Original subtitles

(Narrator): Just moments after taking off

from a remote island in Norway...

- Something's wrong.

(Narrator): ... the pilots of Wideroe Flight 8-3-9

lose control of their plane.

- Oh God.

(Narrator): It plunges into the Norwegian Sea,

killing everyone on board.

In the wreckage, investigators find damage to a critical part.

- The upper end is broken.

- It didn't make a great deal of sense.

(Narrator): And when they learn another Wideroe flight

nearly met the same fate at the same airport...

- It looks like they lost control of the plane

for two minutes...

(passengers screaming) - We're going over.

(passengers screaming)

(Narrator): ...they discover a controversial decision

that put lives at risk.

- I wish that we had put our foot down

and said no more.

(radio): Mayday, mayday!

Pull up.

(radio chatter)

(eerie music)

- Putting the seatbelt sign on.

(Narrator): Wideroe Flight 8-3-6

is heading to a remote outpost on the Lofoten archipelago

in the Norwegian Sea.

- Lofoten is one of the most beautiful places in Norway.

It's a place where Norwegians would want to go on holiday

to experience untouched nature

and especially the beautiful mountains.

(Narrator): Tonight's flight is carrying 11 passengers.

Most are Norwegians,

traveling to the islands from the mainland.

(radio): Wideroe 8-3-6. Runway 25 free.

Winds variable 10 21 at 2-6-0 degrees.

Visibility 25-hundred meters.

- Copy that, Wideroe 8-3-6.

(Narrator): Wideroe is Norway's largest regional airline.

It serves remote communities across the country.

(Lise): Since the 1960's and 70's it was a push in Norway

to build regional airports in rural areas.

It made people feel less isolated

and it made traveling a lot easier.

(Narrator): The plane is heading first

to the small island of Vaeroy

and then southwest to Rost

before returning to the mainland city of Bodo.

- Approach checklist.

(Narrator): 12 miles from the airport,

the crew prepares for landing.

- The crew was experienced

but this was the first time the captain had flown into Vaeroy.

- Altimeters.

- Set.

(Narrator): They're flying a De Havilland Twin Otter.

It's a twin turboprop utility aircraft,

a workhorse for getting in and out

of small remote airports.

- The best airplane in the world.

It's an incredibly sturdy aircraft.

Very pilot-friendly.

We have a long, mountainous coast

and for that the Twin Otter was perfect.

- Landing lights.

On.

(Narrator): Wideroe Flight 8-3-6

is now minutes from landing at Vaeroy.

- And seat belt... already on.

(Narrator): But the airport is notorious

for unpredictable winds.

- Vaeroy translated means "the weather island".

The airport was located to the north of the island

between the mountain and the sea.

It's a very demanding flying environment

because the weather changes all the time,

so the pilots have to adapt to that.

- Set flaps.

Flaps set.

(Narrator): With the runway in sight,

the pilots begin to line up for landing.

But, just as the plane turns...

it's rocked by turbulence.

- I have control.

- You have control.

(Harald): When flying at Vaeroy,

you will experience turbulence,

and you will be tossed around.

- This isn't getting better. Go around.

- He obviously decided that the situation was not good to land

so he went around.

It was a great call on his part.

- Flaps up.

(Narrator): As the captain powers out of the landing,

the plane is hit with a powerful downdraft

and extreme turbulence.

(Harald): You get sort of a tunnel vision

when you're in a situation like that.

And you pull out all your resources

and you try to counteract the situation that you're in.

(Narrator): For two minutes,

the captain struggles to level the plane.

(grunting)

- He was in extreme turbulence.

You're momentarily out of control.

You may or may not regain control.

(grunting)

- We're going over.

(Narrator): The force of the wind becomes so great

that the plane rolls over speeding toward the mountains.

- Altitude?

- I-I can't see anything.

(passengers screaming)

(grunting)

Come on!

Come on!

(passengers screaming)

(Narrator): Only 250 feet from the ground,

the captain levels the plane and pulls out of the dive.

(sighs)

- I just can't believe that he recovered

at such a low altitude.

- Put in headings for Rost.

- Wideroe 8-3-6 has aborted landing,

redirecting to Rost.

(radio): Copy that, Wideroe 8-3-6. Stay safe.

- Everyone okay back there?

(Narrator): Wideroe Flight 8-3-6 escapes disaster.

No one on board is injured.

- I'm still shaking my head at that one.

That was an ace pilot.

(Narrator): In the city of Bodo,

officials from Wideroe Airlines cancel all flights into Vaeroy

while they try and piece together

what happened with Flight 8-3-6.

As part of an internal investigation,

the pilot is interviewed.

- We were lining up for approach.

Turbulence was getting worse and worse.

I have control.

It was obvious we couldn't land.

I applied power to the engines

and we climbed to about 1800 feet

where we got hit with a massive downdraft.

We're going over.

(passengers screaming)

I battled that plane,

trying to keep it away from the mountains.

Come on!

Come on!

Eventually I was able to level out,

climbed to a safe altitude and turned for Rost.

- It would be terrifying for them, I'm sure.

- I've heard stories about that airport.

And they're true.

(Harald): The pilots were not very happy.

We realized this had been a serious incident

and we had to tighten the operational requirement

at the island to make Vaeroy safer.

(Narrator): The first action taken by Wideroe officials

is to reduce the maximum wind speeds for takeoff and landing

at Vaeroy airport from 20 to 15 knots.

Wideroe asks the Civil Aviation Authority

to install anemometers,

devices that monitor and transmit wind speeds.

Two are installed at each end of the airstrip.

And one is installed on the mountain.

- The mountain is its own weather maker.

It can cause winds to change in direction,

change in speed,

which are conducive to making

some serious turbulence.

(Narrator): It's called terrain-induced turbulence.

When winds hit the mountains on Vaeroy,

they tend to accelerate over the top

and drop down towards the airstrip.

This creates powerful downdrafts and crosswinds.

The sudden changes in wind speeds and direction

can create wind shear

and cause a pilot to lose control.

(Harald): This was a difficult place to operate

when the wind was flowing over the mountains

and down onto the airport

and we had to tighten those restrictions

quite severely and quickly.

(Narrator): But will the restrictions at Vaeroy

be enough to ensure the safety of future flights?

r): It's been 15 months since Wideroe Flight 8-3-6

had their close call at Vaeroy airport.

Wideroe flight 8-3-9 has just landed at Vaeroy

and is refueling before heading back to the mainland

for Easter weekend.

- Anti-collision light.

- On.

- Aft and forward boost.

- On.

(Narrator): Captain Idar Nils Persen

is the pilot in command.

(Harald): Idar was a very level-headed fella.

He was a top-rated pilot and he'd been with us for years.

- Start switch.

- Left engine.

(Narrator): The first officer is Arnt Vidar Gronneflåta.

- On. Right engine.

- Right engine. On.

- The first officer was fairly new.

I think he'd been with us for only about a year.

- Look at that windsock. It's flapping like mad.

- Welcome to Vaeroy.

Buckle up, folks.

It's going to be a bit bumpy getting out of here.

(Narrator): There are three passengers onboard,

including a young couple.

- Vaeroy, Wideroe 8-3-9 ready to taxi.

(radio): Wideroe 8-3-9 roger.

No known traffic, runway free,

wind variable middle direction

2-5-0 at 21 max 57,

QNH Niner-8-8.

- Copy, Niner-8-8.

(Doug): The captain, he was a local pilot.

He knew the weather.

He knew the limitations of the aircraft.

Knew the limitations of the airport.

(Narrator): As they line up at the end of the runway,

the crew performs the Before Take-off checklist.

- Flaps set 10.

- Set 10.

- Heading set to 2-8-0.

- Let's make it 3-2-0.

Just get clearance.

It's calm now. We should get going.

- Copy that.

Tower, Wideroe 8-3-9 requesting clearance.

- Wideroe 8-3-9,

Bodo control clears Wideroe 8-3-9 direct Bodo

at 5,000 feet and squawk 0-1-3-5.

- Copy.

Wideroe 8-3-9.

- Here we go.

- Wind has varied

2-1-0 to 2-9-0 degrees

with gusts of 34.

- Yeah. Roger. We are rolling.

70 knots...

80 knots...

rotate.

(Narrator): At 2:43, Wideroe Flight 8-3-9

takes off from Vaeroy and heads for the mainland.

The return flight to Bodo will take less than 30 minutes.

- Flaps up.

(Narrator): 10 seconds after takeoff...

(rattling)

...a strange noise catches the pilots' attention.

(Harald): You don't want anything unusual to happen

in that phase of the flight

since you are very close to the ground.

(Narrator): They struggle to keep the plane level.

- Steady.

(rattling)

Something's wrong.

(Narrator): And then, the nose of the plane drops

and the captain can't do anything to raise it.

- No, no, no, no.

(passengers screaming)

- Oh God.

(Narrator): Just 63 seconds after lifting off...

Wideroe Flight 8-3-9

slams into the sea.

(alarm sounds)

- Wideroe 8-3-9, this is Vaeroy Tower. Do you copy?

Wideroe 8-3-9, Vaeroy information on 119.4.

(Narrator): Within hours, search and rescue teams

spot debris on the ocean's surface,

6.5 kilometers northwest of the airport.

- The wreckage was found three days after the accident.

Harsh sea conditions made it a challenge.

(Narrator): The bodies of the three passengers

and the first officer are recovered.

Captain Persen remains are never found.

- The accident caused a lot of grief.

Vaeroy is a small island where everyone know each other,

so everyone felt they had lost someone close to them.

(Narrator): Investigators

from the Norwegian Accident Commission for Civil Aviation,

or HSL, soon arrive on the island.

- The purpose of the Wideroe investigation

was to find out what happened during that incident.

- I was manager air safety

for Boeing Canada De Havilland Division,

and I traveled to Vaeroy

to assist with the investigation.

The airfield was spectacular,

but I was somewhat surprised in the closeness

of the mountain range which paralleled the entire runway.

- Thank you.

(Narrator): Investigators start by interviewing the controller,

who briefs pilots on the local weather.

- Sorry about that. - That's fine.

Can you walk me through what happened

the day of the accident?

- A normal day by our standards.

They landed at 14:30.

Refueled, changed passengers and asked to taxi out.

The whole turnaround was less than 15 minutes.

- What were the winds when they took off?

- It was gusting when they were parked

but eased off to 34 on the west end.

The winds were coming from every direction.

It's pretty common.

- Did the pilots have any hesitation about taking off?

- No. None at all.

- And what about the take off?

(Narrator): The controller explains

that after the plane passed the tower,

it turned and then disappeared into the clouds.

- What was the cloud ceiling at the time?

- 1,000 feet.

I received a distress signal

and a few seconds later I heard a bang.

That was fast.

They were airborne for just over a minute.

- Did they call mayday

or relay any information about mechanical issues?

- Nothing.

- That was helpful. Thank you.

(Narrator): Could there have been a structural failure

or loss of power which caused Flight 8-3-9

to crash so quickly into the sea?

s survey the wreckage

of Wideroe Flight 8-3-9

for any signs that would explain a crash

so soon after takeoff.

- Nose and cockpit completely crushed.

Both wings, engines,

undercarriage and tail section

severed from the fuselage on impact

and carried forward.

A high energy impact.

(Jim): With the nose buckled the way it was

and the left wing tip buckled;

we had a pretty good idea

of how the aircraft impacted the sea.

(Narrator): The wreckage tells investigators

the plane entered the water nose first at a high speed.

The team considers whether engine failure

caused the high-speed impact.

The manufacturer provides their report.

- No fire damage.

Both engines appeared to be running at high RPM

and torque at the time of impact.

- The engine manufacturer determined

that the engines were running

and they were ruled out very, very quickly.

(Narrator): With engine failure ruled out,

they wonder whether any parts that control the plane's pitch

or steering failed,

causing it to plunge into the sea.

- The right elevator sheared in half,

maybe due to impact.

(Narrator): The elevator is a control surface

on the Twin Otter's tail that adjusts pitch.

Investigators discover something unusual

in the elevator connecting rod.

The elevator connecting rod

moves the elevators up and down on the tail.

It's activated when the pilot pushes or pulls

on the control column.

- The upper end is broken.

(Narrator): What would cause such a vital part to break?

- You shouldn't have any preconceived notions

as to why the part failed.

- Let's get this elevator rod to metallurgy.

I want to know how it failed.

- Did the part fail

because there was a manufacturing defect?

Did it fail because there was a tool mark on it?

You should let the part tell you the story.

(Narrator): While investigators wait

for the metallurgical results,

they research the plane's history,

looking for any clues into what might have caused

the elevator connecting rod to fail.

- The Twin Otter DHC 6-300

was purchased by Wideroe in 1977.

- The last daily inspection was carried out

the day of the accident.

Maintenance all in accordance with current regulations.

- So not a maintenance issue.

(Phone rings)

(Tor): The investigators went through

all the maintenance documentation.

All the inspections was completed

and no deviations was found.

(Narrator): With maintenance ruled out as a cause

for the failure of the elevator connecting rod,

investigators review the results of a metallurgical examination

performed on the rod.

- There's no pre-existing cracks.

There's banding here and here.

- Banding is created because you have a repeated load

that is applied on and off to your part.

And every time the load is applied,

you have a crack that grows a little bit more

and it creates a rainbow on the fracture surface.

(Narrator): The report also reveals the banding occurred

because of sideways bending on the rod.

(Jim): This was highly unusual.

There's never any side loads on that rod.

It just moves up and down.

So, it didn't make a great deal of sense.

(Narrator): Investigators examine schematics

of the tail section of the Twin Otter

to determine what would bend

the elevator connecting rod sideways, causing it to break.

- So what if this elevator broke in flight?

- It would swing freely, and uncontrollably.

- It would definitely cause the rod to bend.

(Narrator): If the right elevator

separated from its mounts in flight,

it would swing in every direction,

putting sideways pressure on the rod,

and ultimately causing it to break.

- First the elevator. Then the rod.

- It's the only thing that makes sense.

- It's kind of like the cart before the horse.

The control rod would not have seen any loads

had the elevator not broken.

(Narrator): What would cause the elevator to break in flight?

- Maybe the cockpit voice recorder

can shed some light on that.

- Okay let's start with the takeoff roll.

(Narrator): Norwegian investigators

listen to the cockpit voice recorder

for clues as to how the right elevator

on Wideroe Flight 8-3-9 might have come loose,

bending the connecting rod.

(recorder): 70 knots. 80 knots.

Rotate.

(Tor): It was amazing that the cockpit voice recorder

was in the aircraft in the first place

because it was not mandatory at the time.

- Flaps up.

(rattling)

- Did you hear that clattering noise?

- Strange.

(recorder): Steady.

Something's wrong.

(rattling)

Stop. There it is again.

- Was that the elevator?

- Play it back again.

(Jim): When I listened to the CVR,

there was nothing that I could pinpoint

as being the source of the clattering sound.

(rattling)

- Could it have been the elevator breaking?

It was possible but we really just don't know.

- Do you hear the propellers?

(Narrator): Fifty-five seconds into the flight,

investigators hear the sound of propellers

rotating out of sync.

This occurs when there's a change in the aircraft's pitch.

- Turbulence?

- It has to be.

- A sudden gust of wind or change in wind direction

would cause the propellers to adjust

to compensate for the changing attitude of the aircraft.

(Narrator): Investigators discover that Wideroe 8-3-9

was struck by severe turbulence shortly after takeoff.

- The crash happens just 10 seconds later.

(passengers screaming)

- No. No, no, no.

- Oh God!

- So where were they exactly

when they were struck by severe turbulence?

- Well, Standard Operating Procedure calls for a rate

of ascent of 1000 to 12-hundred feet per minute.

- So they would have hit turbulence

right after they entered clouds at about 1000 feet.

And, that mountain ridge there is just over a thousand feet.

- It looks like terrain-induced turbulence.

(Harald): The quicker you could get away from the mountains,

the better it was.

- How bad could those winds have been?

(Narrator): Investigators learn of the near crash

of the other Wideroe plane, Flight 8-3-6,

on approach to Vaeroy, 15 months earlier.

- It looks like they lost control of the plane

for two minutes, even went inverted.

- At what altitude did they lose control?

- About 1800 feet,

just after he aborted the landing on runway 25

due to winds.

(Narrator): Both flights encountered dangerous winds

at or above the mountain ridges.

- Were any measures put into place

to prevent this from happening again?

- After Flight 8-3-6's missed approach,

Flight Order 17 was put into place.

So they made this change,

"Landings and departures must not be planned or executed

with variable winds above 15 knots."

So they reduced the maximum allowable wind speeds

for takeoff and landing.

- Wideroe established some very significant wind restrictions

using some very experienced crew to develop them.

But there was still unpredictability.

- Anemometers were also installed

at both ends of the runway

and on the mountain ridge.

(Doug): It's good to have an anemometer

on top of the mountain.

It just gives the pilot more information for the landing.

- So what were the mountain winds

at the time of flight 8-3-9?

- Huh. There is no anemometer data for the mountain.

- If it doesn't provide data, it's absolutely no use.

(Narrator): Investigators contact

the Civil Aviation Authority

to determine why there weren't any mountain anemometer

wind readings at the time of the crash

of Wideroe Fight 8-3-9.

- Thank you.

The anemometer was taken down.

(Narrator): They learn that the anemometer on the mountain

wasn't reliable because of the icy conditions.

A year after being installed,

it was removed from the mountain for repair.

- It gets worse.

It was never reinstalled.

It was officially taken out of service

three days before the accident.

(Doug): The removal of the anemometer

is a degradation of safety.

It's information that a pilot would certainly require

for an airport like that.

- Okay.

So, what wind information

were the pilots actually getting, and when?

(Narrator): Investigators listen to the CVR recording

of Wideroe Flight 8-3-9, before it landed at Vaeroy.

(recording): I'm going to bank west of the island

to avoid more turbulence.

I'm getting updrafts already.

- Copy that.

- Wideroe 8-3-9. Runway free...

Wind east side 270 degrees at max 23.

- Understood.

Wideroe 8-3-9.

- Twenty three knots.

That's eight knots above the limit.

- They shouldn't even have landed the inbound flight

in the first place.

What about when they were on the ground?

(recording): Look at that windsock.

It's flapping like mad.

- Welcome to Vaeroy.

- The pilot was talking a lot about the wind

and they were discussing that the wind

was coming from all directions.

(air traffic control): Wideroe 8-3-9, roger.

No known traffic, runway free,

wind variable middle direction

at two five zero at 21 max 57.

- Could you say again. Max 57?

- Yeah. Max 57.

- Copy.

- 57 knots.

(Narrator): 57 knots is more than 65 miles per hour.

- Yeah. The manual says that the Twin Otter must not be operated

on the ground in winds above 50 knots.

- He is sticking his neck out on the line

and I'm not quite sure why he did that.

- Were the winds that strong when they took off?

- They go through their pre-takeoff checklist

and then...

- Just get clearance.

It's calm now. We should get going.

- Copy that.

- The captain says its calm.

What's he basing that on? Windsocks?

- The rains had stopped.

Maybe it looked like the weather was clearing.

(Harald): If a shower was approaching,

you could expect variable winds.

But when the shower passed,

you could expect a lull in the wind.

- According to the transcript,

they get their next wind report as they're about to take off.

(radio): Wind has varied two one zero

to two nine zero degrees with gusts of 34.

- Yeah. Roger. We are rolling.

- They took off in a 34-knot wind.

That's more than double the limit.

- If the winds were gusting at 57 knots on the ground,

then who knows how strong the winds were

coming off the mountain.

- Strong enough to break the elevator.

(Doug): When he hit the lip of the mountain,

I bet he encountered 60, 70, 80 knot winds.

It obviously caused severe to extreme turbulence.

- Steady.

(Narrator): The team concludes the winds were strong enough

to break the right elevator from of its mounts,

causing the connecting rod to break,

making both elevators unusable.

- Something's wrong.

- They ignored Wideroe's wind limits on the ground

and they had no wind limits

in the dangerous area around the mountain.

Why were they so eager to leave?

- This was Easter weekend

and there is an incentive to get home.

There was clearly some concern, but they went.

(Narrator): To understand why the Captain of Flight 8-3-9

took off in winds that exceeded company limits,

investigators interview other Wideroe pilots

about wind restrictions at Vaeroy.

- What has been your experience at Vaeroy?

I don't like it, none of the pilots do.

The wind reports aren't reliable.

- You could actually sit on the tarmac,

get one wind indication,

move towards the runway, and get another.

- Even though the maximum wind speeds were reduced

from 20 knots to 15?

- Well they were, but they brought it back up to 20.

(Narrator): Nine months after the incident

with the first Wideroe flight,

the wind restrictions were reversed.

- Why would they do that?

- My guess? Too many cancellations.

(Narrator): After Wideroe lowered the wind limits,

cancellations increased.

That led to negative press and anger from local residents.

- The decision to cancel flights

became very unpopular.

It was so unpredictable at Vaeroy.

- Did pilots feel pressure to complete the flights?

- Yeah, but not from the airline.

(Harald): I had a situation

where the weather turned into a hurricane

and I could not take off.

And I got a real workover from some of the passengers.

(Narrator): Investigators research the impact

those wind related cancellations had on Wideroe's operations.

- Hmm. The pressure was piling on from the public.

- Cancellations tripled in the last 12 months.

- Compared to other airports in Europe,

Vaeroy had a lot of cancellations.

And the flights were often cancelled

quite early when the wind was strong,

but when the flight was supposed to arrive,

it could be no wind at all,

which made people question all the cancellations.

- Almost all the cancellations were being caused by winds.

- Because of that, bad press,

which gets the attention of the government.

(Harald): The government paid the company to fly there.

And the company wrote the government

and said it was extremely difficult to operate there.

And the reply from the government was

if you don't fly there, we will have to take the money away.

- Out of curiosity,

how many cancellations were there on departure from Vaeroy?

- None.

(Doug): Basically it's "get-home-itis."

If they're at the airport, pilots are gonna tell themselves

they're capable of taking off as well.

- You know, there's still one thing I don't get.

If the conditions were so treacherous,

why was this airport even built there in the first place?

s location chosen for the airport?

(Narrator): Investigators consult officials

about the viability of Vaeroy airport

to determine if passengers and crew

were placed at risk unnecessarily.

(Tor): Wideroe had two possible locations

for airport at the island.

This one was chosen despite the difficulties

with wind conditions near a mountain ridge.

- Okay. And what testing went into the decision?

(Lise): Wideroe had done test flights at Vaeroy

prior to the decision of building the airport there.

And they had experienced very windy conditions

and did not recommend building the airport there.

- So if Wideroe was against it, then why did it go ahead?

- We knew that the wind conditions at Vaeroy

would be so difficult it would affect regularity.

But that advice was ignored

by the meteorology specialists

that the authorities had consulted

when it came to put the airport on the island.

- Maybe some of the decisions

that were made were more politically motivated

than were practical.

(Narrator): Investigators now know the factors

that led to the deaths of three passengers

and two pilots onboard Wideroe Flight 8-3-9.

- First up, you have an airport next to a mountain

resulting in dangerous winds.

Lower wind limits are imposed

but the result is an increase in cancellations.

- Which forces the limits to change again.

- The limits go back up,

and then finally the unreliable wind data,

which results in wind reports

being ignored by pilots.

- Rules are established for a reason.

If you don't follow the rules, you're taking a big risk.

(radio): Wind has varied two one zero

to two nine zero degrees with gusts of 34.

- Yeah. Roger. We are rolling.

(Narrator): Wideroe Flight 8-3-9 enters turbulent airspace

when the winds coming off the mountain were extreme.

The force of the winds

causes the right elevator to break free...

- Something's wrong.

(Narrator): ...bending the connecting rod

until it fails.

- No. No, no, no.

- It was subject to aerodynamic loads

that exceeded the structural strength of the tail.

(Harald): It must have been absolutely terrifying

because you would pull the control column

without any reaction at all.

- Oh, God!

(Narrator): The Norwegian Accident Commission

for Civil Aviation

recommends new regulations for the distribution

of wind information to crews

and urges Wideroe to ensure their pilots

follow established restrictions.

- The Captain wanted to get the job done

and he probably got away with it other times,

but this time it didn't work out.

(Narrator): Other recommendations are made

for Vaeroy airport,

but ultimately it is deemed too dangerous

and the airport never reopens to commercial traffic.

- Vaeroy airport was open only four years,

which makes it one of the shortest-lived airports

in the world.

(Harald): I wish that we had put our foot down

and said, "No more."

I wish the company had done the same.

I wish the government and the experts

had listened to our warnings earlier.

Then we might have had our colleagues still alive.

(theme music)

Subtilling: difuze