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Short filmTranscript
00:02just moments after taking off from a remote island in Norway
00:10something's wrong the pilots of Videro flight 839 lose control of their plane
00:15oh god it plunges into the Norwegian sea killing everyone on board
00:23in the wreckage investigators find damage to a critical part
00:28the upper end is broken it didn't make a great deal of sense and when they learn
00:37another Videro flight nearly met the same fate at the same airport looks like they
00:43lost control of the plane for two minutes
00:51they discover a controversial decision that put lives at risk I wish
00:58that we had put our foot down and said no more
01:08you
01:29mayday mayday
01:30Put in the seatbelt sign on.
01:34Videro Flight 836 is heading to a remote outpost on the Lofoten archipelago in the Norwegian Sea.
01:43Lofoten is one of the most beautiful places in Norway.
01:49It's a place where a Norwegian would want to go on holiday to experience untouched nature.
01:55And especially the beautiful mountains.
02:01Tonight's flight is carrying 11 passengers.
02:04Most are Norwegians traveling to the islands from the mainland.
02:11Videro 836. Runway 25 free.
02:15Winds variable 1021 at 260 degrees.
02:19Visibility 2500 meters.
02:22Copy that. Videro 836.
02:29Videro is Norway's largest regional airline.
02:33It serves remote communities across the country.
02:38Since the 1960s and 70s, it was a push in Norway to build regional airports in rural areas.
02:46It's made people feel less isolated and it made traveling a lot easier.
02:54The plane is heading first to the small island of Vare, and then southwest to Rust, before returning to the
03:01mainland city of Boda.
03:06Approach checklist.
03:10The crew was experienced, but this was the first time the captain had flown in to Vare.
03:26They're flying a de Havilland Twin Otter.
03:30It's a twin turboprop utility aircraft.
03:34A workhorse for getting in and out of small remote airports.
03:40The best airplane in the world.
03:44It's an incredibly sturdy aircraft.
03:47Very pilot-friendly.
03:50We have a long mountainous coast, and for that, the twin otter was perfect.
03:59Landing lights.
04:02On.
04:04Videro flight 836 is now minutes from landing at Vare.
04:08And seatbelt.
04:11Party on.
04:13But the airport is notorious for unpredictable winds.
04:18Vare translated means the weather island.
04:22The airport was located to the north of the island, between the mountain and the sea.
04:29It's a very demanding flying environment, because the weather changes all the time, so the pilots have to adapt to
04:37that.
04:39Set flaps.
04:43Lapse set.
04:45With the runway in sight, the pilots begin to line up for landing.
04:50But just as the plane turns, it's rocked by turbulence.
05:01I have control.
05:03You have control.
05:08When flying at Vare, you will experience turbulence, and you will be tossed around.
05:18This isn't getting better.
05:20Go around.
05:25He actually decided that the situation was not good to land, so he went around, and it was a great
05:30call on his part.
05:33Lapse up.
05:35As the captain powers out of the landing, the plane is hit with a powerful downdraft and extreme turbulence.
05:47You get sort of a tunnel vision when you're in a situation like that, and you pull out all your
05:54resources, and you try to counteract the situation that you're in.
06:01For two minutes, the captain struggles to level the plane.
06:08He was in extreme turbulence.
06:10You're momentarily out of control.
06:12You may or may not regain control.
06:24We're going over.
06:26The force of the wind becomes so great that the plane rolls over, speeding towards the mountains.
06:36Altitude!
06:39I can't see anything.
06:41I can't see anything.
06:43I can't see anything.
07:15I just can't believe that he recovered at such a low altitude.
07:23Put in headings for Roast.
07:30Vitero, 836 has aborted landing.
07:34Redirecting to Roast.
07:35Copy that, Vitero, 836.
07:38Stay safe.
07:39Everyone okay back there?
07:48Vitero, flight 836 escapes disaster.
07:52No one on board is injured.
07:58I'm still shaking my head at that one.
08:00That was an ace pilot.
08:04In the city of Boda, officials from Videro Airlines cancel all flights into Vare while they try and piece together
08:12what happened with flight 836.
08:16As part of an internal investigation, the pilot is interviewed.
08:21We were lining up for approach.
08:24Turbulence was getting worse and worse.
08:28I have control.
08:32It was obvious we couldn't land.
08:34I applied power to the engines and we climbed to about 1,800 feet where we got hit with a
08:42massive downdraft.
08:57I battled that plane.
09:00Trying to keep it away from the mountains.
09:11Eventually, I was able to level out, climb to a safe altitude and turn for Roast.
09:20It would be terrifying for them, I'm sure.
09:25I've heard stories about that airport.
09:30And they're true.
09:34The pilots were not very happy.
09:38We realized this had been a serious incident and we had to tighten the operational requirement at the island to
09:47make that a safer.
09:51The first action taken by Videro officials is to reduce the maximum wind speeds for take-off and landing at
09:59Vare Airport from 20 to 15 knots.
10:03Videro asks the Civil Aviation Authority to install anemometers, devices that monitor and transmit wind speeds.
10:11Two are installed at each end of the airstrip and one is installed on the mountain.
10:16The mountain is its own weather maker.
10:19It can cause winds to change in direction, change in speed, which are conducive to making some serious turbulence.
10:29It's called terrain-induced turbulence.
10:32When winds hit the mountains on Vare, they tend to accelerate over the top and drop down towards the airstrip.
10:39This creates powerful downdrafts and crosswinds.
10:43The sudden changes in wind speeds and direction can create wind shear and cause a pilot to lose control.
10:52This was a difficult place to operate when the wind was flying over the mountains and down onto the airport.
10:59And we had to tighten those restrictions quite severely and quickly.
11:07But will the restrictions at Vare be enough to ensure the safety of future flights?
11:19It's been 15 months since Videro Flight 836 had their close call at Vare Airport.
11:26Videro Flight 839 has just landed at Vare and is refuelling before heading back to the mainland for Easter weekend.
11:35Videro Flight 936 has just landed at Vare Airport.
11:36Anti-collision light.
11:39On.
11:40Aft and forward boost.
11:42On.
11:44Captain Ida Nils Pearsson is the pilot in command.
11:49Ida was a very level-headed fellow.
11:53He was a top-rated pilot.
11:55And he'd been with us for years.
11:59Start switch.
12:00Left engine.
12:02The first officer is Arndt Vidar Grunerfloter.
12:07On. Right engine.
12:09Right engine.
12:12On.
12:14The first officer was fairly new.
12:17I think he'd been with us for only about a year.
12:23Look at that windsock.
12:25It's flapping like mad.
12:28Welcome to Vare.
12:31Buckle up, folks. It's gonna be a bit bumpy getting out of here.
12:35There are three passengers on board, including a young couple.
12:40All right. Vitero 839 ready to taxi.
12:43Vitero 839, roger.
12:45No known traffic. Runway free.
12:47Wind variable, middle direction 250 at 21, max 57.
12:53QNH, Niner 88.
12:56Copy, Niner 88.
12:59The captain, he was a local pilot.
13:02He knew the weather.
13:03He knew the limitations of the aircraft.
13:06Knew the limitations of the airport.
13:10As they line up at the end of the runway, the crew performs the before takeoff checklist.
13:17Claps set 10.
13:19Set 10.
13:22Heading set to 280.
13:24Let's make it 320.
13:27Just get clearance.
13:29It's calm now. We should get going.
13:31Copy that.
13:33Tower.
13:34Vitero 839 requesting clearance.
13:36Vitero 839.
13:38Vitero 839.
13:38Vodot control clears.
13:39Vitero 839 direct Vodot at 5,000 feet and squawk 0-1-3-5.
13:45Copy.
13:46Vitero 839.
13:48Here we go.
13:55Wind has varied.
13:57210 to 290 degrees.
14:01The gusts of 34.
14:03Yeah, Roger.
14:04We are rolling.
14:0670 knots.
14:0980 knots.
14:15Rotate.
14:17At 2.43, Videro flight 839 takes off from Vare and heads for the mainland.
14:26The return flight to Boda will take less than 30 minutes.
14:34Flaps up.
14:37Ten seconds after takeoff, a strange noise catches the pilot's attention.
14:46You don't want anything unusual to happen in that phase of the flight, since you are very close to the
14:53ground.
14:55They struggle to keep the plane level.
15:00Steady.
15:06Something's wrong.
