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Crash of a Piper PA-31-350 Navajo Chieftain near Cooper Landing: 3 killed

Date & Time: Nov 29, 2019 at 1911 LT
Operator:
Registration:
N4087G
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Anchorage – Seward
MSN:
31-8152127
YOM:
1981
Flight number:
SVX36
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
35000
Captain / Total hours on type:
1200.00
Aircraft flight hours:
5502
Circumstances:
On November 29, 2019, about 1911 Alaska standard time, a Piper PA-31-350 airplane, N4087G, was destroyed by impact and postcrash fire when it collided with mountainous terrain about 15 miles west of Cooper Landing, Alaska. The three occupants; the airline transport pilot, a flight nurse, and the flight paramedic were fatally injured. The airplane was operated by Fly 4 You Inc., doing business as Security Aviation, as a Title 14 Code of Federal Regulations Part 135 visual flight rules air ambulance flight. Dark night visual meteorological conditions existed at the departure and destination locations and company flight following procedures were in effect. The flight departed Ted Stevens International Airport (PANC), Anchorage, Alaska, about 1848, destined for Seward Airport (PAWD), Seward, Alaska. Dispatch records indicated that, on November 29, Providence Seward Medical Center emergency clinic personnel contacted multiple air ambulance companies with a "weather check" for possible air ambulance transportation of a patient from Seward to Anchorage. The first company contacted was Guardian Flight, who declined the flight at 1624 due to limited daylight hours. The second company, LifeMed Alaska, declined the flight at 1637 due to weather. The third and final company contacted for the flight was Medevac Alaska. Their dispatch officer was not notified of the previous declined flight requests and forwarded the request to Security Aviation, who is their sole air charter provider. At 1731 Security Aviation accepted the flight, and Medevac Alaska flight SVX36 was staffed with a nurse and paramedic. A preliminary review of archived Federal Aviation Administration (FAA) radar and automatic dependent surveillance (ADS-B) data revealed that the accident airplane departed PANC and flew south about 3,000 ft mean sea level (msl) toward the Sterling Highway. The airplane was then observed descending to 2,200 ft msl while flying a right racetrack pattern before flying into the valley toward Cooper Landing. The last data point indicated that at 1911:14 the airplane was over the west end of Jean Lake at 2,100 ft msl, on a 127° course, and 122 kts groundspeed. Ground witnesses who were in vehicles on the Sterling Highway near milepost 63, reported that they saw the lights of the airplane flying over the highway that night. One witness stated that he saw the airplane west of the mountains turn in a circle as it descended and then entered the valley. He observed the wings rocking back and forth and while he was looking elsewhere, he heard an explosion and observed a large fire on the mountainside. Another witness reported seeing the airplane flying low and explode when it impacted the mountain. Witnesses to the fire called 911 and observed the wreckage high on the mountainside burning for a long time after impact. The airplane was reported overdue by the chief pilot for Security Aviation and the FAA issued an alert notice (ALNOT) at 2031. The Alaska Rescue Coordination Center dispatched an MH-60 helicopter to the last known position and located the burning wreckage that was inaccessible due to high winds in the area. On December 1, 2019, the Alaska State Troopers coordinated a mountain recovery mission with Alaska Mountain Rescue Group. The wreckage was observed on the mountain at an elevation of about 1,425 ft msl in an area of steep, heavily tree-covered terrain near the southeast end of Jean Lake in the Kenai National Wildlife Refuge. The airplane was highly fragmented and burned, however all major airplane components were accounted for. Multiple large trees around the wreckage were fractured and indicated an easterly heading prior to the initial impact.

Crash of a Saab 2000 in Unalaska: 1 killed

Date & Time: Oct 17, 2019 at 1740 LT
Type of aircraft:
Operator:
Registration:
N686PA
Survivors:
Yes
Schedule:
Anchorage - Unalaska
MSN:
017
YOM:
1995
Flight number:
AS3296
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
14761
Captain / Total hours on type:
131.00
Copilot / Total flying hours:
1447
Copilot / Total hours on type:
138
Aircraft flight hours:
12617
Aircraft flight cycles:
9455
Circumstances:
On October 17, 2019, a Saab SA-2000 airplane, operated by Peninsula Aviation Services Inc. d.b.a. PenAir flight 3296, overran the end of runway 13 at Unalaska Airport (DUT), Unalaska, Alaska. The flight crew executed a go-around during the first approach to runway 13; the airplane then entered the traffic pattern for a second landing attempt on the same runway. Shortly before landing, the flight crew learned that the wind at midfield was from 300° at 24 knots, indicating that a significant tailwind would be present during the landing. Because an airplane requires more runway length to decelerate and stop when a tailwind is present during landing, a landing in the opposite direction (on runway 31) would have favored the wind at the time. However, the flight crew continued with the plan to land on runway 13. Our postaccident calculations showed that, when the airplane touched down on the runway, the tailwind was 15 knots. The captain reported after the accident that the initial braking action after touchdown was normal but that, as the airplane traveled down the runway, the airplane had “zero braking” despite the application of maximum brakes. The airplane subsequently overran the end of the runway and the adjacent 300-ft runway safety area (RSA), which was designed to reduce airplane damage during an overrun, and came to rest beyond the airport property. The airplane was substantially damaged during the runway overrun; as a result, of the 3 crewmembers and 39 passengers aboard, 1 passenger sustained fatal injuries, and 1 passenger sustained serious injuries. Eight passengers sustained minor injuries, most of which occurred during the evacuation. The crewmembers and 29 passengers were not injured.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the landing gear manufacturer’s incorrect wiring of the wheel speed transducer harnesses on the left main landing gear during overhaul. The incorrect wiring caused the antiskid system not to function as intended, resulting in the failure of the left outboard tire and a significant loss of the airplane’s braking ability, which led to the runway overrun.
Contributing to the accident were
1) Saab’s design of the wheel speed transducer wire harnesses, which did not consider and protect against human error during maintenance;
2) the Federal Aviation Administration’s lack of consideration of the runway safety area dimensions at Unalaska Airport during the authorization process that allowed the Saab 2000 to operate at the airport; and
3) the flight crewmembers’ inappropriate decision, due to their plan continuation bias, to land on a runway with a reported tailwind that exceeded the airplane manufacturer’s limit. The safety margin was further reduced because of PenAir’s failure to correctly apply its company-designated pilot-incommand airport qualification policy, which allowed the accident captain to operate at one of the most challenging airports in PenAir’s route system with limited experience at the airport and in the Saab 2000 airplane.
Final Report:

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report: