Unalaska, AK, USA
N19454
Douglas DC-3
A Douglas DC-3 airplane departed an island runway during dark night, VFR conditions without filing a flight plan. The airplane collided with a volcanic mountain at 1,500 feet msl on the runway heading, 4.5 miles from the airport. Earlier in the day, the airplane arrived from Anchorage, Alaska, without a flight plan, having flown along the Alaska Peninsula when VFR flight was not recommended. The crew of the airplane initially planned to remain overnight on the peninsula, but the captain received a request to transport cargo to Anchorage. The airplane was loaded with cargo and fuel, and departed. The crew did not file a flight plan. The end of the departure runway is positioned at the edge of an ocean bay. Beyond the end of the runway, open water and rising volcanic island terrain are present. In the area of intended flight, no illumination of the terrain, or any ground based lighting was present. An obstacle departure procedure for the departure runway recommends a right turn at 2 DME from the runway heading, and then a climb to 7,000 feet. Forty-five minutes after departure, a fire was spotted on the side of a volcano cone, and an ELT signal was detected in the area. No company flight following procedures were found for the accident flight, and the airplane was not reported overdue until the following day. The day after the accident, the airplane wreckage was located on steep, snow-covered terrain. Due to high winds and blowing snow, a rescue team could not get to the accident site until three days after the crash. The captain was the president, the director of operations, and the sole corporate entity of the company. No current maintenance records, flight logs, or pilot logs were located for the company. In the past, the captain's pilot certificate was suspended for 45 days following an accident in a DC-3 airplane when he ran out of gas. Also, the captain's medical certificate had previously been considered for denial after serving 49 months in federal prison for cocaine distribution, but after review, the FAA issued the captain a first class medical. FAA medical records for the captain do not contain any record of monitoring for substance abuse. The first officer's medical had also been considered for denial after an episode of a loss of consciousness. After a lengthy review and an appeal to the NTSB, the FAA issued the first officer a second-class medical. The first officer was part of the flight crew when the captain ran out of gas, and she had two previous aviation accidents. A toxicological examination of the captain, conducted by the FAA, found cocaine and metabolites of cocaine. A toxicological examination of the first officer found two different prescription antidepressant drugs. The FAA prohibits narcotic and mood-altering drug use by pilots.
HISTORY OF FLIGHT On January 23, 2001, about 2135 Alaska standard time, a Douglas DC-3 airplane, N19454, was destroyed by impact and postimpact fire after colliding with mountainous terrain, about 4.5 miles northwest of Unalaska, Alaska. The airplane was being operated as a visual flight rules (VFR), nonscheduled domestic cargo flight, under Title 14, CFR Part 135, when the accident occurred. The airplane was operated by Galaxy Air Cargo Inc., doing business as Majestic Air Cargo, Anchorage, Alaska. The captain and the first officer, both airline transport certificated pilots, received fatal injuries. Dark night, visual meteorological conditions prevailed. A flight plan was not filed. The flight originated at the Unalaska Airport, about 2130. The Federal Aviation Administration (FAA) reported that the crew of the accident airplane telephoned the Kenai Automated Flight Service Station (AFSS) on January 23, at 0807, requesting a weather briefing from Anchorage to Dutch Harbor, Alaska (Unalaska), and indicated the flight anticipated departing Anchorage about 1200, under VFR or instrument flight rules (IFR). The flight service station specialist provided a briefing in which VFR was not recommended due to AIRMETS for IFR conditions, and mountain obscuration along the entire route, conditions that were prevalent on either the Pacific or Bering Sea sides of the Alaska peninsula. The briefing also included low level turbulence, occasional moderate rime icing, wind conditions up to 51 knots, with light rain and snow at Cold Bay, Alaska, and wind conditions up to 28 knots, with light rain and mist at Dutch Harbor. At 0957, the crew telephoned the Kenai AFSS and requested a weather briefing from Anchorage, to Dutch Harbor, via Kenai, Alaska, King Salmon, Alaska, and Cold Bay, again indicated a probable 1200 departure. The specialist indicated the Anchorage weather conditions as wind, 200 degrees at 8 knots, visibility 1 3/4 mile in light snow and mist, few clouds at 500 feet, ceiling 900 feet overcast. The flight service station specialist provided weather conditions for Kenai, Iliamna, Alaska, King Salmon, Cold Bay, and Dutch Harbor, all of which had VFR conditions. The accident airplane departed Anchorage on a VFR flight, but not on a flight plan. The crew of the airplane contacted the Kenai AFSS by radio at 1312, and requested weather information for Kenai, King Salmon, Cold Bay, and Dutch Harbor. The flight service station specialist provided weather data that included AIRMETs along the route of flight for mountain obscuration, turbulence, icing, and low level wind shear. The specialist indicated the weather conditions at Cold Bay were winds of 32 knots with gusts to 40 knots, visibility of 2 1/2 miles in light rain, snow and fog, ceiling 1,400 feet overcast. Dutch Harbor weather included winds to 21 knots in light showers. The crew of the accident airplane contacted the Kenai AFSS by radio at 1407, 1527, and 1607, for updates on weather conditions at King Salmon, Cold Bay, and Dutch Harbor. At 1745, the crew contacted the Cold Bay FSS for a weather update at Dutch Harbor. The FSS specialist indicated the wind was 200 degrees at 11 knots, visibility was 5 miles, scattered clouds at 100 feet, broken clouds at 1,200 feet, overcast at 1,600 feet, altimeter of 28.80 inHg. The remarks included light snow and mist, with visibility and ceilings lower from the northeast though southeast. The crew commented that the airplane was abeam Cold Bay at 10,500 feet, with good weather conditions, having passed a low pressure area near Port Heiden, Alaska, and said their anticipated arrival at Unalaska was going to be near dark. At 1750, the crew contacted the Cold Bay FSS and requested that the specialist telephone Peninsula Airways at the Unalaska Airport for fuel, with an anticipated arrival time of one hour and ten minutes. Investigation by the Unalaska Department of Public Safety (DPS) determined that the accident airplane arrived at the airport on January 23, about 1915. The crew of the airplane initially planned to remain overnight, but the captain received a request to transport about 2,500 pounds of cargo from Unalaska to Anchorage. The airplane was loaded with cargo and fueled with 464 gallons of 100/130 octane fuel. The loading agent recalled hearing the airplane engines start about 2120. The airplane departed Unalaska without filing a flight plan. The U.S. Coast Guard received an emergency locator transmitter (ELT) signal in the Unalaska area about 2300. A search helicopter was unable to reach the area of the signal due to low clouds. On January 24, Unalaska personnel continued to search for the location of the ELT signal on the island of Unalaska. About 1300, the wreckage of an airplane was spotted on a 309 degree magnetic bearing from the airport, about 1,500 feet msl, on the side of a volcanic cinder cone at Eider Point. At 1418, a Coast Guard helicopter spotted the wreckage of a large silver-colored airplane resting on the side of snow-covered terrain, but was unable to land due to the steepness of the terrain. Also on January 24, a witness telephoned the Unalaska DPS to report having seen a fire on the side of the cinder cone, about 2145 on January 23. At the time the witness called, the airplane had not yet been reported overdue. A crewman aboard a vessel anchored in Unalaska Bay, telephoned the Unalaska DPS on January 24, and reported he saw the accident airplane depart from the airport on the night of the 23, and fly over the bay. He said he thought the starboard engine was producing blue spark or flash. He said he did not see the entire departure, and was unaware the airplane had crashed until news of the accident became known. On January 24, the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) was notified by the FAA that the accident airplane was officially reported overdue at 1448 by a friend of the captain. High winds and blowing snow prevented search and rescue personnel from reaching the accident site until January 26, 2001. By that time, the tail section of the airplane had separated from the crash scene, and slid downhill, coming to rest about 500 feet msl. PERSONNEL INFORMATION Captain The captain was the president and the director of operations for the company. He held an airline transport pilot certificate with an airplane multiengine land rating, and a type rating for Douglas DC-3 airplanes. He also held commercial pilot privileges with single-engine land and sea ratings. The most recent first-class medical certificate was issued to the pilot on June 3, 2000, and contained the limitation that he wear corrective lenses. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. On the pilot's application for medical certificate, dated June 3, 2000, the pilot indicated that his total aeronautical experience consisted of 15,000 hours, of which 300 were accrued in the previous 6 months. Review of available company records indicated the captain attended DC-3 initial ground training, conducted by ERA Aviation Inc., Anchorage, April 17 to 18, 1997. He began company operations on July 1, 1997, and completed initial company new-hire training on July 21, 1997. A review of a pilot resume' from 1997 and 1998, indicated the captain had accrued about 15,000 hours of flight time, 5,000 of night, 2,000 of actual instrument, 50 of simulated instrument. A review of the captain's medical records, on file with the FAA's airman branch, revealed the captain was convicted in December, 1985, for conspiracy and distribution of cocaine, and sentenced to 12 years in federal prison, with 6 years suspended. The pilot was released after serving 49 months. The FAA moved to revoke the captain's commercial pilot certificate on November 2, 1989, by sending him a notice of proposed certificate action. The pilot applied for a medical certificate on February 6, 1990, which the FAA evaluated on December 13, 1990. The FAA indicated the pilot needed to submit evidence of recovery from drug dependence, including sustained abstinence from drug dependence for not less than the preceding two years. The pilot submitted testimonial evidence and psychological evaluations to the FAA. On April 29, 1991, the FAA sent the pilot an amended Order of Suspension which ordered a six month suspension of any airman certificate, but the imposition of the suspension was waived, "given the pilot's substantial progress towards rehabilitation following your criminal convictions." On October 21, 1991, following a review of his postincarceration history, the FAA determined the pilot was eligible for a first class medical certificate that he had applied for on March 26, 1991. Since that time, FAA medical records do not contain any reports of monitoring for substance abuse. A review of FAA records indicated the captain was involved in an aviation accident on May 24, 1998, during which a Galaxy Air Cargo DC-3 airplane ran out of gas while landing at Anchorage. A postaccident drug test of the captain was negative. The FAA suspended the captain's pilot certificate for 45 days. The captain was involved in another aviation accident on July 31, 1998, when the tailwheel and fuselage of a Galaxy Air Cargo DC-3 airplane received damage while landing at Anchorage. No postaccident drug test was conducted. As part of the Department of Transportation's Drug Abatement Program, the captain received a random drug test in June 2000. The results were negative. First Officer The first officer held an airline transport pilot certificate with a multiengine rating, and a DC-3 type rating. She held commercial pilot privileges with an airplane single-engine rating. In addition, she held a flight instructor certificate with airplane single-engine and instrument airplane ratings. Her most recent second-class medical certificate was issued on July 18, 2000, with the limitation that she must wear corrective lenses. No personal flight records were located for the first officer and the aeronautical experience listed on page 3 of this report was obtained from a review of airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. On the pilot's application for medical certificate, dated July 18, 2000, the pilot indicated that her total aeronautical experience consisted of 3,000 hours, of which 250 were accrued in the previous 6 months. Review of available company records indicated the first officer attended DC-3 initial ground training, conducted by ERA Aviation Inc., Anchorage, April 17 to 18, 1997. She was hired by the company on July 1, 1997, and completed initial company new-hire training on July 21, 1997. A review of a pilot resume' from 1997 and 1998, indicated she had accrued about 2,590 hours of flight time, including 150 of night, 150 of actual instrument, 70 of simulated instrument, and 410 as an instructor. A review of the first officer's medical records, on file with the FAA, revealed the first officer experienced a loss of consciousness on May 9, 1987, while hiking with a friend. She was treated at a local emergency room where medical personnel characterized the episode as a seizure. The emergency room medical record, completed on the day of treatment, included notations of statements from the first officer as having a history of seizure over the previous 10 years. The episode was reported to the FAA, and the Alaska Regional Flight Surgeon began a review of the first officer's medical history by requesting additional information from the first officer and her physicians. The first officer applied for a second-class medical certificate on May 18, 1988. The FAA moved to deny her medical certificate, and via letter, requested a surrender of her medical certificate on October 31, 1988. The FAA cited disqualifying neurological conditions contained in 14 CFR Part 67, as the basis for the denial. The first officer denied receiving the letter, and did not surrender her medical certificate. Following an application for a medical certificate on May 24, 1989, the FAA again issued a denial of her medical on October 31, 1989. The first officer appealed the denial of her medical certificate to a National Transportation Safety Board, Administrative Law Judge, and supplied the results of several neurological examinations and personal testimonial evidence denying any history of seizure. On July 9, 1991, a NTSB Administrative Law Judge ruled that the FAA did not prove their case with a definitive diagnosis of seizure, and denied the FAA's case for a denial of the first officer's medical certificate. The FAA appealed the Administrative Law Judge decision to the full board of the NTSB. On January 22, 1992, the NTSB upheld the Administrative Law Judge's decision. A review of FAA records indicated the first officer, along with the captain, was involved in an aviation accident on May 24, 1998, during which a DC-3 airplane ran out of gas while landing at Anchorage, and a second accident as first officer on July 31, 1998, when the tailwheel and fuselage of a DC-3 airplane received damage while landing at Anchorage. The first officer did not received postaccident drug testing following either accident. In addition, the first officer, as pilot-in-command, was involved in an aviation accident due to fuel exhaustion on September 29, 1987, and an accident due to an in-flight collision with terrain on August 28, 1993. Company Information At the time of the accident, Galaxy Air Cargo Inc., doing business as Majestic Air Cargo, operated two Douglas DC-3 airplanes. The president, director of operations, and the captain of the accident airplane were the same person, the sole corporate entity for the company. The company maintained an office in Anchorage, but had no other corporate facilities. Current company flight logs, current maintenance logs, current time and duty logs, and the pilot's personal logs, were not located in the company's office. The company's operations specifications, reissued by the FAA on September 14, 2000, indicated the director of operations was responsible for operational control of all flight operations. The director of maintenance for the company is a full-time employee of another company, and had no direct, day-to-day involvement in the operation of the company. The company operations manual stated, in part: "The Pilot-in-command will either file a FAA flight plan, or a company flight plan. If, on a company flight plan, an aircraft is overdue by one hour, notification will be made by Galaxy Air Cargo Inc. to the FSS. Radio communication will be via VHF radio and/or telephone. When on a company flight plan, FSS will be used as necessary to assist with telephone communications. In an area where radio communications cannot be maintained, the pilot-in-command will provide the following information on all flight plans: 1. Location, date and estimated time for reestablishing radio or telephone communications." The company operations specifications stated, in part: "Galaxy Air Cargo Inc.'s flight crews will always file a flight plan with either the FAA, director of maintenance, or his representative. The person guarding the flight plan accepts responsibility for guarding the flight plan until notified the flight is terminated, whether by the pilot/copilot, or an air traffic facility. In the event that a flight becomes overdue by one hour, and all efforts to locate have been unsuccessful, the person guarding the flight plan for the company will notify the nearest air traffic facility and the FAA regional operations center." No company flight plan for the accident flight was discovered by investigators. AIRCRAFT INFORMATION The airplane was maintained on an FAA Approved Airplane Inspection Program (AAIP). The company's AAIP, dated April 1, 1997, specifies an inspection cycle that has a routine inspection (every 7 days, or 25 hours), an interim continuity check (every 50 hours), Phase A (150 hours), Phase B (300 hours), Phase C (450
The airplane flightcrew's failure to maintain adequate distance/altitude from mountainous terrain during a departure climb to cruise flight, and the captain's impairment from drugs. Factors in the accident were dark night conditions, and the first officer's impairment from drugs.
Source: NTSB Aviation Accident Database
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