No fatalities

22 Nov 2013: BEECH 1900C (N575X) — ERA Alaska — Deadhorse, AK

Deadhorse, AK, United States

On 22 Nov 2013, a BEECH 1900C (registration N575X) operated by ERA Alaska was involved in an aviation accident near Deadhorse, AK. No fatalities were reported. Investigators recorded the probable cause as: The captain’s decision to initiate a visual flight rules approach and attempted landing into an area of instrument meteorological conditions, which resulted in the airplane touching down short of the runway. This summary draws on records from NTSB; 15 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On November 22, 2013, a Hageland Aviation Services Beech 1900C landed short of the runway at Badami Airport, Alaska, resulting in substantial damage. No injuries were reported among the two pilots and one passenger.

Accident Overview

On November 22, 2013, at about 1330 Alaska standard time, a twin-engine turboprop Beech 1900C airplane, registration N575X, sustained substantial damage during landing at Badami Airport, located 29 miles east of Deadhorse, Alaska. The airplane was operated by Hageland Aviation Services, Inc., as a visual flight rules on-demand charter flight under 14 CFR Part 135. The airline transport certificated captain, commercial certificated first officer, and sole passenger were not injured. Instrument meteorological conditions were reported at the time of the accident, and company flight-following procedures were in effect. The flight originated from Deadhorse, Alaska, about 1315.

Flight Crew Accounts

According to the first officer, prior to departure Badami reported visibility of 1 1/2 statute miles (sm), scattered clouds, and blowing snow. After departure, Badami reported visibility had deteriorated to 3/4 sm in blowing snow. The captain then assumed all radio communications. The captain informed the Badami weather observer that at least 1 sm visibility was needed to land, and if weather did not improve, the flight would return to Deadhorse or hold. The observer later reported visibility had improved to 1 sm in blowing snow. The captain instructed the first officer to load the final segment of the instrument approach into the GPS and set the radar altimeter to 100 feet, but did not use or fly the instrument approach.

The captain stated that flight visibility was unrestricted and he had the runway environment in sight 20 miles from the airport. The approach was normal until he experienced a sinking sensation and realized he was too low. The first officer reported discomfort during the approach and voiced concerns multiple times, but the captain assured him they were fine. On short final, the first officer asserted "watch out" as it appeared they would land short. The airplane touched down short of the runway, and the main landing gear impacted the elevated edge of the runway surface. The right main gear separated, and the airplane slid along the runway, sustaining substantial damage to the fuselage and right elevator. The captain reported no preaccident mechanical malfunctions or failures.

Weather Conditions

The National Oceanic and Atmospheric Administration-certified weather observer at Badami reported that he notified the pilots via radio that he could occasionally see the cold storage camp 1 1/4 miles away, but did not consistently have 1 mile visibility. He described the weather as "bad" and at times could not see the runway. He instructed the pilots to use their own judgment.

Weather observations at Badami at 1328 and 1332 reported wind 120 degrees, variable 060 to 210 degrees, at 30 knots, visibility 1/2 sm in heavy blowing snow, broken clouds at 1,000 feet, and temperature -16 degrees F.

Operational Control Issues

The company flight coordinator, who had operational control and released the flight, reported she had been with the company for 6-7 years but had not completed flight coordinator training. She stated that before departure the captain said, "it's getting worse, we need to go now." The flight was assigned a risk level of 2 on a 4-tiered scale. She did not discuss risks or weather conditions with the crew.

According to the company's General Operations Manual, the flight coordinator and pilot-in-command were jointly responsible for preflight planning, flight delay, and release. Approximately 80 flight coordinators and 96 pilots were allowed to exercise operational control. The company's FAA-approved training manual required flight coordinator training, consisting of 8 initial classroom hours and 3-4 recurrent hours.

The company used a basic risk assessment form with levels 1-4. Level 2 required a discussion between PIC and flight coordinator about risks. No signoff was required, and the form was not integrated into company manuals. The risk assessment was presented to and accepted by the FAA but not incorporated into the GOM or training program.

FAA Inspections and Noncompliance

From July to October 2013, five operational control inspections by FAA aviation safety inspectors noted deficiencies in training, risk management, and operational control procedures. Enforcement Information System records indicated FAA inspectors observed 11 instances of noncompliance related to flight operations between July 2009 and November 29, 2013; all investigations were closed with no action greater than administrative action.

Cockpit Voice Recorder and Flight Data Recorder

On November 22, the NTSB requested that the operator secure the CVR and FDR. The director of maintenance stated both recorders would be secured by maintenance personnel on scene. On December 5, it was discovered that the CVR had not been secured and engine maintenance runs had been performed on the accident airplane. The CVR and FDR were sent to the NTSB laboratory. The CVR audio was overwritten by maintenance personnel; no listening group was convened and no transcript created. The FDR readout showed the accident sequence consistent with crew reports.

Contributing factors

Causes

Pilot

Other contributing factors

OperatorFAA/RegulatorContributed to outcome