Sunday, May 6, 2018

Cessna 208B Grand Caravan, N208SD, Hageland Aviation Services / Ravn Connect: Fatal accident occurred October 02, 2016 in Togiak, Alaska

Drew Edward Welty

The two pilots that died in the plane crash are identified as Timothy Cline, 43 of Homer, and Drew Welty, 29 of Anchorage. The passenger has been identified as Louie John, 49 of Manokotak. 


The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Anchorage, Alaska
Pratt & Whitney Canada; Montreal, MB
Hageland Aviation Services Inc; Anchorage, Alaska 
Hartzell Propellers; Piqua, Ohio
Honeywell Aerospace; Phoenix, Arizona 
Hageland Aviation; Anchorage, Alaska
Federal Aviation Administration;  Washington, District of Columbia 

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

http://registry.faa.gov/N208SD



Aviation Accident Final Report - National Transportation Safety Board

Location: Togiak, AK
Accident Number: ANC17MA001
Date & Time: 10/02/2016, 1157 AKD
Registration: N208SD
Aircraft: CESSNA 208B
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 3 Fatal
Flight Conducted Under: Part 135: Air Taxi & Commuter - Scheduled

Analysis 

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02.

On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The flight crew's decision to continue the visual flight rules flight into deteriorating visibility and their failure to perform an immediate escape maneuver after entry into instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). 

Contributing to the accident were

(1) Hageland's allowance of routine use of the terrain inhibit switch for inhibiting the terrain awareness and warning system alerts and inadequate guidance for uninhibiting the alerts, which reduced the margin of safety, particularly in deteriorating visibility; 

(2) Hageland's inadequate crew resource management (CRM) training; 

(3) the Federal Aviation Administration's failure to ensure that Hageland's approved CRM training contained all the required elements of Title 14 Code of Federal Regulations 135.330; and 

(4) Hageland's CFIT avoidance ground training, which was not tailored to the company's operations and did not address current CFIT-avoidance technologies. 

Findings

Aircraft
Altitude - Not attained/maintained (Cause)
Ground proximity system - Not used/operated
Ground proximity system - Related operating info
Ground proximity system - Capability exceeded
Ground proximity system - Design

Personnel issues
Decision making/judgment - Flight crew (Cause)
Lack of action - Flight crew (Cause)

Environmental issues
Below VFR minima - Decision related to condition (Cause)
Below VFR minima - Response/compensation (Cause)
Mountainous/hilly terrain - Response/compensation (Cause)
Mountainous/hilly terrain - Contributed to outcome (Cause)

VHF/HF radio - Not specified
Meteo equip coverage/avail - Not specified

Organizational issues
Adequacy of policy/proc - Operator (Factor)
CRM/MRM training - Operator (Factor)
CRM/MRM training - FAA/Regulator (Factor)
Training - Operator (Factor)
Safety programs - FAA/Regulator
Safety programs - Other institution/organization

Factual Information 

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/02.

On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at PATG (which had the closest weather observing station to the accident site), but a second company flight crew (whose flight departed about 2 minutes after the accident airplane and initially followed a similar route) reported that they observed unexpected fog, changing clouds, and the potential for rain along the accident route. Company flight-following procedures were in effect. The flight departed Quinhagak Airport, Quinhagak, Alaska, about 1133 and was en route to PATG. 



History of Flight

Enroute-cruise
VFR encounter with IMC (Defining event)
Controlled flight into terr/obj (CFIT)

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 43, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 07/22/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/07/2016
Flight Time: 6481 hours (Total, all aircraft), 781 hours (Total, this make and model), 6181 hours (Pilot In Command, all aircraft), 271 hours (Last 90 days, all aircraft), 102 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft) 

Co-Pilot Information

Certificate: Commercial
Age: 29, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 None
Last FAA Medical Exam: 07/13/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 09/03/2016
Flight Time: 273 hours (Total, all aircraft), 84 hours (Total, this make and model), 139 hours (Pilot In Command, all aircraft), 84 hours (Last 90 days, all aircraft), 83 hours (Last 30 days, all aircraft), 5 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N208SD
Model/Series: 208B
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 208B0491
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 09/15/2016, AAIP
Certified Max Gross Wt.: 7449 lbs
Time Since Last Inspection:
Engines: 1 Turbo Prop
Airframe Total Time: 20562.1 Hours at time of accident
Engine Manufacturer: P&W
ELT: C126 installed, activated, aided in locating accident
Engine Model/Series: PT6-114A
Registered Owner: ICECAP LLC TRUSTEE
Rated Power: 675 hp
Operator: HAGELAND AVIATION SERVICES INC
Operating Certificate(s) Held: Commuter Air Carrier (135); On-demand Air Taxi (135)
Operator Does Business As: RAVN CONNECT
Operator Designator Code: EPUA

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PATG, 20 ft msl
Observation Time: 1156 AKD
Distance from Accident Site: 11 Nautical Miles
Direction from Accident Site: 124°
Lowest Cloud Condition: Scattered / 3900 ft agl
Temperature/Dew Point: 7°C / 6°C
Lowest Ceiling: Overcast / 4700 ft agl
Visibility:  7 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 29.88 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Light - Rain
Departure Point: QUINHAGAK, AK (PAQH)
Type of Flight Plan Filed: Company VFR
Destination: TOGIAK, AK (PATG)
Type of Clearance: None
Departure Time: 1133 AKD
Type of Airspace: Class G

Airport Information

Airport: TOGIAK (PATG) 
Runway Surface Type: N/A
Airport Elevation: 18 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: Fire At Unknown Time
Ground Injuries: N/A
Aircraft Explosion: Explosion At Unknown Time
Total Injuries: 3 Fatal
Latitude, Longitude: 59.165556, -160.653333


NTSB Identification: ANC17FA001
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, October 02, 2016 in Togiak, AK
Aircraft: CESSNA 208B, registration: N208SD
Injuries: 3 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 October 2, 2016, about 1154 Alaska daylight time, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, sustained substantial damage after impacting steep, mountainous, rocky terrain about 12 miles northwest of Togiak, Alaska. The airplane was being operated as flight 3153 by Hageland Aviation Services, Inc., dba Ravn Connect, Anchorage, Alaska, as a scheduled commuter flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 and visual flight rules (VFR). All three people on board (two commercial pilots and one passenger) sustained fatal injuries. Visual meteorological conditions prevailed at the Togiak Airport, Togiak, and company flight following procedures were in effect. Flight 3153 departed Quinhagak, Alaska, at 1133, destined for Togiak.

Earlier, flight 3153 had originated in Bethel, Alaska; made scheduled stops in Togiak and Quinhagak; and was scheduled to return to Togiak before returning to Bethel, the intended final destination for the day. 

According to the director of operations for Hageland Aviation Services, Inc., about 1214, he received a notification from the Air Force Rescue Coordination Center (RCC) that it received a signal from a 406 megahertz (MHz) Emergency Location Transmitter (ELT), which activated about 1208 and was registered to N208SD. After accessing the aircraft location data provided by an on-board flight tracking system and discovering the aircraft had been stationary for about 20 minutes, the Hageland director of operations contacted the Hageland Operational Control Center (OCC) in Palmer, Alaska, to verify the information. At that time, the operator initiated a company search for the airplane.

At 1326, the Alaska State Troopers (AST) were notified by the RCC personnel of an ELT activation near the village of Togiak, within the confines of the Togiak National Wildlife Refuge. 

Shortly before 1430, an AST helicopter was dispatched from Dillingham, Alaska, about 67 miles east of Togiak, to the coordinates associated with the ELT signal, but poor weather conditions kept the searchers from locating the accident airplane until about 1630. Alaska State Troopers were able to access the scene on foot shortly before 1730 and subsequently confirmed there were no survivors. 

On October 3, the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), along with another NTSB investigator and two Alaska State Troopers reached the accident site. The airplane's fragmented wreckage was located on the southeast side of a steep, loose rock-covered mountainside, adjacent to the Quigmy River, about 12 miles northwest of Togiak. 

An area believed to be the initial impact point was discovered on the northwest side of a mountain ridgeline at the 2,300-foot level. The initial impact point was located north of and about 200 feet below the 2,500-foot mountain summit. The initial impact point contained fragmented portions of fuselage and two severed propeller blades. From the initial impact point, the wreckage path extended southeast to the main wreckage, which was located downslope on the southeast side of the ridgeline at the 1,550-foot level. The outboard portion of the left wing had separated and was located about 200 feet further downslope below the main wreckage site. A postcrash fire incinerated a large portion of the fuselage and right wing.

The airplane was equipped with a Spidertracks flight tracking system, which provides real-time aircraft flight tracking data. The flight tracking information is transmitted via Iridium satellites to an internet-based storage location at 6-minute intervals. According to the Spidertracks data, the airplane's last known location was reported at 1153, about 19 nautical miles northwest of the Togiak Airport, at an altitude of 1,043 feet, traveling at 144 knots across the ground, on a heading of 140 degrees.

At 1156, an aviation routine weather report (METAR) from the Togiak Airport (the closest weather reporting facility) reported, in part: wind calm; visibility 7 statute miles; light rain; sky condition, scattered clouds at 3,900 feet, overcast at 4,700 feet; temperature 45 degrees F, dewpoint 43 degrees F; altimeter, 29.88 inHg.

A detailed wreckage examination is pending. 

The airplane was equipped with a Pratt & Whitney PT6 series engine.

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