The findings and conclusions of the final report of the expert investigation team established following the Swallow plane crash were presented last night (Tuesday) to the Commander of the Air Force, Major General Amikam Norkin.
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In the accident, which occurred on November 24, 2020, the flight instructor, Major (res.) Itai Zeidan, and the pilot, Corporal Lihu Ben-Besse, were killed. The bereaved families were informed of the findings of the final report. The team of experts, led by Brigadier General A., presented the Air Force Commander with the findings and conclusions of the final report, which indicate that the accident was most likely caused by an uncontrolled flight situation due to a stall, while turning, at a low altitude, from which the crew could not - or did not have time - to escape before hitting the ground. A stall is a condition of disruption of normal airflow to the aircraft's wing, in a way that affects the aircraft's lift and may cause a roll and loss of altitude. The expert investigation team determined that lack of familiarity with the risk of loss of control during a high-altitude flight, when the Swallow aircraft stalled, was not identified during the aircraft's acceptance into the Air Force and during its years of service in the force, and as a result, the squadron's aircrews were not familiar with it and were not trained to deal with the risk. In addition, there was a lack of information in the aircraft manufacturer's literature regarding the stalling phenomenon that the crew experienced on this flight. The investigation team noted that from checking with other operators of the aircraft around the world, this risk was not known. The investigation team also presented that low-altitude flights had been carried out for many years in the squadron and were perceived as necessary for screening and training purposes. The lack of familiarity with the phenomenon that was discovered led to a low risk assessment in performing the exercise. The findings indicate that the accident was very likely not due to a technical problem and the aircraft was usable throughout the flight. As part of the investigation, the maintenance aspect of the Snunit company was investigated, jointly with the chief investigator of the Ministry of Transportation, who examined the quality of maintenance and compliance with the required maintenance activities, and his impression was that the level of maintenance was high. The Snunit aircraft is considered a reliable and safe aircraft that has been used by the flight school for nearly 20 years for screening and training purposes, and dozens of air crews have been trained on it over the years. A screening squadron is a unique squadron whose main mission is to perform quality screening during the "preparatory" stage of the flight course, by skilled and experienced air crews. The investigation team revealed that it is necessary to make changes to the squadron's routine and manner of conduct in order to better utilize the extensive experience and professionalism that exists among its personnel. The Air Force Commander accepted the findings of the final report, and determined that the direct cause of the accident most likely lies in a phenomenon that was not recognized in the world or in the Air Force during the aircraft's approximately twenty years of service in it, and directed the execution of a number of actions, including: examining and implementing risk management that will allow for appropriate safety margins in flying students at the flight school, adapting the organizational structure of the training squadron to the needs of the squadron and its challenges, updating military literature and squadron literature, and training air crews to learn and understand the phenomenon that was discovered. He also directed that the various operators around the world be informed of the results of the investigation. Air Force Commander, Major General Amikam Norkin added: "The expert investigation team turned over every stone and carried out a thorough and complex investigation in order to arrive at the cause that most likely caused the serious accident. For the purpose of this investigation, we conducted several test flights in Israel and abroad, on a 'Swanut' aircraft, the purpose of which was to prove the aerodynamic phenomenon that was discovered. Every accident is preventable and the lessons from this accident will be learned in the army. I feel the pain of the dear Zeidan and Ben-Bassa families and we will continue to accompany them along the way.".