ANC17FA039

The pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of visual reference and subsequent controlled flight into terrain. Contributing to the accident was (1) the inadequate preflight weather planning by the pilot and duty officer (2) the operator's inadequate operational control structure, and (3) the inadequate oversight of the operator's operational control structure by the Federal Aviation Administration.

The instrument-rated commercial pilot was conducting a visual flight rules (VFR) on-demand cargo flight over remote, mountainous terrain in an airplane that was not equipped for instrument flight. Low cloud ceilings and visibility prevailed in the area of the accident site from about 30 minutes before the pilot departed through the accident time. Based on the weather conditions in the area and tracking data from onboard the airplane, it is likely that the pilot encountered low cloud ceilings and low visibility conditions en route and attempted to descend in order to continue toward the destination; the airplane impacted trees and terrain in a level attitude consistent with controlled flight into terrain.  The flight occurred during the pilot's first season flying in Alaska. It is likely due to the pilot's lack of flight experience in remote areas and his first season flying in Alaska, poor decision making occurred with his decision to descend in an area of low cloud ceiling and low visibility in mountainous terrain in order to continue toward the destination as opposed to turning around, climbing, or diverting the route of flight. Postaccident examination of the airplane revealed no evidence of preimpact mechanical anomalies that would have precluded normal operation. The company president/director of operations (DO) was out of the country when the accident occurred. Per the DO, either himself or the office manager, as the duty officer, are the ones that exercise operational control over the company's flights. On the day of the accident, the office manager, was exercising first-tier operational control (per the two-tiered operational control concept) over the flight as the duty officer. The office manager, who held a private pilot license, was not listed by name in the company's general operations manual (GOM) or in the Federal Aviation Administration (FAA)-issued operations specifications as an individual who could exercise operational control over a flight. The FAA states that individuals who exercise operational control must be qualified through training, experience, and expertise. The operator did not have an operational control training program. The operator had an operational control organizational structure in place, that was accepted by the FAA, that allowed the office manager to exercise operational control when he was not qualified, nor was he listed by name in the GOM. The operator having an organizational structure in place that allowed any company employee to perform as a duty officer who can exercise first-tier operational control without meeting the requirements of the 14 CFR Part 119 and 14 CFR Part 135, showed a lack of understanding of operational control; in addition to, a loss of operational control with the air carrier due to hands off management resulting in inadequate controls over its own operation and an exercise of operational control by unapproved persons. The pilot nor the office manager received an official weather briefing during the flight release process, nor were they required to by the company's GOM. An Aviation Routine Weather Report (METAR), originating about 12 miles southwest of the accident site was issued about 1 hour and 10 minutes prior to the flight's departure. Few clouds at 300 ft above ground level (agl), a broken ceiling at 1,500 ft agl, and remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass) were listed. The office manager reported that he and the pilot did not assess the METAR that morning. Additionally, the office manager reported that he viewed FAA weather camera images prior to the flight's departure for the Lake Clark Pass area and noticed it had "some fog" but he reported, "it looked like it was just fog right over the camera because everywhere else was blue sky." If an official weather briefing was received, unfavorable weather conditions for the morning of the flight affecting the proposed route would have been observed and communicated to the pilot, particularly with the available METAR data. Information in the official weather briefing from the National Weather Service flying weather chart showed marginal VFR weather for the area encompassing the route of flight and the accident site. A review of FAA weather camera images, from multiple directions, prior to the flight's departure indicated complete mountain obscuration conditions affecting the proposed route with low visibility underneath the overcast cloud layer with all the higher terrain refences obscured by clouds, which would be unfavorable for VFR operations in that area. It is likely the pilot, who was exercising second-tier operational control, did not sufficiently assess the weather for the proposed flight route near Lake Clark Pass during the preflight planning process. The FAA principal operations inspector (POI) assigned to oversee the operator stated that he was saturated with certificate management duties and did not have adequate time to devote to the accident operator. Had the POI had adequate time to devote to the accident operator, the operational control deficiencies may have been identified and corrected.

