What happened
An incident occurred involving two aircraft, identified by the callsigns ASTON and ABBOT, operating within the Moray Firth region. The event involved the controlled flight of both aircraft into the same airspace simultaneously due to a failure to identify converging flight paths. During the mission, the pilot of ASTON 1 made airmanship decisions that resulted in a descent into the Moray Firth environs without the benefit of radar service. The incident was further complicated by the absence of Secondary Surveillance Radar (SSR) and the inherent limitations of visual 'see and avoid' techniques.
The investigation
The Panel examined a wide range of operational, technical, and administrative factors contributing to the loss of situational awareness. The investigation looked into the effectiveness of intra-Squadron deconfliction and the adequacy of supervision at the Squadron level for both ASTON and ABBOT. Investigators also reviewed the ergonomics of the Air Traffic Control (ATC) desks and the efficiency of the authorization processes used for these sorties.
Technical scrutiny was applied to the lack of an electronic planning aid for deconfliction and the absence of specific equipment, such as a Combat Weapons System (CWS) on the Tornado GR4. The Panel also investigated the impact of meteorological conditions in the Morably Firth and the limitations of existing surveillance technology during the event.
Findings
- The primary cause was the failure to recognize converging flight paths, leading both aircraft into the same airspace at once.
- There was insufficient situational awareness among the aircrew of ASTON 1, ABBOT 2, and the Air Warfare Radar Controllers (AWRCs).
- Ineffective deconfliction processes existed within the Squadron, exacerbated by the lack of an electronic planning tool.
- Procedural drift had led to a degradation of established safeguards and AWR practices.
- The investigation identified several systemic issues, including ineffective squadron-level supervision, poor ergonomics at the operations desk, and the confusion of callsigns during communications.
- The absence of SSR and the limitations of visual lookout were critical contributing factors.