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Crash of a Cessna 208B Grand Caravan near Chignik: 1 killed

Date & Time: May 1, 2017 at 1350 LT
Type of aircraft:
Operator:
Registration:
N803TH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Port Heiden - Perryville
MSN:
208B-0321
YOM:
1992
Flight number:
GV341
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4989
Captain / Total hours on type:
904.00
Aircraft flight hours:
17990
Circumstances:
The airline transport pilot was conducting a commercial visual flight rules (VFR) flight. A passenger who was on the first segment stated that the pilot flew the airplane lower than usual for that route, and that the airplane flew through clouds during the flight. The passenger disembarked and the pilot departed on the second segment of the flight with a load of mail. The route included flight across a peninsula of mountainous terrain to a remote coastal airport that lacked official weather reporting or instrument approach procedures. About 28 minutes after departure, an emergency locator transmitter (ELT) signal from the airplane was received and a search and rescue operation was initiated. The wreckage was located about 24 miles from the destination in deep snow on the side of a steep, featureless mountain at an elevation about 3,000 ft mean sea level. The accident site displayed signatures consistent with impact during a left turn. Examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The airplane was not equipped with any recording or flight tracking devices, nor was it required to be; therefore, the airplane's flight track before the accident could not be determined. The airplane was certified for instrument flight and flight in icing conditions and was equipped with a terrain avoidance warning system (TAWS) which was not inhibited during the accident. Although the TAWS should have provided the pilot with alerts as the airplane neared the terrain, it could not be determined if this occurred or if the pilot heeded the alerts. A review of nearby weather camera images revealed complete mountain obscuration conditions with likely rain shower activity in the vicinity of the accident site. Visible and infrared satellite imagery indicated overcast cloud cover over the accident site at the time of the accident. The graphical forecast products that were available to the pilot before the flight indicated marginal VFR conditions for the entire route. There was no evidence that the pilot obtained an official weather briefing, and what weather information he may have accessed before the flight could not be determined. Additionally, the cloud conditions and snow-covered terrain present in the area likely resulted in flat light conditions, which would have hindered the pilot's ability to perceive terrain features and closure rates. Based on the weather camera, surface, and upper air observations, it is likely that the pilot encountered instrument meteorological conditions inflight, after which he performed a left turn to return to visual meteorological conditions and did not recognize his proximity to the mountain due to the flat light conditions. The pilot and the dispatch agent signed a company flight risk assessment form before the flight, which showed that the weather conditions for the flight were within the company's acceptable risk parameters. Although the village agents at the departure and destination airports stated that the weather at those coastal locations was good, the weather assessment for the accident flight was based on hours-old observations provided by a village agent who was not trained in weather observation and did not include en route weather information, the area forecast, or the AIRMET for mountain obscuration effective during the dispatch time and at the time of the accident. Since acquiring the accident route from another operator years earlier, the company had not performed a risk assessment of the route and its associated hazards. Multiple company pilots described the accident route of flight as hazardous and considered it an undesirable route due to the terrain, rapidly changing weather, and lack of weather reporting infrastructure; however, the company did not address or attempt to mitigate these known hazards through its risk assessment processes. The company's controlled-flight-into-terrain (CFIT)-avoidance program stated that each pilot shall have one classroom training session and one CFIT-avoidance training session in an aviation training device (ATD) each year; however, the pilot's training records indicated that his most recent ATD session was 15 months prior. More recent CFIT avoidance training may have resulted in the pilot recognizing and responding to the reduced visibility and flat light conditions sooner.
Probable cause:
The pilot's continued visual flight rules flight into an area of mountainous terrain and instrument meteorological conditions, which resulted in controlled flight into terrain (CFIT). Contributing to the accident was the company's failure to provide the pilot with CFIT-avoidance recurrent simulator training as required by their CFIT avoidance program and the company's inadequate flight risk assessment processes, which did not account for the known weather hazards relevant to the accident route of flight.
Final Report:

Crash of a Cessna 208 Caravan I in Port Heiden

Date & Time: Jan 30, 1998 at 1700 LT
Type of aircraft:
Operator:
Registration:
N9316F
Flight Type:
Survivors:
Yes
Schedule:
Port Heiden - Chignik
MSN:
208-0011
YOM:
1985
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
4500.00
Aircraft flight hours:
13478
Circumstances:
The pilot departed in visual meteorological conditions of three to four miles visibility with high ceilings. He stated the airplane encountered freezing rain about five miles south of the airport while in cruise flight at 1,200 feet msl, and rapidly accumulated ice on the airframe, wings, and windshield. The pilot said he initially changed altitude in an attempt to exit the icing conditions. Ice accumulation continued, so he elected to return. While maneuvering to land at the airport, the airplane was unable to maintain altitude at full engine power. He said that any angle of bank resulted in the onset of pre stall buffet, so he decided to land on a frozen lake south of the airport. He said that the airplane did not reach the lake, 'mushed into the ground,' and during the flare/touchdown, the left wing stalled. The pilot did not have access to the official weather prior to departure. The National Weather Service contracted observer, made his observation from a location about five miles south of the official weather station at the airport. The FAA AWOS-3 was inoperative. Examination of the airplane after the accident revealed a 1/2 inch layer of clear ice covering all the upper and lower airfoil surfaces of the airplane, from leading edges to between 1/3 and 1/2 of the chords. All antennas were coated with approximately 1/2 inch of clear ice. The airplane was not equipped with ice protection equipment except for pitot heat and windshield heat.
Probable cause:
The pilot's inadequate in-flight decision resulting in airframe ice accumulation to the extent that degraded aircraft performance and insufficient airspeed occurred followed by a stall. Contributing factors were freezing rain and icing conditions.
Final Report:

Crash of a Piper PA-31-310 Navajo in Port Heiden: 1 killed

Date & Time: Feb 14, 1985 at 1900 LT
Type of aircraft:
Operator:
Registration:
N63719
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Becharof Lake - Cold Bay
MSN:
31-7712042
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4427
Captain / Total hours on type:
2250.00
Aircraft flight hours:
4284
Circumstances:
This flight originated near Becharof Lake and was destined for Cold Bay. Aircraft crashed into the side of a mountain at the 7,500 feet level, 23 miles left of course. Marginal weather conditions existed including a 35 knot right crosswind. Pilot had flown the same route about 1 hour prior to the accident. Company VFR flight plan was filed. Accident occurred at sunset. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: in flight collision with terrain/water
Phase of operation: cruise
Findings
1. (f) weather condition - obscuration
2. (f) weather condition - unfavorable wind
3. (f) weather condition - snow
4. (c) flight into known adverse weather - intentional - pilot in command
5. (c) vfr flight into imc - continued - pilot in command
6. (c) compensation for wind conditions - inadequate - pilot in command
7. (f) terrain condition - mountainous/hilly
8. (f) light condition - dark night
9. (f) in-flight planning/decision - poor - pilot in command
Final Report:

Crash of a Grumman JRF-5 Goose near Port Heiden: 4 killed

Date & Time: Nov 19, 1943
Type of aircraft:
Operator:
Registration:
34075
Flight Phase:
Survivors:
No
Site:
Schedule:
Port Heiden – Kodiak
MSN:
B004
YOM:
1943
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The seaplane was performing a flight from Port Heiden to Kodiak on behalf of the USCG with one passenger and three crew members on board. Few minutes after take off from Port Heiden, while cruising in poor weather conditions, the aircraft hit the slope of a mountain located northeast of Port Heiden. As the aircraft did not arrive in Kodiak, SAR operations were conducted but eventually suspended few days later as no trace was found. The wreckage was found by hikers on August 26, 1987, 44 years later.
Crew:
Ens Harold D. Bennett,
Rmc J. W. Cole,
Amm1 C. W. Bull.