Weather Sources The closest official weather observation station was located at Port Alsworth Airport (TPO), Port Alsworth, Alaska about 12 miles southwest of the accident site. The Aviation Routine Weather Report (commonly referred to as a "METAR") observation at 0650 (about 2.5 hours before the accident) included calm wind, 10 statute miles visibility, few clouds at 300 ft above ground level (agl), a broken ceiling at 1,500 ft agl, temperature 55°F, dew point 54°F, and an altimeter setting of 29.94 inches of mercury with remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass). Figure 4 shows a National Weather Service (NWS) flying weather graphic issued at 0400 and was valid until 1000, showing the area encompassing the route of flight and the accident site as having forecast marginal VFR conditions. Figure 4 – View of National Weather Service flying weather graphic, issued at 0400 and valid until 1000 (courtesy of the National Weather Service). The following are images captured from a FAA weather camera station located at Lake Clark Pass West about 30 minutes before the pilot departed from LHD. These weather cameras are located about 10 miles east of the accident site and an elevation of 261 ft as shown in figure 5. Figure 6, figure 7, and figure 8 were taken prior to the pilot's departure from LHD and indicated complete mountain obscuration conditions with low visibility underneath the overcast cloud layer with all the higher terrain references obscured by clouds. Figure 5 – Map of the closest FAA weather camera stations and the accident site (courtesy of the NTSB). Figure 6 – FAA weather camera image, Lake Clark Pass West – NorthEast, 0731 (courtesy of the FAA). Figure 7 – FAA weather camera image, Lake Clark Pass West – East, 0734 (courtesy of the FAA). Figure 8 – FAA weather camera image, Lake Clark Pass West – South, 0738 (courtesy of the FAA). The TPO METAR observation at 0958 (about 35 minutes after the accident) included calm wind, 15 statute miles visibility, a broken ceiling at 500 ft agl, overcast at 2,000 ft agl, temperature 57°F, dew point 55°F, altimeter 29.96 inches of mercury with remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass). Figure 9, figure 10, and figure 11 were captured from the FAA weather camera station located at Lake Clark Pass West, about the time of the accident. These three figures, similar to the images captured prior to the flight's departure, indicated complete mountain obscuration conditions with low visibility underneath the overcast cloud layer with all the higher terrain refences obscured by clouds. Figure 9 – FAA weather camera image, Lake Clark Pass West – NorthEast, 0921 (courtesy of the FAA). Figure 10 – FAA weather camera image, Lake Clark Pass West – East, 0926 (courtesy of the FAA). Figure 11 – FAA weather camera image, Lake Clark Pass West – South, 0918 (courtesy of the FAA). A witness, who was a pilot and lived off Lake Clark near Port Alsworth reported that on the morning of the accident, conditions were "very foggy" with about ½ mile visibility until 0830 when the fog started to break up. He reported that by 0930, the sun was "breaking through" over Lake Clark. He departed for Anchorage in his airplane about 1000 and climbed to 4,500 ft over the fog and scattered clouds. He observed that there was still "quite a lot of fog" around which extended through Lake Clark Pass. He estimated that there was about a 300 ft ceiling under the fog in Lake Clark Pass. Accident Weather Flight Planning No record was found of the pilot obtaining an official weather briefing from an FAA Flight Service Station or any Direct User Access Terminal Service (DUATS) before the flight. Prior to the flight departing, the office manager checked two sources of cameras. The office manager checked a private camera in a residential area of Port Alsworth and observed "bright blue sky." The office manager checked the FAA weather camera station located at Lake Clark Pass West and he noticed it had "some fog" but he reported, "it looked like it was just fog right over the camera because everywhere else was blue sky." The office manager also reviewed a weather report he received from the Kautumn Lodge that morning, with the destination reporting "great flying weather." The office manager reported that him and the pilot did not assess the METAR issued for TPO that morning prior to the flight departing. The chief pilot reported that he also checked the weather at the time the pilot was conducting flight planning and did not notice any weather of concern. He further reported that, based on the weather information that he obtained, he felt that there were no weather conditions present for the flight that the pilot could not handle. Weather Flight Planning Procedures FAA Operations Specification A010, Aviation Weather Information, stated that the operator was approved to use NWS for those United States and its territories located outside of the 48 contiguous States, and an Enhanced Weather Information System to obtain and disseminate aviation weather information for the control of flight operations. The Regal Air GOM discussed weather planning procedures for company pilots and stated that, before the flight to each new destination, the pilot will use whatever means he/she deems appropriate for obtaining current weather, including FAA Flight Service, DUATS or National Oceanic and Atmospheric Administration websites, or calling the destination for a current analysis of the weather. The GOM stated that the decision to embark on a flight was at the discretion of the PIC should poor weather exist; but that no flight was to be flown in weather below federal aviation regulations allowable minimums. The Regal Air GOM did not require pilots or individuals in operational control roles to receive an official weather briefing; nor was there any requirement for the individual exercising operational control and the pilot to jointly assess current or forecast weather conditions for a flight. FAA Advisory Circular (AC) 00-45H Aviation Weather Services discusses weather briefings and states in part: Prior to every flight, pilots should gather all information vital to the nature of the flight. This includes a weather briefing obtained by the pilot from an approved weather source, via the Internet, and/or from an flight service station (FSS) specialist. Refer to the NTSB Weather Study in the public docket for additional information. Pilot The operator's pilot training records showed no deficiencies and indicated that the pilot had completed all required training and was current, including a competency check ride on May 22, 2017. This was the pilot's first season working for the operator as a pilot and his first season as a pilot in Alaska. All his experience for the operator were based out of LHD as a dockhand for two summer seasons. The pilot was qualified and current to fly the wheel and float-equipped Cessna 206 and the float-equipped de Havilland DHC-2. The pilot completed all the operator's required initial training in early to mid-May 2017. According to the operator, at the time of the accident the pilot had 20 hours total of actual instrument experience and 84 hours total of simulated instrument experience. Director of Operations The director of operations (DO), is listed in the Regal Air General Operations Manual (GOM) as the president and vice-president/secretary of the company. The DO is also the owner of the company. This was the DO's 18th year working for the company and was his 11th year working as a pilot and as the DO for the company. All his experience for the operator was based out of LHD. The DO was qualified and current to fly the wheel/ski/float-equipped Cessna 206, the wheel/ski/float-equipped de Havilland D