NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to 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 flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures 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 company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
Three weeks later, on July 17, a Wings of Alaska Cessna 207 on a scheduled flight from Juneau to Hoonah crashed into mountainous terrain. The pilot was killed and four passengers seriously injured.
The Promech and Wings crashes had something notable in common: Both companies were members of the Medallion Foundation.
Medallion was formed as a nonprofit by the Alaska Air Carriers Association in 2001 to "improve pilot safety awareness and reduce air carrier insurance rates." Through the direction of the late Sen. Ted Stevens, the nonprofit organization received an initial federal grant of $3 million dollars in 2002.
According to budget requests later filed with the state, Medallion received $17 million in federal funds by 2013.
More recently, the organization has also received more than $750,000 from the state.
According to publicly filed records, an average of 44 percent of Medallion's annual income pays salaries. This does not include other administrative expenses or the minimum of $60,000 paid annually since 2013 for rental of a building owned by Executive Director Gerard Rock, where the foundation's offices are located.
Cornerstone safety programs
Medallion has developed safety programs in five key areas: CFIT (controlled flight into terrain) avoidance, operational control, maintenance and ground service, safety, and internal evaluation.
By completing each "cornerstone," members receive specific Medallion Stars. Those completing all five Stars are then eligible for a Shield after further evaluation.
Current Star and Shield members include Air Excursions, Alaska Central Express, Coastal Helicopters, Grant Aviation, Hageland Aviation, Pacific Airways, Ryan Air, Smokey Bay Air, Taquan Air and Wright Air Service, all of which have suffered accidents with fatalities or serious injuries in the past 10 years.
On its website, the organization points to escalating accident statistics in the 1990s as an impetus to its formation.
According to the National Transportation Safety Board database, in the 10-year period between Jan. 1, 1990, and the last day of 1999 there were 1,733 aircraft accidents in Alaska; 377 of them involved air taxis and small commuters (FAR Part 135 operators).
In the 10-year period after Medallion was founded, from Jan. 1, 2001, to the last day of 2010, there were 1,138 total aircraft accidents; 212 involving air taxis and small commuters.
However, it must be noted there was a far more dramatic impact on the Alaska aviation industry in this period than Medallion.
In 2002, Sen. Stevens spearheaded the passage of the Rural Service Improvement Act. Aimed at stabilizing the passenger, freight and mail system for rural Alaska, RSIA restructured how mail contracts were awarded and resulted in more than two dozen scheduled air carriers going out of business or being purchased by competitors.
The impact of the act on Alaska's aviation landscape cannot be overstated, nor can technological innovations such as Capstone and expansion of the FAA's weather-reporting system be ignored. Medallion does not exist in a vacuum and it would be inaccurate to suggest it is solely, or even primarily, responsible for an overall reduction in accidents.
‘Illusion of safety?’
Most third-party safety organizations like Medallion developed in recent years as air carriers sought to combat rising insurance rates. Generally, they issue public awards, like Stars and Shields, for completion of administered materials.
Recently, the NTSB criticized one such organization, Argus International, after a multiple fatality accident in Ohio. Board Member Robert Sumwalt stated Argus, which had been awarded a "Gold" rating to the charter company involved in the crash, provided only an "illusion of safety" to the aircraft's passengers.
A similar perceived sense of security was evident in Alaska in 2013 when Gov. Sean Parnell spoke to the Chamber of Commerce.
"Medallion certification diminishes the number of lost lives and injuries due to aviation accidents," Parnell said. "So if you are traveling on a Medallion-certified air carrier, you are traveling with people who have been trained above and beyond the minimum."
Ten people were killed in crashes involving Medallion members that year.
The reliance on third parties to provide assurance to passengers was touched on by Medallion's Rock in an interview with the NTSB following the 2013 triple fatality crash of Helo-1, a Department of Public Safety Eurocopter AS350 operated by the Alaska State Troopers. (The Department of Public Safety held a Medallion Safety Star.)
As Rock told investigators:"… A couple of these industries now require anybody flying for them, that they participate in Medallion for flying in Alaska. And I would say the main reason for that, when you look at the oil industry and the mining industry, most of these companies are from Outside and don't have a lot of Alaska safety experience, don't have winter operation experience. And Medallion gives them a tool to make sure the carriers flying for them here in Alaska actually kind of meet the requirements of flying, you know, in this type of environment."
There were problems with Medallion at the Department of Public Safety, however. According to the recently retired aviation section supervisor, the pilots were not involved in the new safety program.
"I don't feel like people really participated in it," she told investigators. "… I couldn't seem to get the trooper pilots to be into it."
The director of the Alaska Wildlife Troopers (who oversaw the aviation section), told investigators: "… Thinking back over these safety meetings, a lot of it was not even aviation related. It was, you know, like ice falling off a roof or, you know, maybe how fuel may have been stored. I don't recall ever seeing one flight-type safety issue."
In its investigation of the Helo-1 crash, the NTSB found in addition to errors by the pilot, there was "… inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training."
Membership intact
Medallion's influence was also studied in the investigations into the Promech and Wings of Alaska accidents, where there was some public confusion over their Medallion status.
In a 2016 interview with Alaska Dispatch News, Rock stated both companies "failed audits required to maintain membership and were on a yearlong suspension to correct deficiencies."
However, the NTSB report on the Wings crash includes a series of email exchanges between Medallion and Wings' owner, SeaPort Airlines, two months before the Hoonah accident. Those exchanges resulted in a voluntary suspension of the Shield but retention of the five Stars. The company's Medallion membership remained intact.
In the Promech investigation, its company president stated they held the CFIT Star and were in the process of obtaining the Safety Star. As that report notes, there was no evidence of Promech's Medallion membership status being suspended.
Rather, the foundation refused to respond to multiple NTSB requests "regarding Promech's external and internal Medallion audits…"
Those investigations made clear that both companies struggled with decision-making, as well as suffering operational control and apparent FAA oversight failures. Further, the circumstances surrounding the Promech crash in particular, which involved a line of air tour carriers following a pre-established route in marginal weather conditions, are familiar.
They echo previous "follow-the-leader" accidents including the 1994 crash of Wings of Alaska enroute to Juneau (seven dead, four seriously injured), the 1995 crash of Island Air Services in Kodiak (four dead), and the 2007 crash of Taquan Air in Misty Fjords (five dead).
‘Pilots just make mistakes’
In all of those accidents, as in nearly all of the finalized reports for fatality crashes in the past 10 years involving Medallion members (in one accident, the cause is unknown as the aircraft was unrecoverable), the probable causes were due to errors committed by the pilot. During the Helo-1 investigation, Bob Gastrock, a Medallion senior program manager, addressed this topic:
"And, you know, the pilot decision processes sometimes probably — I hate to say it, but 90 percent of the time, really why these accidents happen, I don't think it's so much the operator. The operator themself (sic) management, provides the tools, the training, but sometimes pilots just make mistakes and unfortunately that's just kind of what leads (to) this."
The NTSB recently determined the causes for both the Promech Air and Wings of Alaska crashes were the pilot's decisions to fly under visual flight rules into instrument meteorological conditions.
There were contributing factors as well, including, in the case of the Wings crash, the FAA's failure to properly monitor the company, and the company's failure to follow its own operational control procedures.
For Promech Air, the board also cited a corporate culture that "tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators."
Are the programs working?
There are many questions to be raised about the effectiveness of the Medallion Foundation's programs on the recurrent problems plaguing Alaska aviation, and it is doubtful its standardized programs are addressing the issue of individual decision-making with actual pilots themselves.
Medallion supporters need to think about the failures among the foundation's membership and what that says about the organization's methods. At some point, it must be asked if the programs are working to increase flight safety, or serve more to impress unwitting passengers, federal investigators and insurers.
The brutal truth is what happened to Promech Air and Wings of Alaska in 2015 was just more of what has been happening in the state for decades. It was happening before the funding of millions of dollars and the awarding of Stars and Shields, and it shows no signs of stopping.
In May 2016, the FAA issued a letter to the more than 200 regional operators in Alaska. In the wake of five serious crashes dating back to Promech, the agency noted such accidents generally occur due to "inappropriate or nonexistent safety cultures…"
The agency encouraged companies to seek the assistance of the Medallion Foundation.
What the FAA failed to note was three of those accidents, like so many before them, involved Medallion members.
Colleen Mondor is the author of "The Map of My Dead Pilots: The Dangerous Game of Flying in Alaska."
Original article can be found here: https://www.adn.com
NTSB Identification: ANC15MA041
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Thursday, June 25, 2015 in Ketchikan, AK
Aircraft: DEHAVILLAND DHC 3, registration: N270PA
Injuries: 9 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 traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, sustained substantial damage when it impacted mountainous tree-covered terrain, about 24 miles northeast of Ketchikan, Alaska. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135, as an on-demand visual flight rules (VFR) sightseeing flight when the accident occurred. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The commercial pilot and eight passengers were fatally injured. Marginal visual meteorological conditions were reported in the area at the time of the accident. The flight departed a floating dock located in Rudyerd Bay about 44 miles northeast of Ketchikan about 1200 for a tour through Misty Fjords National Monument Wilderness. A company VFR flight plan was in effect. At the time of the accident, the flight was returning to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.
The flight was a sightseeing flight for passengers of a cruise ship that was docked in Ketchikan. The tour, named Cruise/Fly, consisted of two groups of passengers. One group departed Ketchikan onboard a marine vessel and the other group departed via airplane, with a predetermined rendezvous at the floating dock in Rudyerd Bay. Once at the floating dock, the two groups would switch transportation modes for the return trip to Ketchikan.
The operator reported that the accident airplane departed Rudyerd Bay as the third of four float-equipped airplanes on air tour flights over the Misty Fjords National Monument Wilderness. The airplanes departed about 5 minutes apart, and the standard route of flight was southwest, over an area of remote inland fjords, coastal waterways, and mountainous tree-covered terrain.
When the airplane failed to return to Ketchikan, the operator initiated a search for the missing airplane and heard an emergency locator transmitter (ELT) signal along the accident pilot's anticipated route of flight. A helicopter from Temsco Helicopters, Inc., of Ketchikan, was dispatched to the suspected accident site to search for the missing airplane. However, the helicopter pilot said that he was unable to search the upper levels of the mountainous areas due to low ceilings and poor visibility. The helicopter pilot said that, after waiting for the weather conditions to improve, he was able to search the upper elevations of the search area and located the wreckage about 1429. The Ketchikan Volunteer Rescue Squad (KVRS) team members reached the accident site and confirmed that the airplane's occupants had sustained fatal injuries.
The NTSB investigator-in-charge along with another NTSB investigator, with help from KVRS, reached the accident site on the morning of June 27. The airplane impacted trees and a near vertical rock face in a nose high, wings level attitude at an elevation of about 1,600 feet mean sea level and came to rest upright on top of its separated floats, in an area of heavily forested, steep terrain.
The accident airplane was equipped with an avionics package known as automatic dependent surveillance-broadcast (ADS-B), which is also known as "Capstone." ADS-B technology provides pilots with situational awareness by displaying the airplane's position over terrain, while using GPS technology, coupled with an instrument panel mounted, moving map display. The ADS-B equipment installed in the accident airplane included two Chelton multifunction display (MFD) units. One MFD provides the pilot with a moving map with terrain awareness information, and the other provides primary flight display information. The two MFD units were removed from the wreckage and shipped, to the NTSB vehicle recorder laboratory, Washington, D.C.
The accident airplane was equipped with a Pratt & Whitney PT6A-135A engine that produces 750 shaft horsepower.
A comprehensive NTSB postaccident examination of the engine and airframe is pending, after the airplane wreckage is recovered to Ketchikan.
The closest weather reporting facility is Ketchikan Airport (KTN), Ketchikan, AK, about 24 miles southwest of the accident site. At 1153, an aviation routine weather report (METAR) at KTN reported in part: wind 130 degrees at 15 knots, gust 23 knots; visibility 6 statute miles, rain and mist, runway 11 visual range 4,000 variable to greater than 6,000 feet; few clouds 800 feet, broken clouds 1,200 feet, overcast clouds 2,700 feet; 61 degrees F; dew point 57 degrees F; altimeter 29.91 in Hg.
NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to 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 flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures 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 company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
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