A year and a half after Hageland Aviation flight 3153 flew into a mountain on its way to Togiak from Quinhagak, the National Transportation Safety Board (NTSB) has released its reports on the crash along with sweeping recommendations.
The NTSB investigation also took a look at why Alaska continues to have the highest small plane accident rates in the country, and the Board has recommended major changes in the way that the Federal Aviation Administration (FAA) oversees the state’s numerous airlines that use small planes commercially.
The question at the center of the investigation is why an experienced pilot, who had flown the route many times, flew his Cessna 208B Caravan into a mountain outside of Togiak, killing all three on board. The NTSB’s investigators found no evidence that there was anything wrong with the pilot or the plane. They call this type of accident a “controlled flight into terrain.” It is usually caused by weather closing in, making it impossible for pilots to see where they are flying, and Alaska has the highest rates of such accidents in the nation.
This week, NTSB Chairman Robert Sumwalt announced that Alaska needed to upgrade its aviation infrastructure; everything from better weather reporting at tiny airstrips, to communications and instrumentation so that pilots would have the capacity to fly in remote Alaska with Instrument Flight Rules (IFR). Anything else, he said, would be “biting around the fringes of the problem.”
Investigators found that this accident, like others of its kind, was the result of the pilot making a bad decision. How he came to make that decision? There was enough blame to go around. Hageland Aviation (now known as Ravn Connect) routinely allows pilots to turn off the instruments that would warn them they were flying too close to the ground.
That was one of the many problems that drove over 20 recommendations that the NTSB made for changes. Another problem is that the FAA has not required the company that makes that warning system to tweak it to better meet the needs of operators like Hageland. Since the accident the company has voluntarily changed its instruments and future warning systems will be more effective for planes flying at low altitudes, but there are no requirements or commitments to retrofit the units already in use.
The NTSB continues to push the FAA to do more consistent and stringent oversight of small fixed-wing operations. It also said that unless the existing voluntary Medallion Program to assure safety goes beyond just a paper audit, it will not be an effective safety organization. The facts released by the staff indicate that over a period of time, eight of the 10 “controlled flight into terrain” accidents occurred to planes flown by Medallion “shield” and “star” members.
Board members amended their report during the meeting, making it more stringent to push for improving Alaska's aviation infrastructure to the level enjoyed by the lower 48, and to require flight data recorders on small planes. The board also pushed for upgraded training to better reflect conditions in Alaska.
At no point did the NTSB investigators indicate that Hageland’s pilots are being pressured to fly in unsafe conditions. They even complimented the company for voluntarily going further in their training than the level required by the FAA. The board did indicate that the FAA’s failure to provide adequate oversight of that training, along with other issues, played a large part in the conditions that have led to Alaska’s high number of aviation accidents.