Pilot Debrief

CESSNA U206 near Port Alsworth, AK — 2017-07-27

Final reportANC17FA039
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Date
2017-07-27
Location
Port Alsworth, AK, USA
Aircraft
CESSNA U206
Registration
N1749R
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of visual reference and subsequent controlled flight into terrain. Contributing to the accident was (1) the inadequate preflight weather planning by the pilot and duty officer (2) the operator's inadequate operational control structure, and (3) the inadequate oversight of the operator's operational control structure by the Federal Aviation Administration.

Contributing factors

Contributing to the accident was (1) the inadequate preflight weather planning by the pilot and duty officer (2) the operator's inadequate operational control structure, and (3) the inadequate oversight of the operator's operational control structure by the Federal Aviation Administration.

NTSB narrative

The instrument-rated commercial pilot was conducting a visual flight rules (VFR) on-demand cargo flight over remote, mountainous terrain in an airplane that was not equipped for instrument flight. Low cloud ceilings and visibility prevailed in the area of the accident site from about 30 minutes before the pilot departed through the accident time. Based on the weather conditions in the area and tracking data from onboard the airplane, it is likely that the pilot encountered low cloud ceilings and low visibility conditions en route and attempted to descend in order to continue toward the destination; the airplane impacted trees and terrain in a level attitude consistent with controlled flight into terrain. The flight occurred during the pilot's first season flying in Alaska. It is likely due to the pilot's lack of flight experience in remote areas and his first season flying in Alaska, poor decision making occurred with his decision to descend in an area of low cloud ceiling and low visibility in mountainous terrain in order to continue toward the destination as opposed to turning around, climbing, or diverting the route of flight. Postaccident examination of the airplane revealed no evidence of preimpact mechanical anomalies that would have precluded normal operation. The company president/director of operations (DO) was out of the country when the accident occurred. Per the DO, either himself or the office manager, as the duty officer, are the ones that exercise operational control over the company's flights. On the day of the accident, the office manager, was exercising first-tier operational control (per the two-tiered operational control concept) over the flight as the duty officer. The office manager, who held a private pilot license, was not listed by name in the company's general operations manual (GOM) or in the Federal Aviation Administration (FAA)-issued operations specifications as an individual who could exercise operational control over a flight. The FAA states that individuals who exercise operational control must be qualified through training, experience, and expertise. The operator did not have an operational control training program. The operator had an operational control organizational structure in place, that was accepted by the FAA, that allowed the office manager to exercise operational control when he was not qualified, nor was he listed by name in the GOM. The operator having an organizational structure in place that allowed any company employee to perform as a duty officer who can exercise first-tier operational control without meeting the requirements of the 14 CFR Part 119 and 14 CFR Part 135, showed a lack of understanding of operational control; in addition to, a loss of operational control with the air carrier due to hands off management resulting in inadequate controls over its own operation and an exercise of operational control by unapproved persons. The pilot nor the office manager received an official weather briefing during the flight release process, nor were they required to by the company's GOM. An Aviation Routine Weather Report (METAR), originating about 12 miles southwest of the accident site was issued about 1 hour and 10 minutes prior to the flight's departure. Few clouds at 300 ft above ground level (agl), a broken ceiling at 1,500 ft agl, and remarks, "estimate pass closed" (the remark refers to the Lake Clark Pass) were listed. The office manager reported that he and the pilot did not assess the METAR that morning. Additionally, the office manager reported that he viewed FAA weather camera images prior to the flight's departure for the Lake Clark Pass area and noticed it had "some fog" but he reported, "it looked like it was just fog right over the camera because everywhere else was blue sky." If an official weather briefing was received, unfavorable weather conditions for the morning of the flight affecting the proposed route would have been observed and communicated to the pilot, particularly with the available METAR data. Information in the official weather briefing from the National Weather Service flying weather chart showed marginal VFR weather for the area encompassing the route of flight and the accident site. A review of FAA weather camera images, from multiple directions, prior to the flight's departure indicated complete mountain obscuration conditions affecting the proposed route with low visibility underneath the overcast cloud layer with all the higher terrain refences obscured by clouds, which would be unfavorable for VFR operations in that area. It is likely the pilot, who was exercising second-tier operational control, did not sufficiently assess the weather for the proposed flight route near Lake Clark Pass during the preflight planning process. The FAA principal operations inspector (POI) assigned to oversee the operator stated that he was saturated with certificate management duties and did not have adequate time to devote to the accident operator. Had the POI had adequate time to devote to the accident operator, the operational control deficiencies may have been identified and corrected.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain an official weather briefing before the flight.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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