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BE1900 IMC CFIT in Alaska

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BE1900 IMC CFIT in Alaska

Old 14th Mar 2013, 16:55
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BE1900 IMC CFIT in Alaska

NTSB Identification: ANC13FA030
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, March 08, 2013 in Aleknagik, AK
Aircraft: BEECH 1900C, registration: N116AX
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On March 8, 2013, about 0814 Alaska standard time, a twin-engine turboprop Beech 1900C airplane, N116AX, was destroyed when it impacted rising terrain about 10 miles east of Aleknagik, Alaska. The airplane was operated as Flight 51, by Alaska Central Express, Inc., Anchorage, Alaska, as an on-demand cargo flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The airline transport certificated captain and the commercial certificated first officer sustained fatal injuries. Instrument meteorological conditions were reported in the area at the time of the accident, and the airplane was operating on an instrument flight rules (IFR) flight plan. The flight had originally departed Anchorage about 0544, and made a scheduled stop at King Salmon, Alaska, before continuing on to the next scheduled stop, Dillingham, Alaska.

According to Federal Aviation Administration (FAA) personnel, as the airplane approached Dillingham, the flight crew requested the RNAV GPS 19 instrument approach to the Dillingham Airport about 0757 from controllers at the Anchorage Air Route Traffic Control Center (ARTCC). The ARTCC specialist on duty subsequently granted the request by issuing the clearance, with instructions to proceed direct to the Initial Approach Fix (IAF) to begin the approach, and to maintain an altitude of 2,000 feet or above. A short time later the flight crew requested to enter a holding pattern at the IAF so that they could contact the Flight Service Station (FSS) for a runway conditions report, and the ARTCC specialist granted that request. The ARTCC specialist then made several attempts to contact the aircraft, but was unsuccessful and subsequently lost radar track on the aircraft.

When the airplane failed to arrive at the Dillingham Airport, ARTCC personnel initiated a radio search to see if the airplane had diverted to another airport. Unable to locate the airplane, the FAA issued an alert notice (ALNOT) at 0835. Search personnel from the Alaska State Troopers, Alaska Air National Guard, and the U.S. Coast Guard, along with several volunteer pilots, were dispatched to conduct an extensive search effort.

Rescue personnel aboard an Air National Guard C-130 airplane tracked 406 MHz emergency locater transmitter (ELT) signal to an area of mountainous terrain about 20 miles north of Dillingham, but poor weather prohibited searchers from reaching the site until the next morning. Once the crew of a HH-60G helicopter from the Air National Guard's 210th Air Rescue Squadron, Anchorage, Alaska, reached the steep, snow and ice-covered site, they confirmed that both pilots sustained fatal injuries.

The closest official weather observation station is at the Dillingham Airport. At 0745, an aviation routine weather report (METAR) reported, in part: Wind from 100 degrees (true) at 17 knots with gusts to 30 knots; visibility, 7 statute miles in light rain; clouds and sky condition, 1,500 feet overcast; temperature, 34 degrees F; dew point, 34 degrees F; altimeter, 29.09 inHg.

On March 9, the National Transportation Safety Board (NTSB) investigator-in-charge, along with an additional NTSB air safety investigator, and an FAA operations inspector from the Anchorage Flight Standards District Office (FSDO), examined the airplane wreckage at the accident site. A comprehensive wreckage examination and layout is pending following recovery efforts.

RNAV 19 chart: http://aeronav.faa.gov/d-tpp/1303/05166R19.PDF
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Old 14th Mar 2013, 17:27
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According to Federal Aviation Administration (FAA) personnel, as the airplane approached Dillingham, the flight crew requested the RNAV GPS 19 instrument approach to the Dillingham Airport about 0757 from controllers at the Anchorage Air Route Traffic Control Center (ARTCC). The ARTCC specialist on duty subsequently granted the request by issuing the clearance, with instructions to proceed direct to the Initial Approach Fix (IAF) to begin the approach, and to maintain an altitude of 2,000 feet or above. A short time later the flight crew requested to enter a holding pattern at the IAF so that they could contact the Flight Service Station (FSS) for a runway conditions report, and the ARTCC specialist granted that request. The ARTCC specialist then made several attempts to contact the aircraft, but was unsuccessful and subsequently lost radar track on the aircraft.
Hmmm, I hope I am reading this correctly, but looking at the chart that is linked to at the bottom, the minimum over (and northeast of) the IAF (ZEDAG) is 4300' within a 4nm radius, and 6300nm within a 30nm radius, and 5400' 30nm SW of the IAF. I hope the refence to 2000' feet is simply wrong, they would have had charts out with the higher altitudes I think, and 2000 feet is way to low.
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Old 14th Mar 2013, 17:53
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I see that the min altitude over the IAF, Zedag, is 4300 feet, yet they cleared down to 2000 ft. or above. What kind of clearance is that? Looks like they should have crossed Zedag at 4300 and then started descent on a 3 degree angle to the MDA/VDP. Another screw-up?
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Old 14th Mar 2013, 18:28
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I see that the min altitude over the IAF, Zedag, is 4300 feet, yet they cleared down to 2000 ft. or above. What kind of clearance is that? Looks like they should have crossed Zedag at 4300 and then started descent on a 3 degree angle to the MDA/VDP. Another screw-up?
Big time screw up. The minimum holding altitude is 4,300. They asked to hold while they went off frequency. Their last clearance from ATC was "at or above 2,000."
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Old 14th Mar 2013, 19:15
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Sound similar to Adria MD80 in Ajaccio, 1980.
Cleared below MSA by ATC and hit the ground in IMC.
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Old 14th Mar 2013, 19:17
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I accept all the above, even if I am not familiar with Alaskan ATCC procedures, but is it not reasonable to expect crews to:-

a) Know where they are on an RNAV approach
b) Read the chart
c) Maintain a safe altitude vis a vis position /holding etc?

Especially when not under 'Control'
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Old 14th Mar 2013, 19:29
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Sounds like the good old days in Zurich . Turned down many of their shortcuts .
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Old 14th Mar 2013, 19:29
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Their last clearance from ATC was "at or above 2,000.
Let me check on this. Does not sound right. Also that they would descend to that altitude blindly with the APP Chart on their knees.
Something mising here.
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Old 14th Mar 2013, 20:04
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wrong clearance ??

I agree with what was posted here before. However, some remarks from an ATC - Dinosaur.
The flight was IFR in IMC en route from King Salmon to Dillingham. That routing indicates the probability that the flight was about to enter or within the 30 miles arc around ZEDAG with an MSA of 5400 ft. Next the crew requested to enter the holding pattern connected to ZEDAG. That most probably leads to a tear drop entry into the 30 miles sector north of ZEDAG with an MSA of 6300 ft.
With this as a background and the published RNAV Entry Minima at no time a clearance that contains wording to "maintain at or above 2000 ft. altitude" could be issued by ATC. As I remember ATC is responsible for the terrain clearance of IFR flights in IMC!!
So en route to ZEDAG no clearance below 6300 ft or any other MSA to be obeyed. After establishment in the holding pattern descent clearance to 4300 ft. And only than with the approach clearance issued the request - "report Zedag inbound to the field and leaving 4300 ft "
That´s how we did it some time ago !

Last edited by Annex14; 14th Mar 2013 at 20:15.
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Old 14th Mar 2013, 20:26
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ANNEX14 :
As I remember ATC is responsible for the terrain clearance of IFR flights in IMC!!
Your memory fails you , no, responsibility in IFR for terrain avoidance is always with PIC except when under radar vectoring . (ICAO DOC 4444)
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Old 14th Mar 2013, 20:32
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ATC Watcher

Yes, you´re correct, forgot about that "limitation" !!
Never the less, in my active years I wouldn´t even have gotten it in my mind to clear a flight below MSA. Probably part of the "responsibility drill" we went through in education.
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Old 14th Mar 2013, 20:59
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Strangely, or not, the MHA at King Salmon's RANV (GPS) s 2,000'. Could there have been confusion on the IAF by either the crew or the ATCO or in the comm loop?
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Old 14th Mar 2013, 21:17
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Quick Glance

Under stress, I took a quick glance at the approach chart. I saw 1900 feet proceeding down the glideslope, a 2550 foot obstacle and a buch of lower obstacles (1623, 1860 ) and a missed approach of 2600..plus an authority figure in my life just told me 2000 feet. I worried only about the 2550 foot obstacle and vowed to hang around 2600 to keep a cushion
and do the missed. I filtered out all the other information becasue I was under stress.
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Old 14th Mar 2013, 21:29
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ATC Watcher:

Your memory fails you , no, responsibility in IFR for terrain avoidance is always with PIC except when under radar vectoring . (ICAO DOC 4444)
Actually U.S. ATC procedures are much more restrictive in this regard than most of the world as a result of the 1974 TWA 514 CFIT accident.

ATC is responsible for assigning an altitude at, or above the MEA if the flight is on a published route. If the flight is cleared direct then en route ATC (which was the case here) must assign at altitude at or above the ATC center's MIA chart.

The crew also had a duty to challenge this improper clearance because the approach chart had a wealth of operational altitude information.

The ATC clearance per the U.S. FAA controller's manual should have been not less than 4,300 since the flight was cleared direct to ZEDAG.

The preferred clearance would have been, "Cleared direct ZEDAG, maintain 4,300 [or higher], expect clearance for the RNAV Runway 19 approach."

A second compliant clearance would have been, Cleared direct ZEDAG, cross ZEDAG at 4,300 [or 4,300 or above], cleared for the RNAV Runway 19 approach."
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Old 14th Mar 2013, 21:33
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Strangely, or not, the MHA at King Salmon's RANV (GPS) s 2,000'. Could there have been confusion on the IAF by either the crew or the ATCO or in the comm loop?
The Anchorage Center MIA is also 2,000 from King Salmon to fairly near PADL, where it becomes 4,000. Five west, or so, or PADL the MIA is 5,000.
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Old 14th Mar 2013, 23:34
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Under stress, I took a quick glance at the approach chart. I saw 1900 feet proceeding down the glideslope
Relax, there is no glideslope, it is a non precision.
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Old 14th Mar 2013, 23:41
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Wow. A wake-up call for sure. A reminder that under the wrong circumstances you don't have to be very far off your game...

Whatever the NTSB ends up saying, the lesson I'm reminded of when it comes to ATC clearances is best described by one of Ronald Reagan's most notable quotes: "Trust.... But verify."

And I was just telling a story yesterday about that: We were holding short of the runway at KEGE one morning, just finishing the checklist when the tower cleared us for takeoff. I put my hand on the parking brake handle as I looked up the approach path. What I saw made me put my hand back on my lap. I looked at the FO and he looked at me, then I pointed to myself, indicating I'd like to be the one to make the radio call. The FO nodded as I called tower and told them we'd need to hold short for a couple of minutes. The next radio call apparently came from the AA B-757 on a quarter mile final: "Thanks guys." The new voice on tower sounded a little stressed when he canceled our takeoff clearance. Lesson? Everyone makes mistakes, So trust... But verify.

Last edited by westhawk; 14th Mar 2013 at 23:42.
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Old 15th Mar 2013, 00:31
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As a 10 year ATC, and 23 year ATP, Arpster is correct, sort of....

It seems that this accident closely mirrors the TWA accident in Virginia...

However, ATC procedures were changed as a result of that accident...When not on a pulbished segment and subsequently being "cleared for approach", the correct phraseology is "Maintain xxx until ESTABLISHED on the approach, cleared for..."

In this case, the controller didn't " protect" the flight with the clearence to descend to 2000'...Then once they requested holding, the clearence should have been something along the lines of ..."Climb and maintain 4,300, cleared to hold..."...etc...

In any case, the PIC is responsible to insure the clearence is correct, as ATC is responsible to assist when the flight descends below the MVA...

In a non-radar enviornment this becomes critically important...

Seems someone here dropped the ball...from what I've seen posted here, there is enough blame to go around so everyone can have a piece of the pie...
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Old 15th Mar 2013, 01:04
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DownGreen:

As a 10 year ATC, and 23 year ATP, Arpster is correct, sort of
Why sort of?

If nothing else you make the case for MVAs and MIAs being widely distributed aviation public data instead of FAA state secrets.

Last edited by aterpster; 15th Mar 2013 at 01:05.
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Old 15th Mar 2013, 08:24
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aterpster

What I missed yesterday when reading your first post was the height of the crash site. Started a search for and found it in here:
Crash: Ace Air B190 near Dillingham on Mar 8th 2013, wreckage found

They obviously were indeed at the low altitude of 2000 ft which was part part of their clearance from ATCC Anchorage. Aside of what is apparently ATC responsibility the question remains: why for heavens sake the crew descended so low with all the information on the approach charts at hand ??
Hopefully not another case of over confidence in the magic words "identified, Radar contact" and the mentally wrong expectation of flying safe if only the instructions are followed.
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