AT76, en-route, near Førde Airport Norway, 2016

Description

On 14 November 2016, an ATR72-600 (OY-JZC) was being operated by Jet Time for SAS on a
domestic passenger flight from Bergen to Trondheim via Ålesund as SAS 4144. During the first leg of
the flight, the crew continued climbing in day IMC after encountering severe icing conditions and
temporarily lost control of the aircraft before achieving a recovery and completing the remainder of
the flight. No passenger injuries were sustained but there was widespread alarm amongst the
passengers during the loss of control.

Investigation

The event was not notified to the Accident Investigation Board Norway (AIBN) until two days after it
had occurred, when the aircraft operator contacted the Board. The Captain had originally
submitted a ‘Flight Safety Report’ to Jet Time and the Danish Transport Construction and Housing
Authority. The operator later upgraded the report to a Serious Incident. The AIBN was renamed the
Norwegian Safety Investigation Authority on 1 July 2020 by which time this Investigation was almost
complete so no corresponding name change was made to the text of the subsequently published
Investigation Report. Relevant data was obtained from the SSFDR, the QAR, the FDAU (Flight Data
Acquisition Unit) as well as from crew interviews, passenger interviews and ATC voice and radar
recordings. The Investigation “did not have access to recordings from the CVR” for which relevant
data would likely have been overwritten given that the aircraft continued in service.

It was noted that the 60 year-old Captain had a total of 9,423 hours flying experience of which 3,525
hours were on type. He had been employed by Jet Time since 2014, held a Swedish-issued ATPL (Air
Transport Pilot Licence) but had not yet completed the operator’s annually-required UPRT (Upset
Prevention and Recovery Training). Prior to joining the operator he had previously flown ATR 42/72
aircraft as well as other turboprop types including the ATP and the Jetstream whilst working for “a
number of different airlines in Sweden, Norway, Finland and Denmark”. The 51 year-old First Officer
had a total of 7,000 hours flying experience of which 5,850 hours were on type, although only 270 of
these on-type hours had been on the -600 version of the ATR 72. She had been employed by Jet
Time for six months after working for another Danish operator, held a Danish-issued CPL
(Commercial Pilot Licence) and had completed the operator’s annually required UPRT about two
weeks before the event under investigation occurred. Jet Time had previously acquired a small fleet
of new ATR 72-600 aircraft in SAS livery specifically for the SAS contract but this contract was
terminated later in the same month the event under investigation had occurred.

What Happened

Both flight crew had arrived in Bergen the day before and stayed in a hotel overnight. During flight
preparation the next day, they noted that moderate icing was forecast for the first flight leg. Whilst
taxiing out in rain with a 7°C surface temperature, the electric anti-icing systems for the propellers,
windscreens, all flight control horns and key external sensors were switched on and the pneumatic
airframe de icing system, which removed ice from the wing, horizontal stabiliser and vertical
stabiliser leading edges, was cycled.

After takeoff from runway 17 with the First Officer acting as PF, the aircraft was cleared to climb to
FL190 and established on the required northerly track with the AP engaged and a climb speed of
170 KIAS selected. Passing FL100, the aircraft ice detector was activated and the crew responded
by switching on airframe de-icing. The crew observed that as the climb continued, ice started to
form on the aircraft as it passed FL120 and the rate of climb began to reduce. Passing FL127, FDR
data recorded a 765 fpm rate of climb and the Investigation noted that “the data show that during
this period the vertical speed dropped by half in 30 seconds”.

Passing FL137, the Aircraft Performance Monitoring (AMP) system displayed the alert ‘DEGRADED
PER’. Almost immediately, the First Officer reported having seen “two streaks of water or ice
running on her window” and having interpreted this as an indication of freezing rain, she had then
informed the Captain. At the same time, both pilots reported having noticed that ice was forming on
the (electrically heated) flight deck side windows. Selected airspeed was reduced to 165 KIAS and
the power was set to ‘Maximum Continuous’ (MCT) which increased the propeller rpm and would
have assisted ice shedding from the propeller blades.

Passing FL160 at 164 KCAS, an ‘INCREASE SPEED’ APM alert appeared and the aircraft was levelled
off at that altitude, the selected speed was increased back to the original 170 knots and “after a
short discussion, the crew agreed to terminate the climb”. They also decided to reduce altitude
slightly in order not to lose any more speed and on obtaining ATC clearance, a 500 fpm descent
towards FL150 was started with the AP remaining engaged and the engine power was reduced from
‘Maximum Continuous’ to ‘Cruise’. Once at FL150, the 170 knot airspeed began to decrease as
the angle of attack increased. The failure to accelerate or even hold the selected speed was
accompanied by “more and more ice forming on the airframe”.

ATC were advised of the problem and a change of track to the west towards the sea was requested
in the expectation that this would be likely to reduce the severity of the icing. This was approved
and a left turn onto a heading of 330° was selected but the AP then initiated the turn at an
abnormally high bank angle for the airspeed and 12 seconds into the turn, it automatically
disconnected. The left bank “increased abruptly” and simultaneously the stick shaker activated.
The local angle of attack had reached 11.8°.

As PF, the First Officer responded with an attempt to move the control column forwards and to the
right whilst also making a right rudder pedal input. However, the PM Captain simultaneously pulled
back on his control column and the bank angle increased uncontrollably to a recorded 68.2° left.
The First Officer reported finding that “it was unusually difficult to push the control column forward
and wondered if ice had formed on the horizontal tail”. It appeared from their statements that
neither pilot was aware of the fact that they had made opposing pitch inputs, both stating that they
thought “cooperation and communication between them were good”.

During the sharp increase in left bank, the aircraft pitched down to a recorded -3.3° and when the
left bank then changed to a right bank, the pitch attitude decreased further to a recorded -8.1°. The
angle of attack had increased to 14.5° and the stick shaker and stick pusher then activated for two
seconds which recorded data showed had corresponded to the Captain opposing the First Officer’s
continued forward control column pressure. The right bank reached 66.2° before reversing to the
left, this time reaching only 36°. The First Officer continuously responded to the uncontrolled
banking with opposite rudder and aileron inputs. After ceasing for 3 seconds after their first
activation, the stick shaker and stick pusher activated again with the local angle of attack at 15.9°
and again were found to correlate with opposing pitch input by the Captain. Pitch attitude
decreased further to -11.9° and the aircraft quickly lost altitude whilst the forward speed increased
to 190 KCAS and the rate of descent to a maximum of 6,448 fpm before the pitch attitude began to
return towards the horizontal after losing in excess of 1,500 feet of height. However, since the
applicable MSA was 5,800 feet, there had been no risk of collision with terrain.

During recovery from the apparent stall, pitch attitude reached a recorded +12.1° but speed
reduced and when increasing power to maximum continuous again was followed 13 seconds into
the climb by another APM ‘INCREASE SPEED’ message appearing and the speed had dropped to
150 KCAS, the crew eventually decided to descend. Clearance to descend to FL100 was obtained
with approval to operate within the range FL100 - FL140. The track of 330° was continued and on
descent through FL127 at a recorded 212 KCAS, “the ice that had formed on the airframe started to
disappear” and the AP was re-engaged 3 minutes and 23 seconds after it had disconnected. By
FL110, all the airframe ice visible had disappeared and the APM ‘DEGRADED PERF’ alert, which had
been continuously active for around 15 minutes ceased.

The Captain made a short PA and the flight subsequently reached Ålesund after a total of 48
minutes airborne without further event. During the 20 minute transit stop there before continuing to
Trondheim, the First Officer went into the cabin and informed the cabin crew that the aircraft “had
been exposed to icing” but did not provide any further details about what had happened and other
than the Captain’s earlier brief PA, the passengers were given no further information. Also, since
neither pilot reported having “felt uncomfortable” about continuing with the remainder of their four
sector duty that day, “neither considered declaring themselves unfit for further service” and
completed it.

