Kommuneqarfik Sermersooq

Findings:
- The licenses and qualifications held by the flight crew, flight and duty times, the documented technical status of the aircraft and the aircraft mass and balance had no influence on the sequence of events
- The flight crew planned the flight from BGKK to BGGH with the destination alternate BGSF
- The latest BGGH TAF before departure from BGKK indicated marginal weather conditions (strong winds, low visibility and low cloud base) for a successful approach and landing at BGGH
- The forecasted weather conditions at the expected approach time at BGGH were below preplanning minima (use of two destination alternate aerodromes)
- The actual weather conditions at BGGH and enroute weather briefings were equivalent to the forecasted weather conditions
- With reference to the operator’s aerodrome and procedure briefing and the latest reported wind conditions from Nuuk AFIS before landing, a landing was prohibited
- Strong winds and moderate to severe orographic turbulence from the surrounding mountainous terrain increased the flight crew load
- On approach, the flight crew had difficulties of maintaining stabilized approach parameters
- The flight crew most likely suffered from task saturation and information overload
- No flight crew call outs on divergence from the operator’s stabilized approach policy were made
- An optimum crew resource management was not present
- Important low altitude stabilized approach parameters like airspeed, bank angle and runway alignment were not sufficiently corrected
- The flight crew was solely focused on landing and task saturation mentally blocked a decision of going around
- A divergence from the operator’s stabilized approach policy caused an unstabilized approach and a hard landing leading to an excess load of the right MLG at touchdown
- The right MLG fuse pin sheared as a result of overload
Factors:
- A divergence from the operator’s stabilized approach policy caused an unstabilized approach and a hard landing leading to an excess load of the right MLG at touchdown
- The right MLG fuse pin sheared as a result of stress
Summary:
Adverse wind and turbulence conditions at BGGH led to flight crew task saturation on final approach and a breakdown of optimum cockpit resource management (CRM) resulting in a divergence from the operator’s stabilized approach policy.
The divergence from the operator’s stabilized approach policy caused an unstabilized approach and a hard landing leading to an excess load of the right MLG at touchdown. According to its design, the right MLG fuse pin sheared as a result of stress.

The exact cause of the engine failure could not be determined. Except the fact that a hinge pin was missing in the injector air heating system, no technical malfunction was found. It was reported that the pilot was not certified to perform such flight and the passenger was not allowed to take part to such mission according to the provisional airworthiness certificate that was valid till the day of the occurrence. The possible presence of windshear on final approach was not ruled out and it was also reported that the approach was completed with a speed that was approximately 10 to 15 knots below the prescribed approach speed.

Controlled flight into terrain while attempting an approach below weather minimums. At the time of the accident, the aircraft was descending to an altitude of 1,700 feet while the minimum safe altitude for that area was 3,500 feet.

It is believed that the approach speed was too low, causing the airplane to stall during the last segment.

As a result of the technical investigation, it was considered most probable that, because of a mechanical malfunctioning the nose wheel doors were not closed and locked and that there was an aperture of 70 mm when the landing took place. The gaping doors were torn off when the aircraft having landed at rather high speed sank deeply into the water. The extremely great water pressure in the nose wheel well forced the aft bulkhead of the well inwards resulting in severe damage to the front cabin.