72 AUGUST 2018 ÇPlane&Pilot
the cockpit had a needle mark indicating the airplane was
climbing at 2,500 feet per minute when impact occurred.
he airplane’s terrain awareness annunciation control
unit was badly damaged, but remains were recovered for
laboratory examination. X-ray-computed tomography
images revealed that the inhibit switch on the unit was not
engaged as found. his and the VSI climb indication might
indicate that if the pilots had inhibited terrain warning
system alerts early in the light to stop nuisance warnings
due to their being at low altitude, the system had been
uninhibited shortly before impact. But, the NTSB pointed
out that it did not have cockpit voice or image recordings,
which might have shed light on what actions the the pilots
did or did not take during the light.
he accident pilot was 43 years old. He held a commercial
certiicate with airplane single-engine, multi-engine land,
and instrument ratings. He also held a light instructor
certiicate. His FAA second-class airman medical certiicate
was current.
At the time of the accident, the company
recorded him having 6,465 hours, with 765 in
the Cessna 208B. He had been employed by
Hageland Aviation since November 2, 2015.
His recurrent training included crew resource
management (CRM) and CFIT-avoidance
ground and simulator training. Records for
his CFIT-avoidance light simulator training
indicated he performed the speciied escape
maneuvers with no diiculties.
Hageland records show that the pilot had
lown between PAQH and PATG a total of 26
times in the preceding 11 months.
According to the pilot’s wife, after a few of his
friends died in crashes, he became even more safety-
conscious and did not take any chances. he pilot lived
in Montana with his wife and was based in Bethel,
where he lived in a pilot dorm. Hageland pilots worked
two-weeks-on, two-weeks-off schedules. He com-
muted by commercial carrier from Bozeman to Bethel.
he second-in-command, age 29, held a commercial cer-
tiicate with airplane single-engine land and instrument
ratings. His second-class FAA medical was current. He had
273 hours with 84 in Cessna 208B aircraft.
his pilot’s girlfriend told investigators he described
his lying as like the “wild west,” lying in low visibility and
below minimums. She said he told a friend that he would
agree with what the captain of the light wanted to do. he
pilot and the girlfriend lived in Anchorage.
An automated weather observing station was located
at PATG. Field elevation is 18 feet MSL, and it is about 10
nm southeast of the accident location.
he 11:56 observation was: calm wind; visibility 7 miles
in light rain; scattered clouds at 3,900 feet, overcast at 4,700
feet AGL; temperature 7 degrees C.; dew point temperature
6 degrees C.; altimeter 29.88. Rain began at 11:32.
Honeywell representatives developed GA-EGPWS simu-
lations for the light using an estimated cruise altitude
of 1,000 feet MSL and the light track as plotted fromcommercial data. he estimated terrain clearances were
between 500 and 700 feet. he simulation assumed that the
airplane entered a climb after the last known data point
and achieved and maintained an altitude of 2,300 feet MSL
beginning 3 nm from the initial impact point.
Under the simulation, the terrain warning equip-
ment began providing continuous “CAUTION TERRAIN,
CAUTION TERRAIN” alerts 46 seconds before impact.
hen, 36 seconds before impact, the pilots would have
heard “TERRAIN, TERRAIN, PULL UP” with “PULL UP”
repeated until impact.
he NTSB said the probable cause was the light crew’s
decision to continue VFR light into deteriorating visibility
and their failure to perform an immediate escape maneuver
after entry into instrument conditions, which resulted in
controlled light into terrain. Contributing to the accident
were (1) Hageland’s allowance of routine use of the ter-
rain inhibit switch for inhibiting the terrain awareness
and warning system alerts and inadequate guidance for
uninhibiting the alerts, which reduced the
margin of safety, particularly in deteriorating
visibility; (2) Hageland’s CRM training; (3)
the FAA’s failure to ensure that Hageland’s
approved CRM training contained all the
required elements of FAR 135.330; and (4)
Hageland’s CFIT-avoidance ground training,
which was not tailored to the company’s
operations and did not address current CFIT-
avoidance technologies.
CFIT-avoidance training was not required
by regulation for Part 135 airplane operations.
Hageland and many other Alaska operators
provided CFIT-avoidance training through participation
in the Medallion Foundation, an outside organization that
gave a “star” to operators using Medallion guidance to create
a CFIT-avoidance program. he operators were allowed to
use the “star” in their advertising.
he NTSB criticized Hageland’s CRM training for not
providing procedures for flight crew coordination, com-
munication and the division of crew duties. he Safety Board
said that the company didn’t provide flight crews with
the skills to exercise good aeronautical decision-making
and judgment to mitigate the risk of CFIT. It criticized
the FAA for not providing proper oversight of the CRM
training. hat would seem to ignore the fact that the
se c on d Ha gel an d crew lying the same route avoided a
CFIT accident.
While the NTSB’s prevention eforts stemming from
this accident were focused on Part 135, it could just as
easily have served as a hook for a CFIT-avoidance alert for
all pilots. After all, the threat of CFIT is so ubiquitous that
completely eliminating it will require moving mountains. PPPeter Katz is editor and publisher of NTSB Reporter, an independent monthly
update on aircraft accident investigations and other news concerning the
National Transportation Safety Board. To subscribe, visit http://www.ntsbreporter.us
or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY
10602-0831.❯ ❯ “Contributing to
the accident were [the
pilot's] routine use
of the terrain inhibit
switch for inhibiting
the alerts, which
reduced the margin
of safety, especially in
deteriorating visibility.”