KETCHIKAN, AK, USA
N6478H
CESSNA 207A
PRIOR TO DEPARTING ON A SCHEDULED AIR TAXI FLIGHT WITH TWO PASSENGERS, THE PILOT OBTAINED A WEATHER BRIEFING THAT INCLUDED AIRMETS FOR MOUNTAIN OBSCURATION, IFR AND ICING CONDITIONS. VFR FLIGHT WAS NOT RECOMMENDED. A COMPANY FLIGHT THAT DEPARTED BEFORE THE ACCIDENT FLIGHT, RETURNED TO THE COMPANY BASE DUE TO LOW CEILINGS, AFTER THE ACCIDENT FLIGHT DEPARTED. THE FLIGHT DEPARTED ON A VFR FLIGHT PLAN AND ENCOUNTERED LOW CEILINGS IN THE AREA OF MOUNTAINOUS TERRAIN. THE PILOT BEGAN MANEUVERING AROUND THE TERRAIN AND DURING A PERIOD OF OBSCURATION, COLLIDED WITH SEVERAL TREES. THE COMPANY OPERATIONS MANUAL SPECIFIES THAT THE PILOT IS RESPONSIBLE FOR THE CONDUCT OF THE FLIGHT; HOWEVER, PROCEDURES ARE INCLUDED THAT DETAIL THE DISPATCH RESPONSIBILITIES, DISSEMINATION OF WEATHER INFORMATION, AND THE DIRECTOR OF OPERATIONS RESPONSIBILITY TO MONITOR AND CANCEL FLIGHTS IF NECESSARY.
On March 10, 1995, about 0745 Alaska standard time, a Cessna 207, N6478H, collided with terrain about 28 miles northwest of Ketchikan, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled commuter flight to Wrangell, Alaska, under Title 14 CFR Part 135 when the accident occurred. The airplane, operated by Ketchikan Air Service, Ketchikan, was destroyed. The certificated commercial pilot and two passengers received serious injuries. Instrument meteorological conditions prevailed in the area. A VFR flight plan was filed. The flight originated at the Ketchikan International Airport at 0721. At 0719, just prior to departure, the Ketchikan Flight Service Station (FSS) Air Traffic Control (ATC) specialist provided the pilot with a pilot report (PIREP). The specialist stated: "Looks like out in the straits, five hundred overcast, visibility two to three." The pilot acknowledged the report and departed runway 29. After departure, the flight proceeded northwest toward the destination. At 0726 the FSS specialist provided the pilot with a PIREP that indicated, ..."weather five hundred overcast, visibility two to three in straits." The pilot replied, "Roger, I'm going to try Spacious Bay, go up that way then." About 0745, the pilot was overheard on a company radio frequency stating: "I'm crashing, I'm crashing." The last position report for the accident aircraft received by the company dispatcher was in the area of Spacious Bay/Port Stewart. An emergency locator transmitter (ELT) signal was then received by search personnel. The airplane was located about 1150 about 2,000 feet mean sea level (msl). Federal Aviation Administration (FAA) inspectors, Juneau Flight Standards District Office (FSDO), interviewed the passengers of the flight. The pilot's medical condition precluded any interview. The passengers reported that during the flight, the terrain was intermittently obscured by clouds and rain. The airplane entered an area of clouds and the pilot began maneuvering the airplane around the terrain. During a period of obscuration, the airplane collided with trees. The pilot received an in-person weather briefing from the Ketchikan Flight Service Station (FSS) prior to the flight. The briefer provided an abbreviated briefing that included a caution that VFR operations were not recommended. The area forecast included several notice to airmen (AIRMETs) for occasional mountain obscuration due to clouds and precipitation; turbulence below 6,000 feet; instrument conditions with occasional ceilings below 1,000 feet and visibility below 3 miles with light rain, snow, and fog; and icing conditions with light to moderate rime icing in clouds and precipitation between 3,000 and 15,000 feet. The closest official weather observation station is Ketchikan, which is located 28 nautical miles southeast of the accident site. At 0751, a surface observation was reporting in part: Sky condition and ceiling, 1,100 feet scattered, estimated 2,000 feet broken, 2,600 feet overcast; visibility, 5 miles in light rain, light snow and fog; temperature, 35 degrees F; dew point, 32 degrees F; wind, calm; altimeter, 28.93 inHg. A company pilot that departed Ketchikan about 0705 reported low ceilings of about 500 feet with lower conditions toward the northwest. The pilot decided to cancel his flight and returned to his company base. As he was landing, he observed the accident aircraft departing the area and attempted to contact the pilot. There was no response and the company pilot transmitted a weather advisory on the company radio, indicating that the..."weather out in the strait are solid and low." Another pilot conducting search operations in the area of the accident reported that the mountain passes and ridges were obscured by clouds/fog and moderate snow. The ceilings varied from 1,000 to 2,000 feet. A review of the operators operations manual revealed that section 4.02.00, Crew Reporting, states: "As a general rule, one hour prior to departure will be considered sufficient for: 1. Servicing of the aircraft and preflight. 2. Weather briefing and filing of a flight plan." Section 4.03.00, Crew Briefing, states: "Before arrival at the aircraft, flight crew personnel will be briefed by the dispatcher on duty regarding route to be flown, current and forecast weather, fuel requirements and any other information necessary for the planning and execution of the flight." Section 4.06.01, Flight Scheduling, states in part:..."The director of operations will monitor flight conditions and may cancel flights if conditions warrant. If the director of operations is not available during the conduct of any company flight, then the duties will be assigned to the chief pilot. The pilot-in-command is the final authority on all flights and has the responsibility to cancel any flight if, in his opinion the weather and/or other factors would prevent the safe completion of the flight. All flights are to be undertaken in accordance with appropriate Federal Aviation Regulations, VFR flight plan, ATC clearances, operations specifications and other appropriate company policies and procedures set forth in this operations manual."
THE PILOT'S CONTINUED VISUAL FLIGHT RULES (VFR) FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS (IMC). FACTORS IN THE ACCIDENT WERE FOG AND LOW CEILINGS, AND A FAILURE OF THE OPERATOR TO FOLLOW THEIR PROCEDURES SPECIFIED IN THE COMPANY OPERATIONS MANUAL.
Source: NTSB Aviation Accident Database
Aviation Accidents App
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