Zone

Crash of a Cessna 208B Grand Caravan in Bethel

Date & Time: Jul 8, 2019 at 1505 LT
Type of aircraft:
Operator:
Registration:
N9448B
Survivors:
Yes
Schedule:
Nightmute - Bethel
MSN:
208B-0121
YOM:
1988
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing on runway 01L/19R, the single engine airplane went out of control, veered of runway and came to rest in flames. All six occupants escaped with minor injuries while the aircraft was destroyed by fire.

Crash of a Cessna 207 Stationair 7 in Goodnews Bay

Date & Time: Jun 17, 2016 at 1200 LT
Operator:
Registration:
N91170
Flight Type:
Survivors:
Yes
Schedule:
Bethel – Goodnews Bay
MSN:
207-00101
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1150
Captain / Total hours on type:
78.00
Aircraft flight hours:
15089
Circumstances:
During cruise flight through an area of mountainous terrain, the commercial pilot became geographically disoriented and selected the incorrect route through the mountains. Upon realizing it was the incorrect route, he initiated a steep climb while executing a 180° turn. During the steep climbing turn, the airplane inadvertently entered instrument meteorological conditions, and the airplane subsequently impacted an area of rocky, rising terrain. The pilot reported there were no mechanical malfunctions or anomalies that would have precluded normal operation of the airplane.
Probable cause:
The pilot's failure to select the correct route through the mountains as a result of geographic disorientation, and his subsequent visual flight into instrument meteorological conditions, which resulted in collision with terrain.
Final Report:

Crash of a Cessna 207 Skywagon near Bethel: 1 killed

Date & Time: May 30, 2015 at 1130 LT
Operator:
Registration:
N1653U
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bethel - Bethel
MSN:
207-0253
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7175
Captain / Total hours on type:
6600.00
Aircraft flight hours:
28211
Circumstances:
The pilot departed on a postmaintenance test flight during day visual meteorological conditions. According to the operator, the purpose of the flight was to break in six recently installed engine cylinders, and the flight was expected to last 3.5 hours. Recorded automatic dependent surveillance-broadcast data showed that the airplane was operating at altitudes of less than 500 ft mean sea level for the majority of the flight. The data ended about 3 hours after takeoff with the airplane located about 23 miles from the accident site. There were no witnesses to the accident, which occurred in a remote area. When the airplane did not return, the operator reported to the Federal Aviation Administration that the airplane was overdue. Searchers subsequently discovered the fragmented wreckage submerged in a swift moving river, about 40 miles southeast of the departure/destination airport. Postmortem toxicology tests identified 21% carboxyhemoglobin (carbon monoxide) in the pilot's blood. The pilot was a nonsmoker, and nonsmokers normally have no more than 3% carboxyhemoglobin. There was no evidence of postimpact fire; therefore, it is likely that the pilot's elevated carboxyhemoglobin level was from acute exposure to carbon monoxide during the 3 hours of flight time before the accident. As the pilot did not notify air traffic control or the operator's home base of any problems during the flight, it is unlikely that he was aware that there was carbon monoxide present. Early symptoms of carbon monoxide exposure may include headache, malaise, nausea, and dizziness. Carboxyhemoglobin levels between 10% and 20% can result in confusion, impaired judgment, and difficulty concentrating. While it is not possible to determine the exact symptoms the pilot experienced, it is likely that the pilot had symptoms that may have been distracting as well as some degree of impairment in his judgment and concentration. Given the low altitudes at which he was operating the airplane, he had little margin for error. Thus, it is likely that the carbon monoxide exposure adversely affected the pilot's performance and contributed to his failure to maintain clearance from the terrain. According to the operator, the airplane had a "winter heat kit" installed, which modified the airplane's original cabin heat system. The modification incorporated an additional exhaust/heat shroud system designed to provide increased cabin heat during wintertime operations. Review of maintenance records revealed that the modification had not been installed in accordance with Federal Aviation Administration field approval procedures. Examination of the recovered wreckage did not reveal evidence of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airplane's right side exhaust/heat exchanger did not reveal any leaks or fractures that would have led to carbon monoxide in the cabin. Because the left side exhaust/heat exchanger was
not recovered, it was not possible to determine whether it was the source of the carbon monoxide.
Probable cause:
The pilot's failure to maintain altitude, which resulted in collision with the terrain. Contributing to the accident was the pilot's impairment from carbon monoxide exposure in flight. The source of the carbon monoxide could not be determined because the wreckage could not be completely recovered.
Final Report:

