Swedish Special Forces SPIES and Military SMS
The Swedish Accident Investigation Authority (SHK) has issued their report (in Swedish but with an English summary) on a serious incident that occurred when a party of special force troops were being deployed on a trial underslung beneath Sikorsky UH-60M Black Hawk 16238.
On 15 October 2015 the Swedish Armed Forces were conducting an Operational Evaluation (OPEVAL) trial of a new capability, called SPIE (Special Patrol Insertion and Extraction), to deliver a party of 11 troops by a 40m longline under a helicopter to the local ro-ro ferry Christina Brahe in Lake Vättern.
The helicopter lost station momentarily and:
The rope became caught in the vessel temporarily and the people on the rope were dragged towards the vessel’s gunwale, resulting in minor injuries.
The SHK say they were…
…able to establish that there have been major shortcomings in both the production of the OPEVAL plan for SPIE and the implementation of OPEVAL SPIE.
These shortcomings can primarily be traced back to limitations in terms of knowledge and relevant experience of similar mission profiles involving vessels.
These shortcomings have been present throughout the chain of command, from the crew up to those with decision-making responsibility for the implementation.
The lack of such expertise has resulted in no one at any level having understood what risks have been taken and the commander and his crew not having been given the requisite support in advance of and during the implementation of the operation.
Splitting up the planning and implementation of OPEVAL SPIE between the Air Combat Training School’s Tactical Development Training Unit Helicopter (LSS UTV LUFT TU HKP) and the 23rd division of the Helicopter Wing has resulted in the areas of responsibility becoming unclear, which risks leading to essential actions not being taken.
The SHK note that SPIE lacked an airworthiness approval so they concluded its use “was therefore not permitted”. They note…
…there was a difference of opinion between the Swedish Defence Materiel Administration (FMV) and the Armed Forces concerning which requirements applied and how these were to be interpreted. This resulted in the Armed Forces believing it had more opportunities than before to approve new material for use in a simpler manner.
They go on to say there were strong time pressures “as a result of a desire to develop new capabilities quickly”.
Combined with the limited knowledge and experience of similar mission profiles involving vessels, this resulted in the work not taking place in a sufficiently structured and safe manner, which in turn led to risks not being identified and managed in an appropriate manner. A “can-do culture” exists.
At the time of the occurrence, there was a lack of sufficient oversight from senior Flight Operations officers with respect to Flight Operations within the 23rd division. Without such oversight, operations cannot be led and controlled safely and in accordance with the Armed Forces’ regulations.
The SHK note that the Supreme Commander’s 2010 direction to create a safety management system (SMS), based on international civilian standards, has not been implemented. they say:
Parts of an SMS are described in the governance documents, but not in full and there are shortcomings in the application of those parts that do exist.
The Swedish Military Flight Safety Inspectorate’s (FLYGI) supervisory operations have not been capable of identifying the fundamental shortcomings in the system. The Flight Safety Inspector’s independence should be reinforced. In addition, a state safety programme (SSP) should be drawn up for military aviation.
The SHK conclued that this incident was caused by “shortcomings in terms of the prerequisites necessary in order to implement OPEVAL SPIE in a safe manner”. Namely:
- A lack of knowledge and relevant experience among the Flight Operations leadership and the crew in terms of helicopter operations involving vessels.
- Insufficient time for preparations.
- Shortcomings in the organisation and expertise available within the Air Combat Training School’s Tactical Development Training Unit Helicopter (LSS UTV LUFT TU HKP).
Contributory factors have been weaknesses in the safety culture within the helicopter operations investigated and a lack of oversight in operations within the 23rd division from senior Flight Operations officers.
Underlying factors, in terms of how this has been able to arise, have been the lack of an implemented and functional SMS in the Armed Forces’ Air Operator.
To the Swedish Armed Forces:
- Review the organisation and implementation of OPEVAL helicopter, taking into account the weaknesses identified in section 2.1 with respect to expertise, risk evaluation, commencement and termination criteria, pressure of time and divided responsibilities. (RM 2017:01 R1)
- Audit previously conducted OPEVAL within helicopter operations in order to ensure that these have been implemented in a correct manner on the basis of reasonable levels of safety. (RM 2017:01 R2)
- Ensure that senior Flight Operations officers have the requisite expertise with respect to current helicopter systems and mission profiles to enable them able to lead and support subordinate personnel and assess their capability. (RM 2017:01 R3)
- Ensure that FlygSäk (Flight Safety) has the requisite expertise with respect to current helicopter systems and mission profiles and sufficient resources to monitor and analyse the aviation safety situation and management systems application in a satisfactory manner. (RM 2017:01 R4)
- Create and implement an SMS that is adapted to the Armed Forces’ military aviation and ensure that the requisite training is provided to the officers concerned. (RM 2017:01 R5)
- Clarify the meaning of FMV’s technical design responsibility so that the organisations and responsible persons involved have an understanding of and are in agreement as regards the interpretation of SAMO (coordination agreement between FMV and the Armed Forces). (refer to section 2.7.3). (RM 2017:01 R6)
To the Flight Safety Inspector:
- Reinforce the supervision of the Armed Forces’ helicopter operations in order to ensure the safety of these operations until such time as the SMS is implemented by the Armed Forces’ Air Operator. (RM 2017:01 R7)
- Draw up a state safety programme (SSP) for military aviation. (RM 2017:01 R8)
- Ensure that amendments to the RML are implemented in a manner that is quality assured and that all the organisational units involved in the change process are fully aware at all times of their respective roles and interfaces and that they agree on the division of responsibility (refer to section 2.7.3). (RM 2017:01 R9)
- As part of its supervisory role, audit the new reporting system on the basis of the requirements in the RML and the reporting culture within helicopter operations on the basis of the shortcomings identified in this investigation (refer to sections 2.5.5 and 2.5.6). (RM 2017:01 R10)
- Investigate in more detail the feasibility of strengthening the independence of the supervisory function and consider making a request to the Swedish Government in this respect (refer to section 2.6). (RM 2017:01 R11)
Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. We will be presenting for the second year running too. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business?