Incident Overview

Date: Wednesday 11 January 2017
Aircraft Type: Cessna 560 Citation Encore
Owner/operator: Hesnes Air
Registration Number: LN-IDB
Location: S of Oslo-Gardermoen Airport (OSL/ENGM) – ÿ Norway
Phase of Flight: Initial climb
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 2
Component Affected: The tailplane.The tailplane.
Investigating Agency: AIBNAIBN
Category: Accident
This incident report details a near-catastrophic event involving a Cessna Citation Encore during a flight from Bern to Oslo-Gardermoen Airport in Norway. The aircraft experienced a series of challenging conditions, including icing, extreme temperatures, and a sudden and rapid dive. The crew initiated a ground stop to mitigate the icing, but the conditions escalated rapidly. The aircraft’s surfaces were significantly chilled, leading to a loss of control and a dangerous maneuver. The pilot’s initial response to the situation, including a pull-out and subsequent descent, was critical in preventing a potentially severe outcome. AIBN’s analysis points to a combination of factors contributing to the incident, including slush and snow accumulation on the tailplane, a malfunctioning de-icing system, and insufficient pre-flight preparation. The crew’s situational awareness and initial actions were crucial in mitigating the risks. The incident underscores the importance of robust crew resource management (CRM) in handling unexpected and extreme flight conditions.This incident report details a near-catastrophic event involving a Cessna Citation Encore during a flight from Bern to Oslo-Gardermoen Airport in Norway. The aircraft experienced a series of challenging conditions, including icing, extreme temperatures, and a sudden and rapid dive. The crew initiated a ground stop to mitigate the icing, but the conditions escalated rapidly. The aircraft’s surfaces were significantly chilled, leading to a loss of control and a dangerous maneuver. The pilot’s initial response to the situation, including a pull-out and subsequent descent, was critical in preventing a potentially severe outcome. AIBN’s analysis points to a combination of factors contributing to the incident, including slush and snow accumulation on the tailplane, a malfunctioning de-icing system, and insufficient pre-flight preparation. The crew’s situational awareness and initial actions were crucial in mitigating the risks. The incident underscores the importance of robust crew resource management (CRM) in handling unexpected and extreme flight conditions.

Description

The Cessna Citation Encore had flown a passenger from Bern in Switzerland to Oslo-Gardermoen Airport in Norway. The crew had planned a shortest possible ground stop before flying to Torp Sandefjord Airport. The captain flew the aircraft (PF), while the First Officer monitored the flying (PM). During the ground stop at Gardermoen, only one engine was stopped while the First Officer completed an external inspection of the aircraft He did not observe any ice or anything out of the ordinary on the areas of the aircraft that could be inspected. There were icing conditions at Gardermoen and in the airspace above the airport. After flying from Switzerland for more than two hours in approximately minus 50øC, the aircraft’s surfaces (fuselage and wings) were more than likely chilled. When the crew requested taxi clearance, they were assigned a different runway than expected. This entailed a longer taxi time and thus longer exposure to the prevailing weather conditions. The aircraft’s ground stop lasted approximately 15 minutes at an air temperature of 0øC. The taxiways and runway were covered with 3-6 mm of slush and it was snowing when the aircraft took off. Initially, the take-off proceeded as normal. The landing gear was retracted and both pilots observed that the speed was rapidly approaching 200 kt, which is the maximum speed with flaps deployed. As the flaps were retracted, the crew experienced a violent nose-down movement and the pilots were “hanging by their seat belts”, while the aircraft started sharply banking to the left. The aircraft at this moment experienced negative 2.62 G. The captain did not trust the instruments while the First Officer had better situational awareness. The First Officer quickly took control and started a pull-out from the dive. The aircraft descended below the cloud base, and even though it was dark, the pilots could glimpse the ground. Control was regained and the aircraft levelled off 170 ft above the ground. The aircraft was overstressed to 5.99 G during the pull-out. The crew called “MAYDAY” to the Air Traffic Control. Once control was regained, the “MAYDAY” was cancelled and the flight continued towards Torp where an approach and landing took place without further problems. The aircraft was overstressed well above Ultimate Load Factor (-2.16 to +5.40 G) and considered not to be economically viable to repair. Primary conclusion: 1. The probable explanation for the aircraft suddenly diving, is that the tailplane stalled. AIBN has not found other explanations for this than slush spray from the runway and falling snow and sleet settled on the tailplane’s leading edge and underside during taxi and take-off. This contamination is presumed to have frozen to ice. 2. The aircraft’s anti and de-icing systems on the wings and tailplane were switched on, but the tailplane de-icing system had completed a “cycle” before take-off and was in rest mode during take-off. In the assessment by AIBN, the aircraft’s anti- and de-icing systems were not suitable to remove the type of ice and snow that had most likely settled on the aircraft’s tailplane. The aircraft should have been de-iced before take-off, in line with the company’s de-icing procedure, to avoid potential consequences of contamination on the tailplane. 3. This accident shows the significance of good crew resource management (CRM) in the cockpit when an unexpected and extreme flight situation occurs. In this instance, the First Officer’s situational awareness and initial pull-out contributed to the aircraft not crashing.

Primary Cause

The probable cause is a combination of factors, with the tailplane stall being the primary driver of the rapid dive. The slush and snow accumulation on the tailplane, combined with the aircraft’s cold surfaces, created a highly unstable situation that led to a loss of control and a dangerous maneuver. The malfunctioning de-icing system likely exacerbated this problem.The probable cause is a combination of factors, with the tailplane stall being the primary driver of the rapid dive. The slush and snow accumulation on the tailplane, combined with the aircraft’s cold surfaces, created a highly unstable situation that led to a loss of control and a dangerous maneuver. The malfunctioning de-icing system likely exacerbated this problem.

Share on:

Leave a Reply

Your email address will not be published. Required fields are marked *