Crash of a Piper PA-31-350 Navajo Chieftain in Anchorage

Date & Time: Dec 23, 1983 at 1406 LT
Operator:
Registration:
N35206
Flight Phase:
Survivors:
Yes
Schedule:
Anchorage - Kenai
MSN:
31-7952193
YOM:
1979
Flight number:
XE059
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5115
Captain / Total hours on type:
3550.00
Circumstances:
A Piper PA-31, N35206, (South Central Air flight 59) was cleared to taxi to runway 06L. The weather at that time was foggy with about 1/8 mile visibility, but the RVR was improving and the airport was expected soon to be acceptable for takeoffs. The PA-31 crew taxied and waited in the holding area for the visibility to improve. A Douglas DC-10, HL7339, Korean Air Lines flight 084, was cleared to runway 32; however, while taxiing in the fog, the DC-10 crew inadvertently taxied to runway 06L/24R. Tower personnel were unable to see the aircraft in the fog and were unaware of the DC-10's position. The DC-10 was cleared to take-off on runway 32 and the PA-31 was cleared to hold on runway 06L. The DC-10 crew taxied on runway 24R and began taking off toward the PA-31 with 2,400 feet of runway remaining. Its estimated takeoff distance was 8,150 feet. Subsequently, the DC-10 collided with the PA-31, continued off the runway and hit stanchion lights, small trees and rough terrain. An investigation revealed the DC-10 pilot did not confirm his position by using his compass and that there was a lack of legible taxiway and runway signs.
Probable cause:
The failure of the pilot of Korean Air Lines Flight 084 to follow accepted procedures during taxi, which caused him to become disoriented while selecting the runway; the failure of the pilot to use the compass to confirm his position; and the decision of the pilot to take off when he was unsure that the aircraft was positioned on the correct runway. Contributing to the accident was the fog, which reduced visibility to a point that the pilot could not ascertain his position visually and the control tower personnel could not assist the pilot. Also contributing to the accident was a lack of legible taxiway and runway signs at several intersections passed by Flight 084 while it was taxiing.
Final Report:

Crash of a Douglas DC-10-30CF in Anchorage

Date & Time: Dec 23, 1983 at 1406 LT
Type of aircraft:
Operator:
Registration:
HL7339
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Seoul - Anchorage - Los Angeles
MSN:
46960
YOM:
1977
Flight number:
KE084
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12562
Captain / Total hours on type:
6471.00
Copilot / Total flying hours:
8157
Copilot / Total hours on type:
2995
Circumstances:
While taxiing out in fog, the KAL crew became disoriented and ended up on the wrong runway. During the takeoff run, the aircraft collided head-on with South Central Air Flight 59, a Piper PA-31 which was taking off from runway 06L-24R for a flight to Kenai. The 9 occupants of N35206 were injured. The DC-10 overran the runway by 1434 feet and came to rest 40 feet right of the extended centreline.
Probable cause:
The failure of the pilot of Korean Air Lines Flight 084 to follow accepted procedures during taxi, which caused him to become disoriented while selecting the runway; the failure of the pilot to use the compass to confirm his position; and the decision of the pilot to take off when he was unsure that the aircraft was positioned on the correct runway. Contributing to the accident was the fog, which reduced visibility to a point that the pilot could not ascertain his position visually and the control tower personnel could not assist the pilot. Also contributing to the accident was a lack of legible taxiway and runway signs at several intersections passed by Flight 084 while it was taxiing.
Final Report:

Crash of a Boeing 747-230B off Sakhaline Island: 269 killed

Date & Time: Sep 1, 1983 at 0535 LT
Type of aircraft:
Operator:
Registration:
HL7442
Flight Phase:
Survivors:
No
Schedule:
New York - Anchorage - Seoul
MSN:
20559
YOM:
1972
Flight number:
KE007
Country:
Region:
Crew on board:
23
Crew fatalities:
Pax on board:
246
Pax fatalities:
Other fatalities:
Total fatalities:
269
Circumstances:
On 31 August 1983, a Korean Air Lines (KAL) Boeing 747, designated KE 007, departed John F. Kennedy International Airport, New York, United States, on a one-stop scheduled flight for Kimpo International Airport, Seoul, Republic of Korea. The en-route stop occurred at Anchorage International Airport, Alaska, United States. At Anchorage, the aircraft was refuelled and serviced for the remainder of the flight to Seoul and, in accordance with company practice, the flight and cabin crews were changed. The flight departed at the planned time of departure which, in keeping with Korean Air Lines' procedure, was calculated for each KE 007 flight. The departure from Anchorage was flexible to ensure arrival in Seoul at the scheduled arrival time of 21:00 hours* (06:00 hours local time). The actual departure time of 13:00 hours on 31 August would have resulted in an on-time arrival of KE 007 in Seoul, had the flight been completed in accordance with its flight plan. On departing Anchorage, the flight had 269 persons on board consisting of 240 passengers, 3 flight crew members, 20 cabin attendants, and 6 crew members of KAL being repositioned to Seoul. Soon after departure from Anchorage, KE 007 deviated to the right (north) of its direct track to Bethel. This deviation resulted in a progressively greater lateral displacement to the right of its planned route which, ultimately, resulted in its penetration of adjacent high seas airspace in flight information regions (FIR_s) operated by the Union of Soviet Socialist Republics (USSR), as well as of sovereign USSR airspace overlying Kamchatka Peninsula and Sakhalin Island and their surrounding territorial waters. No evidence was found during the investigation to indicate that the flight crew of KE 007 was, at any time, aware of the flight's deviation from its planned route in spite of the fact that it continued for over five hours. According to representatives of the United States, military radar installations in Alaska were not aware in real time that the aircraft was proceeding west with an increasing northerly deviation from the recognized airways system. The military radar installations of the Japanese Defence Agency were aware that an aircraft was tracking in USSR airspace over Sakhalin Island. According to representatives of Japan, they were not a\vare that it was a civil aircraft off its intended track. Approximately between 16:40 and 17:08 hours military aircraft operated by the USSR attempted to intercept KE 007 over Kamchatka Peninsula. The interception attempts were unsuccessful. From about 18:00 hours when KE 007 was approaching Sakhalin Island, USSR, the flight was intercepted by USSR military aircraft. At 18:26:02 hours the aircraft was hit by at least one of t\\'o air-to-air missiles fired by the pilot of one of the USSR interceptor aircraft who had been directed, by his ground command and control units, to shoot down an aircraft which they assumed to be a United States RC-135. As a result of the attack, KE 007 collided with the sea and sank off the southwest coast of Sakhalin Island. There were no survivors. The flight recorders, fragmentary pieces of the aircraft and a small number of items of personal property were salvaged by divers from the USSR during a two month period following the accident. In addition, some flotsam from the aircraft was dispersed by tidal currents and recovered later. The cockpit voice recorder (CVR) and the digital flight data recorder (DFDR) tapes were recovered by the USSR in 1983 and were handed over to ICAO in January 1993 by the representatives of the Russian Federation. They also made available recordings and transcripts of the communications between the pilots of the intercepting fighter aircraft and their ground controllers as well as the communications between the command centres. The representatives of the United States made available certified copies and transcripts of the Anchorage ATC tapes, and the representatives of Japan made available the Tokyo ATC tape. In the course of the investigation, all practical steps were taken to confirm the authenticity of the communications tapes. A comprehensive assessment of the physical characteristics of the CVR and the DFDR tapes and the information recorded thereon was made to ensure that they contained authentic records. The material on the communications tapes and the CVR and DFDR tapes showed no evidence of contradiction with known information and correlated well with other sources of data. There was no evidence to suggest that the crew of flight KE 007 was aware that their aircraft was flying to the north of its planned route or that they knew of the presence of the intercepting fighter aircraft. The DFDR record established that flight KE 007 maintained a constant magnetic heading from soon after departure from Anchorage until the attack by the fighter aircraft. The maintenance of the constant magnetic heading was so accurate it could only have resulted from the autopilot controlling the aircraft. The CVR and the DFDR records also established that the aircraft did not sustain an extensive avionics or navigation systems failure or malfunction prior to the attack by the USSR fighter aircraft. The evidence obtained supported the first hypothesis of those listed in the 1983 ICAO report, Le. that the crew inadvertently flew virtually the entire flight on a constant magnetic heading. The maintenance of a constant magnetic heading and the resulting track deviation was due to the KE 007 crew's failure to note that the autopilot had either been left in heading mode or had been switched to INS when the aircraft was beyond the range (7.5 NM) for the INS to capture the desired track.
Concerning the interception and associated identification, signalling and communications the investigation found the following:

1) Interceptions of KE 007 were attempted by USSR military aircraft over Kamchatka Peninsula and made in the vicinity of Sakhalin Island.

2) The USSR command centre personnel assumed that KE 007 was a United States RC-135 aircraft. KE 007's climb from FL 330 to FL350 during the time of the interception over Sakhalin Island was interpreted as being an evasive action, thus further contributing to the USSR presumption that it was an RC-135 aircraft.

3) No attempt was made by the USSR to contact the crew of KE 007 by radio on the distress frequency 121.5 MHz or on any other VHF or HF frequency. However, the interceptor pilot was instructed by his ground control to attempt to attract the attention of the crew of the intruding aircraft by firing his aircraft's cannon and flashing its navigation lights. It was not possible to assess the distance of the interceptor aircraft from the intruder nor their relative positions when the interceptor's lights were flashed and the cannon fired.

4) The USSR command centre personnel on Sakhalin Island were concerned with the position of the intruder aircraft in relation to USSR sovereign airspace as well as its identity. The time factor became paramount as the intruder aircraft was .about to coast out from Sakhalin Island. Therefore, exhaustive efforts to identify the intruder aircraft were not made, although apparently some doubt remained regarding its identity. .5) It was not possible to determine the position of KE 007 at the time of the missile attack in relation to USSR sovereign airspace.
Probable cause:
1. The considerable lateral deviation of the B-747 aeroplane on Flight KAL-007 from the assigned airway R20 was a result of the crew using an air navigation method based on maintaining a constant magnetic heading immediately after take-off (three minutes after the aeroplane lifted oft) and throughout the whole of the subsequent flight. This basically contradicts the generally accepted standards and rules of air navigation, including the regulated documents of Korean Air Lines. Disregarding the need for multiple corrections of the magnetic heading, which were prescribed by the computer flight plan, as well as the resulting current information from the aeroplane's navigation systems when reaching the intermediate waypoints, cannot be explained by an insufficient professional level of crew training, inattention or even negligence, since in this case what one is talking about is the complete refusal of the crew to comply with all the rules and procedures for the performance of the flight prescribed by the airline's instructions, including those in the event of possible abnormalities in the operation of the equipment. A probable explanation for the situation which developed may be the intentional following of the route which was actually taken. The following facts attest to this:
- in accordance with the ATS plan, the crew informed the Anchorage and Tokyo ATC units of their position with respect to the compulsory reporting points. However, the information did not correspond to the actual position of the aeroplane indicated by the airborne navigation systems;

- when reporting with respect to NABIE and NEEVA, the crew did not ask the ATS units about the serviceability of the NDB and DME on St. Paul Island and that of the VOR and elements of the DME/TACAN .0n "Shemya Island, despite the absence of signals from these radio navigation aids, since,possibly, they knew that they were out of coverage;

- having determined their position with respect to NEEVA, the crew, according to the DFDR data, did not make any attempts to contact the Anchorage ARTCC on communications channel VHF-2,

- the recording, of the radio exchanges (CVR) of the crew of Flight KAL-007 with the crew of Flight KAL-015, which was following it at an interval of approximately 4 minutes, indicates the complete lack of alertness on the part of the crew of KAL-007 with regard to the basic differences in wind force and direction according to the data of these two aeroplanes;

- long before entering Japan's ATS radar area, the crew set on the SSR code selector the code 1300, which refers to the phase of exit from this area prior to entry into the Korean area TAEGU, instead of the prescribed code 2000. The flight path of Flight KAL-007, obtained on the basis of the results of modelling taking into account the data from the radar tracking stations of the United States, the USSR and Japan, essentially coincides over a considerable extent (Anchorage-abeam NIPPI) with a great circle flight path Anchorage - FIR Seoul (the deviations do not exceed ± 15 NM. This is determined by the accuracy of the calculations made). If one assumes that a route along the great circle VOR Anchorage - FIR Seoul was programmed on one of the three INS and that the flight was performed according to this programme, then in this case the crew's actions can be logically explained. However, the investigation materials do not 'contain exhaustive evidence confirming this assumption. Thus, the Commission could not determine the reasons which prompted the crew to decide to follow from Anchorage to Seoul the route which was actually taken and which was close to the great circle.

2. The actions of the USSR Air Defence Forces on the territory of Kamchatka Peninsula and Sakhalin Island were based on the conviction that 'a military intruder aeroplane had entered USSR airspace. The absence of civil aircraft, according to the reports of the USSR ATC units, in the airspace monitored by them and the impossibility of visual recognition of the intruder aeroplane type as a civil aircraft under night flying conditions confirmed the certainty of its military affiliation. Given these circumstances, the rules of interception for civil aircraft, recommended by ICAO and established in the USSR AlP, were not applied by the USSR Air Defence Forces. The USSR Air Defence units were guided by the rules regulating the actions of the Air Defence Forces in the event of violation of the USSR State border by military aeroplanes. This led to the stopping of the flight at 1826 hours. As was shown by an analysis of the objective information on the actions of the Air Defence units in intercepting the intruder aeroplane, all available measures were taken to identify and determine the type and State affiliation of this aeroplane. Further evidence of this is the fact that the flight was stopped not when it flew over Kamchatka Peninsula and not when it again violated the USSR State border in the area of Sakhalin Island, but immediately before the intruder aeroplane exited USSR airspace.
Final Report:

Crash of a Boeing 747-2B5B in Seoul: 14 killed

Date & Time: Nov 18, 1980 at 0725 LT
Type of aircraft:
Operator:
Registration:
HL7445
Survivors:
Yes
Schedule:
Los Angeles – Anchorage – Seoul
MSN:
21773
YOM:
1979
Flight number:
KE015
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
213
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
Following an uneventful flight from Los Angeles via Anchorage, the crew started the approach to Seoul-Gimpo Airport in the early morning, just after sunset. On final to runway 14, with a limited visibility of 1,000 meters due to patches of fog, the crew failed to realize his altitude was insufficient when the airplane landed 90 meters short of runway threshold. Then the aircraft struck a concrete wall, causing all main gears to be torn off or to pushed back in their respective wheel well, except the nose gear which remained intact. The airplane slid on its belly for about 1,200 metres before coming to rest in flames on the left side of the runway. 14 occupants escaped uninjured while 198 others were injured. Unfortunately, eight passengers and six crew members, among them both pilots, were killed. The aircraft was destroyed by a fire that probably ignited in a cargo compartment.
Probable cause:
Wrong approach configuration on part of the flying crew who continued the approach below the glide without any visual contact with the ground until the airplane struck the ground short of runway.

Crash of a Learjet 24D in Dutch Harbor

Date & Time: Dec 2, 1979 at 1621 LT
Type of aircraft:
Operator:
Registration:
N300JA
Flight Phase:
Survivors:
Yes
Schedule:
Dutch Harbor - Anchorage
MSN:
24-282
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15756
Captain / Total hours on type:
5000.00
Circumstances:
During the takeoff roll at Dutch Harbor Airport, the airplane swerved then collided with rocks and the right side of the runway. The crew aborted the takeoff procedure but the airplane went out of control and crashed in flames. All six occupants were injured, three of them seriously. The aircraft was destroyed by fire.
Probable cause:
Swerve on takeoff run and subsequent collision with objects after the crew selected an unsuitable terrain. The following contributing factors were reported:
- The crew delayed action in aborting takeoff,
- Inadequate snow removal from runway on part of the airport supervisory personnel,
- Wet runway,
- Ice/slush on runway,
- Poorly maintained runway surface,
- Soft runway.
Final Report:

Crash of a Learjet 25 in Anchorage: 5 killed

Date & Time: Dec 4, 1978 at 1450 LT
Type of aircraft:
Operator:
Registration:
N77RS
Survivors:
Yes
Schedule:
Juneau - Anchorage
MSN:
25-094
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7000
Captain / Total hours on type:
650.00
Copilot / Total flying hours:
2635
Copilot / Total hours on type:
21
Aircraft flight hours:
1549
Circumstances:
Following an uneventful flight from Juneau, the crew completed the final approach and was attempting to land on runway 06R when the airplane rolled sharply and struck the ground. out of control, it crashed inverted in a snow covered area near the runway. Two passengers were seriously injured while five other occupants were killed.
Probable cause:
It was determined that the probable cause of the accident was an encounter with strong, gusting crosswinds during the landing attempt, which caused the aircraft to roll abruptly and unexpectedly. The ensuing loss of control resulted from inappropriate pilot techniques during the attempt to regain control of the aircraft. Suspected light ice accumulations on the aerodynamic surfaces may have contributed to a stall and loss of control.
Final Report:

Crash of a Boeing 707-321B near Kem: 2 killed

Date & Time: Apr 20, 1978 at 2217 LT
Type of aircraft:
Operator:
Registration:
HL7429
Flight Phase:
Survivors:
Yes
Schedule:
Paris - Anchorage - Seoul
MSN:
19363
YOM:
1967
Flight number:
KE902
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
97
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Flight KE902 departed Paris-Orly Airport at 1339LT on a flight to Seoul with an intermediate stop in Anchorage. After passing the North Magnetic Pole, while approaching Ellesmere Island, Canada, the airplane initiated a turn to the right by 150° instead continuing straight-in to North Canada and Alaska. This caused the airplane to fly to the southeast, over the Barents Sea and then into Soviet airspace, reaching the Soviet coast approximately three hours and 2,400 km after its right turn. The aircraft was intercepted by a Soviet Air Force Sukhoi SU-15TM and was forced to land. For reasons undetermined, the Korean crew did not respond to multiple requests and initiated a turn when the Soviet pilot was instructed to shoot down the Boeing 707. One of the air/air missile struck the left wing and four meters were torn off. The missile also punctured the fuselage, causing rapid decompression and jamming one of the plane's four turbines. From an altitude of 30,000 feet, the crew initiated a rapid descent and eventually completed an emergency landing on the frozen Korpijärvi Lake located in the region of Kem, Republic of Karelia. Two passengers were killed during the attack while all other occupants were evacuated, 13 were injured. Both pilots and the navigator were arrested but released on April 29.
Probable cause:
It is believed that the airplane deviated from the prescribed flight plan directly after it passed over the North Magnetic Pole, causing major disturbance of the aircraft's magnetic compass-based navigation systems. For the Soviet Authorities, the deviation was the consequence of a navigation error on part of the flying crew.

Crash of a Douglas DC-7BF in Yakutat: 4 killed

Date & Time: Sep 12, 1977 at 0012 LT
Type of aircraft:
Operator:
Registration:
N6314J
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yakutat - Anchorage
MSN:
45359/868
YOM:
1957
Location:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from Yakutat Airport, while climbing to a height of 50 feet, one of the engine caught fire. The captain elected to return for an emergency landing when he lost control of the airplane that crashed in flames in a wooded area located 2,5 miles from the airport. The aircraft was destroyed and all four crew members were killed.
Probable cause:
Engine failure during initial climb due to inadequate maintenance and inspection. The following contributing factors were reported:
- Attempted operation with known deficiencies in equipment,
- Powerplant - exhaust system: stacks,
- Valve assemblies,
- Fire in engine,
- Improperly loaded aircraft, weight and CofG,
- Improper emergency procedures,
- Pilot fatigue,
- Aircraft approximately 1,745 pounds over max gross weight,
- Engine not feathered as the autofeather system was not connected,
- 100 octane fuel.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 near Iliamna: 13 killed

Date & Time: Sep 6, 1977 at 1452 LT
Operator:
Registration:
N563MA
Flight Phase:
Survivors:
No
Site:
Schedule:
Iliamna - Anchorage
MSN:
196
YOM:
1969
Flight number:
AAI302
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
4335
Captain / Total hours on type:
1124.00
Copilot / Total flying hours:
1380
Copilot / Total hours on type:
371
Aircraft flight hours:
15369
Circumstances:
Flight 302 departed Iliamna at 1419LT with 11 passengers and 2 crew members on board. It was cleared to Anchorage on an instrument flight rules (IFR) flight plan via the low frequency airways--Red Airway 99 (Red 99) to the Kakon Intersection, and then Green Airway 8 (Green 8) to Anchorage. The flight was to maintain 7,000 ft. At 1425:20, the flight crew of Flight 302 established radio contact with Anchorage Air Route Traffic Control Center's (Anchorage Center) D2 nonradar sector controller. They reported that the flight was level at 7,000 ft and that they estimated arrival at Kakon Intersection at 1434. At 1428:35, Anchorage Center requested the flight's estimate for its arrival at Homer, Alaska. The flight crew responded that they estimated to be over Homer at 1515. The flight crew of Flight 302 did not make radio contact when they were over Kakon Intersection; however, at 1439:40 they requested of Anchorage Center, "302, we would like to file Green 8 and intercept the 192° bearing from Wildwood." Fifteen seconds later, Anchorage Center cleared the flight to proceed along the new route of flight and to remain at 7,000 ft. At 1440:50, the flight crew of Flight 302 advised, "302, we--we'll estimate Clams at 15 past the hour." Anchorage Center acknowledged the advisory. This was the last known radio transmission from Flight 302. At 1452:08, three abrupt, audible sounds were recorded on the Anchorage Center tape of incoming air-to-ground communications with Flight 302. These sounds were similar to those produced by a carrier frequency that was heard during the activation of Flight 302's radio transmitter during earlier radio communications with the Center. After several unsuccessful attempts to contact Flight 302 by several air traffic, control facilities between Iliamna and Anchorage and after the flight could not be detected on radar in the areas where radar coverage was available, Anchorage Center initiated the required actions to alert and notify appropriate authorities of a possible aircraft accident. U.S. Air Force search and rescue aircraft located the wreckage site at 1643 on September 7, 1977. The aircraft had struck a glacier face on the southwest side of Mt Iliamna at the 7,000 ft elevation. There were no survivors. Because of the rapidly changing environmental conditions on the glacier face of Mt Iliamna, recovery of bodies and wreckage was not possible.
Probable cause:
The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to use proper navigational procedures for the route to be flown, especially their failure to use the available backup means of navigation to verify the position and the progress of the flight.
Final Report:

Crash of a Chase YC-122C Avitruc in Anchorage: 1 killed

Date & Time: Jan 31, 1977 at 1416 LT
Type of aircraft:
Operator:
Registration:
N5904V
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Anchorage - Nome
MSN:
CY-886
YOM:
1954
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5226
Captain / Total hours on type:
5.00
Circumstances:
Shortly after takeoff from Anchorage-Intl Airport, while climbing, the airplane stalled and crashed. A crew member was killed while two others were seriously injured.
Probable cause:
Stall during initial climb after the pilot-in-command failed to maintain flying speed. The following contributing factors were reported:
- Inadequate preflight preparation,
- Airframe ice,
- Frost found on wings after impact.
Final Report: