ANC15FA049

The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel.

**This report was modified on March 1, 2023. Please see the public docket for this accident to view the original report.** 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 onboard multifunction 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. Postaccident 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. 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.

HISTORY OF FLIGHT On July 17, 2015, about 1318 Alaska daylight time, a Cessna 207A airplane, N62AK, sustained substantial damage following an in-flight collision with tree-covered terrain about 18 miles west of Juneau, Alaska. The commercial pilot sustained fatal injuries, and four passengers sustained serious injuries. The flight was being operated as flight 202 by SeaPort Airlines, Inc., dba Wings of Alaska, as a 14 Code of Federal Regulations (CFR) Part 135 visual flight rules (VFR) scheduled commuter flight. (Wings of Alaska has been sold and is currently under different ownership.) Visual meteorological conditions were reported at the Juneau International Airport at the time of departure. A company flight plan had been filed, and company flight-following procedures were in effect. Flight 202 departed the Juneau Airport about 1308 for a scheduled 20-minute flight to Hoonah, Alaska. On the day of the accident, the pilot arrived at the company office in Juneau about 1200. The accident flight was the pilot's first scheduled flight of the day. The company flight coordinator on duty at the time told the pilot that most flights to Hoonah were cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. The flight coordinator said that the weather had started lifting around 1000 and that the first flight to Hoonah had departed at 1045. He suggested that the accident pilot talk with the pilot who had just returned. The dispatch group had a shift change between the time the accident pilot came on duty and when the pilot departed. The company flight coordinator on duty at the time of the accident only communicated with the pilot when she reported taxiing off the ramp for departure. No weather information was discussed, and no further radio communications were received from the pilot by the company. According to Juneau Air Traffic Control Tower (ATCT) personnel, the pilot requested and received taxi clearance to depart for the 20-minute VFR flight to Hoonah at 1306. The flight was cleared for takeoff about 2 minutes later by the ATCT specialist on duty with no reported problems. About 15 minutes later, Juneau Police dispatchers received a 911 cell phone call from a passenger on board stating that the airplane had crashed. During an interview with one of the surviving passengers, who was sitting directly behind the pilot, he stated that the pilot seemed normal during the preflight and briefing. After takeoff, the turbulence was heavy, and there were layers of fog and clouds and some rain. He had taken this flight numerous times and thought that the flight route that the pilot was taking was somewhat unusual. Before the impact, he thought that the pilot was trying to climb over the approaching mountain and skirt between a layer of clouds. He saw the trees coming at the windshield, and the pilot jerked back on the controls, and then he heard a "loud boom." The next thing that he remembered was sitting outside the airplane. He said that there were no unusual sounds from the engine and that the airplane appeared to be flying normally before the impact. Automatic dependent surveillance-broadcast (ADS-B) data received by the Anchorage ATCT showed the following: o At 1308:09, the accident airplane took off from JNU. o At 1312:33, the accident airplane started a northwesterly turn around the west side of Portland Island at an ADS-B reported altitude of 825 ft mean sea level (msl). o At 1314:20, the accident airplane began a turn to a westerly heading at an ADS-B reported altitude of 825 ft msl. o At 1316:25, the accident airplane crossed the western shoreline of Admiralty Island at an ADS-B reported altitude of 675 ft msl and continued on a constant heading until the last ADS-B point was recorded. The last ADS-B point was received at 1317:27, when the airplane was over Lynn Canal, about 1 mile from the eastern shoreline of the Chilkat mountain range at an ADS-B reported altitude of 525 ft msl. The last 30 seconds of the flight was missing from the ADS-B data. PERSONNEL INFORMATION The pilot, age 45, held a commercial pilot certificate with airplane single-engine land and sea, multiengine land, and instrument ratings. The pilot was issued a first-class airman medical certificate on April 9, 2015, with the limitation that she "must wear corrective lenses." Company training records indicated that the pilot completed basic indoctrination on May 25, 2015, and initial ground training on June 2, 2015. Ground training curriculum was completed in two locations: Portland, Oregon, and Juneau. The pilot's most recent Part 135 proficiency checks (135.293 (a) (b) and 135.299) were completed in the Cessna 207 on June 12, 2015. Company records indicated that she had a total time of 840 flight hours. The base chief pilot, who provided about half of the accident pilot's flight training, said that she was very good on systems but that she needed a few additional hours of flight training and initial operating experience before he was comfortable signing her off. He noted that the one thing that he really liked about her was that she wasn't afraid of turning around if she was uncomfortable. He did not notice any negative attitudes or habits with her flying. The pilot's normal shift was the p.m. shift, which typically began at 1200 and ended at 2200. The pilot's flight and duty time records indicated that, the day before the accident, she flew 3.7 hours and then went off duty at 2200. The accident flight was the pilot's first flight of the day. In June 2015, the pilot was on duty for 27 days, flew about 23 hours, and had 3 days off. In July 2015, the pilot was on duty for 11 days, including the day of the accident; flew about 41 hours; and had 6 days off. The pilot had not had a day off in the 72 hours preceding the accident flight. During that time, she flew a total of 19 flight segments, totaling 9.4 hours, not including the accident flight. The pilot's roommates and family members reported no unusual activity in the 72 hours preceding the accident. However, in an interview with the pilot's sister, she said that the pilot had told her about an incident that had happened 2 or 3 weeks before the accident where she had gotten into a bad storm during a flight. The pilot said that she and her passengers were praying together to get through the weather and that eventually she saw the runway and was able to land the airplane uneventfully. Other than this event, the accident pilot never mentioned to her sister any concerns about flying for the company for which she worked. AIRCRAFT INFORMATION The accident airplane, a Cessna 207A, N62AK, was manufactured in 1984. Before the accident flight, the airplane had logged a total time in service of 26,613.1 flight hours. The airplane was maintained under a 100-hour/annual inspection program, and the most recent 100-hour inspection of the airframe and engine was on July 6, 2015. The airplane was equipped with a Continental Motors IO-520-F 285-horsepower reciprocating engine. The engine was factory rebuilt on June 16, 2015; installed on the airplane July 14, 2015; and had accumulated about 8.2 hours of operation before the accident flight. METEOROLOGICAL INFORMATION The area forecast issued by the National Weather Service Alaska Aviation Weather Unit (AAWU) at 1210 included an AIRMET for mountain obscuration due to clouds and precipitation, and the AIRMET was valid at the accident site at the accident time. The area forecast mentioned scattered clouds at 1,200 ft msl with broken to overcast ceilings at 2,000 ft msl with cloud tops to flight level 250 and an occasional broken ceiling at 1,200 ft msl with 5 miles visibility and light rain. Isolated instrument flight rules (IFR) conditions were also forecast with rain and mist. The AAWU weather charts produced at 1200 indicated that the accident site was on the boundary of marginal VFR to IFR conditions with isolated moderat