Incident Description
On 14 September 2023 at 15:18 LMT, a crew of the Polish Medical Air Rescue (LPR) at Janowice (WPXL) received a HEMS call to Firlej. The helicopter, an EC 135 P2, departed after contacting TWR Lublin. After leaving CTR Lublin (EPLB), the crew contacted FIS Warsaw, informing them of a HEMS mission and intended landing at Firlej, which was inside the TRA4F active zone—the crew was aware of this. The crew maintained communication with FIS Warsaw but could not determine whether FIS directed them to contact Dęblin APP or informed them of zone occupancy. At 15:37, the crew reported landing at Firlej. While on the ground, the medical supervisor decided the patient would travel by ground ambulance. Before departure, the crew received another HEMS call to Jaszczów Kolonia, inside CTR Lublin. After takeoff at 15:52, the medical dispatcher cancelled the mission. The crew then contacted TWR Lublin before entering CTR Lublin and landed at the LPR base at 16:05. Both flights were conducted at altitude A013. Throughout both missions, air traffic control did not inform the crew about the active TRA4F zone.
Causes
According to the report by the Polish Air Navigation Services Agency (PAŻP), the incident was caused by:
- Lack of information from FIS to the airspace manager (ASM) about the transit of the LPR helicopter "Ratownik 7" through the active TRA4F zone during the HEMS flight.
- Lack of information exchange between the FIS informant and the FIS assistant regarding coordination of the helicopter's transit through the TRA4F zone.
- Lack of radar coverage in the area at the helicopter's transit altitude.
Contributing Factors
The following factors were identified as contributing to the incident:
- Workload of the FIS informant and assistant, assessed as medium to high.
- High number of active zones, which negatively affected the situational awareness and perception of the informant and assistant.
Preventive Actions
The entity investigating the incident implemented the following preventive measures:
- The report was provided to the Director of the Air Traffic Services to analyze the feasibility of supplementing the P21 system with additional data sources, as the area has high general aviation traffic and aircraft are visible on radar only above A025.
- The report was distributed to Regional Information Teams for discussion during FIS staff meetings and refresher training, emphasizing the need for better information exchange between assistants and informants in similar situations.
The State Commission on Aircraft Accident Investigation accepted these actions and issued no additional safety recommendations.