Crash of a Cessna 208B Grand Caravan near Bethel: 2 killed

Date & Time: Apr 8, 2014 at 1557 LT
Type of aircraft:
Operator:
Registration:
N126AR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bethel - Bethel
MSN:
208B-1004
YOM:
2002
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14417
Captain / Total hours on type:
5895.00
Copilot / Total flying hours:
593
Copilot / Total hours on type:
1
Aircraft flight hours:
11206
Circumstances:
The check airman was conducting the first company training flight for the newly hired second-in-command (SIC). Automatic Dependent Surveillance-Broadcast (ADS-B) data showed that, after departure, the airplane began a series of training maneuvers, consistent with normal operations. About 21 minutes into the flight, when the airplane was about 3,400 ft mean sea level, it began a steep descent and subsequently impacted terrain. An airplane performance study showed that the airplane reached a nose-down pitch of about -40 degrees and that the descent rate reached about 16,000 ft per minute. Numerous previous training flights conducted by the check airman were reviewed using archived ADS-B data and interviews with other pilots. The review revealed that the initial upset occurred during a point in the training when the check airman typically simulated an in-flight emergency and descent. Postaccident examination for the airframe and control surfaces showed that the airplane was configured for cruise flight at the time of the initial upset. Examination of the primary and secondary flight control cables indicated that the cables were all intact at the time of impact. Trim actuator measurements showed an abnormal trailing-edge-up, nose-down configuration on both trim tabs. The two elevator trim actuator measurements were inconsistent with each other, indicating that one of the actuators was likely moved during the wreckage recovery. Based on the supporting data, it is likely that one of the actuators indicated the correct trim tab position at the time of impact. Simulated airplane performance calculations showed that, during a pitch trim excursion, the control forces required to counter an anomaly increases to unmanageable levels unless the appropriate remedial procedures are quickly applied. Given the simulated airplane performance calculations, the trim actuator measurements, and the check airman's known training routine, it is likely that the check airman simulated a pitch trim excursion and that the SIC, who lacked experience in the airplane type, did not appropriately respond to the excursion. The check airman did not take remedial action and initiate the recovery procedure in time to prevent the control forces from becoming unmanageable and to ensure that recovery from the associated dive was possible.
Probable cause:
The check airman's delayed remedial action and initiation of a recovery procedure after a simulated pitch trim excursion, which resulted in a loss of airplane control.
Final Report:

Crash of a Cessna 208B Grand Caravan in Saint Mary's: 4 killed

Date & Time: Nov 29, 2013 at 1824 LT
Type of aircraft:
Operator:
Registration:
N12373
Survivors:
Yes
Schedule:
Bethel - Mountain Village - Saint Mary's
MSN:
208B-0697
YOM:
1998
Flight number:
ERR1453
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
25000
Captain / Total hours on type:
1800.00
Aircraft flight hours:
12653
Circumstances:
The scheduled commuter flight departed 40 minutes late for a two-stop flight. During the first leg of the night visual flight rules (VFR) flight, weather at the first destination airport deteriorated, so the pilot diverted to the second destination airport. The pilot requested and received a special VFR clearance from an air route traffic controller into the diversion airport area. Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that, after the clearance was issued, the airplane's track changed and proceeded in a direct line to the diversion airport. Postaccident examination of the pilot's radio showed that his audio panel was selected to the air route traffic control (ARTCC) frequency rather than the destination airport frequency; therefore, although the pilot attempted to activate the pilot-controlled lighting at the destination airport, as heard on the ARTCC frequency, it did not activate. Further, witnesses on the ground at St. Mary's reported that the airport lighting system was not activated when they saw the accident airplane fly over, and then proceed away from the airport. Witnesses in the area described the weather at the airport as deteriorating with fog and ice. About 1 mile from the runway, the airplane began to descend, followed by a descending right turn and controlled flight into terrain. The pilot appeared to be in control of the airplane up to the point of the right descending turn. Given the lack of runway lighting, the restricted visibility due to fog, and the witness statements, the pilot likely lost situational awareness of the airplane's geographic position, which led to his subsequent controlled flight into terrain. After the airplane proceeded away from the airport, the witnesses attempted to contact the pilot by radio. When the pilot did not respond, they accessed the company's flight tracking software and noted that the airplane's last reported position was in the area of the airplane's observed flightpath. They proceeded to search the area where they believed the airplane was located and found the airplane about 1 hour later. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. About 3/4 inch of ice was noted on the nonprotected surfaces of the empennage. However, ice formation on the airplane's inflatable leading edge de-ice boots was consistent with normal operation of the de-ice system, and structural icing likely was not a factor in the accident. According to the company's General Operations Manual (GOM), operational control was held by the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. The flight coordinator assigned the flight a risk level of 2 (on a scale of 1 to 4) due to instrument meteorological and night conditions and contaminated runways at both of the destination airports. The first flight coordinator assigned another flight coordinator to create the manifest, which listed eight passengers and a risk assessment level of 2. According to company risk assessment and operational control procedures, a risk level of 2 required a discussion between the PIC and flight coordinator about the risks involved. However, the flight coordinators did not discuss with the pilot the risks and weather conditions associated with the flight. Neither of the flight coordinators working the flight had received company training on the risk assessment program. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals. A review of Federal Aviation Administration (FAA) surveillance activities revealed that aviation safety inspectors had performed numerous operational control inspections and repeatedly noted deficiencies within the company's training, risk management, and operational control procedures. Enforcement Information System records indicated that FAA inspectors observed multiple incidences of the operator's noncompliance related to flight operations and that they opened investigations; however, the investigations were closed after only administrative action had been taken. Therefore, although FAA inspectors were providing surveillance and noting discrepancies within the company's procedures and processes, the FAA did not hold the operator sufficiently accountable for correcting the types of operational deficiencies evident in this accident, such as the operator's failure to comply with its operations specifications, operations training manual, and GOM and applicable federal regulations.
Probable cause:
The pilot's decision to initiate a visual flight rules approach into an area of instrument meteorological conditions at night and the flight coordinators' release of the flight without discussing the risks with the pilot, which resulted in the pilot experiencing a loss of situational awareness and subsequent controlled flight into terrain. Contributing to the accident were the operator's inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the operator accountable for correcting known operational deficiencies and ensuring compliance with its operational control procedures.
Final Report:

Crash of a Cessna 207A Stationair 7 II in Kwigillingok

Date & Time: Nov 7, 2011 at 1830 LT
Operator:
Registration:
N6314H
Flight Phase:
Survivors:
Yes
Schedule:
Kwigillingok – Bethel
MSN:
207-0478
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1833
Captain / Total hours on type:
349.00
Circumstances:
The pilot departed on a scheduled commuter flight at night from an unlit, rough and uneven snow-covered runway with five passengers and baggage. During the takeoff roll, the airplane bounced twice and became airborne, but it failed to climb. As the airplane neared the departure end of the runway, it began to veer to the left, and the pilot applied full right aileron, but the airplane continued to the left as it passed over the runway threshold. The airplane subsequently settled into an area of snow and tundra-covered terrain about 100 yards south of the runway threshold and nosed over. Official sunset on the day of the accident was 48 minutes before the accident, and the end of civil twilight was one minute before the accident. The Federal Aviation Administration's (FAA) Airport/Facility Directory, Alaska Supplement listing for the airport, includes the following notation: "Airport Remarks - Unattended. Night operations prohibited, except rotary wing aircraft. Runway condition not monitored, recommend visual inspection prior to using. Safety areas eroded and soft. Windsock unreliable." A postaccident examination of the airplane and engine revealed no mechanical anomalies that would have precluded normal operation. Given the lack of mechanical deficiencies with the airplane's engine or flight controls, it is likely the pilot failed to maintain control during the takeoff roll and initial climb after takeoff.
Probable cause:
The pilot's failure to abort the takeoff when he realized the airplane could not attain sufficient takeoff and climb performance and his improper decision to depart from an airport where night operations were prohibited.
Final Report:

Crash of a Cessna T207A Turbo Stationair 8 in Nightmute

Date & Time: Sep 2, 2011 at 1335 LT
Operator:
Registration:
N73789
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Tununak - Bethel
MSN:
207-0629
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1670
Captain / Total hours on type:
216.00
Aircraft flight hours:
19562
Circumstances:
On September 2, 2011, about 1335 Alaska daylight time, a Cessna 208B airplane, N207DR, and a Cessna 207 airplane, N73789, collided in midair about 9 miles north of Nightmute, Alaska. Both airplanes were being operated as charter flights under the provisions of 14 Code of Federal Regulations (CFR) Part 135 in visual meteorological conditions when the accident occurred. The Cessna 208B was operated by Grant Aviation Inc., Anchorage, Alaska, and the Cessna 207 was operated by Ryan Air, Anchorage, Alaska. Visual flight rules (VFR) company flight following procedures were in effect for each flight. The sole occupant of the Cessna 208B, an airline transport pilot, sustained fatal injuries. The sole occupant of the Cessna 207, a commercial pilot, was uninjured. The Cessna 208B was destroyed, and the Cessna 207 sustained substantial damage. After the collision, the Cessna 208B descended uncontrolled and impacted tundra-covered terrain, and a postcrash fire consumed most of the wreckage. The Cessna 207’s right wing was damaged during the collision and the subsequent forced landing on tundra-covered terrain. Both airplanes were based at the Bethel Airport, Bethel, Alaska, and were returning to Bethel at the time of the collision. The Cessna 208B departed from the Toksook Bay Airport, Toksook Bay, Alaska, about 1325, and the Cessna 207 departed from the Tununak Airport, Tununak, Alaska. During separate telephone conversations with the National Transportation Safety Board (NTSB) investigator-in-charge on September 2, the chief pilot for Ryan Air, as well as the director of operations for Grant Aviation, independently reported that both pilots had a close personal relationship. During an initial interview with the NTSB IIC on September 3, in Bethel, the pilot of the Cessna 207 reported that both airplanes departed from the neighboring Alaskan villages about the same time and that both airplanes were en route to Bethel along similar flight routes. She said that, just after takeoff from Tununak, she talked with the pilot of the Cessna 208B on a prearranged, discreet radio frequency, and the two agreed to meet up in-flight for the flight back to Bethel. She said that, while her airplane was in level cruise flight at 1,200 feet above mean sea level (msl), the pilot of the Cessna 208B flew his airplane along the left side of her airplane, and they continued to talk via radio. She said that the pilot of the Cessna 208B then unexpectedly and unannounced climbed his airplane above and over the top of her airplane. She said that she immediately told the pilot of the Cessna 208B that she could not see him and that she was concerned about where he was. She said that the Cessna 208B pilot then said, in part: "Whatever you do, don't pitch up." The next thing she recalled was moments later seeing the wings and cockpit of the descending Cessna 208B pass by the right the side of her airplane, which was instantaneously followed by an impact with her airplane’s right wing. The Cessna 207 pilot reported that, after the impact, while she struggled to maintain control of her airplane, she saw the Cessna 208B pass underneath her airplane from right-to-left, and it began a gradual descent, which steepened as the airplane continued to the left and away from her airplane. She said that she told the pilot of the Cessna 208B that she thought she was going to crash.She said that the pilot of the Cessna 208B simply stated, “Me too.” She said that she watched as the Cessna 208B continued to descend, and then it entered a steep, vertical, nose-down descent before it collided with the tundra-covered terrain below. She said that a postcrash fire started instantaneously upon impact. Unable to maintain level cruise flight and with limited roll control, the Cessna 207 pilot selected an area of rolling, tundra-covered terrain as a forced landing site. During touchdown, the airplane’s nosewheel collapsed, and the airplane nosed down. The Cessna 207’s forced landing site was about 2 miles east of the Cessna 208B’s accident site.
Final Report:

Crash of a Cessna 208B Grand Caravan in Nightmute: 1 killed

Date & Time: Sep 2, 2011 at 1335 LT
Type of aircraft:
Operator:
Registration:
N207DR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Toksook Bay - Bethel
MSN:
208-0859
YOM:
2000
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3719
Captain / Total hours on type:
875.00
Aircraft flight hours:
8483
Circumstances:
On September 2, 2011, about 1335 Alaska daylight time, a Cessna 208B airplane, N207DR, and a Cessna 207 airplane, N73789, collided in midair about 9 miles north of Nightmute, Alaska. Both airplanes were being operated as charter flights under the provisions of 14 Code of Federal Regulations (CFR) Part 135 in visual meteorological conditions when the accident occurred. The Cessna 208B was operated by Grant Aviation Inc., Anchorage, Alaska, and the Cessna 207 was operated by Ryan Air, Anchorage, Alaska. Visual flight rules (VFR) company flight following procedures were in effect for each flight. The sole occupant of the Cessna 208B, an airline transport pilot, sustained fatal injuries. The sole occupant of the Cessna 207, a commercial pilot, was uninjured. The Cessna 208B was destroyed, and the Cessna 207 sustained substantial damage. After the collision, the Cessna 208B descended uncontrolled and impacted tundra-covered terrain, and a postcrash fire consumed most of the wreckage. The Cessna 207’s right wing was damaged during the collision and the subsequent forced landing on tundra-covered terrain. Both airplanes were based at the Bethel Airport, Bethel, Alaska, and were returning to Bethel at the time of the collision. The Cessna 208B departed from the Toksook Bay Airport, Toksook Bay, Alaska, about 1325, and the Cessna 207 departed from the Tununak Airport, Tununak, Alaska. During separate telephone conversations with the National Transportation Safety Board (NTSB) investigator-in-charge on September 2, the chief pilot for Ryan Air, as well as the director of operations for Grant Aviation, independently reported that both pilots had a close personal relationship. During an initial interview with the NTSB IIC on September 3, in Bethel, the pilot of the Cessna 207 reported that both airplanes departed from the neighboring Alaskan villages about the same time and that both airplanes were en route to Bethel along similar flight routes. She said that, just after takeoff from Tununak, she talked with the pilot of the Cessna 208B on a prearranged, discreet radio frequency, and the two agreed to meet up in-flight for the flight back to Bethel. She said that, while her airplane was in level cruise flight at 1,200 feet above mean sea level (msl), the pilot of the Cessna 208B flew his airplane along the left side of her airplane, and they continued to talk via radio. She said that the pilot of the Cessna 208B then unexpectedly and unannounced climbed his airplane above and over the top of her airplane. She said that she immediately told the pilot of the Cessna 208B that she could not see him and that she was concerned about where he was. She said that the Cessna 208B pilot then said, in part: "Whatever you do, don't pitch up." The next thing she recalled was moments later seeing the wings and cockpit of the descending Cessna 208B pass by the right the side of her airplane, which was instantaneously followed by an impact with her airplane’s right wing. The Cessna 207 pilot reported that, after the impact, while she struggled to maintain control of her airplane, she saw the Cessna 208B pass underneath her airplane from right-to-left, and it began a gradual descent, which steepened as the airplane continued to the left and away from her airplane. She said that she told the pilot of the Cessna 208B that she thought she was going to crash.She said that the pilot of the Cessna 208B simply stated, “Me too.” She said that she watched as the Cessna 208B continued to descend, and then it entered a steep, vertical, nose-down descent before it collided with the tundra-covered terrain below. She said that a postcrash fire started instantaneously upon impact. Unable to maintain level cruise flight and with limited roll control, the Cessna 207 pilot selected an area of rolling, tundra-covered terrain as a forced landing site. During touchdown, the airplane’s nosewheel collapsed, and the airplane nosed down. The Cessna 207’s forced landing site was about 2 miles east of the Cessna 208B’s accident site.
Final Report:

Crash of a Cessna 208B Grand Caravan in Kipnuk

Date & Time: Jan 6, 2011 at 1326 LT
Type of aircraft:
Operator:
Registration:
N715HE
Survivors:
Yes
Schedule:
Bethel - Kipnuk
MSN:
208B-0603
YOM:
1997
Flight number:
HAG161
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2800
Captain / Total hours on type:
200.00
Circumstances:
The pilot of the scheduled commuter flight reported that following a normal landing approach, he landed long to avoid a bump in the runway. He applied the brakes during the landing roll, but realized the airplane was still traveling too fast to stop on the snow and ice-covered runway. He said he did not have enough area to abort the landing and applied maximum brakes. The airplane overran the departure end of the runway and impacted a ditch, coming to rest right wing and nose low. The pilot said that there were no preimpact mechanical anomalies with the airplane that would have precluded normal operations. The right wing sustained structural damage.
Probable cause:
The pilot’s decision to land long on the icy snow-covered runway, resulting in a runway excursion and collision with terrain.
Final Report:

Crash of a Cessna 207A Skywagon in Tuluksak

Date & Time: Sep 3, 2010 at 1830 LT
Operator:
Registration:
N9942M
Flight Phase:
Survivors:
Yes
Schedule:
Tuluksak - Bethel
MSN:
207-0756
YOM:
1983
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4545
Captain / Total hours on type:
245.00
Aircraft flight hours:
29550
Circumstances:
Shortly after take off from runway 20, aircraft hit tree tops, stalled and crashed in a wooded area near the airport. Both passenger were slightly injured while the pilot was seriously injured. Aircraft was damaged beyond repair. The director of operations for the operator stated that soft field conditions and standing water on the runway slowed the airplane during the takeoff roll. The airplane did not lift off in time to clear trees at the end of the runway and sustained substantial damage to both wings and the fuselage when it collided with the trees. The pilot reported that he used partial power at the beginning of the takeoff roll to avoid hitting standing water on the runway with full power. After passing most of the water, he applied full power, but the airplane did not accelerate like he thought it would. He recalled the airplane being in a nose-high attitude and the main wheels bouncing several times before the airplane impacted the trees at the end of the runway.
Probable cause:
The pilot's delayed application of full power during a soft/wet field takeoff, resulting in a collision with trees during takeoff.
Final Report: