The National Commission for the Investigation of Aircraft Accidents and Serious Accidents, Extraordinary Events Threatening the Safety of Railway Traffic and Maritime Accidents and Accidents (KINNS) has published the "Final Report of the Serious Accident" of the "air tractor AT-802A" firefighting aircraft, of the Air Helicopter Unit of the MUP, which happened on June 22, 2021 near Podgorica.
"Air tractor" registration number 4O-EAC was then engaged in firefighting in the Mihinja hill area in Beri near Podgorica. On that occasion, the plane is in the phase of the so-called extraction, i.e. climbing after dropping a water bomb on the fire site, hit the top of a pole of a high-voltage transmission line crossing the area of the fire site and suffered severe damage to the left wing, which almost caused it to crash. However, despite this, the pilot managed to get the plane out of a critical situation and land it safely at the airport in Podgorica. KINNS the day after this incident, based on the so-called reports of an extraordinary event submitted to it by the Civil Aviation Agency (ACV), began an investigation.
Although the KINNS report is anonymized and does not mention the specific names of the actors, it is certain that he operated the damaged "air tractor" in the aerial firefighting operation in Beri on June 22, 2021. Branislav Stojanovic (64), the oldest and most experienced pilot in the AHJ of the MUP of Montenegro. The report states that the pilot of the damaged plane had accumulated a total of over 1994 flying hours until that incident in his flying career, which began in 13.743, but of that, only slightly over 282 flying hours were on the "air tractor", of which 100 hours were in aerial firefighting operations themselves. This, as written in the report, "can be considered insufficient, in conditions where continuous training is not carried out, in the scope and structure as provided for in the Operational Manual".
"The pilot participated in an air accident in 2015, with the same operator, on the same type of aircraft, in a fire-fighting operation, in the phase of landing on the lake to take on water, with the landing gear extended, during which the overturning occurred, when irreparable damage occurred. damage to the aircraft, and the pilot escaped without consequences. There is also a citizen's report registered with the Commission for flying low over objects outside the area of fire fighting operations and during training flights where he was part of a group and flew in the position of a companion", it is written, among other things, in the KINNS report about the pilot who on June 22, 2021 .hooked a power line pole in Beri with an "air tractor". According to reports, the pilot had already finished his work that day and was returning home from the Podgorica airport by car, when he received a phone call from the head of flight operations at AHJ who gave him the task of putting out the fire in Beri. From the Podgorica airport, the pilot took off in the "Air tractor" registration 4O-EAC at 15.20:17.25 p.m. and until the incident, which happened at around 11:4 p.m., he made a total of 4 rotations between the airport where he filled the plane's tank with water and the fire area where he threw water bombs. After the first two flights, the 40O-EAC aircraft was joined by another "air tractor" of the Air Helicopter Unit of the Ministry of Internal Affairs, registration XNUMXO-EAD, so that in the next little more than an hour, the two aircraft, with coordinated efforts, were almost completely put out the cotton wool. During the penultimate planned rotation, an incident occurred when the XNUMX-EAC's left wing tip hit the tip of the third and until then unnoticed by the pilot power line pole above the fire area, causing the aircraft to nearly crash.
"After jettisoning the water, the crew starts to climb and in a slight left bank of 15-20°, registers an impact with the left wing, after which the aircraft goes into a sudden uncontrolled tilt to the left and down, with a tendency to roll onto its back. The crew managed to prevent this with the utmost effort, on which occasion they found damage to the left wing, with the wing tip being separated in a length of about 90 cm (terminus assembly with leading edge plating). After the separation (falling off) of the tip of the left wing, the crew, with the help of foot controls and manipulation of the engine power, manages to establish control over the aircraft, with further very difficult control and multiple increased resistance in moving the flight controls, declares "Emergency" and directs the aircraft towards Podgorica airport . With continuous difficult control, she brought the aircraft to the approach plane for runway "18", where she asked and received confirmation from flight control that the landing gear of the aircraft was working undamaged, after which she landed at 17.49:XNUMX p.m. local time," reads the description of this of an event officially classified by KINNS as a “serious accident”.
The experience and skill of the pilot prevented the tragedy, so the "air tractor" safely landed at the Podgorica airport, where heavy damage was noted on the plane: the tip of the left wing was torn off in a length of about 90 centimeters (the terminus assembly with the leading edge plating), and there was and to damage to the main spar, trailing spar, wing trailing edge, ribs, flap and flap-wing mechanical connection. All this is measured at several hundred thousand euros, and the damaged "air tractor" has not been in use since then and does not fly because its repair has not been completed to this day.
Investigating this incident in detail KINNS, or investigator Vladislav Vlahović who led this case, concluded that the accident was decisively caused by a human factor, i.e. pilot error, but several other factors contributed to its occurrence to a greater or lesser extent, including partially reduced visibility due to smoke and dust above the fire area and the rays of the sun that was already quite low on the horizon, a properly unmarked transmission line, non-compliance with the operational manual in flying aircraft in firefighting operations, and numerous other failures in the organization and way of management and work in the AHJ MUP as the operator of this aircraft. Most of these last two factors, which, according to the assessment of the investigator Vlahović, contributed to this accident, are almost identical to those that manifested themselves in the work and management of the AHJ, only half a year earlier - on December 22, 2020, when another "serious accidents" of the second "air tractor" of the Cvnogorsk MUP engaged in firefighting in Sutomore.
On that occasion, the plane is in the phase of releasing the so-called water bombs on the fire, hit the top of a tree and sustained damage to the propeller and right wing. Pilot Miloš Asanović nevertheless managed to land the plane safely at the airport in Podgorica, and the chief investigator and head of KINNS Darko Chonc later investigation of this incident noted major failures in the way of work and management of AHJ, which is why Čonč recommended to the Agency for Civil Aviation an increased inspection of that aircraft operator.
However, in spite of these findings and recommendations of KINNS, just half a year later, a new incident occurred in the Ber area, where, as can be seen from the report of KINNS and the findings of investigator Vlahović, almost nothing had changed for the better in the meantime. previously observed deficiencies and shortcomings in the work of the AHJ. This is evidenced by the identical deficiencies noted in both cases: non-compliance with the operational manual, lack of complete pilot equipment for emergency situations, lack of adequate topographic maps of the area over which aerial fire-fighting operations are carried out, poor or non-existent preparation of flight operations, lack of coordination between aircraft and firefighters on country, lack of reconnaissance of the area of operations before sending the firefighting aircraft, insufficient training of pilots, poor or non-existent records of pilot preparations for carrying out specific tasks, absence of a search and rescue service on standby during firefighting from the air, but also actions after an accident, contrary to what should to respect until the arrival of the investigator on the scene. Thus, the AHJ of the plane pilot who had an accident on June 22, 2021, as stated by KINNS, did not refer immediately after landing to an "urgent medical examination, with a breathalyzer or a test for the presence of psychoactive substances, which should be a mandatory procedure in similar situations, without despite the fact that it was a person who is not inclined to consume alcohol or psychoactive substances", and on the plane that suffered an accident, the AJH technical service did not seal the cockpit after landing at the airport before the arrival of KINNS investigators.
"The factor that had a key impact on the event (The Root Cause) was an inadequate assessment of the conditions in the area affected by the fire and the minimum safety height that the aircraft should have had, in relation to all the natural and artificial obstacles that existed in the area of the fire. The commission found clear and unequivocal indicators and evidence of the absence or deviation from certain procedures in the preparation, organization, control, analysis and execution of flight training, as well as preparation for flying and the execution of flight operations for firefighting, which it categorized as contributory factors in the occurrence of the accident in question ”, according to the KINNS report.
As factors that contributed to the accident, "the practice in the AHJ that during the fire extinguishing operation, the previous run is not carried out along the path along which the water will be rejected, as prescribed by the Operational Manual"; the decision to assign the task to a pilot who was already working full-time, although during the shift he was not engaged in flight operations, due to a possible drop in concentration and insufficient time available for flight preparation and organization; lack of technical and operational capacities and procedures; that the crews participating in the flight operations for extinguishing the fire cannot establish contact with the firefighting units on the ground and in this way get to know the state of the fire even in the phase of arrival towards it (estimated direction and speed of the wind, direction of extension of possible high-voltage electric lines and other artificial obstacles, the possible existence of personnel who put out fires from the ground in the area of the fire, etc.; the absence of a systematized position of manager for the management of the security system in air operations (SMS Manager) in the AHJ of the MUP of Montenegro; the absence of a systematized duty of an air dispatcher in the AHJ, whose the main task would be the preparation and organization of emergency and emergency flight operations, as well as the improvement of the conditions for the implementation of quality preparations and training for the implementation of emergency flight operations in units, and "the absence of a procedure prescribed by the procedure, established with the aim of assessing the expediency of using fire-fighting aircraft in to each specific case".
In the report, among other things, it is stated that KINNS established that "during the critical flight, the operator (AHJ, prim-aut.) did not activate SAR (Search and Rescue Service) in terms of readiness at the airport, although the unit in its composition has capacities and possibilities for it", and that SAR in readiness for action is something that would have to accompany firefighting operations using aircraft given the high degree of security risks that characterizes firefighting flying. It was also established that "the pilots in the unit do not have large scale topographic maps, 1:200.000 scale aeronautical maps, or navigation kits for carrying out navigational flight preparation".
All preparatory actions and other calculations that should be performed before the flight are not recorded, so there is no possibility of checking that these actions and calculations were actually implemented. Without such records, the control function cannot be performed to the required extent, or it is performed to the extent that it does not provide full insight into the state of training, preparedness for the task and the manner of performing flight operations, which may impair the safety of their performance. During the investigation, the Commission found that the crews of this operator had an insufficient degree of knowledge of certain provisions of the operational manual (OM) regarding the operations they perform, and also during the preparation for the flight there were deviations from the procedures and provisions of the OM, in the part that refers to fire-fighting operations, the required training run and personal protective equipment, which is mandatory to use, regardless of the conditions in which the flight operation is carried out," the report states, noting that the management of the AHJ pilot of the plane that experienced the accident instructed to extinguish although since September 2020 he had a break in flight operations for more than seven months. Namely, he "returned to training" only at the beginning of June 2021, but at the same time, as stated by KINNS, he did not have the so-called prescribed by the rules. a flight check that would verify that he really managed to fully restore all skills after such a long break in flying. Likewise, KINNS stated that the pilot was sent to the task of extinguishing the fire in Beri, although "he had not flown in a fire extinguishing operation in the last 6 months, before this accident".
KINNS established that the fire in Beri on June 22, 2021 "was not of a scale or degree of danger that, at the time of its extinguishing from the air and the occurrence of the accident, threatened any significant assets, especially not higher-quality forest cover, or houses and other objects of importance for the life of the population or the economy", and that it should not have been extinguished by airplanes at all, which once again pointed to the extremely poor coordination between the firefighters on the ground and the Directorate for Protection and Rescue of the Ministry of Interior, which approves the use of firefighting airplanes.
Based on the conclusions of the investigation, KINNS sent 12 safety recommendations to the Ministry of Interior, the Protection and Rescue Directorate and the Helicopter Unit, while three recommendations were sent to the Civil Aviation Agency.
Although KINNS, in its reports on investigations of MUP aircraft, constantly points to system failures and poor conditions in the AHJ, which is part of the Directorate for Protection and Rescue, the Government of Montenegro has so far taken no action to put this unit in order, which currently does not have a single of its total seven aircraft (three planes and four helicopters) in operational condition. Last year, almost all tasks of the AHJ, including firefighting from the air, were therefore performed by helicopters of the Air Force of the Army of Montenegro.
Although the Air Force previously presented to the leaders of the Ministry of Defense and the Government a project for additional equipment for that branch of the army and its takeover of firefighting aircraft from the Ministry of Interior, which would concentrate all available state potential for air transport, combat, and civilian operations in one place, which would significantly increased its efficiency and reduced costs to the state, the Government did not react to it. On the contrary, recently the Prime Minister's office Dritan Abazović adopted the "Information on the need to procure medium-sized multi-purpose helicopters" for such a dysfunctional and problematic AHJ, according to which this unit, which for years has not been able to respond to its tasks and in which accidents of its aircraft are frequent, will buy two new or used helicopters worth 16 to 36 million euros , and most likely of a different type compared to those that were already procured for the Air Force of the Republic of Croatia in previous years.
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