. The fuselage remained relatively undamaged during the crash course. All three occupants escaped with minor injuries. A special study of the sequence of events shows that the impact, with the left wing first, caused the airplane's wings to act as shock absorbers, which greatly contributed to that the occupants only received minor injuries. During the accident - which occurred next to a secondary protection zone for water supply to the city of Västerås – a significant amount of fuel leaked out from the wreckage. The accident site was decontaminated after the accident. Examination undertaken in the area after the accident has not showed any trace of residual contamination in the soil.

The accident occurred during a Norwegian military transport flight from Harstad/Narvik Airport (Evenes) in Norway to Kiruna Airport in Sweden. The flight was performed as a part of the Norwegian-led military exercise Cold Response. The aircraft, which was of the model C-130J-30 Super Hercules, had the call sign HAZE 01. HAZE 01 took off with a crew of four and one passenger on board. The aircraft climbed to Flight Level 130 and assumed a holding pattern south of Evenes. After one hour, the flight continued towards Kiruna Airport. The Norwegian air traffic control had radar contact and handed over the aircraft to the air traffic control on the Swedish side. Swedish air traffic control cleared HAZE 01 to descend to Flight Level 100 “when ready” and instructed the crew to contact Kiruna Tower. The crew acknowledged the clearance and directly thereafter, the aircraft left Flight Level 130 towards Flight Level 100. The lower limit of controlled airspace at the location in question is Flight Level 125. HAZE 01 informed Kiruna Tower that the aircraft was 50 nautical miles (NM) west of Kiruna and requested a visual approach when approaching. Kiruna Tower cleared HAZE 01, which was then in uncontrolled airspace, to Flight Level 70, and the aircraft continued to descend towards the cleared flight level. Neither ACC Stockholm nor Kiruna Tower had any radar contact with the aircraft during the sequence of events because the Swedish air navigation services do not have radar coverage at the altitudes at which HAZE 01 was situated. HAZE 01 levelled out at Flight Level 70 at 14.57 hrs. Half a minute later, the aircraft collided with the terrain between the north and south peaks on the west side of Kebnekaise. Data from the aircraft's recording equipment (CVR and DFDR) showed that HAZE 01 was flying in level flight at a ground speed of approximately 280 knots prior to the moment of collision and that the crew was not aware of the imminent danger of underlying terrain. The remaining distance to Kiruna Airport was 42 NM (77 km). Everyone on board received fatal injuries. Accidents in complex systems are rarely caused by a single factor, but there are often several circumstances that must coincide for an accident to occur. The analysis of the investigation deals with the circumstances which are deemed to have influenced the sequence of events and the barriers which are intended to prevent dangerous conditions from arising. In summary, the investigation indicates that latent weaknesses have existed both at the Norwegian Air Force and at LFV. It is these weaknesses and not the mistakes of individual persons that are assessed to be the root cause of the accident. On the part of flight operations, the investigation has found shortcomings with respect to procedures for planning and following up a flight. Together with a probably high confidence in air traffic control, this has led to the crew not noticing that the clearance entailed an altitude that did not allow for adequate terrain separation. In terms of the air traffic services, the investigation demonstrates that the aircraft was not issued clearances and flight information in accordance with applicable regulations. This is due to it not having been ensured that the air traffic controllers in question had sufficient experience and knowledge to guide air traffic from the west in towards Kiruna Airport in a safe manner under the present circumstances. The lack of radar coverage reduced the opportunities for air traffic control to monitor and guide air traffic. The aircraft's Ground Collision Avoidance System is the last barrier and is intended to be activated and provide warning upon the risk of obstacles in the aircraft's flight path. The investigation has shown that with the terrain profile in question and the settings in question, the criteria for a warning were not fulfilled. No technical malfunction on the aircraft has caused or contributed to the occurrence of the accident. The rescue operation was characterized by very good access to resources from both Sweden and abroad. The operations lasted for a relatively long time and were carried out under extreme weather conditions in difficult alpine terrain. The investigation of the rescue operation demonstrates the importance of further developing management, collaboration and training in several areas.

