Crash of a Beechcraft A100 King Air in Charallave: 9 killed

Date & Time: Dec 19, 2019
Type of aircraft:
Operator:
Registration:
YV1104
Flight Type:
Survivors:
No
Schedule:
Guasipati – Charallave
MSN:
B-231
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
On final approach to Charallave-Óscar Machado Zuloaga Airport in marginal weather conditions, the twin engine airplane crashed in unknown circumstances about 8 km from the runway threshold. The aircraft was destroyed and all nine occupants were killed.

Crash of a Piper PA-60-602P Super 700 Aerostar on Gabriola Island: 3 killed

Date & Time: Dec 10, 2019 at 1805 LT
Operator:
Registration:
C-FQYW
Flight Type:
Survivors:
No
Schedule:
Cabo San Lucas – Chino – Bishop – Nanaimo
MSN:
60-8265-020
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
320
Aircraft flight hours:
5752
Circumstances:
On 09 December 2019, a private Piper Aerostar PA-60-602P aircraft (registration C-FQYW, serial number 60-8265020), departed Cabo San Lucas International Airport (MMSL), Baja California Sur, Mexico, with 3 people on board, for a 2-day trip to Nanaimo Airport (CYCD), British Columbia (BC). As planned the aircraft stopped for an overnight rest at Chino Airport (KCNO), California, U.S. At 1142, on 10 December 2019, the aircraft departed KCNO on a visual flight rules (VFR) flight plan to Bishop Airport (KBIH), California, U.S., for a planned fuel stop. The aircraft departed KBIH at approximately 1425 on an instrument flight rules (IFR) flight plan to CYCD. On 10 December 2019, night started at 1654. At 1741, the Vancouver area control centre air traffic controller advised the pilot that an aerodrome special meteorological report (SPECI) had been issued for CYCD at 1731. The SPECI reported visibility as 2 ½ statute miles (SM) in light drizzle and mist, with an overcast ceiling of 400 feet above ground level (AGL). The pilot informed the controller that he would be conducting an instrument landing system (ILS) approach for Runway 16. At 1749, when the aircraft was approximately 32 nautical miles (NM) south of CYCD, the pilot contacted the controller to inquire about the weather conditions at Victoria International Airport (CYYJ), BC. The controller informed the pilot that a SPECI was issued for CYYJ at 1709 and it reported the visibility as 5 SM in mist, a broken ceiling at 600 feet AGL, and an overcast layer at 1200 feet AGL. The controller provided the occurrence flight with pilot observations from another aircraft that had landed at CYCD approximately 15 minutes before. That crew had reported being able to see the Runway 16 approach lights at minimums, i.e., at 373 feet AGL. Between 1753 and 1802, the controller provided vectors to the pilot in order to intercept the ILS localizer. At 1803, the controller observed that the aircraft had not intercepted the localizer for Runway 16. The aircraft had continued to the southwest, past the localizer, at an altitude of 2100 feet above sea level (ASL) and a ground speed of 140 knots. The controller queried the pilot to confirm that he was still planning to intercept the ILS for Runway 16. The pilot confirmed that he would be intercepting the ILS as planned. The aircraft made a heading correction and momentarily lined up with the localizer before beginning a turn to the west. At 1804:03, the pilot requested vectors from the controller and informed him that he “just had a fail.” The controller responded with instructions to “turn left heading zero nine zero, tight left turn.” The pilot asked the controller to repeat the heading. The controller responded with instructions to “…turn right heading three six zero.” The pilot acknowledged the heading; however, the aircraft continued turning right beyond the assigned heading while climbing to 2500 feet ASL and slowing to a ground speed of 80 knots. The aircraft then began to descend, picking up speed as it was losing altitude. At 1804:33, the aircraft descended to 1800 feet ASL and reached a ground speed of 160 knots. At 1804:40, the pilot informed the air traffic controller that the aircraft had lost its attitude indicator.Footnote6 At the same time, the aircraft was climbing into a 2nd right turn. At 1804:44, the air traffic controller asked the pilot what he needed from him; the pilot replied he needed a heading. The controller provided the pilot with a heading of three six zero. At 1804:47, the aircraft reached an altitude of 2700 feet ASL and a ground speed of 60 knots. The aircraft continued its right turn and began to lose altitude. The controller instructed the pilot to gain altitude if he was able to; however, the pilot did not acknowledge the instruction. The last encoded radar return for the aircraft was at 1805:26, when the aircraft was at 300 feet ASL and travelling at a ground speed of 120 knotsControl of the aircraft was lost. The aircraft collided with a power pole and trees in a wooded park area on Gabriola Island, BC, and then impacted the ground. The aircraft broke into pieces and caught fire. The 3 occupants on board received fatal injuries. As a result of being damaged in the accident, the emergency locator transmitter (Artex ME406, serial number 188-00293) did not activate.
Probable cause:
The occurrence aircraft was equipped with a BendixKing KI 825 electronic horizontal situation indicator (HSI) that was interfaced to the flight control system and GPS (global positioning system) Garmin GNS530W/430W. The HSI also supplies the autopilot system with heading information. The investigation determined that the HSI had failed briefly during operation on 22 November 2019 and a 2nd time, 3 days later, on 26 November 2019. The KI 825 HSI is electrically driven and therefore is either on and working, or off and dark with no display. The aircraft owner was in contact with an aircraft maintenance organization located at Boundary Bay Airport (CZBB), BC, and an appointment to bring the occurrence aircraft in for troubleshooting of the 2 brief HSI malfunctions had been made for 11 December 2019, i.e., the day after the accident. In total, 13 flights had been conducted after the 1st failure of the HSI. There were no journey log entries for defects with the HSI or evidence of maintenance completed. RegulationsFootnote9 require that defects that become apparent during flight operations be entered in the aircraft journey logbook, and advisory guidance in the regulatory standardsFootnote10 states that all equipment required for a particular flight or type of operation, such as the HSI in this case, be functioning correctly before flight. The HSI was destroyed in the accident and the investigation was unable to determine if it was operational on impact. Similarly, it could not be determined if the HSI was supplying the autopilot with heading information, or if the autopilot was engaged during the approach.
Final Report:

Crash of a BAe 125-700A in San Andrés Villa Seca

Date & Time: Dec 2, 2019
Type of aircraft:
Operator:
Registration:
XB-PGP
Flight Type:
Survivors:
Yes
MSN:
257171
YOM:
1982
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was engaged in an illegal flight and its crew attempted to land in a bush area located in San Andrés Villa Seca. No one was found on site and the aircraft was damaged beyond repair. It is unclear if the registration is illegal or the original one.

Crash of a Beechcraft 200 King Air in Saint Jean

Date & Time: Nov 23, 2019
Operator:
Registration:
XB-PYB
Flight Type:
Survivors:
Yes
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft crashed in unknown circumstances in a pasture located near Saint Jean, Haiti. There were no casualties while the aircraft was damaged beyond repair. It was engaged in an illegal flight (contraband) and the registration XB-PYB is false. Local authorities were looking for both Mexican pilots and a local involved in the illegal mission.

Crash of a Boeing 737-8F2 in Odessa

Date & Time: Nov 21, 2019 at 2055 LT
Type of aircraft:
Operator:
Registration:
TC-JGZ
Survivors:
Yes
Schedule:
Istanbul – Odessa
MSN:
35739/2654
YOM:
2008
Flight number:
TK467
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6094
Captain / Total hours on type:
5608.00
Copilot / Total flying hours:
252
Copilot / Total hours on type:
175
Aircraft flight hours:
38464
Aircraft flight cycles:
22633
Circumstances:
On November 21, 2019, a regular THY2UT flight en-route Istanbul – Odesa at B737-800 aircraft, nationality and registration mark TC-JGZ of the Turkish Airlines, was performed by the aircraft crew consisting of the Pilot-in-Command (PIC), co-pilot and four flight attendants of the aircraft. In fact, the departure from Istanbul Airport was performed at 17:33. The actual aircraft landing took place at 18:55. According to the flight plan, the alternate aerodromes were Istanbul and Chișinău. There were 136 passengers and 2793 kg of luggage on board the aircraft. The PIC was a Pilot Flying, and the co-pilot was a Pilot Monitoring of the aircraft. The pre-flight briefing of the crew, according to its explanations, was carried out before departure from the Istanbul Airport, after which the PIC took the decision to perform the flight. The climb and level flight were performed in the normal mode. The landing approach was performed to the Runway16 with ILS system at a significant crosswind component of variable directions. At the final stage of approaching with ILS to Runway 16, the ATC controller of the aerodrome control tower (ATC Tower) gave the aircraft crew a clearance for landing. The aircraft crew confirmed the controller’s clearance and continued the landing approach. Subsequently, from a height of about 50 meters, the aircraft performed a go-around due to the aircraft non-stabilization before landing. Following the go-around, the aircraft headed to the holding area to wait for favorable values of wind force and direction. At 18:45, the PIC took the decision to carry out a repeated landing approach, reported of that to the ATC controller, who provided ATS in the Odesa Terminal Maneuvering Area (TMA.) At 18:51, the crew re-contacted the Tower controller and received the clearance to land. At 18:55, after touchdown, during the runway run, the aircraft began to deviate to the left and veered off of the runway to the left onto the cleared and graded area. After 550 m run on the soil, the aircraft returned to the runway with its right main landing gear and nose part (while moving on the soil, the nose landing gear collapsed) and came to rest at the distance of 1612 m from the runway entrance threshold. The crew performed an emergency evacuation of passengers from the aircraft. As a result of the accident, the aircraft suffered a significant damage to the nose part of the fuselage and left engine. None of the passengers or crew members was injured.
Probable cause:
The cause of the accident, i.e. runway excursion, which caused significant damage to the structural elements of the aircraft B-737-800 TC-JGZ of Turkish Airlines, which took place on 21.11.2019 during landing at «Odesa» Aerodrome, was failure to maintain the direction of the aircraft movement during the landing run in the conditions of a strong crosswind of variable directions.
Contributing Factors:
- Use by the crew of the landing approach method using the Touchdown in Crab technique, which is not recommended by FCTM B-737NG document for use on dry runways in the conditions of a strong crosswind;
- Untimely and insufficient actions of the crew to maintain the landing run direction;
- Presence of a significant cross component of the wind;
- Effect of an omnidirectional wind – from cross-headwind to cross-tailwind directions – during the landing run.
Final Report:

Crash of a Cessna 550 Citation II in Maraú: 5 killed

Date & Time: Nov 14, 2019 at 1417 LT
Type of aircraft:
Registration:
PT-LTJ
Flight Type:
Survivors:
Yes
Schedule:
Jundiaí – Maraú
MSN:
550-0225
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8000
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
350
Copilot / Total hours on type:
25
Aircraft flight hours:
6978
Aircraft flight cycles:
6769
Circumstances:
The aircraft took off from the Comandante Rolim Adolfo Amaro Aerodrome (SBJD), Jundiaí - SP, to the Barra Grande Aerodrome (SIRI), Maraú - BA, at about 1458 (UTC), in order to carry out a private flight, with two pilots and eight passengers on board. Upon arriving at the destination Aerodrome, at 1717 (UTC), the aircraft made an undershoot landing on runway 11, causing the main and auxiliary landing gear to burst. The airplane moved along the runway, dragging the lower fuselage and the lower wing, leaving the runway by its left side, and stopping with the heading lagged, approximately, 210º in relation to the landing trajectory. Afterwards, there was a fire that consumed most of the aircraft. The aircraft was destroyed. One crewmember and four passengers suffered fatal injuries and the other crewmember and four passengers suffered serious injuries.
Probable cause:
Contributing factors.
- Control skills – a contributor
The inadequate performance of the controls led the aircraft to make a ramp that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention – undetermined
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach ramp.
- Attitude – undetermined
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the wind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication – undetermined
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management – a contributor
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions – undetermined
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach ramp. In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach ramp.
- Piloting judgment – a contributor
The commander's inadequate assessment of the aircraft's position in relation to the final approach ramp and landing runway contributed to the aircraft touching the ground before the thrashold.
- Perception – undetermined
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning – undetermined
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach ramp at the Aerodrome.
- Other / Physical sensory limitations – undetermined
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.
Final Report:

Crash of a Cessna 414A Chancellor in Colonia: 1 killed

Date & Time: Oct 29, 2019 at 1058 LT
Type of aircraft:
Registration:
N959MJ
Flight Type:
Survivors:
No
Site:
Schedule:
Leesburg - Linden
MSN:
414A-0471
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7173
Captain / Total hours on type:
1384.00
Aircraft flight hours:
7712
Circumstances:
The pilot was conducting a GPS circling instrument approach in instrument meteorological conditions to an airport with which he was familiar. During the final minute of the flight, the airplane descended to and leveled off near the minimum descent altitude (MDA) of about 600 ft mean sea level (msl). During this time, the airplane’s groundspeed slowed from about 90 knots to a low of 65 knots. In the few seconds after reaching 65 knots groundspeed, the flight track abruptly turned left off course and the airplane rapidly descended. The final radar point was recorded at 200 ft msl less than 1/10 mile from the accident site. Two home surveillance cameras captured the final few seconds of the flight. The first showed the airplane in a shallow left bank that rapidly increased until the airplane descended in a steep left bank out of camera view below a line of trees. The second video captured the final 4 seconds of the flight; the airplane entered the camera view already in a steep left bank near treetop level, and continued to roll to the left, descending out of view. Both videos showed the airplane flying below an overcast cloud ceiling, and engine noise was audible until the sound of impact. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions that would have precluded normal operation. The propeller signatures, witness impact marks, audio recordings, and witness statements were all consistent with the engines producing power at the time of impact. The pilot likely encountered restricted visibility of about 2 statute miles with mist and ceilings about 700 ft msl. When the airplane deviated from the final approach course and descended below the MDA, the destination airport remained 3.5 statute miles to the northeast. Although the airplane was observed to be flying below the overcast cloud layer, given the restricted visibility, it is likely that the pilot was unable to visually identify the airport or runway environment at any point during the approach. According to airplane flight manual supplements, the stall speed likely varied from 76 to 67 knots indicated airspeed. The exact weight and balance and configuration of the airplane could not be determined. Based upon surveillance video, witness accounts, and automatic dependent surveillance-broadcast data, it is likely that, as the pilot leveled off the airplane near the MDA, the airspeed decayed below the aerodynamic stall speed, and the airplane entered an aerodynamic stall and spin from which the pilot was unable to recover. Based on a readout of the pilot’s cardiac monitoring device and autopsy findings, while the pilot had a remote history of arrhythmia, sudden incapacitation was not a factor in this accident. Autopsy findings suggested that the pilot’s traumatic injuries were not immediately fatal; soot material in both the upper and lower airways provided evidence that the pilot inhaled smoke. This autopsy evidence supports that the pilot’s elevated carboxyhemoglobin level was from smoke inhalation during the postcrash fire. In addition, there were no distress calls received from the pilot and there was no evidence found that would indicate there was an in-flight fire. Thus, carbon monoxide exposure, as determined by the carboxyhemoglobin level, was not a contributing factor to the accident.
Probable cause:
The pilot’s failure to maintain airspeed during a circling instrument approach procedure, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall and spin.
Final Report:

Crash of a De Havilland DHC-3 Otter off Little Grand Rapids: 3 killed

Date & Time: Oct 26, 2019 at 0845 LT
Type of aircraft:
Operator:
Registration:
C-GBTU
Survivors:
No
Schedule:
Bissett - Little Grand Rapids
MSN:
209
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9500
Captain / Total hours on type:
5800.00
Aircraft flight hours:
16474
Circumstances:
At approximately 0745 Central Daylight Time on 26 October 2019, the Blue Water Aviation float-equipped deHavillandDHC-3 Otteraircraft (registration C-GBTU, serial number 209) departed Bissett Water Aerodrome, Manitoba, with the pilot, 2 passengers, and approximately 800 pounds of freight on board. The destination was Little Grand Rapids, Manitoba, on the eastern shore of Family Lake. At approximately 0845, while on approach to Family Lake, the aircraft’s right wing separated from the fuselage. The aircraft then entered a nose-down attitudeand struck the water surface of the lake. The pilot and the 2 passengers were fatally injured. The aircraft was destroyed by impact forces. The emergency locator transmitter activated momentarily.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. A fatigue fracture originated in the bolt hole bore of the right-hand wing lift strut’s upper outboard lug plate, and eventually led to an overstress fracture of the right-hand wing lift strut’s upper outboard and inboard lug plates during the left turn prior to the final approach.
2. The failure of the outboard and inboard lug plates led to the separation of the righthand wing lift strut from the wing and, subsequently, the separation of the right wing from the aircraft.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If operational flight plans data and load calculations are not available, there is a risk that, in the event of a missing aircraft or accident, aircraft information, including its number of occupants, route, cargo, and weight and balance information, will not be available for search and rescue operations or accident investigation.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The detailed visual inspection prescribed in the Viking Air Ltd. Supplementary Inspection and Corrosion Control Manual, and required by Airworthiness DirectiveCF2018-4, did not identify cracks that could form in the right-hand wing strut’s upper outboard lug plate.
Final Report:

Crash of a Douglas DC-3C off Nassau

Date & Time: Oct 18, 2019 at 1630 LT
Type of aircraft:
Operator:
Registration:
N437GB
Flight Type:
Survivors:
Yes
Schedule:
Miami - Nassau
MSN:
19999
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On the 18th October 2019, at approximately 4:30 PM local time, a Douglas DC-3C aircraft, registration N437GB crashed in the ocean; at coordinates 25°05.55N 077°30.29W, approximately 2.87miles from Runway 14 at the Lynden Pindling International Airport (MYNN) Nassau, Bahamas. There were 2 souls on board. The pilot reported that the left engine failed approximately 25-30 nautical miles from MYNN. The pilot further stated that during single engine operation, the aircraft performance was not optimal so the decision was made to land the aircraft in the ocean. The Air Traffic Control tower was notified by the crew of N437GB, that they will be performing a control water landing. The Royal Bahamas Defense Force was notified. Rescue efforts were then put into place. No injuries were received by the occupants of the aircraft. Aircraft could not be located for physical analysis to be carried out. The weather at the time of the accident was visual meteorological conditions and not a factor in this accident. A limited scope investigation was conducted, no safety message or recommendations were issued.
Probable cause:
Failure of the left engine on approach for unknown reasons.
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: