One year later: The crash of Flight 3296

A commuter airplane has crashed near the airport in a small Alaska community on the Bering Sea, Thursday, Oct. 17, 2019, in Unalaska, Alaska. Freelance photographer Jim Paulin says the crash at the Unalaska airport occurred Thursday after 5 p.m. Paulin says the Peninsula Airways flight from Anchorage to Dutch Harbor landed about 500 feet (152 meters) beyond the airport near the water. (Jim Paulin via AP)
A commuter airplane has crashed near the airport in a small Alaska community on the Bering Sea, Thursday, Oct. 17, 2019, in Unalaska, Alaska. Freelance photographer Jim Paulin says the crash at the Unalaska airport occurred Thursday after 5 p.m. Paulin says the Peninsula Airways flight from Anchorage to Dutch Harbor landed about 500 feet (152 meters) beyond the airport near the water. (Jim Paulin via AP)

Twelve months ago, on Oct. 17, 2019, PenAir Flight 3296 overran the runway while landing at the Dutch Harbor airport, resulting in one passenger killed and four others injured. Since then, Ravn Alaska, which owned PenAir along with sister companies Corvus Airlines and Hageland Aviation, declared bankruptcy and auctioned off or sold the bulk of its assets.

Company executives blamed Ravn’s failure on the coronavirus, but on the Flight 3296 anniversary, it is worth considering just what happened to PenAir in the single year it was owned by Ravn, and what we have learned since the accident that exposes problems within the company in the months leading up to the tragedy.

Soon after the accident, the National Transportation Safety Board released an investigative update detailing the flight crew’s minimal experience in the aircraft. Ravn stopped all flights of the Saab 2000 into Unalaska and Alaska Airlines dropped the lucrative Capacity Passenger Agreement (CPA) it had with Ravn. The loss of the CPA, which paid Ravn for the Unalaska flights at “predetermined rates plus a negotiated margin, regardless of the number of passengers on board or the revenue collected,” had serious financial ramifications for the company. Questions raised by the NTSB’s preliminary investigation, however, left Alaska Airlines with little choice.

According to the NTSB’s initial report, and heavily covered in the media, the pilot in command (PIC) for Flight 3296 had an estimated 20,000 hours total flight time, but only 101 hours in the Saab 2000 (the co-pilot, with 1,446 hours total time, had 147 hours in the aircraft). Under PenAir’s previous ownership by the Seybert family, PICs were required to have 300 hours minimum in the Saab 2000 before operating into Dutch Harbor. (Similar requirements have existed for other companies operating at the challenging airfield.)

Based on the PenAir Operations Manual, flight-time minimums could be waived if approved by the company Chief Pilot. While the existence of such a waiver has not been addressed publicly, one month after the accident, the Federal Aviation Administration confirmed that Chief Pilot Crystal Branchaud had been replaced and no longer held a position of operational control with PenAir. The extent to which she or any other management personnel played a role in assigning the PIC to Flight 3296 will likely receive serious attention in the accident’s final report.

Another area of significant interest for investigators will be the flight crew’s decision to land in turbulent weather conditions. In the report, the NTSB stated that when Flight 3296 first attempted to land on Runway 13, the winds were at 10 knots from 270 degrees. After initiating a go-around, the winds were reported at 16 knots, gusting to 30, from 290 degrees. While on final approach the second time, the winds were 24 knots from 300 degrees, providing almost a direct tailwind. The aircraft was configured for approach with 20 degrees of flaps both times.

Aircraft landing performance standards are based on multiple factors including weight and balance, wind and runway conditions. While Flight 3296′s weight and balance has not been released, it is possible to determine a conservative estimate of its total weight from available data. According to the manufacturer, the aircraft has a basic empty weight of about 30,500 pounds (this includes the three-member crew). Adding fuel for required reserves and Cold Bay as an alternate destination (about 2,000 pounds) and weight for 39 passengers at the FAA standard for summer adults (195 lbs x 39 = 7,605 pounds), a total weight of 40,105 pounds can be calculated. This excludes any baggage that may have been onboard.

For Runway 13 at Dutch Harbor, PenAir’s company performance standards permitted a landing weight, with 20 degrees of flaps, of 40,628 pounds with zero wind, 35,402 pounds for 5 knots of tailwind and 29,955 pounds for 10 knots of tailwind. It recommended a reduction of 1,031 pounds for each additional knot of tailwind. There is thus no discernible calculation that would recommend landing on Runway 13 with the reported winds at the time of the crash at the aircraft’s approximate weight.

According to the NTSB, the flight crew reported touching down about 1,000 feet down the runway, with skid marks first appearing at about 1,840 feet. From there, the marks continued 200 feet before the aircraft crossed a grassy area, impacted the airport’s perimeter fence, crossed a ditch, hit a large rock and then crossed Ballyhoo Road. It was on the opposite shoulder of the road, over the rock seawall and nearly into the waters of Dutch Harbor, that Flight 3296 finally came to rest.

After the aircraft stopped and a desperate but ultimately unsuccessful effort was underway to save the life of passenger David Oltman, the flight crew waited with forward passengers for assistance in exiting. It was at that point, according to passenger Steve Ranney, that a brief verbal exchange occurred. “A passenger asked the captain why he landed,” explained Ranney in an email, “and he calmly said the computer showed he was within the safety margin.” According to Ranney, who was interviewed by NTSB investigators, neither the captain nor co-pilot spoke another word.

There is no onboard computer that calculates landing performance for the Saab 2000; the PIC could only have been referring to an app likely used on his company-issued iPad. “Electronic flight bags” are commonly utilized by pilots, but the use of any software for the purposes of formal flight planning in commercial operation would have to be approved by the FAA. When asked if PenAir had authorization to utilize performance calculation software, the FAA referred the question, as part of an ongoing investigation, to the NTSB. The NTSB would state only that “crew performance standards equipment procedures and a host of other factors” would be part of the investigation.

Decision-making is always an area of particular inquiry following a commercial crash, both on the part of the flight crew and company management. As investigators moved from the aircraft to the cockpit and back to the offices of PenAir, Ravn Air Group and even the FAA, there are other events in 2019 that may have garnered interest and point to further issues within the newly acquired company.
In February last year, PenAir Flight 3298 suffered an engine loss about an hour after departing King Salmon. In a statement to ADN at the time, FAA spokesman Allen Kenitzer said the aircraft “experienced engine trouble, so pilots shut it down.” The flight crew then returned to the village. In a subsequent Service Difficulty Report (SDR), the company reported a “right engine auto shutdown in flight, did not attempt restart. Troubleshooting in progress.” It is unknown what the final remedy was for that engine.

In July, PenAir Flight 2051 was en route from Anchorage to Dillingham when it suffered the loss of the right engine near its destination. As later detailed in a passenger complaint submitted to the FAA, the flight crew chose to turn around and fly all the way back to Anchorage on only one engine.

PenAir subsequently reported in an SDR that there was a “RT engine overtemp in cruise with auto shutdown” and that the engine was to be removed and replaced. Additionally, in a separate SDR the same day, the company reported a problem with the aircraft’s left engine, which went to “0 PU’s 5SEC.” The remedy was for that engine also to be replaced.
No mention of the problems with the left engine nor the necessary replacement of both engines was passed on to the passenger who filed the complaint. Neither was an explanation provided for the flight crew’s decision to forgo immediate landing at the nearest suitable airport (as required by federal regulation 121.565).

FAA Safety Inspector David Friend wrote to the passenger, a licensed pilot from the Bristol Bay region, that “it has been determined that the flight crew acted within the scope of all applicable Federal Aviation Regulations and associated PenAir Operations Specifications.” In a subsequent Freedom of Information Act request I submitted for a deviation of 121.565 report, the FAA responded that nothing pertaining to my request existed.

Months later, in the days after the crash of Flight 3296, Ravn announced a shift to using Dash-8 aircraft on the route and company management initiated a concerted effort to deflect blame to the Saab 2000. In an October 25 town hall meeting, CEO Dave Pflieger said Ravn would “need to go through a multifaceted process to ensure it is safe to land Saabs in Unalaska before they can return to service there.” This negative sentiment was echoed by Ravn’s new management, which acquired the PenAir and Corvus Airlines certificates along with several Dash-8 aircraft in a private sale last summer. In a July interview with KUCB, that company’s CEO, Rob McKinney, responded to questions about safe operations in rural Alaska by commenting on the crash of Flight 3296. “The Saab 2000 has a narrower margin of safety,” he asserted, “so that… potentially was a contributory cause of that unfortunate accident last year.”

Both Pfleiger and McKinney’s assessments ran sharply counter to the more than two years of accident-free flying with the aircraft under the Seyberts’ ownership, including thousands of flights into Unalaska. Further, from the time the Saab 2000s were acquired by the Seyberts and long before they were put into service, there was extensive flight testing, upgrades, modifications and certifications required for their transition to Part 121. All of this was heavily supervised by the FAA. By the time PenAir was purchased by Ravn in October 2018, there was nothing left for the Saab 2000 to prove; the aircraft simply needed the company to assign pilots who were trained how to fly it.

For now, Alaska Airlines flies scheduled service into Cold Bay, with continuing service to Unalaska provided by Grant Aviation. Alaska Central Express offers both regular cargo flights and passenger charter service and other operators, including Dena’ina Airtaxi, Alaska Air Transit, Resolve Aviation and Security Aviation also fly passenger charters. The Saab 2000s, which were leased by PenAir, have been parked at Anchorage International by their Florida-based owner since Ravn’s collapse. They will likely be relocated to the Lower 48 for maintenance and storage in the near future.

The NTSB’s final report on Flight 3296 should be released early next year. What it will reveal about problematic risk management assessments at all levels of the company is of great interest to anyone following aviation safety in Alaska. And while the detrimental fallout from the subsequent pandemic can not be ignored, it must be noted that Ravn was the only Alaska aviation company of significant size to file for bankruptcy after the virus. Further, although Ravn destroyed numerous financial, professional and customer relationships, many other companies shouldered the pieces it left behind while still continuing to navigate the current uncertain economic landscape.

The easiest thing in the world would be to dismiss PenAir’s summer engine problems and the decisions leading up to the Unalaska crash, disregard how long Ravn’s $90 million worth of unpaid bills were accruing, pay no attention to the likely sky-high fleet insurance the company was paying and simply blame everything that happened to it on the coronavirus. But just like the transparent attempt to shift responsibility of the Flight 3296 tragedy onto the aircraft, this would also require a determination to blindly ignore so many events leading up to Ravn’s demise, including its 16 accidents and incidents over the previous ten years. It is worth noting the most recent of those was not Flight 3296, but rather a gear-up landing by Hageland Aviation in Fairbanks, four months before Ravn shut down. It was easy to miss that one when the company was so loudly insisting everything was COVID-19′s fault.

Link: https://www.adn.com/opinions/2020/10/21/one-year-later-the-crash-of-flight-3296/

NTSB EXTENDS TERM FOR GA SAFETY EXPERT LANDSBERG

NTSB Vice Chairman Bruce Landsberg, an aviation safety expert who is a familiar face to general aviation pilots, will serve in his NTSB leadership role for three additional years, the board announced August 26.

The former AOPA Air Safety Institute executive director was appointed to a five-year NTSB board position in August 2018 when he was also designated the NTSB’s vice chairman for a two-year term.

Landsberg is a respected aviation safety advocate and a 7,000-hour pilot who holds an airline transport pilot certificate as well as single-engine, multiengine, and instrument flight instructor certificates.

He has been an AOPA member for more than 40 years and is often seen piloting his pristine Beechcraft Bonanza A36.

“Bruce brings a wealth of experience to the NTSB with his extensive general aviation safety background,” said NTSB Chairman Robert Sumwalt. “While serving as vice chairman during the past two years, Bruce has provided great assistance to me in my role as chairman. I’m delighted that President Trump has allowed him to continue in that capacity for another three years.”

Landsberg is advocating for several GA safety recommendations during his term. He would like to see a more user-friendly notam system, as well as improved weather forecasts and the reduction of weather-related aviation crashes through more extensive in-flight weather reporting by pilots.

He also supports a reduction in driving distractions and speed-related highway crashes, reliable automation in vehicles, and automated enforcement on highways.

Bruce Landsberg. Photo by Christopher Rose.
Bruce Landsberg. Photo by Christopher Rose.

Link: https://www.aopa.org/news-and-media/all-news/2020/august/27/ntsb-extends-term-for-ga-safety-expert-landsberg

Texas pilot warned not to fly plane before fatal 2018 Detroit crash, report says

NTSB agents work at the site of the fatal plane crash in Detroit in June 2018.
NTSB agents work at the site of the fatal plane crash in Detroit in June 2018. (Photo: Daniel Mears, The Detroit News)

A Texas pilot was warned three times not to fly his airplane before it crashed in a Detroit neighborhood in 2018, killing him and his wife and severely injuring his son, according to a federal accident investigation.

The factual report by the National Transportation Safety Board also says the pilot reported running out of fuel while struggling to get his landing gear down as the single-engine Cessna P210N approached Coleman A. Young Municipal Airport on June 24.

Pilot Greg Boaz, a restaurateur, and his wife, Julie, both of League City, Texas, died in the crash. Boaz’s 17-year-old son Peyton rolled out of the burning wreckage and was critically injured.

The family was on its way to watch daughter Krysta play in a volleyball tournament in Detroit.

The NTSB report and documents, filed June 24, detail the final moments before the crash, including the air traffic control recordings of dialogue between the plane and control tower. A final report, which will include a probable cause of the crash, is expected to be filed within a week.

Three weeks before the crash, mechanic Randy Wahlberg at the Pearland Regional Airport told Boaz that it appeared that pieces of the missing oil dipstick had gotten into the engine and “his engine needed to be overhauled since the dipstick was stainless steel and it made it through the oil pump into the filter,” according to an inspector statement in the report.

“The pilot told the mechanic that he had just purchased the airplane and that he could not afford to overhaul the engine,” the report states. “The mechanic then placed a red ‘Do Not Fly’ placard on the pilot-side yoke.”

According to the report, a couple of weeks later, Boaz came back with another oil filter for the mechanic to inspect and told him he had looked up on the internet “how to remove metal from an engine by flushing it with diesel fuel.”

While there was no metal in the filter, “the mechanic again told the pilot that he should not fly the airplane until the engine had been overhauled.”

Another airplane mechanic, Robert Mutina, told investigators that he was a personal friend of Boaz since high school. Although he had not seen the plane, he had discussed it and advised Boaz not to fly it.

According to the report, a post-crash inspection of the engine found three “small metal pieces that were consistent with remnants of the fractured oil gauge rod” as well as “numerous scratches” in the crankcase.

However, the report concluded, “The post-accident engine examination did not reveal any mechanical malfunctions or failures that would have precluded normal operation during the flight.”

The NTSB did find other reasons for concern about the fatal flight, which originated in Baytown, Texas, with a fuel stopover in West Memphis, Arkansas. According to the agency’s report, data recovered from the plane’s engine monitor showed that while cruising during six previous cross-country flights, Boas “would lean rich-of-peak” – meaning the plane consumed more fuel than expected.

The average fuel use while cruising during those flights was about 21 gallons per hour – the same level recorded during the fatal flight, according to the report. The Cessna, with a fuel capacity of 90 gallons, had used 71.6 gallons “when the recorded fuel flow suddenly dropped to zero” seconds before the crash in Detroit, the report states.

According to the Aircraft Owners and Pilots Association, a Cessna P210 normally burns about 17 gallons of gas per hour. Robert McSpadden, senior vice president of the organization’s Air Safety Institute, said the fatal flight’s cruising rate of 21 gallons per hour was unusual.

“That number seems incredibly high to me,” McSpadden said. “The pilot was flying rich-of-peak, meaning he would burn more fuel; it keeps the engine cooler. That’s typical practice. But 21 just seems really high.”

The fuel selector valve was set to draw fuel from the right-wing tank, the report added, instead of drawing fuel from both tanks simultaneously.

“This may not have been a situation of fuel exhaustion, but of fuel starvation,” McSpadden said.

Upon approaching the airport in Detroit at 7:48 p.m., the pilot told the control tower that his land gear had not locked into place, according to the report. The pilot then requested to land on the infield next to the runway.

“It’s not unusual for a plane to land without landing gear engaged on an airstrip,” McFadden said. “All the gear would just have to be retracted.”

Harro Ranter, CEO of Aviation Safety Network, said it “remains to be seen” how the aircraft ran out of fuel. Ranter speculated that either the pilot misread the fuel gauge or was so fixated on the landing gear issue that he neglected to watch it.

A faster burn rate of fuel would mean that a pilot would use more fuel than expected to reach his destination. Pilots are required to have enough fuel on board to reach their destination plus 30 minutes of additional flying during day flights, according to FAA regulations.

McSpadden added: “Seventy-five percent of aviation accidents are pilot errors. There are a lot of clues that show that there was something else wrong with this flight.”

Boaz, 54, was owner of two Texas venues, Lone Star Grill in Bacliff, Texas and Palapa Bar, a nightclub, in Kemah. Julie Boaz was 48. The couple was recently married and were survived by children Tyler, Krysta and Peyton and Daniel Costano Jr. and Cecilia Costano, according to an obituary with Carnes Funeral Home.

Link: https://www.detroitnews.com/story/news/local/detroit-city/2020/08/01/houston-area-pilot-warned-not-fly-plane-before-fatal-detroit-crash/5521343002/

Badly Damaged Firefighting Plane Removed From Remote Site to Aid NTSB Investigation

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An Air Tractor AT-802A Fire Boss like this was damaged when it went down in a stand of trees after attempting to scoop water near the Birch Creek Fire 17 miles northwest of Circle.
Credit U.S. Forest Service

A heavy-lift helicopter moved a badly damaged firefighting airplane over the weekend from a remote site near Circle to an airstrip in Central. From there, the airframe and engine will be taken to the Lower 48, where federal investigators will study them to determine what caused the water-scooping aircraft to go down on July 14th.

The chief of Alaska’s National Transportation Safety Board office says a crew contracted by the insurer of the Minnesota-based company that owns the wrecked aircraft moved it to Central so it can be transported by truck to a facility where the NTSB can take a closer look at it.

“The airplane is going to be relocated to Texas,” Clint Johnson said, “and that’s where we’ll basically do our wreckage layout and see if we can figure out exactly what happened here.”

Johnson says the water-scooping plane leased by the Alaska Fire Service was heavily damaged in what the NTSB has classified as an aircraft accident. The single-engine Air Tractor AT-802A Fire Boss went down into a stand of trees after the pilot was trying to scoop up some water to drop onto the Birch Creek Fire burning near Circle, about 120 miles northeast of Fairbanks.

Johnson says the plane had to be partially dismantled before it could be moved, because of its heavy weight.

“This was an accident – it was a non-injury accident, thankfully,” he said in an interview Tuesday. “The airplane did sustain substantial damage, which puts it into the accident category.”

The pilot was the only person aboard the aircraft when the accident occurred. He was examined at the scene, then medivacked to Fairbanks Memorial Hospital, where he was treated and released. Johnson says NTSB planned to talk with him as part of their investigation. He says the agency officials aren’t ready to talk about possible causes of the accident. But he says they hope to release more information soon.

“The preliminary report will probably be out early next week – mid next week, at the latest,” Johnson said.

A final report on the investigation likely won’t be released for several months.

Johnson says the owners of the aircraft, Dauntless Air Inc., of Appleton, Minn., plan to repair the Fire Boss while it’s at the facility in Texas.

Link: https://fm.kuac.org/post/badly-damaged-firefighting-plane-removed-remote-site-aid-ntsb-investigation