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Final Report RL 2017:10E Final report RL 2017:10e Serious incident after take-off from Gothenburg/Landvetter Airport on 7 November 2016 involving SE-DSV an aeroplane of the model AVRO-RJ 100, operated by Braathens Regional Aviation AB. File no. L-112/16 7 December 2017 RL 2017:10e SHK investigates accidents and incidents from a safety perspective. Its investigations are aimed at preventing a similar event from occurring in the future, or limiting the effects of such an event. The investigations do not deal with issues of guilt, blame or liability for damages. The report is also available on SHK´s web site: www.havkom.se ISSN 1400-5719 This document is a translation of the original Swedish report. In case of discrepancies between this translation and the Swedish original text, the Swedish text shall prevail in the interpretation of the report. Photos and graphics in this report are protected by copyright. Unless other- wise noted, SHK is the owner of the intellectual property rights. With the exception of the SHK logo, and photos and graphics to which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 2.5 Sweden license. This means that it is allowed to copy, distribute and adapt this publication provided that you attribute the work. The SHK preference is that you attribute this publication using the following wording: “Source: Swedish Accident Investigation Authority”. Where it is noted in the report that a third party holds copyright to photos, graphics or other material, that party’s consent is needed for reuse of the material. Cover photo no. 3 - © Anders Sjödén/Swedish Armed Forces. Postadress/Postal address Besöksadress/Visitors Telefon/Phone Fax/Facsimile E-post/E-mail Internet P.O. Box 6014 Sveavägen 151 +46 8 508 862 00 +46 8 508 862 90 [email protected] www.havkom.se SE-102 31 Stockholm Stockholm Sweden RL 2017:10ee Content General observations ...................................................................................................... 5 The investigation ............................................................................................................ 5 SUMMARY ....................................................................................................... 8 1. FACTUAL INFORMATION .......................................................................... 10 1.1 History of the flight .......................................................................................... 10 1.1.1 Preconditions ....................................................................................... 10 1.1.2 History of the flight ............................................................................. 11 1.1.3 Actions after landing ........................................................................... 13 1.1.4 The de-icing operation ......................................................................... 15 1.2 Injuries to persons ............................................................................................ 16 1.3 Damage to aircraft............................................................................................ 16 1.4 Other damage ................................................................................................... 16 1.4.1 Environmental impact.......................................................................... 16 1.5 Personnel information ...................................................................................... 16 1.5.1 Commander ......................................................................................... 16 1.5.2 Co-pilot ................................................................................................ 17 1.5.3 Duty schedule of the crew ................................................................... 17 1.5.4 Cabin crew ........................................................................................... 17 1.5.5 Other personnel ................................................................................... 17 1.6 Aircraft information ......................................................................................... 18 1.6.1 The aeroplane ...................................................................................... 19 1.6.2 Description of parts or systems related to the occurrence ................... 19 1.6.3 Details of the current aeroplane configuration .................................... 20 1.7 Meteorological information ............................................................................. 24 1.8 Aids to navigation ............................................................................................ 25 1.9 Communications .............................................................................................. 25 1.10 Aerodrome information ................................................................................... 25 1.11 Flight recorders ................................................................................................ 25 1.11.1 Flight Recorders (DFDR, QAR) .......................................................... 25 1.11.2 Cockpit Voice Recorder (CVR) .......................................................... 25 1.12 Site of occurrence ............................................................................................ 25 1.13 Medical and pathological information ............................................................. 26 1.14 Fire ................................................................................................................... 26 1.15 Survival aspects ............................................................................................... 26 1.15.1 Rescue operation ................................................................................. 26 1.16 Tests and research ............................................................................................ 26 1.17 Organisational and management information .................................................. 26 1.17.1 The Operator ........................................................................................ 26 1.17.2 The subcontracted de-icing operator ................................................... 27 1.18 Additional information..................................................................................... 29 1.18.1 Pre-flight inspection ............................................................................ 29 1.18.2 Regulatory requirements, guidelines and standards for the de-icing operations ............................................................................................ 30 1.18.3 Other instructions by the operator ....................................................... 31 1.18.4 Aviator’s routines and procedures for the de-icing operation ............. 31 1.18.5 General information from interviews about the de-icing-operations ... 36 1.18.6 Other relevant regulations, recommendations and procedures ............ 38 1.18.7 Supervision of the de-icing operations ................................................ 39 1.18.8 Actions after the event ......................................................................... 39 RL 2017:10e 1.18.9 Measures taken .................................................................................... 40 The operator..................................................................................................... 40 1.19 Useful or effective investigation techniques.................................................... 43 2. ANALYSIS ..................................................................................................... 43 2.1 The incident ..................................................................................................... 43 2.2 What was the cause of the vibrations? ............................................................. 43 2.2.1 Effect of ice on control surfaces .......................................................... 43 2.2.2 Conclusions concerning the aeroelastic stability of the aeroplane ...... 44 2.2.3 Cause of the vibrations ........................................................................ 45 2.3 Why was the aeroplane dispatched with remaining ice on critical surfaces? .. 45 2.3.1 Inspection of the aircraft before take-off ............................................. 45 2.3.2 The de-icing of the aircraft .................................................................. 46 2.4 Other observations ........................................................................................... 50 2.4.1 Damage to aircraft ............................................................................... 50 2.4.2 Actions after landing ........................................................................... 50 2.4.3 The instructions for PFI ...................................................................... 50 2.4.4 De-icing instructions ........................................................................... 51 3. CONCLUSIONS ............................................................................................. 52 3.1 Findings ........................................................................................................... 52 3.2 Causes/Contributing Factors ........................................................................... 52 4. SAFETY RECOMMENDATIONS ................................................................ 53 4 (53) RL 2017:10e General observations The Swedish Accident Investigation Authority (Statens haverikommission – SHK) is a state authority with the task
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