CESSNA 208BHAGELAND AVIATION SERVICES INC
Togiak, AK, USA · 2016-10-02·N208SD
What happened
NTSB summary, verbatimThe NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG.
Photographs
4the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe flight crew's decision to continue the visual flight rules flight into deteriorating visibility and their failure to perform an immediate escape maneuver after entry into instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to the accident were (1) Hageland's allowance of routine use of the terrain inhibit switch for inhibiting the terrain awareness and warning system alerts and inadequate guidance for uninhibiting the alerts, which reduced the margin of safety, particularly in deteriorating visibility; (2) Hageland's inadequate crew resource management (CRM) training; (3) the Federal Aviation Administration's failure to ensure that Hageland's approved CRM training contained all the required elements of Title 14 Code of Federal Regulations 135.330; and (4) Hageland's CFIT avoidance ground training, which was not tailored to the company's operations and did not address current CFIT-avoidance technologies.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · Enroute-cruiseVFR encounter with IMCdefining event
- 2 · Enroute-cruiseControlled flight into terr/obj (CFIT)
Findings
20 causal · 0 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Flight crew
- CAUSEPersonnel issues › Action/decision › Action › Lack of action — Flight crew
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude — Not attained/maintained
- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima — Decision related to condition
- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima — Response/compensation
- CAUSEEnvironmental issues › Physical environment › Terrain › Mountainous/hilly terrain — Response/compensation
- CAUSEEnvironmental issues › Physical environment › Terrain › Mountainous/hilly terrain — Contributed to outcome
- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training › CRM/MRM training — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training › CRM/MRM training — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training — Operator
- CAUSEAircraft › Aircraft systems › Navigation system › Ground proximity system — Not used/operated
- CAUSEAircraft › Aircraft systems › Navigation system › Ground proximity system — Related operating info
- CAUSEAircraft › Aircraft systems › Navigation system › Ground proximity system — Capability exceeded
- CAUSEAircraft › Aircraft systems › Navigation system › Ground proximity system — Design
- CAUSEEnvironmental issues › Operating environment › Communication system › VHF/HF radio — Not specified
- CAUSEEnvironmental issues › Operating environment › Meteorological services › Meteo equip coverage/avail — Not specified
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs — Other institution/organization
- CAUSEAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Not installed/available
Safety recommendations
8 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Although controlled flight into terrain (CFIT)-avoidance training programs are not required by federal regulation for Title 14 Code of Federal Regulations Part 135 fixed-wing operations, work with Part 135 operators in Alaska to improve any voluntarily implemented training programs aimed at reducing the risk of CFIT accidents involving continuation of flight under visual flight rules (VFR) into instrument meteorological conditions, with special attention paid to the human factors issues identified in recent Alaska accident investigations, including, but not limited to, (1) the challenges of flying in mountainous terrain in Alaska and low-altitude VFR flight in an area subject to rapid changes in weather; and (2) limitations of the Alaska infrastructure, particularly weather observations, communications, and navigation aids.
TO THE FEDERAL AVIATION ADMINISTRATION: Work with Title 14 Code of Federal Regulations Part 135 certificate holders that operate under visual flight rules in the aircraft’s required terrain awareness and warning system (TAWS) class to (1) ensure that management and pilots are aware of the risks associated with distraction (from continuous nuisance alerts) and complacency (brought about by routine use of the terrain inhibit feature); (2) develop plans for mitigating those risks and minimizing nuisance alerts; and (3) develop procedures that specifically address when pilots should test, inhibit, and uninhibit the TAWS alerts, considering the operator’s typical operations and the TAWS manufacturer’s guidance.
TO THE FEDERAL AVIATION ADMINISTRATION: Modify the terrain awareness and warning system requirements in Technical Standard Order C151 such that, once the alerts are manually inhibited, they do not remain inhibited indefinitely if the pilot does not uninhibit them.
TO THE FEDERAL AVIATION ADMINISTRATION: Install communications equipment throughout Alaska, after determining what would be most effective, to allow increased access to the instrument flight rules system, giving priority to those areas used by Title 14 Code of Federal Regulations Part 135 operators.
TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that Alaska airports that are served by Title 14 Code of Federal Regulations (CFR) Part 135 operators and have instrument approaches are equipped with weather-reporting capabilities to enable instrument flight rules operations in accordance with 14 CFR 135.225(a).
TO THE MEDALLION FOUNDATION: Expand the criteria for the Medallion stars and shield to include requirements for your members to incorporate Medallion program materials into their Federal Aviation Administration-approved and -accepted training programs and manuals.
TO THE MEDALLION FOUNDATION: Expand the criteria for your safety star to include requirements for a flight data monitoring program.
TO HAGELAND AVIATION: Incorporate into your crew resource management training program ground, simulator, and flight training that define second-in-command responsibilities for dual-pilot operations, including, but not limited to, (1) the use of standard operating procedures and execution of pilot flying/pilot monitoring duties as outlined in Advisory Circular 120-71B and (2) aeronautical decision-making and judgment scenarios that are tailored to Hageland’s flight operations and aviation environment, including communications and teamwork with Operations Control Center personnel.
NTSB analysis
from the final reportThe NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02. On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG.