N62AK

Substantial
Fatal

CESSNA 207AS/N: 20700780

Accident Details

Date
Friday, July 17, 2015
NTSB Number
ANC15FA049
Location
Juneau, AK
Event ID
20150718X04523
Coordinates
58.335277, -135.066940
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
4
Minor Injuries
0
Uninjured
0
Total Aboard
5

Probable Cause and Findings

The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel.

Aircraft Information

Registration
N62AK
Make
CESSNA
Serial Number
20700780
Engine Type
Turbo-shaft
Year Built
1984
Model / ICAO
207AC07T
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
SUTTON AIRCRAFT SALVAGE LLC
Address
13500 E JENSEN AVE
Status
Deregistered
City
PALMER
State / Zip Code
AK 99645-9430
Country
United States

Analysis

HISTORY OF FLIGHT

On July 17, 2015, about 1318 Alaska daylight time, a Cessna 207A airplane, N62AK, sustained substantial damage following an in-flight collision with tree-covered terrain about 18 miles west of Juneau, Alaska. The commercial pilot sustained fatal injuries, and four passengers sustained serious injuries. The flight was being operated as flight 202 by SeaPort Airlines, Inc., dba Wings of Alaska, as a 14 Code of Federal Regulations (CFR) Part 135 visual flight rules (VFR) scheduled commuter flight. (Wings of Alaska has been sold and is currently under different ownership.) Visual meteorological conditions were reported at the Juneau International Airport at the time of departure. A company flight plan had been filed, and company flight-following procedures were in effect. Flight 202 departed the Juneau Airport about 1308 for a scheduled 20-minute flight to Hoonah, Alaska.

On the day of the accident, the pilot arrived at the company office in Juneau about 1200. The accident flight was the pilot's first scheduled flight of the day. The company flight coordinator on duty at the time told the pilot that most flights to Hoonah were cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. The flight coordinator said that the weather had started lifting around 1000 and that the first flight to Hoonah had departed at 1045. He suggested that the accident pilot talk with the pilot who had just returned. The dispatch group had a shift change between the time the accident pilot came on duty and when the pilot departed. The company flight coordinator on duty at the time of the accident only communicated with the pilot when she reported taxiing off the ramp for departure. No weather information was discussed, and no further radio communications were received from the pilot by the company.

According to Juneau Air Traffic Control Tower (ATCT) personnel, the pilot requested and received taxi clearance to depart for the 20-minute VFR flight to Hoonah at 1306. The flight was cleared for takeoff about 2 minutes later by the ATCT specialist on duty with no reported problems. About 15 minutes later, Juneau Police dispatchers received a 911 cell phone call from a passenger on board stating that the airplane had crashed.

During an interview with one of the surviving passengers, who was sitting directly behind the pilot, he stated that the pilot seemed normal during the preflight and briefing. After takeoff, the turbulence was heavy, and there were layers of fog and clouds and some rain. He had taken this flight numerous times and thought that the flight route that the pilot was taking was somewhat unusual. Before the impact, he thought that the pilot was trying to climb over the approaching mountain and skirt between a layer of clouds. He saw the trees coming at the windshield, and the pilot jerked back on the controls, and then he heard a "loud boom." The next thing that he remembered was sitting outside the airplane. He said that there were no unusual sounds from the engine and that the airplane appeared to be flying normally before the impact.

Automatic dependent surveillance-broadcast (ADS-B) data received by the Anchorage ATCT showed the following:

o At 1308:09, the accident airplane took off from JNU.

o At 1312:33, the accident airplane started a northwesterly turn around the west side of Portland Island at an ADS-B reported altitude of 825 ft mean sea level (msl).

o At 1314:20, the accident airplane began a turn to a westerly heading at an ADS-B reported altitude of 825 ft msl.

o At 1316:25, the accident airplane crossed the western shoreline of Admiralty Island at an ADS-B reported altitude of 675 ft msl and continued on a constant heading until the last ADS-B point was recorded.

The last ADS-B point was received at 1317:27, when the airplane was over Lynn Canal, about 1 mile from the eastern shoreline of the Chilkat mountain range at an ADS-B reported altitude of 525 ft msl. The last 30 seconds of the flight was missing from the ADS-B data.

PERSONNEL INFORMATION

The pilot, age 45, held a commercial pilot certificate with airplane single-engine land and sea, multiengine land, and instrument ratings. The pilot was issued a first-class airman medical certificate on April 9, 2015, with the limitation that she "must wear corrective lenses."

Company training records indicated that the pilot completed basic indoctrination on May 25, 2015, and initial ground training on June 2, 2015. Ground training curriculum was completed in two locations: Portland, Oregon, and Juneau. The pilot's most recent Part 135 proficiency checks (135.293 (a) (b) and 135.299) were completed in the Cessna 207 on June 12, 2015. Company records indicated that she had a total time of 840 flight hours.

The base chief pilot, who provided about half of the accident pilot's flight training, said that she was very good on systems but that she needed a few additional hours of flight training and initial operating experience before he was comfortable signing her off. He noted that the one thing that he really liked about her was that she wasn't afraid of turning around if she was uncomfortable. He did not notice any negative attitudes or habits with her flying.

The pilot's normal shift was the p.m. shift, which typically began at 1200 and ended at 2200. The pilot's flight and duty time records indicated that, the day before the accident, she flew 3.7 hours and then went off duty at 2200. The accident flight was the pilot's first flight of the day.

In June 2015, the pilot was on duty for 27 days, flew about 23 hours, and had 3 days off. In July 2015, the pilot was on duty for 11 days, including the day of the accident; flew about 41 hours; and had 6 days off. The pilot had not had a day off in the 72 hours preceding the accident flight. During that time, she flew a total of 19 flight segments, totaling 9.4 hours, not including the accident flight.

The pilot's roommates and family members reported no unusual activity in the 72 hours preceding the accident. However, in an interview with the pilot's sister, she said that the pilot had told her about an incident that had happened 2 or 3 weeks before the accident where she had gotten into a bad storm during a flight. The pilot said that she and her passengers were praying together to get through the weather and that eventually she saw the runway and was able to land the airplane uneventfully. Other than this event, the accident pilot never mentioned to her sister any concerns about flying for the company for which she worked.

AIRCRAFT INFORMATION

The accident airplane, a Cessna 207A, N62AK, was manufactured in 1984. Before the accident flight, the airplane had logged a total time in service of 26,613.1 flight hours. The airplane was maintained under a 100-hour/annual inspection program, and the most recent 100-hour inspection of the airframe and engine was on July 6, 2015.

The airplane was equipped with a Continental Motors IO-520-F 285-horsepower reciprocating engine. The engine was factory rebuilt on June 16, 2015; installed on the airplane July 14, 2015; and had accumulated about 8.2 hours of operation before the accident flight.

METEOROLOGICAL INFORMATION

The area forecast issued by the National Weather Service Alaska Aviation Weather Unit (AAWU) at 1210 included an AIRMET for mountain obscuration due to clouds and precipitation, and the AIRMET was valid at the accident site at the accident time. The area forecast mentioned scattered clouds at 1,200 ft msl with broken to overcast ceilings at 2,000 ft msl with cloud tops to flight level 250 and an occasional broken ceiling at 1,200 ft msl with 5 miles visibility and light rain. Isolated instrument flight rules (IFR) conditions were also forecast with rain and mist. The AAWU weather charts produced at 1200 indicated that the accident site was on the boundary of marginal VFR to IFR conditions with isolated moderate low-level turbulence between the surface and 6,000 ft msl.

The closest official weather observation station is Juneau, which is located about 18 miles east of the accident site. At 1253, a METAR was reporting, in part, wind 110° at 14 knots; visibility 7 statute miles in light rain and mist; clouds and ceiling 200 ft few, 3,500 ft overcast; temperature 57° F; dew point 55° F; altimeter 30.24 inches of Mercury.

Numerous Federal Aviation Administration (FAA) weather cameras are located in the vicinity of the Juneau Airport. Images from several of the cameras closest to the pilot's flight route were obtained for the period from 1100 to 1600 on the day of the accident. Figure 1 shows an image that was taken about 5 minutes before the estimated accident time, facing the direction of the accident location. (Refer to the Meteorology Group Chairman's Factual Report in the public docket for further weather information and weather camera images.)

Figure. A video camera image showing visibility conditions at Juneau Airport about 5 minutes before the estimated accident time, facing the direction of the accident location.

No record was found indicating that the pilot used the company computer to review weather information before the flight nor of her having received or retrieved any weather information before the flight. The flight coordinator did not review weather camera images with the accident pilot before the flight and had no further communication with the pilot about the weather.

FLIGHT RECORDERS

The accident airplane was not equipped, nor was it required to be equipped with, a cockpit voice recorder or a flight data recorder.

WRECKAGE AND IMPACT INFORMATION

On-scene examination revealed that the airplane impacted a large spruce tree at an elevation of about 1,250 ft msl. After the initial impact, the airplane fuselage separated into two pieces. The forward section of the airplane, consisting of the cockpit and engine, separated just forward of the main landing gear assembly and came to r...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ANC15FA049