Circumstances
During a night approach to Namsos Airport, the flight crew encountered poor visibility due to rainfall. The weather conditions were below the established minima for the approach. Despite this, the crew descended below the minimum safe altitude, and the aircraft struck the ground in a swampy area approximately 6 km short of the runway. The impact destroyed the aircraft. Six occupants, including both pilots, were killed. All 13 other occupants sustained injuries.
Investigation Findings
The official investigation determined the probable cause to be a controlled flight into terrain (CFIT). The following specific findings were reported:
- The company had not implemented a standardized concept of aircraft operations that the pilots fully respected and followed.
- The approach briefing was not fully conducted in accordance with the rules. Deficiencies were noted in callouts during the approach, descent rate during the final approach fix (FAF) inbound, timing from the initial approach fix (IAF) outbound, and timing from the FAF to the missed approach point (MAPt).
- The crew did not execute the base turn at the scheduled time, causing the aircraft to end up approximately 14 nautical miles from the airport.
- The pilot flying abandoned the instrument approach and continued a visual approach in darkness without visual reference to the underlying terrain. During this segment, the aircraft's position was not positively checked using available navigational aids.
- Both crew members likely directed most of their attention outside the cockpit after the pilot not flying announced that the airport was in sight.
- The crew was never aware of how close they were to the underlying terrain.
- The final descent from approximately 500 feet indicated altitude to 392 feet may have been caused by inattention to the aircraft possibly being slightly out of trim after the descent.
- Crew cooperation during the approach did not follow Crew Resource Management (CRM) principles and appeared to cease entirely after the pilot not flying called "field in sight."
- Before the accident, the company had not succeeded in implementing standardization and internal control or quality assurance. Management had not adequately emphasized awareness and motivation of employees.
- The self-control system described in the airline operations manual and parts of the quality system were not incorporated into the organization and served as poor safety elements.
- Neither the Norwegian Civil Aviation Authority nor the company had defined what constitutes visual reference to terrain, what sufficient visual references are, or how these references relate to a moving aircraft.