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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
00:42they lost 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
01:06oh
01:07oh
01:07oh
01:31putting 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 it's a place where Norwegian would want to go on
01:51holiday to experience untouched nature and especially the beautiful mountains
02:01tonight's flight is carrying 11 passengers most are Norwegians traveling to the islands from the mainland
02:10videro 836 runway 25 free winds variable 1021 at 260 degrees visibility 2500 meters copy that
02:22videro 836
02:29videro is Norway's largest regional airline it serves remote communities across the country
02:37since the 1960s and 70s it was a push in Norway to build regional airports in rural areas
02:45it'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
03:05approach checklist
03:0812 miles from the airport the crew prepares for landing
03:14the crew was experienced that this was the first time the captain had flown in to Vare
03:20optimeters
03:24set
03:26they're flying a de Havilland twin otter
03:30it's a twin turboprop utility aircraft
03:33a workhorse for getting in and out of small remote airports
03:40the best airplane in the world
03:42the best airplane in the world
03:44it's an incredibly sturdy aircraft
03:47very pilot friendly
03:50we have a long mountainous coast
03:53and 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
04:11already on
04:13but the airport is notorious for unpredictable winds
04:17Vare 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
04:32because the weather changes all the time
04:34so the pilots have to adapt to that
04:39set flaps
04:43flaps set
04:45with the runway in sight
04:47the pilots begin to line up for landing
04:49but just as the plane turns
04:53it's rocked by turbulence
05:01I have control
05:03you have control
05:08when flying into Vare
05:09you will experience turbulence
05:12and 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
05:28so he went around and it was a great call on his part
05:33laps up
05:35as the captain powers out of the landing
05:38the plane is hit with a powerful downdraft
05:41and extreme turbulence
05:47you get sort of a tunnel vision when you're in a situation like that
05:51and you pull out all your resources
05:55and you try to counteract the situation that you're in
06:00for two minutes the captain struggles to level the plane
06:08he was in extreme turbulence
06:10he 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
06:29that the plane rolls over speeding towards the mountains
06:35altitude
06:39I can't see anything
06:42we're going over
06:46and we're going over
06:50we're going over
06:51come on
06:54come on
07:00only 250 feet from the ground
07:04the captain levels the plane
07:05and pulls out of the dive
07:07only 250 feet from the ground
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.
07:38Everyone 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 Vitero 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.
08:35I applied power to the engines and we climbed to about 1800 feet, where we got hit with a massive
08:43downdraft.
08:48We're going over.
08:50We're going over.
08:57I battled that plane.
09:00Trying to keep it away from the mountains.
09:03Come on!
09:12Eventually, 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 weathermaker.
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.
10:42The 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.
11:35S.
11:36Anti-Collision Light.
11:38On.
11:40Aft and forward boost.
11:42On.
11:44Captain Idar Nils-Person is the pilot in command.
11:49Idar was a very level-headed fellow.
11:53He was a top-rated pilot.
11:55and he'd been with us for years start switch left engine the first officer
12:04is aren't V dar Gruner floater on right engine right engine on the first officer
12:15was failing you I think he'd been with us for only about a year
12:23look at that windsock it's flapping like mad welcome to hooray buckle up folks it's going to be a bit
12:33bumpy getting out of here there are three passengers on board including a young couple
12:39all right Vito 839 ready to taxi Vito 839 roger no known traffic runway free wind variable
12:48middle direction 250 at 21 max 57 QNH niner 8 8 copy niner 8 8 the captain he was a
13:01local pilot he knew the
13:02weather he knew the limitations of the aircraft knew the limitations the airport as they line up at the
13:11end of the runway the crew performs the before takeoff checklist flap set 10 set 10 heading set
13:22to two eight zero let's make it three two zero just get clearance it's calm now we should get going
13:31copy that power Vito 839 requesting clearance Vito 839 Vodot control clears Vito 839 direct Vodot at
13:415,000 feet and squawk 0-1-3-5 copy Vito 839 here we go
13:54wind has varied 210 to 290 degrees the gusts of 34 yeah roger we are rolling 70 knots 80 knots
14:16rotate at 243 vidro flight 839 takes off from varay and heads for the mainland
14:26the return flight to boda will take less than 30 minutes
14:34flaps up
14:3710 seconds after takeoff a strange noise catches the pilots attention you don't want anything unusual
14:48to happen in that face of the flight since you are very close to the ground they struggle to keep
14:57the
14:57plane level steady
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 no no no
15:35just 63 seconds after lifting off
15:40vidro flight 839
15:44slams into the sea
15:52vidro 839 this is varay tower do you copy
15:56vidro 839 varay information on 119.4
16:09within hours search and rescue teams spot debris on the ocean's surface
16:146.5 kilometers northwest of the airport
16:19the wreckage was found three days after the accident harsh sea conditions made it to challenge
16:31the bodies of the three passengers and the first officer are recovered captain
16:37and pearson's remains are never found
16:41the accident cost a lot of grief
16:44that is a small island where everyone know each other so everyone felt they had left someone close to them
16:52investigators from the norwegian accident commission for civil aviation or hsl soon arrive on the island
17:02the purpose of the vidro investigation was to find out what happened during that incident
17:13i was manager air safety for boeing canada to have on a division
17:17and i traveled to valroy to assist with the investigation
17:22the airfield was spectacular
17:25but i was somewhat surprised in the closeness of the mountain range which paralleled the entire runway
17:37investigators start by interviewing the controller who briefs pilots on the local weather
17:41sorry about that
17:42that's fine
17:43can 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
17:54the 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
18:04the winds were coming from every direction
18:06it's 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
18:22it turned and then disappeared into the clouds
18:26what was the cloud ceiling at the time
18:281 000 feet
18:30i received a distress signal and a few seconds later
18:33i heard a bang
18:37that was fast
18:38they were airborne for just over a minute
18:42did they call mayday or relay any information about mechanical issues
18:47nothing
18:51that was helpful
18:52thank you
18:55could there have been a structural failure or loss of power which caused flight 839 to crash so quickly into
19:02the sea
19:09investigators survey the wreckage of vidro flight 839 for any signs that would explain a crash so soon after takeoff
19:16nose and cockpit
19:18nose and cockpit completely crushed
19:21both wings engines under carriage 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
19:44we had a pretty good idea of how 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 the 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
20:35causing it to plunge into the sea
20:40the right elevator sheared in half maybe due to impact
20:47the elevator is a control surface on the twin otters 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
21:11it's activated when the pilot pushes or pulls on the control column
21:18the upper end is broken
21:19what would cause such a vital part to break
21:23you shouldn't have any preconceived notions as to why the part failed
21:31let's get this elevator rod to metallurgy
21:34let'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
21:57looking for any clues into what might have caused the elevator connecting rod to fail
22:03so the twin otter dhc 6300 was purchased by vidro in 1977
22:10that the last daily inspection was carried out the day of the accident
22:13maintenance all in accordance with current regulations
22:15so not a maintenance issue
22:23the investigators went through all the maintenance documentation
22:28all 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
22:40investigators review the results of a 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
23:05and it creates a 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 there's never any side loads on that rod it just moves up and down
23:26so it didn't make a great deal of sense
23:31investigators examine schematics of the tail section of the twin otter to determine what would bend the
23:37elevator connecting rods sideways causing it to break so what if this elevator broke in flight
23:46it would swing freely and uncontrollably that would definitely cause the rod to bend
23:59if the right elevator separated from its mounts in flight
24:03it would swing in every direction putting sideways pressure on the rod
24:07and 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
24:34maybe the cockpit voice recorder can shed some light on that
24:45okay let's start with the takeoff roll
24:49Norwegian investigators listened to the cockpit voice recorder for clues as to how the right elevator
24:55on videro flight 839 might have come loose bending the connecting rod
25:0170 knots
25:0380 knots
25:06rotate
25:08it was amazing that the cockpit voice recorder was in the aircraft in the first place because it was not
25:14mandatory at the time
25:19flaps up
25:20the
25:28did you hear that clattering noise
25:32strange
25:38steady
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 cvr there was nothing that i could pinpoint as being the source
26:08of the clattering sound
26:15could it have been the elevator breaking it was possible but we really just don't know
26:21do you hear the propellers 55 seconds into the flight investigators hear the sound of propellers
26:28rotating out of sync
26:31this occurs when there's a change in the aircraft's pitch turbulence
26:38has to be
26:40a sudden gust of wind or change in wind direction would cause the propellers to adjust to compensate
26:48for the changing attitude of the aircraft
26:53investigators discover that videro 839 was struck by severe turbulence shortly after takeoff
27:00the crash happens just 10 seconds later
27:09no
27:10no
27:10no no no no
27:12oh god
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 1000 to 1200 feet per minute
27:34so they would have hit turbulence right after they entered clouds at about 1000 feet
27:42and that mountain ridge there is just over a thousand feet
27:47that 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
28:06investigators learn of the near crash of the other videro plane flight 836 on approach devare 15 months
28:14earlier looks like they lost control of the plane for two minutes
28:20even when inverted
28:26at what altitude did they lose control
28:30about 1800 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 is missed approach flight order 17 was put into place
28:56so they made this change landings and departures must not be planned or executed with variable winds above 15 knots
29:04so they reduced the maximum allowable wind speeds for takeoff and landing
29:12weedero established some very significant wind restrictions
29:17using some very experienced crew to develop them but there was still unpredictability
29:25anemometers were also installed at both ends of the runway
29:32and 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
29:53huh there is no anemometer data for the mountain
30:01if it doesn't provide data it's absolutely no use
30:06investigators contact the civil aviation authority to determine why there weren't any mountain
30:12an anemometer wind readings at the time of the crash of videro flight 839
30:18thank you
30:22the anemometer was taken down
30:27they learned that the anemometer on the mountain wasn't reliable because of the icy conditions
30:33a year after being installed it was removed from the mountain for repair
30:39it gets worse it was never reinstalled it was officially taken out of service three days before the accident
30:53the removal of the anemometer is a decoration safety
30:58it's information that a pilot would certainly require for an airport like that
31:03okay so what wind information were the pilots actually getting and when
31:13investigators listened to the cvr recording of videro flight 839 before it landed at vare
31:20i'm gonna bank west of the island to avoid more turbulence
31:24getting updrafts already copy that
31:27i don't know what's going to happen
31:28videro 839 runway free wind east side 270 degrees at max 23
31:35understood videro 839
31:4023 knots that's eight knots above the limit
31:45they shouldn't even have landed the inbound flight in the first place
31:49what about when they're on the ground
32:00look at that wind suck
32:03it's flapping like mad welcome to hooray
32:10the pilot was talking a lot about the wind and they were discussing that the wind was coming from
32:17all directions
32:19videro 839 roger no known traffic runway free
32:23wind variable middle direction 250 at 21 max 57
32:30did you say again max 57
32:32yeah max 57
32:38copy
32:4357 knots
32:4757 knots is more than 65 miles per hour
32:52yeah the 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 in 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 it's calm now we should get going copy that the captain says it's calm
33:26what's he basing that on wind socks the reins had stopped maybe it looked like the weather was clearing
33:34if 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 gusts of 34
34:03yeah roger we are rolling
34:07they took off in a 34 knot wind that's more than double the limit
34:14if the winds were gusting at 57 knots on the ground and
34:17who 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 the team concludes the winds were strong enough to break the right elevator from its mounts
34:49causing the connecting rod to break making both elevators unusable something's wrong
34:58they ignored vitro's wind limits on the ground
35:02and they had no wind limits in the dangerous area around the mountain
35:07why were they so eager to leave
35:12this was easter weekend and there is an incentive to get home
35:20there was clearly some concern but they went
35:34to understand why the captain of flight 839 took off in winds that exceeded company limits
35:40investigators interview other vitro pilots about wind restrictions at varay
35:46what has been your experience at varay
35:50i don't like it none of the pilots do the wind reports aren't reliable
35:58you could actually sit on the tarmac get one wind indication and move towards the runway and get
36:05another even though the maximum wind speeds were reduced from 20 knots to 15. well they were but
36:12they brought it back up to 20. nine months after the incident with the first vidro flight the wind restrictions
36:23were reversed
36:26why would they do that my guess too many cancellations
36:36after vidro lowered the wind limits cancellations increased that led to negative press and anger from local residents
36:44the decision to cancel flights became very unpopular it was so unpredictable at varoy
36:58did pilots feel pressure to complete the flights yeah but not from the airline
37:07i had a situation where the weather turned into a hurricane and it could not take off and i got
37:13a real work over from some of the passengers
37:18investigators research the impact those wind related cancellations had on vidro's operations
37:26the pressure was piling on from the public cancellations tripled in the last 12 months
37:35compared to other airports in europe that i had a lot of cancellations and the flights were often
37:41canceled quite early when the wind was strong but when the flights was supposed to arrive it could be
37:48no wind at all which made people question all the cancellations almost all the cancellations were being
37:55caused by winds because of that bad press which gets the attention of the government
38:05the government paid the company to fly there the company wrote the government and said it was
38:12extremely difficult to operate there and the reply from the government was if you don't fly there we
38:18will have to take the money away out of curiosity how many cancellations were there on departure from varay
38:36none basically it's get home itis if they're at the airport pilots are going to tell themselves they're capable of
38:43taking off as well you know there's still one thing i don't get
38:50the conditions were so treacherous why was this airport even built there in the first place
39:04so why was this location chosen for the airport
39:09investigators consult officials about the viability of varay airport
39:14to determine if passengers and crew were placed at risk unnecessarily
39:21vidra had two possible locations for the airport at the island this one was chosen despite the difficulties
39:31with wind conditions near the mountain ridge
39:37okay and what testing went into the decision
39:42vidra had done test flights at varay prior to the decision of building the airport there and they
39:49had experienced very windy conditions and did not recommend building the airport there
39:58so if vidra was against it then why did it go ahead
40:03we knew that the wind conditions at varay 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
40:21to put the airport on the island maybe some of the decisions that were made were more politically
40:29motivated than were practical
40:35investigators now know the factors that led to the deaths of three passengers and two pilots on board
40:42vidra flight 839 first up you have an airport next to a mountain resulting in dangerous winds
40:50lower wind limits are imposed but the result is an increase in cancellations which forces the limits to
40:58change again limits go back up and then finally the unreliable wind data which results in wind reports being ignored
41:08by pilots
41:15rules are established for a reason if you don't follow the rules you're taking a big risk
41:23wind has varied 210 to 290 degrees the gusts of 34. yeah roger we are rolling
41:37we are going to see if you don't follow the rules we are going to see if you don't follow
41:42the
41:42winds coming off the mountain we're extreme
41:46the force of the winds causes the right elevator to break free
41:54something's wrong bending the connecting rod until it fails
42:10it was subject to aerodynamic loads that exceeded the structure strength of the tail
42:22it must have been absolutely terrifying
42:25because you would pull the control column without any reaction at all
42:43the norwegian accident commission for civil aviation recommends new regulations for the distribution of wind
42:50wind information to crews and urges vidro to ensure their pilots follow established restrictions
42:58the captain wanted to get the job done and he probably got away with it other times
43:05but this time it didn't work out
43:11other recommendations are made for varay airport but ultimately it is deemed too dangerous
43:17and the airport never reopens to commercial traffic
43:24by the airport was open only four years which makes it one of the shortest lived airports in the world
43:35i wish that we had put our foot down and said no more
43:42i wish the company had done the same
43:49i wish the government and the experts had listened to our warnings earlier
43:57then we might have had our colleagues still alive
44:03well
44:25you
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