9th of April 2018, Human Factors, Blog #741
- V2Aviation
- Apr 6
- 3 min read
On Monday, 9th of April 2018, a Hawker Beechcraft King Air B200 was tasked with transporting medical equipment from Oslo Gardermoen (ENGM) to Stavanger Sola (ENZV).
Before the captain arrived, the first officer completed the pre-flight inspection and taxied the aircraft from the hangar to the parking stand. The aircraft had already been refueled the day before.
Once the cargo was loaded, the crew carried out a routine startup and departure. The first officer acted as Pilot Flying (PF), while the captain took the role of Pilot Monitoring (PM). The en-route portion of the flight was uneventful.
Approach to Sola
As the aircraft approached Stavanger, the crew was cleared to descend to 4,000 feet via the ROXON arrival. Standard checklists were completed, and the ILS Runway 18 approach was properly briefed.
However, as the aircraft intercepted the localizer, the autopilot failed to capture it. The first officer disconnected the autopilot and manually corrected back onto the approach path. From that point onward, he flew the approach by hand, stabilizing the aircraft in both lateral and vertical profiles well before landing.
Both pilots later stated that the aircraft was correctly configured with landing flaps and gear extended, and that the landing checklist had been completed. Final approach speed (Vref) was 105 knots.
A Normal Landing… at First
To the first officer, the touchdown initially felt completely normal. Power was reduced to idle, and everything appeared routine.
Moments later, he noticed the captain leaning over to switch off the landing lights and window heating elements.
Then, approximately three to four seconds after touchdown, things changed dramatically.
The first officer felt the left landing gear give way. Almost immediately, the left propeller struck the runway. While his focus remained outside as PF, he caught a glimpse of the captain moving the landing gear lever up—and then quickly back down again. He also saw the propeller levers being moved into feather.
Within seconds, the right main landing gear collapsed, followed by the nose gear. The aircraft began to shake violently as it slid along the runway for approximately 250 meters.
The first officer shut off fuel to the engines, while the captain transmitted “gear collapsed” to air traffic control. Emergency services arrived shortly thereafter.
The Captain’s Account
According to standard procedures, the captain was responsible for operating several switches after landing—located closer to the first officer’s side, including pitot heat and lighting controls.
As he leaned over to reach these switches, he felt an unusual movement in the aircraft. This triggered a thought: “Did I forget something?”
He reached for the landing gear lever to confirm its position.
What happened next was critical.
Instead of verifying, he made a habitual “gear up” selection.
Almost immediately, he realized the mistake and moved the lever back down—but by then, it was too late. The landing gear system had already begun retracting, and the aircraft was committed to collapse.
Human Factors at Play
The captain later explained that he had eaten less than usual that day and had nothing to eat in the cockpit. During the approach, he had even mentioned to the first officer that he felt very hungry.
He also noted that he struggled more than usual with the checklist, having to read it line by line rather than from memory.
In hindsight, he believed that low blood sugar played a significant role. The incorrect gear selection, in his view, was an automatic action—one he likely would have caught with normal cognitive performance.
Investigation Findings
The Statens havarikommisjon (Norwegian Safety Investigation Authority) conducted a detailed investigation into the accident.
Their conclusion was clear:
The aircraft landed with the landing gear either retracted or in transit.
This ultimately resulted in a belly landing despite a fully functional warning system.
The full investigation report (in Norwegian) provides a deeper look into the technical and human factors involved in this incident, click on the .pdf file below to get access to the report.
** Editorial note **
V2 Aviation - Training & Maintenance has not been able to obtain an English-language investigation report for this accident. This blog is therefore based on a translation of the original report in Norwegian. Should there be inconsistencies in the blog, don't hesitate to get in touch with us. There are two possibilities to do that: via the comments function at the bottom of this page or via the contact page of the website.
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