SAINT MARY'S, AK, USA
N31240
Beech 1900C
The airline transport pilot was cleared for the localizer approach. The airplane impacted the ground 3.2 nautical miles from the runway threshold. The minimum descent altitude (MDA) for the approach was 560 feet msl, which is 263 feet above touchdown. Night, instrument meteorological conditions prevailed at the time of the accident. The surrounding terrain was flat, snow-covered, and featureless. The reported weather was 200 feet overcast, 1 1/2 miles visibility in snow, and winds of 12 knots, gusting to 32 knots. The pilot reported he was established on the final approach course, descending to the MDA, and then woke up in the snow. He said he did not remember any problems with the airplane. No preaccident mechanical anomalies were discovered with the airplane during the investigation. The airport has high intensity runway lights, sequenced flashing lead-in lights, and visual approach slope indicator lights. All airport lights and navigation aids were functioning. The airplane was not equipped with an autopilot. Captains have the option of requesting a copilot, but, the captain's pay is reduced by a portion equal to one-half the copilot's pay. The pilot had returned from the previous nights trip at 0725. He had three rest periods, four hours, two hours, and five hours 15 minutes, since his previous nights flight. Each rest period was interrupted by contact with the company. The company indicated that it is the pilot's responsibility to tell the company if duty times are being exceeded. 14 CFR 135.267 states, in part: '(d) Each assignment ... must provide for at least 10 consecutive hours of rest during the 24 hours that precedes the planned completion of the assignment.'
HISTORY OF FLIGHT On February 11, 1999, at 2345 Alaska standard time, a Beech 1900C airplane, N31240, was destroyed when it collided with terrain 3.2 nautical miles north of the Saint Mary's Airport, Saint Mary's, Alaska. The solo airline transport pilot sustained serious injuries. The on-demand cargo flight was operated under 14 CFR Part 135 by Alaska Central Express, Inc., of Anchorage, Alaska, from Anchorage to Saint Mary's. The flight departed Anchorage at 2145. Night instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed. The flight was cleared for the LOC/DME 16 instrument approach at 2325. The last radar contact with the airplane was at 2340. The radar controller observed the airplane about 10 miles north of the airport, executing the procedure turn for the approach. The flight was reported overdue at 2355. An emergency locator transmitter (ELT) signal was received by satellite about 0100. The wreckage and pilot were located about 0400 by searchers on snow machines. The airplane had broken into three sections, and both pilot seats were found about 200 feet from the cockpit. The airplane came to rest about 1/4 mile east of the localizer course centerline, about the same elevation as the airport. The pilot told the NTSB investigator-in-charge (IIC) during an interview on February 16, and wrote in his NTSB Pilot / Operator report, that he did not recall any discrepancies with the airplane. He said that he was established on the final approach course, inside the final approach fix, and then woke up face down in the snow. PERSONNEL INFORMATION The pilot holds an airline transport pilot certificate for multi-engine airplanes. He holds airplane type ratings in the Beech 1900, and the Boeing 747. His most recent first class medical certificate was issued on December 30, 1998, with no restrictions. The pilot had accrued 12,187 hours of total flight experience at the time of the accident; 1,587 hours were in the Beech 1900C. In the previous 30 and 90 days, he had flown 91, and 206 hours, respectively. All flights were in the Beech 1900C. In the previous 30 days, the pilot had flown all flights without a copilot. A review of the pilot's flight records revealed he had accrued 96.8 hours in the accident airplane since it was put into revenue service with the company. The pilot was hired by the company in March 1997. He completed initial training on March 10, 1997. He completed pilot training, to include a type rating in the Beech 1900, at Flight Safety International, LaGuardia Airport, New York, on May 19, 1997. On May 29, 1997, the pilot was administered a second-in-command, 14 CFR 135.293 and 135.299 proficiency and line check by a company check airman. He was assigned and flew as a second-in-command until he was administered a 14 CFR 135.297 instrument proficiency check on July 31, 1997. At that time, he was assigned as a pilot-in-command in the Beech 1900C. The pilot's most recent flight check was in the Beech 1900C, on September 27, 1998, and met the requirements of 14 CFR 135.293, 297, and 299. The flight check was conducted by a company check airman. According to company records, the pilot had flown to Saint Mary's on five occasions prior to the accident flight. On all of these flights, the airport was reporting weather greater than 1000 feet ceilings and visibility greater than 3 miles. The first three were with a two pilot crew. The last two were single pilot. Flight and Duty Time The pilot was based, and lived, in Fairbanks. He normally flew his trips from there. The pilot flew as a pilot-in-command the night prior to the accident. According to company flight records, the pilot completed his flights at 0604 on February 11. According to the company mail records, he completed unloading the mail at 0725 on February 11, in Fairbanks. The company scheduler / flight follower from Anchorage, contacted the cargo supervisor in Fairbanks about 1130, and asked him to send the pilot to Anchorage on the company's flight leaving Fairbanks at 1425, so he could fly the accident flight. According to the cargo supervisor, he responded that he would not call the pilot because he had just got in and was tired. About 1130, the pilot was called at home by the company scheduler / flight follower from Anchorage, and asked if he would fly the accident flight to Saint Mary's. At 1330 the pilot arrived at the company's base in Fairbanks. The cargo supervisor told an FAA inspector that when the accident pilot arrived for the flight to Anchorage he looked "awfully tired." The flight to Anchorage arrived at 1519. According to the pilot, he went to his brother's home and slept. At 2045, he returned to the company base in Anchorage to begin preparation for the accident flight. When questioned by an FAA inspector about assigning the pilot to the accident flight, both the Director of Operations, and the Anchorage crew scheduler / flight follower replied that they don't assign extra flights. Rather, the company offers them to pilots. The PIC, and the crew scheduler, share responsibility to tell the company if the pilot is exceeding flight or duty times. The Director of Operations also stated that he did not consider the jumpseat flight an assignment, but rather, the same as an airline pilot commuting from his home to an assigned domicile. According to the FAA inspector, he was told by the Fairbanks cargo supervisor that the accident pilot stated "if you turn down flights, you will not be called for flights in the future." The Director of Operations wrote to the NTSB IIC that when company officials asked both the pilot, and cargo supervisor if they had said this, they both denied having made such a statement. The NTSB IIC discussed the pilot's assignment to the flight with the Director of Operations on June 28. The Director of Operations told the IIC that the company did not contact the pilot. He provided copies of the company telephone records which showed no calls from the Anchorage scheduler's number to the pilot's home. Three telephone calls were placed to the Fairbanks freight company number; at 0707, at 1104, and at 1433. He further provided a record showing a call placed from the pilot's home, to the Anchorage scheduler's "1-800" number at 1253. The Director of Operations stated that the pilot called the company asking for a flight, because he wanted the extra flight time. He indicated that there were crews available in Anchorage to fly the accident flight, but the accident pilot was allowed to take the flight because he asked for it. He further said that jumpseating to Anchorage was the pilot's choice. The NTSB IIC attempted between June 29, and July 14, to hold a telephone interview with the pilot to clarify how he was assigned to the accident flight. The IIC was unable to reach the pilot, or the pilot's brother, who told the IIC he was acting as the pilot's legal representative and requested that any interview be conducted from the brother's law offices in Fairbanks. Telephone calls by the NTSB IIC were not returned, and a series of written questions was sent to the pilot via certified mail. The questions were received by the pilot on July 16. No response to these questions was received by the IIC as of August 30, 1999. In the 24 hours prior to the accident, the pilot had flown 5 hours 54 minutes, and been on duty for 12 hours 30 minutes. During this 24 hours, he had three interrupted rest periods. One of four hours, between 0730 and 1130. Two hours rest from 1130 to 1330, after which he traveled via jumpseat on a company airplane to Anchorage. He then had another rest period of five hours 10 minutes, after which he arrived at the company base in Anchorage for the accident flight. AIRCRAFT INFORMATION The airplane was a Beech 1900C, and was used in an all cargo configuration. The airplane was certified as a single pilot airplane. The minimum crew required by the limitations section of the Pilot Operating Handbook was one pilot. The airplane was maintained on a Beech periodic maintenance schedule, under an Approved Aircraft Inspection Program (AAIP). This was authorized on the company's Operating Specifications in paragraph D73. This program contains inspections performed approximately every 100 hours. METEOROLOGICAL INFORMATION The pilot was provided current and forecast weather by the company prior to departing Anchorage. The company weather packages are compiled by the dispatchers, who obtain National Weather Service observations and forecasts. They also access weather through the internet service "PILOTbrief." The weather package recovered from the pilot's flight bag included the Saint Mary's 2000 observation which stated, in part: winds 120 degrees at 19 knots gusting to 29 knots, 9 miles visibility, and 300 feet overcast ceilings. The general outlook provided by "PILOTbrief" said: "Tonight...snow showers. Areas of blowing snow this evening. Winds 15 to 30 mph this evening...diminishing a bit." The pilot told the NTSB IIC, and the last Air Route Traffic Control Center (ARTCC) controller who spoke with him, that he had obtained the most recent Saint Mary's weather from the automated surface observing system (ASOS) broadcast. The ASOS at Saint Mary's, taken at 2255, was a 200 feet overcast ceiling, 3 miles visibility, winds from 110 degrees at 23 knots gusting to 31 knots, altimeter 29.57, and a temperature of -15 degrees Centigrade. The ASOS at Saint Mary's, taken at 2335, was a 200 feet overcast ceiling, 1 1/2 miles visibility, winds from 130 degrees at 12 knots gusting to 32 knots, altimeter 29.59, and a temperature of -14 degrees Centigrade. The ASOS at Saint Mary's, taken at 2355, was a 200 feet overcast ceiling, 2 1/2 miles visibility, winds from 150 degrees at 14 knots gusting to 27 knots, altimeter 29.58, and a temperature of -15 degrees Centigrade. AIDS TO NAVIGATION The FAA performed a postaccident flight inspection of the non-directional beacon (NDB), Localizer, and distance measuring equipment (DME) on February 13. According to the Flight Inspection Report-FAA Form 8240-19 (attached), all navaids and lighting systems tested "satisfactory." After the flight inspection was completed, FAA ground technicians checked the calibration of the transmitting equipment, and these were within specified parameters. The Localizer-DME Runway 16 approach has a final approach course of 164 degrees magnetic. This approach has a minimum descent altitude (MDA) of 560 feet msl. The height above touchdown at this altitude is 263 feet. The weather minima published in the instrument approach procedure to successfully complete the approach is a ceiling of 300 feet, and flight visibility of 1 mile. 14 CFR 91.175 ( c ) states, in part: "no pilot may operate an aircraft...below the authorized MDA...unless...the flight visibility is not less than the visibility prescribed in the standard instrument approach procedure being used..." 14 CFR 135.225 ( a ) states, in part: "No pilot may begin an instrument approach procedure to an airport unless- (2) The latest weather report issued by that weather reporting facility indicates that weather conditions are at or above the authorized IFR landing minimums for that airport." The FAA Terminal Approach Procedures (TERPS) paragraph 310 states, in part: "The weather minimums shall include the visibility required by the procedure, and may include a ceiling value which is equal to or greater than the height of the MDA or DH above airport elevation." COMMUNICATIONS The pilot's last radio contact was with the ARTCC at 2325, when the flight was cleared for the Localizer/DME Runway 16 approach. The pilot reported he had received the Saint Mary's weather, and was descending out of 20,000 feet. The ARTCC provided the NTSB IIC with a plot of radar tracking data from the accident airplane. The plot depicted the airplane approaching the NDB at St. Mary's from the east, at 4,100 feet msl, and then turning northbound at 2337. At 2340, the track reversed course, and descended to 2,300 feet msl. The last altitude recorded from the airplane was 2,100 feet msl at 2341:56, with the airplane tracking 145 degrees. No altitude was received from the airplane for the final one minute of radar positions. The last radar contact was at 2342:56, with the airplane tracking 145 degrees at a position of 62 degrees 11 minutes 51 seconds North latitude, 163 degrees 13 minutes 22 seconds West longitude. This position is about seven miles north of the airport, and about three miles north of the accident site. On April 19, 1999, the NTSB IIC installed the VHF communications, and VHF navigation, control heads from the accident airplane into another company Beech 1900C. The radios were then turned on and the following stored frequencies were read from the radio displays: Active Standby COM 1: 122.3 MHz (CTAF) 124.0 MHz (Anchorage Center) COM 2: unreadable NAV 1: 109.1 MHz (KSM Localizer) 117.2 MHz (Sparrevohn) NAV 2: 114.3 MHz (Anchorage) 117.2 MHz (Sparrevohn) ADF: unreadable DME: unreadable AERODROME INFORMATION The airport is located in an area of gently sloping hills, characterized by tundra and flat terrain. There are two runways, oriented 160 / 340 degrees magnetic, and 060 / 240 degrees magnetic. Only runway 16 / 34 is serviced by an instrument approach. The airport elevation is 311 feet above sea level (msl). Runway 16 / 34 is a 6,003 feet long by 150 feet wide gravel surface. Runway 16 is equipped with visual approach slope indicator (VASI) lights, omnidirectional approach lights (ODALS), runway end identifier lights (REIL), pilot-controlled medium or high intensity runway edge lights, and a rotating beacon. The ODALS incorporate runway threshold lights, and a 1,500 feet long set of sequenced flashing lead-in lights to the threshold. All the lights were operational at the time of the accident. The communications available at the airport are a common traffic advisory frequency (CTAF), and an ASOS. The ASOS was operating at the time of the accident. The pilot told the NTSB IIC that he had received the observation. WRECKAGE AND IMPACT INFORMATION The NTSB IIC began his on-site investigation about 1100 on February 15. The director of operations and chief pilot for the company, and a representative from Raytheon Aircraft Company (Beech). No evidence of preimpact anomalies were found. The airplane came to rest on a bearing of 345 degrees magnetic, at 3.2 nautical miles from the runway threshold. The wreckage site was at 4.2 DME from the DME transmitter. The runway threshold is at 1.0 DME. The site was 1 degree to the left (east) of the inbound final approach course. The NTSB IIC flew over the wreckage site while monitoring the localizer course in a chartered airplane. The wreckage was located 1.3 dots to the left of the localizer course. The wreckage path groundtrack was converging with the final approach course at a two degree angle. The terrain conditions along the wreckage path consisted of essentially level tundra, covered by wind-blown, packed snow. The elevation of the wreckage path was about 300 feet msl, and appeared level with the runway VASI lights, which could be seen from the location of the initial ground scars. The wreckage path was oriented along an axis of 170 degrees magnetic, and extended about 1,100 feet. Three parallel furrows spaced six feet, and 13 feet apart, were the first contact marks visible. The nose wheel assembly was located at the end of the center furrow, 60 feet from the first visible mark. Seven of the eight composite propeller blades were found in a fragmented condition, within the first 180 feet of the wreckage path. The entire vertical and horizontal stabilizer assembly, and both the left and right elevator tips, were located between 270 and 300 feet along the wreckage path. The outboard nine feet of the right wing, and the right aileron, were located 400 feet along the wreckage path. The nose mounted radome was located at 450 feet. The left main landing gear assembly was at 530 feet, and the right m
The pilot's descent below the minimum descent altitude on the instrument approach. Factors were pilot fatigue resulting from the pilot's rest period being interrupted by scheduling discussions and the night weather conditions of low ceilings and whiteout.
Source: NTSB Aviation Accident Database
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