ASN Wikibase Occurrence # 325144
Date: | Wednesday 27 October 1993 |
Time: | 19:16 |
Type: | de Havilland Canada DHC-6 Twin Otter 300 |
Owner/operator: | Widerøes Flyveselskap |
Registration: | LN-BNM |
MSN: | 408 |
Year of manufacture: | 1974 |
Total airframe hrs: | 40453 hours |
Engine model: | Pratt & Whitney Canada PT6A-27 |
Fatalities: | Fatalities: 6 / Occupants: 19 |
Aircraft damage: | Destroyed, written off |
Category: | Accident |
Location: | 6 km ENE of Namsos Airport (OSY) -
Norway
|
Phase: | Approach |
Nature: | Passenger - Scheduled |
Departure airport: | Trondheim-Værnes Airport (TRD/ENVA) |
Destination airport: | Namsos Airport (OSY/ENNM) |
Investigating agency: | HSL |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:Widerøes Flyveselskap flight 744 was a domestic flight from Trondheim to Namsos and Rørvik in Norway.
The DHC-6 Twin Otter departed Trondheim at 18:37 with two pilots and 17 passengers on board. The captain was Pilot Flying.
The plane climbed to an altitude of 5000 ft and at 18:53 the flight contacted Namsos AFIS to obtain weather information.
The flight was approaching the Namsos NDB from the south and reported "Namsos beacon outbound" at 19:07. A teardrop pattern was flown in order to align with the approach track for runway 26.
The AFIS operator then gave a new update on the weather and said: "744, a heavy rainstorm, but the visibility seems to be good".
At 19:10:30 the plane approached the center line of the approach and the copilot said "Localizer alive".
At 19:14:01 the copilot said that they were at 2100 ft with 1100 ft as the next altitude. The descent was continued. The Namsos NDB was passed at 19:15:13. At that point the aircraft should have been at 2100 feet, but it had already descended below that altitude.
At 19:16:48 the plane hit a ridge about 6 km from the airport and crashed.
Significant findings (translated from Norwegian):
The Commission has considered the following findings as particularly important as these factors had a direct or indirect effect on the incident.
a) The circumstances of this aviation accident coincided with a "Controlled Flight Into Terrain". The investigation has shown that the aircraft could be operated normally and was apparently under the control of the crew during the approach;
b) The company had failed to implement a standardized concept of aircraft operation that the pilots fully respected and lived by;
c) The approach briefing was not not fully implemented in accordance with the rules. There were deficiencies in:
- "Call outs" during the approach
- Descent rate (ft/min) during "FAF inbound"
- Timing "outbound" from the IAF and the time from FAF to MAPt;
d) The crew did not execute the "base turn" at the scheduled time, with the consequence that the plane ended up about 14 NM from the airport;
e) The Pilot Flying ended the approach with reference to aircraft instruments and continued on a visual approach in the dark without visual reference to the underlying terrain. During this part of the approach the aircraft's position was not positively checked using any available navigational aids;
f) Both crew members had in all likelihood most of the attention out of the cockpit at the airport after the Pilot Not Flying announced that he had it in sight;
g) The crew was never aware of how close they were the underlying terrain;
h) The last part of the descent from about 500 ft indicated altitude to 392 ft can be caused by inattention to the fact that the plane may have been a little out of trim after the descent;
i) Crew Cooperation during the approach was not in accordance with with the CRM concept and seems to have ceased completely after the Pilot Not Flying called "field in sight";
j) Before the accident the company had not succeeded well enough with the introduction of standardization and internal control/quality assurance. This was essentially because the management had not placed enough emphasis on awareness and motivate employees;
k) The self-control system described in the airline operations manual and the parts of the quality system, was not incorporated in the organization and served as poor safety governing elements;
l) Neither the Norwegian CAA nor the company had defined what visual reference to terrain is, what sufficient visual references are and what the references must be in relation to a moving aircraft.
Accident investigation:
|
| |
Investigating agency: | HSL |
Report number: | RAP.: 07/96 |
Status: | Investigation completed |
Duration: | 2 years and 7 months |
Download report: | Final report |
|
Sources:
ICAO Adrep Summary 4/94 (#268)
Scramble 174
Location
Images:
photo (c) AIBN, remastered by Quin; near Namsos Airport (OSY); 27 October 1993
Revision history:
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