Pilot Debrief

Saab 2000 near Unalaska, AK — 2019-10-18

Final reportDCA20MA002
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Date
2019-10-18
Location
Unalaska, AK, USA
Airport
PADU
Aircraft
Saab 2000
Registration
N686PA
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The landing gear manufacturer’s incorrect wiring of the wheel speed transducer harnesses on the left main landing gear during overhaul. The incorrect wiring caused the antiskid system not to function as intended, resulting in the failure of the left outboard tire and a significant loss of the airplane’s braking ability, which led to the runway overrun. Contributing to the accident were (1) Saab’s design of the wheel speed transducer wire harnesses, which did not consider and protect against human error during maintenance; (2) the Federal Aviation Administration’s lack of consideration of the runway safety area dimensions at Unalaska Airport during the authorization process that allowed the Saab 2000 to operate at the airport; and (3) the flight crewmembers’ inappropriate decision, due to their plan continuation bias, to land on a runway with a reported tailwind that exceeded the airplane manufacturer’s limit. The safety margin was further reduced because of PenAir’s failure to correctly apply its company-designated pilot-in -command airport qualification policy, which allowed the accident captain to operate at one of the most challenging airports in PenAir’s route system with limited experience at the airport and in the Saab 2000 airplane.

NTSB narrative

On October 17, 2019, about 1740 Alaska daylight time, PenAir flight 3296, a Saab 2000, N686PA, overran the runway while landing at the Thomas Madsen Airport (PADU), Unalaska, Alaska. The airplane passed through the airport perimeter fence, crossed a road, and came to rest on shoreline rocks. Of the 42 passengers and crewmembers on board, 1 passenger was fatally injured, and several other passengers sustained serious or minor injuries. The airplane received substantial damage. The regularly scheduled domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from Ted Stevens International Airport (KANC), Anchorage, Alaska, to PADU.

NTSB coding

Evidence available

  • CVR
  • Video
  • FDR / data
  • 40 docket documents
View NTSB final reportView NTSB docket

Docket documents40

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