N12373

HISTORY OF FLIGHTOn November 29, 2013, at 1824 Alaska standard time, a Cessna 208B Grand Caravan airplane, N12373, sustained substantial damage after impacting terrain about 1 mile southeast of St. Mary's Airport, St. Mary's, Alaska. The airplane was being operated as flight 1453 by Hageland Aviation Services, Inc., dba Era Alaska, Anchorage, Alaska, as a visual flight rules (VFR) scheduled commuter flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Of the 10 people on board, the commercial pilot and three passengers sustained fatal injuries, and six passengers sustained serious injuries. Night, instrument meteorological conditions (IMC) prevailed at St. Mary's Airport at the time of the accident, and company flight-following procedures were in effect. Flight 1453 departed from Bethel Airport, Bethel, Alaska, at 1741 destined for Mountain Village, Alaska. Before reaching Mountain Village, the flight diverted to St. Mary's due to deteriorating weather conditions.

The pilot's flight and duty records indicated that, on the day of the accident, the pilot arrived at the company office in St. Mary's about 0800. The accident flight was the pilot's fifth flight of the day. Flight 1453 was to depart Bethel Airport with eight adult passengers and one infant passenger (who was not listed on the flight manifest), make a stop in Mountain Village, and then proceed to St. Mary's.

Hageland Aviation Services had recently incorporated a risk assessment program into its operational control procedures, which required each flight be assigned a risk level on a scale of 1 to 4, with the intention of mitigating the hazards for high-risk flights. Although not required by the Federal Aviation Administration (FAA), the risk assessment was being used as part of the company's operational control procedures; however, it had not been incorporated into the company General Operations Manual (GOM).

Before departure, the flight coordinator checked the weather and assigned the flight a risk assessment level of 2 due to IMC and night conditions and contaminated runways at both of the destination airports. He assigned another flight coordinator to create the manifest, which listed eight passengers and a risk assessment level of 2.

A risk assessment level 2 required a conversation between the flight coordinator and the pilot about possible hazards associated with the flight. However, the flight coordinators did not discuss with the pilot the risk assessment level assigned to the flight, current weather conditions or hazards, or ways to mitigate the hazards as required by the risk assessment program. Neither of the flight coordinators working the flight had received company training on the risk assessment program.

The flight was scheduled to depart at 1700, but it was late arriving into Bethel and did not depart until 1741. The pilot reported his departure from Bethel Airport to the company flight coordinator via radio at 1741, reporting 10 souls on board and 4 hours of fuel.

According to a passenger, they had been flying for about 30 minutes when the airplane entered thick fog. He reported that the airplane was picking up ice and had accumulated about 1/2 to 3/4 inch of ice on the lift strut.

According to an Air Route Traffic Control Center (ARTCC) recording, about 18 miles from Mountain Village, the pilot made an announcement to the passengers that, due to deteriorating weather conditions, the flight was diverting to St. Mary's, which is about 13 miles east of Mountain Village.

At 1819:20, the pilot contacted the Anchorage ARTCC and requested a special VFR clearance to St. Mary's Airport.

At 1819:43, an Anchorage ARTCC controller cleared the flight into the St. Mary's surface area, told the pilot to maintain special VFR conditions, and provided the St. Mary's altimeter setting of 30.35 inches of Mercury (inHg). This was the last communication with the airplane.

About 1822, sounds similar to that of a microphone being keyed to activate pilot-controlled approach lighting were heard on the ARTCC frequency. Postaccident examination of the pilot's radio showed that his audio panel was still selected to the ARTCC frequency rather than the destination airport frequency; therefore, the pilot-controlled lighting would not have activated. Witnesses on the ground at St. Mary's reported that the pilot-controlled airport lighting system was not activated when they saw the accident airplane fly over the airport. A passenger reported that no lights were visible but that she saw the ground about 30 ft below the airplane and was able to make out dark patches of trees.

Witnesses on the ground at St. Mary's Airport reported seeing the airplane fly over the airport at a relatively low altitude, about 300 to 400 ft, traveling southeast. They watched the airplane travel away from the airport until its rotating beacon disappeared. One witness stated that he saw the landing lights of the airplane illuminate something white before he lost sight of the beacon, and he assumed that the airplane had entered the clouds. Due to concern about the direction and altitude the airplane was flying, the witnesses attempted to contact the pilot on the radio, but the pilot did not respond. They then heard another pilot report on the radio that there was an emergency locator transmitter broadcasting in the vicinity of St. Mary's. After checking for the airplane's last reported position on the company's flight-following software, a search was initiated.

About 1 hour after the search was initiated, the airplane was located, and rescue personnel confirmed that the pilot and two passengers died at the scene. One passenger died after being transported to the local clinic. The six surviving passengers were evacuated to Anchorage for treatment.

The airplane impacted the top of a ridge about 1 mile southeast of St. Mary's Airport at an elevation of about 425 ft mean seal level (msl) in a nose-high, upright attitude. The airplane came to rest upright about 200 ft from the initial impact point at an elevation of about 530 ft. PERSONNEL INFORMATIONThe pilot, age 68, held a commercial pilot certificate with an airplane single-engine land, single-engine sea, multiengine land, and instrument ratings. Pilot training records indicated that he had accumulated over 25,000 hours of flight time with over 1,800 hours in Cessna 208 airplanes. His most recent FAA second-class airman medical certificate was issued on August 21, 2013, with the limitation that the pilot must wear corrective lenses for distance and must possess corrective lenses for near vision. The pilot's personal logbooks were not located.

A review of Hageland Aviation Services personnel records indicated that the pilot was hired, completed his initial company training (which included pilot ground and flight training), and was assigned to fly Cessna 207A airplanes on December 18, 2012.

On February 11, 2013, the pilot completed initial Cessna 208B ground training. On June 14, 2013, he completed recurrent ground training. On June 19, 2013, he completed flight training and a check ride and was assigned to fly Cessna 208B airplanes out of the St. Mary's base.

Flight and duty records revealed that, in September 2013, the pilot was on duty for 15 days, flew 60.5 hours, and had 15 days off. In October 2013, the pilot was on duty for 16 days, flew 73.8 hours, and had 15 days off. In November 2013, the pilot was on duty November 1 to 16, flew 63.7 hours, was off duty November 17 to 28, and returned to work on November 29 (the day of the accident).

On the day of the accident, the pilot was on a 14-hour assigned duty day, starting at 0800 and ending at 2200. He flew four trips totaling about 4.4 hours before the accident flight. AIRCRAFT INFORMATIONThe accident airplane was a turboprop Cessna 208B Grand Caravan, registration number N12373, manufactured in 1998. At the time of the accident, the airplane had accumulated 12,653 total flight hours and was maintained under an approved aircraft inspection program. The most recent inspection of the airframe and engine was completed on November 12, 2013.

The airplane was equipped with a Pratt & Whitney PT6A-114A turbine engine that was rated at 675-shaft horsepower. The engine was overhauled 4,655 hours before the accident.

The airplane was equipped for instrument flight and flight into icing conditions and was certificated for single-pilot operation. The airplane was equipped with a Honeywell KGP-560 Terrain Awareness and Warning System (TAWS), and a Midcontinent Avionics MD41 Terrain Awareness Annunciator Control Unit. The fully integrated control unit provided annunciation and mode selection for both TAWS and the general aviation-enhanced ground proximity warning system (GA-EGPWS). METEOROLOGICAL INFORMATIONAt the time of the accident, an airmen's meteorological information (AIRMET) valid for the accident site forecast mountain obscuration conditions due to clouds and precipitation. Another AIRMET for turbulence was valid for flight level (FL) 270 to FL 370. The area forecast issued at 1806 predicted few clouds at 500 ft above ground level (agl), scattered clouds at 2,000 ft, and a broken ceiling at 4,000 ft with tops to 12,000 ft. The ceiling was forecast to be occasionally at 2,000 ft with isolated light snow showers and visibility below 3 miles. No turbulence or icing conditions were forecast for the accident site at the accident time. The area forecast issued at 1210 predicted similar conditions to the 1806 area forecast; however, the 1210 area forecast predicted isolated moderate icing between 3,000 and 9,000 ft along the coast and inland through 1600.

The nearest official weather reporting station was St. Mary's Airport. About 8 minutes before the accident, at 1816, a meteorological aerodrome report (METAR) was reporting, in part, the following: wind from 230 degrees (true) at 6 knots, visibility 3 statute miles, sky condition overcast at 300 ft ...