Descripción del Accidente ASN 23 JUN 2014 Learjet 35A D-CGFI

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Estado:	Accident investigation report completed and information captured
Fecha:	lunes 23 junio 2014
Hora:	14:38
Tipo:	Learjet 35A
Operador:	GFD Gesellschaft für Flugzieldarstellung
Registración:	D-CGFI
Numéro de série:	35A-612
Año de Construcción:	1985
Horas Totales de la Célula:	8259
Motores:	2 Garrett TFE731-2-2B
Tripulación:	Fatalidades: 2 / Ocupantes: 2
Pasajeros:	Fatalidades: 0 / Ocupantes: 0
Total:	Fatalidades: 2 / Ocupantes: 2
Daños en la Aeronave:	Destruido
Consecuencias:	Written off (damaged beyond repair)
Ubicación:	cerca Olsberg-Elpe ( Alemania)
Fase:	En ruta (ENR)
Naturaleza:	Militar
Aeropuerto de Salida:	Hohn Air Base (ETNH), Alemania
Aeropuerto de Llegada:	Hohn Air Base (ETNH), Alemania

Descripción:
A Learjet 35A was destroyed in an accident following a mid-air collision with a Luftwaffe (German Air Force) Eurofighter EF2000 Typhoon jet (30+91) over Elpe, Germany. Both crew members sustained fatal injuries.
The Learjet took off from Hohn Air Base, Germany at 13:04 to carry out a Quick Reaction Alert (QRA) military intercept and identification exercise with the German Air Force.
At 14:20 a formation of two Eurofighter EF2000 Typhoon jets took off from Nörvenich Air Base. The jets were given radar guidance to intercept the Learjet as part of the exercise. At 14:26 the formation reported the target in sight. The formation was cleared to climb to the Learjet's altitude. At the same time the Learjet crew were informed that the Eurofighters had visual contact.
One of the Eurofighters, serial 30+91, then closed in on the Learjet while the other one kept a distance of 2 Nautical Miles. At 14:29 the first Eurofighter pilot began transmitting information about the Learjet (registration mark, colours) to the military controller.
At the same time the Learjet crew noticed the Eurofighter on their left hand side.
At 14:34 the military controller contacted the Learjet crew: "...for your information the QRA will perform an obey-check on your left side and after three minutes you should obey."
After four minutes the controller told the Learjet crew: "... for your information, you overwhelmed the hijacker and now you want to obey the orders of the QRA and call them on the guard."
The Eurofighter pilot wiggled the wings and initiated a left hand turn. The Learjet crew disconnected the autopilot and followed the Eurofigher in the left hand turn.
The Learjet was flying with a 46° left bank angle and the Eurofighter at a 26° left bank angle when a collision occurred. The Learjet entered an uncontrolled descent and impacted terrain. The pilot of the Eurofighter issued a Mayday call: "Mayday, mayday, mayday...crashed with Learjet probably [...] left hand turn direct inbound Nörvenich declaring emergency." The second Eurofighter closed in to observe the damage. He radioed that he was not able to check out the Learjet crash site: "..Currently doing a structural damage check [...] severely damaged on the right hand side he needs my assistance right now."
A safe landing was carried out at Nörvenich at 14:58.

Probable Cause:

Causes
The causes of the flight accident were:
Immediate Causes:
- During positioning for the intervention the collision risk due to unexpected manoeuvres of the intercepted airplane was not sufficiently taken into consideration.
- The Learjet crew did not take into account the risks due to possible limitations of the field of vision and the distraction by using the computer when deciding about the task distribution.
Due to insufficient situational awareness during the intervention, the Learjet crew continued the turn with an excessive bank angle despite the loss of visual contact with the Eurofighter flying at the inside of the turn.

Systemic Causes:
- The operator had not specified in detail how the crew should distribute their tasks during Renegade exercises.
- Neither the operator commissioned to conduct the aerial target demonstration nor the Air Force had sufficiently described the Renegade training nor had a commensurate risk analysis been done.

Accident investigation:

Investigating agency:	BFU Germany
Status:	Investigation completed
Duration:	1 year and 2 months
Accident number:	BFU 1X002-14
Download report:	Final report

Fuentes:

» BFU

Subsiguiente / acciones de seguridad

BFU issued 6 Safety Recommendations

Issued: 13-AUG-2015	To: GFD	AA/2015
The operator should ensure that during aerial target demonstrations a high level of flight safety is reached. Therefore such flights should be investigated in regard to latent flight safety risks and actions be determined to minimise these risks. For aerial target demonstration flights as part of Renegade mission trainings, the following points should especially be considered during risk analysis: - Applicability of cross cockpit procedures - Use of portable computers during critical flight phases - Procedures for loss of visual contact - Application of flight manoeuvres suitable for the kind of target represented during the training.
Issued: 13-AUG-2015	To: Bundeswehr	Bb/2015
The Luftfahrtamt der Bundeswehr (LufABw) should ensure that during interception of civil aircraft a high degree of flight safety is guaranteed. The Renegade procedure should be sufficiently described and rendered more precisely so that the collision risk of aircraft involved is minimised even in the event of unexpected flight manoeuvres of the intercepted aircraft. Therefore the requirements of single-seat military aircraft should be taken into account more strongly when describing the procedures. The demand on the pilots in regard to the attention and task distribution in individual phases of the procedure should be rendered more precisely and the pilot of the second military aircraft should be more involved in the support to guarantee continued observation of the intercepted aircraft.
Issued: 13-AUG-2015	To: Bundeswehr	cc/2015
The Luftfahrtamt der Bundeswehr (LufABw) (Military Aviation Authority) should ensure that companies acting as civil contracting partners for the Bundeswehr conducting aerial target demonstrations meet the highest Bundeswehr standards in regard to their flight operations and flight safety organisations. In case the civil contracting partner does not hold an Air Operator Certificate (AOC) issued by a civil aviation authority, the LufABw should ensure that the civil contracting partner is organised such that hazard analyses are conducted in regard to their aerial target demonstrations operations which are suited to ensure a high degree of operational safety. In case the civil contracting partner is a civil air operator certified by the LuftfahrtBundesamt (LBA), regular information exchange should take place between the LufABw and the LBA in regard to special operational and flight safety issues in order to support the LBA.
Issued: 13-AUG-2015	To: LBA	dd/2015
The Luftfahrt-Bundesamt should effectively supervise the service providers working for the armed forces in terms of their operation. Therefore the Luftfahrt-Bundesamt should cooperate with the Luftfahrtamt der Bundeswehr in order to better understand the military special features. Therefore, regular information exchange should take place between the Luftfahrt-Bundesamt and the Luftfahrtamt der Bundeswehr (Military Aviation Authority) in regard to special operational and flight safety issues.
Issued: 13-AUG-2015	To: LBA	ee/2015
The Luftfahrt-Bundesamt (LBA) should ensure that operators have an effective Safety Management System. It should especially guarantee that the Safety Management System analyses the essential operating modes of an operator in regard to flight safety risks and, if applicable, take actions to minimise the risks.
Issued: 13-AUG-2015	To: EASA	ff/2015
The European Aviation Safety Agency (EASA) should add the term aerial target demonstrations to the list of examples mentioned in Commission Regulation (EC) No 965/2012 Part Specialised Operations (SPO) SPO.GEN.005 Scope (a).

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accident date: 23-06-2014
type: Learjet 35A
registration: D-CGFI

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@BILD pic.twitter.com/rNOt2VqNLw
— Z3tt (@z3tt88) June 23, 2014

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This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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