Investigation of serious incident on approach to Bergen airport Flesland, Norway, 20 January 2020 with DHC-8-300, LN-WFO
Aviation report 2023/01
During climbout from from Kristiansund Airport Kvernberget a Widerøe DHC-8-300 inadvertently flew into an area of severe icing conditions. On its approach to Bergen Airport Flesland, the aircraft lost engine power on the left engine, then on the right engine, and then on the left engine again. The aircraft’s automatic ignition system restarted both engines, but the aircraft was completely without engine power for a brief period. The engines flamed out due to ice detaching from the engine air inlets. The crew acted professionally in a highly demanding situation and landed the aircraft safely at Flesland.
The investigation has identified shortcomings in Widerøe’s documentation concerning operations in icing conditions. In addition, The NSIA calls for a warning from the aircraft manufacturer De Havilland that the aircraft’s engines could stop if exposed to severe icing conditions.
The use of weather radar by air traffic services has been a topic in previous NSIA investigations and a new assessment in order to provide this service is needed.
Neither moderate nor severe icing is explicitly defined in the joint European regulations, and the NSIA calls for clear definitions for use by both pilots and meteorological personnel.
The NSIA submits three safety recommendations following this investigation. One is addressed to Transport Canada, one to the Norwegian Civil Aviation Authority and one to EASA.
Published 08.02.2023
Safety recommendation
Safety Recommendation Aviation No. 2023/01T
On approach to Flesland Airport on 20 January 2020, WF577 lost power on both engines after ice detached from the air inlet and entered the engine. The engines quickly restarted and the aircraft landed without problems. The most likely scenario is that the ice accumulated during flight because the aircraft inadvertently entered an area of severe icing with supercooled large droplets (SLD). The weather radar maps from the Meteorological Institute indicate that WF577 received a clearance after departure from Kvernberget which took the aircraft into an area with more icing than if the original flight plan had been followed. It has already been considered to establish a weather radar in Oslo TMA which will be integrated into the new "en route system" (iTEC). NSIA believes that this should also be considered for other areas in Norway, and especially in the north-west region. Being able to provide weather information in real time will make an important contribution to increased flight safety
The Norwegian Safety Investigation Authority recommends that the Norwegian Civil Aviation Authority implement a project in which Avinor, Norwegian Meteorological Institute and representatives from a suitable airline participate to assess possible solutions on presentation of updated (live) weather information that can be communicated to relevant flights.
Safety Recommendation Aviation No. 2023/02T
On approach to Flesland Airport on 20 January 2020, WF577 lost power on both engines after ice detached from the air inlet and entered the engine. The engines quickly restarted and the aircraft landed without problems. The most likely scenario is that the ice accumulated during flight because the aircraft inadvertently entered an area of severe icing with supercooled large droplets (SLD). Although the DHC-8 300 is not certified to fly in such conditions, the pilots should be warned about the potentially serious consequences of ice accumulation in the air inlet.
The Norwegian Safety Investigation Authority recommends that Transport Canada (TC) assures that De Havilland includes a warning in the Airplane Flight Manual (AFM) in which users are informed that the engines may flame out if an aircraft inadvertently flies into severe icing conditions. Ice can build up in the air inlet and subsequently detach and enter the engine.
Safety Recommendation Aviation No. 2023/03T
On approach to Flesland Airport on 20 January 2020, WF577 lost power on both engines after ice detached from the air inlet and entered the engine. The engines quickly restarted and the aircraft landed without problems. The investigation has identified an inconsistency between the definition of severe icing and meteorological forecasts. The definition of icing intensity contains no reference to atmospheric variables related to icing.
The Norwegian Safety Investigation Authority recommends that EASA clarifies the inadequate definitions as well as the existing inconsistency relating to icing problems and ensure that the results are harmonised with other international authorities.
Facts
Location | Approach to Bergen airport Flesland, Norway (ENBR) |
Occurrence date | 20.01.2020 |
ICAO Location indicator | ENBR |
Aircraft | DeHavilland DHC-8 |
Registration | LN-WFO |
Meteorological conditions | IMC |
County | Vestland |
Type of occurrence | Serious incident |
Type of operation | Scheduled air transport |
Category of operation | Heavy, aeroplane (> 10 000kg) |
Aircraft category | Landplane, Multi-engine, Turboprop/turboshaft |
FIR/AOR | ENSV (Stavanger ATCC) |