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Collision with Terrain, Hageland Aviation Services, Inc., Dba Ravn Connect Flight 3153, Cessna 208B, N208SD, Togiak, Alaska, October 2, 2016

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Collision with Terrain, Hageland Aviation Services, Inc., Dba Ravn Connect Flight 3153, Cessna 208B, N208SD, Togiak, Alaska, October 2, 2016 Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD Togiak, Alaska October 2, 2016 Accident Report NTSB/AAR-18/02 National PB2018-100871 Transportation Safety Board NTSB/AAR-18/02 PB2018-100871 Notation 57810 Adopted April 17, 2018 Aircraft Accident Report Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD Togiak, Alaska October 2, 2016 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, DC 20594 National Transportation Safety Board. 2018. Collision with Terrain, Hageland Aviation Services, Inc., dba Ravn Connect Flight 3153, Cessna 208B, N208SD, Togiak, Alaska, October 2, 2016. NTSB/AAR-18/02. Washington, DC. Abstract: This report discusses the October 2, 2016, accident involving a turbine-powered Cessna 208B Grand Caravan airplane, N208SD, which was operated by Hageland Aviation Services, Inc., dba Ravn Connect flight 3153, and collided with steep, mountainous terrain about 10 nautical miles northwest of Togiak Airport, Togiak, Alaska. The two commercial pilots and the passenger were killed, and the airplane was destroyed. Safety issues identified in this report include inadequacies in Hageland’s Federal Aviation Administration (FAA)-approved crew resource management (CRM) training program; inadequate FAA oversight of Hageland’s CRM training program; the need for improvements in Hageland’s controlled flight into terrain (CFIT)-avoidance training; the lack of FAA requirements for CFIT-avoidance training programs for Title 14 Code of Federal Regulations Part 135 fixed-wing operations; the lack of effective terrain awareness and warning system (TAWS) protections and nuisance-alert mitigations for flights that operate under visual flight rules at altitudes below the TAWS required terrain clearance; Hageland’s inadequate guidance for pilots’ use of the terrain inhibit switch for the TAWS alerts; TAWS design limitations that require pilot action to uninhibit the alerts after they have been inhibited; the need for safety management systems for Part 135 operators; the need for flight data monitoring programs (and supporting devices) for Part 135 operators; the lack of assurance that operators implemented Medallion Foundation programs effectively; the need for improved infrastructure to support low-altitude instrument flight rules operations in Alaska; the lack of a requirement for crash-resistant flight recorder systems capable of capturing cockpit audio and images for Part 135 operators; and the need for improved sharing of pilot weather reports in remote areas in Alaska. As a result of this investigation, the National Transportation Safety Board makes five safety recommendations to the FAA, two to the Medallion Foundation, and one to Hageland and reiterates eight safety recommendations to the FAA. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b). For more detailed background information on this report, visit https://www.ntsb.gov/investigations/SitePages/dms.aspx and search for NTSB accident ID ANC17MA001. Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service’s National Technical Reports Library at https://ntrl.ntis.gov/NTRL/. This product may be accessed using product number PB2018-100871. For additional assistance, contact: National Technical Information Service (http://www.ntis.gov/) 5301 Shawnee Rd. Alexandria, VA 22312 (800) 553-6847 or (703) 605-6000 NTSB Aircraft Accident Report Contents Figures ........................................................................................................................................... iii Abbreviations ............................................................................................................................... iv Executive Summary .................................................................................................................... vii 1. Factual Information ...................................................................................................................1 1.1 History of the Flight ...................................................................................................................1 1.2 Personnel Information ................................................................................................................4 1.2.1 Pilot-In-Command ...........................................................................................................4 1.2.1.1 Preaccident Activities ........................................................................................5 1.2.2 Second-In-Command .......................................................................................................6 1.2.2.1 Preaccident Activities ........................................................................................7 1.3 Airplane Information .................................................................................................................7 1.3.1 General .............................................................................................................................7 1.3.2 Multifunction Display ......................................................................................................8 1.3.3 Terrain Awareness and Warning System ........................................................................9 1.4 Meteorological Information .....................................................................................................11 1.5 Wreckage and Impact Information ..........................................................................................13 1.5.1 General ...........................................................................................................................13 1.5.2 TAWS Component Examinations .................................................................................15 1.6 Medical and Pathological Information .....................................................................................15 1.7 Tests and Research: GA-EGPWS Simulations ........................................................................16 1.8 Organizational and Management Information .........................................................................16 1.8.1 General ...........................................................................................................................16 1.8.2 Pilot Training, Procedures, and Guidance .....................................................................17 1.8.2.1 General .............................................................................................................17 1.8.2.2 Day VFR Weather and Altitude Requirements ...............................................17 1.8.2.3 CRM Training ..................................................................................................18 1.8.2.4 CFIT-Avoidance Training ...............................................................................19 1.8.2.5 Guidance for TAWS Use .................................................................................23 1.8.3 Operational Control .......................................................................................................26 1.8.4 Safety Program ..............................................................................................................29 1.8.5 FAA Oversight ...............................................................................................................30 1.8.5.1 General .............................................................................................................30 1.8.5.2 Previous FAA Activities and NTSB Urgent Safety Recommendation ...........31 1.9 Medallion Foundation ..............................................................................................................33
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