Operator & FAA Shortcomings in Alaskan B1900 Accident
UPDATE 10 April 2018: with details below of further NTSB recommendations after a 2016 C208B accident
The US National Transportation Safety Board (NTSB) has reported on a Beechcraft 1900C accident on the North Slope of Alaska on 23 Nov 2013. The B1900C was being operated by Hageland Aviation Services (doing business as [dba] ERA Alaska) on a passenger shuttle for an oil and gas company to a remote production site. The aircraft, N575X, sustained substantial damage during the landing accident, but neither crew or the single passenger were injured.
The NTSB investigation identified shortcoming in procedures, training and oversight (both by the company and the Federal Aviation Administration [FAA]).
This accident highlights the importance of contractual safety requirements and effective assurance when contracting in air services and operating remote airfields.
The NTSB Investigation
Before departure from Deadhorse on the short flight to Badami, the weather at the destination airport was reported to be wind from the northeast at 27 mph, scattered clouds with blue skies above, and 1.5 statute miles visibility with blowing snow. As the Alaska Dispatch News reported, during the short flight the airport weather observer informed told the NTSB that he notified the pilots he could “…occasionally see the cold storage camp, which was located ‘1.25 miles away,’ but he did not consistently have 1 mile visibility.” The observer further described the weather as “bad” and that he could sometimes not see the runway. He apparently he advised the pilots to “use their own judgment”.
The NTSB comment that “At the time of the accident the Badami METAR reported in part: wind 120 degrees, variable 060 degrees thru 210 degrees, at 30 knots, visibility 0.5 sm in heavy blowing snow, broken clouds at 1,000 feet, and temperature -16 degrees F”. The captain told the NTSB his visibility “…was unrestricted and that he had the runway environment in sight 20 miles from the airport.”
After a brief hold, apparently believing visibility was 1 statute mile, he asked the FO to load the instrument approach into the GPS and the approach commenced.
The Captain described the approach as normal until he realized he “was too low.” However, the FO told the NTSB he voiced concerns multiple times while on approach, finally saying “watch out,” just prior to impact. The aircraft touched down short, the right main landing gear separated and the aircraft slid along the runway.
The investigation does not appear to have reconciled the differences in Captain, FO and weather observer’s statements. This was hampered by the CVR data being overwritten by post-incident engine runs. The ADN reported that the company explained:
This particular CVR issue had to do with the configuration of our BE1900C aircraft, some of which have both a CVR and an FDR and some of which only have a CVR. When the mechanic was dispatched out to retrieve the CVR, he accidentally retrieved the FDR only thinking that he had sent in the CVR. Weeks later, when it was discovered that we had pulled the FDR, the engine runs had already been completed after the replacement of the propeller. The CVR and FDR are both in similar orange boxes and everyone thought the CVR was secured.
When examined, the FDR did show the accident sequence and was consistent with the reports provided by the flight crew. The company had a pre-flight risk assessment process. According to the NTSB it wasn’t completed before the accident flight. The NTSB note:
According to the company, the risk assessment was part of its operational control and flight release system and was presented to and accepted by the FAA but was not incorporated into the GOM [General Operations Manual], training program, or other company manuals.
At the time of the accident, the company’s flights in the area were managed by a local flight coordinator. The flight coordinator had been with the company for 6 or 7 years, but told investigators she had not undergone training. This was contrary to requirements in the operator’s Operations Manual, which required eight hours of initial training and three-four hours of recurrent training annually. The Alaska Dispatch News report that:
Now, according to operational control center manager Greg Tanner, every single Hageland pilot departing from an out station must contact dispatchers in Palmer to receive a flight release. Based on a company-developed risk level assessment, the departure is either approved or may require discussion with upper management. The flight release is active for 30 minutes and if the flight hasn’t departed by then, the pilot must contact Palmer again. According to Tanner, the center averages 140-160 flight releases each day. “This system takes the pressure [to fly] away from the local stations,” Tanner said in a recent phone interview. “Here at the center, our only job and motivation is that the flights be safe and legal.”
In relation to FAA oversight, the FAA report:
A query of the FAA Program Tracking and Reporting Subsystem found that from July 16, 2013, to October 22, 2013, five operational control inspections were completed by FAA aviation safety inspectors. The inspections noted deficiencies in the company’s training, risk management, and operational control procedures. Enforcement Information System records provided by the FAA indicated that FAA inspectors observed 11 instances of the operator’s noncompliance related to flight operations, prompting the initiation of investigations. Between July 2009 and November 29, 2013, the 11 noncompliance investigations were closed with no action taken greater than administrative action.
However no specifics are provided on the nature or significance of these deficiencies (and the NTSB Public Docket is noticeably thin).
The NTSB concluded the probable cause and contributory factors were:
The captain’s decision to initiate a visual flight rules approach and attempted landing into an area of instrument meteorological conditions, which resulted in the airplane touching down short of the runway.
Contributing to the accident was the operator’s inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel.
Also contributing to the accident was the Federal Aviation Administration’s failure to hold the operator accountable for correcting known operational deficiencies and ensure compliance with its operational control procedures.
Although the NTSB made no recommendations on publication of this report in March 2015, in May 2014 they had previously made two recommendations urging the FAA to audit HoTH, Inc., the parent company of Hageland, and its other subsidiaries. The NTSB explain that:
In 2008, HoTH, Inc., an Alaskan corporation, became the parent holding company of Frontier Flying Service; Hageland Aviation Services, Inc.; Era Aviation; and Arctic Circle Air. In January 2014, Era Alaska announced that its brand, which includes Era Aviation; Hageland Aviation Services, Inc.; and Frontier Flying Service, was rebranding as Ravn Alaska. Through this change, Era Aviation would become Corvus Airlines, operating under the provisions of 14CFR Part 121; Hageland Aviation Services, Inc., and Frontier Flying Service would operate as Ravn Connect, operating under the provisions of 14 CFR Part 135.
There is no longer any connection with Era Helicopters, which is a separately owned organisation.
Ravn has many of the characteristics we seek in investment candidates – leading market positions, largely non-discretionary demand for its services, a loyal and longstanding customer base and a strong track record of performance. We plan to invest in growth and operational improvement initiatives to further enhance the service level provided to the residents and businesses of Alaska.
Era Alaska had previously featured in the Discovery Channel series Flying Wild Alaska which ran for 3 seasons in 2011-2012 and focused on former co-owner Jim Tweto and his family. Tweto’s brother Ron died in a B1900C CFIT accident in 2002. The NTSB report on that accident is here.
This investigation followed a total of six accidents in 19 months, two fatal, plus one incident across the group of companies:
- 5 September 2012 Era Aviation (Part 121 – dba Era Alaska) Bombardier Dash 8-103 N886EA experienced an uncommanded left roll incident consistent with a stall and uncontrolled 5000ft descent near Soldotna, Alaska. Investigation report awaited (but the Operations Group and Human Factors Group factual report are available).
- 3 December 2012 Hageland Aviation Services (Part 135 – dba Era Alaska) Cessna 208B N169LJ made a forced landing shortly after takeoff from Mekoryuk, Alaska Probable Cause: The total loss of engine power as a result of a fractured first-stage compressor blade due to fatigue cracking. The source of the fatigue crack could not be determined due to secondary damage sustained to the fracture surface.
- 4 May 2013, Hageland Aviation Services (Part 135 – dba Era Alaska) Cessna 207 N9400M collided with terrain during the second attempt to land at Newtok, Alaska Probable Cause: The pilot’s continued flight into adverse weather and his failure to maintain clearance from terrain while on approach in flat light conditions. Contributing to the accident was the pilot’s delayed decision to initiate a go-around.
- 23 October 2013 Era Aviation (Part 121 – dba Era Alaska) Beechcraft 1900C N575U experienced a nose and main landing gear collapse while landing at Homer, Alaska. UPDATE 2 September 2015: Probable Cause: The first officer inadvertently selecting the landing gear handle up after touchdown during the landing rollout. Contributing to the accident was the first officer’s decision to reconfigure the airplane while still on the active runway. See also the local press reports here and here.
- 22 November 2013 this accident occurred to Hageland Aviation Services (Part 135 – dba Era Alaska) Beechcraft 1900C, N575X at Badami, Alaska. Probable Cause issued (see above).
- 29 November 2013 Hageland Aviation Services (Part 135 – dba Era Alaska) Cessna 208B Caravan N12373, impacted terrain about 1 mile southeast of St. Mary’s Airport, Alaska. The pilot and three passengers died and six passengers sustained serious injuries. Investigation report awaited. UPDATE 23 April 2015: The NTSB has released the public docket (available on the NTSB web site here). UPDATE 26 Feb 2016: NTSB issue Probable Cause: The pilot’s decision to initiate a visual flight rules approach into an area of instrument meteorological conditions at night and the flight coordinators’ release of the flight without discussing the risks with the pilot, which resulted in the pilot experiencing a loss of situational awareness and subsequent controlled flight into terrain. Contributing to the accident were the operator’s inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration’s failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
- 8 April 2014 Hageland Aviation Services (Part 91 - now dba Ravn Connect) Cessna 208B Caravan N126AR impacted terrain, during a Part 91 training flight, about 22 miles southeast of Kwethluk, Alaska. The two pilots were killed. Investigation report awaited. UPDATE 26 Feb 2016: NTSB issue Probable Cause: The check airman’s delayed remedial action and initiation of a recovery procedure after a simulated pitch trim excursion, which resulted in a loss of airplane control.
The FAA responses can be found here: A-14-022 and A-14-023. The Alaska Dispatch News covered the ‘fallout’ last July. The group has in the order of 58 aircraft, flying around 60,000 flight per annum.
UPDATE 31 August 2016: There were five fatalities when Ravn Cessna 208B Grand Caravan EX N752RV suffered a mid air collision with a Piper Super Cub N82452 near Russian Mission, AK. Three died aboard the C208B and two in the Piper.
UPDATE 2 October 2016: A Hageland Aviation Services Cessna 208 Caravan N208SD operating as Ravn Connect Flight #3153 impacted mountainous terrain 12 statute miles NW of its intended destination, Togiak, AK. All three occupants died.
UPDATE 14 July 2017: The operator hosted an air safety forum.
UPDATE 18 July 2017: The NTSB announce they will hold their first hearing in Alaska since Exxon Valdez to examine the N208SD accident on 17 August 2017.
Among the safety issues to be discussed at the investigative hearing are:
- Operational control at Hageland Aviation, including its FAA oversight, organizational structure, policies and procedures, and training and guidance for operational control agents.
- Pilot training and guidance related to deteriorating weather conditions to mitigate controlled flight into terrain risk, including the incorporation of lessons learned from previous controlled flight into terrain accidents.
- Safety management, training and oversight resources available to the Alaskan aviation community.
An NTSB review of accident data revealed Hageland Aviation Services aircraft were involved in six accidents since 2013. Four of those accidents involved controlled flight into terrain and one involved flight into instrument meteorological conditions. The NTSB issued two safety recommendations in 2014 asking the FAA to conduct audits of operators owned by the holding company HoTH, Inc., which included Hageland Aviation Services.
UPDATE 10 April 2018: The NTSB has issued five new recommendations to the FAA and reiterated eight previously issued recommendations, based upon their investigation of an 2 October 2016 Hageland Aviation Services Cessna 208B Caravan N208SD that impacted mountainous terrain near Togiak, Alaska, killing all 3 on board during a Part 135 flight.
Among the reiterated recommendations: “Need for safety management systems (SMS) for Part 135 operators. Hageland did
not have an SMS at the time of the accident but was working toward implementation”. The NTSB also note that “…this investigation found gaps in Hageland’s CRM training and the FAA’s oversight of that training.”
As a result of its investigation the NTSB again called for fixed-wing Part 135 pilots – aviators who operate commuter and on-demand aircraft – to receive the same controlled-flight-into-terrain, or CFIT, avoidance training oversight as their rotary-wing counterparts. Currently, only Part 135 helicopter operators are required to train their pilots using an FAA-approved CFIT avoidance training program. While Hageland offered CFIT training based on guidance from the non-profit Medallion Foundation, the investigation found the training was outdated and did not address specific CFIT risks Hageland pilots face while flying under visual flight rules near Alaska’s mountainous terrain
The investigation also found that while Hageland aircraft were equipped with a terrain avoidance warning system, or TAWS, Hageland pilots routinely turned off the aural and visual alerts while flying at altitudes below the TAWS alerting threshold to avoid receiving nuisance alerts, preventing the system from providing the intended protections.
The full accident report will not be available for several weeks but the executive summary, including the findings, probable cause and safety recommendations, is available. UPDATE: Final report.
UPDATE 11 April 2018: Almost unbelievably the operator had another accident immediately after the NTSB recommendations. The pilot, the sole person onboard a Hageland Aviation C208B, N814GV, making a mail flight, survived when the aircraft crashed on tundra about 2 miles north of the airport in Atqasuk, Alaska.
UPDATE 18 April 2018: The pilot of N814GV said to the NTSB:
…that he departed from Utqiagvik just before 0800 with approximately 1,500 pounds of mail on board that was destined for Atqasuk. He noted that weather conditions at the time of departure consisted of clear skies, 9 miles visibility, and a light wind. After takeoff, the airplane climbed to 2,500 feet msl, and proceeded southbound towards Atqasuk.
The pilot said that as the airplane neared Atqasuk, with the autopilot engaged, the airplane descended to about 1,500 feet msl, but then he noticed an area of low fog around Atqasuk. He said that when the airplane was about two miles from the airport, he heard the audible autopilot disengagement annunciator tone sound, which was immediately followed by the pilot’s control column pitching forward. The pilot said that he was unable to pull the control column back, and the airplane subsequently descended into instrument meteorological conditions. He said that the airplane continued to descend into the fog, then it struck the snow-covered tundra, and nosed over.
The ELT did not activate.
The pilot made a mobile phone call to alert his company. The NTSB say:
…a North Slope Borough Search and Rescue helicopter pilot said that while en route from Utqiagvik to the accident site he encountered ice fog, reduced visibility, and flat light conditions that made it difficult to discern topographical features on the snow-covered tundra. He noted that as the flight continued, both pilots noticed ice beginning to accumulate on the helicopter’s windscreen, so the decision was made to abort the search and rescue flight, and the helicopter returned to Utqiagvik. A search team from Atqasuk eventually reached the accident site on snow machines and transported the pilot to Atqasuk.
UPDATE 28 May 2020: NTSB issue their report on N814GV:
It is likely that the unexpected instrument approach procedure increased the pilot’s workload as he maneuvered to set up for the approach. Further, when the autopilot disconnected, the airplane continued to descend; although the pilot reported that he heard the autopilot disconnect, he did not arrest the airplane’s descent rate. Given the low visibility conditions, it is likely that the pilot did not detect the airplane’s descent, and the airplane descended into the terrain.
The pilot stated that he did not recall hearing the  EGPWS warnings.
The NTSB probable cause was:
The pilot’s decision to continue a visual flight rules flight into an area of instrument meteorological conditions and his subsequent failure to level the airplane after the autopilot disconnected, which resulted in a collision with terrain.
Local Background Badami Airport is 29nm East of Deadhorse, Alaska on the Alaskan North Slope. It has two gravel runways, unlike some other seasonal man-made ice runways. Badmi serves an oilfield originally discovered by Conoco in 1990, initially operated by BP, but subsequently sold in 2011 to Savant Alaska. Savant has since been purchased by Tennessee based Miller Energy Resources.
In 2014 Aerossurance reported on a B1900C accident with an unrelated operator, also in Alaska (Alaska B1900C Accident – Contributory ATC Errors).
UPDATE 31 May 2017: All Aboard CFIT: Alaskan Sightseeing Fatal Flight
UPDATE 7 April 2018: Investigators Criticise Cargo Carrier’s Culture & FAA Regulation After Fatal Somatogravic LOC-I. A Shorts 360 N380MQ, operated by SkyWay Enterprises as a Part 135 flight on contract to FedEx crashed in the Caribbean after the crew likely suffered a Somatogravic Illusion raising the flaps on a dark night in 2014. The lack of an FAA SMS regulation for Part 135, the operator’s poor safety culture and implications for the wider industry culture stand out in a thoughtful accident report.
UPDATE 8 July 2018: Distracted B1900C Wheels Up Landing in the Bahamas
UPDATE 13 October 2018: Low Viz Helicopter Accident, Alaska
UPDATE 20 November 2019: Unalaska Saab 2000 Fatal Runway Excursion: PenAir N686PA 17 Oct 2019
UPDATE 3 June 2020: Beechcraft 1900C Landing Gear Collapse at San Antonio, TX
Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. We will be presenting for the second year running too. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business?