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N408GV accident description

Alaska map... Alaska list
Crash location Unknown
Nearest city Wainwright, AK
70.636944°N, 160.038333°W
Tail number N408GV
Accident date 10 Apr 1997
Aircraft type Cessna 208B
Additional details: None

NTSB Factual Report

HISTORY OF FLIGHT

On April 10, 1997, about 2030 Alaska daylight time, N408GV, operated by Hageland Aviation Services, Inc., as Flight 502, collided with the frozen Arctic Ocean while maneuvering near Wainwright, Alaska. The commercial pilot and all four passengers were fatally injured and the airplane was destroyed. Instrument meteorological conditions prevailed. The pilot had previously filed an instrument flight rules (IFR) flight plan, but departed with a visual flight rules (VFR) flight plan. The regularly scheduled commuter airline passenger flight had departed from Barrow, Alaska, at 1955 and was destined for Wainwright. The flight was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135.

According to transcripts, statements, and records (attached) provided by the Federal Aviation Administration (FAA), a person identifying himself as the pilot of N408GV telephoned the Barrow Flight Service Station (FSS) at 0819 on the morning of the accident and requested a "... standard briefing for the North Slope." The FSS briefer provided a briefing that described instrument meteorological conditions (IMC) at the Barrow Airport. The pilot continued to telephone and visit the FSS in person to determine if the weather would improve to visual meteorological conditions (VMC). [At the time of the accident, Federal Aviation Regulations (FAR) prohibited commercial passenger-carrying operations in single-engine airplanes during IMC.]

At 1231, the pilot telephoned the FSS again and asked if there were "... any changes in the weather?" The briefer again reported that the visibility at Barrow was below VFR minimums. About one hour later, the pilot telephoned a third time and told the FSS briefer that VMC were being reported by a local automated weather observation station (AWOS). Sky conditions at Barrow were reported as scattered clouds at 200 feet with a visibility of 10 miles. The pilot then filed an instrument flight rules (IFR) flight plan for a proposed 20-minute flight to Wainwright. The flight plan called for a cruising altitude of 4,000 feet with six hours of fuel on board and a departure time of 1430 local time.

Twenty minutes later, at 1402, the pilot called again and asked if the weather went "... back down again?" After the briefer responded that it had, the pilot stated: "Shoot... [as] soon as I call the passengers the darned stuff comes down." The briefer replied that "...VFR flights still not recommended..." and told the pilot that the reported visibility at Barrow was one and one-half mile with an indefinite ceiling of 300 feet overcast. The pilot asked the briefer "... if it's legal?" The briefer stated: "Well I don't know. I don't delve into the legal or no-legal area. You have to decide."

Thirty-six minutes later, at 1440, the pilot called the FSS again and was told that the ceiling remained at 300 feet overcast. At 1600, the pilot personally visited the FSS and obtained an abbreviated weather briefing. The reported weather conditions had not changed. After casually talking with the briefer, the pilot left the FSS. He then called the FSS four more times at 1645, 1703, 1733, and 1853. Each time he was told by the FSS briefer that the weather conditions had remained the same.

At 1920, the pilot called the FSS once more. The briefer told the pilot "... VFR flight still not recommended," and that the ceiling had risen to 500 feet overcast with a visibility of 7 miles. The pilot responded with: "Okay, that's fine. I guess I'm going to Wainwright." The pilot then boarded the passengers and began the flight.

At 1952, the pilot contacted the FSS by radio and requested a "taxiing advisory." The briefer replied that the "...weather in the Barrow Class E surface area is below VFR minimas. Air traffic control clearance is required to depart the surface area. Say intentions." The pilot requested and was granted a special VFR clearance out of the Barrow Class E surface area. He also filed and activated a VFR flight plan to Wainwright.

At 1958, the pilot reported that he was clear of the Class E surface area. This was his last recorded radio transmission with the FSS.

The Safety Board requested and received recorded radar data from the U.S. Air Force for the time and location of the accident. According to recorded radar data (raw data attached), a radar target was tracking from Barrow toward Wainwright (plot of data attached) beginning about 30 minutes before the accident. The radar track began near Barrow at 2002 and ended near Wainwright at 2021. The recorded track of the target never deviated from 243 degrees during the entire period of recorded radar coverage. The recorded ground speed of the target varied between 135 and 145 knots during the majority of the track, and then gradually increased to 157 knots as the target descended toward Wainwright. The recorded altitude values initially varied between 4,000 feet and 5,000 feet msl, and then gradually decreased to 2,200 feet as the target approached Wainwright and disappeared below radar coverage.

According to a representative of the U.S. Air Force's 611th Communication Flight in Anchorage, Alaska, the recorded values for latitude, longitude, speed, and heading from the radar equipment are considered reliable and accurate; however, the altitude values have a tolerance of plus and minus 3,000 feet due to the characteristics of the radar and the lack of a mode-C signal from the target. The radar data is a computer compilation of data extracted from three Air Force FPS-117 long range, three-dimensional Alaska radar antenna sites located in Barrow, Olitok, and Cape Lisburne. According to the Air Force representative, the radar has a usable range of 200 miles and utilizes a FYQ-93 computer processor.

According to a Wainwright ground agent employed part-time by Hageland Aviation Services (statements attached), the pilot contacted him by radio about 2030 to report that the flight was inbound for landing. The ground agent stated that he was outside on the ramp of the Wainwright Airport at the time. He stated that he was communicating with the pilot via a portable marine radio that was tuned to "Marine 83." He stated that the normal procedure was to communicate with Hageland pilots via the marine radio, not the aviation radio, for improved communications.

The ground agent stated that he heard an airplane make two passes over the Wainwright Airport. During the first pass, the ground agent could hear the airplane, but he could not see it. The ground agent stated that the airplane approached the airport "... from the north" and was "... above the weather." During the second approach, the ground agent remembered that the airplane flew "... from the south heading north," and the airplane was flying "... parallel to the runway." He stated that he "... could see definitely the windows and tail of the airplane" as it flew overhead during the second pass, but "... there was weather" between him and the airplane.

The ground agent stated that he told the pilot via radio that the weather was overcast and the visibility was about 1/4-mile to the east with a "half a sock" of wind. At the time the ground agent heard the airplane directly overhead during the first approach, the pilot radioed something similar to: "I can't see the village. I'm going down south to make another run through."

The ground agent remembered that as the pilot flew overhead during the second pass, the pilot announced that he could not see the airport and he was "going to go back." The ground agent stated that he could see the outline of the airplane in the haze, about 500 to 600 feet above the ground, on a northerly heading, and one-eighth of a mile laterally from the center line of the runway. The ground agent stated that the propeller sounded like the airplane was at landing speed.

The ground agent stated that the pilot immediately responded with a "good bye" statement, and he "...picked up no weird noises [from the airplane and ] no frustration in [the pilot's] communications... no excitement." About 10 seconds later, he radioed to the pilot in order to ask him when he would be returning again. He received no response from the pilot. The ground agent stated that he may have asked the pilot a second time, but he is not sure. He never heard from the pilot again. Another ground witness, a resident of Wainwright who was employed as a part-time ticket agent for another operator, reported (statement attached) that he was in his home near the Wainwright Airport on the evening of the accident. He stated that he heard the Hageland ground agent over his citizens band radio talking to other villagers. He heard that the Hageland airplane was going to be landing at Wainwright, so he "... turned up the volume" on his airport scanner. "A few minutes later," the resident heard "clicking" over the airport radio and surmised that the pilot was attempting to activate the pilot-controlled lighting at the Wainwright Airport.

The resident stated that he then attempted to contact the pilot via his airport radio to tell the pilot that he "... didn't want [the pilot] to land..." because the weather was "pretty bad." The resident attempted to contact the pilot "four or five times," and he tried three different aviation frequencies; he never received a response from the pilot.

The resident remembered that he heard the airplane fly over his house on two separate occasions. He stated that it flew "... from the north... coming up over the village toward the airport" on the "first pass." The airplane then sounded like it "turned left." On the "second pass," he thought that the airplane "... sounded like he was higher." He also stated that the engine sounded "normal" during both passes, and that "about 10 minutes passed" between the first and second "passes."

The North Slope Borough Search and Rescue Unit was subsequently notified of an emergency locator transmitter (ELT) signal near Wainwright. The airplane wreckage was located 4.3 nautical miles northwest of Wainwright in the partially frozen Arctic Ocean the following day. The accident occurred during the hours of daylight near the following coordinates: 70 degrees, 42.2 minutes North and 160 degrees, 05.4 minutes West.

PERSONNEL INFORMATION

The pilot, male, age 41, possessed a commercial pilot certificate containing ratings for single-engine land, single-engine sea, multiengine land, and instrument airplanes. He also held a flight instructor airman certificate containing a rating for single engine land airplanes. According to FAA records, the pilot was issued an FAA First Class Medical Certificate on July 1, 1996, with the limitation that he "...shall wear correcting lenses while exercising the privileges of his/her airman certificate."

An examination of Hageland's pilot training records and daily flight logs (excerpts attached) indicate that the pilot had accumulated a total of about 3,660 hours of flight time at the time of the accident, most of which was accrued in single engine, piston-powered airplanes. The records further indicate that the pilot accumulated 299 hours of total instrument time.

The records further indicate that pilot had flown a total of about 60 hours in the Cessna 208B, all of which were accrued during a 60-day period preceding the accident. No evidence was found to indicate that the pilot had ever flown any aircraft other than a single or multiengine, piston-powered airplane prior to his experience in the turbine-powered Cessna 208B.

The pilot was hired and began training at Hageland Aviation Services on February 2, 1997, about two months prior to the accident. He had been previously employed as a pilot by another 14 CFR Part 135 operator in Barrow for about five months prior to his resignation from that operator in order to become employed by Hageland Aviation Services. During his previous employment, he flew the single-engine, piston-powered Cessna 207. After being hired by Hageland, the pilot was subsequently sent to FlightSafety International in Wichita, Kansas, for a one-week pilot initial training course in the Cessna 208B. (At the time of the pilot's training, Hageland Aviation Services held an FAA exemption that authorized the use of FlightSafety International for the training and checking of pilots.)

After receiving 6.5 hours of Cessna 208B flight simulator training, the pilot satisfactorily completed an FAA Part 135 Airmen Competency/Proficiency Check (FAA Form 8410-3 attached) on February 14, 1997, in Wichita. The final FlightSafety check ride was 1.5 hours in duration and included instrument procedures and approaches.

The pilot returned to Barrow and began initial operating experience (IOE) in the Cessna 208B on February 24, 1997. He accumulated 13.8 hours and 13 landings during IOE, and satisfactorily completed the experience required by the FAA on February 27, 1997. During the next six weeks, according to Pilot Daily Flight Log sheets, the pilot exclusively flew the accident airplane on VFR revenue flights to villages along Alaska's North Slope, including Wainwright, on an almost daily basis.

According to the FAA, the pilot had no previous accidents; however, a review of the pilot's history of enforcement actions revealed a pending enforcement action for failure to remove a tail stand prior to flight in the accident airplane in March 1997.

In an interview with the Safety Board, the chief pilot of Hageland Aviation Services reported that he went to Barrow after the tail stand incident to take corrective action. The chief pilot stated that he was more concerned with the pilot's failure to check for damage after landing with the tail stand attached, than with the initial failure to remove it prior to flight. The chief pilot stated that after this incident, the company made a change to their checklist to prevent a similar incident from happening again. The chief pilot also stated that he had a long talk with the pilot of the accident aircraft and severely chastised him. He also reassured the pilot that he was doing a "good job," that his job was not in jeopardy, and that the pilot must "slow down."

The chief pilot stated that he considered the accident pilot to be an above average airman with above average judgement. He also stated the pilot may have felt self-induced pressure, or pressure from the passengers to conduct a flight under adverse conditions, but that the company did not pressure him.

In an interview with the Safety Board, Hageland Aviation Service's director of operations was asked if he felt there was any pressure on the pilot to conduct flights under adverse conditions. The director stated that all of the pilots are paid a salary and are not paid by the hour, and that the company stresses safety. He stated that there was no pressure from the company to fly because the pilots are paid whether they fly or not. The director also stated that the pilot may have felt some pressure to conduct the accident flight from the passengers and also from the pilot's own desire to perform satisfactorily for the company.

In an interview with the Safety Board, the pilot's wife stated that she had also been hired by Hageland Aviation Services in February 1997. She stated that she and her husband worked as a team and that her duties included performing the office work at the Barrow base. The pilot's wife stated that working as a team was new for them. She stated that the pilot had been working all winter in Barrow, and that he would routinely arrive home about 1900 every evening.

The pilot's wife stated that she and her husband were being paid a salary and there was no pressure to fly. She also stated that there was no pressure from the U.S. Post Office to fly by-pass mail, and that the by-pass mail had never been taken away from them. She stated that the payments to carry the mail often made up the difference (profit) after the passenger revenue.

The pilot's wife said that the pilot's normal sleep pattern was to go to sleep around 2200 or 2230 at night, and then awaken about 0730 the following morning. She stated that there appeared to be nothing unusual about the pilot on the day of t

NTSB Probable Cause

The pilot's intentional VFR flight into instrument meteorological conditions and his failure to maintain altitude/clearance from terrain. Factors contributing to the accident were the weather conditions.

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