Zone

Crash of a Beechcraft B200 King Air off Dutch Harbor

Date & Time: Jan 16, 2020 at 0806 LT
Operator:
Registration:
N547LM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dutch Harbor - Adak
MSN:
BB-1642
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6470
Captain / Total hours on type:
756.00
Aircraft flight hours:
7058
Circumstances:
According to the pilot, when the airplane’s airspeed reached about 90 knots during the takeoff roll, he applied back pressure to the control yoke to initiate the takeoff and noted a brief positive rate of climb followed by a sinking sensation. The airspeed rapidly decayed, and the stall warning horn sounded. To correct for the decaying airspeed, he lowered the nose then pulled back on the airplane’s control yoke and leveled the wings just before impacting the ocean. The pilot stated there were no pre accident mechanical malfunctions or anomalies that would have precluded normal operation. Wind about the time of the accident was recorded as 110º downwind of the airplane at 15 knots gusting to 28 knots. The passengers recalled that the pilot’s preflight briefing mentioned the downwind takeoff but included no discussion of the potential effect of the wind conditions on the takeoff. The airplane’s estimated gross weight at the time of the accident was about 769.6 pounds over its approved maximum gross weight, and the airplane’s estimated center of gravity was about 8.24 inches beyond the approved aft limit at its maximum gross weight. It is likely that the pilot’s decision to takeoff downwind and operate the airplane over the maximum gross weight with an aft center of gravity led to the aerodynamic stall during takeoff and loss of control. Downwind takeoffs result in higher groundspeeds and increase takeoff distance. While excessive aircraft weight increases the takeoff distance and stability, and an aft center of gravity decreases controllability. Several instances of the operator’s noncompliance with its operational procedures and risk mitigations were discovered during the investigation, including two overweight flights, inaccurate and missing information on aircraft flight logs, and the accident pilot’s failure to complete a flight risk assessment for the accident flight. The operator had a safety management system (SMS) in place at the time of the accident that required active monitoring of its systems and processes to ensure compliance with internal and external requirements. However, the discrepancies noted with several flights, including the accident flight, indicate that the operator’s SMS program was inadequate to actively monitor, identify, and mitigate hazards and deficiencies.
Probable cause:
The pilot’s improper decision to takeoff downwind and to load the airplane beyond its allowable gross weight and center of gravity limits, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the inadequacy of the operator’s safety management system to actively monitor, identify, and mitigate hazards and deficiencies.
Final Report:

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 in Unalaska

Date & Time: Feb 14, 2017 at 1323 LT
Operator:
Registration:
N313HS
Survivors:
Yes
MSN:
BB-1300
YOM:
1988
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the aircraft belly landed at Unalaska-Tom Madsen Airport runway 13/31. The airplane slid for few dozen metres before coming to rest and was damaged beyond repair. All three occupants evacuated safely.
Probable cause:
There were no investigations about this event. Nevertheless, it was reported that the pilot was distracted and forgot to lower the landing gear on final approach.

Crash of a Grumman G-21A Goose in Unalaska

Date & Time: Apr 9, 2008 at 1630 LT
Type of aircraft:
Operator:
Registration:
N741
Survivors:
Yes
Schedule:
Akutan - Unalaska
MSN:
B097
YOM:
1944
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7040
Captain / Total hours on type:
320.00
Aircraft flight hours:
12228
Circumstances:
The airline transport pilot was on an approach to land on Runway 30 at the conclusion of a visual flight rules (VFR)scheduled commuter flight. Through a series of radio microphone clicks, he activated threshold warning lights for vehicle traffic on a roadway that passes in front of the threshold of Runway 30. Gates that were supposed to work in concert with the lights and block the runway from vehicle traffic were not operative. On final approach, the pilot, who was aware that the gates were not working, noticed a large truck and trailer stopped adjacent to the landing threshold. As he neared the runway, he realized that the truck was moving in front of the threshold area. The pilot attempted to go around, but the airplane's belly struck the top of the trailer and the airplane descended out of control to the runway, sustaining structural damage. The truck driver reported that, as he approached the runway threshold, he saw the flashing red warning lights, but that the gates were not closed. He waited for about 45 seconds and looked for any landing traffic and, seeing none, drove onto the road in front of the threshold. As he did so, he felt the airplane impact the trailer, and saw it hit the runway. The accident truck's trailer is about 45 feet long and 13 feet tall. The Federal Aviation Administration (FAA) Facility Directory/Alaska Supplement recommends that pilots maintain a 25-foot minimum threshold crossing height. The NTSB's investigation revealed that the gate system had been out of service for more than a year due to budgetary constraints, and that there was no Notice to Airman (NOTAM) issued concerning the inoperative gate system. The FAA certificated airport is owned and operated by the State of Alaska. According to the Airport Certification Manual, the airport manager is responsible to inspect, maintain, and repair airport facilities to ensure safe operations. Additionally, the airport manager is responsible for publishing NOTAM's concerning hazardous conditions. A 10-year review of annual FAA certification and compliance inspection forms revealed no discrepancy listed for the inoperative gates until 16 days after the accident.
Probable cause:
The pilot's failure to maintain clearance from a truck while landing, and the vehicle operator's decision to ignore runway warning signals. Contributing to the accident was an inoperative vehicle gate system and the failure of airport management to adequately maintain the gate system and issue a NOTAM.
Final Report:

Crash of a Grumman G-21A Goose off Unalaska: 2 killed

Date & Time: Aug 11, 1996 at 1615 LT
Type of aircraft:
Operator:
Registration:
N660PA
Flight Phase:
Survivors:
No
Schedule:
Anderson Bay - Dutch Harbor
MSN:
B138
YOM:
1945
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
13381
Circumstances:
On August 11, 1996, about 1615 Alaska daylight time, an amphibious Grumman G21-G, N660PA, is presumed to have been involved in a fatal accident about 20 miles south of Dutch Harbor, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country on demand passenger flight under Title 14 CFR Part 135 when the accident occurred. The airplane, registered to and operated by Peninsula Airways Inc., Anchorage, Alaska, is presumed to have been destroyed. The certificated airline transport pilot, and the sole passenger are presumed to have received fatal injuries. Low ceilings were reported in the area of departure by the operator. VFR company flight following procedures were in effect. The flight originated from Anderson Bay, on the Island of Unalaska, about 1610.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined.
Final Report:

Crash of a Grumman G-21A Goose off Dutch Harbor: 2 killed

Date & Time: Jan 23, 1981
Type of aircraft:
Operator:
Registration:
N95468
Flight Phase:
Survivors:
No
Schedule:
Nikolski – Dutch Harbor
MSN:
1140
YOM:
1942
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16068
Captain / Total hours on type:
237.00
Circumstances:
En route from Nikolski to Dutch Harbor on a taxi mail flight, the twin engine seaplane crashed in unknown circumstances into the sea off Dutch Harbor. Pieces from a wing were found floating on water while the main wreckage and the two occupants were not found.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

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 Volpar Turboliner II (G18S) in Dutch Harbor: 5 killed

Date & Time: Jul 22, 1976 at 0905 LT
Type of aircraft:
Registration:
N600WA
Flight Type:
Survivors:
No
Schedule:
Cold Bay - Dutch Harbor
MSN:
BA-463
YOM:
1959
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
15868
Captain / Total hours on type:
3605.00
Circumstances:
On approach to Dutch Harbor, the crew encountered poor weather conditions. On final, the twin engine airplane was too low and struck the ground few miles short of runway and crashed. The aircraft was destroyed and all five occupants were killed.
Probable cause:
Controlled flight into terrain on final approach following improper IFR operation. The following contributing factors were reported:
- Low ceiling,
- Rain,
- Fog,
- CLGS below 1,000 feet,
- Areas of visibility below 3 miles in drizzle and fog.
Final Report:

Crash of a Beechcraft 65-90 King Air off Akutan Island

Date & Time: Apr 17, 1976 at 1020 LT
Type of aircraft:
Registration:
N2400X
Flight Phase:
Survivors:
Yes
Schedule:
Kenai - Dutch Harbor
MSN:
LJ-18
YOM:
1965
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6350
Captain / Total hours on type:
61.00
Circumstances:
While flying along the Aleutian Islands on a charter flight from Kenai to Dutch Harbor, the crew realized his fuel reserve was low and decided to reduce his altitude and to ditch the aircraft off Akutan Island. All five occupants were quickly rescued while the aircraft was lost.
Probable cause:
Inadequate preflight preparation on part of the crew. The following contributing factors were reported:
- Improper in-flight decisions,
- Mismanagement of fuel,
- Miscalculation of fuel consumption,
- Airways facilities,
- Pilot ditched the aircraft due to low fuel state,
- Driftwood Bay beacon inoperative due to antenna damage.
Final Report:

Crash of a Douglas R4D-1 in Dutch Harbor: 10 killed

Date & Time: Jul 2, 1943
Operator:
Registration:
01990
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dutch Harbor - Dutch Harbor
MSN:
4554
YOM:
1942
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
Six minutes after take off from Dutch Harbor Airport, while climbing, the aircraft crashed on Mt Table Top. All ten crew members were killed.