15:16And then, the nose of the plane drops and the captain can't do anything to raise it.
15:22No.
15:24No, no, no.
15:35Just 63 seconds after lifting off, Videro flight 839 slams into the sea.
15:52Videro 839, this is Vare Tower. Do you copy?
15:57Videro 839, Vare information on 119.4.
16:09Within hours, search and rescue teams spot debris on the ocean's surface, 6.5 kilometers northwest of the airport.
16:19The wreckage was found three days after the accident.
16:24Harsh sea conditions made it a challenge.
16:31The bodies of the three passengers and the first officer are recovered.
16:36Captain Pearson's remains are never found.
16:41The accident caused a lot of grief.
16:44Vare is a small island where everyone know each other, so everyone felt they had lost someone close to them.
16:53Investigators from the Norwegian Accident Commission for Civil Aviation, or HSL, soon arrive on the island.
17:02The purpose of the Videro investigation was to find out what happened during that incident.
17:13I was manager air safety for Boeing Canada to have on a division, and I traveled to Vare to assist
17:20with the investigation.
17:23The airfield was spectacular, but I was somewhat surprised in the closeness of the mountain range, which paralleled the entire
17:32runway.
17:37Investigators start by interviewing the controller, who briefs pilots on the local weather.
17:42Sorry about that.
17:43That's fine.
17:44Can you walk me through what happened the day of the accident?
17:46Normal day, by our standards.
17:49They landed at 14.30, refueled, changed passengers, and asked to taxi out.
17:55The whole turnaround was less than 15 minutes.
17:57What were the winds when they took off?
18:00It was gusting when they were parked, but eased off to 34 on the west end.
18:05The winds were coming from every direction.
18:07It was pretty common.
18:09Did the pilots have any hesitation about taking off?
18:12No, not at all.
18:13And what about the takeoff?
18:16The controller explains that after the plane passed the tower, it turned and then disappeared into the clouds.
18:26What was the cloud ceiling at the time?
18:291,000 feet.
18:30I received a distress signal, and a few seconds later, I heard a bang.
18:54Could there have been a structural failure or loss of power which caused Flight 839 to crash so quickly into
19:02the sea?
19:082,000 feet.
19:092,000 feet.
19:09Investigators survey the wreckage of Videro Flight 839 for any signs that would explain a crash so soon after takeoff.
19:16Nose and cockpit completely crushed.
19:22Both wings, engines, undercarriage, and tail section severed from the fuselage on impact and carried forward.
19:34High energy impact.
19:38With the nose buckled the way it was, and the left wingtip buckled, we had a pretty good idea of
19:46how the aircraft impacted the sea.
19:52The wreckage tells investigators the plane entered the water nose first at high speed.
20:03The team considers whether engine failure caused the high speed impact.
20:08The manufacturer provides their report.
20:11No fire damage.
20:13Both engines appeared to be running at high RPM and torque at the time of impact.
20:20The engine manufacturer determined that the engines were running, and they were ruled out very, very quickly.
20:28With engine failure ruled out, they wonder whether any parts that control the plane's pitch or steering failed, causing it
20:37to plunge into the sea.
20:41The right elevator is sheared in half, maybe due to impact.
20:47The elevator is a control surface on the twin otter's tail that adjusts pitch.
20:57Investigators discover something unusual in the elevator connecting rod.
21:06The elevator connecting rod moves the elevators up and down on the tail.
21:12It's activated when the pilot pushes or pulls on the control column.
21:18The upper end is broken.
21:20What would cause such a vital part to break?
21:24You shouldn't have any preconceived notions as to why the part failed.
21:31Let's get this elevator rod to metallurgy.
21:34I want to know how it failed.
21:38Did the part fail because there was a manufacturing defect?
21:43Did it fail because there was a tool mark on it?
21:47You should let the part tell you the story.
21:52While investigators wait for the metallurgical results, they research the plane's history, looking for any clues into what might have
22:00caused the elevator connecting rod to fail.
22:03So the twin otter DHC-6300 was purchased by Vidro in 1977.
22:10The last daily inspection was carried out the day of the accident.
22:13Maintenance all in accordance with current regulations.
22:16So not a maintenance issue.
22:23The investigators went through all the maintenance documentation, all the inspections was completed, and no deviations was found.
22:34With maintenance ruled out as a cause for the failure of the elevator connecting rod, investigators review the results of
22:42a metallurgical examination performed on the rod.
22:46There's no pre-existing cracks.
22:49There's banding here and here.
22:53Banding is created because you have a repeated load that is applied on and off to your part.
22:59And every time the load is applied, you have a crack that grows a little bit more, and it creates
23:07a rainbow on the fracture surface.
23:10The report also reveals the banding occurred because of sideways bending on the rod.
23:18This was highly unusual.
23:20There's never any side loads on that rod.
23:24It just moves up and down.
23:26So it didn't make a great deal of sense.
23:31Investigators examined schematics of the tail section of the twin otter to determine what would bend the elevator connecting rods
23:39sideways, causing it to break.
23:41So what if this elevator broke in flight?
23:46It was being freely and uncontrollably.
23:51It would definitely cause the rod to bend.
23:59If the right elevator separated from its mounts in flight, it would swing in every direction, putting sideways pressure on
24:07the rod and ultimately causing it to break.
24:12First the elevator, then the rod.
24:17It's the only thing that makes sense.
24:21It's kind of like the cart before the horse.
24:24The control rod would not have seen any loads had the elevator not broken.
24:31What would cause the elevator to break in flight?
24:35Maybe the cockpit voice recorder can shed some light on that.
24:45Okay, let's start with the take-off roll.
24:49Norwegian investigators listened to the cockpit voice recorder for clues as to how the right elevator on Videro flight 839
24:57might have come loose, bending the connecting rod.
25:0170 knots.
25:0380 knots.
25:06Rotate.
25:07It was amazing that the cockpit voice recorder was in the aircraft in the first place because it was not
25:14mandatory at the time.
25:19It was amazing that it was not mandatory at the time.
25:20Flaps up.
25:28Did you hear that clattering noise?
25:32Strange.
25:39Steady.
25:46Something's wrong.
25:49Stop.
25:51There it is again.
25:54Is that the elevator?
25:57Play it back again.
26:00When I listened to the CBR, there was nothing that I could pinpoint as being the source of the clattering
26:10sound.
26:15Could it have been the elevator breaking?
26:18It was possible, but we really just don't know.
26:22Did you hear the propellers?
26:2355 seconds into the flight, investigators hear the sound of propellers rotating out of sync.
26:31This occurs when there's a change in the aircraft's pitch.
26:35Turbulence?
26:38Has to be.
26:40A sudden gust of wind or change in wind direction would cause the propellers to adjust to compensate for the
26:49changing attitude of the aircraft.
26:53Investigators discover that Videro 839 was struck by severe turbulence shortly after takeoff.
27:01The crash happens just 10 seconds later.
27:09No.
27:10No, no, no, no.
27:11Oh, God!
27:13No!
27:24So, where were they exactly when they were struck by severe turbulence?
27:28A standard operating procedure calls for a rate of ascend of 1,000 to 1,200 feet per minute.
27:34So, they would have hit turbulence right after they entered clouds at about 1,000 feet.
27:43And that mountain ridge there is just over 1,000 feet.
27:47Now, it looks like terrain induced turbulence.
27:54The quicker you could get away from the mountains, the better it was.
28:01How bad could those winds have been?
28:07Investigators learn of the near crash of the other Videro plane, flight 836, on approach to Vare 15 months earlier.
28:16Looks like they lost control of the plane for two minutes, even when inverted.
28:26At what altitude did they lose control?
28:30About 1,800 feet.
28:33Just after he aborted the landing on runway 25 due to winds.
28:40Both flights encountered dangerous winds at or above the mountain ridges.
28:46Were any measures put into place to prevent this from happening again?
28:50After flight 836's missed approach, flight order 17 was put into place.
28:56So, they made this change.
28:59Landings and departures must not be planned or executed with variable winds above 15 knots.
29:05So, they reduced the maximum allowable wind speeds for takeoff and landing.
29:12Videro established some very significant wind restrictions,
29:17using some very experienced crew to develop them.
29:21But there was still unpredictability.
29:26Anemometers were also installed at both ends of the runway and on the mountain ridge.
29:37It's good to have an anemometer on top of a mountain.
29:40Just gives the pilot more information for the landing.
29:44So, what were the mountain winds at the time of flight 839?
29:54There is no anemometer data for the mountain.
30:01If it doesn't provide data, it's absolutely no use.
30:07Investigators contact the Civil Aviation Authority
30:10to determine why there weren't any mountain anemometer wind readings
30:14at the time of the crash of Videro Flight 839.
30:22The anemometer was taken down.
30:27They learned that the anemometer on the mountain wasn't reliable
30:31because of the icy conditions.
30:33A year after being installed, it was removed from the mountain for repair.
30:39It gets worse.
30:41It was never reinstalled.
30:44It was officially taken out of service three days before the accident.
30:53The removal of the anemometer is a degradation safety.
30:58It's information that a pilot would certainly require for an airport like that.
31:03Okay.
31:05So, what wind information were the pilots actually getting and when?
31:13Investigators listened to the CVR recording of Videro Flight 839
31:18before it landed at Vare.
31:20I'm going to bank west of the island to avoid more turbulence.
31:24I'm getting up drafts already.
31:26Copy that.
31:27Videro 839, runway free, wind east side, 270 degrees at max 23.
31:35Understood.
31:37Videro 839.
31:4123 knots.
31:42That's 8 knots above the limit.
31:45They shouldn't even have landed the inbound flight in the first place.
31:49What about when they were on the ground?
32:00Look at that windsock.
32:03It's flapping like mad.
32:05Welcome to Vare.
32:10The pilot was talking a lot about the wind
32:12and they were discussing that the wind was coming from all directions.
32:19Videro 839, roger.
32:21No known traffic, runway free.
32:23Wind variable, middle direction 250.
32:27At 21, max 57.
32:29What did you say again, max 57?
32:32Yep.
32:33Max 57.
32:38Copy.
32:4357 knots.
32:4757 knots is more than 65 miles per hour.
32:52The manual says that the twin otter must not be operated on the ground in winds above 50 knots.
33:01Well, he is sticking his neck out on the line and I'm not quite sure why he did that.
33:08Were the winds that strong when they took off?
33:13They go through their pre-takeoff checklist and then...
33:19Just get clearance.
33:20It's calm now.
33:21We should get going.
33:23Copy that.
33:24The captain says it's calm.
33:26What's he basing that on?
33:28Windsocks?
33:29The reins had stopped.
33:30Maybe it looked like the weather was clearing.
33:35If a shower was approaching, you could expect variable winds.
33:39But when the shower passed, you could expect a lull in the wind.
33:48According to the transcript, they get their next wind report as they're about to take off.
33:56Wind has varied 210 to 290 degrees.
34:00With gusts of 34.
34:03Yeah, Roger. We are rolling.
34:08They took off in a 34-knot wind.
34:11That's more than double the limit.
34:14If the winds were gusting at 57 knots on the ground,
34:17then who knows how strong the winds were coming off the mountain.
34:22Strong enough to break the elevator.
34:29When he hit the lip of the mountain, I bet he encountered 60, 70, 80-knot winds.
34:38It obviously caused severe to extreme turbulence.
34:43Steady.
34:44The team concludes the winds were strong enough to break the right elevator from its mounts,
34:50causing the connecting rod to break, making both elevators unusable.
34:58They ignored Vitero's wind limits on the ground.
35:02And they had no wind limits in the dangerous area around the mountain.
35:08Why were they so eager to leave?
35:12This was Easter weekend, and there is an incentive to get home.
35:21There was clearly some concern, but they went.
35:33To understand why the captain of Flight 839 took off in winds that exceeded company limits,
35:41investigators interview other Vitero pilots about wind restrictions at Vare.
35:46What has been your experience at Vare?
35:50I don't like it.
35:51None of the pilots do.
35:52The wind reports aren't reliable.
35:58You could actually sit on the tarmac, get one wind indication,
36:03move towards the runway, and get another.
36:07Even though the maximum wind speeds were reduced from 20 knots to 15?
36:11Well, they were, but they brought it back up to 20.
36:17Nine months after the incident with the first Vitero flight,
36:21the wind restrictions were reversed.
36:26Why would they do that?
36:28My guess?
36:30Too many cancellations.
36:35After Vitero lowered the wind limits, cancellations increased.
36:40That led to negative press and anger from local residents.
36:44The decision to cancel flights became very unpopular.
36:52It was so unpredictable at Vare.
36:58Did pilots feel pressure to complete the flights?
37:03Yeah, but not from the airline.
37:07I had a situation where the weather turned into a hurricane and it could not take off.
37:13And I got a real workover from some of the passengers.
37:18Investigators researched the impact those wind-related cancellations had on Vitero's operations.
37:26The pressure was piling on from the public.
37:30Cancellations tripled in the last 12 months.
37:35Compared to other airports in Europe, Vare had a lot of cancellations.
37:39And the flights were often cancelled quite early when the wind was strong.
37:44But when the flights were supposed to arrive, it could be no wind at all.
37:49Which made people question all the cancellations.
37:54Almost all the cancellations were being caused by winds.
37:57Because of that, bad press.
37:59Which gets the attention of the government.
38:05The government paid the company to fly there.
38:09The company wrote the government and said it was extremely difficult to operate there.
38:14And the reply from the government was, if you don't fly there, we will have to take the money away.
38:22Out of curiosity, how many cancellations were there on departure from Vare?
38:33None.
38:36Basically, it's get home, Midas.
38:39If they're at the airport, pilots are going to tell themselves they're capable of taking off as well.
38:45You know, there's still one thing I don't get.
38:50The conditions were so treacherous.
38:54Why was this airport even built there in the first place?
39:04So, why was this location chosen for the airport?
39:10Investigators consult officials about the viability of Vare Airport.
39:14To determine if passengers and crew were placed at risk unnecessarily.
39:21Vidre had two possible locations for the airport at the island.
39:27This one was chosen despite the difficulties with wind conditions near a mountain ridge.
39:37Okay, and what testing went into the decision?
39:42Vidre had done test flights at Vare prior to the decision of building the airport there.
39:48And they had experienced very windy conditions and did not recommend building the airport there.
39:59So, if Vidre was against it, then why did it go ahead?
40:02We knew that the wind conditions at Vare would be so difficult, it would affect regularity.
40:11But that advice was ignored by the meteorology specialists that the authorities had consulted when it came to put the
40:22airport on the island.
40:24Maybe some of the decisions that were made were more politically motivated than were practical.
40:36Investigators now know the factors that led to the deaths of three passengers and two pilots on board Vidreau Flight
40:43839.
40:44First up, you have an airport next to a mountain, resulting in dangerous winds.
40:51Lower wind limits are imposed, but the result is an increase in cancellations.
40:56Which forces the limits to change again.
40:59Limits go back up, and then finally, the unreliable wind data, which results in wind reports being ignored...
41:08...by pilots.
41:15Rules are established for a reason.
41:18If you don't follow the rules, you're taking a big risk.
41:23Wind has varied. 210 to 290 degrees. The gusts of 34.
41:30Yeah, Roger, we are rolling.
41:38Vidreau Flight 839 enters turbulent airspace when the winds coming off the mountain were extreme.
41:46The force of the winds causes the right elevator to break free.
41:54Something's wrong.
41:57Bending the connecting rod until it fails.
42:10It was subject to aerodynamic loads that exceeded the structural strength of the tail.
42:22It must have been absolutely terrifying, because you would pull the control column without any reaction at all.
42:31Oh, God!
42:43The Norwegian Accident Commission for Civil Aviation recommends new regulations for the distribution of wind information to crews.
42:52...and urges Vidreau to ensure their pilots follow established restrictions.
42:58The captain wanted to get the job done.
43:01And he probably got away with it other times, but this time, it didn't work out.
43:11Other recommendations are made for Vare Airport, but ultimately, it is deemed too dangerous, and the airport never reopens to
43:20commercial traffic.
43:24Vare Airport was open only four years, which makes it one of the shortest-lived airports in the world.
43:36I wish that we had put our foot down and said no more.
43:43I wish that we had put our foot down and said no more.
43:44I wish the company had done the same.
43:48I wish the government and the experts had listened to our warnings earlier.
43:57Then we might have had our colleagues still alive.
44:28We'll see you next time.
44:31You're wrong.
44:31No, I'm not sure if there's no worries.
44:34You're wrong.
44:36You're wrong.
44:39You're wrong.
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