ANC14MA008

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.

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.

There were no reported malfunctions or anomalies with aids to navigation at the time of the accident. Hageland Aviation Services is a 14 CFR Part 135 air carrier that holds on-demand and commuter operations specifications and is authorized to conduct business exclusively under the business names "Hageland Aviation Services, Inc." or "Era Alaska." The company headquarters are located at the Ted Stevens Anchorage International Airport, Anchorage, Alaska. The president, director of operations, and chief pilot in place at the time of the accident all resided in Anchorage. The director of maintenance resided in Palmer, Alaska. At the time of the accident, Hageland operated 56 airplanes and employed about 130 pilots. The company had 12 bases located throughout Alaska at Anchorage, Palmer, Aniak, Barrow, Bethel, Deadhorse, Fairbanks, Galena, Kotzebue, Nome, St. Mary's, and Unalakleet. According to the company's GOM, the flight coordinator had operational control 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. Authority for operational control is specified in federal regulations, the company's operations specifications, and the procedures outlined in the GOM. In all, about 80 flight coordinators and 96 company pilots were allowed to release flights and exercise operational control on behalf of the company. A review of the company's FAA-approved operations training manual revealed that flight coordinator training was required for personnel authorized to exercise operational control. Initial flight coordinator training consisted of 8 hours of classroom time, and recurrent training consisted of between 3 and 4 hours, depending on the student's experience. Both of the flight coordinators working at the time of the accident had completed the initial flight coordinator training. In addition, the company used a basic risk assessment form containing a four-tiered numbered system to determine the level of operational control needed for a specific flight, with 1 being the lowest risk and 4 being the highest risk. A risk level of 1 required no risk mitigation, a level 2 required a discussion between the PIC and flight coordinator about the risks involved, a level 3 required a phone call to management for evaluation and approval, and a level 4 required canceling the flight. At the time of the accident, no signoff was required for flight coordinators or PICs on the risk assessment form, and the form was not integrated into the company manuals. According to the company, the risk assessment was part of its operational control and flight release system and was presented to and accepted by the FAA but was not incorporated into the GOM, training program, or other company manuals. An FAA principal operations inspector in the Anchorage FSDO was assigned to oversee the company. He had been employed with the FAA for about 7 years at the time of the accident and had been temporarily assigned to the Hageland certificate from October 2012 to April 2013 and permanently assigned to the certificate in September 2013, about 3 months before the accident. A query of the FAA Program Tracking and Reporting System found that from July 16, 2013, to October 22, 2013, FAA aviation safety inspectors conducted five operational control inspections of Hageland. The inspections noted deficiencies in the company's training, risk management, and operational control procedures. After the witnesses on the ground at St. Mary's saw the airplane fly overhead, they attempted to contact the pilot by radio. When the pilot did not respond, they accessed the company's flight tracking software and discovered 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 after about 1 hour of searching. Additional search and rescue personnel were then directed to the accident site to aid in the rescue operation. The fuselage sustained extensive impact damage and the forward section of fuselage (forward of the aft wing carry-through spar) was severely fragmented. The forward fuselage section was rotated about 90 degrees on the longitudinal axis and was laying on the right side. The top cabin roof section had separated at the aft wing carry-through spar and shifted forward and down leaving an exposed area of the floor and cabin. The floor of the airframe was buckled upward. The survivable cabin space in the area directly below and forward of the wing was severely compromised. The aft section of the fuselage was more intact. There were multiple areas of tearing of the skin around the window frames. The cargo door frame was buckled forward and torn just above the upper door's attachment bracket. The lower section of doorframe was mostly undamaged, and the door moved freely. The rear of the cargo door frame had another forward buckle near both corners of the aft window. The door was opened, likely by the first responders. One of the four fatalities was an infant who was being carried as a "lap child" by his mother in a forward-facing backpack carrier. The accident airplane was not equipped, nor was it required to be equipped with, a cockpit voice recorder or a flight data recorder. Automatic Dependent Surveillance-Broadcast (ADS-B) Tracking and Recording The airplane was equipped with ADS-B technology. In typical applications, an airplane equipped with ADS-B uses an ordinary GPS receiver to derive its precise position from the Global Navigation Satellite System constellation and then combines that position with any number of aircraft parameters, such as speed, heading, altitude and flight number. This information is then simultaneously broadcast to other aircraft equipped with ADS-B and to ADS-B ground or satellite communications transceivers, which then relay the aircraft's position and additional information to ARTCCs in real time. A review of the ADS-B data received by the Anchorage ARTCC showed the following: At 1820:31, the airplane passed 1 nautical mile (nm) west of the ONEPY intersection at 800 ft msl inbound to St. Mary's Airport on a heading of 357 degrees magnetic. At 1823:01, the airplane started a descent from 900 ft msl (800 ft agl) while about 3/4 nm from the runway 35 threshold and 1/4 nm left of the runway 35 extended centerline. At 1823:09, the airplane started a right turn that continued until radar contact was lost about 36 seconds later. The average turn rate was 7 degrees per second with an average ground speed in the turn of 119 knots and an average descent rate of 835 ft per minute. During the turn, at 1823:18, the airplane passed through the runway 35 extended centerline, about 1/10 nm from the runway threshold, passing through a heading of about 051 degrees magnetic. The last radar return occurred at 1823:45, which showed the airplane at 450 ft msl (75 ft agl). The airplane heading showed that the airplane was flying toward rising terrain and that the last radar return was less than 1/10 nm from terrain that was 450 ft msl. St. Mary's Airport is a public airport in Class E airspace, located 4 miles west of St. Mary's, Alaska, at a surveyed elevation of 312 ft msl. The airport had two open runways (17/35 and 6/24) at the time of the accident. Runway 17/35 was 6,008 ft long and 150 ft wide, and runway 6/24 was 1,520 ft long and 60 ft wide. Runway 17 was equipped with pilot-controlled high-intensity runway edge lights, a visual approach slope indicator (VASI), and a 1,400-ft medium-intensity approach lighting system with runway alignment indicator lights, but they were not illuminated at the time of the accident. It was serviced by a LOC/DME and an RNAV (GPS) instrument approach. Runway 35 was equipped with high-intensity runway edge lights and a VA