Narrative:
Flight EXC 204 departed Bergen at 17:40 and the following climb to FL150 was normal. The first officer was pilot flying on the flight to Skien. A descent for an LLZ/DME (non-precision) approach to runway 19 at Skien was initiated. During the descent through the clouds down to Geiteryggen, some ice formed on the wings. This was noted by the captain at 15 DME. At a distance of 8 DME, while descending through about 3050 feet, the Ground Proximity Warning System (GWPS) sounded and warned: "Terrain... terrain. Pull up ... pull up." The captain told the first officer: "Just easy, easy, easy ... easy that is all right" and warned him not to descend too fast. The same thing happened at 7 DME and also at 6 DME when the plane was about 100 feet too low in relation to the approach procedure. The first officer began to climb and the captain now shouted: "Are you climbing? You are going to 2,200 ft Sir. Dont start to f.... it up again now (first officers name)." As a result of the climb, the aircraft passed the locator Myra (MR) at an altitude of 2,800 ft, around 600 ft too high, and the descent to D3 was steep. The tone in the cockpit was strained and the Commander began to give orders to the first officer. With three miles to go the gear was selected down but the captain expressed his doubts: "We never gonna make this... Come on, go down, go down. Stay on the localizer, stay on
the localizer." The aircraft maintained an indicated speed of approx. 110-115 kt when the aircraft encountered an abnormally high sink rate and hit the runway at 6g. The landing led to permanent deformation of the left wing on the forward wing beam. As a result of this deformation, the left landing gear leg was bent backwards, with the engine and propeller pointing obliquely downwards. The left propeller touched the runway and the crew lost directional control so the aircraft skewed out to the left and left the runway. It continued, skidding in an arc to the left, crossed a taxiway twice and hit a gravel bank with great force. The gravel bank was hit by the nose of the aircraft and the left propeller at an assumed angle of 45° in the horizontal plane. The aircraft continued up the gravel bank in a virtually horizontal attitude while the tail was thrown out to the right. Then the aircraft fell so that it was resting on its tail and main wheels with the nose up on the gravel bank.
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 companys operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The companys quality system contributed little to ensuring Safe Operational Practices in the company.
h) Authority inspection of the company was deficient.
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
| Status: | Accident investigation report completed and information captured |
| Date: | Friday 30 November 2001 |
| Time: | 18:28 |
| Type: |  British Aerospace 3101 Jetstream 31 |
| Operator: | European Executive Express |
| Registration: | SE-LGA |
| MSN: | 636 |
| First flight: | 1984 |
| Total airframe hrs: | 14074 |
| Cycles: | 16666 |
| Engines: | 2 Garrett TPE331-10UF |
| Crew: | Fatalities: 0 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 11 |
| Total: | Fatalities: 0 / Occupants: 13 |
| Aircraft damage: | Damaged beyond repair |
| Location: | Skien Airport (SKE) ( Norway)
|
| Phase: | Landing (LDG) |
| Nature: | Domestic Scheduled Passenger |
| Departure airport: | Bergen-Flesland Airport (BGO/ENBR), Norway |
| Skien Airport (SKE/ENSN), Norway | |
| Flightnumber: | 204 |
Flight EXC 204 departed Bergen at 17:40 and the following climb to FL150 was normal. The first officer was pilot flying on the flight to Skien. A descent for an LLZ/DME (non-precision) approach to runway 19 at Skien was initiated. During the descent through the clouds down to Geiteryggen, some ice formed on the wings. This was noted by the captain at 15 DME. At a distance of 8 DME, while descending through about 3050 feet, the Ground Proximity Warning System (GWPS) sounded and warned: "Terrain... terrain. Pull up ... pull up." The captain told the first officer: "Just easy, easy, easy ... easy that is all right" and warned him not to descend too fast. The same thing happened at 7 DME and also at 6 DME when the plane was about 100 feet too low in relation to the approach procedure. The first officer began to climb and the captain now shouted: "Are you climbing? You are going to 2,200 ft Sir. Dont start to f.... it up again now (first officers name)." As a result of the climb, the aircraft passed the locator Myra (MR) at an altitude of 2,800 ft, around 600 ft too high, and the descent to D3 was steep. The tone in the cockpit was strained and the Commander began to give orders to the first officer. With three miles to go the gear was selected down but the captain expressed his doubts: "We never gonna make this... Come on, go down, go down. Stay on the localizer, stay on
the localizer." The aircraft maintained an indicated speed of approx. 110-115 kt when the aircraft encountered an abnormally high sink rate and hit the runway at 6g. The landing led to permanent deformation of the left wing on the forward wing beam. As a result of this deformation, the left landing gear leg was bent backwards, with the engine and propeller pointing obliquely downwards. The left propeller touched the runway and the crew lost directional control so the aircraft skewed out to the left and left the runway. It continued, skidding in an arc to the left, crossed a taxiway twice and hit a gravel bank with great force. The gravel bank was hit by the nose of the aircraft and the left propeller at an assumed angle of 45° in the horizontal plane. The aircraft continued up the gravel bank in a virtually horizontal attitude while the tail was thrown out to the right. Then the aircraft fell so that it was resting on its tail and main wheels with the nose up on the gravel bank.
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 companys operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The companys quality system contributed little to ensuring Safe Operational Practices in the company.
h) Authority inspection of the company was deficient.
Accident investigation:
 |
|
Classification:
Runway excursion
Sources:
» SKYbrary Follow-up / safety actions
AIBN issued 7 Safety Recommendations
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Photos
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
accident date: 30-11-2001
type: BAe 3101 Jetstream 31
registration: SE-LGA
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 Bergen-Flesland Airport to Skien Airport as the crow flies is 271 km (169 miles).
Accident location: Exact; as reported in the official accident report.
Distance from Bergen-Flesland Airport to Skien Airport as the crow flies is 271 km (169 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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