Crash of an Antonov AN-26B in Wau

Date & Time: Mar 20, 2017 at 1525 LT
Type of aircraft:
Operator:
Registration:
S9-TLZ
Survivors:
Yes
Schedule:
Juba - Wau
MSN:
133 10
YOM:
1983
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Juba, the crew initiated the approach to Wau Airport when he encountered poor weather conditions and limited visibility. On short final, during the last segment, the aircraft collided with a fire truck and near the runway 27 threshold, bursting into flames. All 45 occupants were rescued, among them 18 were injured. The airplane was totally destroyed by a post crash fire.

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 Cessna 402C in Virgin Gorda

Date & Time: Feb 11, 2017 at 2004 LT
Type of aircraft:
Registration:
N603AB
Survivors:
Yes
Schedule:
Charlotte Amalie – Virgin Gorda
MSN:
402C-0603
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5458
Captain / Total hours on type:
809.00
Circumstances:
The aircraft was flying from St Thomas in the US Virgin Islands to Virgin Gorda (VIJ) in the British Virgin Islands. There were eight passengers on board, together with the pilot. It was the pilot’s eleventh flight of the day, and his fourth flight to Virgin Gorda. All these flights were short, with the longest flight being about 40 minutes duration and the shortest just a few minutes. The flight from St Thomas to Virgin Gorda took 35 minutes. The weather in Virgin Gorda was excellent with a light easterly wind and little cloud. The pilot commenced his approach to Virgin Gorda using his usual turning and configuration points. The aircraft touched down normally on runway 03 and the pilot retracted the flaps before applying the brakes. The brakes responded, although the pilot commented that the right brake did not seem to respond as positively as he expected. The pilot reapplied the brakes but the left brake pedal “flopped to the floor”. Judging he had insufficient room to abort the landing, the pilot continued to pump the brakes which he did not consider to be responding. He shut down the engines before the aircraft left the paved surface, struck signage and then a low wall before coming to rest on a bank. The pilot vacated the aircraft through the side window and then opened the main door to allow the passengers to exit the aircraft. None of the occupants was injured. The aircraft was extensively damaged.
Probable cause:
The aircraft landed at Virgin Gorda in conditions (of weight, altitude, temperature and surface condition) where the landing distance required was very close to the landing distance available and without the required safety margin. Hence, when the performance of the brakes was not as expected, probably due to debris in the braking system, the aircraft could not be stopped on the runway. Analysis of the maintenance state of the aircraft involved in this accident indicated that the maintenance capability, processes and planning of its operator were not consistent with the standards expected in conducting international passenger charter services. This appeared also to be the case for the operational procedures and data management.
Final Report:

Crash of an ATR72-600 in Semarang

Date & Time: Dec 25, 2016 at 1824 LT
Type of aircraft:
Operator:
Registration:
PK-WGW
Survivors:
Yes
Schedule:
Bandung – Semarang
MSN:
1234
YOM:
2015
Flight number:
IW1896
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4065
Captain / Total hours on type:
3805.00
Copilot / Total flying hours:
3300
Copilot / Total hours on type:
3200
Aircraft flight hours:
3485
Aircraft flight cycles:
4104
Circumstances:
On 25 December 2016, an ATR 72-600 aircraft registered PK-WGW was being operated by PT. Wings Abadi Airlines (Wings Air) as a scheduled passenger flight from Husein Sastranegara International Airport (WICC), Bandung to Ahmad Yani International Airport (WAHS), Semarang with flight number WON 1896. On board the aircraft were two pilots, two flight attendants and 68 passengers. There was no report or record of aircraft system malfunction prior to the departure. The aircraft departed from Bandung at 1734 LT (1034 UTC). The Pilot in Command (PIC) acted as Pilot Flying (PF) and the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight from departure until commenced for landing approach was uneventful. At 1112 UTC, at night condition, the air traffic controller of Semarang Approach unit (approach controller) informed to all traffic that the rain was falling over the airport and the pilot confirmed whether the rain was heavy and was replied that it was slight rain. At 1115 UTC, the flight held over waypoint KENDA for separation with another aircraft and maintained altitude of 4,000 feet. Two minutes later, the flight was approved to descend to altitude of 3,000 feet. At 1118 UTC, the approach controller issued clearance for RNAV approach to runway 13 and advised the pilot to report when leaving waypoint KENDA. One minute later, the pilot reported leaving waypoint KENDA and the approach controller instructed to continue approach and to contact to the air traffic controller of Semarang Tower unit (tower controller). At 1120 UTC, the pilot advised to the tower controller that the aircraft was on final and the runway was in sight. The tower controller instructed to continue the landing approach and advised that the surface wind direction was 190° with velocity of 15 knots, altimeter setting 1,008 mbs and the runway was wet. At 1121 UTC, the tower controller had visual contact to the aircraft and issued landing clearance, the pilot read back the clearance and requested to reduce the approach light intensity. The tower controller reduced the light intensity and confirmed whether the intensity was appropriate then the pilot affirmed. At 1124 UTC, the aircraft touched down and bounced. After the third bounce, the pilot attempted to go around and the aircraft touched the runway. The tower controller noticed that the red light on the right wing was lower than the green light on the left wing. The aircraft moved to the right from the runway centerline and stopped near taxiway D. The tower controller realized that the aircraft was not in normal condition and pressed the crass bell then informed the Airport Rescue and Fire Fighting (ARFF) personnel by phone that there was aircraft accident near the taxiway D. At 1126 UTC, the pilot advised the tower controller that the aircraft stopped on the runway and requested assistance. The tower controller acknowledged the message and advised the pilot to wait for the assistance. While waiting the assistance, the pilot kept the engines run to provide lighting in the cabin. At 1129 UTC, the tower controller advised the pilot to shut down the engines since the ARFF personnel had arrived near the aircraft to assist the evacuation. Passenger evacuation completed at approximately 10 minutes after the aircraft stopped.
Probable cause:
Contributing Factors:
- The visual illusion of aircraft higher than the real altitude resulted in late flare out which made the aircraft bounced.
- The unrecovered bounce resulted in abnormal landing attitude with vertical acceleration up to 6 g and collapsed the right main landing gear.
Final Report:

Crash of a Boeing 737-46J in Kabul

Date & Time: Dec 10, 2016 at 1224 LT
Type of aircraft:
Operator:
Registration:
JY-JAQ
Survivors:
Yes
Schedule:
Herat - Kabul
MSN:
27826/2694
YOM:
1995
Flight number:
4Q502
Location:
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5078
Captain / Total hours on type:
4877.00
Copilot / Total flying hours:
3380
Copilot / Total hours on type:
3177
Aircraft flight hours:
56805
Aircraft flight cycles:
28611
Circumstances:
On 10 December 2016, JAV Boeing 737-400 Aircraft, registration JY-JAQ, operating a leased scheduled passenger flight SFW 502, on behalf of SAFI Airways under wet lease contract with the later call sign, departed a domestic flight from Herat Airport (OAHR), at 07:00 Z from RWY 36 to Kabul International Airport (OAKB) Afghanistan. At approximately 07:57:45 Z, the Aircraft touched down RWY 29 at Kabul. The aircraft departed Herat with 164 passengers ,07 Operating Crewmembers and 02 Engineers , Total on board were 173 person. As the flight approached OAKB, the crew received the automatic terminal information service (ATIS) from OAKB station at 07:45 Z indicating normal weather with visibility of 6 Km, temperature 07 degrees Celsius and wind of 150/07. The Aircraft was configured for landing with the flaps set to 30, and approach speed selected of 152 knots (VREF + 10) indicated airspeed (IAS). The Aircraft was cleared to approach ILS 29. The Aircraft was vectored by the radar for RWY 29. Air traffic control cleared the flight to land, with the wind reported to be 190 degrees at 15 knots. The crew stated that a few seconds after the touchdown, they felt the aircraft vibrating, during which they applied brakes and deployed the reverse thrust. The vibration was followed by the aircraft rolling slightly low to the right. It later came to a full stop left of the runway centre line, resting on its left main landing gear and the right engine, with the nose landing gear in the air. The occurrence occurred at approximately 3,806 ft / 1,160 m past the threshold. The PIC declared Emergency to the ATC and the cockpit crew initiated an evacuation command from the left side of the aircraft. Evacuation was successfully accomplished with No reported injuries. Kabul airport RFF reached the occurrence aircraft and observed the smoke coming from right side and immediately deployed their procedures by spraying foam on engine # 2. The aircraft sustained substantial damage due to the separation of the right main gear resulting on the aircraft skidding on the right engine cowlings. No injuries were sustained by any of the occupants during the occurrence or the evacuation sequence. Operating crew of the incident flight were called by the Afghani Civil Aviation Authority (ACAA) for interview and medical examination (alcohol and drugs, blood test). No injuries were reported by the occupants of the Aircraft or the ground crew.
Probable cause:
The Investigation committee determines that the airplane occasionally experienced main landing gear shimmy and the most probable cause indicated that the struts were extended for long period of time. As a result, the torsion link of the shimmy damper remained in an extended vertical position, where the damper has less mechanical advantage for longer periods of time. Despite the presence of shimmy damper hardware which is designed to reduce the torsional vibration energy generated during landing.
Contributing factors to the event include:
- High altitude airport of 5,877 feet.
- An overly soft landing, allows the landing gears to remain in the air mode longer, which makes them more vulnerable to shimmy,
- Touchdown with a closure rate of 1 fps, which is considered overly soft and may increase the risk of shimmy torsional forces,
- High ground speed at touchdown of 178 knots ,which resulted from the high touchdown airspeed of 158 knots , touchdown at (VREF+16).
Final Report:

