Background
A company flight coordinator briefed the pilot before departure that most flights to the intended destination had been cancelled that morning due to poor weather and that one pilot had turned around. No record was found of the pilot reviewing weather information before the flight; had she done so, she would have seen that conditions were marginal visual flight rules to instrument flight rules.
Flight and Accident
The pilot departed on a scheduled commuter flight with four passengers, expecting a 20-minute flight. Automatic dependent surveillance-broadcast data showed the airplane flew farther north than the typical track and did not turn south toward the destination after crossing a channel. Onboard multi-function display data indicated a series of erratic pitch-and-roll maneuvers as the airplane approached mountainous terrain before impacting trees and terrain. Post-accident examination revealed no mechanical malfunctions. One passenger reported heavy turbulence, layers of fog and clouds, and rain. Based on weather reports, the passenger statement, and the flight's erratic movements, it is likely the flight encountered instrument meteorological conditions and the pilot lost situational awareness.
Operational Control and Procedures
The company's General Operations Manual (GOM) delegated operational control to the flight coordinator, and both the flight coordinator and pilot-in-command were jointly responsible for preflight planning, including completing a flight risk assessment (FRA) form. The pilot did not fill out the form. The flight coordinator did not discuss all risks and weather conditions with the pilot, contrary to the GOM. When the flight coordinator did not receive a completed FRA, he did not stop the flight from departing, contrary to company policy. By not completing an FRA, the total risks were likely not adequately assessed. Interviews and a review of FRA forms revealed that company personnel lacked fundamental knowledge of operational control. The company provided no formal flight coordinator training, and no formal method existed to document qualifications.
Regulatory Oversight
The previous Federal Aviation Administration (FAA) principal operations inspector stated that the company used minimum regulatory standards for ceiling and visibility and had no company minimums; a 500-foot ceiling and 2-mile visibility would not allow for a power-off glide to land. The current FAA principal operations inspector was also aware that the company operated contrary to regulatory standards for gliding distance to shore. A post-accident FAA surveillance inspection noted deficiencies in the company's operational procedures, but the FAA did not hold the company accountable for correcting them. If the FAA had conducted an investigation or enforcement action before the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained.
Medallion Shield Status
The company held a Medallion Shield but voluntarily suspended that status while retaining "Star" status and continuing to advertise as a Shield carrier. Medallion stated there would be no official communication to the FAA regarding the suspension. Medallion advertises that Shield status involves FAA recognition of higher safety standards; withholding information about the suspension seems contrary to safety.
Probable Cause
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. Also contributing to the accident was the Federal Aviation Administration's failure to hold the company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.