Final Report RL 2017:05e Serious incident at Vilhelmina Airport, Västerbotten County, on 6 April 2016 involving the aeroplane SE-LLO of model BAe ATP, operated by NextJet AB. Reference no. L-35/16 5 April 2017 RL 2017:05e SHK investigates accidents and incidents from a safety perspective. Its investigations are aimed at preventing a similar event from occurring again, or limiting the effects of such an event. However, it is not the purpose of SHK investigations to apportion blame or liability, whether criminal, civil or administrative. The report is also available on our website: www.havkom.se ISSN 1400-5719 Illustrations in SHK’s reports are protected by copyright. Unless otherwise stated, SHK is the copyright owner. With the exception of the SHK logo and figures, images or maps to which a third party owns copyright, reports are made available under the Creative Commons Attribution 2.5 Sweden licence. This means that reports may be copied, redistributed and adapted, provided that the work is attributed to SHK. This may, for example, be done in the following way: “Source: The Swedish Accident Investigation Authority”. Where it is noted next to diagrams, images, maps or other material in the report that the copyright holder is another party, that party’s permission is required to re-use the material. Cover image three – Photo: Anders Sjödén/Swedish Armed Forces. Postal Address Visitors Phone Fax Email Website P.O. Box 12538 Sveavägen 151 +46 8 508 862 00 +46 8 508 862 90 [email protected] www.havkom.se SE-102 29 Stockholm Stockholm Sweden RL 2017:05e Contents General observations ...................................................................................................... 5 The investigation ............................................................................................................ 5 SUMMARY ....................................................................................................... 8 1. FACTUAL INFORMATION .......................................................................... 10 1.1 History of the flight .......................................................................................... 10 1.1.1 Circumstances ...................................................................................... 10 1.1.2 Sequence of events .............................................................................. 10 1.1.3 Interviews ............................................................................................ 12 1.2 Injuries to persons ............................................................................................ 14 1.3 Damage to the aircraft ...................................................................................... 14 1.4 Other damage ................................................................................................... 14 1.4.1 Environmental impact.......................................................................... 14 1.5 Crew information ............................................................................................. 15 1.5.2 The pilots’ time on duty....................................................................... 15 1.5.3 Other personnel involved..................................................................... 15 1.6 The aircraft ....................................................................................................... 15 1.6.1 General ................................................................................................ 16 1.6.2 Damage to the aeroplane ..................................................................... 17 1.6.3 Description of parts or systems significant to the occurrence ............. 18 1.6.4 Performance regulations ...................................................................... 19 1.6.5 Measurement of friction ...................................................................... 21 1.6.6 Aquaplanning ...................................................................................... 22 1.6.7 Checks of the aeroplane ....................................................................... 22 1.7 Meteorological information ............................................................................. 23 1.8 Aids to navigation ............................................................................................ 23 1.9 Radio communications..................................................................................... 24 1.10 Aerodrome information ................................................................................... 25 1.10.1 General ................................................................................................ 25 1.10.2 Communication between ground staff and the crew ........................... 25 1.11 Flight recorders ................................................................................................ 27 1.11.1 Flight data recorders ............................................................................ 27 1.11.2 Cockpit voice recorder (CVR) ............................................................. 28 1.12 Site of the occurrence....................................................................................... 28 1.13 Medical and pathological information ............................................................. 29 1.14 Fire ................................................................................................................... 29 1.15 Survival aspects ............................................................................................... 29 1.15.1 Rescue operation ................................................................................. 29 1.16 Tests and research ............................................................................................ 29 1.16.1 Limitations when operating on certain runways .................................. 29 1.16.2 Snow clearance at airports ................................................................... 30 1.16.3 Investigation of performance conditions ............................................. 30 1.17 Organisational and management information .................................................. 31 1.17.1 Supervision .......................................................................................... 31 1.17.2 Action taken ......................................................................................... 32 1.18 Deviations ........................................................................................................ 32 2. ANALYSIS ...................................................................................................... 33 2.1 The first incident .............................................................................................. 33 2.1.1 Planning of the flight ........................................................................... 33 2.1.2 Approach and landing .......................................................................... 33 RL 2017:05e 2.1.3 Touchdown .......................................................................................... 34 2.1.4 Landing roll ......................................................................................... 34 2.1.5 Performance data ................................................................................. 35 2.1.6 Overall picture ..................................................................................... 36 2.2 The second incident ......................................................................................... 38 2.2.1 Taxiing in and the ground stop ............................................................ 38 2.2.2 Damage to the aircraft ......................................................................... 39 2.2.3 Inspections of the aeroplane ................................................................ 40 2.3 The operator’s systematic safety work ............................................................ 41 3. CONCLUSIONS ............................................................................................. 42 3.1 Findings ........................................................................................................... 42 3.2 Causes .............................................................................................................. 43 4. SAFETY RECOMMENDATIONS ................................................................ 43 4 (43) RL 2017:05e General observations The Swedish Accident Investigation Authority (Statens haverikommission – SHK) is a state authority with the task of investigating accidents and incidents with the aim of improving safety. SHK accident investigations are intended to, as far as possible, determine both the sequence of events and the cause of the events, along with the damage and effects in general. An investigation shall provide the basis for decisions which are aimed at preventing similar events from happening in the future, or to limit the effects of such an event. At the same time the investigation provides a basis for an assessment of the operations performed by the public emergency services in connection with the event and, if there is a need for them, improvements to the emergency services. SHK accident investigations thus aim to answer three questions: What happened? Why did this happen? How can a similar event be avoided in future? SHK does not have any supervisory remit, nor is it charged with apportioning blame or liability with respect to damages. This means that issues concerning liability are neither