In a report released Monday on the probable cause of the March 8, 2013 ACE Air Cargo crash in poor weather that killed pilot Jeff Day, 38, and first officer Neil Jensen, 21, the NTSB cites “the flight crew's failure to maintain terrain clearance, which resulted in controlled flight into terrain in instrument meteorological conditions.”
A variety of factors are listed as contributing to the Beech 1900C’s crash in the Muklung Hills, including “the flight crew's failure to correctly read back and interpret clearance altitudes issued by the air traffic controller,” as well as “the air traffic controller's issuance of an ambiguous clearance to the flight crew, which resulted in the airplane's premature descent.”
Day and Jensen, both Anchorage residents, took off from Ted Stevens Anchorage International Airport at about 5:45 a.m., stopping in King Salmon before continuing to Dillingham. They called the FAA’s Air Route Traffic Control Center in Anchorage at 7:57 a.m. to say they had reached the local airport’s holding pattern.
A Federal Aviation Administration area navigation, or RNAV, chart for landing in Dillingham under instrument flight rules indicates the minimum altitudes planes should maintain at various points of their approach. The chart shows that as Day and Jensen’s flight came in from the southeast toward ZEDAG, the point at which planes enter the holding pattern to land in Dillingham, it should have been at an altitude of at least 5,300 feet, with only a slight reduction in that minimum within the pattern after arriving.
“One of three peaks in the Muklung Hills with an elevation of 2,550 feet is located about 6 miles north-northwest of ZEDAG,” NTSB officials wrote. “The published minimum safe altitude while flying in the holding pattern is 4,300 feet (above mean sea level).”
An NTSB log of transmissions shortly after between the ARTCC and the ACE Air Cargo flight, with the call sign Ace Air 51 or AER51, lists the plane at an altitude below those approved minimums. The controller, calling the Dillingham Flight Services Station for an update on runway conditions, apparently doesn’t notice:
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 (feet) until a published segment of the approach Ace Air fifty one.
ARTCC: Is Ace Air fifty one Beech nineteen hundred Dillingham one seven two zero RNAV one nine.
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.
Just after receiving a runway update from Dillingham, the controller relayed it to Day and Jensen at 8:09 a.m. -- but he never heard from them again. Heavy snow and wind kept searchers from reaching the crash site until the next day, when Alaska Air National Guard chopper arrived and confirmed that both men were dead.
NTSB investigators found that the plane had crashed at an elevation of about 2,000 feet, leaving an uphill fan of debris over several hundred feet from its point of contact. The crash destroyed three cockpit computers in the Beech, precluding any attempt to determine whether terrain warnings from them had been suppressed; while ACE Air Cargo had been installing cockpit video and flight recorders fleetwide after two people died in a 2010 crash near Sand Point, the wrecked aircraft didn’t yet have them.
“The first structural piece was located about 400 feet from the initial impact point,” NTSB officials wrote. “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.”
When NTSB investigators spoke with the controller in the crash, he told them he hadn’t been fully aware of Day and Jensen’s altitude during their final minutes of flight.
“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,” NTSB officials wrote. “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 (above mean sea level) as shown in the profile view of the approach procedure.”
Recorded data at the center indicated that the system had attempted to warn the controller about the imminent crash.
“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,” NTSB officials wrote. “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.”
While the NTSB report quotes FAA regulations calling for important numbers like altitude restrictions to be read back in communications between pilots and controllers, it quotes more extensively from those governing a pilot’s autonomy in flight – including one which states that “The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.”
“‘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,’” NTSB officials quoted. “‘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].’”
Clint Johnson, the NTSB’s chief investigator in Alaska, says the report indicates shared responsibility for the crash both in the air and on the ground.
“There’s culpability on both sides,” Johnson said. “There are a lot of checks and balances and safety initiatives that are in play, but for whatever reason they were all ignored.”
Johnson says much about the crash that could be known never will be, due to the absence of voice or data recorders -- cheap technology that wasn’t required aboard the ACE flight.
“One of the most frustrating things is that we don’t know what was going on in that cockpit,” Johnson said.
The NTSB report also found that Day and Jensen violated company regulations governing descent approaches.
- Source: http://www.ktuu.com
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.
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.
http://www.legacy.com
(1974 - 2013)
Obituary
Anchorage resident Jeffrey Gordon Day left our lives all too soon when his plane went down outside of Dillingham, Alaska on March 8, 2013. Jeff led his life with passion as a pilot, gifted musician, skilled carpenter, and outdoor enthusiast. But, most importantly, he was a loving husband, dedicated father, caring son and brother, and dear friend to many.
Jeff was born June 4, 1974 in Cincinnati, OH to Stan and Sandra Day, and as the younger brother of Debbie Day. He received his B.A. in Cultural Anthropology with a minor in Business and English at Washington University in St Louis. Jeff quickly became an avid traveler and explorer. He spent summers working in Denali National Park, participated in a NOLS course in Chile and Argentina, lived in Antarctica, and kayaked the length of the Inside Passage. Eventually, he settled in Juneau, where he was often found playing guitar, fiddle, or banjo within the music community. He met his wife Kelly in Juneau, and they were married on the edge of the water on a rare bluebird Juneau summer day. They eventually relocated to Anchorage and had two beautiful children, Talia and Zach, with whom Jeff was often found sharing his passions: taking them skiing, playing them music, and camping around the state. It was with his family, that Jeff seemed to shine the brightest.
In Anchorage, Jeff discovered a new passion for aviation. He often expressed his love of getting above the clouds and into the sun, flying about the Alaskan wilderness. He lost his life doing something he loved deeply.
Jeff will be remembered as a talented man with abundant energy, full of life, and with a gentle soul. He was loved and will be missed by many, but Jeff's light will continue to shine brightly in all of us.
http://www.legacy.com
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