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Safety Recommendation Details

Safety Recommendation A-18-020
Details
Synopsis: On October 2, 2016, about 1157 Alaska daylight time, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport (PATG), Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. The scheduled commuter flight was operated under visual flight rules (VFR) by Hageland Aviation Services, Inc., Anchorage, Alaska, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. The National Transportation Safety Board’s (NTSB) investigation determined that instrument meteorological conditions (IMC) were likely in the vicinity of the accident site at the time of the accident. The flight departed Quinhagak Airport, Quinhagak, Alaska, at 1133 and was en route to PATG. Data available for the accident flight showed that, after departure in visual meteorological conditions, the airplane proceeded along a generally direct route toward the destination at an altitude of about 1,000 ft mean sea level (msl), which resulted in terrain clearances between 500 and 700 ft above ground level (agl). During the last 4 minutes of the flight, the airplane climbed as it approached the mountain ridge that it eventually struck at an elevation of about 2,300 ft msl after having likely entered IMC. The airplane was equipped with a Class B terrain awareness and warning system (TAWS) that had an en route required terrain clearance (RTC) of 700 ft agl; flight at altitudes below the RTC (and not within 15 miles of an airport, given certain criteria) would result in TAWS terrain alerts. Hageland flights operated under VFR were allowed to fly as low as 500 ft agl, as was seen with this flight, which was flown en route below the TAWS alerting threshold. The system was equipped with a terrain inhibit switch that allowed the pilot to manually inhibit all TAWS aural and visual caution and warning alerts. A TAWS simulation that used an estimated flightpath for the accident airplane (assuming a level cruise altitude between known data points and a climb after the last data point to the accident elevation) showed that, if the alerts were not inhibited, the TAWS would have provided continuous alerts for most of the assumed flight. The investigation concluded that the TAWS alerts were likely inhibited for most, if not all, of the flight, eliminating a margin of safety.
Recommendation: TO HAGELAND AVIATION: Incorporate into your crew resource management training program ground, simulator, and flight training that define second-in-command responsibilities for dual-pilot operations, including, but not limited to, (1) the use of standard operating procedures and execution of pilot flying/pilot monitoring duties as outlined in Advisory Circular 120-71B and (2) aeronautical decision-making and judgment scenarios that are tailored to Hageland’s flight operations and aviation environment, including communications and teamwork with Operations Control Center personnel.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Togiak, AK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ANC17MA001
Accident Reports: Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD
Report #: AAR-18-02
Accident Date: 10/2/2016
Issue Date: 4/26/2018
Date Closed:
Addressee(s) and Addressee Status: Hageland Aviation Services, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Hageland Aviation Services, Inc.
Date: 9/19/2018
Response: We note that you have created a new Cessna 208 flight standards manual, which addresses dual-pilot operating procedures and policy, including pilot-in-command and second in-command duties, pilot flying and pilot not flying/pilot monitoring duties, briefings for dual-pilot crews, and dual-pilot checklists. We also note that you are in the process of revising your operations training manual (OTM), which will address initial and recurrent simulator training, communications training, and aeronautical decision-making and judgment training. In addition, we are pleased to learn that you plan to require your operational control agents to obtain Part 65 aircraft dispatcher certificates. We believe that your actions thus far, as well as your planned revisions to the OTM, are responsive to this recommendation. Pending our review of the revised OTM, Safety Recommendation A-18-20 is classified OPEN--ACCEPTABLE RESPONSE.

From: Hageland Aviation Services, Inc.
To: NTSB
Date: 7/9/2018
Response: -From David H. Pflieger, Jr., President and CEO, Ravn Air Group: Hageland has created a new Cessna 208 Flight Standards Manual that has already been distributed to all line check airmen and new hire SICs (those hired since March) and all other pilots will get this manual in September once they have completed recurrent training. This new manual contains, among other things, dual-pilot operating procedures and policy. A copy of this new manual is attached. Please note that the complete manual also contains a section specifically applicable to the Grand Caravan EX, but we omitted that section from the attachment to make the file size more manageable. The Cessna 208 Flight Standards Manual contains detailed sections addressing dual-pilot operations, the respective duties of the PIC and SIC, and the PF (Pilot Flying) and PNF/PM (Pilot Not Flying/Pilot Monitoring), briefings for two pilot crews, and dual-pilot checklists. These sections are included in both Normal Procedures (Chapter 2) and Emergency and Abnormal Procedures (Chapter 3). The new policies and procedures will be included in our ground school training per our Operations Training Manual (OTM), which is currently undergoing revision. In addition, these items will be incorporated into a simulator-training curriculum containing scenarios for both initial and recurrent training, and we will provide them to the NTSB as soon as they are available. We are also revising our OTM to enhance our pilot training with respect to communications with crewmembers, operational control personnel, Air Traffic Control, and passengers. The training specifically includes aeronautical decision-making and judgment training tailored to Hageland's flight operations and aviation environment, including remote operations, high altitude operations, and weather considerations, among other things. (In addition, we intend to require that our operational control agents obtain Part 65 aircraft dispatcher certificates, which will further assist our flight crews with respect to communications, aeronautical decision making, and judgment.) We anticipate having a new OTM approved by the FAA in August/September. The lesson plan is set forth in Pages 3.15 and 3.16 of the OTM, and the requirement for PICs and SI Cs to undergo this training as part of their initial training, recurrent training and, if necessary, requalification training, is contained in Page 3.2 of the OTM. The specific training modules can be taught during flight and/or simulator training, per Page 1. 7 of the OTM. These pages are attached. These enhancements are based on industry best practice guidance, including Advisory Circular 120-71B. If you have any questions, please let me know.

From: NTSB
To: Hageland Aviation Services, Inc.
Date: 4/26/2018
Response: On April 17, 2018, the NTSB adopted its report, Collision with Terrain, Hageland Aviation Services, Inc., dba Ravn Connect Flight 3153, Cessna 208B, N208SD, Togiak, Alaska, October 2, 2016, NTSB/AAR-18/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the Safety Recommendations, one is issued to Hageland Aviation Services, Inc., and can be found on page 72 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response.