Crash of a Swearingen SA226T Merlin IIIB off Bergen: 3 killed

Date & Time: Jun 20, 2008 at 1026 LT
Type of aircraft:
Operator:
Registration:
LN-SFT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bergen - Bergen
MSN:
T-342
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15750
Captain / Total hours on type:
12000.00
Copilot / Total flying hours:
6310
Aircraft flight hours:
13551
Aircraft flight cycles:
5732
Circumstances:
The flight was a skill-test for a candidate that was hired as a first officer on SA226-T(B) Merlins for the operator Helitrans. He was one of two candidates that were employed by the company in early 2008. They underwent ground school and flight training in cooperation with the Swedish Type Rating Training Organisation (TRTO) Trafikkhögskolan. Later it became clear that the Swedish Civil Aviation Authority (CAA) did not accept skill-tests limited to first officer duties on a single pilot certified airplane, as the Norwegian CAA did. The candidates did not possess the skills to act as commanders on the Merlin, and there was a period of uncertainty while the operator and the Norwegian CAA discussed how to conduct the skill-tests, in particular whether to use a simulator or an actual airplane. After several months the issues were resolved and an examiner was appointed. There was a limited slot on a Thursday and a Friday where the examiner, the instructor/commander and the aircraft was available at Bergen Airport Flesland. The first candidate performed the skill-test on Thursday. The weather was not suited for flying skill tests. It was low ceiling, rain showers and winds up to 40 kt and turbulence. Turbulence caused the stick pusher to activate during the demonstration of slow flight. The commander decided to pull the circuit breaker for the Stall Avoidance and Stability Augmentation System (SAS) presumably to avoid nuisance activations of the stick pusher. After the slow flight demonstration, the examiner asked the candidate to demonstrate a stall. The candidate found this exercise frightening as she experienced great difficulties, having to use all her available physical strength to regain normal flight with the engines on full power and in IMC conditions. The weather was similar on Friday with even stronger winds. The SAS circuit breaker was not reset. This was confirmed during the start-up check. The examiner requested a similar program during this skill-test as he did the day before. However, when it came to demonstrating stalls, the examiner asked for a slow flight up to first indication of stall, and not an actual stall. He asked for call outs and a minimum loss of altitude recovery. The commander undertook the tasks of adding power and retracting gear and flaps on the candidate’s request. It was IMC. During this exercise the crew lost control of attitude and airspeed. The stall warning came on, but the airspeed decreased, even with full power applied. Radar data show that the altitude increased 200 – 400 ft during the period where control was lost. Airspeed decreased to about 30 kt and a sink rate of about 10 000 ft/min eventually developed. The airplane hit the sea in a near horizontal attitude about 37 sec. after control was lost. All three on board were fatally injured. The accident aircraft was used for coastguards duties and was modified with external sensors and antennas. The AIBN made a Computational Fluid Dynamics analysis in order to determine whether these installations influenced on stability and flight characteristics in the slow flight and pre-stall regime. It was found that the modifications reduced the overall performance, but did not result in any significant degradation of stability and control in this regime. There was no investigation as to any influence on the characteristics of a fully developed stall. The AIBN is of the opinion that this accident highlights the need for a change in the current training on initial stall recovery techniques, especially the focus on minimum loss of altitude at the expense of breaking the stall by lowering the nose and thus reducing the angle of attack. The AIBN has issued two safety recommendations to the Norwegian CAA; one regarding the conduct of skill-tests for pilots in a multi crew concept on single pilot airplanes, and one suggesting increased focus on flight examiners tasks.
Probable cause:
The following findings were identified:
- Even if the weather on the day of the accident was within the permitted limits, it was not suitable to perform 'airwork' or training exercises,
- The captain thought the weather was not suitable for conducting the skill test for the second candidate. That he nevertheless agreed to take the test may be due to the fact that he felt
a pressure to complete the mission,
- The flight was conducted in challenging conditions and there is reason to believe that atmospheric turbulences may have contributed to the loss of control during the skill flight,
- The flight was completed in clouds, and it can be assumed that the lack of visual references in the clouds contributed to the loss of control.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Skien