Crash of an ATR42-500 near Havelian: 47 killed

Date & Time: Dec 7, 2016 at 1620 LT
Type of aircraft:
Operator:
Registration:
AP-BHO
Flight Phase:
Survivors:
No
Site:
Schedule:
Chitral – Islamabad
MSN:
663
YOM:
2007
Flight number:
PK661
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
11265
Captain / Total hours on type:
1216.00
Copilot / Total flying hours:
570
Copilot / Total hours on type:
369
Aircraft flight hours:
18739
Circumstances:
On 07 December 2016 morning, after a routine daily inspection at Benazir Bhutto International Airport (BBIAP) Islamabad, Pakistan International Airlines (PIA) aircraft ATR42-500 Reg No AP-BHO operated 05 flights (ie Islamabad to Gilgit and back, Islamabad to Chitral, Chitral to Peshawar and back). As 6th and last flight of that day, it took off from Chitral at time 10:38:50 UTC (15:38:50 PST) with 42 passengers (including 01 engineer) and 05 crew members (03 pilots and 02 cabin crew) aboard for Islamabad. It crashed after 42 minutes of flight at 11:20:38 UTC (16:20:38 PST) about 3.5 Nautical Miles (NM) SSE of Havelian, and 24 NM North of BBIAP Islamabad. All 47 souls aboard were fatally injured. The aircraft remained in air for about 42 minutes before crash (all timings in UTC). These 42 minutes have been split into three stages of flight, described hereunder:

(a) Initial Stage: From 10:38 to 11:04 (~26 minutes) degraded speed governing accuracy of the port propeller was evident in the DFDR data, but was apparently not observed by the cockpit crew. The flight stabilized at an altitude 13,500 feet AMSL and a cruising speed of 186 knots IAS (instead of expected 230 knots IAS). There were two latent pre-existing technical anomalies in the aircraft (a Fractured / dislodged PT-1 blade due to a known quality issue and a fractured pin inside the OSG), and one probable latent pre-existing condition (external contamination) inside the PVM of No 1 Engine. Digital Flight Data Recorder (DFDR) analysis indicates that No 1 Engine was degraded.

(b) Middle Stage (Series of Technical Malfunctions): From 11:04 to 11:13 (~09 minutes), a series of warnings and technical malfunctions occurred to No 1 Engine (left side) and its related propeller control system. These included Propeller Electronic Control (PEC) fault indications, followed by No 1 Engine power loss, and uncontrolled variation of its propeller speed / blade pitch angle abnormal system operation). The propeller speed which was initially at 82% (cruise setting) decreased gradually to 62% and later at the time of engine power loss it increased to 102% (and stayed at that value for about 15 to 18 seconds). It then reduced down to Non Computed Data (NCD) as per DFDR. At this point, (based on simulation results) the blade pitch angle increased (possibly close to feather position). Later, the propeller speed increased to 120% to 125% (probably caused due to unusual technical malfunctions) and stayed around that value for about 40 to 45 seconds. It finally showed an abrupt drop down to NCD again. At this point, (based on simulation results) the blade pitch angle may have settled at a value, different from the expected feathered propeller. During this unusual variation of propeller speed, there were drastic variations in the aircraft aerodynamic behaviour and sounds. The directional control was maintained initially by the Auto-Pilot. A relatively delayed advancement of power (of No 2 Engine) post No 1 Engine power loss, reduction of power (of No 2 Engine) for about 15 seconds during the timeframe when left propeller rpm was in the range of 120% to 125%, and once again a reduction of power towards the end of this part of flight, were incorrect pilot actions, and contributed in the IAS depletion. Auto-Pilot got disengaged. Towards the end of this part of flight, the aircraft was flying close to stall condition. No 1 Engine was already shutdown and No 2 Engine (right side) was operating normal. At this time, IAS was around 120 knots; aircraft started to roll / turn left and descend. Stick shaker and stick pusher activated. Calculated drag on the left side of the aircraft peaked when the recorded propeller speed was in the range of 120% to 125%. During transition of propeller speed to NCD, the additional component of the drag (possibly caused due to abnormal behaviour of left propeller) suddenly reduced. The advancement of power of No 2 Engine was coupled with excessive right rudder input (to counter the asymmetric condition). This coincided with last abrupt drop in the propeller speed. As a combined effect of resultant aerodynamic forces aircraft entered into a stalled / uncontrolled flight condition, went inverted and lost 5,100 feet AMSL altitude (ie from ~13,450 feet to 8,350 feet AMSL).

(c) Final Stage: The final stage of flight from 11:13 to 11:20 (~07 minutes) started with the aircraft recovering from the uncontrolled flight. Although blade pitch position was not recorded (in the DFDR – by design), and it was not possible to directly calculate that from the available data, a complex series of simulations and assumptions estimated that the blade pitch of left propeller may have settled at an angle around low pitch in flight while rotating at an estimated speed of 5%. Aircraft simulations indicated that stable additional drag forces were present on the left side of the aircraft at this time and during the remaining part of flight. Aircraft had an unexpected (high) drag from the left side (almost constant in this last phase); the aircraft behavior was different from that of a typical single engine In Flight Shutdown (IFSD) situation. In this degraded condition it was not possible for the aircraft to maintain a level flight. However, that level of drag did not preclude the lateral control of the aircraft, if a controlled descent was initiated. The aircraft performance was outside the identified performance envelope. It was exceptionally difficult for the pilots to understand the situation and hence possibly control the aircraft. Figure hereunder shows different stages of flight.
Probable cause:
The following factors were reported:
Probable Primary Factors:
(a) The dislodging / fracture of one PT-1 blade of No 1 Engine triggered a chain of events. Unusual combination of fractured / dislodged PT-1 blade with two latent factors caused off design performance of the aircraft and resulted into the accident.
(b) The dislodging / fracture of PT-1 blade of No 1 Engine occurred after omission from the EMM (Non-Compliance of SB-21878) by PIA Engineering during an unscheduled maintenance performed on the engine in November 2016, in which the PT-1 blades had fulfilled the criteria for replacement, but were not replaced.
(c) Fracture / dislodging of PT-1 blade in No 1 Engine, after accumulating a flying time slightly more than the soft life of 10,000 hrs (ie at about 10004.1 + 93 hrs) due to a known quality issue. This aspect has already been addressed by re-designing of PT-1 blades by P&WC.
Probable Contributory Factors:
(a) A fractured pin (and contamination inside the OSG), contributed to a complex combination of technical malfunctions. The pin fractured because of improper re-assembly during some unauthorized / un-documented maintenance activity. It was not possible to ascertain exact time and place when and where this improper re-assembly may have occurred.
(b) Contamination / debris found in overspeed line of PVM of No 1 Engine probably introduced when the propeller system LRU"s were not installed on the gearbox, contributed to un-feathering of the propeller. It was not possible to ascertain exact time and place when and where this contamination was introduced.
Final Report:

Crash of a Boeing 767-323ER in Chicago

Date & Time: Oct 28, 2016 at 1435 LT
Type of aircraft:
Operator:
Registration:
N345AN
Flight Phase:
Survivors:
Yes
Schedule:
Chicago – Miami
MSN:
33084
YOM:
2003
Flight number:
AA383
Crew on board:
9
Crew fatalities:
Pax on board:
161
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17400
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
22000
Copilot / Total hours on type:
1846
Aircraft flight hours:
50632
Aircraft flight cycles:
8120
Circumstances:
On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O’Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident. The uncontained engine failure resulted from a high-pressure turbine (HPT) stage 2 disk rupture. The HPT stage 2 disk initially separated into two fragments. One fragment penetrated through the inboard section of the right wing, severed the main engine fuel feed line, breached the fuel tank, traveled up and over the fuselage, and landed about 2,935 ft away. The other fragment exited outboard of the right engine, impacting the runway and fracturing into three pieces. Examination of the fracture surfaces in the forward bore region of the HPT stage 2 disk revealed the presence of dark gray subsurface material discontinuities with multiple cracks initiating along the edges of the discontinuities. The multiple cracks exhibited characteristics that were consistent with low-cycle fatigue. (In airplane engines, low-cycle fatigue cracks grow in single distinct increments during each flight.) Examination of the material also revealed a discrete region underneath the largest discontinuity that appeared white compared with the surrounding material. Interspersed within this region were stringers (microscopic-sized oxide particles) referred to collectively as a “discrete dirty white spot.” The National Transportation Safety Board’s (NTSB) investigation found that the discrete dirty white spot was most likely not detectable during production inspections and subsequent in-service inspections using the procedures in place. The NTSB’s investigation also found that the evacuation of the airplane occurred initially with one engine still operating. In accordance with company procedures and training, the flight crew performed memory items on the engine fire checklist, one of which instructed the crew to shut down the engine on the affected side (in this case, the right side). The captain did not perform the remaining steps of the engine fire checklist (which applied only to airplanes that were in flight) and instead called for the evacuation checklist. The left engine was shut down as part of that checklist. However, the flight attendants had already initiated the evacuation, in accordance with their authority to do so in a life-threatening situation, due to the severity of the fire on the right side of the airplane.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in-service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant’s deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.
Final Report:

Crash of a De Havilland DHC-8-Q402 in Dire Dawa

Date & Time: Oct 24, 2016
Operator:
Registration:
ET-ANY
Flight Phase:
Survivors:
Yes
Schedule:
Dire Dawa – Addis Ababa
MSN:
4334
YOM:
2010
Flight number:
ET212
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 15/33 at Dire Dawa-Aba Tenna Dejazmach Yilma Airport, the aircraft collided with wild animals. The captaint abandoned the takeoff procedure and initiated an emergency braking manoeuvre when the aircraft veered off runway and came to rest. All 80 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Collision with wild animals during takeoff.

Crash of an Antonov AN-26-100 in Belaya Gora

Date & Time: Oct 11, 2016 at 1638 LT
Type of aircraft:
Operator:
Registration:
RA-26660
Survivors:
Yes
Schedule:
Yakutsk - Belaya Gora
MSN:
8008
YOM:
1979
Flight number:
PI203
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11439
Captain / Total hours on type:
2697.00
Copilot / Total flying hours:
11142
Copilot / Total hours on type:
122
Aircraft flight hours:
34490
Aircraft flight cycles:
16367
Circumstances:
On final approach to Belaya Gora Airport, the aircraft was too low and hit the ground. On impact, the right main gear and the nose gear collapsed. The aircraft slid for several yards before coming to rest in a snow covered field about 400 meters short of runway threshold and 300 meters to the left of the approach path. The propeller on the right engine was torn off and it appears that the fuselage was bent as well. All 33 occupants were evacuated safely. At the time of the accident, weather conditions were marginal with limited visibility caused by snow falls. It was reported the visibility was about 2,5 km at the time of the accident while the crew needed at least 4 km on an NDB approach.
Probable cause:
The accident was caused by the combination of the following factors:
- Absence of standard operating procedures issued by the operator of how to conduct NDB approaches,
- Violation of procedures by tower who only transmitted information about snow fall and recommended to perform a low pass over the runway but did not transmit the actual visibility was 1900 meters below required minimum
- Absence of information that the visibility was below required minimum, the last transmission indicated minimum visibility was present,
- Presence of numerous landmarks (abandoned ships, ship cranes, fuel transshipment complex, ...) covered by snow within 700-1000 meters from the unpaved runway which could be taken as runway markers by flight crew,
- Presence of a number of "bald spots" due to the transitional period of year where the underlying surface became visible making it difficult to visualize and recognize the unpaved runway covered with snow (it was the first flight into Belaya Gora for the crew in the winter season, they had operated into the aerodrome only in summer so far),
- Insufficient use of the available nav aid on final approach which led to lack of proper control of the aircraft position relative to the glide path,
- Lack of possibility for tower to watch the aircraft performing the NDB approach from his work place.
Final Report:

Crash of a Cessna 208B Grand Caravan near Togiak: 3 killed

Date & Time: Oct 2, 2016 at 1157 LT
Type of aircraft:
Operator:
Registration:
N208SD
Flight Phase:
Survivors:
No
Site:
Schedule:
Quinhagak – Togiak
MSN:
208B-0491
YOM:
1995
Flight number:
HAG3153
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6481
Captain / Total hours on type:
781.00
Copilot / Total flying hours:
273
Copilot / Total hours on type:
84
Aircraft flight hours:
20562
Circumstances:
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:
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:
- 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;
- Hageland's inadequate crew resource management (CRM) training;
- 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;
- Hageland's CFIT avoidance ground training, which was not tailored to the company's operations and did not address current CFIT-avoidance technologies.
Final Report: