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ASN Wikibase Occurrence # 230905
Last updated: 25 November 2021
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Date:25-NOV-2019
Time:19:40 LT
Type:Silhouette image of generic AS32 model; specific model in this crash may look slightly different
Aérospatiale AS 532UL Cougar
Owner/operator:ALAT (French Army Light Aviation)
Registration: 2272/F-MCGE
MSN: 2272
Fatalities:Fatalities: 11 / Occupants: 11
Other fatalities:2
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:W of Ménaka -   Mali
Phase: Manoeuvring (airshow, firefighting, ag.ops.)
Nature:Military
Departure airport:Ménaka
Destination airport:Ménaka
Investigating agency: BEA-É
Narrative:
Ground troops of the Barkhane force located in the Liptako region west of Ménaka, Mali, were asking for a succession of air reinforcements following a clash with an armed terrorist group.
A patrol of two Gazelle helicopters took off on alert from the Ménaka forward base, followed by a Cougar helicopter carrying six commandos and an air mission commander (AMC). In addition, a patrol of two Tigre helicopters was sent as reinforcements from Gao.
The Gazelles arrived on the scene shortly after nightfall and intervened in the area indicated by the ground troops, to the north of a fire covering several dozen hectares triggered by the fighting on the ground. The Cougar was positioned to the north-east of this area.
The Tigre patrol arrived later and split in two. The leader came to orbit above the two Gazelles to the north of the fire at an altitude of about 3,000 feet. The wingman came to fly over the French troops in the south. The Cougar announced itself 8 nautical miles (NM) to the north-east of the action zone, at an altitude of 3200 feet.
A few minutes later, the Tigre leader and the Cougar collided in flight. All the occupants died and the helicopters were destroyed.

Causes of the event:
The collision could not be avoided because the crews did not detect the presence of the other aircraft.
Their respective awareness of the situation was erroneous. The causes lie exclusively in the field of organisational and human factors.
In the highly dynamic, complex and high-risk context of a combat operation, safety is mainly based on aircraft coordination and therefore communication. The crews developed an erroneous situational awareness leading to a situation of imminent risk of collision, due to poor coordination and communication caused by the following problems:
- a lack of a clear regulatory framework in the ALAT for managing aircraft deconfliction;
- a lack of a common safety briefing for all those involved, whether generic or conducted in flight;
- omission of safety messages or use of a channel to which all stakeholders do not have access;
- imprecise phraseology and a lack of collation of safety messages;
- a multiplicity of communication channels complicating the intelligibility of discussions, sometimes simultaneous;
- a lack of common and unique references for reporting aircraft positions;
- an increased mental load for the Tiger Patrol Leader and the AMC, due to construction experience and an intermittent radio transmission failure of the Tiger leader ;
- a perfectible ergonomics of the Tiger HAD PCB cockpit that does not allow immediate altitude control;
- for the AMC, live communication of orders via the on-board intercom, which does not allow other aircraft to know them, and a lack of subsidiarity in its decisions, which makes it impossible to adapt the system to the tactical situation in real time;
- a focus of crew members' attention on the area of action and on the camera images, particularly for the crew members of the Cougar who have taken part in an image-based intelligence mission and have not undergone CRM training in the use of the camera, in the absence of a doctrine on the use of this tool;
- a concern linked to an ethical dilemma over the rules for opening fire mobilising the crews and particularly the AMC, made aware by a previous event, which diverts it from its role of coordinating aircraft that it does not explicitly delegate;
- an imbalance in prioritisation between involvement in the operational objectives of the mission on the one hand and the imperatives of safety and boarding risk management on the other.
Some of these failures may have been caused by a high mental workload for the crews in relation to the complexity of the mission, particularly in terms of the number of people involved and the pressure of the ground troops. None of the crew members was able to acquire and maintain an overall view of the air situation that was in line with reality and evolving in all three dimensions.
This was due to the lack of detection of the impending collision:
- the absence of an anti-collision system or a means of displaying in real time the position of the surrounding aircraft;
- to a degraded visual environment: very dark night and the use of JVNs, with the presence of a fire on the ground interfering with vision using JVNs ;
- the voluntary extinction of position and anti-collision lights in the context of a combat mission and in the absence of suitable means of light signalling;
- insufficient monitoring of the distance displayed by the TACAN, influenced by erroneous situational awareness or a focus on the mission and objective, in the absence of a TACAN doctrine requiring such monitoring.

Sources:

https://www.rtl.fr/actu/international/mali-13-militaires-francais-tues-dans-l-accident-de-deux-helicopteres-7799557657
https://www.lefigaro.fr/international/mali-treize-militaires-francais-tues-dans-l-accident-de-deux-helicopteres-20191126
https://www.lci.fr/amp/international/en-direct-treize-militaires-tues-au-mali-apres-une-collision-entre-deux-helicopteres-2138676.html?__twitter_impression=true
http://aerossurance.com/helicopters/mali-military-midair-hf-alat/

_____________________
https://aviation-safety.net/wikibase/wiki.php?id=230904

Accident investigation:
cover
  
Investigating agency: BEA-É
Status: Investigation completed
Duration: 1 year and 2 months
Download report: Final report

Media:


Images:




Revision history:

Date/timeContributorUpdates
26-Nov-2019 09:14 Iceman 29 Added
26-Nov-2019 09:24 Iceman 29 Updated [Aircraft type, Narrative, Photo]
26-Nov-2019 09:29 Iceman 29 Updated [Source]
26-Nov-2019 09:32 Iceman 29 Updated [Embed code]
26-Nov-2019 09:43 Iceman 29 Updated [Aircraft type, Source, Embed code]
26-Nov-2019 09:49 Iceman 29 Updated [Narrative]
26-Nov-2019 09:50 Iceman 29 Updated [Time, Location]
26-Nov-2019 09:54 Iceman 29 Updated [Embed code]
26-Nov-2019 09:57 Iceman 29 Updated [Total fatalities, Embed code, Photo]
26-Nov-2019 10:30 gerard57 Updated [Other fatalities]
26-Nov-2019 10:42 Iceman 29 Updated [Photo]
26-Nov-2019 13:49 TB Updated [Aircraft type, Operator]
26-Nov-2019 19:50 Iceman 29 Updated [Operator]
03-Dec-2019 10:53 Iceman 29 Updated [Embed code]
29-Jan-2021 16:07 harro Updated [Registration, Cn, Location, Departure airport, Source, Embed code, Narrative]
13-Feb-2021 13:40 Aerossurance Updated [Source, Embed code, Accident report]
13-Feb-2021 13:41 Aerossurance Updated [Departure airport, Destination airport, Embed code, Accident report]
13-Feb-2021 13:41 Aerossurance Updated [Phase, Accident report]

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