Report on serious aviation incident involving a C-130J Hercules transport aircraft on 11 March 2020, near Mosken in Værøy municipality, Nordland county
Defence report 2021/02
At 20:26 on 11 March 2020, 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 evasive 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 flight with night optics under night visual conditions. The investigation into the incident has shown that the Royal Norwegian Air Force (RNoAF) should intensify its safety management work, including risk management, competency and safety culture. The investigation has also identified a need for an independent and comprehensive supervisory body for military aviation.
The aircraft cleared the terrain by 144 ft (44 metres). Source: Royal Norwegian Air Force
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 incident happened during low-level flying with night optics and in demanding weather and light conditions. In addition it was a training flight for the commander candidate in the first aircraft in the formation. The authorised mission entailed too high a risk and was not in accordance with the regulations governing C-130J operations. The authorisation process thus failed to function as a safety barrier. En route the formation deviated from the planned route and several aspects of the crew resource management (CRM) failed.
The incident is related to weaknesses in the RNoAF's safety management, pressure to deliver in combination with understaffing 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.
Based on this investigation, the Norwegian Safety Investigation Authority (NSIA) submits three safety recommendations.
Published 19.04.2021
English translation of the report was published 28.06.2021
Safety recommendation
Safety recommendation Defence no 2021/05T
The investigation into the near collision with the rocky island Mosken on 11 March 2020 involving a C-130J Hercules aircraft has shown that the mission that was authorised was complex and involved a high level of risk. The mission was not adjusted on the basis of a risk assessment. The Royal Norwegian Air Force had not established acceptance criteria and requirements for compensatory measures for mission risk assessments.
The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Air Force review and improve its risk management procedures in terms of identification of hazards, safety barriers and risk factors, as well as acceptance criteria, requirements for compensatory measures and follow-up of the above.
Safety recommendation Defence no 2021/06T
The investigation into the near collision with the rocky island Mosken on 11 March 2020 involving a C-130J Hercules aircraft has shown that an internal wish to perform and external pressure to deliver exerted by the leadership and other parties may have contributed to reducing the safety margins of the 335 squadron's operations. The Norwegian Safety Investigation Authority is of the opinion that pressure to deliver and a high-performance culture, combined with an organisation that is not sufficiently well informed and learning, could affect the level of safety throughout the Royal Norwegian Air Force's activities.
The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Air Force conduct a survey to enable it to describe and understand the organisation's safety culture, both at command level and in operational units, as well as possible. Such a survey can establish a benchmark for subsequent safety work and efforts to improve the organisation's safety culture.
Safety recommendation Defence no 2021/07T
The investigation into the near collision with the rocky island Mosken on 11 March 2020 involving a C-130J Hercules aircraft has shown that the Royal Norwegian Air Force's safety management, internal supervision and follow-up of the 335 squadron have been inadequate. The Royal Norwegian Air Force's management has failed to identify safety-related weaknesses in the 335 squadron. The Norwegian Safety Investigation Authority questions whether the Royal Norwegian Air Force 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.
The Norwegian Safety Investigation Authority recommends that the Ministry of Defence establish an independent and comprehensive military aviation authority (supervisory authority). This aviation authority must be allocated new resources and not be established at the expense of the Royal Norwegian Air Force's existing activities.
Facts
| Location | Mosken, Værøy municipality, Nordland county |
| Occurrence date | 11.03.2020 |
| Category of Occurrence | Incident |
| Defence branch | Norwegian Air Force |