What happened
On September 14, 2023, an EC 135 P2 helicopter, operated by LPR, was performing HEMS (Helicopter Emergency Medical Service) duties near Janowice within the Lublin CTR. After departing the CTR, the crew established contact with FIS Warszawa to report their mission to land in Firlej. The crew was aware that the planned landing site was located within the TRA4F airspace.
During the mission, the crew maintained continuous communication with FIS Warszawa; however, they were unable to confirm whether the controller had redirected them to Dęblin APP or provided specific information regarding airspace occupancy. At the landing site in Firlej, medical personnel decided the patient would be transported via ground ambulance instead. Following this, the crew received a new HEMS mission to Jaszczów Kolonia, located within the Lublin CTR. During the flight to the new destination, the medical dispatcher canceled the mission. The crew subsequently contacted Lublin Tower and landed at the LPR base at 16:05. Both flight segments were conducted at altitude A013. Throughout both missions, Air Traffic Services did not inform the crew that the TRA4F zone was active.
The investigation
The investigation focused on the communication breakdown between air traffic services and the flight crew, as well as the coordination between FIS personnel. The investigation examined the coordination between the FIS informant and the FIS assistant, the adequacy of radar coverage in the area, and the workload of the controllers during the period in question.
Findings
- The primary cause of the incident was the failure of FIS to notify the Airspace Manager (ASM) regarding the flight of the helicopter through the active TRA4F zone.
- There was a lack of information exchange between the FIS informant and the FIS assistant regarding whether the flight through the TRA4F zone had been coordinated.
- There was a lack of radar coverage in the specific region at the altitude at which the helicopter was operating.
- High workload levels (rated from medium to high) for both the FIS informant and the assistant contributed to the incident.
- The presence of a large number of active airspace sectors negatively impacted the situational awareness and perception of the FIS personnel.