The National Transportation Safety Board took the unusual step this week of citing not only errors committed by the pilot, but also company practices and Federal Aviation Administration oversight as factors in the November 2013 crash of a Hageland Aviation flight at a landing strip on Alaska's North Slope.
Neither of the aircraft's pilots nor the single passenger were injured in the accident that saw the Beechcraft 1900 touch down short of the landing strip at the Badami oil field airstrip, but the plane sustained substantial damage in the crash, according to a final report on the accident issued Tuesday by the NTSB.
Officially, the cause of the accident was determined by the NTSB to be “the captain’s decision to initiate a visual flight rules approach and attempted landing into an area of instrument meteorological conditions..." But also contributing were Hageland Aviation's “inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel” and the FAA’s “failure to hold the operator accountable for correcting known operational deficiencies and ensure compliance with its operational control procedures.”
The Badami accident was one of a string of accidents and incidents involving aircraft operated by Ravn Alaska members between 2012 and 2014.
Ravn includes Hageland Aviation, now known as Ravn Connect, Era Aviation, now known as Corvus Airlines, and Frontier Flying Service. Following fatality accidents in St. Marys and near Bethel, both of which are still under investigation, the NTSB issued two safety recommendations directing the FAA to conduct audits of flight operations, training, maintenance and inspection, and safety management programs of Ravn Alaska members. The NTSB also recommended the FAA audit its own oversight of the carriers.
Recently, the FAA has placed investigators in Bethel seven days a week on four-day rotations and is also providing continuing surveillance in Nome, Kotzebue, Barrow and Deadhorse.
Weather concerns
The Beechcraft in the Nov. 22, 2013 accident was carrying its single passenger the 29 miles between Deadhorse and the private oil field support airport at Badami. The flight departed at about 1:15 PM when the latest weather from Badami’s private weather observer reported 1 1/2 miles visibility, scattered clouds with blue skies above and blowing snow, according to NTSB interviews with the flight's first officer.
The accident occurred about 15 minutes later.
While en route, the flight's first officer told investigators he contacted the Badami weather observer again and learned the weather had deteriorated to 3/4 miles visibility in blowing snow. At that point, the first officer told the NTSB that the captain took over all radio communications.
The captain told investigators that a few minutes later the weather observer informed him he had 1 mile visibility, but the weather observer told the NTSB that he notified the pilots he could “...occasionally see the cold storage camp, which was located ‘1 1/4 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 told investigators he advised the pilots to “use their own judgment”.
The captain told the NTSB his visibility “...was unrestricted and that he had the runway environment in sight 20 miles from the airport.” He asked the first officer to load the instrument approach into the GPS, although he did not use it. He described the approach as normal until he realized he “was too low.”
The first officer told investigators he voiced concerns multiple times while on approach, finally saying “watch out,” just prior to impact. The aircraft then touched down short, with the main landing gear impacting the elevated edge of the runway surface. The right main gear separated and the aircraft slid along the runway.
Cockpit Voice Recorder not secured
The flight was equipped with both a flight data recorder and cockpit voice recorder, the latter of which provides a record of the most recent 30 minutes of radio communications aboard the aircraft.
On the day of the accident, NTSB investigators requested that Hageland secure the FDR and CVR and the company's director of maintenance assured them both recorders would be secured by maintenance personnel on scene.
But on Dec. 5, 2013, it was discovered that the CVR was never secured and engine maintenance runs had subsequently been performed on the aircraft. The NTSB vehicle laboratory in Washington, D.C. later determined that the pre-accident audio had been completely overwritten by maintenance personnel rendering the CVR useless to investigators.
In an email, Bob Hajdukovich, CEO for Ravn Alaska, provided the following explanation for how the CVR data was lost:
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.
Without the CVR, the NTSB was unable to verify the account of communications between the pilot, first officer and weather observer at Badami.
NTSB Alaska Region Chief Clint Johnson said last week that the loss of the voice recorder "does not allow the NTSB to know the sequence of events leading to the accident.”
Changes in flight management
In 2014 Hageland made a change in its dispatching procedures when the company opened an operational control center in Palmer. But at the time of the Badami accident, per the company's FAA-approved procedures, flights in the area were managed by a flight coordinator who was responsible for completing a flight risk assessment with pilots before takeoff, including weather conditions.
Such an assessment wasn't completed in the case of the accident flight.
The flight coordinator, a longtime employee, told investigators she had not completed required company training concerning her job. She also did not discuss weather or any risks associated with the flight with the crew. This was contrary to requirements in the Hageland’s Operations Manual, which required eight hours of initial training and three to four hours of recurrent training.
Out station flight coordinators no longer participate in flight decisions and instead concentrate on filling out load manifests, coordinating with ramp personnel and customer service with passengers. They do not contact the operational control center in Palmer, nor are they part of those discussions.
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.”
There are still four open accident and incident investigations involving Ravn Alaska air group members.
Original article can be found here: https://www.adn.com
NTSB Identification: ANC14LA007
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, November 22, 2013 in Deadhorse, AK
Probable Cause Approval Date: 03/10/2015
Aircraft: BEECH 1900C, registration: N575X
Injuries: 3 Uninjured.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
Before departure of the short, nonscheduled charter flight, 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 1/2 statute miles (sm) visibility with blowing snow. According to the first officer, after departure, he contacted the destination airport and was advised that the visibility had deteriorated to 3/4 sm. The captain then informed the private weather observer that the flight would need at least 1 sm visibility to land. A few minutes later, the weather observer informed the captain that the visibility had improved to 1 sm. The captain stated that the approach was normal until he had a “sinking sensation” and realized that the airplane was too low. The airplane subsequently touched down short of the runway, and the main landing gear impacted the elevated edge of the runway surface, which resulted in the right main gear separating. The airplane then slid along the runway surface, which resulted in substantial damage to the fuselage and right elevator. The captain reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
The private weather observer on duty at the destination airport the day of accident reported that he notified the pilots via radio that he could occasionally see a cold storage camp located 1 1/4 miles away but that he did not have 1-mile visibility. He said that, the weather was “bad” and that, at times, he could not see the runway. He said that he instructed the pilots to use their own judgment. Based on reported weather observations, at the time of the accident, the visibility had deteriorated to 1/2 mile in heavy blowing snow. Therefore, it is likely that the flight crew lost sight of the runway during the visual approach, which resulted in the airplane touching down short of the runway.
According to the company’s General Operations Manual (GOM), operational control was held by the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. The flight coordinator who had operational control of the flight and released it the day of the accident had not completed flight coordinator training, which was required per the company’s Federal Aviation Administration (FAA)-approved operations training manual. She assigned the flight a risk level of 2 (on a scale of 1 to 4), which, according to company risk assessment and operational control procedures, required a discussion between the PIC and flight coordinator about the risks involved. However, the flight coordinator did not discuss with the flight crew the risks and weather conditions associated with the flight. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals.
A review of FAA surveillance activities revealed that aviation safety inspectors had performed numerous operational control inspections and repeatedly noted deficiencies within the company’s training, risk management, and operational control procedures. Enforcement Information System records indicated that FAA inspectors observed multiple incidences of the operator’s noncompliance related to flight operations and opened investigations but that the investigations were closed after administrative action had been taken. Therefore, although FAA inspectors were providing surveillance and noting discrepancies within the company’s procedures and processes, the FAA did not hold the operator sufficiently accountable for correcting the types of operational deficiencies evident in this accident, such as the operator’s failure to comply with its operations specifications, operations training manual, and GOM and applicable federal regulations.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
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.
http://www.ntsb.gov
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment