The Accident Investigation Board Norway (AIBN) released the final report of their investigation into a serious incident involving an ATR-42 in September 2005.
The crew experienced uncommanded roll movements in icing conditions.
The AIBN has uncovered several latent contributing factors and safety problems in this investigation. These safety problems can roughly be subdivided into four groups:
– Operation of this aircraft type in icing conditions
– Serious deficiencies in the company’s quality system and flight safety programme
– Insufficient follow-up and rule enforcement on the part of the CAA-N after it had disclosed serious deficiencies in the quality system and flight safety programme in its flight operations inspections of the company over several years prior to the incident.
– The company was assigned two new tendered routes despite the deficiencies in its safety management persisting. (AIBN)