Issued April 2012 REPORT SL 2012/04 REPORT ON AIRCRAFT ACCIDENT ON 10 OCTOBER 2006 AT STORD AIRPORT, SØRSTOKKEN (ENSO) NORWAY INVOLVING A BAE 146-200, OY-CRG, OPERATED BY ATLANTIC AIRWAYS Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01 www.aibn.no • [email protected] This report has been translated into English and published by the AIBN to facilitate access by international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference. The Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board’s task to apportion blame or liability. Use of this report for any other purpose than for flight safety should be avoided. Photos: AIBN and Trond Isaksen/OSL Accident Investigation Board Norway Page 2 TABLE OF CONTENTS NOTIFICATION OF THE ACCIDENT ................................................................................... 4 SUMMARY ............................................................................................................................... 4 1. FACTUAL INFORMATION .................................................................................... 5 1.1 History of the flight ................................................................................................... 5 1.2 Personal injuries ...................................................................................................... 11 1.3 Damage to aircraft ................................................................................................... 12 1.4 Other damage ........................................................................................................... 12 1.5 Personnel information ............................................................................................. 12 1.6 Aircraft information ................................................................................................. 14 1.7 Meteorological information ..................................................................................... 32 1.8 Aids to navigation.................................................................................................... 34 1.9 Communication ....................................................................................................... 35 1.10 Aerodrome information ........................................................................................... 35 1.11 Flight recorders ........................................................................................................ 40 1.12 Wreckage and impact information .......................................................................... 42 1.13 Medical and pathological information ..................................................................... 52 1.14 Fire ........................................................................................................................... 52 1.15 Survival aspects ....................................................................................................... 54 1.16 Tests and research .................................................................................................... 61 1.17 Organisation and management ................................................................................ 63 1.18 Other information .................................................................................................... 72 1.19 Useful or effective investigation techniques ........................................................... 78 2. ANALYSIS .............................................................................................................. 79 2.1 Introduction ............................................................................................................. 79 2.2 Analysis of sequence of events ................................................................................ 81 2.3 Survival aspects ....................................................................................................... 85 2.4 Failure of the lift spoiler system .............................................................................. 88 2.5 Lack of braking action and reverted rubber hydroplaning ...................................... 90 2.6 Operational issues .................................................................................................... 92 2.7 Stord airport ............................................................................................................. 94 2.8 Aircraft type BAe 146 ............................................................................................. 96 2.9 The CAA Norway's safety oversight of Stord Airport, Sørstokken ........................ 96 2.10 Atlantic Airways’ operations relating to Stord Airport, Sørstokken ....................... 97 2.11 Overall risk considerations ...................................................................................... 98 3. CONCLUSIONS ...................................................................................................... 99 3.1 The accident............................................................................................................. 99 3.2 The fire .................................................................................................................. 100 3.3 Survival aspects ..................................................................................................... 100 3.4 The aircraft ............................................................................................................ 101 3.5 Operational conditions ........................................................................................... 101 3.6 The airport ............................................................................................................. 101 3.7 Organisational matters ........................................................................................... 102 Accident Investigation Board Norway Page 3 4. SAFETY RECOMMENDATIONS ....................................................................... 102 ABBREVIATIONS ............................................................................................................... 104 ANNEXES ............................................................................................................................. 107 Accident Investigation Board Norway Page 4 REPORT ON AIRCRAFT ACCIDENT Aircraft: British Aerospace BAe146-200 Nationality and registration: Danish, OY-CRG Owner: Atlantic Airways User: Atlantic Airways Vagar Airport FO-380 Sørvágur Faroe Islands Crew: 4 (2 pilots and 2 cabin crew) Passengers: 12 Accident site: Stord Airport, Sørstokken (ENSO) Norway (59°47’50’’N 005°19’53’’E) Time of accident: Tuesday 10 October 2006 at 0732 hours All times stated in this report are local times (UTC + 2 hours) unless otherwise stated. NOTIFICATION OF THE ACCIDENT At 0745 hours the Accident Investigation Board Norway's (AIBN) officer on duty was notified by the Joint Rescue Coordination Center, South Norway (JRCC), of an accident. The notification concerned an aircraft from Atlantic Airways with 16 persons on board that had run off the runway at Stord airport. At 0800 hours the officer on duty received another notification from Air Traffic Control at Bergen Airport Flesland (ENBR) with similar content, at which time it was stated that the aircraft was on fire. The AIBN responded by deploying six accident investigators, the first four of whom arrived at Stord airport by helicopter at 1308 hours the same day. The UK Air Accidents Investigation Branch (AAIB) was informed immediately in accordance with ICAO Annex 13, Aircraft Accident Investigation. The AAIB appointed an accredited representative, who, supported by advisors from the aircraft manufacturer BAE Systems, has participated in parts of the investigation. SUMMARY During normal approach and landing at Stord Airport Sørstokken OY-CRG ran off the runway and plunged down a steep slope. The aircraft sustained considerable damage and caught fire immediately. The fire spread so fast that there was not enough time for everybody to evacuate the aircraft. Four people died and six were seriously injured. Accident Investigation Board Norway Page 5 In its investigation of the accident, the AIBN found that several factors contributed to the accident. The accident was initiated when none of the aircraft's six lift spoilers were deployed after landing1. The AIBN believes it has found two possible technical reasons for this. The wings continued to produce lift, so that the weight of the aircraft was not sufficiently transferred to the landing wheels. Hence, the main wheels did not get sufficient contact with the runway and the braking effect was reduced. The pilots perceived this as wheel brake failure and the emergency brakes were engaged. The emergency brakes do not have anti-skid protection, and the wheels locked. In combination with the damp runway this led to 'reverted rubber hydroplaning' (the rubber in the tyres started boiling), and the aircraft was unable to stop on the runway. The AIBN believes that the lift spoilers’ failure to deploy in isolation would not have caused the aircraft running off the end of the runway. The aircraft