Investigation Summary
Flight 744 was a scheduled domestic service from Trondheim to Namsos. During the approach, the crew encountered poor visibility due to rain and wind reaching 30 knots. The aircraft was not equipped with a Ground Proximity Warning System (GPWS), which was not legally required for the Twin Otter at the time. The investigation revealed that the crew failed to execute the base turn at the scheduled time, resulting in the aircraft being approximately 14 nautical miles from the airport when they began their final descent. The Pilot Flying transitioned to a visual approach in the dark without positively checking the aircraft's position using available navigational aids. Crew cooperation effectively ceased after the Pilot Not Flying announced he had the field in sight, leading to a lack of altitude awareness. The aircraft descended to 392 feet, striking the terrain while the crew remained unaware of their proximity to the ground. The aftermath was marked by a legal battle between the police and the accident board over access to the Cockpit Voice Recorder (CVR), which the airline had voluntarily installed despite no legal requirement to do so.
Final Conclusions
The Accident Investigation Board Norway (HSL) published its final report on July 10, 1996. The board concluded the primary cause was pilot error, specifically descending below minimum safe altitude without visual terrain reference. However, the report placed heavy systemic responsibility on Widerøe, citing a failure to implement standardized operational concepts and poor safety governance. The investigation found that the approach briefing was incomplete, call-outs were deficient, and CRM was not followed. The Norwegian Prosecuting Authority declined to charge the airline in 1997, noting that direct culpability lay with the deceased pilots.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Jan Bjørstad, age 43
First Officer
Systems & Failure Modes
Ground Proximity Warning System (GPWS)
The aircraft was not equipped with GPWS, which would have provided an automated alert as the aircraft descended toward the terrain.
Cockpit Voice Recorder (CVR)
Although not required for this aircraft type, the airline had installed a CVR. The data was used by investigators to determine that CRM had broken down during the final approach.
Instrument Landing System (ILS)
Post-crash testing confirmed the airport's ILS was functioning correctly, ruling out ground-based navigation equipment failure.
Interesting Facts
- 01The aircraft was a De Havilland DHC-6 Twin Otter, registration LN-BNM, serial number 408, built in 1974.
- 02The crash occurred approximately 6 kilometers (3.7 miles) short of the runway threshold.
- 03The airline voluntarily installed a CVR, though not required by law, which became the center of a major legal dispute regarding police access.
- 04Widerøe grounded approximately ten pilots following the accident for failing to follow company routines during observations.
- 05The accident was the fifth fatal Twin Otter crash in Norway and the fourth fatal Widerøe accident in eleven years.
Safety Actions & Advisories
Operational Reorganization
Widerøe reorganized its aircraft operation and quality assurance divisions and overhauled its internal reporting systems.
Pilot Standardization
The airline implemented stricter observation and training protocols, leading to the grounding or retraining of pilots who did not adhere to standard operating procedures.
Fleet Modernization
Widerøe accelerated the replacement of Twin Otter and Dash 7 aircraft with newer Dash 8 models to improve overall fleet safety and efficiency.
Known Controversies & Unanswered Questions
CVR Access Dispute
Reference ↗A significant legal conflict arose between the Accident Investigation Board (HSL) and the police over the Cockpit Voice Recorder tapes. The police sought the tapes for criminal investigation, while the HSL and pilot unions argued they should be protected to encourage open safety reporting.