Accident
Last updated: 23 December 2014
Status:Schlussbericht
Datum:Mittwoch 27 Oktober 1993
Zeit:19:16
Flugzeugtyp:Silhouette image of generic DHC6 model; specific model in this crash may look slightly different
de Havilland Canada DHC-6 Twin Otter 300
Fluggesellschaft:Widerøes Flyveselskap
Kennzeichen: LN-BNM
Werknummer: 408
Baujahr: 1974
Betriebsstunden:40453
Triebwerk: 2 Pratt & Whitney Canada PT6A-27
Besatzung:Todesopfer: 2 / Insassen: 2
Fluggäste:Todesopfer: 4 / Insassen: 17
Gesamt:Todesopfer: 6 / Insassen: 19
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:6 km (3.8 Meilen) ENE of Namsos Airport (OSY) (   Norwegen) show on map
Flugphase: Annäherung (APR)
Betriebsart:Inländischer planmäßiger Passagierflug
Flug von:Trondheim-Værnes Airport (TRD/ENVA), Norwegen
Flug nach:Namsos Airport (OSY/ENNM), Norwegen
Flugnummer: 744
Unfallbericht:
The Twin Otter descended below minima during a localizer approach without glide path and struck the ground.

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.

Informationsquelle:
» ICAO Adrep Summary 4/94 (#268)
» Scramble 174

Official accident investigation report
investigating agency: Havarikommisjonen for sivil luftfart (HSL) - Norway
report status: Final
report number: RAP.: 07/96
download report: Rapport om luftfartsulykke ved Namsos den 27. oktober 1993 med DHC-6-300 Twin Otter, LN-BNM (HSL RAP.: 07/96)

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Trondheim-Værnes Airport to Namsos Airport as the crow flies is 116 km (72 miles).

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