What happened
On the morning of April 5, 2019, two serious near-miss incidents occurred in the control zone of Jyväsebylä Airport (EFJY) involving Finnish Air Force flight formations and a general aviation aircraft. The incidents took place during the 'Final 2019' flight training exercise.
The first incident involved the Spade1 formation, consisting of four Hawk jet trainers, which was performing a landing pattern for runway 30. As the formation attempted to maneuver to provide separation from a Patria Pilot Training Oy Tecnam P-2002 JF (OH-TPI) flying on a parallel approach, the formation leader initiated a turn to avoid the civilian aircraft. Because the leader could not visually acquire OH-TPI, the maneuver caused the formation to break up. The second aircraft in the formation attempted to follow the leader's maneuver but failed to react in time, forcing a downward avoidance maneuver that caused the third aircraft in the formation to also dive, exceeding its negative G-limit. The student pilot in OH-TPI did not see the formation, which passed approximately 200 feet above the aircraft.
Immediately following this, a second near-miss occurred when the disrupted Spade1 formation flew through the Spade5 formation, which was also approaching runway 30. The individual aircraft from the first group passed through the middle of the second group at a lower altitude.
The investigation
The investigation examined the coordination between air traffic control (ATC) units, the management of the flight training exercise, and the communication protocols used during the events. The investigation looked into the coordination between the Coordinator (COR), Arrival Radar (ARR), and Aerodrome Control (TWR) workstations, as well as the effectiveness of the Air Force's operational risk management (ORM) for the exercise.
Findings
- Lack of coordination: The coordination between the different ATC workstations was insufficient, particularly regarding the timing and sequencing of aircraft arrivals.
- Inadequate risk assessment: The operational risk management for the 'Final 2019' exercise did not specifically include a safety review of the arrival and departure phases of the training maneuvers.
- Communication confusion: The use of similar-sounding aircraft callsigns during high-traffic periods increased the risk of confusion between military and civil aircraft.
- Visual separation failure: The formation leader was unable to maintain visual contact with the civilian aircraft, leading to the breakdown of the formation structure.
- Inconsistent ATC ergonomics: Differences in the layout and equipment of ATC workstations at different airports hindered effective verbal communication and coordination.