Kustbevakningen (The Swedish Coastguard), henceforth called KBV, intended on that particular day to perform two routine maritime surveillance tasks with flights over the southern Baltic Sea and along the south and west coasts of Sweden, including a flight over the Kattegatt. The flights would be carried out by the aircraft registered SE-IVF, with call sign 585. The crew consisted of two pilots and two system operators. The first flight of the day would take off from Ronneby, with Malmö/Sturup as the landing airport. According to the submitted flight plan the flight from Ronneby would depart north-east outwards across the southern tip of Öland, via reporting point KOLJA and onwards to a point south of Gotland. Thereafter the route would be via KOLJA back on a south-west course to a point south of Smygehamn in the southern Baltic Sea and then directly to Malmö/Sturup airport.

The take off from Ronneby
When KBV 585 taxied out for take off, route clearance had been obtained for take off in accordance with the submitted flight plan. The flight would be undertaken in VFR (Visual Flight Rules) weather conditions. The flight plan did not state the desired altitude, so at the initiative of air traffic control KBV 585 was assigned the altitude band “1500 feet or lower” in connection with the flight clearance. Take off was at 11:09 on runway 19. Immediately after take off the crew requested a “360”, i.e. to make a complete turn from their current position. This request was accepted by air traffic control and KBV 585 performed a circuit at about 500 feet in a left turn around the airfield. No comments or explanations were offered by the crew during this manoeuvre. In an interview with SHK the air traffic controller stated that he thought that the aircraft had suffered a technical fault and/or the crew wanted to carry out some form of check. It later transpired that the reason for the extra circuit may have been to show off the aircraft to a practical work experience student who was at the KBV as part of work experience training. After the completed left hand circuit the pilots returned to their original flight plan and continued, with an initial climb to the south, to then turn left and follow the planned flight route.

The first phase of the flight
During the continuing climb the pilots received an instruction to change radio frequency from Ronneby air traffic control tower to Ronneby control, i.e. the air traffic control section covering the Ronneby terminal area, that normally includes radar surveillance. As KBV 585 continued to climb, the air traffic controller noted that it continued to climb above the maximum altitude of 1500 feet that the stated flight clearance had included. At about 2000 feet while still climbing the pilots requested permission to climb to and maintain 2500 feet, which was granted. When the aircraft left the Ronneby terminal area the pilots changed radio frequency without reporting this to the air traffic control area controller. The air traffic controller on duty on that particular day at Ronneby stated that this was unusual behaviour by the KBV pilot, both to climb through the cleared altitude and to depart from the radio frequency without reporting it. The flight continued to the north-west in accordance with the flight plan. Apart from the routine tasking order concerning environmental and fishing surveillance, the tasking included instructions to search for traces from a previously sunken barge. The flight was performed without any problems being reported. During the flight the pilots were in radio contact both with air traffic controllers and the KBV coordination centre. As the aircraft was en route south-west after having turned at the southern tip of Gotland, the crew received a message from the coordination centre concerning a request they had received to perform a fly-by over Falsterbo. KBV has a base at the Falsterbo canal, which on that particular day was hosting a study visit by two school classes. Therefore a request came from the base to ask whether the pilots could consider performing a fly-by as they were on their way to Malmö/Sturup, so as to demonstrate the aircraft. The pilots accepted this and revised the final part of their flight plan so that a demonstration of the aircraft over the Falsterbo canal could be performed.

The fly-by over the KBV base
At 13:23 KBV 585 came in over the coast at Falsterbonäset on a north-northwesterly course along the canal. The aircraft then continued out over the sea and after a left turn returned to approach the base. The aircraft then performed another fly-by at low speed over the base and along the canal in the opposite direction, i.e. south-south-east, at low altitude. The route of the flight was partly over the canal, partly over the strip of beach and the buildings along the north-eastern shore. Beyond the far end of the canal the aircraft performed a 180 degrees left turn, first climbing and then descending. On its last approach to the base the aircraft came over the beach at the northeastern side of the canal, on a north-westerly course, which was later altered to north-north-westerly as it once again came over the canal.

The accident
As the aircraft neared the base once more it began wing tipping. After two or three wing tippings, by which time the aircraft was approximately above the bridge at the north-west entrance to the canal, a loud bang was heard and the entire left wing separated from the aircraft, to fall into the basin. The aircraft then rolled over onto its back and also fell into the basin, somewhat further out. The impact created a huge cascade of water. The remains of the aircraft and wing then quickly sank to the bottom. The whole sequence of events took place quickly and afterwards various pieces of wreckage could be seen floating on the surface at the point of impact. All on board were fatally injured. The accident took place at position 55° 25' N 012° 56' E; at sea level.

The pilots were scheduled to fly the aircraft, a BAe Jetstream 32, on scheduled flight EXC403 from Pajala Airport to Luleå/Kallax Airport. This was the third flight together for the day. Before takeoff they noted that the flight was planned without passengers. Since the co-pilot was shortly to undergo an Operator’s Proficiency Check and the commander had long flying experience, including as an instructor, the commander decided to take the opportunity to have the co-pilot train flying with simulated engine failure. The takeoff from Pajala was at 17.57 hrs with the co-pilot as Pilot Flying. During the climb the commander reduced thrust on the right engine to simulate engine failure. This was done by moving the engine control lever to its rear stop. The commander understood this to represent what is termed ”simulated feather” in which an engine generates no drag and causes the least possible resistance. The exercise passed off without problem and the co-pilot had no difficulties in handling the aircraft. It was decided to practise flying with simulated engine failure during the landing as well. During the approach to Luleå/Kallax Airport when the aircraft was at an altitude of about 3500 feet the commander accordingly reduced thrust on the right engine once again. The co-pilot understood that the whole landing, including touchdown, would be with one engine on reduced thrust. However, the commander’s intention was to restore normal thrust on the right engine before touchdown. Prior to landing the reference speed (Vref1) had been calculated at 107 knots IAS2 and the flaps lowered 20°, based on the calculated landing mass of 5 640 kg. During the approach when the aircraft was at about 3500 feet, the commander reduced right engine thrust. According to the FDR recording thrust was reduced initially to just over 19 % and subsequently, for six minutes, further to just under 11% at the same time as altitude decreased to 900 feet. The co-pilot flew the aircraft in a right turn to runway 32 and started his final 2 nautical miles from the runway threshold at a height of 900 feet. The final was entered with a somewhat higher glide angle than normal. As the aircraft approached the runway threshold the thrust on the right engine had decreased to approximately 7%. The approach took place with applied rudder and opposite banking to counteract the lateral forces generated by the asymmetrical thrust. During the approach the co-pilot experienced an inertia in the ailerons that he had never experienced previously. Shortly after the aircraft had crossed the runway threshold and was about 5 metres above the runway, both the co-pilot and the commander felt how the aircraft suddenly yawed and rolled to the right. Neither pilot remembers hearing the stall warning sounding. Despite application of full aileron and rudder the pilots were unable to stop the aircraft’s uncontrolled motion. This continued until the right wing tip hit the ground. The fuselage then struck the ground. The aircraft slid on its belly about 50 metres alongside the runway before stopping. The pilots hastily evacuated the aircraft. The accident was observed by the air traffic controller who immediately alarmed the airport rescue service, which arrived at the accident scene within a minute or so. After its arrival the commander boarded the aircraft and turned off the fuel supply and the main electricity, whereafter the rescue service covered the aircraft with foam. The accident occurred on 17 September 2003 at 18.28 hrs in position 6532N 02207E; 20 m above sea level in daylight.