What happened
On March 7, 2017, at 14:34 LMT, a crew from the LPR Warszawa Okęcie branch was conducting a Helicopter Emergency Medical Service (HEMS) mission. The flight route included departures and arrivals between Warsaw (EPWA), Kraków (EPKK), the Kraków Prokocim hospital (landing site H329), and the Children's Health Center in Warsaw (landing site H622). The flight was conducted under Visual Flight Rules (VFR) in Visual Meteorological Conditions (VMC).
After completing the medical mission and transferring the patient at the Children's Health Center, the crew departed for their base at Okęcie. Upon reaching point November, the pilot established contact with Warsaw Okęcie Tower (TWR EPWA) and received clearance to enter the airport controlled zone (CTR), follow the approach via points Oskar-Echo, and land on runway 33 at taxiway "S2".
Following landing, the pilot received instructions from the tower to continue taxiing from taxiway "S2" toward taxiway "Z4," proceeding into the military section of the airport. The pilot also established contact with the Military Air Traffic Coordination Service to provide flight information and request further instructions. The pilot eventually reached taxiway "Z4," where a "Follow Me" vehicle assisted the crew to their parking position. The pilot subsequently notified both the Warsaw Tower and the military coordination service that taxiing had concluded and the aircraft was on the ground.
The investigation
The investigation, conducted by the LPR Company Committee, examined radio communications and operational procedures. The review of reconstructed radio correspondence confirmed that the pilot performed the approach in accordance with the clearance received from Warsaw Tower. Furthermore, the pilot received confirmation from Warsaw Okęcie Ground (GND) to continue the approach. The investigation established that the segment of taxiing from taxiway "Z4" to the final parking position was performed with the assistance of the "Follow Me" vehicle.
Findings
- The taxiing from taxiway "S2" to "Z4" was performed without the required assistance.
- This movement was in violation of NOTAM nr 0479/17, which specifically mandated that taxiing via the designated taxiways must be conducted under the assistance of a "Follow Me" vehicle.