Juneau

The company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long. Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an on board multi-function display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Post-accident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain. According to the company's General Operations Manual (GOM), operational control was delegated to 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 flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form. The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident. Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight. The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications. In post-accident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies. If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.

The certificated airline transport pilot was departing on a 14 CFR Part 91 personal flight. The purpose of the flight was to deliver a load of wooden roofing shakes to a friend's remote lodge. Witnesses reported that just after takeoff, as the airplane climbed to about 200 to 300 feet above the ground, the airplane abruptly pitched up about 70 degrees, and drifted to the right. The airplane continued to turn to the right as the nose of the airplane lowered momentarily. As the airplane flew very slowly the landing gear was extended. The nose of the airplane pitched up again, the right wing dropped, and the airplane descended. One witness described the descent as: "The wings rocked back and forth as it descended, like a card in the wind, with the nose of the airplane slightly higher." The airplane impacted shallow water in an area of tidal mud flats. A postaccident investigation revealed that the estimated gross weight of the airplane at takeoff was 11,500.8 pounds, 1,400.8 pounds in excess of the airplane's maximum takeoff gross weight. The airplane's center of gravity could not be calculated due to the fact that the exact location/station of the cargo could not be determined. Examination of the airplane revealed no evidence of any preimpact mechanical anomalies.

The pilot of the air taxi cargo flight departed his base of operations in Juneau, Alaska for a series of flights in southeast Alaska that would ultimately return him to Juneau. On the accident leg of the intended round robin, the pilot was en route from Hoonah to Elfin Cove. The flight would originate and end at sea level, and traverse a mountain pass, with minimum obstruction clearance in the pass estimated at 500 feet msl. The airplane collided with steeply rising terrain at the 1,250-foot level about one mile south of the proposed flight path. The airplane was partially consumed by a post impact fire. The operator initiated a helicopter search within two hours of the time of the accident. The helicopter pilot and his passenger both reported that the area where the accident airplane was eventually located was obscured in low clouds, and that many of the other valleys and mountain sides were covered in clouds. Low clouds persisted in the area of the crash site for the following two days.

The flight departed Juneau, Alaska on a VFR flight to King Salmon, Alaska. When the flight was 50 miles southwest of the Yakutat VOR, the pilot requested an IFR clearance. He was cleared direct to Middleton Island VOR, then direct to King Salmon VOR. When the flight was 20 miles northwest of Middleton Island, the pilot contacted ARTCC and indicated his right engine had come apart. The pilot attempted to fly to and land at Middleton Island, Alaska. During the flight, the airplane consistently lost altitude. He flew past the island and was southeast of the island, when radar contact was lost. The airplane was not recovered. Flight crew of rescue aircraft stated they saw bubbles, an oil slick, and airplane debris in the ocean approximately 3 miles south of the Middleton Island Airport. The 1126 adt weather at the airport was in part: 600 feet broken, visibility 5 miles, wind from 117° at 17 gusting 25 knots.

Five aircraft departed a lodge, one behind the other. Fog and drizzle were encountered, and the pilot of the first aircraft radioed to the pilots of the other aircraft to cross the river to the east shoreline. A passenger in the fourth aircraft (N13GA) stated that when the aircraft was over the middle of the river, she could not see either shore due to fog. The pilot of N13GA (a floatplane) stated that he encountered deteriorating weather and started a descent, intending to make a precautionary landing. He began to level, expecting conditions to improve. Subsequently, the floatplane hit the surface of 'glassy water' and crashed. Seven passengers were killed and four other occupants were seriously injured. The aircraft was destroyed.

The crew started the descent to Juneau Airport in poor weather conditions. At an altitude of 2,600 feet, while cruising in clouds, the twin engine aircraft struck the slope of a mountain located in the Chilkat Mountain Range, about 38 miles northwest of Juneau Airport. The aircraft was destroyed upon impact and all eight occupants were killed among them General Thomas C. Carroll, second Chief of Staff of the USAF in Alaska.
Crew:
Col Thomas Clark, pilot,
Cwo John Pospisil, copilot.
Passengers:
Sfc Richard E. Brink,
Gen Thomas C. Carroll,
Mg Kenneth W. Himsel,
Sgm Llewellyn A. Kahklen,
Sgt Michael J. Schmidt,
Col Wilfred E. Wood.

The pilot landed the amphibian landing gear equipped aircraft on water with the wheels extended, and the aircraft flipped over to an inverted attitude on touchdown. The pilot, sole on board, was killed.

During a flight from Juneau to Pelican, AK, the aircraft collided with terrain approximately 12 miles east of Pelican while crossing over Chichagof Island. Impact occurred on a vertical rock wall at an elevation of about 1,950 feet. No preimpact part failure or malfunction of the aircraft was evident. Another pilot, who had planned to fly the same route about 1 hr and 45 min earlier, decided to fly around the island due to low clouds, rain and fog in the area. He reported that he flew over icy straits rather than take a more direct route and that ceilings were about 2,000 feet broken with lower stratus in the valleys. A helicopter pilot said he was unable to work in mountain passes in the vicinity of the accident due to low clouds, rain and fog; he also said the passes were 'socked in.' Both occupants were killed.

The flight was cleared on an IFR flight from Whitehorse to Juneau, via V-428 to Chill intersection, then direct to Juneau. Chill intersection was located on V-428, 36 miles south of Haines NDB on a bearing of 146°. On reaching Haines NDB, the pilot cancelled his IFR clearance and continued under visual flight rules (VFR). Subsequently, the aircraft crashed on a glacier between Haines and Juneau, approximately 15 miles southeast of Haines NDB at an elevation of about 4,500 feet. A pilot, flying about 5 miles southwest of the crash site at the time of the accident, reported a broken to overcast ceiling at 2,500 feet to 3,000 feet msl. The accident site was near the Haines transition of the Barlo 4 departure (sid). In that area, the minimum en route altitude for flight on the Haines transition was 9,000 feet under instrument flight rules.

During arrival to pick up a medevac patient, the flight was cleared for an LDA-1 runway 08 approach via the Asort transition. Thus, the pilot should have continued southeast on J-541 toward the SSR vortac and intercepted the localizer (loc) at Asort; then track inbound on the loc (062°), using I-JDL frequency 109.9 MHz (frequency for loc and co-located DME). After Asort, minimum altitude was 6,500 feet to Dibol intersection, 5,100 feet to Lynns intersection and 3,400 feet to the faf at Barlo intersection. DME from I-JDL to the intersections was: 18.2, 13.5 and 8 miles. DME from SSR (south of loc track) to the intersections was 11.2, 12.7 and approximately 16 miles. Flight reported Asort inbound while descending thru approximately 9,500 feet. Last radio call was 30 seconds later while descending thru 8,200 feet, 14 miles west of Dibol. Approximately 4 miles west of Dibol, aircraft impacted mountain side at 3,500 feet msl. No preimpact mechanical malfunction was found. There was evidence that both nav's were tuned to 109.9 MHz, but DME control head was inadvertently left in 'hold' position (locking DME to SSR rather than I-JDLl) and crew began a premature descent. Juneau weather was in part: 600 feet scattered, 3,000 feet overcast, 7 miles visibility. Pilot-in-command was currently flying both Learjet and DHC-7. All four occupants, two pilots and two doctors, were killed.