What happened
On December 26, 2001, at approximately 10:12 AM, a Britten Norman BN-2B-26 departed from the Bremerhaven/Am Luneort airfield for a scheduled VFR flight to Wangerooge. The aircraft was carrying a pilot and eight passengers. Prior to departure, a heavy snow shower had passed over the airfield, leaving the aircraft covered in snow.
Shortly after takeoff from runway 34, the aircraft entered a climb that failed to gain significant altitude. After crossing a nearby dike, the aircraft leveled off but began to lose altitude while executing a left turn over the Weser river. The aircraft banked sharply to the left, causing the left wing to strike the water surface. The nose then dipped into the river, and the aircraft sank rapidly. Of the nine people on board, 8 fatalities and 1 serious injury were recorded. Three individuals were rescued from the water, but only one passenger survived.
The investigation
The BFU investigation focused on the aircraft's condition and the operational procedures of the air carrier. Investigators examined the aircraft's wreckage and engines, finding no mechanical defects in the powerplants. The investigation also reviewed meteorological data, which confirmed recent snowfall and a wet, slushy runway surface.
Crucially, the BFU examined the company's operations manual (FBH), which contained specific instructions for winter operations. The investigation found that while these procedures existed, they were not known to the pilot, rendering them ineffective. Furthermore, the investigation looked into the organizational structure of the operator, noting a lack of separation between management and technical oversight roles.