The Investigation interviewed two passengers who had been on the flight and were very familiar with
such flights as passengers, one of whom was also a PPL (Private Pilot Licence) holder. He had been
seated in row 2 on the right and the adjacent seat was unoccupied. From this position, he had been
able to see the right engine and propeller as well as most of the wing leading edge outboard of the
engine nacelle. He stated that on departure from Bergen, cloud was soon entered and that he had
then seen “an increasing amount of white ice forming on the leading edge of the wing as well as on
the propeller spinner and the engine nacelle”. He also observed the operation of wing leading edge
de-icing boots and heard the sound of what he had presumed was ice shed from the propeller
blades hitting the side of the fuselage. At one point, he thought he had detected an increase in
propeller rpm and a simultaneous reduction in ice shedding impacts. He also “observed that the
de-icing boots did not manage to remove all the ice (and) saw that the ice along the wing leading
edge changed character and colour (and) seemed clearer and more translucent”.

As the aircraft stopped climbing and appeared to level out, he noticed that it “started buffeting
(and) identified this as the initial stage before a stall” finding it “strange that the crew did not lower
the nose of the aircraft to prevent this”. When he saw the wing drop and the nose of the aircraft
pitched sharply down, he was “convinced that the aircraft had stalled” and had “feared the worst
and that he would not survive”. He also stated that “other passengers on the aircraft were
screaming”'. After the recovery, he heard the Captain make a PA announcement '“informing the
passengers that the crew had regained control of the aircraft” and having “interpreted this as
confirmation of the severity of the situation that had occurred” he had expected to be given more
information about what had happened on arrival at Ålesund and “expressed disappointment that
this did not take place”. The second passenger interviewed had similar but “less
technical” recollections and had similarly formed the opinion from the “severe” wing drops, sharp
nose pitch down and the Captain’s subsequent very brief PA after it was over as “confirmation that
the incident had been serious”. He added that he had “never experienced anything like it before”.

An animation of the loss of control trajectory (download, 200mb) was created during the
Investigation.

The Context for What Happened

The forecast weather for the route valid for the time of departure included a locally produced
forecast significant weather chart and an AIRMET which both indicated that moderate icing should
be expected en route. The route was expected to be just behind and parallel to an active eastward-
moving warm front. Following ATC awareness of the investigated event, an AIREP SPECIAL was
issued for severe icing at the event location encountered by the AT76 at FL150.
The Norwegian Meteorological Institute, which was responsible for aviation weather service,
subsequently informed the Investigation that whilst they had concluded that moderate icing was
the appropriate forecast, especially in areas where the orographic lift was strongest, this icing was
expected to be “close to severe”. They added that after the report of the investigated severe ice
encounter was received, “new assessments were made according to the procedure, and a ‘SEV
ICE’ SIGMET was issued”.

It was noted that five minutes before the ATR 76 took off from Bergen, a rather smaller passenger
aircraft, a DHC8-100 operating a Widerøe flight to Kristiansund, had taken off and followed a
parallel, but slightly more easterly, route north. The Captain of the Wideroe flight informed the
Investigation that after climbing for about 25 minutes, the planned cruise altitude of FL230 had
been reached without airframe icing “being of a particularly noticeable nature". The climb profiles
of the two aircraft are shown on the illustration below which clearly shows the reduced climb
performance of the ATR 72 above FL110 compared to a normal climb, which could have been
expected to continue similarly to that of the DHC8 had the icing conditions not affected its climb
rate. It was notable that the DHC-8 had passed close to the location of the ATR 72 loss of control
three minutes before it occurred but by then it was at FL230.

The vertical profiles of the ATR72 (SK4144) and the DNC8 (WIF564). [Reproduced from the Official
Report]

It was noted that following the introduction of the ATR 72 in 1989, airframe icing risk soon became a
focus for action after the fatal accident to an ATR 72-300 at Roselawn in the USA in 1994 when the
NTSB Investigation found that the roll upset which caused the accident had been due to an aileron
hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-
icing boots during earlier holding in icing conditions which had been - unknown to the crew -
outside the icing certification envelope.

Having modified the aircraft design to address this problem, ATR subsequently began a wider
review of both the design and the operating procedures relevant to flight in icing conditions. Design
modifications were made to improve banking stability in both icing conditions and in the event of
stalling and the introduction of the Aircraft Performance Monitoring (APM) function, which was
specifically configured to address avoidance of severe icing conditions. This does not use any
dedicated sensors or any calculation of atmospheric ice content, it simply compares actual aircraft
performance with the expected performance and computes the actual minimum icing and severe
icing speeds for the given flight conditions. These data were the source of the ‘DEGRADED PERF’
and ‘INCREASED SPEED’ messages annunciated during the investigated event. Icing-
related SOPs were also modified. A new memory item was added to both the stall recovery
procedure and the abnormal roll control procedure to require the selection of flaps 15 if not already
set and, since it was considered that use of the AP may mask the signs that control is about to be
lost, the severe icing procedure was modified to require that it must be disengaged if such
conditions were encountered. All changes as a result of this effort were incorporated in the ATR 72-
600 which remains in production.

The Investigation did note a potential lack of clarity in respect of the QRH drill for recovery from a
wing drop and/or stall in that it was found to make no mention of aileron or rudder use whereas the
Flight Crew Operating Manual (FCOM) contained a cautionary note about the use of rudder which
stated unequivocally that, unless an aileron jam has occurred, rudder should not be used to induce
or counter roll, adding that “aggressive, full or nearly full opposite rudder must not be
applied” because such inputs can lead to control loading beyond the limit or possibly the ultimate
limit and cause structural damage or failure. Given the First Officer’s use of both aileron and rudder
to oppose the rolls experienced when stalled, the Investigation raised the issue and ATR then made
it clear that only the ailerons must be used to level the wings and that, in such a situation, the use
of rudder should be avoided.

The flight crew’s decision making prior to and during the flight and aircraft handling during it were
both considered and some observations, including but not limited to the following, were made (in
summary) as follows:

• Both pilots told the Investigation that “they hoped to climb above the cloud and thus above
the icing conditions” and seemed to have been surprised that this did not happen when
they expected it to. This was considered to be an indication that they had not made a
sufficiently thorough pre-flight assessment of the relative severity of icing on the track to be
used or how high up icing would occur or that it may (as it appears to have done) increase in
intensity above FL100, something to be expected when relatively warm maritime air rises
over mountainous terrain.

• Although it was not clear whether there had been any visual signs of ice accretion before
the ice detector warning light illuminated, the FCOM procedure requires activation of the
airframe de-icing at the first indication of ice accretion without waiting for the ice detection
to be activated.

• Over the next few minutes, there were multiple indications that icing was developing into a
problem and soon there were two clear indications that severe icing had been encountered
and that the icing intensity had surpassed the capacity of the aircraft ice protection
systems. These indications were the decreased rate of climb and the decreasing airspeed
which had activated the ‘DEGRADED PERF’ APM alert and the appearance of streaks of
water/ice along the window, both mentioned under ‘Detection’ in the Severe Icing Checklist.
The required procedure was to disconnect the AP and immediately exit icing neither of
which was done.

• Having continued to attempt to climb for a further one thousand feet in circumstances
where it was completely contrary to procedures to do so, on levelling off and having to
accept that further climb was impossible, the ‘INCREASE SPEED’ APM alert was activated.
 It became necessary to use the ‘SEVERE ICING’, ‘DEGRADED PERF’, AND ‘INCREASE
SPEED’ Checklists one after another. It was noted that one item in all of these checklists
was a requirement to ensure that the indicated airspeed remained at least 10 knots
above the preset ‘Icing Bug’ speed which on this flight was 156 knots, but this was not
done.

• Having descended back to FL150, using the ‘Cruise’ power setting, power was not returned
to ‘Maximum Continuous’ despite still being in severe icing conditions which required
this.

• On levelling at FL150, the altitude hold mode of the AP was selected despite still
experiencing icing. It was noted that as the AP gradually and imperceptibly increased the
angle of attack in order to compensate for the loss of lift and increased drag as ice built up,
this, in turn, would have exposed the aircraft to the further icing that eventually led to loss of
control.

• Once at FL150 and having decided to change course seawards, there was a delay talking to
ATC to arrange this which “resulted in unnecessary loss of time in an already tight time
frame”. Since this delay and the ice accretion which occurred was enough to create the
conditions for a stall, it was concluded that following the old, but still current, pilot task
prioritisation mantra of "Aviate-Navigate-Communicate" had been applicable.

• When the right turn was commenced, it was made using the HDG function of the AP which,
as the angle of attack continued to increase resulted in an abnormally high bank angle of
around 30°.

• As the airspeed dropped in the turn, the angle of attack eventually reached the stick shaker
threshold which automatically disconnected the AP and immediately released the aileron
deflection required for the turn. It was not clear whether this or the wings being stalled (or
close to stalling) had caused the sudden left wing drop, although the latter was considered
as an explanation for the subsequent sharp roll to the right.

• It was not possible to determine whether the First Officer’s prompt response to the wing
drop had improved the situation. FDR data showed no indications of aileron hinge moment
reversal having occurred and it was concluded that it was not a factor.

• The angle of attack may have been increased during both stick shaker activations by the
Captain opposing the First Officer’s pitch down attempt and may have contributed to the
first sharp roll to the left when it was not reduced quickly enough. The Investigation
was “not able to determine whether the aircraft actually did experience an aerodynamic
stall, or if the nose pitched down due to elevator inputs”.

• Neither pilot seemed to have noticed that they were applying opposite forces on the control
column nor the two stick pusher activations. Two important memory items from the ‘Stall or
Abnormal Roll Recovery’ Checklist, Flaps 15° and Power to Maximum Continuous were
omitted. It was noted that it is unusual for extending flaps to be part of a stall/abnormal roll
recovery procedure but considered that this may have a stabilising effect on aircraft that
lack sufficient lateral stability near the critical angle of attack.

• It was concluded that the Captain’s inappropriate initial response may have been a result
of startle effect.

• It was noted that there seemed to have been no callouts when the loss of control occurred.
Relevant calls would have been ‘STALL’ when the stick shaker activated and if the Captain
 had wanted to take over control he should have called ‘MY CONTROLS’ and received the
acknowledgement ‘YOUR CONTROLS’. Timely callouts may also have prevented ‘startle
effect’. It was found that Jet Time had standards for callouts in the OM but none referred to
these two circumstances.

• It was, however, recognised that the crew had “managed to recollect themselves and gain
control of the situation, thus averting an accident”.

The Investigation considered that it was “hardly a coincidence that the First Officer, who had
recently completed simulator training as part of her UPRT requirement, was the one to respond
correctly when she tried to push the control wheel forward when the stick shaker activated”'. It was
concluded that “considering the occasionally challenging flying conditions along the Norwegian
coast during the icing season, it would probably have been better had the Captain not been
assigned these routes until he had completed this annual training requirement”.

Finally, the Investigation noted that it had previously been concerned at the effectiveness
of regulatory oversight of ACMI (Aircraft, Crews, Maintenance, Insurance) operations like the one in
this case where an operator from another jurisdiction undertakes flights for an operator’s flights, in
this case with aircraft bearing an external appearance to the lessor’s own aircraft. Reference was
made to this issue in the investigation of both a 2008 Sikorsky S61 event near Bodø in 2008 and a
BAe 146-200 event at Stord in 2006.

The concern in both the current investigation and these two earlier ones was the risk of inadequate
operational safety oversight when fully crewed aircraft are operated on behalf of a Norwegian AOC
holder by aircraft approved for operations under the AOC of a foreign operator. The operational risks
foreseen previously and reviewed again here were:

• The unfamiliarity of foreign operators with Norwegian winter conditions.

• A lack of information transfer between the two aviation authorities with an interest in such
an operation.

• The possibility of the object of inspection, in this case Danish operator Jet Time operating
aircraft based long term in Norway “falling between two stools”.

In respect of the current Investigation, an explicit concern was that “icing sensitivity did not appear
to have been given special attention", either by Jet Time, SAS or by the Scandinavian regulatory
authorities and it was not a subject included in the Danish regulatory oversight regime for Jet Time
prior to the investigated event. It was therefore stated that the AIBN would like to call attention to
the following relating to operations during the icing season:

• The Norwegian icing season must be characterised as challenging, particularly along the
coast.

• The icing certification of the majority of existing aircraft types give little or no guarantee of
the aircraft's resistance and performance should it encounter icing conditions
involving SLD.

• This and two other serious icing incidents involving the ATR 72 500/600 (see below) illustrate
the importance of monitoring airspeed and climb in order to operate this aircraft within its
defined performance limitations.

Recent Similar Occurrences

It was noted that similar airframe icing loss of control events have occurred to two other ATR72
aircraft, an ATR72-500 in the UK in 2016 and an ATR 72-500 in Spain in 2017.
In addition to the fact that the commander of the aircraft in the Spanish event also initially reacted
by pulling the control wheel back when the stick pusher activated, a number of significant
similarities were observed between both these events and the one under investigation:

• Prior to losing control of the aircraft, the crew had tried to climb out of the icing conditions.

• The aircraft autopilot was engaged in severe icing conditions.

• The airspeed dropped to below Vmin-ops + 10 knots.

• The aircraft went into a combination of large uncontrolled banking excursions and pitching
oscillations.

It was also noted that both of these aircraft were equipped with the same upgraded icing protection
system as the aircraft which was the subject of this investigation.

The main Conclusions of the Investigation included the following:

• The loss of control was the result of a combination of insufficient planning and
inappropriate decisions en route, particularly the crew's attempt to climb above the icing
conditions despite degraded aircraft performance and the continued use of the autopilot
when it should be been disconnected.

• Recovery of control may have been impeded by the Captain’s initial response of pulling
back on the control column as the stick shaker activated. It is likely that he became startled
when the stick shaker activated and the autopilot automatically disconnected whilst at the
same time, the aircraft suddenly banked sharply and simultaneously pitched nose down.
He may consequently have pulled the control wheel back due to the so-called startle
effect.

• The non-optimal recovery of control was affected by the omission of two memory items on
the checklist for stalling/abnormal roll control, the deployment of flaps and the increase in
engine power.

• In-flight icing should be a priority item in risk analyses for airlines when planning to operate
in Norway during the icing season, and that it is important to take the characteristics of the
aircraft type into account. Such analysis should conjointly consider the routes and flight
levels flown, expected icing conditions and mitigation of the consequences of adverse en
route weather conditions including icing, taking account of the aircraft type involved and its
specific performance capability.

Safety Action taken by ATR following this event was noted as having included the following:

• The issue of the revision 3 of the ‘Aeroplane Upset Prevention and Recovery Training Aid -
AUPRTA’ in cooperation with ICAO, Airbus, Boeing, Bombardier and Embraer in February
2017 and the adoption of the AUPRTA Manual procedures with a view to identifying
objective criteria for providing better decision support for crews.

• The speed margin for high bank angle protection now takes into account the APM degraded
performance alert so that if this is active, the high bank (30°) speed threshold will increase
to the applicable manoeuvring speed in icing conditions plus 20 knots instead of plus 10
knots.

The Final Report was published on 9 September 2020. No Safety Recommendations were made.