NTSB-AAR-78-5 5. 5.Report Date

NTSB-AAR-78-5 5 . Title and Subtitle Aircraft Accident Report - Alaska Aeronautical Industries, Inc., DeHavilland DHC-6-200, N563MA, Near Iliamna, Alaska, September 6, 1977 7. Author(s)

I

3 . Performing Organization Name and Address 1 10.Work Unit No.

5.Report Date May 4, 1978

6. Performi ng Organ i z a t ion Code

8.Performing Organization Report No.

National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594

1g.Security Classification 20.Security Classification (of this report) (of this page)

UNCLASSIFIED UNCLASSIFIED

2202B 1 1 .Contract o r Grant No.

21.No. of Pages 22.Price

28

13.Type of Report and Period Covered

12.Sponsoring Agency Name and Address Aircraft Accident Report

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594

September 6, 1977-

14.Sponsoring Agency Code

I

15.Supplementary Notes

16 .Abstract About 1452 Alaska daylight time, on September 6, 1977, Alaska Aeronautical

Industries, Inc., Flight 302 crashed into a glacier on the southwest side of Mt. Iliamna,' Alaska, about 7,000 feet above mean sea level. The aircraft crashed in level flight in instrument meteorological conditions while en route from Iliamna, Alaska, to Anchorage, Alaska. There were 2 crewmembers and 11 passengers aboard the aircraft; there were no survivors. The aircraft was destroyed. Because of the rapidly changing environmental conditions on the glacier face, recovery of bodies or wreckage was not possible.

The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew to use proper navigational procedures for the route to be flown, especially their failure to use the available backup means of navigation to verify the position and the progress of the flight.

17. Key Words Level flight; instrument meteorological conditions; low frequency airways; intersections; ADF, VOR/DME, cockpit discipline; false bearing; flightplan.

Identifier: DeHavilland DHC-6-200 Accident

18.Distribution Statement This document is available to the public through the National Technical Informa- tion Service, Springfield, Virginia 22152

TABLE OF CONTENTS

Page

1. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.17.1 1.17.2 1.17.3 1.17.4 1.17.5

1.17.6 1.17.7 1.18 2. 3. 3.1 3.2 4. 5.

. . . . . . . . . . . . . . . . . . . . . . 1 Synopsis. . . . . . . . . . . . . . . . . . 1 Factual Information History of the Flight . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . 3 Injuries to Persons . . . . . . . . . . . . . . . . . 3 Damage to Aircraft. . . . . . . . . . . . . . . . . . . . . 3 OtherDamage. . . . . . . . . . . . . . . . . 3 Personnel Information . . . . . . . . . . . . . . . . 3 Aircraft Information.

8 . . . . . . . . . . . . . . . . . 9 Aids to Navigation. . . . . . . . . . . . . . . . . . . . 10 Communications. . . . . . . . . . . . . . . . . 10 Aerodrome Information Flight Recorders. . . . . . . . . . . . . . . . . . . 10

10 Wreckage and Impact Information . . . . . . . . . . . 11 Medical and Pathological Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Survival Aspects. . . . . . . . . . . . . . . . . . . 11 . . . . . . . . . . . . . . . . . 11 Additional Information. . . . . . . . . . . . . . . . 11 Flight Information Publication, Alaska Supplement . . 11 Federal Aviation Administration Surveillance. . . . . Seismograph Recording . . . . . . . . . . . . . . . . 12

in Command . . . . . . . . . . . . . . . . . . . . 12 Company Maintenance Practices . . . . . . . . . . . . 13 Company Training Practices. . . . . . . . . . . . . . 13 New Investigation Techniques. . . . . . . . . . . . . 13 Analysis. . . . . . . . . . . . . . . . . . . . . . . 13

Meteorological Information. . . . . . . . . . . . . .

Fire.

Tests and Research.

12

14 CFR 135.136 - Flight and Duty Time Limitations . . 12 14 CFR 91.3 - Responsibility and Authority of the Pilot

. . . . . . . . . . . . . . . . . . . . . 20 . . . . . . . . . . . . . . . . . . . . . . 20 . . . . . . . . . . . . . . . . . . . 21 Safety Recommendations. . . . . . . . . . . . . . . . 21 Appendixes. . . . . . . . . . . . . . . . . . . . . . 23 Appendix A - Investigation and Hearing. . . . . . . 23 Appendix B - Personnel Information. . . . . . . . . 24 Appendix C - Aircraft Information Appendix D - Probable Route Chart . . . . . . . . . 27

Conclusions Findings. Probable Cause.

. . . . . . . . . 25

ii

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

Adopted: May 4, 1978

ALASKA AERONAUTICAL INDUSTRIES, INC. DEHAVILLAND DHC-6-200, N563MA

NEAR ILIAMNA, ALASKA SEPTEMBER 6, 1977

SYNOPSIS

About 1452 Alaska daylight time, on September 6, 1977, Alaska Aeronautical Industries, Inc., Flight 302 crashed into a glacier on the southwest side of Mt. Iliamna, Alaska, about 7,000 feet above mean sea level. The aircraft crashed in level flight in instrument meteorological conditions while en route from Iliamna, Alaska, to Anchorage, Alaska. There were 2 crewmembers and 11 passengers aboard the aircraft; there were no survivors. The aircraft was destroyed. Because of the rapidly changing environmental conditions on the glacier face, recovery of bodies or wreckage was not possible.


1. FACTUAL INFORMATION

1.1 History of the Flight

On September 6, 1977, Alaska Aeronautical Industries, Inc., Flight 302, a DeHavilland DHC-6-200 (N563MA), operated as a scheduled flight from Iliamna, Alaska, to Anchorage, Alaska. The flight was to be conducted in accordance with 14 CFR 135.

Flight 302 departed Iliamna at 1419 11 with 11 passengers and 2 crewmembers on board. It was cleared to Anchorage on an instrument flight rules (IFR) flight plan via the low fre uency airways--Red

(Green 8) to Anchorage. (See Appendix D.) The flight was to maintain Airway 99 (Red 99) to the Kakon Intersection 2 9 , and then Green Airway 8 7,000 ft. 21

1/ All times herein are Alaska daylight, based on the 24-hour clock. - 2/ 3/ All altitudes herein are mean sea level unless otherwise indicated.

- The intersection of Red Airway 99 and Green Airway 8.

-

- 2 -

A t 1425:20, t h e f l i g h t c r e w of F l i g h t 302 e s t a b l i s h e d r a d i o c o n t a c t w i t h Anchorage A i r Route T r a f f i c Cont ro l Center ' s (Anchorage Center ) D2 nonradar .$/ s e c t o r c o n t r o l l e r . w a s l eve l a t 7,000 f t and t h a t they es t imated a r r iva l a t Kakon I n t e r s e c t i o n a t 1434.

They r e p o r t e d t h a t t h e f l i g h t

A t 1428:35, Anchorage Center reques ted t h e f l i g h t ' s estimate f o r i t s a r r iva l a t Homer, Alaska 21. es t imated t o be over Homer a t 1515.

The f l i g h t c r e w responded t h a t they

The f l i g h t c r e w of F l i g h t 302 d i d n o t make r a d i o c o n t a c t when they were over Kakon I n t e r s e c t i o n ; however, a t 1439:40 they reques ted of Anchorage Center, "302, w e would l i k e t o f i l e Green 8 and i n t e r c e p t t h e 192' b e a r i n g from Wildwood." 61 F i f t e e n seconds l a t e r , Anchorage Center c l e a r e d t h e f l i g h t t o proceed along t h e new r o u t e of f l i g h t and t o remain a t 7,000 f t .

A t 1440:50, t h e f l i g h t c r e w of F l i g h t 302 advised , "302, we-- w e ' l l estimate C l a m s 71 a t 15 p a s t t h e hour." t h e advisory . This w a s t h e l a s t known r a d i o t ransmiss ion from F l i g h t 302.

Anchorage Center acknowledged

A t 1452:08, t h r e e a b r u p t , a u d i b l e sounds were recorded on t h e Anchorage Center t a p e of incoming air-to-ground communications wi th F l i g h t 302. These sounds were similar t o t h o s e produced by a carrier frequency t h a t w a s heard dur ing t h e a c t i v a t i o n of F l i g h t 302 ' s r a d i o t r a n s m i t t e r d u r i n g earlier r a d i o communications w i t h t h e Center .

A f t e r several unsuccessfu l a t t e m p t s t o c o n t a c t F l i g h t 302 by several a i r t r a f f i c , c o n t r o l f a c i l i t i e s between I l iamna and Anchorage and a f t e r t h e f l i g h t could n o t b e d e t e c t e d on r a d a r i n t h e areas where r a d a r coverage w a s a v a i l a b l e , Anchorage Center i n i t i a t e d t h e r e q u i r e d a c t i o n s t o a l e r t and n o t i f y a p p r o p r i a t e a u t h o r i t i e s of a p o s s i b l e a i r c r a f t a c c i d e n t . U.S. A i r Force s e a r c h and rescue a i r c r a f t l o c a t e d t h e wreckage s i t e a t 1643 on September 7 , 1977. The a i r c r a f t had s t r u c k a g l a c i e r f a c e on t h e southwest s i d e of M t . I l iamna 81 a t t h e 7,000 f t e l e v a t i o n .

- 4 / I 5 /

There w a s no f l i g h t - f o l l o w i n g r a d a r a v a i l a b l e i n t h e I l iamna area. A VOR a long , b u t n o t a s s o c i a t e d w i t h t h e formation o f , Green 8 used f o r VOR n a v i g a t i o n a l guidance, f o r r e p o r t i n g , and f o r o t h e r a i r t r a f f i c c o n t r o l purposes . It i s l o c a t e d about 6 nmi n o r t h of Kachemak n o n d i r e c t i o n a l beacon (NDB) on Green 8. Wildwood NDB--part of t h e low a l t i t u d e airway system l o c a t e d 43 nmi s o u t h of Anchorage a long Green 8. I t is coloca ted wi th t h e Kenai VOR which w a s o u t of s e r v i c e on t h e day of t h e a c c i d e n t . Clams I n t e r s e c t i o n i s a p o i n t on t h e 192' b e a r i n g from Wildwood NDB l o c a t e d about 23 nrni n o r t h e a s t of t h e i n t e r s e c t i o n of t h a t Wildwood b e a r i n g and Green 8. M t . I l iamna i s l o c a t e d about 58 nmi e a s t - n o r t h e a s t of I l i amna A i r p o r t , about 29 nmi n o r t h of Green 9 a t i t s n e a r e s t p o i n t , and about 25 nrni northwest of t h e 192. b e a r i n g from Wildwood NDB a t i t s n e a r e s t p o i n t .

- 6 /

- 7 /

- 8/

- 3 -

There were no survivors. Because of the rapidly changing environmental conditions on the glacier face of Mt. Iliamna, recovery of bodies and wreckage was not possible. (See figures lA, lB, 1C and 1D.)

The accident occurred during daylight hours in instrument meteorological conditions at 60'02'N latitude and 153'05'W longitude. There were no witnesses to the accident.

1.2 Injuries to Persons

1.3

In j ur ies

Fatal Nonfatal None

Damage to Aircraft

Crew - 2 0 0

Passengers Others

11 0 0

0 0 0

The aircraft was destroyed.

1.4 Other Damage

None

1.5 Personnel Information

The two crewmembers were properly certificated for this flight. (See Appendix B.) reported for duty about 0400 and had flown 5.4 hours before the takeoff from Anchorage for Iliamna.

On the day of the accident, both flight crewmembers

The crewmembers had received the flight training to qualify in the DeHavilland DHC-6-200. The company training manual outlined the applicable criteria for the training program which was, in part, contingent upon the new hire's past air taxi/commuter experience.

1.6 Aircraft Information

The aircraft was certificated and maintained in accordance with Federal Aviation Administration (FAA) requirements. weight and c.g. were within prescribed limits for takeoff. At the time of the accident, about 970 lbs of Jet A-1 fuel was onboard. (See Appendix C.)

The gross

The aircraft was not equipped with sufficient low frequency (ADF) navigational radio receivers for the flight from Iliamna to Anchorage.

- 4 -

Figure 1 A . M t . I l i amna.

F igu re 1 B . Glacial f i e l d .

- 5 -

Figure 1C. Impact point on ice cliff.

Figure 1D. Wreckage area and crevasses.

- 6 -

14 CFR 135.159(a) (5) states:

" ( a ) N o persons may o p e r a t e an a i r c r a f t under IFR o r i n extended over-water o p e r a t i o n s u n l e s s i t has a t least t h e fo l lowing r a d i o communications and n a v i g a t i o n a l equipment a p p r o p r i a t e t o t h e f a c i l i t i e s t o be used and a b l e t o t r ansmi t t o , and receive from, a t any p l a c e on t h e r o u t e , a t least one ground f a c i l i t y ... :

(5) Two independent r e c e i v e r s f o r nav iga t ion . "

I

The S a f e t y Board reques ted t h a t t h e FAA f u r n i s h an o f f i c i a l i n t e r p r e t a t i o n of t h i s r e g u l a t i o n . I n t h e i r r e p l y t h e FAA s t a t e d , "under t h e s e c i rcumstances ( those of t h i s a c c i d e n t ) , i t i s our opin ion t h a t o p e r a t i o n of t h e a i r c r a f t w i th only one low frequency n a v i g a t i o n a l r e c e i v e r a v a i l a b l e i n t h e a i r c r a f t d id n o t comply wi th t h e requirement i n 135.159(a)(5) , s i n c e t h a t r e g u l a t i o n r equ i r ed t h e a i r c r a f t t o have a t least two independent r e c e i v e r s f o r nav iga t ion , a p p r o p r i a t e t o t h e low frequency f a c i l i t i e s , t o be used on t h e p a r t i c u l a r r o u t e involved." S ta tements made by company personnel dur ing t h e acc iden t i n v e s t i g a t i o n and a t t h e p u b l i c hea r ing d i s c l o s e d t h a t t h e company and i t s f l i g h t crewmembers had t h e same unders tanding of t h e r e g u l a t i o n , and f l i g h t o p e r a t i o n s were t o be conducted accord ingly .

N563MA had only one low frequency, f ixed-card , 91 n a v i g a t i o n a l receiver i n s t a l l e d and o p e r a t i o n a l . It w a s , however, equipped wi th two o p e r a t i o n a l h igh frequency (VOR) r e c e i v e r s w i th d i s t a n c e measuring (DME) c a p a b i l i t y . were equipped i n t h i s manner. w i t h two ADF receivers.

About one-half of t h e Alaska Aeronaut ica l I n d u s t r i e s a i r c r a f t The remainder of t h e a i r c r a f t were equipped

Company p o l i c y w a s t o schedule t h e a i r c r a f t w i th two ADF r e c e i v e r s on t h e f l i g h t s t o I l iamna. This w a s t h e case on t h e day of t h e a c c i d e n t ; however, t h e a i r c r a f t o r i g i n a l l y scheduled had maintenance d i f f i c u l t i e s e a r l y i n t h e day. A d e c i s i o n w a s made by a company r e p r e s e n t a t i v e , whose r e s p o n s i b i l i t i e s d i d no t i nc lude the d i s p a t c h of a i r c r a f t , t o s u b s t i t u t e N563MA t o f l y t h e t r i p s of t h e o r i g i n a l l y scheduled a i r c r a f t , i nc lud ing t h e t r i p t o I l iamna. The c a p t a i n accepted t h i s d e c i s i o n .

- 9 / I n f ixed-card ADF nav iga t ion , O " ( 3 6 0 " ) remains under t h e l i n e a t t h e top of t h e ADF ins t rument i n s t e a d of t h e a c t u a l magnetic heading of t h e a i r c r a f t . The p i l o t must r e l y on t h e angu la r d i f f e r e n c e between t h e a c t u a l magnetic heading be ing flown and t h e needle on t h e ADF ins t rument which r e p r e s e n t s t h e heading t o t h e tuned ADF s t a t i o n . A t u r n t o t h e heading t o t r a c k inbound t o t h e s t a t i o n on a d e s i r e d bea r ing from t h a t s t a t i o n is no t made u n t i l t h e c o r r e c t angular r e l a t i o n s h i p i s e s t a b l i s h e d .

I n v e s t i g a t i o n r evea led t h a t t h e p rope r ly equipped a i r c r a f t o r i g i n a l l y scheduled f o r t h e I l iamna f l i g h t w a s r e p a i r e d and a v a i l a b l e f o r t h e f l i g h t . However, as f a r as could b e determined, t h e c a p t a i n w a s never informed of t h i s nor d i d h e i n q u i r e as t o t h e o t h e r a i r c r a f t ' s maintenance s ta tus .

I n t h e 30 days b e f o r e t h e a c c i d e n t , bo th t h e p i l o t ' s and t h e c o p i l o t ' s d i r e c t i o n a l gyro had been r e p o r t e d seven t i m e s by several company p i l o t s as having v a r i o u s o p e r a t i o n a l d i f f i c u l t i e s . These r e p o r t s recorded gyro p r e c e s s i o n rates of as much as 30" i n 15 minutes. Each r e p o r t showed t h a t c o r r e c t i v e a c t i o n e i t h e r w a s t aken o r w a s de layed because no replacement i t e m s were a v a i l a b l e . However, i n one case, a gyro mal func t ion w a s s igned o f f as c o r r e c t e d , when, i n f a c t , t es t imony a t t h e p u b l i c hea r ing r evea led t h a t no work had been accomplished on t h e i t e m .

According t o a s t a t emen t by t h e I l iamna F l i g h t Se rv ice S t a t i o n (FSS) s p e c i a l i s t on duty when N563MA w a s inbound t o I l iamna, t h e f l i g h t c r e w asked i f I l i amna had d i r e c t i o n f i n d i n g equipment because of ' 'erratic need le r ead ings on h i s ADF. I r e p l i e d t h a t t h e FSS ( I l iamna) had no DF equipment and t h a t I l i amna r a d i o beacon monitored good, minute l a t e r , he (N563MA) c a n c e l l e d IFR w i t h I l iamna V i l l a g e i n s i g h t . " A t t h e S a f e t y Board's p u b l i c hea r ing , t h e s p e c i a l i s t t e s t i f i e d t h a t he made no f u r t h e r i n q u i r i e s and t h e c a p t a i n made no f u r t h e r remarks concerning t h e ADF equipment onboard N563MA w h i l e t h e two t a l k e d a t t h e I l iamna FSS b e f o r e F l i g h t 302 depa r t ed I l iamna.

Approximately 1

1 4 CFR 135.60 r e q u i r e s a commuter a i r l i n e t o use an FAA- approved a i r c r a f t i n s p e c t i o n system. The system used by Alaska Aeronau t i ca l I n d u s t r i e s and approved by FAA is an equa l i zed maintenance maximum a v a i l a b i l i t y (EMMA) system. EMMA pe rmi t s a i r c r a f t i n s p e c t i o n t o b e completed i n a f i x e d number of i n s p e c t i o n t r i p s t o t h e maintenance f a c i l i t y . During t h e i n v e s t i g a t i o n and p u b l i c h e a r i n g , i t w a s d i scovered t h a t , a l though t h e EMMA i n s p e c t i o n s were completed on t i m e and recorded p r o p e r l y , t h e procedures used by t h e company t o record t h e l o c a l maintenance requi rements and work were n o t i n keeping wi th good recordkeeping p r a c t i c e s . A s a r e s u l t of t h e s e methods, i t w a s d i f f i c u l t f o r crewmembers t o be knowledgeable of p rev ious d iscrepancy r e p o r t s .

The i n v e s t i g a t i o n r evea led a l s o t h a t i t w a s d i f f i c u l t f o r t h e company p i l o t s t o de te rmine t h e maintenance s t a t u s of t h e a i r c r a f t they w e r e t o f l y on any s p e c i f i c day. The p i l o t s who w e r e t o f l y t h e f i r s t f l i g h t of t h e day on a n a i r c r a f t had t h e maintenance r eco rds a v a i l a b l e t o them because they went t o t h e a i r c r a f t a t t h e company hangar where t h e r eco rds were kep t . However, p i l o t s who f l ew those same a i r c r a f t l a t e r i n t h e day would have t o r e l y on v e r b a l in format ion about any a i r c r a f t problem because they boarded t h e a i r c r a f t a t t h e a i r p o r t t e r m i n a l about a m i l e from t h e company hangar. a i r c r a f t logbook w e r e kep t on t h e a i r c r a f t . n o t t o l e a v e "carry-over" items i n t h e a i r c r a f t logbook.

No r e c o r d s except t h e It w a s company procedure

- 8 -

1.7 Meteorological Information

The 1500 surface weather chart showed a cold front near the Anchorage-Homer-Kodiak line, with a moist, unstable west-southwest flow of air to the west of the front.

The 1500 850-millibar chart (about 5,000 ft) showed a deep low pressure system that was centered over Norton Bay, with strong southwesterly winds at King Salmon and strong south-southeasterly winds at Anchorage.

Surface weather observations made by the FSS specialists at Iliamna and Homer, both of whom are certified by the National Weather Service (NWS), were as follows:

I liamna

1400: 1,200 ft scattered; ceiling--estimated 2,500 ft broken, 4,000 ft overcast; visibility--20 mi; temperature--54'F; dewpoint-- 50'F; wind--210" at 1 2 kn; altimeter setting--29.58 in.Hg. Rain ended at 1335, breaks in the overcast.

1500: 2,500 ft scattered, 4,000 ft scattered; visibility-- 30 mi; temperature--57'F; dewpoint--50°F; wind--220' at 18 kn; altimeter setting--29.57 in.Hg. Rainshowers of unknown intensity east.

Homer

1400: 600 ft scattered; ceiling--estimated 2,000 ft broken, 4,000 ft overcast; visibility--8 mi, light rain; temperature-- 56°F; dewpoint--52"F; wind--200 at 12 kn; altimeter setting--29.66 in.Hg.

1500: 1,000 ft scattered; ceiling--estimated 2,500 ft broken, 4,000 ft overcast; visibility--10 mi, light rainshowers; temperature-- 56°F; dewpoint--5l0F; wind--090" at 6 kn; altimeter setting--29.62 in.Hg.

At 1029, the flightcrew received a complete weather briefing from the Kenai FSS. At 1058, a man who identified himself as the pilot of Flight 301 E/ received another complete weather briefing including winds aloft information from the Anchorage FSS. About 1135, a man who identified himself as the pilot of Flight 301 received the 1100 Iliamna weather, the Bristol Bay area forecast, and a pilot report for occasional light rime ice at 16,000 ft from the Iliamna FSS via telephone. pilot of the accident aircraft received a weather briefing over the radio from the Iliamna FSS about 1419. The briefing contained only the 1400 Anchorage surface weather observation.

The

I T T h e flight number used by the accident aircraft during its earlier - flight from Anchorage to Iliamna.

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The 1500 King Salmon winds aloft observations were as follows for the heights indicated: (King Salmon is about 83 nmi southwest of Iliamna. )

Height (ft)

1,000 2,000 3,000 4 , 000 6 , 000 7,000 8 , 000 9,000

Direct ion ('True)

220 2 20 225 225 2 35 2 40 235 230

Speed (Kn)

27 31 33 34 35 35 36 34

The 1500 King Salmon radiosonde observation (below 10,000 ft) showed moist, generally conditionally unstable air below 9,000 ft, with dry, stable air above. The freezing level was 5,157 ft.

1.8 Aids to Navigation

Red 99 and Green 8 are low to medium frequency airways formed by NDB'S. -- Red 99 is formed by a bearing from the Iliamna NDB, and Green 8 is formed by bearings between the Big Mountain, the Kachemak (Homer), and the Wildwood NDB's. These four NDB's are Class H =/ radio facilities. Each facility was flight checked after the accident and was found to be within acceptable tolerances.

The normal Green 8 route from Kakon Intersection to Anchorage proceeds eastward from Kakon to the Kachemak NDB, turns north to the Wildwood NDB, and then northeast to Anchorage. The new routing which the flightcrew of Flight 302 requested and received from Anchorage Center would have shortened the flight time.

The 192" bearing from the Wildwood NDB is coincident with Victor Airway 334 (the 192" radial of the Kenai VOR) and intercepts the Green 8 route about 37 nmi west of Kachemak NDB which is located about 6 nmi south of Homer VORTAC. At the time of the accident, the use of the 192" bearing from Wildwood as a substitute part of the low-frequency navigation structure had been approved and flight checked by the FAA while the high-frequency structure (Victor 334) was out of service for facility maintenance. The FAA flight check showed that, even though the

- 111 A Class H radio facility is a nondirectional homing beacon with a power range between 50 watts and 2,000 watts and a guaranteed usable distance of 50 nmi at all altitudes and on all bearings. at the public'hearing revealed that the Wildwood NDB was designed to serve a 100-nmi radius with a minimum of 70-microvolt signal at that distance.

Testimony

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i n t e r s e c t i o n of t h e 192" bear ing from Wildwood NDB and Green 8 w a s about 76 nmi from Wildwood NDB, s i g n a l s t r e n g t h a t t h e i n t e r s e c t i o n w a s s u f f i c i e n t f o r r e c e i v i n g t h e bear ing . had been r e p o r t e d by o t h e r a i r c r a f t .

No r e c e p t i o n d i f f i c u l t i e s a t t h e i n t e r s e c t i o n

On September 10 and 11, 1977, t h e f l i g h t c r e w s of t h r e e a i r c r a f t , two Cessna 402 's and a Douglas DC-3, r e p o r t e d t h a t t h e ADF needle i n t h e i r a i r c r a f t i n d i c a t e d t h a t they w e r e i n t e r c e p t i n g t h e 192" bear ing of t h e Wildwood NDB when t h e i r a c t u a l p o s i t i o n w a s between 14 nmi and 20 nmi east of Kakon I n t e r s e c t i o n . These crews repor ted no d i f f i c u l t y i n r e c e i v i n g a good a u r a l i d e n t i f i e r o r a s t e a d y needle i n d i c a t i o n a t t h a t d i s t a n c e -- about 100 nmi. They r e p o r t e d a l s o t h a t , a t t h e t i m e they had rece ived t h e s e i n d i c a t i o n s on t h e i r ADF equipment, t h e i r DME d i s t a n c e from Homer VOR ranged from 68 nrni t o 74 nmi.

A t t h e r e q u e s t of t h e S a f e t y Board, t h e FAA discont inued immediately t h e use of t h e 192" b e a r i n g of Wildwood NDB as a p a r t of t h e s u b s t i t u t e r o u t e s t r u c t u r e f o r V i c t o r 334. The u s e of t h e 192" bear ing h a s n o t been r e i n s t a t e d because t h e Kenai VOR w a s placed i n service s h o r t l y a f t e r t h i s a c c i d e n t thereby r e a c t i v a t i n g V i c t o r 334.

1.9 Communications

No air-to-ground communications d i f f i c u l t i e s were repor ted .

1.10 Aerodrome Information

Not a p p l i c a b l e .

1.11 F l i g h t Recorders

No f l i g h t d a t a recorder o r cockpi t v o i c e recorder w a s i n s t a l l e d i n N563MA, nor w a s e i t h e r requi red .

1 .12 Wreckage and Impact Information

The a i r c r a f t wreckage s i t e w a s l o c a t e d about 56 nmi east- n o r t h e a s t of I l iamna A i r p o r t on September 7 , 1977, by U.S. A i r Force s e a r c h and r e s c u e a i r c r a f t . The wreckage w a s o r i e n t e d along a heading o f about 012". A r e s c u e team w a s landed a t t h e s i t e and they determined t h a t t h e r e w e r e no s u r v i v o r s . Because of t h e extremely hazardous environmental c o n d i t i o n s , t h e t e a m w a s forced t o l e a v e t h e area s h o r t l y a f t e r t h e i r a r r i v a l .

Weather i n t h e M t . I l iamna area delayed u n t i l September 1 2 a t t e m p t s t o f l y a t e a m of mountain c l imbers i n t o t h e area t o a t tempt recovery of a i r c r a f t p a r t s o r documents. The team reached t h e a c c i d e n t s i t e b u t w a s unable t o recover anyth ing from t h e wreckage except two pages of a v i o n i c s maintenance records . most of which w a s s i t u a t e d i n numerous deep crevasses.

Snow had covered t h e wreckage,

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Further attempts to recover the bodies of the crash victims, aircraft parts, and flight instruments were abandoned because of the extremely hazardous climbing conditions and the inability of the mountain climbers to locate either the bodies of the victims or the cockpit area of the aircraft in the deep snow.

1.13 Medical and Pathological Information

A review of the flightcrew's medical records disclosed no evidence of preexisting physical problems which could have affected their judgment or performance.

Since bodies were not recovered, post-mortem examinations were not possible.

1.14 Fire

There were no indications of fire at the accident site.

1.15 Survival Aspects

The accident was not survivable.

1.16 Tests and Research

None.

1.17 Additional Information

1.17.1 Flight Information Publication, Alaska Supplement, effective 11 August 1977

"Navigational Aid Disturbances:

Radio beacons and low frequency ranges are subject to disturbances that result in false and displaced or multiple courses, ADF needle deviations, signal fades and interference from distant stations, particularly during night operations. Be alert for these conditions, particularly in mountainous terrain....

Extreme variations in compass deviations may be experienced due to magnetic storms at geographic latitudes greater than 60"N. The variations may have durations of several minutes to several hours and cause compass swings of 5"- l o o . I'

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1.17.2 Federal Aviation Administration Surveillance

The FAA General Aviation District Office (GADO) at Anchorage was responsible for the surveillance of Alaska Aeronautical Industries operations. This GADO was responsible also for the surveillance of 151 other 14 CFR 135 operators in and around Anchorage, 1 of which was 400 miles from Anchorage, at Bethel. The principal operations inspector assigned to the company was also responsible for the surveillance of 53 other 14 CFR 135 operators, including the 1,400 miles away. There are 221 14 CFR 135 operators in Alaska. The FAA surveillance of these operators is accomplished by 15 principal operations inspectors and 10 principal maintenance inspectors.

From January 1977 until the date of this accident, 13 en route inspections of company pilots had been conducted, During the same period 15 separate base, ramp, and other surveillance inspections had been conducted.

1.17.3 Seismograph Recording

A seismograph belonging to the Geophysical Institute of the University of Alaska, located at Redoubt, Alaska, (about 27 nmi from Mt. Iliamna) recorded a small tremor beginning at 1452:06. This tremor was about twice the magnitude and three to four times the duration of other tremors recorded before and after that time. The travel time for sound waves between the seismograph and Mt. Iliamna is about 7 seconds.

1.17.4 14 CFR 135.136-Flight and Duty Time Limitations

"(a) No certificate holder may assign any flight crewmember, and no flight crewmember may accept an assignment, for duty during flight time if the total flight time of that flight in addition to any other commercial flying by that flight crewmember exceeds the following during any 24 consecutive hours:

(2) Ten hours for a flight crew consisting of two pilots required by this chapter.

(b) No certificate holder may assign a flight crewmember, and no flight crewmember may accept an assignment, for duty during flight time unless that assignment provides for at least 10 consecutive hours of rest during the 24-hour period preceding the planned completion of the assignment."

1.17.5 14 CFR 91.3-Responsibility and Authority of the Pilot in Command

"(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. I'

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1 .17 .6 Company Maintenance Practices

A review of t h e company's maintenance p r a c t i c e s d i s c l o s e d t h a t a i r c r a f t s p a r e p a r t s w e r e n o t tagged o r o the rwise i d e n t i f i e d as t o t h e i r o p e r a t i o n a l s t a t u s . p a r t s . The company's Chief of Maintenance s t a t e d t h a t he knew t h e exac t c o n d i t i o n of each i t e m i n s t o c k and, t h e r e f o r e , t h e r e w a s no need t o t a g them. H e s t a t e d f u r t h e r t h a t i f replacement p a r t s were needed, he could de te rmine t h e c o n d i t i o n of t h e i t e m .

S e r v i c e a b l e p a r t s were in te rmixed wi th unse rv iceab le

A t t h e p u b l i c hea r ing , company p i l o t s and company maintenance pe r sonne l w e r e confused as t o t h e c o r r e c t u s e of t h e maintenance logbook. T h e i r op in ions v a r i e d when asked t o de te rmine from a logbook page e n t r y t h e s t a t u s of i n d i v i d u a l p a r t s which had been r epor t ed d e f i c i e n t o r t h e a i r w o r t h i n e s s of an a i r c r a f t t o be flown on a p a r t i c u l a r f l i g h t .

1 . 1 7 . 7 Company Tra in ing P r a c t i c e s

A rev iew of t h e company t r a i n i n g r e c o r d s and tes t imony a t t h e p u b l i c hea r ing d i s c l o s e d t h a t r e q u i r e d by t h e company t r a i n i n g manual b e f o r e they became a f i r s t o f f i c e r o r a c a p t a i n . When t r a i n i n g w a s r ece ived , i t w a s u s u a l l y t h e minimum requ i r ed by t h e manual, which'was t h e case f o r t h e two crewmembers of t h e a c c i d e n t a i r c r a f t .

of t e n crewmembers d id n o t r e c e i v e t r a i n i n g

1.18 New I n v e s t i g a t i o n Techniques

None.

2. ANALYSIS

The f l i g h t crewmembers w e r e c e r t i f i c a t e d and q u a l i f i e d i n accordance wi th company and FAA r e g u l a t i o n s .

The a i r c r a f t w a s c e r t i f i c a t e d and maintained accord ing t o a p p l i c a b l e r e g u l a t i o n s ; however, i t w a s n o t equipped p rope r ly f o r an IFR f l i g h t t o I l iamna. Two independent n a v i g a t i o n a l r e c e i v e r s f o r t h e en r o u t e f a c i l i t i e s t o be used are requ i r ed by 14 CFR 135.159. The r o u t e t o b e flown i n t h i s c a s e w a s se rved by low- and medium-frequency naviga- t i o n a l r a d i o f a c i l i t i e s only. r e c e i v e r . The company w a s aware of t h e FAA's requirements f o r t h i s r o u t e w i t h r ega rd t o t h e n a v i g a t i o n a l r e c e i v e r s and d i spa tched t h e a i r c r a f t i n s p i t e of t h i s knowledge. The S a f e t y Board f u r t h e r b e l i e v e s t h a t t h e c a p t a i n accepted t h e a i rc raf t f o r f l i g h t t o I l iamna wi th knowledge t h a t two ADF r e c e i v e r s were r e q u i r e d and t h a t on ly one ADF r e c e i v e r w a s i n s t a l l e d aboard N563MA.

N563MA w a s equipped wi th only one ADF

The a i r c r a f t ' s g r o s s weight and c.g. w e r e w i t h i n p re sc r ibed l i m i t s . I t ' s a i r f r ame , powerplants , and components w e r e n o t f a c t o r s i n t h i s a c c i d e n t .

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There w a s no reason t o b e l i e v e t h a t t h e f l i g h t c r e w w a s exper ienc ing any major d i f f i c u l t i e s wi th t h e ADF r e c e i v e r on board N563MA. It i s t r u e t h a t , when F l i g h t 301 approached I l iamna, t h e crew asked t h e FSS a t t e n d a n t i f t h e s t a t i o n w a s equipped w i t h d i r e c t i o n f i n d i n g equipment. However, t h e crew s t a t e d t h a t t h e i r reason f o r t h e r e q u e s t w a s e r ra t ic needle r e a d i n g s on t h e ADF. The c a p t a i n made no f u r t h e r r e f e r e n c e t o a problem w i t h h i s ADF b e f o r e landing o r when he f i l e d t h e IFR f l i g h t p l a n back t o Anchorage. I f h e b e l i e v e d t h e r e w a s a problem he would n o t have l e f t I l iamna, s i n c e he would have had no means of n a v i g a t i n g v ia t h e r o u t e s p e c i f i e d i n h i s c l e a r a n c e . Thus, t h e S a f e t y Board concludes t h a t t h e one ADF n a v i g a t i o n receiver w a s o p e r a t i n g s a t i s f a c t o r i l y .

A f t e r t a k e o f f , t h e a i r c r a f t f lew a long Red 99 t o Kakon I n t e r - s e c t i o n . T h i s w a s t h e r o u t i n g t h e crew had r e q u e s t e d , and i t w a s t h e r o u t e they had used t o reach I l iamna earlier t h a t day. This r o u t i n g i s a l s o t h e only IFR r o u t i n g o u t of t h e I l iamna area. The conclus ion t h a t t h e a i r c r a f t w a s flown s o u t h e a s t on Red 99 is f u r t h e r supported by ATC r e p o r t s made by F l i g h t 302. A t 1425:20, t h e crew r e p o r t e d level a t 7,000 f t , e s t i m a t i n g Kakon I n t e r s e c t i o n a t 1434. Other f a c t s which suppor t t h e conclus ion t h a t t h e a i r c r a f t w a s flown toward Kakon on Red 99 are: (1) The impact heading -- t h e heading was 012". Had t h e crew flown d i r e c t l y t o Wildwood NDB from I l iamna, t h e impact heading would have been c l o s e r t o 050". (2) The t i m e of t h e l a s t r a d i o c o n t a c t . The l a s t r a d i o c o n t a c t w i t h F l i g h t 302 w a s a t 1440:50. Had t h e a i r c r a f t been flown d i r e c t l y toward Wildwood NDB, t h e f l y i n g t i m e t o t h e c r a s h s i t e would have been about 20 min based on wind from 210" a t 37 kn. The t i m e of impact would t h e n have been near 1440, which would n o t correspond w i t h t h e l a s t ATC t r a n s m i s s i o n o r t h e suspec ted t i m e of impact of 1452. (3) The crew d i d n o t mistune t h e ADF. I n o r d e r t o have flown o t h e r t h a n t h e reques ted r o u t e , t h e crew would have had t o mistune t h e ADF, then a c c e p t a heading of 050" r a t h e r t h a n a s o u t h e a s t heading of 123" toward Kakon I n t e r s e c t i o n . Thus, t h e S a f e t y Board concludes t h a t t h e f i r s t l e g of t h e r o u t e , t o Kakon v i a Red 99, w a s flown according t o t h e f l i g h t p lan .

A f t e r a t a k e o f f a t 1419, and based on es t imated winds of 210" a t 37 kns between I l iamna and t h e a c c i d e n t s i t e , t h e top of F l i g h t 302 's climb would have been reached a t 1427, and Kakon I n t e r s e c t i o n would have been reached a t 1434. This i s v e r i f i e d by t h e r e p o r t of level a t 7,000 f t a t 1425:20, w i t h a n estimate of 1434 t o Kakon. Once reaching Kakon I n t e r s e c t i o n t h e c r e w should have used Big Mountain NDB t o t r a c k outbound on Green 8 toward Kachemak NDB. However, based on tes t imony rece ived a t t h e p u b l i c hear , ing, t h e crew would have probably s e l e c t e d Kachemak NDB t o t r a c k outbound from Kakon I n t e r s e c t i o n on Green 8 because of t h e g e n e r a l f e e l i n g by company p i l o t s t h a t Big Mountain NDB w a s weak and u n r e l i a b l e . I f Wildwood NDB w a s tuned a t Kakon, t h e a i r c r a f t would have been flown on a course which would have gone almost d i r e c t l y t o t h e

- 15 -

a c c i d e n t s i te . However, t h i s would have r equ i r ed t h e crew t o accep t a heading of about 023" when they should have expected t o t u r n t o about 070" t o s t a y on Green 8 (059" p l u s 11" wind c o r r e c t i o n ) .

Furthermore, they would have had t o tune i n t h e wrong NDB. Although t h e f r e q u e n c i e s of Wildwood NDB (379 kHz) and Kachemak NDB (387 kHz) are similar, t h e r e i s no ev idence t h a t t h e NDB w a s mistuned. The on ly f ac t which would suppor t t h e theo ry t h a t t h e a i r c r a f t w a s flown d i r e c t l y t o Wildwood NDB from Kakon I n t e r s e c t i o n is t h a t i t would t a k e about 20 min t o t r a v e l t h e 54 nmi from Kakon t o t h e a c c i d e n t s i t e (wind 210' a t 37 kns , groundspeed 170 kn) . This would p l a c e t h e t i m e of impact nea r 1453, c l o s e t o t h e suspec ted t i m e of impact. However, o t h e r exp lana t ions f o r t h e a c c i d e n t which invo lve fewer assumptions can a l s o p l a c e t h e a i r c r a f t a t t h e a c c i d e n t s i t e a t 1452.

Assuming t h a t t h e a i r c r a f t w a s e s t a b l i s h e d on Green 8 a f t e r pas s ing Kakon a t 1434, t h e nex t c a l l t o Anchorage Center a t 1439:40 would be l o g i c a l s i n c e t h e crew d i d want t o t a k e t h e s h o r t e s t r o u t e back -- t h e 192" bea r ing from Wildwood NDB -- and they would have had more than 5 mins t o e s t a b l i s h t h e a i r c r a f t on Green 8 and t o d i s c u s s t h e proposed r o u t e . From 1434 a t Kakon t o 1439:40 on Green 8 , t h e fo l lowing c o n d i t i o n s would have e x i s t e d : groundspeed 1 6 1 kns , and d i s t a n c e t r a v e l e d about 14 nmi. have p laced t h e a i r c r a f t on Green 8 , 14 nmi east of Kakon, and about 40 nmi t o 43 nrni from t h e a c c i d e n t s i te . Once t h e f l i g h t w a s c l e a r e d via t h e 192" b e a r i n g , t h e crew could have, and l o g i c a l l y would have, checked t h e i r p o s i t i o n on Green 8 by tun ing i n t h e Wildwood NDB. A t t h i s p o i n t , i f t h e ADF i n d i c a t e d t h a t t h e a i r c r a f t w a s a l r e a d y on t h e 192" bea r ing and t h e e r r o r was n o t d i scovered , t h e a i r c r a f t would be turned t o t r a c k t o t h e Wildwood NDB. 170 kns , i t would have taken 14 o r 15 mins t o a r r i v e a t t h e a c c i d e n t s i t e . This would p l a c e t h e a i r c r a f t a t t h e impact s i t e w i t h i n seconds of 1452 -- w i t h i n seconds of t h e sounds similar t o t h e carrier frequency of t h e a i r c r a f t heard on t h e Anchorage Center t a p e a t 1452:08 and t h e seismographic r eco rd ing of a s m a l l t remor which s t a r t e d a t 1451:59.

Wind 210" a t 37 kns , heading 070", This would

Using winds of 210" a t 37 kns and a groundspeed of

During t h e i n v e s t i g a t i o n , t h e S a f e t y Board determined t h a t t h e Wildwood NDB could be r ece ived wh i l e on Green 8 , i n a p o s i t i o n 14 nrni east of t h e Kakon I n t e r s e c t i o n . The d i r e c t d i s t a n c e between t h i s p o i n t and Wildwood NDB w a s about 100 nmi. This w a s proven by success ive f l i g h t s i n a Cessna 402 and a Douglas DC-3 a t a l t i t u d e s from as high as 7,000 f t t o as low as 2,800 f t . I n t h i s p o s i t i o n t h e s t a t i o n could be i d e n t i f i e d by t h e a u r a l i d e n t i f i e r and t h e ADF needle would p o i n t t o t h a t s t a t i o n . Based on r ead ings taken from ADF's i n a DC-3 used by t h e FAA f o r f l i g h t checks, a p o i n t 1 4 nrni east of Kakon I n t e r s e c t i o n i s about t h e 206" t o 204" bea r ing from Wildwood NDB. A p rope r ly o p e r a t i n g ADF would i n d i c a t e t h e p o s i t i o n of t h e a i r c r a f t on Green 8 and i t s r e l a t i o n t o t h e 192" bea r ing from Wildwood NDB, t hus no t u r n t o a

- 1 6 -

heading of 012", t h e inbound heading t o Wildwood NDB on t h e 192" bea r ing , would begin u n t i l t h e a i r c r a f t reached t h e 192" bear ing . t h e 192" bea r ing i n t e r s e c t s Green 8 about 52 nmi east of Kakon, o r 19 mins f l y i n g t i m e from Kakon I n t e r s e c t i o n .

Furthermore,

C l e a r l y , t h e 192" bea r ing w a s no t i n t e r c e p t e d a t t h e proper p o i n t on Green 8 . Had t h i s i n t e r c e p t i o n been made, t h e a i r c r a f t would have had t o be turned back t o a heading of about 325" t o reach t h e a c c i d e n t s i t e , r a t h e r t han t h e 012" (+ wind c o r r e c t i o n ) r equ i r ed t o be p rope r ly on t h e 192" bea r ing t o t h e Wildwood NDB. It is u n l i k e l y t h a t t h i s d r a s t i c change from t h e gene ra l d i r e c t i o n of t h e f l i g h t would have gone unnot iced by t h e f l i gh tc rew. The ques t ion which must be r e so lved , t hen , i s why t h e a i r c r a f t l e f t Green 8 be fo re t h e 192" bear ing was a c t u a l l y reached.

The most reasonable exp lana t ion i s t h a t Kachemak ADF w a s used t o e s t a b l i s h t h e a i r c ra f t on Green 8 . Once on course , t h e amended r o u t i n g w a s reques ted v ia t h e 192" bea r ing from Wildwood. when t h i s r eques t w a s g ran ted , Wildwood NDB w a s tuned. The a i r c r a f t would have been about 14 nmi east of Kakon. The crew should have expected a r r i v a l a t t h e 192" bear ing about 1453. However, they d id no t r e p o r t t h e i r a r r i v a l a t Kakon a t t h e es t imated t i m e of 1434, and they may no t have noted what t i m e they a c t u a l l y d i d pass i t . It is apparent t h a t they d id no t n o t e o r pay a t t e n t i o n t o t h e time when Kakon was passed o r they would no t have turned toward t h e Wildwood NDB a t 1440 t o 1442 i n s t e a d of an es t imated t i m e of 1453. The Sa fe ty Board b e l i e v e s t h a t t h e i n d i c a t i o n s of t h e ADF needle , and no t a c t u a l t ime-dis tance planning o r DME d i s t a n c e from Homer VOR, were t h e primary means t h e crew used t o i d e n t i f y t h e 192" bea r ing .

A t 1440 :15 ,

A s s t a t e d be fo re , a t a p o i n t 1 4 nmi east of Kakon t h e ADF should i n d i c a t e about t h e 206" bea r ing . Two f a c t s must be considered as t o why t h e a i r c r a f t l e f t Green 8 a t t h a t t i m e . ADF w a s a f ixed-card system. based on c o r r e c t heading informat ion from t h e d i r e c t i o n a l gyro heading i n d i c a t o r . I n t h i s case, i f t h e a i r c r a f t w a s on t h e airway wi th a no wind heading of 059", t h e a i r c r a f t would be flown on t h a t heading u n t i l t h e ADF need le poin ted 47" t o t h e l e f t . would be 012", o r t h e inbound course f o r t h e 192" bear ing . c o r r e c t i o n w a s needed t o keep t h e a i r c r a f t on t h e airway, t h e wind c o r r e c t i o n would be app l i ed t o 059". For example, i f t h e r equ i r ed heading w a s 070" , a t u r n onto t h e 012" course would be made when t h e needle poin ted 58" t o t h e l e f t of t h e nose of t h e a i r c r a f t .

F i r s t , t h e a i r c r a f t ' s The accuracy of a f ixed-card system i s

Forty-seven degrees t o t h e l e f t I f a wind

The angular r e l a t i o n s h i p between t h e a i r c r a f t heading and t h e

However, by i t s e l f , t h e ADF need le does not i n d i c a t e t h e s t a t i o n , measured clockwise from t h e nose of t h e a i r c r a f t , is t h e r e l a t i v e bea r ing . p o s i t i o n of t h e a i r c r a f t . b e a r i n g , must be r e l a t e d t o t h e a i r c r a f t heading. i s i n c o r r e c t , i n c o r r e c t in format ion w i l l be der ived from t h e ADF i n d i c a t i o n s .

The a c t u a l p o s i t i o n , as shown by t h e r e l a t i v e I f t h e heading i n d i c a t o r

- 1 7 -

I f t h e heading i n d i c a t o r was n o t reset a f t e r t akeof f from I l i amna , o r even i f i t w a s allowed t o p recess only 10" by 1439, t h e crew would have had an i n d i c a t i o n t h a t t h e a i r c r a f t w a s on t h e 196" o r 194" bea r ing from Wildwood NDB a t a p o i n t 1 4 nrni east of Kakon. a i r c r a f t w a s f a r t h e r east, a t a p o i n t 20 nrni from Kakon, t h e ADF might a c t u a l l y have i n d i c a t e d t h e 192' bea r ing .

I f t h e

The same 10" e r r o r could have been induced even i f t h e crew reset t h e heading i n d i c a t o r by r e f e r e n c e t o t h e magnetic compass. A t 7,000 f t i n t h e e x i s t i n g c o n d i t i o n s , t h e r e w a s a s t r o n g p o s s i b i l i t y of l i g h t t o moderate turbulence . o b t a i n p r e c i s e heading informat ion . Furthermore, compass swings of 5' t o 10" are n o t uncommon i n t h i s area as a r e s u l t of t h e n o r t h l a t i t u d e . Whatever t h e reason t h e a i r c r a f t l e f t Green 8 and t racked inbound t o Wildwood NDB, i t i s l o g i c a l t h a t t h e crew would b e l i e v e t h e i r ADF s i n c e t h e e n t i r e f l i g h t w a s probably i n ins t rument me teo ro log ica l c o n d i t i o n s and conducted s o l e l y by r e f e r e n c e t o t h e one ADF f o r nav iga t ion . This does n o t e x p l a i n , however, t h e f a i l u r e t o use backup methods of n a v i g a t i o n as a crosscheck. w i t h DME c a p a b i l i t y onboard.)

This would have made i t d i f f i c u l t t o

(There w e r e two ope rab le VOR n a v i g a t i o n a l r e c e i v e r s

Another s i t u a t i o n which must be cons idered is t h a t of an u n r e l i a b l e s i g n a l from t h e Wildwood NDB. from Wildwood NDB. A p o i n t 14 nrni east of Kakon i s about 107 nrni away from Wildwood. The Wildwood NDB i s a Class H f a c i l i t y , which has an optimum range of 50 nmi. According t o tes t imony taken a t t h e p u b l i c hea r ing , t h e Wildwood NDB w a s designed t o o p e r a t e up t o a r a d i u s of 100 nmi. may have been beyond t h e u s a b l e range of t h e f a c i l i t y . The company ch ie f p i l o t t e s t i f i e d t h a t any ADF s i g n a l from a s t a t i o n more than 50 nmi d i s t a n t should n o t b e r e l i e d on.

Kakon I n t e r s e c t i o n is 120 nmi

Thus, any s i g n a l r ece ived a t o r i n t h e v i c i n i t y of Kakon I n t e r s e c t i o n

The r e l i a b i l i t y of t h e s i g n a l a t t h a t range (100 nmi) i s even more ques t ionab le because of t h e warning i n t h e F l i g h t Informat ion P u b l i c a t i o n Supplement f o r Alaska t h a t warns of d i s t u r b a n c e s , e s p e c i a l l y i n mountainous t e r r a i n , which may a f f e c t ADF i n d i c a t i o n s .

On September 10 and 11, t h e f l i g h t c r e w s of t h r e e s e p a r a t e a i r c r a f t , l o c a t e d 14 t o 20 nrni east of Kakon I n t e r s e c t i o n , r epor t ed t h a t t h e ADF need le i n d i c a t e d t h e i r a i r c r a f t w e r e on t h e 192" bea r ing from Wildwood NDB. A t t h i s time, t h e DME equipment aboard t h e s e a i r c r a f t i n d i c a t e d d i s t a n c e s ranging from 68 nmi t o 7 4 nmi from Homer VOR. I f t h i s occurred t o F l i g h t 302 and any DME i n d i c a t i o n s were ignored , t h e crew could have be l i eved t h e ADF need le and turned t o 012".

The c r e w of F l i g h t 302 must have had some i n d i c a t i o n from t h e ADF t h a t they were on t h e 192" bea r ing from Wildwood. w a s tuned, they probably r ece ived a s i g n a l i n d i c a t i n g they w e r e on o r

When Wildwood NDB

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n e a r t h e 192" bear ing . heading i n d i c a t o r , d i f f i c u l t y i n s e t t i n g p r e c i s e l y t h e heading i n d i c a t o r , o r because of t h e g r e a t d i s t a n c e of t h e a i r c r a f t from t h e Wildwood NDB. Whichever w a s t h e case, a prudent p i l o t should have known t h e range l i m i t a t i o n of t h e NDB, t h e e f f e c t of d i s t u r b a n c e s which might a f f e c t a n ADF, and how much t i m e should e l a p s e b e f o r e t h e a i r c r a f t could t rave l from Kakon to t h e i n t e r c e p t i o n p o i n t of t h e 192" b e a r i n g from Wildwood.

T h i s could have been a r e s u l t of a p r e c e s s i n g

F i n a l l y , a prudent p i l o t should u s e a l l a v a i l a b l e n a v i g a t i o n a i d s t o assist i n h i s naviga t ion . F l i g h t 302 had VOR and DME c a p a b i l i t y . The company c h i e f p i l o t s ta ted t h a t he would expect company p i l o t s t o u s e t h e ADF as t h e primary means of n a v i g a t i o n on Green 8. However, he would expect them t o tune t h e VOR t o t h e Homer VOR and t o use t h e DME t o doublecheck t h e p r o g r e s s on t h e r o u t e . Since t h e Kachemak NDB and t h e Homer VOR are almost co loca ted , once e s t a b l i s h e d on Green 8 us ing t h e ADF, t h e Homer VOR would be tuned. This would a l low a p i l o t t o observe t h e mileage t o Homer. When t h e DME mileage read 40 nmi t o Homer, t h e a i r c r a f t would be n e a r t h e 192" b e a r i n g from Wildwood. This would be used t o v e r i f y t h e ADF needle i n d i c a t i o n s . The p o i n t 14 nmi east of Kakon I n t e r s e c t i o n would b e 7 4 nmi from Homer on t h e DME. I f t h e c r e w had used t h e VOR/DME i n t h i s accepted manner, t h e r e i s no way they could have accepted and b e l i e v e d they were on t h e 192" b e a r i n g from Wildwood,

Thus, t h e S a f e t y Board b e l i e v e s t h a t t h e VOR/DME w a s n o t used t o monitor t h e p r o g r e s s of t h e a i r c r a f t on Green 8. The Board a l s o b e l i e v e s t h a t t h e crew w a s n o t aware of t h e expected f l y i n g t i m e from Kakon I n t e r s e c t i o n t o t h e 192" b e a r i n g . The f a c t t h a t they could have had a n i n d i c a t i o n t h a t they were on t h e 192" b e a r i n g should n o t have been t h e only informat ion which t h e f l i g h t c r e w should have r e l i e d upon a t t h a t p o i n t . Thus, t h e Board concludes t h a t w h i l e i t i s p o s s i b l e t h a t t h e crew observed i n d i c a t i o n s t h a t t h e a i r c r a f t w a s on t h e 192' b e a r i n g , and t h i s i n d i c a t i o n came from a s p u r i o u s s i g n a l from t h e Wildwood NDB, i t should n o t have, by i t s e l f , in f luenced t h e crew. A d d i t i o n a l c ross - checks -- t ime-dis tance and VOR/DME backups -- were a v a i l a b l e and v i r t u a l l y r e q u i r e d t o b e used.

The S a f e t y Board concludes t h a t t h e o p e r a t i o n a l c o n t r o l e x e r c i s e d by company management w a s d e f i c i e n t because N563MA w a s d i spa tched f o r t h e f l i g h t from Anchorage t o I l iamna by a company r e p r e s e n t a t i v e who had no knowledge of t h e n a v i g a t i o n a l equipment requirements f o r t h e f l i g h t and whose r e s p o n s i b i l i t i e s d i d n o t i n c l u d e t h e assignment o r t h e d i s p a t c h of company a i r c r a f t . Company personnel w i t h t h i s knowledge and respon- s i b i l i t y were a v a i l a b l e , b u t were n o t consul ted . The a i r c r a f t o r i g i n a l l y scheduled f o r t h e f l i g h t w a s equipped wi th two ADF r e c e i v e r s .

The FAA r e g u l a t i o n s g i v e t h e p i l o t t h e u l t i m a t e r e s p o n s i b i l i t y t o a c c e p t o r r e f u s e a n a i r c r a f t f o r a f l i g h t based on h i s own judgment of t h e s i t u a t i o n . The Board w a s unable t o p o s i t i v e l y i d e n t i f y t h e r e a s o n o r reasons why t h e p i l o t d i d n o t e x e r c i s e h i s a u t h o r i t y t o r e f u s e

- 1 9 -

t h i s a i r c r a f t . H e w a s e i t h e r n o t aware of t h e requirement f o r two ADF r e c e i v e r s on t h e r o u t e t o be flown o r he knowingly d i s r ega rded i t . I n view of t h e p i l o t ' s expe r i ence and q u a l i f i c a t i o n s , and t h e company's s t a t e d p o l i c y i n t h i s r ega rd , i t i s u n l i k e l y t h a t h e w a s n o t aware of t h e requirement . I t i s e q u a l l y u n l i k e l y t h a t he would w i l l i n g l y d i s r e g a r d t h e requirement w i thou t reason.

One r eason f o r t h e p i l o t ' s acceptance of t h e a i r c r a f t could have been h i s d e s i r e t o complete t h e day ' s f l i g h t s . This w a s h i s l a s t t r i p a f t e r a long day of f l i g h t i n adve r se me teo ro log ica l cond i t ions . Also, t h e f l i g h t t o I l iamna w a s a l r e a d y la te l eav ing Anchorage. These two f a c t o r s could have been inducement enough f o r t h e p i l o t ' s a c t i o n s .

Another p o s s i b i l i t y w a s p r e s s u r e p laced on him by t h e company t o complete t h e a s s igned f l i g h t i n t h e a s s igned a i r c r a f t . Testimony a t t h e S a f e t y Board 's p u b l i c hea r ing r evea led t h a t , on a t least one occas ion , a c a p t a i n was d ismissed by a company o f f i c i a l f o r h i s r e f u s a l t o accep t a f l i g h t because of adve r se weather which w a s f o r e c a s t f o r t h e proposed r o u t e of f l i g h t . Other i n s t a n c e s of company p r e s s u r e of t h i s kind were r e p o r t e d t o t h e Board du r ing t h e i n v e s t i g a t i o n . I f t h e s e p r e s s u r e s w e r e p r e s e n t , o r i n f e r r e d , when t h e c a p t a i n of t h i s f l i g h t w a s awa i t ing t h e s t a r t of h i s t r i p t o I l iamna, h i s d e c i s i o n t o accep t N563MA f o r t h e t r i p could have been a f f e c t e d .

The S a f e t y Board concluded t h a t t h e one ADF n a v i g a t i o n a l r e c e i v e r onboard t h e a i r c r a f t w a s o p e r a t i o n a l . Along t h i s p a r t i c u l a r a i rway system, w i t h two VOR r e c e i v e r s and DME c a p a b i l i t y t o cross-check t h e ADF in fo rma t ion be ing r e c e i v e d , t h e f l i g h t should have been completed s u c c e s s f u l l y . Notwithstanding t h e f a c t t h a t t h e Board b e l i e v e s t h a t one ADF should have been s u f f i c i e n t t o n a v i g a t e t h i s r o u t e , t h e d i s p a t c h of a n a i r c r a f t w i thou t t h e r e q u i r e d equipment by persons n o t q u a l i f i e d o r au tho r i zed t o do so , c o n s t i t u t e s an unsa fe and dangerous p r a c t i c e and i s a matter of concern t o t h e Board.

During i t s i n v e s t i g a t i o n and p u b l i c h e a r i n g , t h e S a f e t y Board r e a l i z e d t h a t t h e company's management of o p e r a t i o n s , i t s t r a i n i n g program, i t s maintenance p r a c t i c e s and procedures , and FAA's s u r v e i l l a n c e of t h e s e areas w e r e inadequate . Improper a i r c r a f t schedul ing and d i s p a t c h procedures and t h e f a i l u r e by management t o a s s i g n t h e s e r e s p o n s i b i l i t i e s t o key company pe r sonne l p l a c e s an undue decisionmaking burden on t h e i n d i v i d u a l p i l o t s . Th i s burden i s inc reased when o t h e r p r e s s u r e s , such as t h e t h r e a t of d i s c i p l i n a r y a c t i o n , are brought t o bea r on t h e p i l o t when company management does n o t a g r e e wi th h i s d e c i s i o n s .

Although t h e company t r a i n i n g program meets t h e requi rements of 1 4 CFR 135.55, t h e Board a l s o b e l i e v e s t h a t t h e a d m i n i s t r a t i o n of t h e program w a s weak and c o n t r a d i c t o r y t o t h e s p e c i f i c a t i o n s of t h e company t r a i n i n g manual. Seve ra l i n s t a n c e s were found where, a l though t h e t r a i n i n g manual se t f o r t h requi rements f o r newly h i r e d p i l o t s , t h e a c t u a l t r a i n i n g g iven b e f o r e q u a l i f i c a t i o n w a s g ran ted w a s less than

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required. These conditions indicated that the training program lacked the control and supervision necessary to implement and monitor an aggressive and comprehensive program.

The company maintenance practices were deficient because it was extremely difficult for a pilot to know the exact maintenance status of his aircraft before takeoff. Also, the company maintained no control over serviceable and unserviceable items in its spare part stock. The Board believes that these practices could lead to unserviceable parts being placed in an aircraft.

, The Safety Board believes that the FAA’s surveillance of the company’s operations and maintenance practices should have detected and caused to be corrected the deficiencies discovered during the Board’s investigation. The Board realizes that the same FAA personnel responsible for surveillance of this company were also responsible for about 151 other Part 135 operations in the Anchorage area. However, the detection and correction of operations such as the one uncovered during this investigation are vital to safe operation.

3 , CONCLUSIONS

3.1 Findine s

1.

2.

3 .

4 .

5.

6.

7.

The flightcrew was certificated and trained for the flight.

The aircraft conformed to the proper takeoff weight and c. g. limitations.

The aircraft was not properly equipped for the flight in that there was only one ADF receiver on board.

The aircraft was dispatched by a company representative whose responsibilities did not include the dispatch of aircraft . The crew accomplished the preflight planning properly with the exception of accepting an aircraft with one ADF receiver instead of the two required for this flight.

The one ADF on board the aircraft was operating properly at the time of the accident.

The flight plan route was followed from Iliamna Airport to Kakon Intersection via Red 99.

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8. The accident did not result from tuning the wrong ADF.

9. The Wildwood NDB signal can be received, although not necessarily with a reliable signal, while on Green 8, 14 nmi east of Kakon Intersection.

10. About 14 nmi east of Kakon Intersection, while established on Green 8, the crew turned northeastward toward Wildwood NDB.

11. The crew believed they were tracking inbound to the Wildwood NDB because the heading indicator was not properly set, because of precession of the heading indicator, or because they were relying on the Wildwood NDB beyond its reliable range.

12. The 192" bearing from Wildwood NDB would not be intercepted until a point about 40 nmi from the Kachemak NDB. This should have been known by the crew.

13. The flying time from Kakon Intersection to the 192" bearing from Wildwood NDB was about 18 min. This should have been known by the crew.

14. The crew was not using the Homer VOR/DME to backup or doublecheck the primary ADF navigation on Green 8.

15. The company's operational, maintenance, and training practices were inadequate. these areas was also inadequate.

The FAA's surveillance of

3.2 Probable Cause


4 . SAFETY RECOMMENDATIONS

As a result of this accident, the National Transportation Safety Board recommended that the Federal Aviation Administration:

Revise the surveillance requirements of commuter airlines I t

by FAA inspectors to provide more stringent monitoring. (Class I1 - Priority Action) (A-78-37)

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"Identify FAA offices responsible for the surveillance of large numbers of air taxi/commuter operators and insure that an adequate number of inspectors are assigned to monitor properly each operator. (Class I1 - Priority Action) (A-78-38)

"Review the flight operations and training manuals of all commuter airlines to insure that the requirements of 14 CFR 135 are met and practiced. (Class I1 - Priority Action) (A-78-39)

"Amend 14 CFR 135.27 to require that flight operations manuals specify: (1) The duties and responsibilities of key management personnel, and (2) positive means to insure the control of flights by company management as well as by the pilots. (Class I1 - Priority Action) (A-78-40)

Review the maintenance procedures of air taxi and commuter II

airlines operators to evaluate the effectiveness of those procedures and to insure adequate company control. (Class I1 - Priority Action) (A-78-41)"

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

/ s / JAMES B. KING Chairman

/ s / FRANCIS H. McADAMS Member

/ s / PHILIP A. HOGUE Member

/ s / ELWOOD T. DRIVER Member

May 4, 1978

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5. APPENDICES

APPENDIX A

INVESTIGATION AND HEARING

1. Investigation

The Safety Board was notified of a missing aircraft about 1640 on September 6, 1977. About 1143 on September 7, 1977, notification was received that the wreckage had been located. The investigation team went immediately to the scene. Working groups were established for operations, air traffic control, and maintenance records.

Participants in the on-scene investigation included repre- sentatives of Alaska Aeronautical Industries, Inc., the Federal Aviation Administration, the Union of Professional Airmen, the Pratt & Whitney Aircraft Division of United Technologies, Inc., and the Alaska Transportation Commission.

2. Public Hearing

A 3-day public hearing at Anchorage, Alaska, began on November 9, 1977. Parties represented at the hearing were: Alaska Aeronautical Industries, Inc., the Federal Aviation Administration, the Union of Professional Airmen, the State of Alaska Transportation Commission, and the National Association of Air Traffic Specialists, Inc.

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APPENDIX B

PERSONNEL INFORMATION

Capta in M i t c h e l l E. C r a n d a l l

Captain M i t c h e l l E. Crandal l , 31, w a s employed by Alaska Aeronaut ica l I n d u s t r i e s , I n c . , as a f i r s t o f f i c e r on February 27, 1977. H e w a s upgraded t o DHC-6 c a p t a i n on A p r i l 28, 1977, The c a p t a i n he ld A i r l i n e Transpor t P i l o t C e r t i f i c a t e No. 2178380 wi th a t y p e r a t i n g i n t h e DHC-6 and as a F l i g h t I n s t r u c t o r . H i s r a t i n g s inc luded a i r p l a n e , s i n g l e - and mult i -engine, ins t ruments , and a i r p l a n e and ground i n s t r u c t o r , H i s f i r s t - c l a s s medical c e r t i f i c a t e w a s da ted September 2 , 1976, w i t h no l i m i t a t i o n s .

Capta in C r a n d a l l had a t o t a l of 4,335 f l i g h t - h o u r s , of which 1,124 hours were i n t h e DHC-6 a i r c r a f t . H e had accumulated about 591 f l i g h t - h o u r s as a DHC-6 c a p t a i n . H e had flown about 220 f l i g h t - h o u r s i n a c t u a l ins t rument meteoro logica l c o n d i t i o n s , of which 12.6 hours were recorded i n August and September of 1977. On t h e day of t h e a c c i d e n t , h e had r e p o r t e d f o r work about 0400 and had flown 5.4 hours b e f o r e t h e takeoff of F l i g h t 302.

F i r s t O f f i c e r Gary F. B i b l e

F i r s t O f f i c e r Gary F. B i b l e , 21, w a s employed by Alaska Aeronaut ica l I n d u s t r i e s , I n c . , as a f i r s t o f f i c e r on June 14 , 1977. H e h e l d Commercial P i l o t C e r t i f i c a t e No. 564060746 da ted May 26, 1975, w i t h r a t i n g s i n a i r p l a n e s i n g l e - and mult i -engine land and ins t rument a i r p l a n e . H i s f i r s t - c l a s s medical c e r t i f i c a t e w a s da ted February 17, 1977, and had no l i m i t a t i o n s .

F i r s t O f f i c e r B i b l e had accumulated 1,380 t o t a l f l i g h t - h o u r s of which 371 f l i g h t - h o u r s were i n t h e DHC-6 a i r c r a f t . H e had flown 53 f l i g h t - h o u r s i n a c t u a l ins t rument m e t e o r o l o g i c a l c o n d i t i o n s . On t h e day of t h e a c c i d e n t , h e had r e p o r t e d f o r work about 0400 and had flown 5.4 hours b e f o r e t h e takeoff of F l i g h t 302.

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APPENDIX C

AIRCRAFT INFORMATION

DeHavilland DHC-6-200, Serial No. 19837, N563MA, was owned by NBC Leasing Co. , of New York, New York, and operated by Alaska Aeronautical Industries, Inc., under a lease-buy back arrangement. It was certificated and maintained according to procedures approved by the FAA. w a s manufactured in 1969. At the time of the accident the aircraft had accumulated 15,369.2 flight-hours; 69 hours had been flown since the last progressive inspection.

The aircraft

Engines: Two Pratt & Whitney PT-6-A-20's

No. 1

No. 2

No. 1

No. 2

Serial No.

P C-E- 2 1101

Total Time

5,690.3 hrs.

PC- E- 2 2 23 2 2,491.9 hrs.

Propellers: Two Hartzel HCB-3-TN-3B's

Total Time

978.2 hrs.

1,609.6 hrs.

Documents

NTSB-AAR-78-5 5. 5.Report Date