Alaska

The pilot was conducting an on-demand air taxi flight in a float-equipped airplane from a seaplane base on a public lake to a remote lakeside home, with a passenger and her young son. The passenger brought cargo to transport as well, including an unexpected 800 lbs of mortar bags. Witnesses who labored to push the airplane out after loading reported that the airplane appeared very aft heavy and the pilot said he would offload "cement blocks" if he could not take off. A review of witness videos revealed that the pilot attempted one takeoff using only 3/4 of the available waterway, then step taxied around the lake and performed a step-taxi takeoff, again not using the full length of the lake. The airplane eventually lifted off, and barely climbed over trees on the south end of the lake, before descending and impacting terrain. A home surveillance video that captured the airplane seconds before the crash revealed that 3 seconds before ground impact, the estimated altitude of the airplane was 115 ft above ground level (agl) and the groundspeed was about 64 miles per hour (mph), which was low and much slower than normal climb speed (80 mph). As the airplane banked to the left to turn on course, it rolled through 90° likely experiencing an aerodynamic stall. Analysis of the engine rpm sound revealed that the engine was operating near maximum continuous power up until impact, and a postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. A calculation performed by investigators postaccident revealed the airplane's estimated gross weight at the time of the accident was 75 lbs over the approved maximum gross takeoff weight, and the airplane's estimated center of gravity was 1.76 inches aft of the rear limit. The pilot had been recently hired by the operator and he flew his first commercial flight in the same make and model, float-equipped airplane the week before the accident. He had accumulated 12.9 flight hours, and 13 sea landings/takeoffs in the accident model airplane since being hired as a part-time pilot. Although the airplane was able to takeoff, the aircraft's out-of-limit weight-and-balance condition increased its stall speed and degraded its climb performance, stability, and slow-flight characteristics. When the pilot turned the airplane left, the critical angle of attack was exceeded resulting in an aerodynamic stall at low altitude. If the pilot had performed a proper weight and balance calculation, he may have recognized the airplane was overweight and out of balance and should not have attempted the flight without making a load adjustment.

