Cause
The panel concluded that the accident was caused by a lack of recognition of converging flight paths, which resulted in the controlled flight of both aircraft into the same airspace at the same time.
Contributory Factors
The panel identified 19 contributory factors, including:
- Ineffective intra-squadron deconfliction.
- Absence of an electronic planning (deconfliction) aid and the inability of the procurement process to provide one.
- Ineffective squadron-level supervision of the two flights, designated ASTON and ABBOT.
- Inefficiencies in the ergonomics and information display of the Authorization Desk and Operations Desk.
- Ineffective authorization of the ASTON flight.
- Airmanship decisions by the lead aircraft of ASTON that led to a descent into the Moray Firth environs without a radar service.
- Insufficient situational awareness among the crews of ASTON 1, ABBOT 2, and the Aerial Weapons Range Controllers (AWRCs).
- Lack of Secondary Surveillance Radar (SSR).
- Degradation of safeguards due to procedural drift of AWR procedures and practices.
- Limitations of the "See and Avoid" principle.
- Meteorological conditions in the Moray Firth.
- ASTON 1's lack of a Radar Homing and Warning Receiver (RHWR).
- Lack of a Collision Warning System (CWS) on Tornado GR4 aircraft and the inability of the procurement process to equip them.
- Lack of a formalized and effective care plan for the Weapons Systems Officer of ASTON 1.
- Ineffective assurance of the Operational Conversion Unit (OCU).
- AWR culture issues.
- Shortcomings in the risk management process.
No aggravating factors were identified.
Other Factors
The panel identified seven other factors:
- Aircrew safety and survival currency.
- Ineffective authorization of both ASTON and ABBOT.
- The altitude at which the incident occurred and the ineffectiveness of automated alerting mechanisms.
- Elements of the design and configuration of the Post-Survival Platform (PSP).
- Survival organization, policy, training, and equipment integration.
- Breaches of recognized and mandated engineering safeguards.
- Inadequate safeguarding of the Military Secondary Surveillance Radar (MSSR) and TACAN.
Observations
The panel made 56 observations, including:
- Tornado GR4 flight simulator projectors have limited ability to display realistic entities for lookout training; lookout training is not routinely assessed.
- "See and Avoid" has known limitations mitigated through training and education.
- Primary Surveillance Radar maintenance scheduled for Sundays is often completed during the week due to watch patterns.
- SSR user availability may not be fully understood by higher command; confusion exists between actual availability to end users and reported serviceability.
- The chip in the left-hand quarterlight of aircraft ZD812 had not been blended or polished out.
- The Tactical Air Combat Training System (TACTS) had not been updated to track currency of rear-cockpit training selections.
- XV(R) Squadron did not have Training Orders.
- The Station Commander had not promulgated local orders defining minimum experience for the positions of Deputy Controller Forces (DCF) and Duty Authorizer (DA).
- External aircrew should adhere to squadron regulations when flying with that squadron.
- Only Records of Flight from other flying squadrons are displayed at the Authorization Desk.
- The Flypro display at the Authorization Desk would not have been an updated version regardless of monitor serviceability.
- The DA did not request evidence of a waiver for sea survival drills for ASTON 1 WSO as not mandated.
- Timing differences between ABBOT 2's strafe checks and guidance from OC Standards.
- Mandatory joining call information differs between JSP 403 and the ACAWEWROs.
- US AWRCs monitor AWR users via radar or Mode 3 repeater displays, providing only a Basic Service but can offer traffic information.
- ACAWEWROs do not reflect current operating practices.
- Resolution and generation of traffic information for TCAS II equipped aircraft increases above 1000 ft.
- The ASTON sortie took place over remote sections of NW Scotland; extended detection times could occur without beacon location, OF, squawk, or radio alert.
- Provision of Trauma Risk Management (TRiM) for supernumerary crew is not mandated.
- ASTON and ABBOT callsigns were confused during the Post-Crash Management (PCM) process.
- On the day of the accident, the 2nd DA was also Orderly Officer and received conflicting calls.
- The Emergency Coordination Centre (ECC) had been moved; at 17:00 hrs all telephone lines went down as limited to daytime working hours.
- Creation of an ECC Group email and limited folder improved communication but initially prevented personnel from reviewing the log.
- ASTON 1 WSO's e-folder was not impounded after the accident and was deleted.
- XV(R) STANEVAL Training Folder was not impounded; ABBOT 2 RS Pilot had another training folder not impounded.
- The Logistics Information and Tracking System (LITS) cannot function with aircraft quarantined as required by MRP RA 4305.
- Electronic copies of online documents were not provided as part of PCM.
- Accommodation and financial support to the PCMIO team was lacking; an advance of pay was issued.
- The squadron aircrew crewroom was no longer regularly used.
- RAF SAR Force SOPs were contravened in both aircrew recoveries but not identified by squadron OC.
- RAF SAR Force SOPs retain mandatory language that can convey mixed messaging.
- Recovery of subsurface loads is not covered in RAF SAR Force SOPs.
- RN SAR had not developed SOPs outside the Maritime Sea King Flying Guide.
- Significance of potential liferaft valve failure under tension cannot be assessed due to unknown survivable water entry speeds.
- Both RAF Lossiemouth FOB and JSP 911 SERE are in error regarding SAR helicopter readiness states.
- JSP 898 Part 3 Chapter 3 requires updating; ownership and review process unclear.
- No evidence of trials for wave splash with RAF life preservers.
- Lack of coherent auditing process of Flight Medical Officer currency for Aviation Medicine training.
- No tracking of MAME CME despite responsibility stated in AP1269.
- RAF Lossiemouth CMP was out of date for Aviation Medicine Continuation Training.
- Squadron Medical Officer stated he did not know if there was a currency requirement for training.
- MoD F700 Quality Checklist contained out of date references.
- An individual's understanding of maintenance conduct stagnated at point of last formal training.
- Use of a STANEVAL representative from another platform could improve assurance visits.
- OCU staff Operational Status Certificates would be easier to interpret with breakdown of categories.
- No regulations define who can award ATC endorsements or delegation level.
- An infringement of a GRI had been identified.
Probable Cause
Lack of recognition of converging flight paths, resulting in the controlled flight of both aircraft into the same airspace at the same time.