Beech 1900C N575X accident near Deadhorse, Alaska

Probable cause

The captain’s decision to initiate a visual flight rules approach and attempted landing into an area of instrument meteorological conditions, which resulted in the airplane touching down short of the runway. Contributing to the accident was the operator’s inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration’s failure to hold the operator accountable for correcting known operational deficiencies and ensure compliance with its operational control procedures.

NTSB analysis

Before departure of the short, nonscheduled charter flight, the weather at the destination airport was reported to be wind from the northeast at 27 mph, scattered clouds with blue skies above, and 1 1/2 statute miles (sm) visibility with blowing snow. According to the first officer, after departure, he contacted the destination airport and was advised that the visibility had deteriorated to 3/4 sm. The captain then informed the private weather observer that the flight would need at least 1 sm visibility to land. A few minutes later, the weather observer informed the captain that the visibility had improved to 1 sm. The captain stated that the approach was normal until he had a "sinking sensation" and realized that the airplane was too low. The airplane subsequently touched down short of the runway, and the main landing gear impacted the elevated edge of the runway surface, which resulted in the right main gear separating. The airplane then slid along the runway surface, which resulted in substantial damage to the fuselage and right elevator. The captain reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The private weather observer on duty at the destination airport the day of accident reported that he notified the pilots via radio that he could occasionally see a cold storage camp located 1 1/4 miles away but that he did not have 1-mile visibility. He said that, the weather was "bad" and that, at times, he could not see the runway. He said that he instructed the pilots to use their own judgment. Based on reported weather observations, at the time of the accident, the visibility had deteriorated to 1/2 mile in heavy blowing snow. Therefore, it is likely that the flight crew lost sight of the runway during the visual approach, which resulted in the airplane touching down short of the runway.

According to the company's General Operations Manual (GOM), operational control was held by the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and release of the flight, which included the risk assessment process. The flight coordinator who had operational control of the flight and released it the day of the accident had not completed flight coordinator training, which was required per the company's Federal Aviation Administration (FAA)-approved operations training manual. She assigned the flight a risk level of 2 (on a scale of 1 to 4), which, according to company risk assessment and operational control procedures, required a discussion between the PIC and flight coordinator about the risks involved. However, the flight coordinator did not discuss with the flight crew the risks and weather conditions associated with the flight. At the time of the accident, no signoff was required for flight coordinators or pilots on the risk assessment form, and the form was not integrated into the company manuals.

A review of FAA surveillance activities revealed that aviation safety inspectors had performed numerous operational control inspections and repeatedly noted deficiencies within the company's training, risk management, and operational control procedures. Enforcement Information System records indicated that FAA inspectors observed multiple incidences of the operator's noncompliance related to flight operations and opened investigations but that the investigations were closed after administrative action had been taken. Therefore, although FAA inspectors were providing surveillance and noting discrepancies within the company's procedures and processes, the FAA did not hold the operator sufficiently accountable for correcting the types of operational deficiencies evident in this accident, such as the operator's failure to comply with its operations specifications, operations training manual, and GOM and applicable federal regulations.

Text from the NTSB. Open the NTSB docket for ANC14LA007 for the full record.