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 Beechcraft C90 King Air in Skien: 10 killed

Date & Time: Apr 2, 1987 at 1736 LT
Type of aircraft:
Operator:
Registration:
LN-KCR
Survivors:
No
Schedule:
Munich - Hanover - Skien - Oslo
MSN:
LJ-793
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1858
Captain / Total hours on type:
331.00
Aircraft flight hours:
3617
Circumstances:
Following an uneventful flight from Hanover, the pilot started the approach to Skien-Geiteryggen Airport in marginal weather conditions. After crossing the last cloud layer, the twin engine was approaching runway 01 when, at an altitude of 100 feet, the aircraft banked right to an angle of 60° then nosed down and crashed few km from the runway threshold, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all 10 occupants were killed.
Probable cause:
Due to the total destruction of the aircraft by impact forces and fire, the exact cause of the accident could not be determined with certainty. However, it is believed that icing conditions encountered from 3,000 to 5,000 feet may have affected the aircraft stability and controllability and thus, may be considered as a contributing factor.
Final Report:

Crash of a Cessna 441 Conquest II in Skien: 1 killed

Date & Time: Oct 11, 1985 at 1150 LT
Type of aircraft:
Operator:
Registration:
LN-VIP
Flight Type:
Survivors:
No
Schedule:
Oslo - Skien
MSN:
441-0279
YOM:
1983
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6969
Captain / Total hours on type:
232.00
Aircraft flight hours:
1145
Circumstances:
The pilot, sole on board, departed Oslo-Fornebu Airport on a 20 minutes flight to Skien where the aircraft should be inspected by customs before the pilot would continue to Finland where 9 passengers should be embarked for a on-demand taxi flight. Following an uneventful flight at an altitude of 6,000 feet, the pilot started the descent in good weather conditions, passed 4,000 feet and then was cleared for an approach to runway 19. On short final, at a distance of 700 meters from the runway threshold, the twin engine aircraft initiated a right turn then continued via heading 325° when it lost altitude and crashed in the Meierelva River. The wreckage was found partially submerged on the shore of the river, about 1,500 meters northwest of runway 19 threshold. The aircraft was destroyed and the pilot was killed.
Probable cause:
At the time of the accident, weather conditions were good and the aircraft was correctly configured for a VFR approach, gear and flaps down. Investigations were unable to determine the exact cause of the accident.
Final Report: