The captain of the flight, Jeff Day, had 5,770 hours of flight time, 5,470 of it in the Beech 1900, the type of aircraft involved in the accident. He had been with the company since 2008 and upgraded to captain in 2011. Co-pilot Neil Jensen had 470 flight hours, 250 of which were in the Beech 1900 and was hired on Nov. 30 of 2012.
Flight 51 departed Anchorage about 5:45 a.m. and was routed to King Salmon, Dillingham and return. Light rain and snow made the status of the Dillingham runway unknown and its condition was a concern. On the ground in King Salmon, the crew contacted Kenai Flight Service and requested any updated runway conditions at the next destination. There was no update and flight 51 departed King Salmon at 7:55 a.m.
According to the NTSB investigation, the air traffic controller at Anchorage Center who handled flight 51's departure from King Salmon was relieved by another controller at 8:00 a.m., while the flight was still en route to Dillingham. He briefed his replacement on the status of the five aircraft in their sector prior to leaving. At about 8:04 a.m., flight 51 made its request for clearance to an instrument approach to Dillingham via a point identified on charts as Zedag, the initial approach fix. The aircraft was then flying at about 6,000 feet.
At that point, the new controller approved the request and directed the crew to “maintain at or above 2,000" feet until established on a published segment of the approach. The published minimum altitude when approaching Zedag from the direction of King Salmon is 5,400 feet, and the altitude at the approach fix is 4,300 feet due to rising terrain in the area. The ambiguous nature of the clearance -- “until established on a published segment” -- and the flight crew’s slightly altered read back to “maintain 2,000” until established, led the NTSB to determine this communication was a factor in the crash.
The controller told the NTSB that “he did not expect the aircraft to descend below 5,400 feet, and did not notice when the pilot did so.” Other controllers and supervisors gave conflicting opinions on how they felt about the clearance. One referred to it as “not good” and another stated it was a “bad clearance.” Still, another said that while the accident sequence was unfortunate, in his opinion, “the crew was trying to cut corners.”
As flight 51 continued to the initial approach fix, the aircraft’s altitude sparked a warning from the automated Minimum Safe Altitude Warning system in ATC. This warning, characterized by a visual display and an audible series of short beeps that sound for one second, is designed to inform the controller that an aircraft is in danger of colliding with the surrounding terrain. The ATC controller communicating with flight 51 ignored the warnings, which remained active during his final transmission with the flight crew.
In his interview with the NTSB, the controller said that “he was not consciously aware that the MSAW alert was going off,” and that “The frequent MSAW nuisance alarms conditioned controllers to not be as attentive as they otherwise would be.”
This “alarm fatigue” was echoed by others in ATC who told the NTSB it was “quite common to hear aural alarms in the control room”, and that the system “generates frequent warnings, and many of them are invalid.” One supervisor countered that conclusion however, asserting that “all MSAW alerts should be evaluated and a safety alert issued if warranted.”A second discounted the belief that MSAWs were nuisances, saying that “most were valid.” He professed "shock" that there had been no response to the flight 51 MSAW alert.
While communicating with ATC, flight 51 was still trying to ascertain the condition of the Dillingham runway. At 8:07 a.m., the flight crew contacted flight service there, and one minute later was in touch with flight service personnel and the truck that was going out to physically check on the runway. The driver, who was heading for the active runway, asked for an estimated time on flight 51’s arrival. The flight crew offered to hold and at 8:09 a.m. made its last transmission to ATC requesting a hold at Zedag, which was immediately approved. No one spoke with flight 51 again.
Concerns with FAA oversight
As a scheduled air carrier operating under part 135 of the Federal Aviation Regulations, ACE is assigned FAA safety inspectors. The operations inspector is specifically tasked with such things as evaluating pilot competence, company flight training programs and operations to ensure safety and compliance with regulations. Typically inspectors work closely with companies, but it's clear from the NTSB interview that there was a disconnect between ACE’s operations inspector and the company. Further, according to the investigation, the ACE operations inspector was also responsible for oversight of another large part 135 operator, several flight schools, Part 91 operators and the designated pilot examiners in the Anchorage District.
According to the NTSB report, at the end of January 2013, ACE’s Director of Operations, a management position requiring FAA approval, resigned and notified their ops inspector by telephone. He subsequently submitted a letter of request for another employee to be made acting DO. He assumed this request -- not uncommon in the industry -- was accepted until the morning of the accident when the inspector contacted him and requested he resume his former job, because the acting DO did not currently meet the position’s regulatory requirements. During an NTSB interview, the inspector displayed no knowledge of the former’s DO’s resignation, revealing a lack of involvement with ACE “from the end of January 2013, and extending to March 10 [sic], the day of the accident.” It was possible the inspector might have forgotten the phone call, but “could not recall,” the NTSB report said.
As the interview continued, it was made clear the inspector never observed Crew Resource Management (or CRM) training at ACE, which would have provided the FAA with insight into how flight crews were trained to work together. The inspector professed no knowledge to the NTSB of how ACE conducted operational control over its flights and further had no training or experience in the Beech 1900. Because of this, another inspector from the Anchorage office was identified in the report as the person required to conduct pilot checkrides in the aircraft. It is unclear why the FAA assigned an inspector to ACE who had never been qualified to fly in the only aircraft the company operates.
CRM training was developed to prevent human errors and emphasize crew interactions, which are critical to flight safety. In the case of flight 51, effective communication in the cockpit would likely have addressed any confusion presented by the ATC clearance and reinforce company procedures. According to the report, Alaska Central Express requires that the pilot who is flying briefs the approach and both crew members are supposed to have the approach plate open on their control yoke. It is unknown why this communication apparently did not take place. The failure of the flight crew to follow procedures was cited as a factor in the accident by the NTSB.
Lost opportunities to prevent accident
The ATC controller told the NTSB that “informing the pilot of his position in reference to the initial approach fix was not required.” The crew of flight 51 however, appears to have been preoccupied with Dillingham runway conditions; they appear not to have noticed the discrepancy between the altitude instructions and their position, as they should have. This is why redundancies are built into the air traffic control system and why flight crews read back instructions -- so ATC can catch and prevent any miscommunications.
The MSAW system exists to alert ATC when a potentially dangerous situation occurs so they can then alert a flight crew. CRM teaches pilots to work together to avoid and solve problems before they become unrecoverable. The FAA is tasked with effective air carrier oversight so it can contribute its vast resources to supporting the best learning environment possible.
None of these programs, warnings or training procedures saved flight 51.
As the probable cause report makes clear, mistakes were made by multiple people on the ground and in the air. Unfortunately, the aircraft was not equipped with an optional voice recorder or cockpit image recording technology. The image technology in particular would have provided a visual of what took place inside the aircraft and without it the NTSB does not have critical information from the cockpit.
“It would tell us a great deal about the human factors involved here,” said Clint Johnson, chief of the NTSB Alaska Region. “All we can do is theorize what was going on in the cockpit and without that information, I feel that a golden opportunity has been missed to learn from this tragedy. As the plaque at the NTSB Training Center recites, 'from tragedy we draw knowledge to improve the safety of us all.'"
With the release of the probable cause report, factual narrative and public docket, the final documents on the crash of Alaska Central Express flight 51 have all been filed. Jeff Day and Neil Jensen are now just one more part of Alaska’s long tragic aviation record. According to the FAA, the employee who provided them with those questionable instructions out of King Salmon is still listed as a controller in the state of Alaska. The operations inspector who oversaw ACE at the time of the accident has since relocated to another office out-of-state.
What can be learned from flight 51 moving forward is up to the entire Alaska aviation community. Its members will have to think long and hard about how much it matters to fully understand what took place on the way to Dillingham on March 8, 2013, and what can be taught, both on the ground and in the air, to make sure such a tragedy never happens again.
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NTSB Identification: ANC13FA030
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, March 08, 2013 in Aleknagik, AK
Probable Cause Approval Date: 08/11/2014
Aircraft: BEECH 1900C, registration: N116AX
Injuries: 2 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The airplane was operating in instrument meteorological conditions and, as it approached the destination airport, the pilot requested the RNAV/GPS runway 19 approach and asked for routing directly to ZEDAG, the initial approach fix (IAF). At the time of the pilot's request, the airplane was about 30 miles southeast of the IAF at an altitude of about 5,900 feet mean sea level (msl). The air traffic controller cleared the airplane to fly directly to the IAF followed by the ZEDAG transition and the RNAV/GPS runway 19 approach, stating, "maintain at or above 2,000" feet until established on a published segment of the approach. The flight crewmembers repeated the clearance back to the controller as "maintain 2,000" feet until established, and they began descending the airplane toward the IAF. About 6 minutes later, the pilot requested to enter the holding pattern while they checked on runway conditions on another radio frequency, and the controller cleared them to hold "as published." At the time of the pilot's request, the airplane was at an altitude of about 2,200 feet msl.
As depicted on the published instrument approach procedure, the terminal arrival area (TAA) minimum altitude when approaching the IAF from the southeast (the direction from which the accident flight approached) is 5,400 feet msl, and the published holding pattern at the IAF is 4,300 feet msl due to rising terrain in the area.Therefore, the flight crewmember's acceptance of what they believed to be a clearance to 2,000 feet, their descent to that altitude, and their initiation of a hold at that altitude indicates a lack of awareness of the information contained on the published procedure. Such a lack of awareness is inconsistent with pilot-in-command responsibilities and company procedures that require an instrument approach briefing during the descent and approach phases of flight. If the flight crewmembers had reviewed the published approach procedure and briefed it per the company's descent and approach checklist, they should have noticed that the minimum safe altitude in the TAA southeast of the IAF was 5,400 feet msl and that the minimum altitude for the hold was 4,300 feet msl. Examination of the wreckage and debris path evidence is consistent with the airplane having collided with rising terrain at 2,000 feet msl while flying in a wings-level attitude on the outbound leg of the holding pattern, which the flight crew should have flown at 4,300 feet msl.
However, the air traffic controller did not adhere to guidance contained in Federal Aviation Administration Order 7110.65, and his approach clearance to "maintain at or above 2,000 feet" msl until established on a published segment of the approach was ambiguous. The controller's approach clearance should have instructed the pilot to "proceed direct to ZEDAG, enter the TAA at or above 5,400 feet, cleared RNAV runway 19 approach." Instead, he instructed the pilot without specifying the segment of the approach that should be flown at 2,000 feet. Further, the controller did not notice the pilot's incorrect readback of the clearance in which he indicated that he intended to "maintain 2,000 feet" until established on the approach. Further, he did not appropriately monitor the flight's progress and intervene when the airplane descended to 2,000 feet msl. As a result, the airplane was permitted to descend below the minimum instrument altitudes applicable to the route of flight and enter the holding pattern well below the published minimum holding altitude.
Air traffic control (ATC) recorded automation data showed that the airplane's trajectory generated aural and visual minimum safe altitude warnings on the controller's radar display. However, the controller did not issue any terrain warnings or climb instructions to the flight crew. The controller said that he was not consciously aware of any such warnings from his display. These automated warnings should have been sufficient to prompt the controller to evaluate the airplane's position and altitude, provide a safety alert to the pilot in a timely manner, and instruct the pilot to climb to a safe altitude; it could not be determined why the controller was unaware of the warnings. The airplane was equipped with three pieces of navigation equipment that should have provided visual and aural terrain warnings to the flight crewmembers if they had not inhibited the function and if the units were operating properly. Damage precluded testing the equipment or determining the preaccident configuration of the units; however, the flight crew reported no equipment anomalies predeparture.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The flight crew's failure to maintain terrain clearance, which resulted in controlled flight into terrain in instrument meteorological conditions. Contributing to the accident were the flight crew's failure to correctly read back and interpret clearance altitudes issued by the air traffic controller, their failure to adhere to minimum altitudes depicted on the published instrument approach chart, and their failure to adhere to company checklists.
Also contributing to the accident were the air traffic controller's issuance of an ambiguous clearance to the flight crew, which resulted in the airplane's premature descent, his failure to address the pilot's incorrect read back of the assigned clearance altitudes, and his failure to monitor the flight and address the altitude violations and issue terrain-based safety alerts.
HISTORY OF FLIGHT
On March 8, 2013, about 0815 Alaska standard time, a Beech 1900C airplane, N116AX, operating as Alaska Central Express flight 51, was destroyed when it collided with rising terrain about 10 miles east of Aleknagik, Alaska. The captain and first officer were fatally injured. Flight 51 was a cargo flight operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Instrument meteorological conditions (IMC) prevailed along the route of flight, and the airplane was operating on an instrument flight rules (IFR) flight plan. The flight departed King Salmon Airport, King Salmon, Alaska, about 0750, and was en route to Dillingham Airport (DLG), Dillingham, Alaska.
A postaccident review of Federal Aviation Administration (FAA) radar data and radio communication recordings revealed that, about 0803, the pilot requested the RNAV/GPS runway 19 approach to DLG and asked for routing directly to ZEDAG, the initial approach fix (IAF). At the time of the pilot's request, the airplane was about 30 miles southeast of ZEDAG at an altitude of about 5,900 feet mean sea level (msl). The on-duty Anchorage Air Route Traffic Control Center (ARTCC) radar controller cleared the airplane to fly directly to ZEDAG followed by the ZEDAG transition and the RNAV/GPS runway 19 approach. The controller told the pilot to maintain an altitude "at or above 2,000 feet msl until established on a published segment of the approach." The pilot read back, "Maintain two thousand until a published segment of the approach." About 6 minutes later, as the airplane descended toward the IAF, the pilot requested to enter the holding pattern while checking on runway conditions on another radio frequency, and the controller granted the request. At the time of the pilot's request, the airplane was at an altitude of about 2,200 feet msl. The airplane subsequently disappeared from the controller's radar display, and all contact with the flight was lost.
At 0830, the on-duty ARTCC operations manager notified the Anchorage rescue coordination center (RCC) of the missing airplane, and, at 0835, the FAA issued an alert notice. About 0854, a 406-MHz beacon activation notification was received by the RCC, and search and rescue operations were initiated. Initial attempts to reach the accident site were hampered by poor weather conditions.
On March 9, about 0606, aerial searchers located the accident site about 6 miles north-northwest of ZEDAG in an area of steep, snow and ice-covered terrain known as "the Muklung Hills." About 0703, a ground search party reached the accident site, which was at an elevation of about 1,996 feet msl.
FLIGHT CREW INFORMATION
Captain
The captain, age 38, held an airline transport pilot certificate with an airplane multiengine land rating and commercial pilot privileges with an airplane single-engine land rating and a type rating in the Beech 1900. His most recent first-class FAA medical certificate was issued June 11, 2012, with no limitations.
The captain was hired by Alaska Central Express on July 18, 2008, and, at that time, he had 260 hours of total flight experience. He completed his initial company training, including Beech 1900 second-in-command (SIC) ground training, on July 28, 2008, and was assigned to fly as SIC of Beech 1900 airplanes at the company's base in Anchorage. On September 7, 2011, he was upgraded to a Beech 1900 captain. The operator reported that the captain had accumulated 5,770 total flight hours, including 5,470 hours in the accident airplane make and model. His most recent airman competency/proficiency check, which was administered by a company check airman, was completed on October 20, 2012.
On March 5, the captain's duty day started at 0330 and ended at 1130, and he flew 4.4 hours. On March 6, his duty day started at 0330 and ended at 1300, and he flew 4.5 hours. On March 7, his duty day started at 0430 and ended at 1000, and he flew 3.3 hours. On March 8, the day of the accident, his duty day started at 0430, and he flew 1.6 hours before the accident.
First Officer
The first officer, age 21, held a commercial pilot certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. His most recent FAA second-class medical certificate was issued August 9, 2012, with no limitations.
The first officer was hired by Alaska Central Express on November 12, 2012, and, at that time, he had 220 hours of total flight experience. He completed his initial company training, including Beech 1900 SIC ground and flight training, on November 30, 2012, and was assigned to fly as SIC of Beech 1900 airplanes at the company's base in Anchorage. The operator reported that the first officer had accumulated 470 total flight hours, including 250 hours in the accident airplane make and model. His most recent airman competency/proficiency check, which was administered by a company check airman, was completed on December 1, 2012.
On March 5, the first officer's duty day started at 1100 and ended at 2200, and he flew 7.4 hours. On March 6, his duty day started at 1200 and ended at 1930, and he flew 4.2 hours. On March 7, he was off duty. On March 8, the day of the accident, his duty day started at 0430, and he flew 1.6 hours before the accident.
AIRCRAFT INFORMATION
The airplane, manufactured in 1992, was a twin-engine Beech 1900C equipped with retractable landing gear, two Pratt and Whitney PT6A-65B engines, and controllable-pitch propellers. Alaska Central Express maintained the airplane in accordance with an approved continuing airworthiness program, and the most recent required inspection was completed on March 7, 2013, when the airplane had accumulated 29,824 total hours.
The airplane was equipped with a Bendix/King KMD 850 multifunction display capable of providing audible and visual terrain warnings. The airplane was also equipped with dual Garmin 430W units capable of providing visual terrain warnings. Both warnings could be inhibited by the flight crew.
The airplane was equipped for instrument flight into icing conditions and could be operated by a single pilot. The airplane was not equipped with, nor was it required to be equipped with, a cockpit voice recorder or a flight data recorder.
WRECKAGE AND IMPACT INFORMATION
The airplane's wreckage was located in an area of steep, ice and snow-covered terrain on a southeast-facing slope. The terrain was rough and uneven, and high-wind conditions after the accident had created areas of drifted snow, moved lighter pieces of debris, and buried some debris. The initial impact point was at an elevation of about 1,996 feet, and the debris path extended about 900 feet uphill to an elevation of about 2,300 feet in a triangular/fan shape. About 700 feet from the initial point of impact, the major debris field was more than 400 feet wide, and single pieces of debris could be seen at greater distances in all directions. The debris path was on a magnetic heading of about 340 degrees. According to topographic maps, the peak elevation is 2,550 feet. The initial impact point was a rock outcrop protruding from the snow. Metal scrapings were found on the rock surface consistent with damage observed on the center of the airplane's fuselage. No indications of any wing impact were found near the initial impact point. The first structural piece was located about 400 feet from the initial impact point. Large sections of fuselage and expelled cargo were located about 525 feet from the initial impact point. The fuselage and cockpit were found separated into three large pieces.
Subsequent examination of the engines and propellers indicated that the propeller blades had all sheared off at the propeller hub, and the engines' exhausts exhibited signs of hot metal folding.
Damage to the Bendix/King KMD 850 and dual Garmin 430W units precluded testing, and the preaccident configuration of the units (including which functions were enabled or inhibited by the flight crew) could not be determined.
MEDICAL AND PATHOLOGICAL INFORMATION
Captain
A postmortem examination of the captain was performed under the authority of the Alaska State Medical Examiner in Anchorage on March 11, 2013. The cause of death was reported as multiple blunt force injuries sustained in an airplane crash, and the manner of death was an accident. However, the autopsy identified severe coronary artery disease with greater than 85% stenotic lesion in the distal left anterior descending artery. Nevertheless, there was no suggestion of medical impairment or incapacitation related to the probable cause of the accident.
A toxicological examination by the FAA's Civil Aeromedical Institute (CAMI), Oklahoma City, Oklahoma, on April 30, 2013, revealed dextrorphan and doxylamine in urine and 0.016 ug/ml doxylamine in blood.
According to CAMI doxylamine is a sedating antihistamine available over the counter and by prescriptions and used to treat cold and allergy symptoms. Its therapeutic window is 0.050 to 0.150 ug/ml and it carries the following warning: "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." The absence of dextromethorphan or its metabolite in the blood suggests the cough suppressant was no longer having any effect on the captain.
Given that the toxicology testing identified a level well below the therapeutic window, there is no evidence that it was impairing the captain at the time of the accident.
First Officer
A postmortem examination of the first officer was performed under the authority of the Alaska State Medical Examiner in Anchorage on March 11, 2013. The cause of death was reported as multiple blunt force injuries sustained in an airplane crash. The manner of death was an accident.
A toxicological examination by CAMI on April 18, 2013, was negative for any alcohol or drugs.
METEOROLOGICAL INFORMATION
The DLG weather observation at 0745 reported cloud ceiling 1,500 feet overcast, wind from 100 degrees at 17 knots gusting to 30 knots, 7 miles visibility in light rain, temperature of 34 degrees F, dew point temperature of 32 degrees F, and an atmospheric pressure of 29.09 inches of mercury. IMC prevailed along the route of flight and in the holding pattern area for the DLG RNAV/GPS runway 19 approach.
AIR TRAFFIC CONTROL
DLG is southwest of the ZEDAG IAF, and the published DLG RNAV/GPS runway 19 instrument approach procedure indicates that the terminal arrival area (TAA) minimum altitude when approaching ZEDAG from the southeast (the direction from which the accident flight approached) is 5,400 feet msl within 30 nautical miles of ZEDAG.
One of three peaks in the Muklung Hills with an elevation of 2,550 feet is located about 6 miles north-northwest of ZEDAG. The published minimum safe altitude while flying in the holding pattern is 4,300 feet msl.
An annotated copy of the RNAV/GPS runway 19 instrument approach procedure and diagrams showing the airplane's route of flight are contained in the public docket for this report.
The following is an excerpt from the FAA Anchorage ARTCC transcript of the radio communications between the flight crew (call sign AER51) and the ARTCC specialist, beginning at 0803:33, when the flight crew requested an approach clearance to DLG and of a call between the ARTCC specialist and the DLG flight service station (FSS), which took place between 0804:19 and 0804:36:
0803:33 AER51: Anchorage Center Ace Air fifty one current weather down into
Dillingham requesting RNAV one nine approach any chance we can get direct
ZEDAG?
ARTCC: Ace Air fifty one cleared direct to the Dillingham Airport via direct
ZEDAG ZEDAG transition. Maintain ah maintain at or above two thousand until
established on a published segment of the approach. Cleared RNAV runway one
niner approach to Dillingham Airport. Remain this frequency.
AER51: We'll stay with you. Cleared to ZEDAG transition for RNAV one nine
approach into Dillingham. Maintain [ARTCC controller dialing the DLG
FSS] two thousand until a published segment of the approach Ace Air fifty one.
0804:18 ARTCC: Is Ace Air fifty one Beech nineteen hundred Dillingham one
seven two zero RNAV one nine.
0809:31 AER51: Anchorage Center Ace Air fifty one [we're] approaching ZEDAG we'd
like to hold waiting for more information if possible.
ARTCC: Ace Air fifty one say again?
AER51: Ace Air fifty one requesting hold at ZEDAG for runway conditions.
ARTCC: Ace Air fifty one hold north of ZEDAG as published expect further
clearance one eight zero zero upon your request.
AER51: Hold north of ZEDAG expect further clearance one eight zero zero.
We're still checking on runway conditions Ace Air fifty one thanks.
ARTCC: Ace Air fifty one roger.
0814:25 Dillingham FSS: Dillingham Radio reference Ace Air fifty one
ARTCC: Yeah
Dillingham FSS: Ah he said he was going to hold ah and wait for an update
on the runway conditions. I'm trying to get a hold of him. I've got an update on
the runway…been trying to get a hold of him.
ARTCC: Do you want me to relay to em?
Dillingham Airport FSS: Ah yeah we're just showing patchy thin water on
the runway now.
ARTCC: Okay I'll let him know. Thanks.
Dillingham Airport FSS: Alright thank you.
0814:50 ARTCC: Ace Air fifty one you up?
The flight's last radio transmission was made at 0809:51. During postaccident interviews, the controller who handled the flight stated that he did not expect the airplane to descend below 5,400 feet and that he did not notice when it did so. He stated that he did not notice the airplane's actual altitude when the pilot requested holding at ZEDAG. He stated that, when he cleared the pilot to hold at ZEDAG "as published," he expected the pilot to climb the airplane to 4,300 feet msl as shown in the profile view of the approach procedure.
Air traffic control (ATC) recorded automation data showed that the airplane's trajectory generated aural and visual minimum safe altitude warnings (MSAW) on the controller's radar display, which included a 1-second aural alarm at 0809:16 and a flashing "MSAW" indication in the airplane's data block that continued from 0809:16 until the end of the flight. The controller said that he was not consciously aware of any such warnings from his display. The controller did not issue any terrain conflict alerts or climb instructions to the flight crew. A complete ATC transcript and the ATC Group Chairman Factual Report are contained in the public docket for this report.
OPERATOR INFORMATION
Alaska Central Express is a 14 CFR Part 135 air carrier and holds on-demand and commuter operations specifications. The company headquarters is located at the Ted Stevens Anchorage International Airport, Anchorage, Alaska, and serves various communities throughout the Aleutian Islands and western, southwestern, and southeast Alaska.
Company policy requires flight crews to use approved checklists during all phases of flight. The Alaska Central Express BE-1900/1900C Normal Checklist includes a descent and approach checklist that specifies that the flight crew complete a briefing for the approach to be conducted. A typical instrument approach briefing includes, in part, referencing the published approach information and verbally verifying the navigation frequencies to be used, the headings to be flown, and the minimum safe altitudes for the various segments of the approach. The normal checklist also includes a prestart checklist that specifies a circuit breakers check/test to ensure power to all instruments and avionics. The after-start checklist requires an electrical system check, the post-run-up checklist requires a check of all avionics, and the before-takeoff checklist requires that all avionics and flight instruments be checked and set. Before and during the flight, the flight crew maintained radio communications with ATC. The flight crew reported no anomalies with any navigation instruments, radios, engines, or flight controls. A copy of the Alaska Central Express BE-1900/1900C Normal Checklist and the Operations Group Chairman Factual report are contained in the public docket for this report.
ADDITIONAL INFORMATION
Federal Aviation Regulations and Related Guidance
Title 14 CFR 91.3(a) states, "The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." In addition, the FAA Aeronautical Information Manual (AIM) Section 4-4-1(b) states, "If ATC issues a clearance that would cause a pilot to deviate from a rule or regulation, or in the pilot's opinion, would place the aircraft in jeopardy, IT IS THE PILOT'S RESPONSIBILITY TO REQUEST AN AMENDED CLEARANCE. Similarly, if a pilot prefers to follow a different course of action…THE PILOT IS EXPECTED TO INFORM ATC ACCORDINGLY [capitalization emphasis in original document]."
Further, FAA AIM Section 4-4-3(e) states, "If the holding pattern is charted, and the controller doesn't issue complete holding instructions, the pilot is expected to hold as depicted on the appropriate chart. When the pattern is charted, the controller may omit all holding instructions except the charted holding direction and the statement AS PUBLISHED, e.g., 'HOLD EAST AS PUBLISHED'. Controllers must always issue complete holding instructions when pilots request them [capitalization emphasis in original document]." In addition, FAA AIM Section 4-4-7(b) states, "Pilots of airborne aircraft should read back those parts of ATC clearances and instructions containing altitude assignments, vectors, or runway assignments as a means of mutual verification. The read back of the 'numbers' serves as a double check between pilots and controllers and reduces the kinds of communications errors that occur when a number is either 'misheard' or is incorrect."
FAA Order 7110.65, "Air Traffic Control," contains instructions to controllers on the handling of aircraft during approaches, compliance with minimum instrument altitudes, and issuance of safety alerts. Paragraph 5-9-4, "Arrival Instructions," states, in part, "Issue all of the following to an aircraft before it reaches the approach gate: a. Position relative to a fix on the final approach course…. b. Vector to intercept the final approach course if required. c. Approach clearance except when conducting a radar approach. Issue approach clearance only after the aircraft is: 1. Established on a segment of a published route or instrument approach procedure, or… 2. Assigned an altitude to maintain until the aircraft is established on a segment of a published route or instrument approach procedure." Phraseology examples are provided in paragraph 5-9-4 and all of the examples specify that the clearance should include the specific point or segment of the approach where the pilot is expected to join the approach course.
Previous Accident
The operator had a previous Beech 1900C accident (ANC10FA014) on January 21, 2010, near Sand Point, Alaska, which resulted in the death of the two flight crewmembers. According to Alaska Central Express management personnel, at the conclusion of the Sand Point accident investigation, the board of directors opted to voluntarily install cockpit image recording systems in all company-owned and operated aircraft; however, the airplane involved in the March 8, 2013, accident was not yet equipped with such a system.
NTSB Identification: ANC13FA030
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, March 08, 2013 in Aleknagik, AK
Aircraft: BEECH 1900C, registration: N116AX
Injuries: 2 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On March 8, 2013, about 0814 Alaska standard time, a twin-engine turboprop Beech 1900C airplane, N116AX, was destroyed when it impacted rising terrain about 10 miles east of Aleknagik, Alaska. The airplane was operated as Flight 51, by Alaska Central Express, Inc., Anchorage, Alaska, as an on-demand cargo flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The airline transport certificated captain and the commercial certificated first officer sustained fatal injuries. Instrument meteorological conditions were reported in the area at the time of the accident, and the airplane was operating on an instrument flight rules (IFR) flight plan. The flight had originally departed Anchorage about 0544, and made a scheduled stop at King Salmon, Alaska, before continuing on to the next scheduled stop, Dillingham, Alaska.
According to Federal Aviation Administration (FAA) personnel, as the airplane approached Dillingham, the flight crew requested the RNAV GPS 19 instrument approach to the Dillingham Airport about 0757 from controllers at the Anchorage Air Route Traffic Control Center (ARTCC). The ARTCC specialist on duty subsequently granted the request by issuing the clearance, with instructions to proceed direct to the Initial Approach Fix (IAF) to begin the approach, and to maintain an altitude of 2,000 feet or above. A short time later the flight crew requested to enter a holding pattern at the IAF so that they could contact the Flight Service Station (FSS) for a runway conditions report, and the ARTCC specialist granted that request. The ARTCC specialist then made several attempts to contact the aircraft, but was unsuccessful and subsequently lost radar track on the aircraft.
When the airplane failed to arrive at the Dillingham Airport, ARTCC personnel initiated a radio search to see if the airplane had diverted to another airport. Unable to locate the airplane, the FAA issued an alert notice (ALNOT) at 0835. Search personnel from the Alaska State Troopers, Alaska Air National Guard, and the U.S. Coast Guard, along with several volunteer pilots, were dispatched to conduct an extensive search effort.
Rescue personnel aboard an Air National Guard C-130 airplane tracked 406 MHz emergency locater transmitter (ELT) signal to an area of mountainous terrain about 20 miles north of Dillingham, but poor weather prohibited searchers from reaching the site until the next morning. Once the crew of a HH-60G helicopter from the Air National Guard's 210th Air Rescue Squadron, Anchorage, Alaska, reached the steep, snow and ice-covered site, they confirmed that both pilots sustained fatal injuries.
The closest official weather observation station is at the Dillingham Airport. At 0745, an aviation routine weather report (METAR) reported, in part: Wind from 100 degrees (true) at 17 knots with gusts to 30 knots; visibility, 7 statute miles in light rain; clouds and sky condition, 1,500 feet overcast; temperature, 34 degrees F; dew point, 34 degrees F; altimeter, 29.09 inHg.
On March 9, the National Transportation Safety Board (NTSB) investigator-in-charge, along with an additional NTSB air safety investigator, and an FAA operations inspector from the Anchorage Flight Standards District Office (FSDO), examined the airplane wreckage at the accident site. A comprehensive wreckage examination and layout is pending following recovery efforts.
NTSB Investigator
Brice Banning investigates the accident site of an ACE Air Cargo plane
that went down on Friday, March 08, 2013, killing pilot Jeff Day, 38 and
Neil Jensen, 21, both of Anchorage.
Obituary
Anchorage resident Neil Torvald Jensen died March 8, 2013, in a plane crash near Dillingham. A service will be held at St. Elizabeth Ann Seaton Catholic Church at 4 p.m. Wednesday, March 13. Neil was born in Ann Arbor, Michigan, but lived in Anchorage since the age of two years. He attended his neighborhood public schools and graduated from Robert Service High School in 2009. He enrolled at Embry-Riddle Aeronautical University, and in three years received a BSc in Aeronautical Science, with honors. Last November he was hired for a First Officer position by Ace Air Cargo, piloting Beechcraft 1900s. The work was challenging, but he was fulfilled working alongside fellow pilots. Recreational time was spent skiing, hiking, and mountain biking. Close friendships were maintained with friends from college. Neil was unusually attentive to his extended family, his younger brother, and his older sister. His parents could not have been more pleased with Neil's integrity, compassion, dedication, creativity, and humor.
Read more here: http://www.legacy.com
The family of pilot Neil Jensen released this photo. Jensen, 21, was the First Officer in a cargo plane crash near Dillingham. Crews found the wreckage on Mar. 9, 2013 and said the bodies of Jensen and Capt. Jeff Day, 38 of Anchorage, were recovered.
(Peter and Shelly Jensen / March 9, 2013)
ANCHORAGE, Alaska— Alaska State Troopers say the bodies of two Anchorage pilots in a cargo plane crash near Dillingham were recovered Saturday morning by the Alaska Air National Guard.
AST identified the victims of the downed plane as Capt. Jeff Day, 38, and First Officer Neil Jensen, 21, both of Anchorage.
Troopers said that an Air National Guard HH-60 Pavehawk found the wreckage of a downed Beech 1900 plane around 6:00 a.m. Saturday. A helicopter crew recovered the bodies and flew them to Dillingham and then to Anchorage. The bodies were turned over to the State Medical Examiner’s Office.
Jensen's father spoke with KTUU Channel 2 News Saturday afternoon.
"He loves being a pilot," said Peter Jensen, Neil's father. "He loves the other pilots he's working with and got a lot a of good advice from the captains."
Peter Jensen said his son recently graduated from Embry-Riddle Aeronautical University in Arizona.
Weather conditions on Friday kept rescue crews from spotting the plane wreckage after troopers said the plane was expected to arrive in Dillingham Friday morning.
The cargo plane left King Salmon shortly before 8:00 a.m. Friday and the Rescue Coordination Center received an alert from the FAA of an overdue plane around a half-hour later. The Alaska National Guard said the plane had relayed radio communication that it was on approach to the Dillingham Airport.
Troopers said the “initial information is that the aircraft was flying instrument flight rules (IFR) and was cleared to land at the Dillingham airport and the aircraft never landed.”
Around 9:15 a.m. Friday, the Emergency Locator Beacon (ELT) began transmitting a signal. Troopers said the signal transmitted about 20 miles northeast of Dillingham in the the Muklung Hills.
In August 2010, former Sen. Ted Stevens and four others were killed in a DeHavilland DHC-3 Otter plane crash in the same region.
The National Transporation Safety Board arrived on scene Saturday morning after crews found the wreckage and spent most of the day investigating the scene. The next step is to recover the the airplane pieces, which broke into three main pieces spread over an extensive area, according to the NTSB.
"I think the odds of being in a fatal car accident are similar, so to me his death is tragic and I'll miss him a lot but it could have as easily been a car accident," said Peter Jensen.
Story and Reaction/Comments: http://www.ktuu.com
The twin-engine Beechcraft 1900, owned by Ace Air Cargo, is thought to be on the ground about 20 miles northeast of Dillingham, where it went down while approaching the city's airport sometime before 8:30 a.m. Friday. An Alaska Air National Guard helicopter sent from Joint Base Elmendorf-Richardson, about 330 miles away near Anchorage, hovered over the plane Friday afternoon but the chopper's crew could not see through the clouds, Air National Guard spokeswoman Kalei Rupp said. The helicopter and a plane supporting it left the area at about 4 p.m. to refuel and were back searching as of 7 p.m., Rupp said.
Because they had been unable to see the terrain below them, it was too dangerous to attempt a landing or lower rescuers to the ground, Rupp said.
"Our crews got on scene but the cloud ceiling is very low," she said. "They can't see the ground to assess the situation."
Rupp said fresh teams on another helicopter and plane would likely be sent to take over for the search personnel working late Friday, if needed.
Ace Air Cargo said a pilot and copilot were on board the Beechcraft. A weather station at the airport reported light rain and snow about the time the plane went down, with wind at 17 mph gusting to 26 mph and seven miles visibility.
The Beechcraft's pilot radioed the Dillingham airport to say the plane was approaching for a landing Friday morning, according to spokespeople for the Alaska State Troopers and the Alaska Air National Guard. At about 8:30 a.m., the Federal Aviation Administration issued an alert that the plane had not landed, Rupp said. An emergency locator beacon on the plane indicated it was about 20 miles northeast of Dillingham, Rupp said.
The plane is down in the Muklung Hills, troopers spokeswoman Megan Peters said. A plane crash in the same area in 2010 killed five people, including former U.S. Sen. Ted Stevens.
An Alaska state trooper trying to reach the plane on a snowmachine had to turn back to Dillingham because of the poor weather, Peters said. Others, including firefighters and medics gearing up to head out for a search, stayed in Dillingham, she said.
"It's in mountainous terrain and the weather's bad," Peters said. "They have very wet snow and thick fog."
At about 11:30 a.m., the Air National Guard's Rescue Coordination Center in Anchorage dispatched an HH-60 Pave Hawk helicopter with a rescue team on board and an HC-130 Hercules refueling plane carrying another team, Rupp said. The Coast Guard also sent an MH-60 Jayhawk helicopter with rescuers from Kodiak, she said.
It's unclear if the downed cargo plane crashed or made an emergency landing. Rupp said she was unaware of any radio traffic from the pilot or copilot.
"Once it makes contact and says it's on approach, if it doesn't land within a certain amount of time, the FAA puts out an overdue-aircraft alert. So that's what triggered that," Rupp said. "Since nobody has actually gotten to the site or seen the site, we don't necessarily know if the plane has crashed or what."
The Coast Guard helicopter arrived first and was relieved by the Air National Guard chopper about 2 p.m., Rupp said. The low-hanging clouds and, later, snowfall made it impossible to see anything on the ground, she said.
While satellites showed the general location of the plane's beacon, the searchers could not pick up its signal while flying above the area, Rupp said. That could be due to terrain blocking the signal or damage to the beacon, she said.
About 4 p.m., the Pave Hawk flew to Dillingham to refuel and the Hercules went to King Salmon to do the same, Rupp said. They planned to continue searching into Friday night.
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