Date & Time: Nov 30, 2001 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LGA
Survivors:
Yes
Schedule:
Bergen - Skien
MSN:
636
YOM:
1984
Flight number:
EXC204
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6590
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
390
Aircraft flight hours:
14074
Aircraft flight cycles:
16666
Circumstances:
The aircraft was on its way to Skien with a crew of two and 11 passengers. During the flight, ice was observed on the aircraft’s wings, but the ice was considered to be too thin to be removed. During descent towards runway 19 at Geiteryggen the aircraft’s ground proximity warning system (GPWS) sounded a total of three times. The aircraft was then in clouds and the crew did not have visual contact with the ground. The warnings, combined with somewhat poorly functioning crew coordination, resulted in the crew forgetting to actuate the system for removing ice from the wings. The subsequent landing at 1828 hrs was unusually hard, and several of the passengers thought that the aircraft fell the last few metres onto the runway. The hard landing caused permanent deformation of the left wing so that the left-hand landing gear was knocked out of position, and the left propeller grounded on the runway. The crew lost directional control and the aircraft skewed to the left and ran off the runway. The aircraft then hit a gravel bank 371 metres from the touchdown point. The collision with the gravel bank was so hard that the crew and several of the passengers were injured and the aircraft was a total loss. It was dark, light rain and 4 °C at Geiteryggen when the accident occurred. The wind was stated to be 120° 10 kt. The investigation shows that it is probable that ice on the wings was the initiating factor for the accident. The AIBN has not formed an opinion on whether the ice resulted in the high sink rate after the first officer reduced the power output of the engines, or whether the aircraft stalled before it hit the runway. Investigation has to a large extend focused on the crew composition and training. A systematic investigation of the organisation has also taken place. In the opinion of the AIBN, the company has principally based its operations on minimum standards, and this has resulted in a number of weaknesses in organisation, procedures and quality assurance. These conditions have indirectly led to the company operating the route Skien – Bergen with a crew that, at times, did not maintain the standard that is expected for scheduled passenger flights. The investigation has also revealed that procedures for de-icing of the aircraft wings could be improved.
Probable cause:
Significant investigation results:
a) The decision was made to wait to remove the ice from the wings because, according to the SOP, it should only be removed if it had been “typically half an inch on the leading edge”. This postponement was a contributory factor in the ice being forgotten.
b) At times, the relationship between the flight crew members was very tense during the approach to Skien. This led to a breakdown in crew coordination.
c) Among the consequences of the warnings from the GPWS was a very high workload for the crew. In combination with the defective crew coordination, this contributed to the ice on the wings being forgotten.
d) It is probable that the aircraft hit the runway with great force because the wings were contaminated with ice. The AIBN is not forming a final opinion on whether the wings stalled, whether the aircraft developed a high sink rate due to ice accretion or whether the hard landing was due to a combination of the two explanatory models.
e) The company could only provide documentary evidence to show that the Commander had attended an absolute minimum of training after being employed within the company. Parts of the mandatory training had taken place by means of self-study without any form of formal verification of achievement of results.
f) The company’s operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The company’s quality system contributed little to ensuring ‘Safe Operational Practices’ in the company.
h) Authority inspection of the company was deficient.
Final Report:

Crash of a Cessna 208B Caravan I in Oslo: 1 killed

Date & Time: Dec 4, 1994 at 0502 LT
Type of aircraft:
Operator:
Registration:
LN-PBC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oslo - Bergen
MSN:
208B-0310
YOM:
1992
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1676
Captain / Total hours on type:
327.00
Aircraft flight hours:
2193
Circumstances:
The aircraft was completing a cargo flight to Bergen, carrying one pilot and 1,389 kilos of newspapers. Following a night takeoff from runway 19, while climbing in poor weather conditions at an altitude of about 390 metres, the single engine aircraft stalled and crashed in a wooded area located 1,5 km from the airport. The pilot, sole on board, was killed.
Probable cause:
The accident was the consequence of a stall during initial climb to an excessive accumulation of ice on wings and tail as the aircraft had not been deiced prior to departure. The following contributing factors were reported:
- The plane was outdoors for an estimated time of 20 minutes under conditions in which ice could adhere on the surface of the plane's hull, wings and tail surfaces.
- The plane was not de-iced by the pilot prior to departure.
- The company had not developed adequate written instructions for de-icing. The company had no written instructions to prevent icing during ground stay.
- The company had no sufficient equipment available, or added conditions sufficiently organized so that icin accretion be prevented or removed before departure from Gardermoen.
- The plane took off with ice on the surface of the wings and tail surfaces
- Ice on the surface of the wings and tail surfaces reduced flight characteristics in such a degree that the pilot did not manage to gain height after departure and therefore crashed.
Final Report:

Crash of a Beechcraft 200 Super King Air in Dagali: 3 killed

Date & Time: Mar 19, 1993 at 2002 LT
Operator:
Registration:
LN-TSA
Survivors:
Yes
Schedule:
Bergen - Dagali
MSN:
BB-308
YOM:
1978
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5058
Captain / Total hours on type:
1330.00
Copilot / Total flying hours:
686
Copilot / Total hours on type:
11
Aircraft flight hours:
4032
Aircraft flight cycles:
4787
Circumstances:
The twin engine aircraft was performing an on-demand taxi flight from Bergen to Dagali, carrying eight passengers and two pilots. The descent to Dagali Airport was completed visually by night and poor weather conditions with clouds down to 1,200 feet and a visibility near minima. On final approach, the crew failed to realize his altitude was too low when the aircraft crashed in a hilly and snowy terrain located 5 km short of runway 26. Both pilots and a passenger were killed while seven other occupants were injured.
Probable cause:
The crew failed to adhere to the published procedures and continued a visual approach in difficult conditions. The following contributing factors were reported:
- Poor weather conditions and limited visibility,
- The captain was also General Manager, Operations Manager, Instructor, flight manager and member of the board of the operator. Thus, he was reporting to himself in case of any safety issue,
- The crew was not sufficiently trained,
- Lack of crew coordination during the final stage of the flight.
Final Report:

Crash of a Bristol 142 Blenheim IV off Bergen: 3 killed

Date & Time: May 16, 1941
Type of aircraft:
Operator:
Registration:
T2118
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lossiemouth - Lossiemouth
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane departed RAF Lossiemouth at 1430LT on an anti-shipping mission. Approaching the Norwegian coast, it was shot down by enemy fire and crashed into the sea off Bergen. All three crew members were killed.
Crew:
P/O Richard Alban Richards, pilot,
Sgt Arthur Charles North, observer,
Sgt Ernest Edmund Farrow Snutch, wireless operator.
Probable cause:
Shot down by enemy fire.

Crash of a Bristol 142 Blenheim IV off Bergen: 1 killed

Date & Time: Jul 6, 1940 at 1000 LT
Type of aircraft:
Operator:
Registration:
L8842
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Sumburgh - Sumburgh
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The airplane departed Sumburgh Airport on a raid over Bergen. Approaching the Norwegian Coast, it was shot down by the pilot of a German fighter and crashed into the sea some 50 km west of Bergen. A crew member was killed and two others were rescued.
Crew:
Sgt Albert W. Tubbs, pilot,
Sgt Robert Alexander McVeigh, observer, †
Sgt Arthur C. Johnstone, wireless operator and air gunner.
Probable cause:
Shot down by a German fighter.

Crash of a Bristol 152 Beaufort I off Bergen: 4 killed

Date & Time: Jun 21, 1940 at 1630 LT
Type of aircraft:
Operator:
Registration:
L4501
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wick - Wick
MSN:
8362
YOM:
1940
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The airplane departed Wick at 1425LT to attack the German battleship 'Scharnhorst' and eight enemy destroyers which were in the coastal waters off Norway. While approaching Bergen, it was shot down by the pilot of a Me.109 and crashed into the sea. All four crew members were killed.
Crew:
P/O Marcel Adrian Philips, pilot,
P/O Alan George Rigg,
LAC Denholm Gow,
AC1 George Edward Tanner.
Probable cause:
Shot down by a German fighter.

Crash of a Bristol 152 Beaufort I off Bergen: 4 killed

Date & Time: Jun 21, 1940 at 1630 LT
Type of aircraft:
Operator:
Registration:
L4486
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wick - Wick
MSN:
8347
YOM:
1940
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The airplane departed Wick at 1425LT to attack the German battleship 'Scharnhorst' and eight enemy destroyers which were in the coastal waters off Norway. While approaching Bergen, it was shot down by the pilot of a Me.109 and crashed into the sea. All four crew members were killed.
Crew:
F/O Herbert J. Seagrim, pilot,
Sgt Francis J. Willoughby, pilot,
Sgt Colin A. Malcolm,
LAC John White.
Probable cause:
Shot down by a German fighter.

Crash of a Dornier DO.26AV2 off Ballangen

Date & Time: May 9, 1940 at 1710 LT
Type of aircraft:
Operator:
Registration:
P5+BH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bergen – Narvik
MSN:
792
YOM:
1938
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Bergen to Narvik, the float plane was attacked by three RAF Blackburn Skua. The captain attempted to ditch the airplane that crashed off Ballangen. All 23 occupants were rescued and became PoW. The aircraft was lost.
Crew:
Oblt Siegfried Graf Schack von Wittenau, pilot,
Hptm Joachim Fehling, observer,
Ofw Wilhelm Küpper, radio operator,
Uffz Herbert Peukert, chief,
Uffz Hans Brettschneider, chief.
Probable cause:
Shot down by RAF Skua.

Crash of a Bristol 142 Blenheim IV off Bergen: 3 killed

Date & Time: May 9, 1940
Type of aircraft:
Operator:
Registration:
L9482
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hatston - Hatston
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane departed RAF Hatston at 1620LT to bomb the harbor of Bergen. Approaching the target, the airplane was shot down by Flak and crashed in the harbor. All three crew members were killed.
Crew:
Lt Alick C. Heath, pilot,
Sgt Stanley A. Nicholls, observer,
Lt Robin B. Nuthall.
Probable cause:
Shot down by Flak.