N9530F

HISTORY OF FLIGHT

On October 10, 2001, about 0926 Alaska daylight time (all times in this brief are Alaska daylight time based on a 24-hour clock), Peninsula Airways, Inc. (PenAir) flight 350, a Cessna CE-208 Caravan, N9530F, crashed shortly after takeoff from the Dillingham Airport (DLG), Dillingham, Alaska. The pilot and nine passengers were killed, and the airplane was destroyed. (One passenger was evacuated to Anchorage, Alaska, but died the next day.) There was no fire. The impact site was located about 0.7 nautical miles (nm) northeast of the departure end of runway 01 at DLG. The accident occurred during daylight hours, and visual meteorological conditions prevailed at the time of the accident. The flight was operated by PenAir as a visual flight rules flight in accordance with Title 14 Code of Federal Regulations (CFR) Part 135 of the Federal Aviation Regulations (FAR). Flight 350 was bound from DLG to King Salmon, Alaska.

The pilot of the accident airplane arrived for duty at DLG about 0800 the morning of the accident. The flight coordinator informed the pilot that he would fly N9530F to King Salmon, Alaska, with nine passengers.

The airplane had been parked outside on the ramp overnight, and flight 350 was to be its first flight of the day. DLG had experienced light rain and mist for most of the day before the accident. This precipitation turned to light snow and mist about 2016 and continued until about midnight as the first major winter weather of the season passed through the Dillingham area. Temperatures dropped steadily to about -4 degrees C (24 degrees F).

Several pilots whose airplanes were also parked outside overnight were interviewed about the snow accumulation on their airplanes the morning of the accident. A PenAir check airman who was scheduled to fly a Cherokee to King Salmon, Alaska, with the overflow passengers from PenAir flight 350 described the contamination on his airplane as "like epoxy" and said that he observed that the snow/ice on his airplane and on the accident airplane were the same. Another PenAir pilot reported that his airplane had 1/8-inch-thick icy patches covered by about 1/4 inch of snow. Another pilot on the field stated that his airplane was covered with 1/4 to 1/2 inch of clear ice with snow/frost on top.

Between about 0830 and 0840, a pilot from another operator on the field observed the accident pilot conducting a preflight check of the accident airplane. The accident airplane had not yet been deiced.

The PenAir ramp supervisor reported that, sometime before 0900, the accident pilot asked him to fuel the accident airplane with 60 gallons of Jet A fuel (30 gallons in each wing tank). The ramp supervisor told the pilot that his airplane would need deicing. The pilot did not acknowledge this comment. While returning to the flight office, the pilot met the PenAir check airman and asked what the deicing procedures were in Dillingham. The check airman told Safety Board investigators that he did not think the pilot's question was unusual because the pilot had not deiced at Dillingham previously. He told the pilot that the deicing procedures were the same as for a Cherokee and that the pilot should make sure that his airplane was thoroughly deiced that morning.

The PenAir ramp employee who fueled the accident airplane said that he had trouble removing the accident airplane's left fuel cap due to what he described as "1/4 inch of frost with maybe ice underneath." He reported that he had to use a tool to remove the fuel cap.

After the fueling was complete, the ramp supervisor sprayed deicing fluid on the accident airplane. The PenAir ramp employee who had fueled the airplane drove the forklift with the deicing equipment attached. The supervisor described the accident airplane as having 1/8 inch of frost that covered the entire airplane. He said that he did not physically touch the surfaces of the wing after the deicing process because he believed that the upper surface of the wing was clear of ice. The ramp employee driving the forklift said that he could not see the accident airplane's wing after deicing but that "a lot of glycol" had been applied. The pilot was not present during the deicing.

About 0850, the PenAir check airman flying the Cherokee to King Salmon was on the ramp and watched as the accident airplane was deiced. He stated that he saw the accident airplane deiced one time and that the process was completed in about 20 minutes. The same crew and equipment that deiced the accident airplane deiced his airplane.

No witnesses were found who could verify whether, after the fueling and deicing of the accident airplane was complete, the accident captain climbed a ladder or used any other means to check that the fuel caps were replaced properly or that the upper wing surfaces were clear of ice, snow, or frost. A PenAir customer service manager did state that he saw glycol on the accident pilot's coat prior to the accident airplane's departure. In addition, the PenAir check airman reported that, when he looked at the accident airplane from the ground and again from the wing of his own airplane, the accident airplane appeared to be free of snow.

About 0920, as he taxied the Cherokee out to the runway, the check airman observed the accident airplane's takeoff roll. He said that the accident airplane used the normal amount of runway. After aligning the Cherokee with the centerline of runway 01, the check airman looked up and saw the accident airplane make the standard 45-degree right turn to depart the local airport traffic pattern. The check airman reported that everything appeared normal about the accident airplane at that time. A pilot doing a preflight check on his airplane on the north end of the field said that he glanced up and saw the accident airplane during takeoff, about 50 feet above the Bravo intersection.

A private pilot who was talking on the telephone in his office less than 1 mile from the accident site watched as the accident airplane took off. This witness said that the airplane was traveling from left to right and was moving slightly away from him. The airplane appeared to be straight and level and at an altitude of less than 1000 feet above ground level. The sound of the engine was normal and gradually dissipated as the airplane traveled across his field of view. This witness stated further that the flight appeared to be normal until the airplane abruptly pitched up, rolled more than 90 degrees to the left, and yawed to the left, "back towards the airport," when he was able to see the entire top of the airplane. The witness reported that the nose of the airplane then dropped until the nose pointed directly down as the airplane rolled to the right. The airplane did not spin. The airplane finally disappeared behind a small hill in a nose-down attitude. The witness immediately hung up the telephone, dialed 911, and left for the accident site. When he arrived, fire and rescue personnel were already on scene.

PERSONNEL INFORMATION

The pilot, age 41, held a commercial pilot certificate with an airplane single-engine and multi-engine land, and instrument rating; he also held an airframe and powerplant mechanic certificate. His most recent second-class medical certificate was issued on February 9, 2001, with the limitation, "The holder shall wear corrective lenses."

PenAir hired the accident pilot on October 16, 2000, and he had accrued 869 hours of total flight experience since that time. PenAir records also indicate that, at the time of the accident, the pilot's total flight experience consisted of about 3,100 hours. In the 90 days, 30 days, and 24 hours prior to the accident, PenAir records show that the pilot had accrued a total of 271, 86, and 4.4 hours, respectively.

PenAir records show further that the pilot had accrued a total of about 74 hours in the Cessna CE-208 Caravan, the same airplane make and model as the accident airplane. Records also show that the pilot's initial flight training in the CE-208 occurred on June 4, 2001, that his last CE?208 FAR 135.293 competency check and FAR 135.299 line check prior to the accident also occurred on June 4, 2001, and that his initial operating experience in the CE-208 occurred on August 11, 2001. PenAir's records indicate that the accident pilot was also qualified in the Piper PA-32.

AIRCRAFT INFORMATION

The accident airplane, a Cessna Caravan CE-208, N9530F, S/N 20800088, was manufactured in 1986. The airplane had accumulated 10,080 hours since it was manufactured. The most recent inspection was accomplished on October 5, 2001, 12.4 hours before the accident.

The airplane was equipped with a Pratt & Whitney Canada (PW&C) PT6A-114 turbopropeller engine and a three-bladed Hartzell Propeller, model number HC-B3MN-3, with M10083K composite blades. The engine had accumulated 10,984 hours.

The airplane's weight and balance were within the normal operating range. A review of the airplane and engine logbooks revealed no discrepancies and no deferred items for the accident flight.

METEOROLOGICAL INFORMATION

At 0851, the on-field Federal Aviation Administration (FAA) flight service station reported the DLG weather as follows: wind, from 260 degrees at 5 knots; visibility, 10 statute miles with a few clouds at 2,000 feet; temperature, -4 degrees C (24.8 degrees F); dew point temperature, -10 degrees C; and altimeter, 29.40 inches of Hg.

AIRPORT INFORMATION

Dillingham airport is an uncontrolled airport with a part-time FAA Flight Service Station located on the field. The airport has one grooved asphalt runway, 01/19, which is 6,404 feet long. No radar services are available locally.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in a level attitude approximately 0.7 nm northeast of the departure end of runway 01 at approximately N59°03.15' latitude and W158°28.41' longitude. The entire debris field stretched along a ...