Narrative:A Hageland Aviation Services Cessna 208 Caravan operating as Ravn Connect Flight 3153 from Quinhagak with two crew and one passenger onboard impacted mountainous terrain 12 statute miles northwest of its intended destination of Togiak. All three occupants died in the crash.
Flight 3153 had originated in Bethel, Alaska; made scheduled stops in Togiak and Quinhagak; and was scheduled to return to Togiak before returning to Bethel, the intended final destination for the day. The aircraft departed Quinhagak at 11:33.
An area believed to be the initial impact point was discovered on the northwest side of a mountain ridgeline at the 2300-foot level. The initial impact point was located north of and about 200 feet below the 2500-foot mountain summit and contained fragmented portions of fuselage and two severed propeller blades. From the initial impact point, the wreckage path extended southeast to the main wreckage, which was located downslope on the southeast side of the ridgeline at the 1,550-foot level. The outboard portion of the left wing had separated and was located about 200 feet further downslope below the main wreckage site. A postcrash fire incinerated a large portion of the fuselage and right wing.
Probable Cause:
PROBABLE CAUSE:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crews 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
(1) Hagelands 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;
(2) Hagelands inadequate crew resource management (CRM) training;
(3) the Federal Aviation Administrations failure to ensure that Hagelands approved CRM training contained all the required elements of Title 14 Code of Federal Regulations 135.330; and
(4) Hagelands CFIT-avoidance ground training, which was not tailored to the companys operations and did not address current CFIT-avoidance technologies.
Accident investigation:
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Investigating agency: | NTSB |
Status: | Investigation completed |
Duration: | 1 year and 7 months | Accident number: | NTSB-AAR-18/02 | Download report: | Final report
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Classification:
VFR flight in IMC
Controlled Flight Into Terrain (CFIT) - Mountain
Sources:
»
ADN»
KTUU»
Ravn statement» NTSB
METAR Weather report:
21:09 UTC / 13:09 local time:
PATG 022109Z AUTO 00000KT 7SM -RA BKN015 OVC021 07/06 A2990 RMK AO2 P000121:40 UTC / 13:40 local time:
PATG 022140Z AUTO 00000KT 10SM FEW021 OVC042 08/07 A2990 RMK AO2 RAE13 P0001
Follow-up / safety actions
NTSB issued 8 Safety Recommendations
Issued: 26-APR-2018 | To: FAA | A-18-13 |
Although controlled flight into terrain (CFIT)-avoidance training programs are not required by federal regulation for Title 14 Code of Federal Regulations Part 135 fixedwing operations, work with Part 135 operators in Alaska to improve any voluntarily implemented training programs aimed at reducing the risk of CFIT accidents involving continuation of flight under visual flight rules (VFR) into instrument meteorological conditions, with special attention paid to the human factors issues identified in recent Alaska accident investigations, including but not limited to, (1) the challenges of flying in mountainous terrain in Alaska and low-altitude VFR flight in an area subject to rapid changes in weather; and (2) limitations of the Alaska infrastructure, particularly weather observations, communications, and navigation aids. |
Issued: 26-APR-2018 | To: FAA | A-18-14 |
Work with Title 14 Code of Federal Regulations Part 135 certificate holders that operate under visual flight rules in mountainous terrain at altitudes below the required terrain clearance of the aircrafts required terrain awareness and warning system (TAWS) class to (1) ensure that management and pilots are aware of the risks associated with distraction (from continuous nuisance alerts) and complacency (brought about by routine use of the terrain inhibit feature); (2) develop plans for mitigating those risks and minimizing nuisance alerts; and (3) develop procedures that specifically address when pilots should test, inhibit, and uninhibit the TAWS alerts, considering the operators typical operations and the TAWS manufacturers guidance. |
Issued: 26-APR-2018 | To: FAA | A-18-15 |
Modify the terrain awareness and warning system requirements in Technical Standard Order C151 such that, once the alerts are manually inhibited, they do not remain inhibited indefinitely if the pilot does not uninhibit them. |
Issued: 26-APR-2018 | To: FAA | A-18-16 |
Install communications equipment throughout Alaska, after determining what would be most effective, to allow increased access to the instrument flight rules (IFR) system, giving priority to those areas used by 14 Code of Federal Regulations Part 135 operators. |
Issued: 26-APR-2018 | To: FAA | A-18-17 |
Ensure that Alaska airports that are served by 14 Code of Federal Regulations (CFR) Part 135 operators and have instrument approaches are equipped with weather reporting capabilities to enable instrument flight rules operations in accordance with 14 CFR 135.225(a). |
Issued: 26-APR-2018 | To: Medallion Foundation | A-18-18 |
Expand the criteria for the Medallion stars and shield to include requirements for your members to incorporate Medallion program materials into their Federal Aviation Administration-approved and -accepted training programs and manuals. |
Issued: 26-APR-2018 | To: Medallion Foundation | A-18-19 |
Expand the criteria for your safety star to include requirements for a flight data monitoring program. |
Issued: 26-APR-2018 | To: Hageland Aviation | A-18-20 |
Incorporate into your crew resource management training program ground, simulator, and flight training that define second-in-command responsibilities for dual-pilot operations, including but not limited to (1) the use of standard operating procedures and execution of pilot flying/pilot monitoring duties as outlined in Advisory Circular 120- 71B and (2) aeronautical decision-making and judgment scenarios that are tailored to Hagelands flight operations and aviation environment, including communications and teamwork with Operations Control Center personnel. |
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Photos
accident date:
02-10-2016type: Cessna 208B Grand Caravan
registration: N208SD
accident date:
02-10-2016type: Cessna 208B Grand Caravan
registration: N208SD
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Quinhagak Airport, AK to Togiak Village Airport, AK as the crow flies is 112 km (70 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.