The pilot reported that, following a precautionary shutdown of the No. 2 engine, he diverted to an alternate airport that was closer than the original destination. During the landing in tailwind conditions, the airplane touched down "a little fast." The pilot added that, as the brakes faded from continuous use, the airplane was unable to stop, and it overran the end of the runway, which resulted in substantial damage to the fuselage. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The airline transport pilot was conducting a commercial visual flight rules (VFR) flight transporting 10 passengers from a remote fishing lodge. According to the pilot, while in level cruise flight about 1,100 ft mean sea level (msl) and as the flight progressed into a mountain pass, visibility decreased rapidly. In an attempt to turn around and return to VFR conditions, the pilot initiated a climbing right turn. Before completing the 180° right turn, he saw what he believed to be a body of water and became momentarily disoriented, so he leveled the wings. Shortly thereafter, he realized that the airplane was approaching an area of snow-covered mountainous terrain, so he applied full power and initiated a steep climb; the airspeed decayed, and the airplane collided with an area of rocky, rising terrain, which resulted in substantial damage to the wings and fuselage. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operation, and the examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The weather forecast at the accident time included scattered clouds at 2,500 ft msl, overcast clouds at 5,000 ft msl with cloud tops to 14,000 ft and clouds layered above that to flight level 250, and isolated broken clouds at 2,500 ft with light rain. AIRMET advisory SIERRA for "mountains obscured in clouds/precipitation" was valid at the time of the accident. Conditions were expected to deteriorate. Passenger interviews revealed that through the course of the flight, the airplane was operating in marginal visual meteorological conditions and occasional instrument meteorological conditions (IMC) with areas of precipitation, reduced visibility, obscuration, and, at times, little to no forward visibility. Thus, based on weather reports and forecasts, and the pilot's and passengers' statements, it is likely that the flight encountered IMC as it approached mountainous terrain and that the pilot then lost situational awareness. The airplane was equipped with a terrain awareness and warning system (TAWS); however, the alerts were inhibited at the time of the accident. Although the TAWS was required to be installed per Federal Aviation Administration (FAA) regulations, there is no requirement for it to be used. All company pilots interviewed stated that the TAWS inhibit switch remained in the inhibit position unless a controlled flight into terrain (CFIT) escape maneuver was being accomplished. However, the check airman who last administered the accident pilot's competency check stated that the TAWS inhibit switch was never moved, even during a CFIT escape maneuver. The unwritten company policy to leave the TAWS in the inhibit mode and the failure of the pilot to move the TAWS out of the inhibit mode when weather conditions began to deteriorate were inconsistent with the goal of providing the highest level of safety. However, if the pilot had been using TAWS, due to the fact that he was operating at a lower altitude and thus would have likely received numerous nuisance alerts, the investigation could not determine the extent to which TAWS would have impacted the pilot's actions. At the time of the accident, the director of operations (DO) for the company resided in another city and served as DO for another air carrier as well. He traveled to the company's main base of operation about once per month but was available via telephone. According to the chief pilot, he had assumed a large percentage of the DO's duties. The president of the company said that the chief pilot had taken over "officer of the deck" and "we're just basically using him [the DO] for his recordkeeping." The FAA was aware that the company's DO was also DO for another commuter operation. FAA Flight Standards District Office management and principal operations inspectors allowed him to continue to hold those positions, although it was contrary to the guidance provided in FAA Order 8900.1. The company's General Operations Manual (GOM) only listed the DO, the chief pilot, and the president by name as having the authority to exercise operational control. However, numerous company personnel stated that operational control could be and was routinely delegated to senior pilots. The GOM stated that the DO "routinely" delegated the duty of operational control to flight coordinators, but the flight coordinator on duty at the time of the accident stated that she did not have operational control. In addition, the investigation revealed numerous inadequate and missing operational control procedures and processes in company manuals and operations specifications. Based on the FAA's inappropriate approval of the DO, the insufficient company onsite management, the inadequate operational control procedures, and the exercise of operational control by unapproved persons likely resulted in a lack of oversight of flight operations, inattentive and distracted management personnel, and a loss of operational control within the air carrier. However, the investigation could not determine the extent to which any changes to operational control, company management, and FAA oversight would have influenced the pilot's decision to continue the VFR flight into IMC.

Two wheel-equipped, high-wing airplanes, a Cessna 207 and a Cessna 175, collided midair while in cruise flight in day visual meteorological conditions. Both airplanes were operating under visual flight rules, and neither airplane was in communication with an air traffic control facility. The Cessna 175 pilot stated that he was making position reports during cruise flight about 1,000ft above mean sea level when he established contact with the pilot of another airplane, which was passing in the opposite direction. As he watched that airplane pass well below him, he noticed the shadow of a second airplane converging with the shadow of his airplane from the opposite direction. He looked forward and saw the spinner of the converging airplane in his windscreen and immediately pulled aft on the control yoke; the airplanes subsequently collided. The Cessna 207 descended uncontrolled into the river. Although damaged, the Cessna 175 continued to fly, and the pilot proceeded to an airport and landed safely. An examination of both airplanes revealed impact signatures consistent with the two airplanes colliding nearly head-on. About 4 years before the accident, following a series of midair collisions in the Matanuska Susitna (MatSu) Valley (the area where the accident occurred), the FAA made significant changes to the common traffic advisory frequencies (CTAF) assigned north and west of Anchorage, Alaska. The FAA established geographic CTAF areas based, in part, on flight patterns, traffic flow, private and public airports, and off-airport landing sites. The CTAF for the area where the accident occurred was at a frequency changeover point with westbound Cook Inlet traffic communicating on 122.70 and eastbound traffic on 122.90 Mhz. The pilot of the Cessna 175, which was traveling on an eastbound heading at the time of the accident, reported that he had a primary active radio frequency of 122.90 Mhz, and a nonactive secondary frequency 135.25 Mhz in his transceiver at the time of the collision. The transceivers from the other airplane were not recovered, and it could not be determined whether the pilot of the Cessna 207 was monitoring the CTAF or making position reports.