Scandinavian Airlines Flight 751

Gottröra Crash

Accident summary
Date	27 December 1991
Type	Propulsion loss
Site	Gottröra, Sweden
Passengers	122
Crew	7
Injuries	92
Fatalities	0
Survivors	129 (all)
Aircraft type	McDonnell-Douglas MD-81
Aircraft name	Dana Viking
Operator	SAS
Tail number	OY-KHO
Flight origin	Stockholm-Arlanda Airport
Stopover	Copenhagen Airport
Destination	Warsaw-Frederic Chopin Airport

Scandinavian Airlines Flight 751 was a regularly scheduled Scandinavian Airlines flight from Stockholm, Sweden to Copenhagen, Denmark and Warsaw, Poland that crashed on 27 December 1991. The McDonnell Douglas MD-81 was piloted by Danish captain Stefan G. Rasmussen and Swedish first officer Ulf Cedermark. Ice had collected on the wings prior to take off, which broke off and was sucked into the engines when the aircraft became airborne. After losing both engines, the pilots were forced to make an emergency landing in a field near Gottröra, Sweden. Coordinates: 59°46′6.12″N 18°7′54.6″E / 59.7683667°N 18.131833°E / 59.7683667; 18.131833

The incident is known as Gottrörakraschen (English: Gottröra crash) in Sweden.

Accident

The aircraft had arrived from Zürich on the previous evening and was parked overnight at temperatures of around 0 to 1 °C. About 2550 kg of flight-chilled very cold fuel remained in the wing tanks. Because of this, clear ice had formed on the upper side of the wings, but was not detected. The aircraft was de-iced with 850 liters of de-icing fluid, but not checked afterwards for remaining ice by either the de-icing personnel or the captain.^[1]

At lift-off and rapidly after it, pieces of ice slammed onto the fans of both engines, deforming the fan blades sufficiently to disturb the airflow to the compressors. The disturbed airflow caused the compressors to stall and this in turn caused engine surge. Because the engines were not throttled down sufficiently, the surges continued. The high loads from repeated engine surges quickly led to the breakup of both engines.

The airliner was piloted by Danish captain Stefan G. Rasmussen and Swedish first officer Ulf Cedermark. It was headed to Warsaw, Poland through Copenhagen, Denmark.

From the pilot's point of view, after 25 seconds of flight, noise, bangs and vibrations caused by no. 2 engine being in surge were first noticed. The flight crew responded by throttling down a little, but an automatic system (ATR, Automatic Thrust Restoration) that had not been described to the flight crew by SAS, simultaneously increased throttle as a response to increasing altitude. As a consequence, the engine surges continued. An SAS flight captain, Per Holmberg, who was on board as a passenger, noticed the problems early and hurried to the cockpit to assist the crew. Engine no. 1 surged 39 seconds later, and both engines failed at 76 and 78 seconds into flight, at an altitude of 980 meters.

The pilot responded to the loss of both engines by pitching the aircraft down in a dive before leveling it, to try and have the aircraft glide the longest possible distance without stalling. The pilots requested a return to Arlanda and attempted the restart procedure,^[2] but with the plane breaking through the cloud cover at 270 meters the pilot chose a field in the forest, near Vängsjöbergs säteri in Gottröra, Uppland, for an immediate emergency landing.

During the final descent the plane hit some trees, losing a large part of the right wing. It impacted the ground tail-first, sliding along the field for 110 m, breaking into three parts before coming to a stop. Twenty-five people were injured, two of them seriously, but there were no fatalities. One of the reasons for the lack of fatalities was said to be the brace position that had been instructed by the flight stewardesses.^[3]

The flight crew, and especially Captain Rasmussen, were lauded for the skilled emergency landing in a fast-developing, potentially fatal situation. Rasmussen commented that "few civilian air pilots are ever put to a test of the skills they have acquired during training to this degree"^{[citation needed]} and said he was proud of his crew and very relieved everyone had survived.

Investigation and recommendations

According to the official accident report, the problem of clear ice formation in the wings in this type of aircraft was a well known phenomenon at the time of the accident. From 1985 on McDonnell Douglas gave extensive information, including several "All Operators Letters" that dealt with the clear ice problem. In the "All Operators Letter" of 14 Oct 1986 operators were informed of how Finnair had solved the problem of discovering clear ice. In 1988 and 1989 McDonnell Douglas arranged "Theme Conferences" dealing with clear ice formation. SAS took part in these conferences.^[1]

On 26 October 1991 SAS distributed a "Flight Deck Bulletin/Winterization" to all pilots. It said: "It is the Pilot-in-Charge's responsibility to check the aircraft for any ice or snow that may affect performance" and on the section "Clear Ice" it noted, "Although the awareness within Line Maintenance is mostly good, the responsibility again rests with the Pilot-in-Charge that the aircraft is physically checked by means of a hands-on check on the upper side of the wing. A visual check from a ladder or when standing on the ground is not enough"^[1]

Another contribution to the accident was insufficient training of the crew: they were not trained in restoring engine operation after they repeatedly surged.^[4] There was no simulator or other training on the engine surging problem. Secondly, they were not informed about a pre-installed automatic thrust system (ATR for Automatic Thrust Restoration). The reason for this lapse of information was that there was no knowledge of ATR within SAS. However, ATR was described in manuals by the aircraft builders which every operator is obliged to know. Even though the system was developed for use in procedures not applied by SAS, a sufficiently careful study of the manuals should have led to SAS noting the system and training its pilots in its function.^[1]

The conclusion of the official accident report states:

The accident was caused by SAS' instructions and routines being inadequate to ensure that clear ice was removed from the wings of the aircraft prior to takeoff. Hence the aircraft took off with clear ice on the wings. In connection to lift-off, the clear ice disengaged and was sucked in by the engines. The ice caused damage to the engine fan stages, which led to engine surges, and these triggered irreparable engine failure. The pilots were not trained to identify and eliminate engine surging; furthermore, the Automatic Thrust Restoration system was not known by the pilots, nor noticed by the airline.

In the section "Compressor failures" the report states:

With sufficiently reduced thrust in the right engine and maintained thrust (not increased) in the left engine, the engines would probably not have failed. The aircraft would then have been able to return for landing.

Dramatization

The accident was featured in Air Crash Investigation's episode "Pilot Betrayed", along with interviews of the some of the crew, and the poignant resignation of Pilot Rasmussen.

External links and references

	Denmark portal
	Norway portal
	Sweden portal
	Aviation portal
	Disasters portal

• Swedish Accident Investigation Board (SHK)
  • Final report - Translated from the original Swedish by Tim Crosfield M.A., at the request of the SHK. (Archive)
  • Final report (Swedish) - The original version. (Archive)
• Radio documentary from Swedish Radio P3 about the incident. (Swedish)

1. ^ ^{a b c d} Official accident report
2. ^ Cockpit Voice Recorder transcript for SK 751 Hosted at aviation-safety.net
3. ^ "Brace". Warman.demon.co.uk. http://www.warman.demon.co.uk/anna/brace.htm. Retrieved 2011-01-21. 
4. ^ Accident description at the Aviation Safety Network

Coordinates: 59°46′6.12″N 18°7′54.6″E / 59.7683667°N 18.131833°E / 59.7683667; 18.131833