History of Flight
On January 29, 2019, about 1811 Alaska standard time, a Raytheon Aircraft Company B200 airplane, N13LY, was destroyed when it impacted the ocean waters of Frederick Sound near Kake, Alaska. The pilot, flight paramedic, and flight nurse were presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 air ambulance flight by Guardian Flight LLC.
The flight departed Ted Stevens Anchorage International Airport (ANC) at 1604 on an instrument flight rules (IFR) flight plan destined for Kake Airport (AFE). At 1806:07, the radar controller cleared the pilot for the RNAV runway 11 approach to AFE, which the pilot confirmed. At 1807:45, the controller advised the pilot to change frequency, which the pilot also confirmed. No further communications were received from the accident flight.
Archived radar and ADS-B data showed the airplane crossed the CEMGA waypoint at about 7,000 ft msl, then turned northeast and crossed ZOLKO at about 5,000 ft msl. It initiated a gradual descent toward JOJOE. At about 1810, between ZOLKO and JOJOE, the airplane entered a right turn toward a southerly heading and began a rapid descent, losing about 2,575 ft in 14 seconds. The last radar data point at 1810:36 showed the airplane at 1,300 ft msl, heading 143°, with a ground speed of 174 knots.
A witness at the destination airport, who was scheduled to meet the airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company.
The airplane impacted Frederick Sound. On January 30, debris was located about 22 miles west of Kake near Point Gardner in Chatham Strait.
Personnel Information
According to the operator's training records, the pilot completed initial training at Guardian Flight and was eligible for duty as a pilot-in-command in a B200 on May 15, 2015. His personal logbook showed a total flight time of about 16,878 hours, including 1,937.9 hours of actual IFR, 1,371.5 hours of simulated IFR, 3,720.2 hours of night time, and 12,559.2 hours cross country. He had accumulated about 1,644.5 hours in the accident airplane make and model since starting with the company. His most recent airman competency/proficiency check was completed on October 11, 2018.
Records indicated that on January 26, the duty day started at 0600 and ended at 1800 with no flying. On January 27, duty started at 0600, ended at 1830, with 2.4 flight hours. On January 28, duty started at 0600, ended at 1800, with 1.5 flight hours. On the day of the accident, the duty start time was not recorded, but Guardian Flight indicated it started at 0600 and he flew about 2.5 hours prior to the accident flight.
Aircraft Information
The Raytheon Aircraft Company B200 was a six-seat, low-wing, multiengine airplane manufactured in 2000. It was equipped with two tandem LifePort stretcher systems and Aerosleds installed per supplemental type certificate No. SA00273WI. The cockpit had two flight crew seats. The cabin had the stretcher systems on the right side and three passenger seats on the left side (two forward-facing, one aft-facing). Maintenance was performed per Beechcraft Super King Air 200 Series Maintenance Manual.
Wreckage and Impact Information
The airplane impacted the ocean waters of Frederick Sound. On March 19, 2019, a remote operated vehicle (ROV) located the wreckage at a depth of about 500 ft. A cone-shaped debris field spanned about 1,650 ft on a bearing of 45°, with lighter debris farther northeast due to ocean current.
From March 22 to 26, 2019, recovery crews recovered most major components from the ocean floor and transported them to Juneau, Alaska. Unrecovered items included the right aileron, portions of both wings, and portions of both elevators.
The cockpit and instrument panel exhibited extensive impact damage. The cabin floor separated from the structure; no seats were within the airplane. The left wing was fragmented but relatively intact; the outboard section separated but remained attached by control cables. The left inboard flap actuator was extended 2.55 inches (about 0°–10° extended); the left outboard flap actuator was extended 2.95 inches (about 10° extended). Both left flap actuator flex drive cables were fractured.
The right wing was heavily fragmented into three main sections. The right inboard flap actuator was extended 2.10 inches (fully retracted); the outboard actuator was extended 1.70 inches (fully retracted). The right aileron was not recovered.
The vertical stabilizer separated, with leading-edge impact damage; the rudder remained attached. The right horizontal stabilizer, right elevator, and a section of the left elevator separated; parts were not recovered.
Cockpit flight crew seats were recovered with seat belts unbuckled. One passenger seat was recovered with the belt unbuckled; the base of another passenger seat was recovered without the seat back or belt. One rear passenger seat was not recovered.
Both engines exhibited no fire damage, contamination, or evidence of malfunction. Internal components showed contact signatures consistent with developing power at impact. No mechanical failures precluding normal operation were found.
Both propeller hubs fractured at the shaft. Left propeller blades had torsional twisting, leading-edge gouging, and one missing tip. Right propeller blades also had twisting and gouging, and one tip was missing.
Control continuity could not be established due to numerous fractures and missing cabling and flight control surfaces.
Additional Information
SSCVR Test
The Beechcraft Pilot's Operating Handbook and FAA Approved Flight Manual Supplement for the Fairchild A100S SSCVR stated that the SSCVR self-test must be successfully accomplished prior to flight. The Guardian Flight Normal Procedures checklist did not contain an item for the SSCVR self-test.
FAA Order 8900.1 and SAFO 06019 emphasized the importance of CVR functional testing.
Flight Recorders
The airplane was not equipped with a flight data recorder (FDR), nor was it required. It was equipped with a Fairchild A100S solid-state cockpit voice recorder (SSCVR), but the last audio recorded was from May 15, 2015.
Medical and Pathological Information
As of the report, the remains of the pilot and the two additional crewmembers had not been located; therefore, no pathological or toxicology information existed. At the pilot's last medical examination, no concerns were reported, and no significant issues were identified by the medical examiner.